PHPprime | Medicare Shared Savings Program

PHP Prime, LLC
999 17th St.
Suite 500
Denver, CO 80202

Colleen Daywalt, MPP
Colleen.Daywalt@phpmcs.com
720-612-6896

ACO Participants	ACO Participant in Joint Venture
ALEJANDRO LOPEZ JR, MD PA	NO
ALLIANCE FAMILY PRACTICE	NO
Alpine Medical Group Colorado PLLC	NO
ARBOR FAMILY MEDICINE	NO
AURORA FAMILY PRACTICE GROUP PC	NO
AURORA INTERNAL MEDICINE CLINIC PC	NO
CLINIX HEALTH SERVICES OF COLORADO INC	NO
COLORADO PHYSICIAN PARTNERS PLLC	NO
CORPUS CHRISTI FAMILY MEDICINE CENTER PA	NO
DENVER FAMILY MEDICINE, PC	NO
DENVER OSTEOPATHIC CLINIC	NO
DINH NGUYEN	NO
DOUTHIT FAMILY MEDICINE	NO
FAMILY MEDICINE ASSOCIATES, PC	NO
FIRST HEALTH FAMILY MEDICINE, LLC	NO
GERIATRIC MEDICINE ASSOCIATES, PC	NO
HAI BUI	NO
HALL MEDICAL, LLC	NO
Hemamalini Achuthan Md Pc	NO
INTERNAL MEDICINE ASSOC. OF WHEAT RIDGE, P.C.	NO
JOEL SHEBOWICH MD PC	NO
JOHN D MCLAUGHLIN MD PC PRESBYTERIAN AURORA MED BLDG	NO
LUIS H ROBLES MD PA	NO
MARK S FRALEY, D.O.,P.C.	NO
MATTHEWS-VU MEDICAL GROUP, P.C.	NO
MELECIA FUENTES MD PA	NO
MILE HIGH FAMILY MEDICINE INC	NO
MONZER H YAZJI MD & ASSOCIATES PLLC	NO
OUR LADY OF HOPE MEDICAL CLINIC INC	NO
PANKAJ NASHIKKAR MD LLC	NO
PEAK TO PEAK FAMILY PRACTICE, P.C.	NO
PINON FAMILY PRACTICE LLP	NO
RIPLEY R HOLLISTER MD PC/DBA: DYNAMIC HEALTHCARE TEAM	NO
SAN BENITO MEDICAL ASSOCIATES, PLLC	NO
SCALA MEDICAL PC	NO
VALLEY MEDICAL ARTS CLINIC PA	NO
WESTMED PRIMARY CARE	NO
WESTMINSTER, INC	NO
WHEAT RIDGE FAMILY PHYSICIANS LLC	NO
WHEAT RIDGE INTERNAL MEDICINE PC	NO
WILLIAM G CURTIS, MD PA	NO

Member First Name	Member Last Name	Member Title/ Position	Member's Voting Power (Expressed as a percentage)	Membership Type	ACO Participant Legal Business Name, if applicable
Adam	Robinson	Board Member	11.111%	ACO Participant Representative	Alpine Medical Group Colorado PLLC
Carol	Pittman	ACO Medical Director	11.111%	Other	N/A
Hemamalini	Achuthan	Board Member	11.111%	ACO Participant Representative	Hemamalini Achuthan Md Pc
Laura	Simmons	Board Member	11.111%	Medicare Beneficiary Representative	N/A
Luis	Delgado	Board Member	11.111%	ACO Participant Representative	MONZER H YAZJI MD & ASSOCIATES PLLC
Monzer	Yazji	Board Member	11.111%	ACO Participant Representative	MONZER H YAZJI MD & ASSOCIATES PLLC
Philip	Rosenblum	Board member	11.111%	ACO Participant Representative	Alpine Medical Group Colorado PLLC
Thomas	Cain	Board Member	11.112%	ACO Participant Representative	GERIATRIC MEDICINE ASSOCIATES, PC
W. Scott	Allan	Board Member	11.111%	ACO Participant Representative	WHEAT RIDGE INTERNAL MEDICINE PC

ACO Executive: Colleen Daywalt
Medical Director: Carol Pittman, MD
Compliance Officer: Heather Piernik
Quality Assurance/Improvement Officer: Zula Solomon

Networks of individual practices of ACO professionals

Amount of Shared Savings/Losses

N/A

Shared Savings Distribution

N/A

Quality Performance Results

N/A

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.

