Mary Washington Health Alliance MSSP Enhanced (2022-Current)

ACO Name and Location

Mary Washington Health Alliance, LLC.

2300 Fall Hill Ave.
Suite 308A
Fredericksburg, Virginia 22401

ACO Primary Contact

Primary Contact Name	Travis Turner
Primary Contact Phone Number	(540) 741-1557
Primary Contact Email Address	travis.turner@mwhc.com

Organizational Information

ACO Participants:

ACO Participants	ACO Participant in Joint Venture
MARY WASHINGTON MEDICAL GROUP HOSPITALIST SERVICES, LLC	N
MARY WASHINGTON HEALTHCARE PHYSICIANS	N
RADIOLOGIC ASSOCIATES OF FREDERICKSBURG	N
MEDICAL IMAGING OF FREDERICKSBURG, LLC	N
VIRGINIA URGENT CARE LLC	N
STAFFORD HOSPITAL, LLC	N

OBHG VIRGINIA LLC	N
ELITE WOMENS HEALTH INC	N
MARY WASHINGTON HOSPITAL INC	N
ACCESS EYE CENTERS, PC	N
CENTERCARE FAMILY PRACTICE LLC	N
RAPPAHANNOCK WOMEN'S HEALTH CENTER PC	N

VIRGINIA CENTER FOR ALLERGY AND ASTHMA INC.	N
FREDERICKSBURG EMERGENCY MEDICAL ALLIANCE, INC.	N
GASTROENTEROLOGY ASSOCIATES OF FREDERICKSBURG, P.C.	N
Pinnacle Dermatology, SC	N
Polaris Heart and Vascular, PLLC.	N
CARDIOLOGY ASSOCIATES OF FREDERICKSBURG, LTD.	N
UROLOGY ASSOCIATES OF FREDERICKSBURG, PC	N

CENTRAL VIRGINIA ORTHOPAEDICS & SPORTS MEDICINE	N
PATHOLOGY ASSOCIATES OF FREDERICKSBURG PTR	N
COLONIAL INTERNAL MEDICINE ASSOCIATES PC	N

VIRGINIA ONCOLOGY CARE PC	N
FALL HILL GASTROENTEROLOGY ASSOCIATES, LTD.	N
DERMATOLOGY CENTER PC	N

Dynamic Foot and Ankle Center LLC
CENTRAL VIRGINIA OB GYN GROUP PC	N
ORACLE HEART & VASCULAR PLLC	N
LEE'S HILL FAMILY PHYSICIANS, P.C.	N
PULMONARY ASSOCIATES OF FREDERICKSBURG	N

EAR NOSE AND THROAT AND FACIAL PLASTIC SURGERY CENTER OF FREDERICK	N
NEW BEGINNINGS OB GYN PC	N
Christopher Harrington MD PC
CENTRAL VIRGINIA INTERNAL MEDICINE PLC	N
WOMENS HEALTH AND SURGERY CENTER	N
OPTIMUM CARE LLC	N
MEDICAL & URGENT CARE CENTER, PC	N
Fredericksburg Christian Health Center	N
PEDSPLUS URGENT CARE LLC	N
MAP RC LLC	N
FREDERICKSBURG ANESTHESIA SERVICES LLC	N
METROPOLITAN HEALTH CARE PROVIDERS, INC.	N
VISTA EYE SPECIALISTS PC	N
NORTHERN VIRGINIA HEMATOLOGY ONCOLOGY ASSOCIATES PC	N
BLUE NILE MEDICAL CENTER, P.C.	N
THE CENTER FOR ORTHOPEDICS, INC.	N
COMMONWEALTH INTERNAL MEDICINE PC	N
SLEEP DISORDER CENTER OF FREDERICKSBURG PLC	N
CENTRAL VIRGINIA SLEEP CENTER PLC	N
MARY WASHINGTON EYE CARE CENTER, LLC	N
METROHEALTH INTERNAL MEDICINE, PC	N
FAMILY FOOT AND ANKLE CENTER	N
RADIATION ONCOLOGY SPECIALISTS OF CENTRAL VIRGINIA PLC	N
Vision Innovation Centers of Virginia LLC	N
RAPIDAN MEDICAL CENTER	N
FAMILY CARE OF FREDERICKSBURG PLC	N


INTERNAL MEDICINE OF VIRGINIA, P.C.	N
FREDERICKSBURG FOOT & ANKLE CENTER	N
MCMANUS & ASSOCIATES INTERNAL MEDICINE PC	N
DIABETES & THYROID ASSOCIATES	N
CHANCELLOR PRIMARY CARE PLLC	N
BELMONT AESTHETIC & RECONSTRUCTIVE PLASTIC SURGERY	N
PSYCHIATRIC CARE INC	N
DHMR CLINICS, INC	N

