Rocky Mountain Accountable Health Network (ACO)

Annual Results

Quality Performance Results

2017 Quality Performance Results:

ACO#	Measure Name	Rate	ACO Mean
ACO-1	CAHPS: Getting Timely Care, Appointments, and Information	82.10	80.60
ACO-2	CAHPS: How Well Your Providers Communicate	94.62	93.13
ACO-3	CAHPS: Patients' Rating of Provider	93.16	92.31
ACO-4	CAHPS: Access to Specialists	84.00	83.32
ACO-5	CAHPS: Health Promotion and Education	62.49	62.30
ACO-6	CAHPS: Shared Decision Making	80.69	75.85
ACO-7	CAHPS: Health Status/Functional Status	76.62	73.05
ACO-34	CAHPS: Stewardship of Patient Resources	21.66	25.68
ACO-8	Risk-Standardized, All Condition Readmission	14.55	15.01
ACO-35	Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)	17.92	18.46
ACO-36	All-Cause Unplanned Admissions for Patients with Diabetes	54.42	53.95
ACO-37	All-Cause Unplanned Admissions for Patients with Heart Failure	77.39	79.16
ACO-38	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions	63.23	61.74
ACO-43	Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91)	1.75	1.93
ACO-11	Use of Certified EHR Technology	100.00	98.48
ACO-12	Medication Reconciliation	49.27	75.32
ACO-13	Falls: Screening for Future Fall Risk	99.60	74.38
ACO-44	Imaging Studies for Low Back Pain	46.43	67.32
ACO-14	Preventive Care and Screening: Influenza Immunization	76.47	72.52
ACO-15	Pneumonia Vaccination Status for Older Adults	82.66	72.92
ACO-16	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up	56.45	70.69
ACO-17	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	98.39	90.48
ACO-18	Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan	93.90	61.98
ACO-19	Colorectal Cancer Screening	71.37	64.58
ACO-20	Breast Cancer Screening	81.05	70.05
ACO-42	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	70.28	79.89
ACO-27	Diabetes Mellitus: Hemoglobin A1c Poor Control	12.10	16.74
ACO-41	Diabetes: Eye Exam	52.82	50.37
ACO-28	Hypertension (HTN): Controlling High Blood Pressure	65.73	71.47
ACO-30	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	93.55	86.86

Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low samples.

For 2017 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2017-Shared-Savings-Program-SSP-Accountable-Care-O/gk7c-vejx/data
For 2016 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care-O/3jk5-q6dr/data
For 2015 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu/data/a>

For 2014 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/ucce-hhpu/data

Note: In the Quality Performance Results file(s) above, search for â€œRocky Mountain Accountable Health Network, Inc." to view the quality performance results. This ACO can also be found by using the ACO ID A29971 in the public use files on data.cms.gov.

