ACO name and location

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

ACO primary contact

Sarah Habeeb
Sarah.Habeeb@BSWHealth.org
214.865.4665

Organizational information

ACO ParticipantsACO Participant in Joint Venture (Y/N)
Baylor Scott & White Medical Center – CentennialN
Baylor Scott & White Medical Centers – Capitol AreaN
Baylor Scott & White All Saints Medical Center – Fort WorthN
Baylor Scott & White Medical Center – IrvingN
Baylor Scott & White Medical Center – WaxahachieN
Baylor Scott & White Medical Center – Greater North TexasN
Baylor Scott & White Medical Center – GrapevineN
Baylor Scott & White Medical Center – PlanoN
Baylor University Medical CenterN
HealthTexas Provider NetworkN
Hillcrest Baptist Medical CenterN
Hillcrest Family Health CenterN
Hillcrest Physician ServicesN
Lake Pointe Operating Company LLCN
Scott & White ClinicN
Scott & White Hospital - BrenhamN
Scott & White Hospital – College StationN
Scott & White Hospital – Marble FallsN
Scott & White Hospital – Round RockN
Scott & White Hospital – TaylorN
Scott & White Memorial HospitalN
Texas Heart Hospital of the Southwest LLPN
ACO participants

 

Member First NameMember Last NameMember Title/PositionMember's Voting Power
(Expressed as a percentage)		Membership TypeACO Participant Legal Business Name, if applicable
JamesGrahamMD, Chair9.09%ACO Participant RepresentativeHillcrest Baptist Medical Center
W. StuartJohnstonMD, Voting Member9.09%ACO Participant RepresentativeBaylor Scott & White Medical Center – Plano
JosephKilianskiMD, Secretary9.09%ACO Participant RepresentativeBaylor Scott & White Medical Center - Grapevine
LeighNordstromMD, Vice Chair9.09%ACO Participant RepresentativeBaylor Scott & White Medical Center - Waxahachie
AlbertoParraMD, Voting Member9.09%ACO Participant RepresentativeBaylor All Saints Medical Center
MichaelVolkMD, Voting Member9.09%ACO Participant RepresentativeScott & White Clinic
ClarenceMillerVoting Member9.09%Medicare Beneficiary RepresentativeN/A
JenniferMitznerCFO9.09%OtherN/A
BrentWalkerMD, Voting Member9.09%ACO Participant RepresentativeHealthTexas Provider Network
JasonRammMD, Voting Member9.09%ACO Participant RepresentativeScott & White Clinic
MuralidharJatlaMD, Voting Member9.09%ACO Participant RepresentativeScott & White Clinic
ACO governing body

Key ACO clinical and administrative leadership

  • ACO Executive: Ed Lee
  • Medical Director: Dr. Michael Massey     
  • Compliance Officer: Gabriela Serrano
  • 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 Alan Jones MD, Chair, Co-Chair; Jennifer Wilkerson MD, Co-Chair
Membership and Standards Committee Joseph Kilianski MD, Co-Chair, Clark Meador MD, Co-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

Fifth agreement period

  • Performance year 2024, $76,821,106

Fourth agreement period

  • Performance year 2023, $79,111,511
  • 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

Fifth agreement period

Performance year 2024

  • Proportion invested in infrastructure: 18%
  • Proportion invested in redesigned care processes/resources: 11%
  • Proportion of distribution to ACO participants: 71%

Performance year 2023

  • Proportion invested in infrastructure: 12%
  • Proportion invested in redesigned care processes/resources: 8%
  • Proportion of distribution to ACO participants: 80%

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

Quality performance results are based on CMS Web Interface

2024 quality performance results
Measure # Measure Name Collection Type Reported Performance Rate Current Year Mean Performance Rate (SSP ACOs)
001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) CMS Web Interface 5.62 9.44
134 Preventative Care and Screening: Screening for Depression and Follow-up Plan CMS Web Interface 94.23 81.46
236 Controlling High Blood Pressure CMS Web Interface 84.57 79.49
318 Falls: Screening for Future Fall Risk CMS Web Interface 99.43 89.99
110 Preventative Care and Screening: Influenza Immunization CMS Web Interface 70.1968.60
226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS Web Interface 91.18 79.98
113 Colorectal Cancer Screening CMS Web Interface86.25 77.81
112 Breast Cancer Screening CMS Web Interface 90.22 80.93
438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS Web Interface 90.96 86.50
370 Depression Remission at Twelve Months CMS Web Interface 6.58 17.35
479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups Administrative Claims 14.76 15.17
484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions Administrative Claims N/A 37.00
CAHPS-1 Getting Timely Care, Appointments, and Information CAHPS for MIPS Survey 79.14 83.70
CAHPS-2 How Well Providers Communicate CAHPS for MIPS Survey 94.94 93.96
CAHPS-3 Patient's Rating of Provider CAHPS for MIPS Survey 93.63 92.43
CAHPS-4 Access to Specialists CAHPS for MIPS Survey 76.13 75.76
CAHPS-5 Health Promotion and Education CAHPS for MIPS Survey 71.04 65.48
CAHPS-6 Shared Decision Making CAHPS for MIPS Survey 62.80 62.31
CAHPS-7 Health Status and Functional Status CAHPS for MIPS Survey 75.38 74.14
CAHPS-8 Care Coordination CAHPS for MIPS Survey 87.38 85.89
CAHPS-9 Courteous and Helpful Office Staff CAHPS for MIPS Survey 93.55 92.89
CAHPS-11 Stewardship of Patient Resources CAHPS for MIPS Survey 29.72 26.98

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.