WV MSSP 2016 Enhanced

Colleen Wagner

ACO Primary Contact

Location

Aledade West Virginia ACO, LLC
4550 Montgomery Ave, Ste 950N
Bethesda, MD 20814

ACO Participants	ACO Participant in Joint Venture
ADVANCED FAMILY PRACTICE, PLLC	N
Charleston Internal Medicine Inc	N
Chesapeake Medical Center, PLLC	N
CROSS LANES INTERNAL MEDICINE GROUP INC	N
DUNBAR MEDICAL ASSOCIATES PLLC	N
Family Health Associates of the Kanawha Valley PLLC	N
Finbar Powderly	N
Healthy Habits Wellness Ctr, Inc	N
JOHN HOLLOWAY	N
Kanawha Medical Center Inc	N
MOUNTAIN STATE MEDICAL ASSOCIATES PLLC	N
Mountain State Medicine and Rheumatology PLLC	N
Patel Inc	N
Prestige Primary Care Associates PLLC	N
Spring Hill Primary Care Physicians PLLC	N
Williamson Health & Wellness Center Inc	N
WV Primary Care Inc	N

Member First Name	Member Last Name	Member Title/Position	Member's Voting Power (Expressed as a percentage)	Membership Type	ACO Participant Legal Business Name
GHALI	BACHA	Board Member	4.762	ACO Participant Representative	Chesapeake Medical Center, PLLC
ROY	BOWDEN	Board Member	4.762	ACO Participant Representative	Charleston Internal Medicine Inc
JULIE	DETEMPLE	Board Member	4.762	ACO Participant Representative	Family Health Associates of the Kanawha Valley PLLC
JOSEPH	DONZELLA	Board Member	4.762	ACO Participant Representative	Advanced Family Practice, PLLC
KELLI	DUMM	Board Member	4.762	ACO Participant Representative	Mountain State Medical Associates PLLC
JOHN	HOLLOWAY	Board Member	4.762	ACO Participant Representative	John Holloway
THOPSIE	JAGANNATH	Board Member	4.762	ACO Participant Representative	Kanawha Medical Center Inc
VICKI	JOHNSON	Board Member	4.762	ACO Participant Representative	Williamson Health & Wellness Center Inc
JOHN	LILLY	Board Member	4.762	ACO Participant Representative	Dunbar Medical Associates PLLC
JONATHAN	LILLY	Board Member/ACO Medical Director/ Compliance Committee Lead	4.762	ACO Participant Representative	Dunbar Medical Associates PLLC
JON	MILLER	Board Member	4.762	ACO Participant Representative	Healthy Habits Wellness Ctr, Inc
FRANKLIN	MOORE	Board Member	4.762	ACO Participant Representative	Prestige Primary Care Associates PLLC
MENA	NIEMIEC	Board Member/Vice Chair	4.762	Other	Aledade
ROHIT	PATEL	Board Member	4.762	ACO Participant Representative	Patel Inc
FINBAR	POWDERLY	Board Member	4.762	ACO Participant Representative	Finbar Powderly
ASHISH	SHETH	Board Member	4.762	ACO Participant Representative	WV Primary Care Inc
CHRISTOPHER	SKAGGS	Board Member	4.762	ACO Participant Representative	Spring Hill Primary Care Physicians PLLC
REGGIE	TRIPLETT	Board Member	4.762	ACO Participant Representative	Mountain State Medicine and Rheumatology PLLC
ARVIND	VIRADIA	Board Member	4.762	ACO Participant Representative	Cross Lanes Internal Medicine Group Inc
COLLEEN	WAGNER	Board Member/Chair	4.762	Other	Aledade
JOHN	WILSHERE	Board Member/Medicare Beneficiary Representative	4.762	Medicare Beneficiary Representative	N/A

Due to rounding, ‘Member’s Voting Power’ may not equal 100 percent.

