NC ACO Public Reporting – MSSP
ACO Name and Location:
Carolinas HealthCare System ACO, LLC
Previous Names: N/A
1000 Blythe Blvd.
Charlotte, NC 28203
ACO Primary Contact:
Abbie Gruseth
605-610-5966
Abbie.Gruseth@AtriumHealth.org
| ACO Participants | ACO Participant in Joint Venture (Enter Y or N) |
|---|---|
| AHSNF, Inc. | N |
| Arboretum Urgent Care Center | N |
| Aswad Surgical Group, PC | N |
| Barnett Family Practice | N |
| Cabarrus Gastroenterology Associates PLLC | N |
| Cabarrus Pathology Associates, P.A. | N |
| Carmel Family Physicians | N |
| Carolina Bone & Joint, P.A. | N |
| Carolinas Ambulatory Surgery, Inc. | N |
| Carolinas Emergency Physicians, P.A. | N |
| Carolinas Imaging Services, LLC | N |
| Carolinas Medical Center | N |
| Carolinas Medical Center at Home, LLC | N |
| Carolinas Palliative Care and Hospice Network, Inc. | N |
| Carolinas Pathology Group, PA | N |
| Carolinas Physicians Network Inc. | N |
| Eastover Obstetrics and Gynecology Associates, Inc. | N |
| Carolinas Rehabilitation | N |
| Carolinas-Anson Healthcare, Inc. | N |
| Charlotte Eye Ear Nose & Throat Associates, P.A. | N |
| Charlotte Medical Clinic, Inc. | N |
| Charlotte Obstetric and Gynecological Associates | N |
| Charlotte Radiology, P.A. | N |
| Cleveland Ambulatory Services, LLC | N |
| Columbus Regional Health Network | N |
| Cornerstone Ear Nose & Throat, P.A. | N |
| Cotswold Family Medicine | N |
| Davidson Clinic | N |
| East Carolina Surgical, P.A. | N |
| Eastland Urgent Care | N |
| Eastover University Obstetrics & Gynecology Associates | N |
| Eastridge Family Medicine | N |
| ENT Carolina, P.A. | N |
| Emergency Medicine Physicians of Mecklenburg County, PLLC. | N |
| Harrisburg Family Physicians | N |
| Hospice of Cabarrus County, Inc. | N |
| Mecklenburg Medical Group | N |
| Medical Associates of Rock Hill | N |
| Mercy Hospital, Inc. | N |
| Northcross Family Physicians | N |
| Northeast Anesthesia & Pain Specialists, P.A. | N |
| OrthoCarolina, P.A. | N |
| Paragon Surgical Specialists, P.A. | N |
| Pulmonary Clinic of The Carolinas, P.C. | N |
| Queen City Ear, Nose and Throat PLLC | N |
| Randolph Internal Medicine Associates | N |
| Riverbend Family Physicians | N |
| Scotland Regional Health Network | N |
| Scotland Memorial Hospital Inc. | N |
| South Charlotte Primary Care | N |
| Southeast Radiation Oncology Group, P.A. | N |
| Steele Creek Urgent Care | N |
| St. Luke's Physician Network, Inc. | N |
| St. Luke's Hospital, Inc. | N |
| Surgical Specialists of Charlotte, P.A. | N |
| The Medical Center of Central Georgia Inc. | N |
| Urology Specialists of The Carolinas | N |
| Carolinas Rehabilitation | N |
| Member Last Name | Member First Name | Member Title/Position | Member’s Voting Power - Expressed as a percentage or number | Membership Type | ACO Participant Legal Business Name and D/B/A, if applicable |
|---|---|---|---|---|---|
| Brady, MD | Jennifer | Co-Chair | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Collins, MD | Johnathon | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Bowe | Christopher | Member | 6.25% | ACO Participant Representative | CAROLINAS MEDICAL CENTER |
| Terry | Jennifer | Member | 6.25% | ACO Participant Representative | THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY |
| Kauserud, MD | Susanne | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Broyhill, DNP, ACNP-BC, NP | Brittany | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Rose, MD | Geoffrey | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Zbinden, MD | Louis | Member | 6.25% | ACO Participant Representative | SURGICAL SPECIALISTS OF CHARLOTTE, P.A. |
| Seeburg, MD | Robert | Member | 6.25% | ACO Participant Representative | CHARLOTTE RADIOLOGY, P.A. |
| Anderson | Matthew | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Senft, MD | Daniel | Member | 6.25% | ACO Participant Representative | LINCOLN FAMILY PRACTICE |
| Little, MD | Gary | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Steinbacher, MD | Erika | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Kersten, MD | Brian | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
| Sheppard | Ellen | Member | 6.25% | Medicare Beneficiary Representative | N/A |
| Rebecca | Chassie | Member | 6.25% | ACO Participant Representative | CAROLINAS PHYSICIAN NETWORK, INC. |
