ACO Name and Location

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

ACO Primary Contact

Primary Contact Name

James McDeavitt, Chief Physician Executive, CHI St. Luke's Health Network, LLC

Primary Contact Phone Number

(713) 798-4495

Primary Contact Email Address

James.McDeavitt@bcm.edu

Organizational Information

ACO participants:

ACO Participants

ACO Participant in Joint Venture (Enter Y or N)

CenterforPulmonaryandSleepDisorders

N

Lazaro Cherem MD

N

Bernardino Flores Abaya

N

Dr Kaushal K Gupta Md Pa

N

L. Ehrlich & Associates Medical Clinic, P.L.L.C.

N

Kevin M. Moran, MD

N

Carlos Araujo Preza

N

Abraham G. Thomas, M.D., P.A.

N

Allergy And Asthma Care Center Pa

N

Endocrine And Psychiatry Center Epc Llc

N

NorthsideGastroenterologyAssociates

N

FairfieldFamilyPhysicians

N

Geetha Subramanyam

N

Timothy J. Sehorn, MD, PA

N

DavidHKorfinDPMPA

N

RamakrishnaVChavaMDPA

N

Pulmonary Critical Care And SlepMedicine Consultants, Llp

N

Medical Clinic of Bellaire

N

Brain&SpineClinic

N

Josier M. Nisnisan Md, Pllc

N

MedicalCenterAssociatesofHoustonLLP

N

Claire H Chang Md Pa

N

BrianHKaplanMDPA

N

IKPFamilyMedicinePA

N

Northwest Colon & Rectal Surgery, P.A.

N

NorthwestHoustonHeartCenter

N

Texas Family Medicine Center, PA

N

The Center For Family Medicine Wellness & Aesthetics Pa

N

Adnan Afzal, Md, Pa

N

LockhartMedicalServicesPA

N

Neurology and SlepSpecialists, P.A.

N

HoustonMetroUrologyPA

N

Elizabeth Yang Md Pa

N

Amer Zaheer MD Pa

N

CyFairHeartAndVascularCenter

N

NamietaMJanssenMDPLLC

N

The Woodlands Retina Center

N

St Lukes Community Development Corporation - Sugar Land

N

AzitaMadjidiMDMSPA

N

Center For Spine, Sports And Rehabilitation Excellence Pa

N

Anita Fulton

N

Vicki Carr Md Pa

N

St. Luke'S Community Development Corporation-The Vintage

N

Houston Thyroid And Endocrine Specialists

N

Naureen Alim, MD, PLLC

N

Woodlands Heart And Vascular Institute Pa

N

PCP For Life PA

N

InpatientInfectiousDiseaseConsultants

N

Kidney Specialists Of North Houston

N

Pmc Hospital, Llc

N

AllergyRheumatologySpecialistsofHouston

N

MagedAmineMDPA

N

Baylor College of Medicine

N

Comprehensive Cardiovascular Care of the Woodlands PA

N

NorthwestGastroenterologyAssociates

N

MichaelJStreitmannMDPA

N

David Netscher

N

James Wallace

N

The Schrader Clinic

N

Kwok Li MD PA

N

Satyadevi Sista

N

LeCureFamilyPracticePA

N

Kaushal Gupta

N

Judith Feigon

N

Richard Roby Md Pa

N

Fred Bakht Md Pa

N

SpringCreekUrologySpecialistsLLC

N

KaranSBhallaMDPLLC

N

PristineObGynCarePLLC

N

OrthopedicSurgeonPLLC

N

Center For Spine Sports And Physical Medicine P.A.

N

Yaiyun Cheng

N

WilsonHandSurgeryPLLC

N

Randolph Evans

N

Houston Southwest Colon and Rectal Clinic, PLLC

N

John Berry

N

Saba Asad Ansari M.D.