Fraud and Abuse Waivers

Our ACO does not have any Pre-Participation or Participation waivers.

Updated 1/1/2026

PHP Prime, LLC
999 17th St.
Suite 500
Denver, CO 80202

Colleen Daywalt, MPP
Colleen.Daywalt@phpmcs.com
720-612-6896

ACO Participants	ACO Participant in Joint Venture
AGEWELL MEDICAL ASSOCIATES PC	N
WESTMINSTER, INC	N
WHEAT RIDGE INTERNAL MEDICINE PC	N
JOEL SHEBOWICH MD PC	N
GFMA ACQ LLC	N
WISDOM HEALTH PC	N
PINON FAMILY PRACTICE LLP	N
KC MEDICAL PC	N
PRAIRIE VIEW FAMILY CARE LLC	N
AURORA FAMILY PRACTICE GROUP PC	N
Alpine Medical Group Colorado PLLC	N
MATTHEWS-VU MEDICAL GROUP, P.C.	N
SOUTHWEST FAMILY MEDICINE PC	N
ALLIANCE FAMILY PRACTICE	N
MARK S FRALEY, D.O.,P.C.	N
OUR LADY OF HOPE MEDICAL CLINIC INC	N
PANKAJ NASHIKKAR MD LLC	N
RIPLEY R HOLLISTER MD PC	N
MILE HIGH FAMILY MEDICINE INC	N
Hemamalini Achuthan Md Pc	N
DOUTHIT FAMILY MEDICINE	N
COLORADO PHYSICIAN PARTNERS PLLC	N
FIRST HEALTH FAMILY MEDICINE, LLC	N
FAMILY MEDICINE ASSOCIATES, PC	N
GERIATRIC MEDICINE ASSOCIATES, PC	N
DENVER FAMILY MEDICINE, PC	N
AURORA INTERNAL MEDICINE CLINIC PC	N
HAI BUI	Y
DINH NGUYEN	Y
ARBOR FAMILY MEDICINE	N
JOHN D MCLAUGHLIN MD PC PRESBYTERIAN AURORA MED BLDG	N
CLINIX HEALTH SERVICES OF COLORADO INC	N
SCALA MEDICAL PC	N
WESTMED PRIMARY CARE	N
MAYFAIR INTERNAL MEDICINE PC	N
PEAK TO PEAK FAMILY PRACTICE, P.C.	N
DENVER OSTEOPATHIC CLINIC	N
INTERNAL MEDICINE ASSOC. OF WHEAT RIDGE, P.C.	N
WHEAT RIDGE FAMILY PHYSICIANS LLC	N

First Name	Last Name	Title/Position	Voting Power	Membership Type	ACO Participant Legal Business Name
Laura	Simmons	Board Member	25%	Beneficiary and Community Stakeholder Representative	N/A
W. Scott	Allan, MD	Board Member	25%	ACO Participant Representative	WHEAT RIDGE INTERNAL MEDICINE PC
Thomas	Cain, MD	Chair	25%	ACO Participant Representative	Geriatric Medicine Associates, PC
Phil	Rosenblum, MD	Board Member	25%	ACO Participant Representative	Alpine Medical Group Colorado, PLLC

ACO Executive: Ken Nielsen
Medical Director: Thomas Cain, MD
Compliance Officer: Heather Piernik
Quality Assurance/Improvement Officer: Zula Solomon

Committee Name	Committee Leader Name and Position
Program Performance & Standards Committee	Thomas Cain, MD, Chair

Networks of individual practices of ACO professionals

Amount of Shared Savings/Losses

N/A

Shared Savings Distribution

N/A

Quality Performance Results

N/A

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.

