St. Luke's Health Texas Health Network for Healthcare Professionals

Baylor St. Luke's Health Network ACO

Shared Savings Program The Centers for Medicare & Medicaid Services (CMS) has established a Medicare Shared Savings Program (Shared Savings Program) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by: Promoting accountability for the care of Medicare FFS beneficiaries Requiring coordinated care for all services provided under Medicare FFS Encouraging investment in infrastructure and redesigned care processes The Shared Savings Program will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary.

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ACO Public Reporting Information

ACO Name and Location

CHI St. Luke's Health Network, LLC
6624 Fannin, Suite 1100, Houston, TX 77030

ACO Primary Contact

Megan Harkey
512-433-9051
Megan.Harkey@CommonSpirit.org

Organizational Information

ACO participants:

ACO Participants	ACO Participant in Joint Venture (Enter Y or N)
Adnan Afzal, Md, PA	N
Karan S Bhalla MD PLLC	N
Pasadena Surgical Association	N
TAYLOR FAMILY PRACTICE, PA	N
Baylor College of Medicine	N
William Burns	N
Yai-Yun Cheng, MD	N
EXCELLENCE CARE CLINIC MD PA	N
Medical Clinic of Bellaire, PA.	N
LeCure Family Practice PA	N
Angiocardiac Care of Texas P.A.	N
SOUTHWEST FAMILY CLINIC PC	N
Lockhart Medical Services PA	N
Houston Southwest Colon & Rectal Clinic PLLC	N
Houston Neurocare PA	N
VU DOAN THERIOT, MD PA	N
Comprehensive Cardiovascular Care of the Woodlands, PA	N
Sim Family Clinic, P.A.	N
TEXAS AVENUE MEDICAL CLINIC	N
SUNRISE FAMILY CLINIC PA	N
The Center For Family Medicine Wellness & Aesthetics Pa	N
Fred Bakht Md Pa	N
Baylor St Lukes Medical Group	N
J & S MEDICAL SERVICES LLC	N
Inpatient Infectious Disease Consultants	N
Cyfair Headache and Neurological Clinic	N
Conrado J Ordonez MD PA	N
NIHAL U SIDDIQUI MD PA	N
Pulmonary Critical Care And Sleep Medicine Consultants, Llp	N
The Schrader Clinic, PA	N
SF Hartley DPMPC	N
RAMAKRISHNA V CHAVA MD PA	N

ACO governing body:

Member			Member's Voting Power – Expressed as a percentage or number	Membership Type-	ACO Participant Legal Business Name/DBA, if Applicable
Last Name	First Name	Title/Position		Membership Type-	ACO Participant Legal Business Name/DBA, if Applicable
Bigler	Peter	Physician	14.3% vote	ACO Participant	Baylor St. Luke's Medical Group
Lembcke	Bradley	CMO	14.3% vote	ACO Participant	Baylor St. Luke's Medical Group
McDeavitt	James	Chair	14.3% vote	ACO Participant	Baylor College of Medicine
Markos	Ferenc	Physician	14.3% vote	ACO Participant	Baylor College of Medicine
Zoorob	Roger	Physician	14.3% vote	ACO Participant	Baylor College of Medicine
Roper	Margaret	Voting Member	14.3% vote	ACO Participant	Baylor College of Medicine
Spatz	Edward	Medicare Beneficiary	14.3% vote	Community Stakeholder	n/a

Key ACO Clinical and Administrative Leadership:

ACO Executive: Megan Harkey
Medical Director: James McDeavitt, MD
Compliance Officer: Christi Knox
Quality Assurance/Improvement Officer: Tracy Maddox

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
N/A

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
Networks of individual practices of ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses:

Second Agreement Period
- Performance Year 2021, $5,997,624
- Performance Year 2020, $8,512,151
- Performance Year 2019, $4,996,168
- Performance Year 2018, $0
First Agreement Period
- Performance Year 2017, $0
- Performance Year 2016, $0
- Performance Year 2015, $0

Shared Savings Distribution

Second Agreement Period
- Performance Year 2021
  - Proportion invested in infrastructure: 33.98%
  - Proportion invested in redesigned care processes/resources: 33.01%
  - Proportion of distribution to ACO participants: 33.01%
- Performance Year 2020
  - Proportion invested in infrastructure: 36.02%
  - Proportion invested in redesigned care processes/resources: 26.13%
  - Proportion of distribution to ACO participants: 37.85%
- Performance Year 2019
  - Proportion invested in infrastructure: 56.66%
  - Proportion invested in redesigned care processes/resources: 0.00%
  - Proportion of distribution to ACO participants: 43.34%
- Performance Year 2018
  - 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 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

2021 Quality Performance Results:

Measure #	Measure Name	Rate	ACO Mean
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control²	11.04	12.46
236	Controlling High Blood Pressure	78.96	74.87
318	Falls: Screening for Future Fall Risk	96.25	87.03
110	Preventative Care and Screening: Influenza Immunization	72.53	80.52
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	86.49	80.97
113	Colorectal Cancer Screening	71.85	73.63
112	Breast Cancer Screening	70.99	75.11
321	CAHPS for MIPS3	N/A	N/A
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups²	0.1610	0.1540
MCC1	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)²	31.00	33.99
CAHPS-1	Getting Timely Care, Appointments, and Information	81.10	84.67
CAHPS-2	How Well Providers Communicate	93.83	93.56
CAHPS-3	Patient’s Rating of Provider	92.23	92.19
CAHPS-5	Health Promotion and Education	62.73	61.61
CAHPS-6	Shared Decision Making	55.24	60.89
CAHPS-8	Care Coordination	86.75	85.66
CAHPS-9	Courteous and Helpful Office Staff	93.12	91.88
CAHPS-11	Stewardship of Patient Resources	28.14	24.71

For Previous Years’ Financial and Quality Performance Results, 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.

Fraud and Abuse Waivers

ACO Pre-Participation Waiver:

ACO Public Reporting