2016 Quality Performance Results:

ACO#	Measure Name	Rate	ACO Mean
ACO-1	CAHPS: Getting Timely Care, Appointments, and Information	85.01	80.51
ACO-2	CAHPS: How Well Your Providers Communicate	93.91	93.01
ACO-3	CAHPS: Patients' Rating of Provider	94.19	92.25
ACO-4	CAHPS: Access to Specialists	84.00	83.49
ACO-5	CAHPS: Health Promotion and Education	57.02	60.32
ACO-6	CAHPS: Shared Decision Making	78.46	75.40
ACO-7	CAHPS: Health Status/Functional Status	72.46	72.30
ACO-34	CAHPS: Stewardship of Patient Resources	26.16	26.97
ACO-8	Risk-Standardized, All Condition Readmission	14.17	14.70
ACO-35	Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)	17.03	18.17
ACO-36	All-Cause Unplanned Admissions for Patients with Diabetes	54.27	53.20
ACO-37	All-Cause Unplanned Admissions for Patients with Heart Failure	76.92	75.23
ACO-38	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions	67.82	59.81
ACO-9	Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)	5.07	9.27
ACO-10	Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 )	13.08	14.53
ACO-11	Percent of PCPs who Successfully Meet Meaningful Use Requirements	100.00	82.72
ACO-39	Documentation of Current Medications in the Medical Record	97.78	87.54
ACO-13	Falls: Screening for Future Fall Risk	99.19	64.04
ACO-14	Preventive Care and Screening: Influenza Immunization	61.37	68.32
ACO-15	Pneumonia Vaccination Status for Older Adults	85.08	69.21
ACO-16	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up	56.05	74.45
ACO-17	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	98.39	90.98
ACO-18	Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan	93.33	53.63
ACO-19	Colorectal Cancer Screening	58.06	61.52
ACO-20	Breast Cancer Screening	72.29	67.61
ACO-21	Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented	80.41	76.79
ACO-42	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	76.15	77.72
ACO-27	Diabetes Mellitus: Hemoglobin A1c Poor Control	15.73	18.24
ACO-41	Diabetes: Eye Exam	41.94	44.94
ACO-28	Hypertension (HTN): Controlling High Blood Pressure	63.71	70.69
ACO-30	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	90.32	85.05
ACO-31	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	84.06	88.67
ACO-33	Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%)	68.55	79.67

Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low samples.

For 2016 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care-O/3jk5-q6dr/data
For 2015 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu
For 2014 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/ucce-hhpu

Note: In the Quality Performance Results file(s) above, search for Rocky Mountain Accountable Health Network, Inc. to view the quality performance results. This ACO can also be found by using the ACO ID A29971 in the public use files on data.cms.gov.

Measure number	Performance measure	2015 reporting period
Measure number	Performance measure	ACO performance rate	Mean performance rate (SSP- ACOs)
ACO-1	CAHPS: Getting Timely Care, Appointments, and Information	76.92	80.61
ACO-2	CAHPS: How Well Your Providers Communicate	90.88	92.65
ACO-3	CAHPS: Patients' Rating of Provider	92.17	91.94
ACO-4	CAHPS: Access to Specialists	77.91	83.61
ACO-5	CAHPS: Health Promotion and Education	55.34	59.06
ACO-6	CAHPS: Shared Decision Making	75.00	75.17
ACO-7	CAHPS: Health Status/Functional Status	75.29	72.30
ACO-34	CAHPS: Stewardship of Patient Resources*	22.19	26.87
ACO-8	Risk Standardized, All Condition Readmission	14.84	14.86
ACO-35	Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)* Readmission	17.85	18.07
ACO-36	All-Cause Unplanned Admissions for Patients with Diabetes*	55.49	54.60
ACO-37	All-Cause Unplanned Admissions for Patients with Heart Failure*	77.58	76.96
ACO-38	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions	62.81	62.92
ACO-9	Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)	0.42	1.11
ACO-10	Ambulatory Sensitive Condition Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8)	0.00	1.04
ACO-11	Percent of Primary Care Physicians who Successfully Meet Meaningful Use Requirements	54.17%	80.14%
ACO-39	Documentation of Current Medications in the Medical Record*	89.10%	84.07%
ACO-13	Falls: Screening for Future Fall Risk	90.73%	56.46%
ACO-14	Preventative Care and Screening: Influenza Immunization	44.63%	62.03%
ACO-15	Pneumonia Vaccination Status for Older Adults	68.95%	63.73%
ACO-16	Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-up	54.25%	71.15%
ACO-17	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	90.32%	90.16%
ACO-18	Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan	38.31%	45.25%
ACO-19	Colorectal Cancer Screening	54.49%	60.06%
ACO-20	Breast Cancer Screening	61.80%	65.67%
ACO-21	Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	43.40%	70.04%
ACO-40	Depression Remission at Twelve Months*	N/A	N/A
ACO-27	Diabetes Mellitus:Hemoglobin A1c Poor Control	28.00%	20.38%
ACO-41	Diabetes: Eye Exam*	28.00%	41.05%
ACO-28	Hypertension: Controlling High Blood Pressure	57.67%	69.62%
ACO-30	Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic	93.62%	83.82%
ACO-31	Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	100.00%	87.22%
ACO-33	Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%)	57.14%	77.73%
"CAHPS = Consumer Assessment of Healthcare Providers and Systems, PQI = Prevention Quality Indicator, LVSD = left ventricular systolic dysfunction, ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, CAD = coronary artery disease. *= Measure required beginning Reporting Year 2015 N/A= Reporting on the depression remission measure is not required for 2015, as indicated by N/A "