Executive Director: Colleen Wagner
Medical Director: Jonathan Lilly
Compliance Officer: Amy Youtz
Quality Assurance/Improvement Officer: Emily Maxson

Committee Name	Committee Leader Name and Position
Compliance Committee	Dr. Jonathan Lilly / Compliance Committee Lead
Beneficiary Engagement Committee	Dr. Jonathan Lilly / Beneficiary Engagement Committee Lead
Transitions of Care Committee	Dr. Franklin Moore /Transitions of Care Committee Lead
Evidence-Based Medicine Committee	Dr. Christopher Skaggs / Evidence-Based Medicine Committee Lead

Networks of individual practices of ACO professionals

Second Agreement Period

Performance Year 2022, $4,639,799.86
Performance Year 2021, $5,374,760
Performance Year 2020, $4,840,442
Performance Year 2019, $4,866,915

First Agreement Period

Performance Year 2019, $4,866,915
Performance Year 2018, $1,187,169
Performance Year 2017, $2,950,672
Performance Year 2016, $1,566,654

Note: Our ACO participated in multiple performance years during Calendar Year 2019. The shared savings/losses amount reported for Performance Year 2019 therefore represents net shared savings or losses across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.

Second Agreement Period

Performance Year 2022
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 40%
- Proportion of distribution to ACO participants: 50%
Performance Year 2021
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 40%
- Proportion of distribution to ACO participants: 50%
Performance Year 2020
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 40%
- Proportion of distribution to ACO participants: 50%
Performance Year 2019
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 40%
- Proportion of distribution to ACO participants: 50%

First Agreement Period

Performance Year 2019
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 30%
- Proportion of distribution to ACO participants: 60%

Performance Year 2018
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 30%
- Proportion of distribution to ACO participants: 60%

Performance Year 2017
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 30%
- Proportion of distribution to ACO participants: 60%
Performance Year 2016
- Proportion invested in infrastructure: 10%
- Proportion invested in redesigned care processes/resources: 30%
- Proportion of distribution to ACO participants: 60%

Note: Our ACO participated in multiple performance years during Calendar Year 2019. The shared savings/losses amount reported for Performance Year 2019 therefore represents net shared savings or losses across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.

2022 Quality Performance Results

Measure #	Measure Name	Collection Type	Rate	ACO Mean
Quality ID# 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1]	CMS Web Interface	11.43	10.71
Quality ID# 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	92.33	76.97
Quality ID# 236	Controlling High Blood Pressure	CMS Web Interface	82.2	76.16
Quality ID# 318	Falls: Screening for Future Fall Risk	CMS Web Interface	91.82	87.83
Quality ID# 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	71.78	77.34
Quality ID# 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	84.38	79.27
Quality ID# 113	Colorectal Cancer Screening	CMS Web Interface	76.73	75.32
Quality ID# 112	Breast Cancer Screening	CMS Web Interface	77.81	78.07
Quality ID# 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	92.16	86.37
Quality ID# 370	Depression Remission at Twelve Months	CMS Web Interface	27.27	16.03
Quality ID# 321	CAHPS for MIPS [3]	CMS Web Interface	N/A	N/A
Measure# 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1]	CMS Web Interface	0.1667	0.151
Measure# 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	CMS Web Interface	31.46	30.97
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS	90.06	83.96
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS	95.15	93.47
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS	94.39	92.06
CAHPS-4	Access to Specialists	CAHPS for MIPS	74.18	77
CAHPS-5	Health Promotion and Education	CAHPS for MIPS	64.96	62.68
CAHPS-6	Shared Decision Making	CAHPS for MIPS	60.63	60.97
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS	71.08	73.06
CAHPS-8	Care Coordination	CAHPS for MIPS	87.39	85.46
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS	93.71	91.97
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS	28.87	25.62

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

Fraud and Abuse Waivers

ACO Pre-Participation Waiver:: N/A

ACO Participation Waiver:

- Parties to the arrangement: Aledade West Virginia ACO, LLC

- Date of arrangement: 10/17/2023

- Items, services, goods, or facility provided: Staffing of value based care initiatives.

The ACO will make payments as necessary to Participants in the ACO to reimburse the staffing costs required to complete certain value based care activities, which includes:

a) Conduct outreach to patients.b) Contact patients recently discharged from a hospital emergency department or inpatient/outpatient status to assess if needs were met and schedule a follow up visit with their primary care physician if needed.

c) Contact patients who have not been seen by their primary care physician in 6-12 months (depending on chronic conditions) and schedule annual wellness or other diagnostically appropriate appointments.

d) Contact patients who are new to the Medicare program and schedule a “Welcome to Medicare” visit.

e) Implement and routinize use of the Aledade application to provide insights into patient health, diagnosis coding opportunities, and visibility into the total cost of patient care.

f) Reviewing the “care gap worklist” in the Aledade App to apprise patients of test results, conducting outreach to patients to schedule preventive screenings, and follow up with patients concerning medication adherence concerns.

g) Support accurate and complete diagnosis documentation and coding.