Coordinated Care

Welcome to Houston Methodist Coordinated Care (HMCC), an Accountable Care Organization

Shared Savings Program ACO Public Reporting Instructions

With Pre-Populated Template

Introduction

The purpose of this document is to provide ACOs participating in the Shared Savings Program with a public reporting template, pre-populated with ACO-specific information obtained from CMS records. Information to populate the template is obtained from ACO reported information submitted to the Health Plan Management System (HPMS). ACOs participating in the Shared Savings Program are required to publicly report ACO organizational information and performance results on a designated webpage.

Instructions

ACOs will receive a pre-populated template from CMS near the start of every performance year and shortly after performance year quality and financial reconciliation concludes. ACOs that completed the previous performance year must use the template to report that year’s final financial and quality results. All ACOs must use the template to report other organizational changes as needed. At both of these junctures, each ACO must take the following steps to meet the Shared Savings Program’s public reporting requirements (42 CFR 425.308):

  1. Verify the pre-populated information is correct. If any of the pre-populated information is incorrect, please notify CMS by emailing SharedSavingsProgram@cms.hhs.gov. In the Subject line of your email, please include the phrase “Public Reporting Template” and your ACO ID. CMS will review and correct the template, as necessary, and re-issue it to the ACO. If you find an error with your organizational information, please correct it in HPMS.
  1. Provide the remaining information in the (unpopulated) highlighted fields in the template and remove the highlighting once completed.
  2. Report all information on your ACO’s public reporting webpage. ACOs can select one of two ways to report it. 1) Display all of the information from the completed template on the webpage using existing webpage styles (e.g., fonts, text sizes, headers). Or, 2) create a PDF of the completed template, without modifying the format, and link to it from your public reporting webpage:
    • Remove all yellow highlighting and these instructions before displaying template content on the webpage.
    • Do not add data that isn’t required or omit data from the template.
  3. Update information on your ACO’s public reporting webpage by the stated deadline. The deadline for reporting performance year 2016 quality and financial results and any new organizational information is Friday, December 1, 2017. Separately, if there are any changes to your ACO’s organizational information throughout the year that you are required to publicly report, ACOs must update your public reporting webpage within 30 days of the change. Please make corresponding updates in HPMS because HPMS is CMS’ source for data that is made publicly available.

Your ACO’s pre-populated template is included in the subsequent pages of this document.

Definitions and Notes

Finally, for ease of reference, the terms below in the public reporting template are defined as the following:

  • ACO Participant in Joint Venture: a joint venture is when two or more persons or entities engage in a defined project in which all of the following exists: 1) an express agreement; 2) a common purpose that the parties intend to carry out; 3) shared profits and losses related to the project; and 4) each party has a voice in controlling the project.
  • ACO Governing Body Member Voting Power: governing body member voting power refers to the number of votes the member has, expressed as a percentage or number.
  • ACO Governing Body Membership Type: membership types include ACO participant representative, Medicare beneficiary representative, community stakeholder representative, or other.

 

For your ACO participants listed in the Organizational Information section, CMS populated your ACO participants’ legal business name. If the ACO participant has a doing business as (D/B/A) name and you would prefer to include it, enter it in parentheses next to the ACO participant’s legal business name in the ACO participants table.

 

ACO Name and Location

Houston Methodist Coordinated Care
6565 Fannin Street
Suite D200
Houston, Texas 77030

ACO Primary Contact

Primary Contact Name

Dr. Julia D. Andrieni

Primary Contact Phone Number

713.441.7638

Primary Contact Email Address

jdandrieni@houstonmethodist.org

Organizational Information

ACO participants:

ACO Participants

ACO Participant in Joint Venture (Enter Y or N)

Amir Salim MD PA

N

Clear Creek Clinic, P.A.

N

Cypress Physicians Association

N

Family Health Consultants PA

N

Fort Bend Primary Care, P.A.

N

Hanh Truong MD PA

N

Hema Patel MD, Pa

N

IKP Family Medicine PA

N

Jacinto Medical Group, P.A.

N

James J Bernick MD, Pa

N

Katy Internists

N

N. Christine Le MD PA

N

Northern Pines Health Partners PA

N

Parul R. Shah DO PA

N

Preventive Medicine Institute, PA

N

Priti Jadav

N

Rakesh Patel M.D. P. A.

N

Saba Asad Ansari P.A.