N

Kevin Dixon Do Pa

N

Anderson Eye, Pllc

N

MichelleCunninghamMD

N

David Netscher

N

CyfairHeadacheandNeurologicalClinic

N

Geetha Subramanyam

N

Adnan Yousef, MD

N

James Westmoreland M.D. PA

N

Chi St. Luke's Health Baylor College Of Medicine Medical Center

N

Bone & Joint Clinic of Houston

N

NigroDermatologyGroupPA

N

AndresHKeichianMD

N

James Wallace

N

IrvingJFishmanMDPA

N

FLyoneHochmanMDFRCPC PA

N

Sim Family Clinic, P.A.

N

VincentVirgadamoMDPA

N

ParulRShahDOPA

N

Cesar A. Andino, M.D. P.A.

N

PadmaRKumashiMDPA

N

Sean M Moran Md Pa

N

Michael Arnold, M.D., P.A.

N

Memorial Multispecialty Associates

N

Michael Hunt Huber Md Pa

N

Thang Hoang, MD PA

N

Aphado Eye Care Llp

N

Allen Chu Md Pa

N

FayazAFaizMDPA

N

Randolph Evans

N

SFHartleyDPMPC

N

Angiocardiac Care of Texas

N

MHRadiationOncologyAssociated

N

EyeExcellence

N

GreenspointMedicalCenter

N

Brian C Douglas Md Pa

N

Texas Gastro Consultants Pa

N

M Sandra Scurria, MD

N

Marc N Stock

N

Stuart M. Weil, M.D., P.A.

N

Renal Specialists Of Houston, Pa

N

Infectious Diseases Associates Of Houston, Pa

N

AnhVanNguyenMDPA

N

Baylor St Lukes Medical Group

N

FernandoUrrutiaMD

N

PasadenaSurgicalAssociation

N

MedinetFamilyCareClinicPA

N

John C Sparks MD PA

N

Judith T Feigon Md Pa

N

Clinic For Cardiovascular Care

N

John Berry MD

N

St. Luke's Community Health Services

N

Pinky S Tiwari MD PA

N

HoustonNeurocarePA

N

Chernosky Dermatological Associates

N

KidneyAssociatesPLLC

N

Endocrine Associates

N

PlasticSurgerySpecialistsPA

N

ConradoJOrdonezMDPA

N

PulmonaryMedicalConsultantsPA

N

WeberMosesHungPowitzkyLLP

N

Raka C Gohel Md

N

DavidTLeMD

N

YaiYunChengMD

N

Gulf Coast Pathology Associates Pa

N

Asif Cochinwala MD

N

AtaAhmadMDPA

N

ShabbirHusainJamaliMDPA

N

KidneyCenterofNorthHouston

N

John M Fackler MD PA

N

Womens OBGYN Center PA

N

Harry Sokolow M.D. P.A.

N

LiverAssociatesofTexasPA

N

DigestiveAssociatesofHoustonPA

N

Transplantation And General Surgery

N

Saba Ansari

N

Carroll Clinic

N

HoustonInternalMedicineAssociatesPA

N

Renal Care Clinic PA

N

Alden Health Center PLLC

N

JunaidAKhan MD PA

N

Texas Inpatient Consultants,Lllp

N

Tamar Brionez Md Pa

N

ACO governing body:

Member

Member's Voting Power

MembersipType

ACO Participant TIN Legal Business Name/DBA, if Applicable

Last Name

First Name

Title/Position

McDeavitt

James

Executive & Chair

1 vote

ACO Participant Representative

Baylor College of Medicine

Steinbauer

Jeffrey

Chief Medical Officer

1 vote

ACO Participant Representative

Baylor College of Medicine

Glenn

David

Medical Director, Memorial

1 vote

Medical Director

n/a

Rosengart

Todd

Physician

1 vote

ACO Participant Representative

Baylor College of Medicine

Zoorob

Roger

Physician

1 vote

ACO Participant Representative

Baylor College of Medicine

Ehrlich

Lisa

Physician

1 vote

ACO Participant Representative

Baylor St. Luke's Medical Group

Sherwood

Ann

Medicare Beneficiary

1 vote

Community Stakeholder

n/a

Key ACO clinical and administrative leadership:

