ACO Public Reporting Information

ACO Name and Location

Memorial Hermann Accountable Care Organization
929 Gessner, Suite 2700
Houston, Texas 77024

ACO Primary Contact

Organizational Information

ACO Participants

ACO Governing Body

Key ACO Clinical and Administrative Leadership

Associated Committees and Committee Leadership

Types of ACO Participants, or Combinations of Participants, That Formed the ACO

• Hospital employing ACO professionals
• Partnership or joint venture arrangement between hospitals and ACO professionals
• Networks of individual practices of ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

• Second Agreement Period
• Performance Year 2023, $3,527,341
• Performance Year 2022, $6,957,179
• Performance Year 2021, $0
• Performance Year 2020, $11,491,733
• Performance Year 2019, $10,117,659
• Performance Year 2018, $7,965,918
• Performance Year 2017, $14,499,448
• Performance Year 2016, $14,025,212
• First Agreement Period
• Performance Year 2015, $41,912,527
• Performance Year 2014, $22,723,305
• Performance Year 2013, $28,338,705

“Note: Our ACO participated in multiple performance years during Calendar Year 2019. Shared savings/losses amount reported for Performance Year 2019 therefore represents net shared savings or losses across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.”

Shared Savings Distribution

• Third Agreement Period
  • Performance Year 2023
    • Proportion invested in infrastructure: 19%
    • Proportion invested in redesigned care processes/resources: 16%
    • Proportion of distribution to ACO participants: 65%
• Second Agreement Period
  • Performance Year 2022
    • Proportion invested in infrastructure: 19%
    • Proportion invested in redesigned care processes/resources: 16%
    • Proportion of distribution to ACO participants: 65%
  • Performance Year 2021 - N/A
  • Performance Year 2020
    • Proportion invested in infrastructure: 20%
    • Proportion invested in redesigned care processes/resources: 15%
    • Proportion of distribution to ACO participants: 65%

  Quality Performance Results

  2023 Quality Performance Results

  Quality performance results are based on CMS Web Interface

  Measure Number	Measure Name	Rate	ACO Mean
  001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1	11.49	9.84
  134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	79.09	80.97
  236	Controlling High Blood Pressure	74.23	77.80
  318	Falls: Screening for Future Fall Risk	93.30	89.42
  110	Preventative Care and Screening: Influenza Immunization	69.66	70.76
  226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	81.25	79.29
  113	Colorectal Cancer Screening	73.94	77.14
  112	Breast Cancer Screening	80.94	80.36
  438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	85.46	87.05
  370	Depression Remission at Twelve Months	10.00	16.58
  321	CAHPS for MIPS2	7.57	6.25
  479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups1	0.1561	0.1553
  484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions1	---	35.39

  [1] A lower performance rate corresponds to higher quality. [2] CAHPS for MIPS survey data provided by authorized third-party CAHPS for MIPS vendor

  2022 Quality Performance Results

  Quality performance results are based on CMS Web Interface

  Measure Number	Measure Name	Rate	ACO Mean
  001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control1	6.61	10.71
  134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	78.06	76.97
  236	Controlling High Blood Pressure	71.78	76.16
  318	Falls: Screening for Future Fall Risk	95.78	87.83
  110	Preventative Care and Screening: Influenza Immunization	79.35	77.34
  226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	84.21	79.27
  113	Colorectal Cancer Screening	81.73	75.32
  112	Breast Cancer Screening	76.94	78.07
  438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	88.17	86.37
  370	Depression Remission at Twelve Months	17.19	10.03
  479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups1	0.1503	0.1510
  MCC1	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)1	26.64	30.97

  [1] A lower performance rate corresponds to higher quality.

  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 Fraud and Abuse Waivers:

  Arrangements Disclosed

  The MHACO Board has approved the following arrangements for the waivers authorized by CMS and the OIG pursuant to the “Medicare Program; Final Waivers in Connection with the Shared Savings Program” originally published on November 2, 2011 and finalized on October 29, 2015.

