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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

Adnan Afzal, Md, PA

N

Angiocardiac Care of Texas P.A

N

Baylor College of Medicine

N

Baylor St Luke’s Medical Group

N

Comprehensive Cardiovascular Care of the Woodlands, PA

N

Conrado J. Ordonez MDPA

N

Cyfair Headache and Neurological Clinic

N

DIABETES PLUS CLINIC PLLC

N

EXCELLENCE CARE CLINIC MD PA

N

Fred Bakht Md Pa

N

GUARDIAN FAMILY MEDICINCE PLLC

N

HARSHIDABEN CHAUDHARI

N

Houston Southwest Colon & Rectal Clinic PLLC

N

Houston Neurocare PA

N

Inpatient Infectious Disease Consultants

N

J & S MEDICAL SERVICES LLC

N

Karan S. Bhalla MDPLLC

N

LeCure Family Practice PA

N

Medical Clinic of Bellaire, PA

N

NIHAL U SIDDIQUI MD PA

N

Pasadena Surgical Association

N

Sim Family Clinic, P.A.

N

SOUTHWEST FAMILY CLINIC PC

N

SUNRISE FAMILY CLINIC PA

N

TEXAS AVENUE MEDICAL CLINIC

N

The Center For Family Medicine Wellness & Aesthetics Pa

N

VU DOAN THERIOT, MD PA

N

WILLIAM E BURNS JR M D PLLC

N

William Burns

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

Bigler

Peter

Physician

1 vote

ACO Participant

Baylor St. Luke's Medical Group

Markos

Ferenc

Physician

1 vote

ACO Participant

Baylor College of Medicine

Patel

Mitesh

Physician

1 vote

ACO Participant

Baylor St. Luke's Medical Group

Zoorob

Roger

Physician

1 vote

ACO Participant

Baylor College of Medicine

Spatz

Edward

Medicare Beneficiary

1 vote

Community Stakeholder

n/a

Key ACO Clinical and Administrative Leadership:

ACO Executive: Megan Harkey
Medical Director: Bradley Lembcke, MD
Compliance Officer: David Walsh
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 2022, $0
    • 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 2022
      • N/A
    • 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

2022 Quality Performance Results:

Measure #

Measure Name

Rate

ACO Mean

001

Diabetes: Hemoglobin A1c (HbA1c) Poor Control²

8.24

10.71

134

Preventative Care and Screening: Screening for Depression and Follow-up Plan

87.37

76.97

236

Controlling High Blood Pressure

80.33

76.16

318

Falls: Screening for Future Fall Risk

95.05

87.83

110

Preventative Care and Screening: Influenza Immunization

73.53

77.34

226

Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

92.00

79.27

113

Colorectal Cancer Screening

85.32

75.32

112

Breast Cancer Screening

73.59

78.07

321

CAHPS for MIPS3

N/A

N/A

479

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups²

0.1570

0.1510

MCC1

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)²

30.55

30.97

CAHPS-1

Getting Timely Care, Appointments, and Information

80.79

83.96

CAHPS-2

How Well Providers Communicate

94.17

93.47

CAHPS-3

Patient’s Rating of Provider

93.08

92.06

CAHPS-5

Health Promotion and Education

71.34

62.68

CAHPS-6

Shared Decision Making

64.39

60.97

CAHPS-8

Care Coordination

87.71

85.46

CAHPS-9

Courteous and Helpful Office Staff

91.32

91.97

CAHPS-11

Stewardship of Patient Resources

27.03

25.62

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:
    • NA


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    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.