NC ACO Public Reporting – MSSP
ACO Name and Location:
Carolinas HealthCare System ACO, LLC
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 Pathology Associates, P.A. | N |
| Carolina Bone & Joint, P.A. | N |
| Carolinas Ambulatory Surgery, Inc. | N |
| Carolinas Emergency Physicians, P.A. | 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 Rehabilitation | 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 |
| Cabarrus Gastroenterology Associates PLLC | N |
| Carmel Family Physicians | N |
| Carolinas Imaging Services LLC. | N |
| Carolinas Physicians Network Inc. | N |
| Davidson Clinic | N |
| East Carolina Surgical, P.A. | N |
| Eastland Urgent Care | N |
| Eastover University Obstetrics & Gynecology Associates | N |
| Eastover Obstetrics & Gynecology Associates, Inc. | N |
| Eastridge Family Medicine | N |
| Emergency Medicine Physicians of Mecklenburg County, PLLC. | N |
| ENT Carolina, P.A. | 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 |
| Member First Name | Member Last Name | Member Title/Position | Member’s Voting Power (Expressed as a percentage) | Membership Type | ACO Participant Legal Business Name, if applicable |
|---|---|---|---|---|---|
| Matthew | Anderson | Vice Chair | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Christopher | Bowe | Member | 6.25% | ACO Participant Representative | Carolinas Medical Center |
| Jennifer | Brady, MD | Executive Director | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Brittney | Broyhill, DNP, ACNP-BC, NP | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Rebecca | Chassie | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Mark | Fromke | Member | 6.25% | ACO Participant Representative | Charlotte Radiology, P.A. |
| Suzanne | Kauserud, MD | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Brian | Kersten, MD | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Troy | Leo, MD | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Gary | Little, MD | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Daniel | Senft, MD | Member | 6.25% | ACO Participant Representative | Lincoln Family Practice |
| Ellen | Sheppard | Member | 6.25% | Medicare Beneficiary representative | N/A |
| Leo | Spector, MD | Member | 6.25% | ACO Participant Representative | OrthoCarolina |
| Erika | Steinbacher, MD | Member | 6.25% | ACO Participant Representative | Carolinas Physician Network, Inc. |
| Jennifer | Terry | Member | 6.25% | Medicare Beneficiary Representative | The Charlotte-Mecklenburg Hospital Authority |
| Louis | Zbinden, MD | Member | 6.25% | ACO Participant Representative | Surgical Specialists of Charlotte, P.A. |
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 |
|---|---|
| Clinical Effectiveness Committee | Dave Cosenza, MD, Chair |
| Finance Committee | Daniel Senft, MD, Co-Chair Stuart Burri, MD, Co-Chair |
| Network Development Committee | Cara Pearsall, Chair |
| Nominating Committee | Jennifer H. Brady, MD, Co-Chair Matthew Anderson, Co-Chair |
| Operations Committee | Gary Little, MD, 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:
- Fifth Agreement Period
- Performance Year 2023, $0
- Fourth Agreement Period
- Performance Year 2022, $0
- Third Agreement Period
- Performance Year 2021, $14,928,446
- Second Agreement Period
- Performance Year 2020, $0
- First Agreement Period
- Performance Year 2019, $0
Shared Savings Distribution
Fifth Agreement Period
- Performance Year 2023
- Proportion invested in infrastructure: N/A%
- Proportion invested in redesigned care processes/resources: N/A%
- Proportion of distribution to ACO participants: N/A%
Fourth Agreement Period
- Performance Year 2022
- Proportion invested in infrastructure: N/A%
- Proportion invested in redesigned care processes/resources: N/A%
- Proportion of distribution to ACO participants: N/A%
Third Agreement Period
- Performance Year 2021
- Proportion invested in infrastructure: 50%
- Proportion invested in redesigned care processes/resources: 28.5%
- Proportion of distribution to ACO participants: 31.5%
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%
First Agreement Period
- Performance Year 2019
- 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 | Collection Type | Rate | ACO Mean |
|---|---|---|---|---|
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | CMS Web Interface | 8.83 | 10.71 |
| 134 | Screening for Depression and Follow-up Plan | CMS Web Interface | 75.76 | 76.97 |
| 236 | Controlling High Blood Pressure | CMS Web Interface | 71.40 | 74.87 |
| 318 | Falls: Screening for Future Fall Risk | CMS Web Interface | 86.86 | 87.83 |
| 110 | Influenza Immunization | CMS Web Interface | 73.25 | 77.34 |
| 226 | Tobacco Use: Screening and Cessation Intervention | CMS Web Interface | 91.67 | 79.27 |
| 113 | Colorectal Cancer Screening | CMS Web Interface | 74.22 | 75.32 |
| 112 | Breast Cancer Screening | CMS Web Interface | 82.18 | 78.07 |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | CMS Web Interface | 91.23 | 86.37 |
| 370 | Depression Remission at Twelve Months | CMS Web Interface | 9.64 | 16.03 |
| 479 | Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups | Administrative Claims | 0.1475 | 0.1510 |
| MCC1 | All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC) | Administrative Claims | 32.75 | 30.97 |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | CAHPS for MIPS Survey | 77.64 | 83.96 |
| CAHPS-2 | How Well Providers Communicate | CAHPS for MIPS Survey | 91.27 | 93.47 |
| CAHPS-3 | Patient’s Rating of Provider | CAHPS for MIPS Survey | 90.54 | 92.06 |
| CAHPS-4 | Access to Specialists | CAHPS for MIPS Survey | 74.63 | 77.00 |
| CAHPS-5 | Health Promotion and Education | CAHPS for MIPS Survey | 59.56 | 62.68 |
| CAHPS-6 | Shared Decision Making | CAHPS for MIPS Survey | 60.13 | 60.97 |
| CAHPS-7 | Health Status and Functional Status | CAHPS for MIPS Survey | 72.97 | 73.06 |
| CAHPS-8 | Care Coordination | CAHPS for MIPS Survey | 84.49 | 85.46 |
| CAHPS-9 | Courteous and Helpful Office Staff | CAHPS for MIPS Survey | 91.08 | 91.97 |
| CAHPS-11 | Stewardship of Patient Resources | CAHPS for MIPS Survey | 25.04 | 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:
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
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