ACO Public Reporting Information

Organizational Information

  • ACO Participants

    ACO Participant in Joint Venture (Y or N)

  • Allergy Asthma Sinus Center

    N

  • Carolina Family Practice PA

    N

  • Dr. Lindaberry at Carolina Forest, PC

    N

  • Family Medicine of SayeBrook, LLC

    N

  • Florence Ears Nose & Throat, PC

    N

  • Florence Neurosurgery and Spine, PC

    N

  • Florence Women's Health

    N

  • Hartsville Medical Associates LLC

    N

  • Internal Medicine Specialists of Florence, LLC

    N

  • John McLeod

    N

  • Lumberton Internal Medicine Group, PA

    N

  • McLeod Health Cheraw

    N

  • McLeod Health Clarendon

    N

  • McLeod Loris Seacoast Hospital

    N

  • McLeod Medical Center-Dillon

    N

  • McLeod Physician Associates II

    N

  • Mcleod Regional Medical Center Of The Pee Dee Inc

    N

  • Palmetto Family Medicine of Chesterfield County, LLC

    N

  • Plastic & Reconstructive Surgery of Sumter, PA

    N

  • Strand Physician Specialists PA (Carolina Health Specialists)

    N

  • Trucare Family Practice PLLC

    N

  • W Dean Lorenz, MD PC

    N

ACO Governing Body

  • Member Last Name

    Member First Name

    Title/Position

    Member Voting Power

    Membership Type

    ACO Participant TIN Legal Business Name/DBA, if Applicable corporis architecto quisquam

  • Alexander

    C. Richard

    Voting Member and Chairperson

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Boulware

    William N.

    Voting Member and Vice-Chairperson

    1

    ACO Participant Representative

    Internal Medicine Specialists of Florence, LLC

  • Blaker

    Alan M.

    Voting Member and Secretary

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Cole

    Brad

    Voting Member

    1

    ACO Participant Representative

    McLeod Physicians Associates II

  • Eagerton Jr.

    Robert S.

    Voting Member

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Harless

    Michael E.

    Voting Member

    1

    ACO Participant Representative

    Hartsville Medical Associates LLC

  • Hollingsworth

    Scott A.

    Voting Member

    1

    ACO Participant Representative

    Strand Physician Specialists, PA dba Carolina Health Specialists

  • Isgett

    Donna

    Voting Member

    1

    ACO Participant Representative Representative

    McLeod Health

  • Jagadeesha

    Vinay

    Voting Member

    1

    ACO Participant Representative

    McLeod Regional Medical Center

  • Jordan

    Charles M.

    Voting Member

    1

    Medicare Beneficiary Representative

  • Lindaberry

    Jeffrey S.

    Voting Member

    1

    ACO Participant Representative

    Dr. Lindaberry at Carolina Forest, PC

Key ACO Clinical and Administrative Leadership

  • Michelle Dore

    ACO Executive

  • Dr. Dale Lusk

    Medical Director

  • Thomas Richardson

    Compliance Officer

  • Michelle Dore

    Quality Assurance/Improvement Officer

Associated Committees and Committee Leadership

  • Quality Operations Committee

    Alan Blaker, MD, Chair

  • Payment Transformation & Finance Committee

    Fulton Ervin, CFO McLeod Health, 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

Shared Savings and Losses


Amount of Shared Savings/Losses

  • First Agreement Period
    • Performance Year 2018, $4,347,851

Shared Savings Distribution


  • First Agreement Period
    • Performance Year 2018
      • Proportion invested in infrastructure: 100%
2018 Quality Performance Results