Measure number	Performance measure	2012 reporting period		2013 reporting period		2014 reporting period
Measure number	Performance measure	ACO performance rate	Mean performance rate for all ACOs	ACO performance rate	Mean performance rate for all ACOs	ACO performance rate	Mean performance rate for all ACOs
ACO #1	Getting Timely Care, Appointments, and Information	Not in operations	Not in operations	Not in operations	Not in operations	80.16	80.13
ACO #2	How Well Your Doctors Communicate	Not in operations	Not in operations	Not in operations	Not in operations	91.68	92.39
ACO #3	Patients' Rating of Doctor	Not in operations	Not in operations	Not in operations	Not in operations	92.00	91.58
ACO #4	Access to Specialists	Not in operations	Not in operations	Not in operations	Not in operations	84.69	83.97
ACO #5	Health Promotion and Education	Not in operations	Not in operations	Not in operations	Not in operations	56.05	58.29
ACO #6	Shared Decision Making	Not in operations	Not in operations	Not in operations	Not in operations	76.06	74.60
ACO #7	Health Status/Functional Status	Not in operations	Not in operations	Not in operations	Not in operations	72.53	71.10
ACO #8	Risk Standardization, All Condtion Readmissions	Not in operations	Not in operations	Not in operations	Not in operations	14.65	15.15
ACO #9	ASC Admissions: COPD or Asthma in Older Adults	Not in operations	Not in operations	Not in operations	Not in operations	0.84	1.08
ACO #10	ASC Admission: Heart Failure	Not in operations	Not in operations	Not in operations	Not in operations	1.33	1.19
ACO #11	Percent of PCPs who Qualified for EHR Incentive Payment	Not in operations	Not in operations	Not in operations	Not in operations	86.67	76.71
ACO #12	Medication Reconciliation	Not in operations	Not in operations	Not in operations	Not in operations	94.99	82.61
ACO #13	Falls: Screening for Falls	Not in operations	Not in operations	Not in operations	Not in operations	93.43	45.60
ACO #14	Influenza Immunization	Not in operations	Not in operations	Not in operations	Not in operations	47.13	57.51
ACO #15	Pneumococcal Vaccination	Not in operations	Not in operations	Not in operations	Not in operations	56.07	55.03
ACO #16	"Adult Weight Screening and Follow-up"	Not in operations	Not in operations	Not in operations	Not in operations	51.53	66.75
ACO #17	Tobacco Use Assessment and Cessation Intervention	Not in operations	Not in operations	Not in operations	Not in operations	87.85	86.79
ACO #18	Depression Screening	Not in operations	Not in operations	Not in operations	Not in operations	33.81	39.27
ACO #19	Colorectal Cancer Screening	Not in operations	Not in operations	Not in operations	Not in operations	47.61	56.14
ACO #20	Mammography Screening	Not in operations	Not in operations	Not in operations	Not in operations	55.95	61.41
ACO #21	Proportion of Adults who had blood pressure screened in past 2 years	Not in operations	Not in operations	Not in operations	Not in operations	39.87	60.24
ACO #22	Hemoglobin A1c Control (HbA1c) (<8 percent)	Not in operations	Not in operations	Not in operations	Not in operations	68.19	N/A
ACO #23	Low Density Lipoprotein (LDL) (<100 mg/dL)	Not in operations	Not in operations	Not in operations	Not in operations	N/A	N/A
ACO #24	Blood Pressure (BP) < 140/90	Not in operations	Not in operations	Not in operations	Not in operations	66.11	N/A
ACO #25	Tobacco Non Use	Not in operations	Not in operations	Not in operations	Not in operations	86.28	N/A
ACO #26	Aspirin Use	Not in operations	Not in operations	Not in operations	Not in operations	75.33	N/A
ACO #27	Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent)	Not in operations	Not in operations	Not in operations	Not in operations	19.42	20.35
ACO #28	Percent of beneficiaries with hypertension whose BP <140/90	Not in operations	Not in operations	Not in operations	Not in operations	58.28	68.02
ACO #29	Percent of beneficiaries with IVD with complete lipid profile and LDL control <100 mg/dL	Not in operations	Not in operations	Not in operations	Not in operations	N/A	N/A
ACO #30	Percent of beneficiaries with IVD who use Aspirin or other antithrombitic	Not in operations	Not in operations	Not in operations	Not in operations	81.40	80.79
ACO #31	Beta-Blocker Therapy for LVSD	Not in operations	Not in operations	Not in operations	Not in operations	85.96	82.71
ACO #32	Drug Therapy for Lowering LDL Cholesterol	Not in operations	Not in operations	Not in operations	Not in operations	N/A	N/A
ACO #33	ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and /or LVSD	Not in operations	Not in operations	Not in operations	Not in operations	74.30	N/A