  1. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization, will engage MHMD, the Memorial Hermann Physician Network, to administer a program to advance evidence-based medicine, increase patient satisfaction, and manage the cost of care for the hospitalist service line of MHHS, and may be extended to intensivists an anesthesiologists. The focus will be inpatients and observation and eligible physicians will be eligible for compensation based upon meeting quality and cost metrics. In September 2015 the program was modified to establish the physician compensation caps, clarify the dates for measurement and other program administrative changes. In March 2016, the program was modified to make the program adaptable as new information becomes available to incentive activities to advance MSSP, while maintaining the overall purposes of the original program. In September 2019, the program was extended for the duration of the new MSSP Renewal Period “Pathways to Success.” On June 9, 2025, the program was extended for the duration of the MHACO’s participation in the Medicare Shared Savings Program.
  2. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization, will engage MHMD, the Memorial Hermann Physician Network, to administer a program to advance evidence-based medicine, increase patient satisfaction, and manage the cost of care for the orthopedic service line of MHHS. The focus will be total joint replacement, and other inpatient services and eligible physicians will be eligible for compensation based upon meeting quality and cost metrics. The program was approved in February 2014. In May of 2014, the program was supplemented to permit MHMD to develop criteria for a physician list eligible to receive referrals from call centers, nurse navigators or other sources using criteria such as geographic proximity, and the physician’s overall level of experience and expertise. In September 2015 the program was modified to establish the physician compensation caps, clarify the dates for measurement and other program administrative changes. In March 2016, the program was modified to make the program adaptable as new information becomes available to incentive activities to advance MSSP, while maintaining the overall purposes of the original program. In September 2019, the program was extended through the end of the MSSP renewal period in 2019. The program was extended for the duration of the new MSSP Renewal Period “Pathways to Success.” On June 9, 2025, the program was extended for the duration of the MHACO’s participation in the Medicare Shared Savings Program.
  3. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization, will engage MHMD, the Memorial Hermann Physician Network, to administer a program to advance evidence-based medicine, increase patient satisfaction, and manage the cost of care for the cardiovascular service line of MHHS. The focus will be inpatient surgeries services and eligible physicians will be eligible for compensation based upon meeting quality and cost metrics. In September 2015 the program was modified to establish the physician compensation caps, clarify the dates for measurement and other program administrative changes. In March 2016, the program was modified to make the program adaptable as new information becomes available to incentive activities to advance MSSP, while maintaining the overall purposes of the original program. The program was extended through the end of the MSSP renewal period in 2019. In September 2019, the program was extended for the duration of the new MSSP Renewal Period “Pathways to Success.” On June 9, 2025, the program was extended for the duration of the MHACO’s participation in the Medicare Shared Savings Program.
  4. The Memorial Hermann Accountable Care Organization (“MHACO”) will provide referral coordination service to physicians who participate in MHACO. MHACO will identify preferred providers, utilizing quality, cost and operational efficiency considerations, but will also coordinate referrals to physicians outside the preferred network. The expectation is that this will make the delivery of care more efficient, and will influence patients to utilize physicians with demonstrated quality and efficiency. The program was approved in February 2014.
  5. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization (“MHACO”) has engaged the University of Texas Health Science Center (“UTHSC”) to provide academic, professional and administrative services, including the configuration of an ambulatory orthopedic network. Additionally, UTHSC will provide clinical and administrative leadership to advance quality and safety metrics of the orthopedic service line inclusive of a regional leadership structure; supplement and support the orthopedics call coverage requirements of the Hospital emergency departments; provide qualified physician leaders to coordinate the medical direction of local campuses and programs; provide guidance on operating room efficiency and operations to ensure the safest environment possible for patient care where requested; provide guidance on strategic sourcing solutions to improve overall quality of care and value to patients; and provide high quality care. The arrangement was approved for a June 1, 2014 start date with a 5 year term. The parties renewed the arrangement for an additional 5 year term, effective January 1, 2019.
