Medicare Shared Savings ACO

For Providers

What is an ACO?

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program. Click here for more information.

Medicare Annual Wellness Visits


The Annual Wellness Visits booklet gives providers an overview of all components of Medicare Wellness Visit. This Preventive Services Chart is a guide to all covered Medicare preventive services.

Care Management Programs

The ACO Care Management Team provides Transitional Care Management and Chronic Care Management for eligible Medicare beneficiaries. Learn more about these programs for recently discharged beneficiaries and those beneficiaries with multiple chronic diseases below.

Quality Reporting for the Provider MACRA Merit-Based Incentive Program

This 5-minute video gives you, the Provider, an introduction to the Merit-based Incentive Program known as the Quality Payment Program for understanding how your quality scores are derived.

2017 & 2018 Results

For Policymakers


On Jan. 1, 2015, Cape Fear Valley Health became one of 405 Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. These ACOs provide nearly 9 million Medicare beneficiaries with access to high-quality, coordinated care throughout the United States.

ACOs are groups of doctors, hospitals, and other healthcare providers that work together to give Medicare beneficiaries in Original Medicare (fee-for-service) high quality, coordinated care. ACOs can share in any savings they generate for Medicare, if they meet specified quality targets. Beneficiaries seeing healthcare providers in ACOs always have the freedom to choose doctors inside or outside of the ACO.

For general questions or additional information about Accountable Care Organizations, please visit www.medicare.gov/acos.html or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

ACO Name and Location

Cape Fear Valley Accountable Care Organization, LLC
Previous Names: N/A
1638 Owen Dr
Fayetteville, NC 28304

ACO Primary Contact

Primary Contact Name Joseph Fiser
Primary Contact Phone Number (910) 615-5572
Primary Contact Email Address jfiser@capefearvalley.com

Organizational Information

ACO Participants:

ACO Participants ACO Participant in Joint Venture (Enter Y or N)
CFVHS ED Physicians N
Regional Diabetes And Endocrine Center N
CFV Express Care Billing Services, LLC N
CFV Specialty Care Billing Services, LLC N
Cape Fear Valley Health System Specialty Group, LLC N
Angier Medical Services, LLC N
Hoke Healthcare, LLC N
Lillington Medical Services, LLC N
Dunn Medical Services, LLC N
Harnett OBGYN LLC N
Coats Medical Services, LLC N
SRRC Psychology N
HARNETT HEALTH SYSTEM INC N
Cumberland County Hospital System, Inc. N
Behavioral Health Care of Cape Fear Valley Health System N
Heritage Family Physicians N
Cape Fear Neurosurgery N
Valley Infectious Disease Care N
Bladen Healthcare, LLC N


ACO Governing Body:

Members Member's Voting Power Membership Type ACO Participant TIN Legal Business Name/DBA, if Applicable
Last Name First Name Title/Position
Nagowski Michael Chairperson 1 ACO Participant Representative Cumberland County Hospital System, Inc.
Wells Roxie Voting Member 1 ACO Participant Representative Hoke Healthcare, LLC; Bladen Healthcare, LLC
Vann Shirley Voting Member 1 Medicare Beneficiary Representative N/A
Williams Sandra Voting Member 1 ACO Participant Representative Cumberland County Hospital System, Inc.
Zappa Michael Voting Member 1 ACO Participant Representative Cumberland County Hospital System, Inc.
Fleishman Sam Voting Member 1 ACO Participant Representative Cumberland County Hospital System, Inc.
Lang Jessica Voting Member 1 ACO Participant Representative Harnett Health System, Inc.


Key ACO Clinical and Administrative Leadership:

Joseph Fiser ACO Executive
Samuel Fleishman, MD Medical Director
Tricia Urquhart-Jones Compliance Officer
Michelle Taylor Quality Assurance/Improvement Officer


Associated Committees and Committee Leadership:

Committee Name Committee Leader Name and Position
Clinical Advisory Committee Sam Fleishman, MD – Chief Medical Officer
Primary Care Quality and Improvement Committee Michelle Taylor - Quality Assurance and Improvement Officer


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

  • Hospital employing ACO professionals
  • Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings/Losses

Amount of Shared Savings/Losses

  • First Agreement Period
    • Performance Year 2017, $0
    • Performance Year 2016, $0
    • Performance Year 2015, $0

Shared Savings Distribution

  • First Agreement Period
    • 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
    • Performance Year 2015
      • 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

2017 Quality Performance Results:

ACO# Measure Name Rate ACO Mean
ACO-1 CAHPS: Getting Timely Care, Appointments, and Information 78.65 80.60
ACO-2 CAHPS: How Well Your Providers Communicate 91.73 93.13
ACO-3 CAHPS: Patients' Rating of Provider 91.46 92.31
ACO-4 CAHPS: Access to Specialists 81.77 83.32
ACO-5 CAHPS: Health Promotion and Education 64.03 62.30
ACO-6 CAHPS: Shared Decision Making 72.97 75.85
ACO-7 CAHPS: Health Status/Functional Status 69.53 73.05
ACO-34 CAHPS: Stewardship of Patient Resources 25.45 25.68
ACO-8 Risk-Standardized, All Condition Readmission 15.11 15.01
ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) 18.79 18.46
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure 92.04 79.16
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 74.02 61.74
ACO-43 Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91)) 2.82 1.93
ACO-11 Use of Certified EHR Technology 100.00 98.48
ACO-12 Medication Reconciliation 96.34 75.32
ACO-13 Falls: Screening for Future Fall Risk 94.84 74.38
ACO-44 Imaging Studies for Low Back Pain 72.22 67.32
ACO-14 Preventive Care and Screening: Influenza Immunization 66.67 72.52
ACO-15 Pneumonia Vaccination Status for Older Adults 63.53 72.92
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up 83.00 70.69
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 96.43 90.48
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan 92.68 61.98
ACO-19 Colorectal Cancer Screening 57.26 64.58
ACO-20 Breast Cancer Screening 63.71 70.05
ACO-42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 78.63 79.89
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 15.44 16.74
ACO-41 Diabetes: Eye Exam 26.32 50.37
ACO-28 Hypertension (HTN): Controlling High Blood Pressure 64.23 71.47
ACO-30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 91.73 86.86


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

Note: In the Quality Performance Results file(s) above, search for “Cape Fear Valley Accountable Care Organization, LLC” or "Valley Connected Care" to view the quality performance results. This ACO can also be found by using the ACO ID A47392 in the public use files on data.cms.gov.

Payment Rule Waivers

No, our ACO does not use the SNF 3-Day Rule Waiver.

For Medicare Beneficiaries

Medicare.gov Guides Preventive Services

Preventive & Screening Services
Beneficiary Notice

Voluntary Beneficiary Assignment

Empowering Patients to Make Decisions About Their Healthcare: Register for MyMedicare.gov and Select Your Primary Clinician.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/vol-alignment-bene-fact-sheet.pdf