MSSP Performance

ACO Name and Location

Franciscan Northwest Physicians Health Network, LLC
Previous Names: N/A
1149 Market Street
MS 10-34
Tacoma, Washington, 98402

ACO Primary Contact

Primary Contact Name	Paulette Cranshaw
Primary Contact Phone Number	253-428-8444
Primary Contact Email Address	RHN@chifranciscan.org

Organizational Information
ACO participants:

ACO Participants	ACO Participant in Joint Venture
Amos Shirman	N
Adam Nickel	N
Aesthetic General Dermatology Of Seattle	N
Allcare Medical Clinic Inc.	N
Bonney Lake Medical Center	N
Cynthia Taylor, MD	N
Daniel Gottlieb	N
DANIEL ZIPEROVICH	N
David C Reed MD PLLC	N
Dennis N Gusman	N
DONALD LOOMIS	N
Electrodiagnosis & Rehabilitation Associates Of Tacoma Ps	N
Enumclaw Regional Hospital Association	N
Fhs Inpatient Team	N
Franciscan Health System	N
Franciscan Medical Group	N
George Ankuta	N
Hanmi Medical Clinic Llc	N
Harrison Medical Center	N
HARRY A. PIERCE, DO, PS	N
Highline Medical Center	N
Home Towne Family Medicine, PLLC	N
Hsushi Yeh	N
Integrated Neurology Health Services, PS	N
Jeanne Isaacson, M.D., Pc	N
Jeff Cooper Do Pllc	N
Jeffrey Evans	N
Jeffrey Frankel	N
JEFFREY HOFF	N
Kenneth L P Morton Md Pc	N
KENT FAMILY PRACTICE PS	N
Kevin Kennedy	N
Key Medical Center, PLLC	N
Lisa Cowden	N
Lisa Cowden	N
Marcus R. Kauffman, MD, PLLC	N
MB2K LLC	N
Michael E Blatner Md Ps	N
Michael Steiner	N
Northwest Family & Spinal Clinic Inc Ps	N
Northwest Physicians Medical Group, PLLC	N
Northwest Vein And Aesthetic Center Ps	N
Nw Pain Management And Rehabilitation Associates, Inc	N
Nw Regional Hospital For Respiratory & Complex Care	N
Pacific Cardiovascular DPM, PS	N
Pacific Podiatry Group, Ps	N
Peninsula Family Medical Center	N
PENINSULA RAD ONC CTR LLC	N
PORTLAND AVENUE CLINIC MANAGEMENT	N
Primary Care Northwest Pllc	N
Proliance Surgeons, Inc, PS	N
Puget Sound Allergy Asthma & Immunology	N
Puyallup Dermatology Clinic Inc P.S.	N
Rainier Nephrology, PLLC	N
Razan R Al-Kudsi Md	N
Robert K Chow Md Ps	N
Saint Clare Hospital	N
SALISH INTEGRATIVE MEDICINE INC	N
Seatac Primary Care Physicians, Inc.	N
Sheldon J Cowen MDPS	N
Skin Cancer Clinic Of Seattle Inc Ps	N
Sound Clinical Medicine, P.S.	N
South Puget Sound Neurology PLLC	N
South Seattle Nephrology Associates	N
St Francis Community Hospital	N
Steve Feller	N
Steven Mcclean Md Pc	N
Surgical Associates Northwest, P.C.	N
Synergy Health	N
Tacoma Radiation Center Inc	N
TERRILL HARRINGTON	N
TLC Physicians PLLC	N
WEST HILL MEDICAL CLINIC INC	N

ACO governing body

Member			Member's Voting Power	Membership Type	ACO Participant Legal Business Name/DBA, if Applicable
Last Name	First Name	Title/Position	Member's Voting Power	Membership Type	ACO Participant Legal Business Name/DBA, if Applicable
Mercado, MD	Francis	Physician Member/Board Chair	1	ACO Participant	Franciscan Medical Group
Verzosa, MD	Jude	Physician Member/CMO	1	ACO Participant	Franciscan Medical Group
Kennedy-Schlicher, MD	Jessica	Physician Member/Treasurer	1	ACO Participant	Franciscan Health System
Anderson	Michael	Member	1	ACO Participant	Franciscan Health System
Ross, MD	Andrew	Physician Member	1	Community Stakeholder	N/A
Semerdjian, MD	Greg	Physician Member	1	Medicare Beneficiary	N/A (Retired)
Watson, MD	Michael	Physician Member	1	ACO Participant	Harrison Medical Center
Lal	Dhyan	ACO Executive/Secretary	0	Ex-Officio	Franciscan Health System

