MSSP Public Reporting

ACO name and location

Baylor Quality Health Care Alliance LLC
2301 N Washington Ave
Dallas, TX 75246

ACO primary contact

Organizational information

ACO participants

ACO Participants	ACO Participant in Joint Venture (Y/N)
Baylor Heart & Vascular Center LLP	N
Baylor Scott & White Medical Center – Centennial	N
Baylor Scott & White Medical Centers – Capitol Area	N
Baylor All Saints Medical Center	N
Baylor Medical Center at Irving	N
Baylor Medical Center at Waxahachie	N
Baylor Medical Centers at Garland and McKinney	N
Baylor Regional Medical Center at Grapevine	N
Baylor Regional Medical Center at Plano	N
Baylor University Medical Center	N
HealthTexas Provider Network	N
Hillcrest Baptist Medical Center	N
Hillcrest Family Health Center	N
Hillcrest Physician Services	N
Lake Pointe Operating Company LLC	N
Scott & White Clinic	N
Scott & White Hospital - Brenham	N
Scott & White Hospital – College Station	N
Scott & White Hospital – Marble Falls	N
Scott & White Hospital – Round Rock	N
Scott & White Hospital – Taylor	N
Scott & White Memorial Hospital	N
Texas Heart Hospital of the Southwest LLP	N

ACO governing body

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
Aval-Na’Ree	Green	MD, Voting Member, Secretary	11%	ACO Participant Representative	Scott & White Memorial Hospital
James	Graham	MD, Voting Member, Vice Chair	11%	ACO Participant Representative	Hillcrest Baptist Medical Center
W. Stuart	Johnston	MD, Voting Member	11%	ACO Participant Representative	Baylor Scott & White – Plano
Joseph	Kilianski	MD, Voting Member	11%	Other	N/A
Kimberly	McMillin	MD, Voting Member, Chair	11%	ACO Participant Representative	Baylor Scott & White – Plano
Leigh	Nordstrom	MD, Voting Member	11%	ACO Participant Representative	Baylor Scott & White Medical Center - Waxahachie
Alberto	Parra	MD, Voting Member	11%	Other	N/A
Mohanakrishnan	Sathyamoorthy	MD, Voting Member	11%	Other	N/A
Suneel	Vallabhaneni	MD, Voting Member	11%	ACO Participant Representative	Scott & White Memorial Hospital
Clarence	Miller	Business Consultant	0%	Medicare Beneficiary Representative	N/A

Key ACO clinical and administrative leadership

ACO Executive: Jennifer Reed
Medical Director: Dr. Michael Massey
Compliance Officer: Alyssa Moore
Quality Assurance/Improvement Officer: Melissa Arana

Associated committees and committee leadership

Committee Name	Committee Leader Name and Position
Quality Improvement Committee	Mike Massey MD, Chair; James Graham MD, Vice-Chair
Compliance Committee	Keith Newman MD, Chair
Membership and Standards Committee	Joseph Kilianski MD, Chair

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

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

Fourth agreement period

Performance year 2022, $61,442,789

Third agreement period

Performance year 2021, $61,050,959
Performance year 2020, $47,128,683
Performance year 2019-A, $20,420,593

Second agreement period

Performance year 2019, $13,907,640
Performance year 2018, $18,761,481

First agreement period

Performance year 2017, $0
Performance year 2016, $0
Performance year 2015, $0

Shared savings distribution

Fourth agreement period

Performance year 2022

Proportion invested in infrastructure: 15%
Proportion invested in redesigned care processes/resources: 42.5%
Proportion of distribution to ACO participants: 42.5%

Third agreement period

Performance year 2021

Proportion invested in infrastructure: 16%
Proportion invested in redesigned care processes/resources: 42%
Proportion of distribution to ACO participants: 42%

Performance year 2020

Proportion invested in infrastructure: 11% Proportion invested in redesigned care processes/resources: 45%
Proportion of distribution to ACO participants: 44%

Second agreement period

Performance year 2019

Proportion invested in infrastructure: 20%
Proportion invested in redesigned care processes/resources: 40%
Proportion of distribution to ACO participants: 40%

Performance year 2018

Proportion invested in infrastructure: 16%
Proportion invested in redesigned care processes/resources: 42%
Proportion of distribution to ACO participants: 42%

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

Quality performance results are based on CMS Web Interface

Measure #	Measure Name	Collection Type	Rate	ACO Mean
001	Diabetes: Hemoglobin A1c Poor Control	CMS Web Interface	8.02	10.71
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	92.55	76.97
236	Controlling High Blood Pressure	CMS Web Interface	75.23	76.16
318	Falls: Screening for Future Fall Risk	CMS Web Interface	99.04	87.83
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	84.19	77.34
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	90.62	79.27
113	Colorectal Cancer Screening	CMS Web Interface	84.27	75.32
112	Breast Cancer Screening	CMS Web Interface	88.61	78.07
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	91.89	86.37
370	Depression Remission at Twelve Months	CMS Web Interface	8.75	16.03
321	CAHPS for MIPS	CAHPS for MIPS Survey	N/A	N/A
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	15.26	15.10
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims	31.36	30.97

For previous year's Financial and Quality Performance Results, please 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.

Medicare Shared Savings Program (MSSP) Public Reporting