ACO Name and Location

Covenant ACO, Inc.
Previous Legal Business Entity Name: Covenant Health Partners, Inc.
3615 19th St
Lubbock, Texas 79410

ACO Primary Contact

Nathan Taylor
(806) 725-3296
Nathan.Taylor@stjoe.org

Organizational Information

ACO Participants:

ACO Governing Body:

Member			Member's Voting Power – Expressed as a percentage or number	Membership Type	ACO Participant Legal Business Name/DBA, if Applicable
Last Name	First Name	Title/Position
Snodgrass	Brad	Chair	0	ACO Participant Representative	Covenant Medical Group
Hill	Joshua	Vice Chair	1	ACO Participant Representative	Hill Medical Associates, LLP
Brown	Jeremy	Member	1	ACO Participant Representative	Covenant Medical Group
Collins	Christopher	Member	1	ACO Participant Representative	Grace Clinic of Lubbock
Crow	Steven	Member	1	ACO Participant Representative	Covenant Medical Group
Dalley	Ethan	Member	1	Community Stakeholder Representative	Neurosurgical Associates LLP
Dalton	Jeremy	Member	1	ACO Participant Representative	Covenant Medical Group
Foster	Dominique	Member	1	ACO Participant Representative	Covenant Medical Group
Gadwala	Swetha	Member	1	Community Stakeholder Representative	Sound Physicians
Henderson	Richard	Member	1	ACO Participant Representative	Covenant Medical Group
Parmar	Kompal	Member	1	ACO Participant Representative	Covenant Medical Group
Rose	Christopher	Member	1	ACO Participant Representative	Christopher R Rose MD PA
Rozean	Randy	Member	1	ACO Participant Representative	Family First HealthCare
Sallee	Caleb	Member	1	ACO Participant Representative	SWAT Surgical Associates
Soriano	Karen	Member	1	ACO Participant Representative	Covenant Medical Group
Starnes	Joel	Member	1	ACO Participant Representative	Covenant Medical Group
Strefling	Jason	Member	1	ACO Participant Representative	Covenant Medical Group
Tiemann	Kirk	Member	1	ACO Participant Representative	Kirk J Tiemann, MD, PA
West	Andrew	Member	1	ACO Participant Representative	Covenant Medical Group
Yates	Marissa	Member	1	ACO Participant Representative	Covenant Medical Group
Deshan	Preston	Member	0	Medicare Beneficiary Representative	N/A
Franklin	Linda	Member	0	Medicare Beneficiary Representative	N/A
Neal	Nancy	Member	0	Medicare Beneficiary Representative	N/A
Shropshire	Jack	Member	0	Medicare Beneficiary Representative	N/A
Zwiacher	Ann	Member	0	Medicare Beneficiary Representative	N/A

Key ACO Clinical and Administrative Leadership:

Title	Name
ACO Executive	Walter Cathey
Medical Director	Michael Robertson, MD
Compliance Officer	Nathan Taylor
Quality Assurance/Improvement Officer	Lisa Barrington

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
Credentials Committee	Dr. Jeremy Brown, Chair
Population Health Committee	Dr. Randolph Rozean, Chair
Quality & Performance Committee	Dr. Christopher Collins, Chair

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

• Networks of individual practices of ACO professionals
• Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses:

• Third Agreement Period
  • Performance Year 2023, $5,249,167
  • Performance Year 2022, $5,349,938
  • Performance Year 2021, $3,392,164
  • Performance Year 2020, $2,467,947
• Second Agreement Period
  • Performance Year 2019, -$688,512
    • Note: Our ACO participated in multiple performance years during Calendar Year 2019. The shared losses amount reported for Performance Year 2019 therefore represents net shared losses across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.
  • Performance Year 2018, $2,415,533
  • Performance Year 2017, $282,266
• First Agreement Period
  • Performance Year 2016, $2,659,327
  • Performance Year 2015, $0
  • Performance Year 2014, $2,542,945

Shared Savings Distribution:

• Third Agreement Period
  • Performance Year 2023
    • Proportion invested in infastructure: 20%
    • Proportion invested in redesigned care processes/resources: 20%
    • Proportion of distribution to ACO participants: 60%
  • Performance Year 2022
    • Proportion invested in infastructure: 25%
    • Proportion invested in redesigned care processes/resources: 25%
    • Proportion of distribution to ACO participants: 50%
  • Performance Year 2021
    • Proportion invested in infastructure: 25%
    • Proportion invested in redesigned care processes/resources: 25%
    • Proportion of distribution to ACO participants: 50%
  • Performance Year 2020
    • Proportion invested in infastructure: 26%
    • Proportion invested in redesigned care processes/resources: 20%
    • Proportion of distribution to ACO participants: 54%
• Second Agreement Period
  • Performance Year 2019
    • Proportion invested in infastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
    • Note: Our ACO participated in multiple performance years during Calendar Year 2019. The distribution of shared savings reported for Performance Year 2019 therefore represents net shared savings across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.
  • Performance Year 2018
    • Proportion invested in infastructure: 17%
    • Proportion invested in redesigned care processes/resources: 35%
    • Proportion of distribution to ACO participants: 48%
  • Performance Year 2017
    • Proportion invested in infastructure: 25%
    • Proportion invested in redesigned care processes/resources: 8%
    • Proportion of distribution to ACO participants: 66%
• First Agreement Period
  • Performance Year 2016
    • Proportion invested in infrastructure: 25%
    • Proportion invested in redesigned care processes/resources: 8%
    • Proportion of distribution to ACO participants: 66%
  • 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
  • Performance Year 2014
    • Proportion invested in infrastructure: 25%
    • Proportion invested in redesigned care processes/resources: 25%
    • Proportion of distribution to ACO participants: 50%

Quality Performance Results

2023 Quality Performance Results:

Quality performance results are based on CMS Web Interface

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOs)
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	88.88	83.68
CAHPS-2	How Well Your Providers Communicate	CAHPS for MIPS Survey	94.23	93.69
CAHPS-3	Patients’ Rating of Provider	CAHPS for MIPS Survey	92.68	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	77.74	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	59.53	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	59.43	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	75.20	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	86.28	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	92.49	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	32.20	26.69
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	12.68	9.84
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	80.33	80.97
236	Controlling High Blood Pressure	CMS Web Interface	65.40	77.80
318	Falls: Screening for Future Fall Risk	CMS Web Interface	87.41	89.42
110	Preventive Care and Screening: Influenza Immunization	CMS Web Interface	70.20	70.76
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	66.67	79.29
113	Colorectal Cancer Screening	CMS Web Interface	74.28	77.14
112	Breast Cancer Screening	CMS Web Interface	80.07	80.36
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	78.79	87.05
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1511	0.1553
484	Clinician & Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims		35.39

• 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.
• Payment for Telehealth Services
  • Our ACO clinicians provide telehealth services using the flexibilities under 42 CFR §425.612(f) and 42 CFR §425.613.