  • ACO#

    Measure Name

    Rate

    ACO Mean

  • ACO-1

    CAHPS: Getting Timely Care, Appointments, and Information

    85.31

    86.14

  • ACO-2

    CAHPS: How Well Your Providers Communicate

    93.33

    93.93

  • ACO-3

    CAHPS: Patients’ Rating of Provider

    92.38

    92.45

  • ACO-4

    CAHPS: Access to Specialists

    79.51

    81.50

  • ACO-5

    CAHPS: Health Promotion and Education

    48.74

    59.26

  • ACO-6

    CAHPS: Shared Decision Making

    58.47

    61.94

  • ACO-7

    CAHPS: Health Status/Functional Status

    73.57

    73.35

  • ACO-8

    Risk Standardized, All Condition Readmission

    15.23

    14.98

  • ACO-11

    Use of Certified EHR Technology

    98.68

    98.20

  • ACO-12

    Medication Reconciliation Post-Discharge

    97.44

    85.91

  • ACO-13

    Falls: Screening for Future Fall Risk

    87.10

    79.73

  • ACO-14

    Preventive Care and Screening: Influenza Immunization

    76.82

    72.71

  • ACO-15

    Pneumonia Vaccination Status for Older Adults

    75.81

    75.97

  • ACO-16

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

    80.97

    76.83

  • ACO-17

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

    80.77

    72.81

  • ACO-18

    Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan

    83.72

    66.74

  • ACO-19

    Colorectal Cancer Screening

    66.13

    68.27

  • ACO-20

    Breast Cancer Screening

    73.79

    71.96

  • ACO-27

    Diabetes Mellitus: Hemoglobin A1c Poor Control

    14.84

    15.51

  • ACO-28

    Hypertension (HTN): Controlling High Blood Pressure

    68.70

    73.10

  • ACO-30

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

    92.91

    88.92

  • ACO-34

    CAHPS: Stewardship of Patient Resources

    28.43

    26.26

  • ACO-35

    Skilled Nursing Facility 30-day All-Cause Readmission measure (SNFRM)

    19.39

    18.59

  • ACO-36

    All-Cause Unplanned Admissions for Patients with Diabetes

    37.60

    37.01

  • ACO-37

    All-Cause Unplanned Admissions for Patients with Heart Failure

    80.84

    76.75

  • ACO-38

    All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

    63.35

    59.00

  • ACO-41

    Diabetes: Eye Exam

    27.34

    52.42

  • ACO-42

    Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

    87.50

    81.47

  • ACO-43

    Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91)

    2.44

    1.98

  • ACO-44

    Use of Imaging Studies for Low Back Pain

    74.67

    64.36


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

Note: In the Quality Performance Results file(s) above, search for “McLeod Healthcare Network, LLC” to view the quality performance results. This ACO can also be found by using the ACO ID A3677 in the public use files on data.cms.gov.

Public Disclosure Language for MSSP ACO Waivers


  • Pursuant to Section 1899(f) of the Social Security Act (42 U.S.C. § 1395jjj) the Secretary of the Department of Health and Human Services has made available certain waivers of federal fraud and abuse laws in connection with the operation of accountable care organizations that have entered into a participation agreement, as defined under 42 C.F.R. § 425.20, under the Medicare Shared Savings Program (“MSSP”) with the Centers for Medicare & Medicaid Services (“CMS”). To avail itself of the Participation Waiver, the board of McLeod Health Network, LLC (“the ACO”), has made a good faith determination that the following arrangements are reasonably related to the purposes of the Medicare Shared Savings Program (MSSP) (and the Triple Aim of better health for individuals, better health for populations, and lowered growth in expenditures) and is publically disclosing such arrangements in accordance with the requirements of the MSSP.

Assistance with MSSP Quality Measure Tracking and Reporting.

The ACO will provide support to independent practices with the goal of meeting requirements for reporting on the MSSP’s quality and cost measures. Specifically, the ACO may support independent practices with:

– The creation of reports in their EMR related to the ACO’s quality program

– Quality data extraction from their EMR to support the ACO’s quality program

– EMR workflow improvement specifically related to quality metric tracking related to the ACO’s quality program

– Training on workflow for capturing quality metrics in the ACO’s quality program

– Advancing Care Information attestation support to improve the ACO’s collective performance

– Correspondence with EMR vendor for purposes of creating reports and extracting quality data for the ACO’s quality program

Outpatient Case Management

The ACO will provide outpatient case management for a limited period of time to beneficiaries who are considered high risk for healthcare complications as determined by an appropriate algorithm. This effort will achieve triple aim results through enhanced care coordination with the goal of reducing the incidence of healthcare complications.