N

Saira Hirani

N

St. Michael Medical Clinic, PA

N

TMH Physician Associates, PLLC

N

 

ACO governing body:

Last Name

First Name

Title/Position

Board Member's Voting Power

Board Member Type

ACO Participant TIN Legal Business Name/DBA, if Applicable

Andrieni, MD

Julia

President & CEO, Houston Methodist Coordinated Care

Voting

President

 

Aquino, MD

Brian

 

Voting

ACO Participant

Clear Creek Clinic, PA

Bishop, MD

Rachel

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Burns, MD

Tiffany

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Dryden, MD

Natalie

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Irvine, MD

Timothy

 

Voting

ACO Participant

IKP Family Medicine

Jain, MD

Mahendra

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Papageorge, MD

Seva

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Patel, MD

Maya

 

Voting

ACO Participant

Preventive Medicine Institute

Nguyen, MD

TomThuan

 

Voting

ACO Participant

St. Michael Medical Clinic, PA

Robben, MD

Chris

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Terry, MD

Greg

 

Voting

ACO Participant

TMH Physician Associates, PLLC

Pardo, MD

Rafael

 

Voting

ACO Participant

Jacinto Medical Group, PA

Baucum

Carl

 

Voting

Medicare Beneficiary Representative

 

Finder, RN, MSN

Janice

 

Voting

Community Stakeholder Representative

 

Orth, RN, MBA

Heather

Voting

Community Stakeholder Representative

 

 

 

Key ACO clinical and administrative leadership:

Julia Andrieni, MD

President and CEO

Chris Robben, MD

Medical Director, Primary Care

Kathryn Agarwal, MD

Medical Director, Post-Acute Care

Michael Udwin, MD

Medical Director, Specialty Care

Robert Jackson, MD

Medical Director, Readmissions

Chetan Paydenkar

General Manager

Jeff Carr, MBA, MHA

Treasurer

Megan Harkey, MHA

Secretary

Catherine Meents

Compliance Officer

Chris Robben, MD

Quality Assurance/Improvement Officer

 

Associated committees and committee leadership:

Committee Name

Committee Leader Name and Position

Quality Improvement Committee

Dr. Chris Robben, Chair

Finance & Operations Committee

Jeff Carr, MBA, MHA, Chair

Physician Advisory Council

Dr. Mahendra Jain, Chair

 

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

  • ACO professionals in a group practice arrangement
  • Networks of individual practices of ACO professionals
  • Hospital employing ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

  • N/A

Shared Savings Distribution

  • N/A

Quality Performance Results

2016 Quality Performance Results:

ACO#

Measure Name

Rate

ACO Mean

ACO-1

CAHPS: Getting Timely Care, Appointments, and Information

N/A

80.51

ACO-2

CAHPS: How Well Your Providers Communicate

N/A

93.01

ACO-3

CAHPS: Patients' Rating of Provider

N/A

92.25

ACO-4

CAHPS: Access to Specialists

N/A

83.49

ACO-5

CAHPS: Health Promotion and Education

N/A

60.32

ACO-6

CAHPS: Shared Decision Making

N/A

75.40

ACO-7

CAHPS: Health Status/Functional Status

N/A

72.30

ACO-34

CAHPS: Stewardship of Patient Resources

N/A

26.97

ACO-8

Risk-Standardized, All Condition Readmission

N/A

14.70

ACO-35

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

N/A

18.17

ACO-36

All-Cause Unplanned Admissions for Patients with Diabetes

N/A

53.20

ACO-37

All-Cause Unplanned Admissions for Patients with Heart Failure

N/A

75.23

ACO-38

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

N/A

59.81

ACO-9

Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)

N/A

9.27

ACO-10

Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 )

N/A

14.53

ACO-11

Percent of PCPs who Successfully Meet Meaningful Use Requirements

N/A

82.72

ACO-39

Documentation of Current Medications in the Medical Record

N/A

87.54

ACO-13

Falls: Screening for Future Fall Risk

N/A

64.04

ACO-14

Preventive Care and Screening: Influenza Immunization

N/A

68.32

ACO-15

Pneumonia Vaccination Status for Older Adults

N/A

69.21

ACO-16

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up

N/A

74.45

ACO-17

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

N/A

90.98

ACO-18

Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan

N/A

53.63

ACO-19

Colorectal Cancer Screening

N/A

61.52

ACO-20

Breast Cancer Screening

N/A

67.61

ACO-21

Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented

N/A

76.79

ACO-42

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

N/A

77.72

ACO-27

Diabetes Mellitus: Hemoglobin A1c Poor Control

N/A

18.24

ACO-41

Diabetes: Eye Exam

N/A

44.94

ACO-28

Hypertension (HTN): Controlling High Blood Pressure

N/A

70.69

ACO-30

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

N/A

85.05

ACO-31

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

N/A

88.67

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%)

N/A

79.67

 

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

Payment Rule Waivers

  • Yes, our ACO does use the SNF 3-Day Rule Waiver.