  6. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization (“MHACO”) has engaged the University of Texas Health Science Center (“UTHSC”) to provide academic, professional and administrative services, including the configuration of an ambulatory cardiovascular professional services network. Additionally, UTHSC will provide clinical and administrative leadership to advance quality and safety metrics of the heart & vascular service line inclusive of a regional leadership structure; supplement and support the cardiovascular call coverage requirements of the Hospital emergency departments; provide qualified physician leaders to coordinate the medical direction of local campuses and programs; provide guidance on operating room efficiency and operations to ensure the safest environment possible for patient care where requested; provide guidance on strategic sourcing solutions to improve overall quality of care and value to patients; and provide high quality care. The arrangement was approved for a July 1, 2019 for a five year term.
  7. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization (“MHACO”) has engaged the University of Texas Health Science Center (“UTHSC”) to provide academic, professional and administrative services, including the configuration of an ambulatory professional services network for neuroscience, heart & vascular, and women & children’s services. Additionally, UTHSC will provide clinical and administrative leadership to advance quality and safety metrics of the service lines inclusive of a regional leadership structure; supplement and support the call coverage requirements of the Hospital emergency departments; provide qualified physician leaders to coordinate the medical direction of local campuses and programs; provide guidance on operating room efficiency and operations to ensure the safest environment possible for patient care where requested; provide guidance on strategic sourcing solutions to improve overall quality of care and value to patients; and provide high quality care. The arrangements were approved for a January 1, 2019 start date for a five year term, except for neurosciences which commenced on September 1, 2019.
  8. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization (“MHACO”) has engaged the MHS Physicians of Texas (“PhyTex”), a certified nonprofit health care corporation of which MHHS is the sole member, to provide academic, professional and administrative services, including the configuration of an ambulatory neuroscience network. Additionally, PhyTex will provide clinical and administrative leadership to advance quality and safety metrics of the neuroscience service line inclusive of a regional leadership structure; supplement and support the neuroscience call coverage requirements of the Hospital emergency departments; provide qualified physician leaders to coordinate the medical direction of local campuses and programs; provide guidance on operating room efficiency and operations to ensure the safest environment possible for patient care where requested; provide guidance on strategic sourcing solutions to improve overall quality of care and value to patients; provide high quality care. An initial component of the program will provide financial incentives to neurosurgeons for meeting defined quality and cost metrics. The arrangement was approved April for April 15, 2014, for a one year automatically renewing term.
  9. The MHACO Board has approved a pilot program to utilize a scribe in certain clinically integrated physician offices to determine whether the program should be expanded and utilized to increase physician productivity, quality and patient satisfaction. The program was approved to commence July 1. The subsidy for the service would be for a 1 year period with staggered start dates after the commencement for the participating physician offices.
  10. The MHACO Board has approved a subsidy to cover part of the cost for its academic affiliated physician group to transition to the EMR platform as Memorial Hermann.
  11. The Memorial Hermann Accountable Care Organization Board has approved a small holdback of the available bonus pool if in-network utilization for the MHACO members remains flat or declines over the baseline. The MHACO Board considered documentation showing evidence that use of the network improved care quality and decreased the overall cost on a per patient basis. The impact on the bonus pool is aggregate, and does not take into account the utilization of physicians at the individual level. The program was approved for the 2016 bonus year.
  12. For purposes of managing covered lives including MSSP, the MHACO Board approved certain network utilization tools for MHACO or MHMD to utilize along with its participants, partners, and affiliated entities. The network tools include the publication and distribution of reports to inform leadership on the various metrics and for the development of care networks for population health management; the publication and distribution of network directories; the development of limited, aggregate financial incentives to align network utilization to the extent that it advances MSSP purposes, and other similar related tools as necessary for these purposes. The network resources would be utilized for the duration of the MSSP renewal period through 2019.
