ACO Name and Location

CPSI ACO 3 LLC
dba Myriad Health Alliance
7509 NW Tiffany Springs Parkway
Ste. 310
Kansas City, Missouri 64153

ACO Primary Contact

Primary Contact Name	Deven Killough
Primary Contact Phone Number	916-542-4582
Primary Contact Email Address	dkillough@caravanhealth.com

Organizational Information

ACO participants:

ACO Participants	ACO Participant in Joint Venture (Enter Y or N)
SURGERY CLINIC OF PHILADELPHIA	N
OCH PULMONOLOGY	N
OCH CENTER FOR PAIN MANAGEMENT	N
Alonzo Davis	N
MAGNOLIA HOSPITALIST GROUP	N
OCH PROFESSIONAL SERVICES	N
MAGNOLIA CARDIOVASCULAR AND THORACIC CLINIC	N
MAGNOLIA REGIONAL COMMUNITY CARE CLINIC	N
OCH FAMILY PRACTICE ACKERMAN	N
ST. DOMINIC MEDICAL ASSOCIATES LLC	N
OCH GENERAL SURGERY ASSOCIATES	N
Moore Orthopedics and Sports Medicine	N
MAGNOLIA PHYSICIAN SERVICES, INC.	N
ANDERSON PHYSICIAN ALLIANCE INC	Y
CARTERET MEDICAL GROUP LLC	N
MAGNOLIA CARDIOLOGY ASSOCIATES	N
MAGNOLIA SPECIALTY CLINIC	N
South Central Clinics, Inc	N
KDMC PHYSICIAN CLINICS LLC	N
WINSTON MEDICAL CLINIC LLC	N
RALEIGH FAMILY HEALTH CLINIC PLLC	N
CHOCTAW REGIONAL MEDICAL CENTER	N
OCH ORTHOPEDIC CENTER	N
MAGNOLIA GENERAL AND VASCULAR SURGERY CLINIC	N
Effingham Hospital Inc	Y
CARTERET COUNTY GENERAL HOSPITAL CORPORATION	Y
Carteret Surgical Associates	N
Sea Breeze Family Practice PA	N
MAGNOLIA PROFESSIONAL ASSOCIATES	N
TAYLOR REGIONAL HOSPITAL	Y
KINGS DAUGHTERS MEDICAL CENTER	Y
ANDERSON REGIONAL MEDICAL CENTER	Y
JASPER GENERAL HOSPITAL	N
YALOBUSHA GENERAL HOSPITAL	N
OKTIBBEHA COUNTY HOSPITAL	N
DELTA REGIONAL MEDICAL CENTER	N
MERIDIAN MEDICAL ASSOCIATES, PA	Y
Jefferson Medical Associates	N
PEARL RIVER COUNTY HOSPITAL & NURSING HOME	N
DELTA MEDICAL GROUP	N
NESHOBA COUNTY GENERAL HOSPITAL	Y
COPIAH COUNTY MEDICAL CENTER	Y
TIPPAH COUNTY HOSPITAL	N
FRANKLIN COUNTY MEMORIAL HOSPITAL	N
NORTH SUNFLOWER MEDICAL CENTER	Y
WAYNE GENERAL HOSPITAL	N
South Central Regional Medical Center	Y
Covington County Hospital	Y
Noxubee General Critical Access Hospital	Y
FIELD MEMORIAL COMMUNITY HOSPITAL	N
MEMORIAL HOSPITAL AT GULFPORT	Y
WINSTON COUNTY MEDICAL FOUNDATION	N
TALLAHATCHIE GENERAL HOSPITAL	Y
Alonzo J. Davis, IV, M.D., PHD., PC	N
NESHOBA PHYSICIAN BILLING SERVICE	N
OCH CENTER FOR BREAST HEALTH	N
CALHOUN MEDICAL CLINIC LLC	Y
MAGNOLIA REGIONAL HEALTH CENTER	Y
OCH FAMILY HEALTH CLINIC	N
MAGNOLIA EXPRESS CARE	N
MAGNOLIA FAMILY CLINIC	N
MAGNOLIA WOMEN'S CENTER	N
MAGNOLIA ER PROVIDERS	N
MAGNOLIA EAR NOSE & THROAT	N
MAGNOLIA WOUND & HYPERBARIC CLINIC	N
MEA PRIMARY CARE PLUS, LLC	N
MAGNOLIA INTERNAL MEDICINE	N
MAGNOLIA REGIONAL BEHAVIORAL HEALTH SERVICES	N
ST. DOMINIC HOSPITAL MEDICINE LLC	Y
MAGNOLIA NEPHROLOGY CLINIC	N
PERRY COUNTY GENERAL HOSPITAL	Y
MAGNOLIA PROFESSIONAL BILLING	N
MAGNOLIA PRIMARY CARE	N
MAGNOLIA FAMILY MEDICAL PRACTICE	N
MAGNOLIA SURGICAL GROUP	N
OCH MEDICAL ASSOCIATES	N
Annointed Nephrology & HTN PLLC	N
Cardiology Associates of North MS	N
Clay County Medical Corporation	N
Family Care of Ripley	N
Marion Regional Medical Center, INC.	N
North Mississippi Elctrophysiology, LLC	N
North Mississippi Medical Clinics INC	N
Pontotoc Health Services, INC.	N
Relias Emergency Medicine Specialists of Tupelo LLC	N
Tishomingo Health Services, INC.	N
Tupelo Medical Group, LLC	N
Webster Health Services INC	N
Surgery Associates PA	Y
Surgery Clinic of Tupelo PA	N
James White	N
Clyde Phillips	N
North Mississippi Faculty Practic Plan LLC	N
North Mississippi Gilmore Clinics LLC	N
Barry Clark	N
North East Orthopaedics PA	N
Orthopaedic Institute of North Mississippi, LLC	N