Fraud and Abuse Waivers

Our ACO does not have any Pre-Participation or Participation waivers.

Updated 1/1/2026

PHP Prime, LLC
999 17th St.
Suite 500
Denver, CO 80202

Colleen Daywalt, MPP
Colleen.Daywalt@phpmcs.com
720-612-6896

ACO Participants	ACO Participant in Joint Venture
AGEWELL MEDICAL ASSOCIATES PC	N
ALLIANCE FAMILY PRACTICE	N
Alpine Medical Group Colorado PLLC	N
ARBOR FAMILY MEDICINE	N
AURORA FAMILY PRACTICE GROUP PC	N
AURORA INTERNAL MEDICINE CLINIC PC	N
CLINIX HEALTH SERVICES OF COLORADO INC	N
COLORADO PHYSICIAN PARTNERS PLLC	N
DENVER FAMILY MEDICINE, PC	N
DENVER OSTEOPATHIC CLINIC	N
DINH NGUYEN	N
DOCTORS MEDICAL GROUP OF COLORADO	N
DOUTHIT FAMILY MEDICINE	N
DR JACKIE L MCCOLLUM, MD. P.C.	N
FAMILY MEDICINE ASSOCIATES, PC	N
FIRST HEALTH FAMILY MEDICINE, LLC	N
GERIATRIC MEDICINE ASSOCIATES, PC	N
GFMA ACQ LLC	N
HAI BUI	N
Hemamalini Achuthan Md Pc	N
INTERNAL MEDICINE ASSOC. OF WHEAT RIDGE, P.C.	N
JOEL SHEBOWICH MD PC	N
JOHN D MCLAUGHLIN MD PC PRESBYTERIAN AURORA MED BLDG	N
KC MEDICAL PC	N
MARK S FRALEY, D.O.,P.C.	N
MATTHEWS-VU MEDICAL GROUP, P.C.	N
MAYFAIR INTERNAL MEDICINE PC	N
PEAK TO PEAK FAMILY PRACTICE, P.C.	N
PINON FAMILY PRACTICE LLP	N
PRAIRIE VIEW FAMILY CARE LLC	N
PRESKEN FAMILY CARE PC	N
SCALA MEDICAL PC	N
SOUTHWEST FAMILY MEDICINE PC	N
WESTMED PRIMARY CARE	N
WESTMINSTER, INC	N
WHEAT RIDGE FAMILY PHYSICIANS LLC	N
WHEAT RIDGE INTERNAL MEDICINE PC	N
WISDOM HEALTH PC	N

First Name	Last Name	Title/Position	Voting Power	Membership Type	ACO Participant Legal Business Name
Laura	Simmons	Board Member	10%	Beneficiary and Community Stakeholder Representative	N/A
Alan	Aboaf, MD	Board Member	10%	ACO Participant Representative	AURORA INTERNAL MEDICINE CLINIC PC
W. Scott	Allan, MD	Board Member	10%	ACO Participant Representative	WHEAT RIDGE INTERNAL MEDICINE PC
Erika	Altneu, MD	Board Member	10%	ACO Participant Representative	Geriatric Medicine Associates, PC
David	Bolshoun, MD	Board Member	10%	ACO Participant Representative	Mayfair Internal Medicine PC
Thomas	Cain, MD	Chair	10%	ACO Participant Representative	Geriatric Medicine Associates, PC
David	Conway, MD	Board Member	10%	ACO Participant Representative	Alpine Medical Group Colorado, PLLC
DeAun	Gehring, MD	Board Member	10%	ACO Participant Representative	Denver Family Medicine, PC
Annie	Imhof, MD	Board Member	10%	ACO Participant Representative	Alpine Medical Group Colorado, PLLC
Phil	Rosenblum, MD	Board Member	10%	ACO Participant Representative	Arbor Family Medicine