ACO Governing Body:


Member's Last Name	Member's First Name	Member's Title/Position	Member's Voting Power (Expressed as a percentage)	Membership Type	ACO Participant TIN Legal Business Name/DBA, if Applicable
McDowell	Kenneth	DO, Chairman/Voting Member	10%	ACO Participant Representative	Colonial Internal Medicine Associates PC
McDermott	Michael	MD, Vice Chair/Voting Member	10%	ACO Participant Representative	Mary Washington Hospital, Inc.
Newman	Christopher	MD, Secretary/Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
Frazier	Jeffrey	MD, Treasurer/Voting Member	5%	ACO Participant Representative	Radiologic Associates of Fredericksburg, Ltd.
Nakave	Abhijeet	MD, Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
Thott	Kurian	MD, Voting Member	5%	ACO Participant Representative	Womens Health and Surgery Center
Szlyk	Gregory	MD, Voting Member	5%	ACO Participant Representative	Urology Associates of Fredericksburg, PC
Amory	Charles	MD	0	Other – Community Physician	Chancellor Pediatrics
DeTrane	Frank	MD	5%	ACO Participant Representative	Gastroenterology Associates of Fredericksburg
Vacant		MD, Voting Member	0	ACO Participant Representative	TBD
Sims	Adam	MD, Voting Member	5%	ACO Participant Representative	Fredericksburg Emergency Medical Alliance, Inc.
Woodford	Dan	MD, Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
McManus	Patrick	MD, Voting Member	5%	ACO Participant Representative	McManus & Associates Internal Medicine, PC
Gamache	Donna	MD, Voting Member	5%	ACO Participant Representative	Lee's Hill Family Physicians, PC
Brown	Dana	MD, Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
Sherwood	Timothy	MD, Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
Aiken	Matthew	DO, Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.
Branscome	Ronald	Voting Member	5%	Medicare Beneficiary Representative	N/A
Davis	Bruce	Voting Member	5%	Community Stakeholder Representative	N/A
Barden	Sean	Voting Member	5%	ACO Participant Representative	Mary Washington Hospital, Inc.

Key ACO Clinical and Administrative Leadership:

ACO Executive: Travis Turner

Medical Director: Richard Lewis, MD

Compliance Officer: Lauren Blalock

Quality Assurance/Improvement Officer: Dan Woodford, MD

Associated Committees and Committee Leadership:

Kenneth McDowell, DO; MWMD Board Chair
Dan Woodford, MD; Chair, Clinical Quality Committee
Kurian Thott, MD; Chair, Communications and Education Committee
Jeffrey Frazier, MD; Chair, Finance and Contracting Committee
Gregory Szlyk, MD; Chair, Information Technology Committee
Patrick McManus, MD; Chair, Nominating and Membership/Operations Committees

Types of ACO Participants, or Combinations of Participants, That Formed the ACO:

Networks of individual practices of ACO professionals
Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses:

First Agreement Period
- Performance Year 2021, N/A
Second Agreement Period
- Performance Year 2022, $3,807,505

Shared Savings Distribution:

First Agreement Period
- Performance Year 2021
  - Proportion invested in infrastructure: N/A
  - Proportion invested in redesigned care processes/resources: N/A
  - Proportion of distribution to ACO participants: N/A
Second Agreement Period
- Performance Year 2022
  - Proportion invested in infrastructure: 50%
  - Proportion invested in redesigned care processes/resources: 35%
  - Proportion of distribution to ACO participants: 15%