Key ACO clinical and administrative leadership:

ACO Executive: Dhyan Lal

Medical Director: Jude Verzosa, MD

Compliance Officer: Christi Knox

Quality Assurance/Improvement Officer: Jude Verzosa, MD

Associated committees and committee leadership:

Committee Name	Committee Leader Name and Position
Quality of Care	Jude Verzosa, MD - Chair
Contracting & Product Developing	Dhyan Lal - Chair
Finance	Mike Fitzgerald - Chair
Executive	Francis Mercado, MD - Chair

Types of ACO participants, or combinations of participants, that formed the ACO:

Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

Third Agreement Period
- Performance Year 2019, $ 9,982,459.69

Second Agreement Period
- Performance Year 2018, $6,705,312
- Performance Year 2017, $0
- Performance Year 2016, $0

First Agreement Period
- Performance Year 2015, $2,981,335
- Performance Year 2014, $0
- Performance Year 2013, $0

Our ACO participated in multiple performance years during Calendar Year 2019. Distribution of shared savings reported for Performance Year 2019 therefore represents the distribution of the net shared savings across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.

Shared Savings Distribution

Third Agreement Period
- Performance Year 2019
  - Proportion invested in infrastructure: 80%
  - Proportion invested in redesigned care processes/resources: 20%
  - Proportion of distribution to ACO participants: N/A

Second Agreement Period
- Performance Year 2018
  - Proportion invested in infrastructure: 80%
  - Proportion invested in redesigned care processes/resources: 20%
  - Proportion of distribution to ACO participants: 0
- Performance Year 2017
  - Proportion invested in infrastructure: N/A
  - Proportion invested in redesigned care processes/resources: N/A
  - Proportion of distribution to ACO participants: N/A
- Performance Year 2016
  - Proportion invested in infrastructure: N/A
  - Proportion invested in redesigned care processes/resources: N/A
  - Proportion of distribution to ACO participants: N/A

First Agreement Period
- Performance Year 2015
  - Proportion invested in infrastructure: 20%
  - Proportion invested in redesigned care processes/resources: 20%
  - Proportion of distribution to ACO participants: 60%
- Performance Year 2014
  - Proportion invested in infrastructure: N/A
  - Proportion invested in redesigned care processes/resources: N/A
  - Proportion of distribution to ACO participants: N/A
- Performance Year 2013
  - Proportion invested in infrastructure: N/A
  - Proportion invested in redesigned care processes/resources: N/A
  - Proportion of distribution to ACO participants: N/A

Quality Performance Results

2019 Quality Performance Results:

ACO#	Measure Name	Rate	ACO Mean
ACO-1	CAHPS: Getting Timely Care, Appointments, and Information	80.46	85.86
ACO-2	CAHPS: How Well Your Providers Communicate	91.62	94.11
ACO-3	CAHPS: Patients’ Rating of Provider	89.48	92.69
ACO-4	CAHPS: Access to Specialists	76.89	81.54
ACO-5	CAHPS: Health Promotion and Education	58.23	60.44
ACO-6	CAHPS: Shared Decision Making	61.35	62.78
ACO-8	Risk Standardized, All Condition Readmission	14.01	14.86
ACO-7	CAHPS: Health Status/Functional Status	71.66	73.79
ACO-13	Falls: Screening for Future Fall Risk	90.10	84.04
ACO-34	CAHPS: Stewardship of Patient Resources	21.43	26.17
ACO-45	CAHPS: Courteous and Helpful Office Staff	93.77	92.84
ACO-46	CAHPS: Care Coordination	84.21	86.89
ACO-14	Preventive Care and Screening: Influenza Immunization	72.54	74.77
ACO-17	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	81.25	78.04
ACO-18	Preventive Care and Screening: Screening for Depression and Follow-up Plan	57.66	70.40
ACO-19	Colorectal Cancer Screening	77.23	70.76
ACO-20	Breast Cancer Screening	77.06	73.84
ACO-42	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	91.48	82.17
ACO-27	Diabetes: Hemoglobin A1c Poor Control (>9%)	12.48	13.88
ACO-28	Controlling High Blood Pressure	78.68	75.04
ACO-38	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions	50.03	58.15
ACO-43	Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91))	1.07	1.87

Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size. In addition, the Centers for Medicare & Medicaid Services (CMS) waived the requirement for ACOs to field a CAHPS for ACOs survey data.

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.