American Family Children's Hospital

UW Health ACO Governance

ACO Name and Location


UW Health ACO

University Crossing Building

749 University Row, Suite 251

Madison, WI 53705


ACO Primary Contact


Jonathan Jaffery, MD

President and CEO, UW Health ACO


Phone:  (608) 821-4998


Organizational Information


ACO participants:

ACO participants in joint ventures between ACO professionals and hospitals:


No participants are involved in a joint venture between ACO professionals and hospitals.


ACO governing body:

  • Matthew Anderson, MD. Voting Member and Chair. Senior Medical Director, Ambulatory Operations, UW Health
  • Sarah Davis, JD. Voting Member and Consumer Advocate. Associate Director, Center for Patient Partnerships
  • Jennifer Edgoose, MD. Voting Member. Associate Professor, University of Wisconsin School of Medicine and Public Health
  • R. Allan Jhagroo, MD. Voting Member. Director, Wisconsin Dialysis
  • Michael Sloan, MD. Voting Member. Senior Medical Director, Specialty Care, UW Health
  • Julianne Pofahl. Voting Member and Medicare Beneficiary

Key ACO clinical and administrative leadership:

  • ACO Executive: Jonathan Jaffery, MD
  • Medical Director: Jeff Huebner, MD
  • Compliance Official: Troy Lepien
  • Quality Assurance/Improvement Officer: Jeff Huebner, MD

Associated committees and committee leadership:

  • Population Health and Quality Committee: Chair TBD
  • Finance Committee: Chair TBD
  • Network Development Committee: Chair TBD
  • Data and Analytics Committee: Chair TBD
  • Compliance and Legal Committee: Chair TBD

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

  • ACO professionals in a group practice arrangement
  • Hospital employing ACO professionals

Shared Savings and Losses


Amount of Shared Savings/Losses

  • Agreement Period beginning 2013, Performance Year 1: $0
  • Agreement Period beginning 2013, Performance Year 2014: $0
  • Agreement Period beginning 2013, Performance Year 2015: $0

Payment Rule Waivers


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


Shared Savings Distribution

  • Agreement Period beginning 2013, Performance Year 1: $0
  • Agreement Period beginning 2013, Performance Year 2014: $0
  • Agreement Period beginning 2013, Performance Year 2015: $0

Quality Performance Results


2015 Quality Performance Results Table



Measure number

Measure Name

2015 reporting period


performance rate

Mean performance rate


ACO-1 CAHPS: Getting Timely Care, Appointments, and Information 85.97 80.61
ACO-2 CAHPS: How Well Your Providers Communicate 91.80 92.65
ACO-3 CAHPS: Patients' Rating of Provider 91.63 91.94
ACO-4 CAHPS: Access to Specialists 82.88 83.61
ACO-5 CAHPS: Health Promotion and Education 58.29 59.06
ACO-6 CAHPS: Shared Decision Making 74.76 75.17
ACO-7 CAHPS: Health Status/Functional Status 73.81 72.30
ACO-34 CAHPS: Stewardship of Patient Resources* 22.76 26.87
ACO-8 Risk Standardized, All Condition Readmission 14.35 14.86
ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)* Readmission 18.03 18.07
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes* 43.38 54.60
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure* 66.21 76.96
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 55.10 62.92
ACO-9 Ambulatory Sensitive Condition Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) 0.60 1.11
ACO-10 Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8) 0.84 1.04
ACO-11 Percent of Primary Care Physicians who Successfully Meet Meaningful Use Requirements 100.00 76.22
ACO-39 Documentation of Current Medications in the Medical Record* 94.63 84.07
ACO-13 Falls: Screening for Future Fall Risk 73.83 56.46
ACO-14 Preventive Care and Screening: Influenza Immunization 90.36 62.03
ACO-15 Pneumonia Vaccination Status for Older Adults 94.38 63.73
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up 62.20 71.15
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 98.01 90.16
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan 52.10 45.25
ACO-19 Colorectal Cancer Screening 81.91 60.06
ACO-20 Breast Cancer Screening 82.27 65.67
ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up 70.03 70.04
ACO-40 Depression Remission at Twelve Months* N/A N/A
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 7.01 20.38
ACO-41 Diabetes: Eye Exam* 64.58 41.05
ACO-28 Hypertension: Controlling High Blood Pressure 79.72 69.62
ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 93.73 83.82
ACO-31 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 93.10 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%) 88.42 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


More information on how to interpret scores on the above quality performance measures


2012-2014 Quality Performance Results


UW Health ACO Compliance Reporting


Please submit concerns to:


Troy Lepien, Compliance Officer, UW Health ACO, Inc.

749 University Row, Suite 251

Madison, WI 53705


Anonymous UW Health ACO Reporting Hotline (8am–5pm Central, Monday-Friday)

  • (608) 821-4130 (local)
  • (888) 225-8282 (toll free)