Primary Contact Name	Carol Beam
Primary Contact Phone Number	(406) 238-6066
Primary Contact Email Address	cbeam@rmhn.org

ACO Participants	ACO Participant in Joint Venture
Montana Allergy, PLLC	N
Ottun Chiropractic, PC	N
SCL Health Medical Group-Billings, LLC	Y
Billings Family Chiropractic, Inc	N
Rehder Hearing Clinic Inc	N
Eye Physicians & Surgeons	N
Ear Nose and Throat Associates, PC	N
Drs. McBride & McBride Optometrists, PC	N
Yellowstone Pathologists, PC	N
BILLINGS OB/GYN ASSOCIATES, PC	N
Kerry Sanchez	N
Yellowstone Pathology Institute, Inc.	N
Yellowstone Sports Medicine and Bone & Joint Clinic, LLC	N

Member			Member's Voting Power- Expressed as a percentage or number	Membership Type	ACO Participant TIN Legal Business Name/DBA, if Applicable
Last Name	First Name	Title/Position		Membership Type
Loveless	Steve	Board Chair	1	Other - SCL Montana Region CEO	N/A
Sears, MD	Scott	Treasurer	1	AOC Participant Representative	SCL Health Medical Group-Billings, LLC
Hagan, MD	Michael	Secretary	1	ACO Participant Representative	SCL Health Medical Group-Billings, LLC
Zavala, MD	Jeff	Medical Director	1	ACO Participant Representative	SCL Health Medical Group-Billings, LLC
Demars	Sean	Board Member	1	ACO Participant Representative	Ear Nose and Throat Associates
Phillips, MD	William	Board Member	1	ACO Participant Representative	SCL Health Medical Group-Billings, LLC
Peet	Walter	Medicare Beneficiary	1	Medicare Beneficiary Representative	N/A
Lebsock, OD	Shawn	Board Member	1	ACO Participant Representative	Drs. McBride & McBride Optometrists, PC
Nynas, DC	Marcus	Board Member	1	ACO Participant Representative	Billings Family Chiropractic

Carol Beam	ACO Executive
Jeffery Zavala, MD	Medical Director
Joanne Davidson	Compliance Officer
Jeffery Zavala, MD	Quality Assurance/Improvement Officer

Committee Name	Committee Leader Name and Position
Quality Committee	Jeffrey Zavala, MD, Committee Chair
Compliance Committee	Joanne Davidson, Committee Chair
Finance Committee	Dale Squires, Committee Chair

(406) 238-6066