  13. THE MH ACO Board approved on June 27, 2018 a subsidized cost structure for electronic health records for primary care physicians participating in the MH Accountable Care Organization for the benefit of care coordination purposes.
  14. The Memorial Hermann Health System (“MHHS”), a participant in the Memorial Hermann Accountable Care Organization, will engage MHMD, the Memorial Hermann Physician Network, to administer a program to advance evidence-based medicine, increase patient satisfaction, and manage the cost of care for the oncology service line of MHHS. The focus will be quality metrics for inpatient and outpatient services as well as patient satisfaction. Physicians will be eligible for compensation based upon meeting quality and cost metrics. This program is concurrent with the MSSP participation period for MHACO. On June 9, 2025, the program was extended for the duration of the MHACO’s participation in the Medicare Shared Savings Program.
  15. The MH ACO Board approved in June 2020 the establishment of a general surgery incentive program based on metrics that promote accountability for quality cost and over all care for patients. On June 9, 2025, the program was extended for the duration of the MHACO’s participation in the Medicare Shared Savings Program.
  16. The MH ACO Board approved on December 12, 2022 the provision of interoperability EMR integration support for MHMD clinically integrated providers to establish a bi-directional interface through the Digital Front Door Initiative to advance efficiencies in various care coordination efforts.
  17. The MH ACO Board approved on June 7, 2021 the provision of EMR interoperability support for MHMD clinically integrated providers through EcW EMR Direct Access, a solution for the digital endpoint and care coordination advancements under the CMS Interoperability and Patient Access final rule. 
  18. The MH ACO Board approved on December 12, 2022 the provision of financial support to support care coordination and value-based activities for clinically integrated providers specializing in both surgical and non-surgical medical weight management in order to improve quality and lower cost through reduction of unwanted variability.
  19. On June 21, 2023, the MHACO Board approved a subsidy to cover a portion of the MHHS EMR implementation costs for MHMD clinically integrated providers effective August 1, 2023 through July 31, 2024. On December 4, 2023, the MHACO Board amended this waiver to include a subsidy for a population health management platform until September 30, 2024. On May 1, 2024, the MHACO Board amended this waiver to extend the subsidy for transition and implementation costs until October 31, 2024. On June 21, 2024, the MHACO Board approved an amended waiver to provide additional support of implementation and transition costs for MHMD clinically integrated providers by providing additional training go-live support through March 31, 2025. On May 8, 2025, the MHACO Board approved a subsidy to cover a portion of the MHHS EMR implementation costs for MHMD clinically integrated providers effective May 9, 2025 (“May 9 Waiver Effective Date”) for such MHMD clinically integrated providers who join the MHHS EMR on or after the May 9 Waiver Effective Date. Further the MHACO Board extended the waiver for training go-live support through May 1, 2026. Finally, the MHACO Board approved a reduction of recurring monthly fees for the MHHS EMR for eighteen month for MHMD clinically integrated providers who went live on the MHHS EMR before the May 9 Waiver Effective Date and paid implementation fees in excess of the subsidies of the implementation fees outlined in this disclosure.
  20. On September 11, 2023, the MHACO Board approved a subsidy to cover part of the MHHS EMR transition costs for MHMD clinically integrated providers effective August 1, 2023 through September 30, 2024.
  21. On December 4, 2023, the MHACO Board approved a population health management platform integration subsidy for MHMD clinically integrated providers contracted with eClinicalWorks for their electronic medical record.
  22. Upon a motion duly made and seconded, the Board Members present unanimously approved the MSSP Waiver Request for equipment issues wherein MHACO proposes to provide no-interest loans not to exceed $10,000 to physicians who meet predetermined criteria with an effective date of September 9, 2024-October 31, 2027.
  23. Upon a motion duly made and seconded, the Board Members present unanimously approved the MSSP Waiver Request for Fax Issues wherein MHACO proposes to provide MHMG employees and/or contracted services to 10 MHMD clinically integrated practices who have implemented MH Community Connect and have acute fax issues. Such services will not exceed $2,500 per practice location and shall last no longer than two weeks with an effective date of September 9, 2024-October 31, 2024.