ACO Executive: Ken Nielsen
Medical Director: Lisa Price, MD
Compliance Officer: Heather Piernik
Quality Assurance/Improvement Officer: Lisa Price, MD

Committee Name	Committee Leader Name and Position
Program Performance & Standards Committee	Erika Altneu, MD, Chair

Networks of individual practices of ACO professionals

Amount of Shared Savings/Losses

$8,866,552.14

Shared Savings Distribution

Proportion invested in infrastructure: 20%
Proportion invested in redesigned care processes/resources: 30%
Proportion of distribution to ACO participants: 50%

Quality Performance Results

Quality performance results are based on the CMS Web Interface collection type.

Measure #	Measure Title	Collection Type	Performance Rate	Current Year Mean Performance Rate (Shared Savings Program ACOs)
321	CAHPS for MIPS	CAHPS for MIPS Survey	8.16	6.67
479*	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1422	0.1517
484*	Clinician and Clinician Group Risk- standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)	Administrative Claims	-	37
318	Falls: Screening for Future Fall Risk	CMS Web Interface	82.91	88.99
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	74.83	68.6
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	68.97	79.98
113	Colorectal Cancer Screening	CMS Web Interface	87.02	77.81
112	Breast Cancer Screening	CMS Web Interface	74.29	80.93
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	86.39	86.5
370	Depression Remission at Twelve Months	CMS Web Interface	11.11	17.35
001*	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	9.12	9.44
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	72.56	81.46
236	Controlling High Blood Pressure	CMS Web Interface	85.39	79.49
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	84.56	83.7
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	95.39	93.96
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	93.1	92.43
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	70.73	75.76
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	71.64	65.48
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	69.32	62.31
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	75.47	74.14
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	87.81	85.89
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	94.12	92.89
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	28.4	26.98

For previous years’ Financial and Quality Performance Results, please visit: Data.cms.gov.

*For Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [Quality ID #001], Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [Measure #479], and Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], a lower performance rate indicates better measure performance.

*For Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], patients are excluded if they were attributed to Qualifying Alternative Payment Model (APM) Participants (QPs). Most providers participating in Track E and ENHANCED track ACOs are QPs, and so performance rates for Track E and ENHANCED track ACOs may not be representative of the care provided by these ACOs' providers overall. Additionally, many of these ACOs do not have a performance rate calculated due to not meeting the minimum of 18 beneficiaries attributed to non-QP providers.

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.

Fraud and Abuse Waivers

Our ACO does not have any Pre-Participation or Participation waivers.

Updated 1/1/2026

PHP Prime, LLC
999 17th St.
Suite 500
Denver, CO 80202

Colleen Daywalt, MPP
Colleen.Daywalt@phpmcs.com
720-612-6896

ACO Participants	ACO Participant in Joint Venture
GERIATRIC MEDICINE ASSOCIATES, PC	N
SCALA MEDICAL PC	N
WESTMINSTER, INC	N
HAI BUI	N
PEAK TO PEAK FAMILY PRACTICE, P.C.	N
JOEL SHEBOWICH MD PC	N
ARBOR FAMILY MEDICINE	N
FIRST HEALTH FAMILY MEDICINE, LLC	N
JOHN D MCLAUGHLIN MD PC PRESBYTERIAN AURORA MED BLDG	N
WHEAT RIDGE FAMILY PHYSICIANS LLC	N
WISDOM HEALTH PC	N
DENVER FAMILY MEDICINE, PC	N
WESTMED PRIMARY CARE	N
WHEAT RIDGE INTERNAL MEDICINE PC	N
DINH NGUYEN	N
DENVER OSTEOPATHIC CLINIC	N
PRESKEN FAMILY CARE PC	N
DOUTHIT FAMILY MEDICINE	N
FAMILY MEDICINE ASSOCIATES, PC	N
CLINIX HEALTH SERVICES OF COLORADO INC	N
AURORA FAMILY PRACTICE GROUP PC	N
PINON FAMILY PRACTICE LLP	N
AURORA INTERNAL MEDICINE CLINIC PC	N
MAYFAIR INTERNAL MEDICINE PC	N
DR JACKIE L MCCOLLUM, MD. P.C.	N
COLORADO PHYSICIAN PARTNERS PLLC	N
R B AIKIN MD PC	N
INTERNAL MEDICINE ASSOC. OF WHEAT RIDGE, P.C.	N
GFMA ACQ LLC	N