  
ACO governing body:

Member			Member’s Voting Power	Membership Type	ACO Participant TIN Legal Business Name/DBA, if Applicable
Last Name	First Name	Title/Position
McKay	Danny	Board Member	1	ACO Participant Representative	Noxubee General Critical Access Hospital
Higginbotham	Douglas	Board Member	1	ACO Participant Representative	South Central Regional Medical Center
Brvenik	Richard	Board Member	1	ACO Participant Representative	CARTERET COUNTY GENERAL HOSPITAL CORPORATION
Gibbes	Gregg	Board Member	1	ACO Participant Representative	Covington County Hospital
Green	Jonathan	Board Member	1	ACO Participant Representative	TAYLOR REGIONAL HOSPITAL
Baker-Witt	Fran	Board Member	1	ACO Participant Representative	Effingham Hospital, Inc.
Anderson	John	Treasurer	1	ACO Participant Representative	Anderson Physician Alliance Inc.
Dickerson	Marie	Board Member	1	Medicare Beneficiary Representative
Rogers	Jamie	Board Member	1	ACO Participant Representative	Choctaw Regional Medical Center
Lott	Benjamin	Board Member	1	ACO Participant Representative	Copiah County Medical Center
Christensen	Scott	Board Member	1	ACO Participant Representative	Delta Regional Medical Center
Netterville	Chad	Board Member	1	ACO Participant Representative	Field Memorial Community Hospital
Boleware	Mike	Board Member	1	ACO Paricipant Representative	Franklin County Memorial Hospital
Jordan	Eric	Board Member	1	ACO Participant Representative	Jasper General Hospital
Hoover	Alvin	Chairman	1	ACO Participant Representative	Kings Daughter Medical Center
Nakagawa	Marc	Board Member	1	ACO Participant Representative	Magnolia Regional Health Center
Nicaud	Kent	Vice-Chairman	1	ACO Participant Representative	Memorial Hosptial at Gulfport
Thomas	Gene	Board Member	1	ACO Participant Representative	Memorial Hospital at Gulfport
Haarala	Casey	Board Member	1	ACO Participant Representative	Meridian Medical Associates, PA
Gardner	Paul	Executive Director	1	ACO Participant Representative	Mississippi Hospital Association
McCall	Lee	Board Member	1	ACO Participant Representative	Neshoba County General Hospital
Miller	Sam	Board Member	1	ACO Participant Representative	North Sunflower Medical Center
Jackson	James	Board Member	1	ACO Participant Representative	Oktibbeha County Hospital
Mitchell	Donna	Board Member	1	ACO Participant Representativae	Pearl River County Hospital & Nursing Home
Paris	David	Board Member	1	ACO Participant Representative	Perry County General Hospital
Higginbottom	Douglas	Secretary	1	ACO Participant Representative	South Central Regional Medical Center
Morgan	William	ACO Medical Director	1	ACO Participant Representative	St. Dominic Hospital Medicine LLC
Blackwood	Jim	Board Member	1	ACO Participant Representative	Tallahatchie General Hospital
Chapman	Patrick	Board Member	1	ACO Participant Representative	Tippah County Hospital
Staten	Gary	Board Member	1	ACO Participant Representative	Trace Regional Hospital
Waddell	Kathy	Board Member	1	ACO Participant Representative	Wayne General Hospital
Black	Paul	Board Member	1	ACO Participant Representative	Winston County Medical Foundtation
Varner	Terry	Board Member	1	ACO Participant Representative	Yalobusha General Hospital

 
Key ACO clinical and administrative leadership:

Robert Humphrey	ACO Executive
Thomas Dobbs, MD	Medical Director
Leeann Hastings	Compliance Officer
Rayna Caplan	Quality Assurance/Improvement Officer

 
Associated committees and committee leadership:

Committee Name	Committee Leader Name and Position
Information Technology Committee	James Patterson, Chairman
Care Coordination & Patient Engagement Committee	Nina Brown, Chairman
Evidence-Based Medicine Committee	James Medlin, MD, Chairman
Finance Committee	Meg Ebert, Chairman
Quality & Performance Improvement Committee	Holly Rigdon, Chairman

