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

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 Scott & White All Saints Medical Center – Fort Worth N
Baylor Scott & White Medical Center – Irving N
Baylor Scott & White Medical Center – Waxahachie N
Baylor Scott & White Medical Center – McKinney N
Baylor Scott & White Medical Center – Grapevine N
Baylor Scott & White Medical Center – 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 9.09% ACO Participant Representative Scott & White Memorial Hospital
James Graham MD, Voting Member, Vice Chair 9.09% ACO Participant Representative Hillcrest Baptist Medical Center
W. Stuart Johnston MD, Voting Member 9.09% ACO Participant Representative Baylor Scott & White Medical Center – Plano
Joseph Kilianski MD, Voting Member 9.09% ACO Participant Representative Baylor Scott & White Medical Center - Grapevine
Kimberly McMillin MD, Voting Member, Chair 9.09% ACO Participant Representative Baylor Scott & White Medical Center – Plano
Leigh Nordstrom MD, Voting Member 9.09% ACO Participant Representative Baylor Scott & White Medical Center - Waxahachie
Alberto Parra MD, Voting Member 9.09% ACO Participant Representative Baylor All Saints Medical Center
Mohanakrishnan Sathyamoorthy MD, Voting Member 9.09% ACO Participant Representative Baylor All Saints Medical Center
Suneel Vallabhaneni MD, Voting Member 9.09% ACO Participant Representative Scott & White Memorial Hospital
Clarence Miller Business Consultant 9.09% Medicare Beneficiary Representative N/A
Jennifer Mitzner CFO 9.09% Other N/A

Key ACO clinical and administrative leadership

  • ACO Executive: Akila Malik
  • Medical Director: Dr. Robert Waterhouse     
  • 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 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

Fourth agreement period

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

2023 quality performance results
Measure # Measure Name Collection Type Reported Performance Rate Current Year Mean Performance Rate (SSP ACOs)
001 Diabetes: Hemoglobin A1c Poor Control CMS Web Interface 4.80 9.84
134 Preventative Care and Screening: Screening for Depression and Follow-up Plan CMS Web Interface 91.47 80.97
236 Controlling High Blood Pressure CMS Web Interface 79.00 77.80
318 Falls: Screening for Future Fall Risk CMS Web Interface 99.77 89.42
110 Preventative Care and Screening: Influenza Immunization CMS Web Interface 74.66 70.76
226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS Web Interface 95.24 79.29
113 Colorectal Cancer Screening CMS Web Interface 87.16 77.14
112 Breast Cancer Screening CMS Web Interface 91.36 80.36
438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS Web Interface 90.17 87.05
370 Depression Remission at Twelve Months CMS Web Interface 9.46 16.58
479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups Administrative Claims 15.52 15.53
484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions Administrative Claims N/A 83.63
CAHPS-1 Getting Timely Care, Appointments, and Information CAHPS for MIPS Survey 82.87 83.68
CAHPS-2 How Well Providers Communicate CAHPS for MIPS Survey 93.46 93.69
CAHPS-3 Patient's Rating of Provider CAHPS for MIPS Survey 91.93 92.14
CAHPS-4 Access to Specialists CAHPS for MIPS Survey 73.82 75.97
CAHPS-5 Health Promotion and Education CAHPS for MIPS Survey 67.10 63.93
CAHPS-6 Shared Decision Making CAHPS for MIPS Survey 63.80 61.60
CAHPS-7 Health Status and Functional Status CAHPS for MIPS Survey 76.16 74.12
CAHPS-8 Care Coordination CAHPS for MIPS Survey 87.19 85.77
CAHPS-9 Courteous and Helpful Office Staff CAHPS for MIPS Survey 91.79 92.31
CAHPS-11 Stewardship of Patient Resources CAHPS for MIPS Survey 34.66 26.69

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.