First Name	Last Name	Title/Position	Voting Power	Membership Type	ACO Participant Legal Business Name
Laura	Simmons	Board Member	8.333%	Beneficiary and Community Stakeholder Representative	N/A
Alan	Aboaf, MD	Board Member	8.333%	ACO Participant Representative	AURORA INTERNAL MEDICINE CLINIC PC
W. Scott	Allan, MD	Board Member	8.333%	ACO Participant Representative	WHEAT RIDGE INTERNAL MEDICINE PC
Erika	Altneu, MD	Board Member	8.333%	ACO Participant Representative	Geriatric Medicine Associates, PC
David	Bolshoun, MD	Board Member	8.333%	ACO Participant Representative	Mayfair Internal Medicine PC
Gerald	Brown, MD	Board Member	8.333%	ACO Participant Representative	Colorado Physician Partners PLLC
Thomas	Cain, MD	Chair	8.333%	ACO Participant Representative	Geriatric Medicine Associates, PC
David	Conway, MD	Board Member	8.333%	ACO Participant Representative	Colorado Physician Partners PLLC
DeAun	Gehring, MD	Board Member	8.333%	ACO Participant Representative	Denver Family Medicine, PC
Annie	Imhof, MD	Board Member	8.333%	ACO Participant Representative	Colorado Physician Partners PLLC
Phil	Rosenblum, MD	Board Member	8.333%	ACO Participant Representative	Arbor Family Medicine
Richard	Vu, MD	Board Member	8.333%	Other	Matthews-Vu Medical Group

ACO Executive: Ken Nielsen
Medical Director: Lisa Price, MD
Compliance Officer: Heather Piernik
Quality Assurance/Improvement Officer: Lisa Price, MD

Committee Name	Committee Leader Name and Position
Program Performance & Standards Committee	Erika Altneu, MD, Chair

Networks of individual practices of ACO professionals

Amount of Shared Savings/Losses

Second agreement period -- performance year 2023: $ 4,728,673.00

Proportion invested in infrastructure: 20%

Proportion invested in redesigned care processes/resources: 30%

Proportion of distribution to ACO participants: 50%

First agreement period – performance year 2022: $4,347,169.61

Proportion invested in infrastructure: 20%
Proportion invested in redesigned care processes/resources: 30%
Proportion of distribution to ACO participants: 50%

Quality performance results are based on the CMS Web Interface collection type.

For previous years’ Financial and Quality Performance Results, please visit: Data.cms.gov

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOs)
Quality ID#: 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [1]	CMS Web Interface	4.95	9.84
Quality ID#: 134	Preventive Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	52.17	80.97
Quality ID#: 236	Controlling High Blood Pressure	CMS Web Interface	87.87	77.80
Quality ID#: 318	Falls: Screening for Future Fall Risk	CMS Web Interface	77.56	89.42
Quality ID#: 110	Preventive Care and Screening: Influenza Immunization	CMS Web Interface	74.64	70.76
Quality ID#: 226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	82.93	79.29
Quality ID#: 113	Colorectal Cancer Screening	CMS Web Interface	85.06	77.14
Quality ID#: 112	Breast Cancer Screening	CMS Web Interface	86.02	80.36
Quality ID#: 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	78.08	87.05
Quality ID#: 370	Depression Remission at Twelve Months	CMS Web Interface	9.52	16.58
Quality ID#: 321	CAHPS for MIPS [2]	CMS Web Interface	6.16	6.25
Measure # 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [1]	Administrative Claims	0.1563	0.1553
Measure # 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	Administrative Claims	29.47	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	82.60	83.68
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	93.16	93.69
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	92.08	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	74.22	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	68.48	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	63.13	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	75.22	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	87.07	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	91.94	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	25.94	26.69