James McDeavitt

ACO Executive

Jeffrey Steinbauer

Medical Director

Cecilia Bishop

Compliance Officer

Tracy Maddox

Quality Assurance/Improvement Officer

Associated committees and committee leadership:

Committee Name Committee Leader Name and Position

COMPLIANCE AND PERFORMANCE IMPROVEMENT

Jeffrey Steinbauer Committee Chair & Division Chief Medical Officer

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

  • Networks of individual practices of ACO professionals
  • Partnerships or joint venture arrangements between hospitals and ACO professionals
  • Hospital employing ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

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

Shared Savings Distribution

  • First Agreement Period
    • 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

2016 Quality Performance Results:

ACO#

Measure Name

Rate

ACO Mean

ACO-1

CAHPS: Getting Timely Care, Appointments, and Information

79.5

79.9

ACO-2

CAHPS: How Well Your Providers Communicate

93.01

92.63

ACO-3

CAHPS: Patients' Rating of Provider

91.69

91.93

ACO-4

CAHPS: Access to Specialists

79.32

83.52

ACO-5

CAHPS: Health Promotion and Education

59.61

60

ACO-6

CAHPS: Shared Decision Making

72.25

75.28

ACO-7

CAHPS: Health Status/Functional Status

70.23

71.82

ACO-34

CAHPS: Stewardsipof Patient Resources

37.7

27.52

ACO-8

Risk-Standardized, All Condition Readmission

14.92

14.7

ACO-35

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

20.43

18.17

ACO-36

All-Cause Unplanned Admissions for Patients with Diabetes

58.75

53.2

ACO-37

All-Cause Unplanned Admissions for Patients with Heart Failure

82.76

75.23

ACO-38

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

64.02

59.81

ACO-9

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

12.15

9.27

ACO-10

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

15.11

14.53

ACO-11

Percent of PCPs who Successfully Meet Meaningful Use Requirements

84.29

82.72

ACO-39

Documentation of Current Medications in the Medical Record

96.28

87.54

ACO-13

Falls: Screening for Future Fall Risk

47.66

64.04

ACO-14

Preventive Care and Screening: Influenza Immunization

64.98

68.32

ACO-15

Pneumonia Vaccination Status for Older Adults

63.6

69.21

ACO-16

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

76.58

74.45

ACO-17

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

97.61

90.98

ACO-18

Preventive Care and Screening: Screening for Clinical Depression and FollowupPlan

36.81

53.63

ACO-19

Colorectal Cancer Screening

51.95

61.52

ACO-20

Breast Cancer Screening

59.36

67.61

ACO-21

Preventive Care and Screening: Screening for High Blood Pressure and FollowupDocumented

80.55

76.84

ACO-42

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

78.57

77.72

ACO-27

Diabetes Mellitus: Hemoglobin A1c Poor Control

27.5

18.24

ACO-41

Diabetes: Eye Exam  

31.79

44.94

ACO-28

Hypertension (HTN): Controlling High Blood Pressure

67.95

70.52

ACO-30

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

84.34

85.05

ACO-31

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

88.19

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%)

70.2

79.67

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

  • For 2016 Quality Performance Results please visit: <ahref="https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care-O/3jk5-q6dr/data">https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care-O/3jk5-q6dr/data
  • For 2015 Quality Performance Results please visit: <ahref="https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu">https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu

Note: In the Quality Performance Results file(s) above, search for “CHI St. Luke's Health Network, LLC” or "Baylor St. Luke's Health Network ACO"to view the quality performance results. This ACO can also be found by using the ACO ID A44499 in the public use files on data.cms.gov.

Payment Rule Waivers

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