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

  • Family Medicine of SayeBrook, LLC

    N

  • Florence Ears Nose & Throat, PC

    N

  • Florence Neurosurgery and Spine, PC

    N

  • Hartsville Medical Associates LLC

    N

  • Healing Hands Family Practice, PLLC

    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

  • Palmetto Radiation Oncology PA

    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 PA

    N

ACO Governing Body

  • Member Last Name

    Member First Name

    Member Title/Position

    Member Voting Power

    Membership Type

    ACO Participant Legal Business Name/DBA, if applicable

  • Alexander

    C. Richard

    Chair

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Boulware

    William N.

    Vice-Chair

    1

    ACO Participant Representative

    Internal Medicine Specialists of Florence, LLC

  • Blaker

    Alan M.

    Secretary

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Bornfreund

    Jon

    Voting Member

    1

    ACO Participant Representative

    Family Medicine of SayeBrook, LLC

  • Cole

    Brad

    Voting Member

    1

    ACO Participant Representative

    McLeod Physician Associates II

  • Eagerton

    Donald

    Voting Member

    1

    ACO Participant Representative

    Strand Physician Specialists, PA dba Carolina Health Specialists

  • 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, PA

  • Jagadeesha

    Vinay

    Voting Member

    1

    ACO Participant Representative

    McLeod Regional Medical Center

  • Johnson

    Matt

    Voting Member

    1

    ACO Participant Representative Representative

    McLeod Health

  • Jordan

    Charles M.

    Voting Member

    1

    Medicare Beneficiary Representative

    NA

Key ACO Clinical and Administrative Leadership

  • ACO Executive

    Michelle Dore

  • Medical Director

    Dr. Dale Lusk

  • Compliance Officer

    Thomas Richardson

  • Quality Assurance/Improvement Officer

    Michelle Dore

Associated Committees and Committee Leadership

  • Quality Operations Committee

    Alan Blaker, MD, Chair

  • Payment Transformation & Finance Committee

    Fulton Ervin, CFO, 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:

  • Second Agreement Period
    • Performance Year 2022, N/A
  • First Agreement Period
    • Performance Year 2018, $4,347,851
    • Performance Year 2019, $4,225,332
    • Performance Year 2020, $0
    • Performance Year 2021, N/A

Shared Savings Distribution:

  • Second 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
  • First Agreement Period
    • Performance Year 2018
      • Proportion invested in infrastructure: 100%
      • Proportion invested in redesigned care processes/resources: 0%
      • Proportion of distribution to ACO participants: 0%
    • Performance Year 2019
      • Proportion invested in infrastructure: 15%
      • Proportion invested in redesigned care processes/resources: 0%
      • Proportion of distribution to ACO participants: 85%
    • 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: N/A
        • Proportion invested in redesigned care processes/resources: N/A
        • Proportion of distribution to ACO participants: N/A
2021 Quality Performance Results

  • ACO#

    Measure Name

    Rate

    ACO Mean

  • MCC1

    All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

    34.45

    33.99

  • 318

    Falls: Screening for Future Fall Risk

    89.52

    87.03

  • 110

    Preventive Care and Screening: Influenza Immunization

    86.90

    80.52

  • 226

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

    73.68

    80.97

  • 134

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

    78.95

    74.38

  • 113

    Colorectal Cancer Screening

    59.04

    73.63

  • 112

    Breast Cancer Screening

    66.13

    75.11

  • 438

    Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

    86.83

    84.24

  • 001

    Diabetes: Hemoglobin A 1 c Poor Control (>9%)

    16.53

    12.46

  • 236

    Controlling High Blood Pressure

    69.08

    74.87

  • CAHPS-1

    Getting Timely Care, Appointments, and Information

    85.69

    84.67

  • CAHPS-2

    How Well Providers Communicate

    93.22

    93.56

  • CAHPS-3

    Patient's Rating of Provider

    92.99

    92.19

  • CAHPS-4

    Access to Specialists

    77.33

    78.80

  • CAHPS-5

    Health Promotion and Education

    52.37

    61.61

  • CAHPS-6

    Shared Decision Making

    62.05

    30.89

  • CAHPS-7

    Health Status and Functional Status

    71.98

    71.78

  • CAHPS-8

    Care Coordination

    84.77

    85.66

  • CAHPS-9

    Courteous and Helpful Office Staff

    91.57

    91.88

  • CAHPS-11

    Stewardship of Patient Resources

    26.54

    24.71


“Please note, the Quality ID#: 370 Depression Remission at 12 months quality measure is not included in public reporting due to low sam pie size.”

For Previous Years’ 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.

Fraud and Abuse Waivers


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.

  • Parties to the arrangement: ACO Facility Participants, ACO Practice Participants, including Independently owned Physician Practices
  • Date of arrangement: 05/23/2021
  • Items, services, goods, or facility provided: OP-CDI Program Manager; dedicated OP-CDI specialists; technology to support opportunity assessment, workflow development, and monitor program performance
  • Date and nature of any amendments to the arrangement, if applicable: N/A