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.

Fraud and Abuse Waivers

Our ACO does not have any Pre-Participation or Participation waivers.

Updated 11/22/2024

PHP Prime, LLC
999 17th St.
Suite 500
Denver, CO 80202

Colleen Daywalt, MPP
Colleen.Daywalt@phpmcs.com
720-612-6896

ACO Participants	ACO Participant in Joint Venture
PHP Prime, LLC	N

First Name	Last Name	Title/Position	Voting Power	Membership Type	ACO Participant Legal Business Name
Alan	Aboaf	Board Member	25%	ACO Participant Representative	Aurora Internal Medicine Clinic, PC
David	Conway	Board Member	25%	ACO Participant Representative	Colorado Physician Partners, PLLC
Laura	Simmons	Board Member	12.5%	Beneficiary and Community Stakeholder Representative	N/A
Thomas	Cain	Board Member, Chair	25%	ACO Participant Representative	Geriatric Medicine Associates, P.C.
Debra	Munley	Board Member	12.5%	Other	Physician Health Partners

ACO Executive: Ken Nielsen
Medical Director: Lisa Price, MD
Compliance Officer: Heather Piernik
Quality Assurance/Improvement Officer: Lisa Price, MD

Committee Name	Committee Leader Name and Position
Program Performance & Standards Committee	Erika Altneu, MD, Chair

Networks of individual practices of ACO professionals

Amount of Shared Savings/Losses

First agreement period – performance year 2022: $4,347,169.61

Shared Savings Distribution

Proportion invested in infrastructure: 20%
Proportion invested in redesigned care processes/resources: 30%
Proportion of distribution to ACO participants: 50%

Quality Performance Results

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOs)
Quality ID# 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1]	CMS Web Interface	7.95	10.71
Quality ID# 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	74.09	76.97
Quality ID# 236	Controlling High Blood Pressure	CMS Web Interface	81.84	76.16
Quality ID# 318	Falls: Screening for Future Fall Risk	CMS Web Interface	86.05	87.83
Quality ID# 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	88.89	77.34
Quality ID# 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	72.73	79.27
Quality ID# 113	Colorectal Cancer Screening	CMS Web Interface	87.08	75.32
Quality ID# 112	Breast Cancer Screening	CMS Web Interface	86.61	78.07
Quality ID# 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	67.56	86.37
Quality ID# 370	Depression Remission at Twelve Months	CMS Web Interface	16.67	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	0.1384	0.1510
Measure# 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	CMS Web Interface	25.92	30.97
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS	81.52	83.96
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS	93.84	93.47
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS	91.76	92.06
CAHPS-4	Access to Specialists	CAHPS for MIPS	78.30	77.00
CAHPS-5	Health Promotion and Education	CAHPS for MIPS	65.10	62.68
CAHPS-6	Shared Decision Making	CAHPS for MIPS	63.93	60.97
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS	71.74	73.06
CAHPS-8	Care Coordination	CAHPS for MIPS	86.18	85.46
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS	91.67	91.97
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS	27.87	25.62

Payment Rule Waivers

Our ACO does not participate in any payment rule waivers for Performance Year 2022.

Fraud and Abuse Waivers

Our ACO does not have any Pre-Participation or Participation waivers for Performance Year 2022.

Updated 09/22/2023