Quality Performance Results

2022 Quality Performance Results:

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOs)
CAHPS_1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	84.1	83.96
CAHPS_2	How Well Providers Communicate	CAHPS for MIPS Survey	94.6	93.47
CAHPS_3	Patient’s Rating of Provider	CAHPS for MIPS Survey	93.7	92.06
CAHPS_4	Access to Specialists	CAHPS for MIPS Survey	77.2	77
CAHPS_5	Health Promotion and Education	CAHPS for MIPS Survey	57.3	62.68
CAHPS_6	Shared Decision Making	CAHPS for MIPS Survey	63.9	60.97
CAHPS_7	Health Status and Functional Status	CAHPS for MIPS Survey	74.0	73.06
CAHPS_8	Care Coordination	CAHPS for MIPS Survey	87.1	85.46
CAHPS_9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	93.1	91.97
CAHPS_11	Stewardship of Patient Resources	CAHPS for MIPS Survey	16.3	25.62
Measure_479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1]	Administrative Claims	0.1605	0.1510
Measure_484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	Administrative Claims	36.1	30.97
QualityID_318	Falls: Screening for Future Fall Risk	CMS Web Interface	82.9	87.83
QualityID_110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	73.5	77.34
QualityID_226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	66.7	79.27
QualityID_134_WI	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	54.0	76.97
QualityID_113	Colorectal Cancer Screening	CMS Web Interface	67.5	75.32
QualityID_112	Breast Cancer Screening	CMS Web Interface	83.3	78.07
QualityID_438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	92.5	86.37
QualityID_370	Depression Remission at Twelve Months	CMS Web Interface	5.0	16.03
QualityID_001_WI	Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1]	CMS Web Interface	15.8	10.71
QualityID_236_WI	Controlling High BP	CMS Web Interface	75.0	76.16
QualityID_321	CAHPS for MIPS [3]	CMS Web Interface	N/A	N/A

For Previous Years’ Financial and Quality Performance Results, Please Visit data.cms.gov

Payment Rule Waivers

Skilled Nursing Facility (SNF) 3-Day Rule Waiver:
- Our ACO uses the SNF 3-Day Rule Waiver, pursuant to 42 CFR § 425.612.

Waiver for Payment for Telehealth Services:
- Our ACO clinicians provide telehealth services using the flexibilities under 42 CFR § 425.612(f) and 42 CFR § 425.613.

Fraud and Abuse Waivers

ACO Pre-Participation Waiver:

Our ACO is not using any Pre-Participation Waivers

ACO Participation Waiver:

The Secretary of the Department of Health and Human Services (HHS) has made available a participation waiver of federal fraud and abuse laws in connection with the operation of accountable care organizations (ACOs) that have entered into a participation agreement under the Medicare Shared Savings Program (MSSP) with the Centers for Medicare & Medicaid Services (CMS).

The Mary Washington Health Alliance (ACO) Governing Body has duly authorized the arrangements below and made a bona fide determination that each arrangement is reasonably related to the purposes of the MSSP because the arrangements will promote accountability for the quality, cost and overall care for Medicare beneficiaries assigned to ACO. The descriptions of relevant arrangements are set forth below for the purpose of ACO availing itself of the protections afforded under the MSSP Waivers:

ACO has implemented a care coordination arrangement beginning January 1, 2016, pursuant to which the ACO identifies certain Medicare beneficiaries as being at high risk or rising risk and actively engages such beneficiaries under a navigation program constituting an evidenced-based approach to improving patient engagement and improving the overall efficiency of care.
ACO has entered into a Hospital Quality and Efficiency Program with Mary Washington Hospital, of the ACO’s providers/suppliers as of January 1, 2016, for purposes of the implementation by the ACO of quality initiatives that will support the efficiency and efficacy of various transitions of care processes in a manner that is transparent to patients, has detailed quality controls and implements safeguards to ensure compliance with applicable laws. Specifically, the ACO Governing Body has made a bona fide determination that the program promotes accountability for the quality and cost of overall care for Medicare beneficiaries assigned to the ACO.
The ACO has approved the Surgical Advanced Practitioner Arrangement (the “Arrangement”) which will begin on or about September 1, 2016. Under the Arrangement, the ACO will employ a full-time qualified, experienced, and appropriately licensed allied health professional (e.g., a nurse practitioner or physician assistant) (“Allied Health Professional”) who will be located at Mary Washington Hospital (“MWH”) or Stafford Hospital (“SH”) for the purpose of assisting physician-participants of the ACO with respect to surgical procedures performed in MWH and SH. Such duties shall be assigned by the ACO, and may evolve from time to time, but shall include clinical and administrative activities designed to optimize the coordination among and engagement of health care team members and the patient in promotion of the ACO’s quality and cost objectives.

The Arrangement is designed to promote MWHA’s population health management capabilities, improve management and coordination of patient care for Medicare beneficiaries to encompass the hospital setting, and represents a key investment in MWHA’s infrastructure and redesigned care processes to achieve high quality and efficient service delivery for patients, including Medicare beneficiaries. This Arrangement will be located at MWH and SH for the purpose of assisting physician-participants of MWHA with respect to surgical procedures performed in MWH and SH. Specifically, the ACO Governing Body has made a bona fide determination that the program promotes accountability for the quality and cost of overall care for Medicare beneficiaries assigned to the ACO.

Types of ACO Participants or Combinations of Participants that Formed the ACO:

Networks of individual practices of ACO professionals
Partnerships or joint venture arrangements between hospitals and ACO professionals