Key ACO Clinical and Administrative Leadership
ACO Executive: Jennifer Brady, MD
Medical Director: Brian Kersten, MD
Compliance Officer: Yates Lackey
Quality Assurance/Improvement Officer: Sarah Davis
Associated Committees and Committee Leadership
| Committee Name | Committee Leader Name and Position |
|---|---|
| Network Development Committee | Cara Pearsall, Chair |
| Clinical Effectiveness Committee | Zeev Neuwirth, MD, Co-Chair Louis Zbinden, MD, Co-Chair |
| Finance Committee | Daniel Senft, MD, Co-Chair Stuart Burri, MD, Co-Chair |
| Operations Committee | Garry Little, MD, Chair |
| Nominating Committee | Jennifer H. Brady, MD, Co-Chair Matthew Anderson, Co-Chair |
Types of ACO participants, or combinations of participants, that formed the ACO:
- ACO professionals in a group practice arrangement
- Hospital employing ACO professionals
- Network of individual practices of ACO professionals
- Partnership or joint venture arrangement between hospitals and ACO professionals
Shared Savings and Losses
Amount of shared savings/losses:
- Second Agreement Period
- Performance Year 2020: $0 Savings/$0 Losses
- Performance Year 2021: $14.9M Savings/$0 Losses
- First Agreement Period
- Performance Year 2018: $0 Savings/$0 Losses
Shared Savings Distribution
Second Agreement Period
- Performance Year 2020
- 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 2021
- Proportion invested in infrastructure: 50%
- Proportion invested in redesigned care processes/resources: 18.5%
- Proportion of distribution to ACO participants: 31.5%
First Agreement Period
- 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%
Quality performance results are based on CMS Web Interface.
| Measure # | Measure Name | Rate | ACO Mean |
|---|---|---|---|
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | 5.56 | 12.46 |
| 134 | Preventative Care and Screening: Screening for Depression and Follow-up Plan | 76.60 | 74.38 |
| 236 | Controlling High Blood Pressure | 72.82 | 74.87 |
| 318 | Falls: Screening for Future Fall Risk | 93.73 | 87.03 |
| 110 | Preventative Care and Screening: Influenza Immunization | 87.26 | 80.52 |
| 226 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | 96.00 | 80.97 |
| 113 | Colorectal Cancer Screening | 81.21 | 73.63 |
| 112 | Breast Cancer Screening | 81.85 | 75.11 |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 87.76 | 84.24 |
| 479 | Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups | 0.1505 | 0.1540 |
| MCC1 | All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC) | 37.11 | 33.99 |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | 85.78 | 84.67 |
| CAHPS-2 | How Well Providers Communicate | 95.58 | 93.56 |
| CAHPS-3 | Patient’s Rating of Provider | 92.59 | 92.19 |
| CAHPS-4 | Access to Specialists | 83.72 | 78.80 |
| CAHPS-5 | Health Promotion and Education | 62.02 | 61.61 |
| CAHPS-6 | Shared Decision Making | 63.17 | 60.89 |
| CAHPS-7 | Health Status and Functional Status | 72.21 | 71.78 |
| CAHPS-8 | Care Coordination | 88.20 | 85.66 |
| CAHPS-9 | Courteous and Helpful Office Staff | 94.69 | 91.88 |
| CAHPS-11 | Stewardship of Patient Resources | 31.02 | 24.71 |
Please note, the Quality ID #: 370 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size.
For previous years’ financial and quality performance results, visit data.cms.gov.
Payment Rule Waivers
No, our ACO does not use the SNF 3-Day Rule Waiver.
Fraud and Abuse Waivers
ACO Pre-Participation Waiver:
The following information describes each arrangement for which our ACO seeks protection under the ACO Pre-Participation Waiver, including any material amendment or modification to a disclosed arrangement.
[For each arrangement, provide the following information]:
- Parties to the arrangement: N/A
- Date of arrangement: N/A
- Items, services, goods, or facility provided: N/A
- Date and nature of any amendments to the arrangement, if applicable: N/A N/A
ACO Participation Waiver:
The following information describes each arrangement for which our ACO seeks protection under the ACO Participation Waiver, including any material amendment or modification to a disclosed arrangement.
[For each arrangement, provide the following information]:
- Parties to the arrangement: N/A
- Date of arrangement: N/A
- Items, services, goods, or facility provided: N/A
- Date and nature of any amendments to the arrangement, if applicable: N/A N/A