 

Types of ACO participants, or combinations of participants, that formed the ACO:

• Critical Access Hospital (CAH) billing under Method II
• Hospital employing ACO professionals
• Partnerships or joint venture arrangements between hospitals and ACO professionals
• Rural Health Clinic (RHC)

 

Shared Savings and Losses

Amount of Shared Savings/Losses

• First Agreement Period
  • Performance Year 2018, $0

 

Shared Savings Distribution

• First Agreement Period
  • Performance Year 2018
    • 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

2018 Quality Performance Results:

ACO#	Measure Name	Rate	ACO Mean
ACO-1	CAHPS: Getting Timely Care, Appointments, and Information	86.19	86.14
ACO-2	CAHPS: How Well Your Providers Communicate	94.95	93.93
ACO-3	CAHPS: Patients’ Rating of Provider	93.72	92.45
ACO-4	CAHPS: Access to Specialists	82.52	81.50
ACO-5	CAHPS: Health Promotion and Education	56.64	59.26
ACO-6	CAHPS: Shared Decision Making	63.95	61.94
ACO-7	CAHPS: Health Status/Functional Status	69.38	73.35
ACO-34	CAHPS: Stewardship of Patient Resources	29.97	26.26
ACO-8	Risk Standardized, All Condition Readmission	15.57	14.98
ACO-35	Skilled Nursing Facility 30-day All-Cause Readmission measure (SNFRM)	18.79	18.59
ACO-36	All-Cause Unplanned Admissions for Patients with Diabetes	49.98	37.01
ACO-37	All-Cause Unplanned Admissions for Patients with Heart Failure	102.45	76.75
ACO-38	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions	80.31	59.00
ACO-43	Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91)	3.22	1.98
ACO-11	Use of Certified EHR Technology	100.00	98.20
ACO-12	Medication Reconciliation Post-Discharge	68.69	85.91
ACO-13	Falls: Screening for Future Fall Risk	52.96	79.73
ACO-44	Use of Imaging Studies for Low Back Pain	59.09	64.36
ACO-14	Preventive Care and Screening: Influenza Immunization	74.57	72.71
ACO-15	Pneumonia Vaccination Status for Older Adults	66.02	75.97
ACO-16	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up	49.00	76.83
ACO-17	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	70.18	72.81
ACO-18	Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan	21.05	66.74
ACO-19	Colorectal Cancer Screening	57.71	68.27
ACO-20	Breast Cancer Screening	68.55	71.96
ACO-42	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	79.55	81.47
ACO-27	Diabetes Mellitus: Hemoglobin A1c Poor Control	17.00	15.51
ACO-41	Diabetes: Eye Exam	43.87	52.42
ACO-28	Hypertension (HTN): Controlling High Blood Pressure	68.65	73.10
ACO-30	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	87.90	88.92

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

• For 2018 Quality Performance Results please visit: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2018-Shared-Savings-Program-SSP-Accountable-Care-O/v47u-yq84/data

 
Note: In the Quality Performance Results file(s) above, search for “CPSI ACO 3 LLC” or “Myriad Health Alliance” to view the quality performance results. This ACO can also be found by using the ACO ID A3566 in the public use files on data.cms.gov.

Payment Rule Waivers

• No, our ACO does not use the SNF 3-Day Rule Waiver.

Arrangements Disclosed
 
The ACO Board of Managers for CPSI ACO 3 LLC (“Board”) has formally determined the following arrangements are reasonably related to the purposes of the Medicare Shared Savings Program (“MSSP”), as required for use of the MSSP ACO Participation Waiver:
 
Participant Support Arrangements
 
Under the applicable Participant Agreements between the ACO and the Participants listed above, certain Participants are designated as Principal Participants and others are Non-Principal Participants.  Under the Service Agreements between each Participant and Caravan Health, Inc., the Principal Participants have agreed to pay for certain ACO-related expenses of the Non-Principal Participants in their respective regions, including management fees owed by each Non-Principal Participant.  In each case, the fees and other expenses paid by the Principal Participants on behalf of the Non-Principal Participants will be set in advance, will not vary based on the volume or value of any referrals between the Principal Participants and Non-Principal Participants (except to the extent such referrals indirectly contribute to the earning of shared savings or shared losses as applicable).
 
Through a formal resolution dated March 27, 2018, the Board determined that these arrangements are reasonably related to the purposes of the Medicare Shared Savings Program because they facilitate the participation of the Non-Principal Participants in the Medicare Shared Savings Program, which: i) promotes the accountability of Non-Principal Participants for the quality, cost, and overall care for a Medicare patient population as described in the Shared Savings Program; ii) promotes the management and coordination of care for Medicare fee-for-service beneficiaries attributed to Non-Principal Participants through an ACO; and iii) encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery for patients, including Medicare beneficiaries, served by Non-Principal Participants.