Public Reporting

Accountable Care Public Reporting Information

Accountable Care Organization (ACO) Name and Location

Freedom Healthcare Alliance, LLC
8761 Dorchester Road
Suite 230
North Charleston, SC 29420

ACO Primary Contact
Primary Contact Name: Lissa Lara, CEO
Primary Contact Phone Number: 843-412-1590
Primary Contact Email Address: lissalara@qualityhealthcaredevelopment.com

Organizational Information

ACO PARTICIPANTS ACO PARTICIPANT IN JOINT-VENTURE (Enter Y or N)
James T Martin Jr MD N
Liberty Doctors, LLC N
Dorchester Medical Associates N
Internal Medicine of Walterboro N
Lake City Family Medicine, LLC N

ACO Governing Body

Member First Name Member Last Name Title/Position Member’s Voting Power – Expressed as a percentage or number Membership Type ACO Participant TIN Legal Business Name/DBA, if Applicable
Lissa Lara CEO 16 Other N/A
Hugh Durrence MD CMO Board Member 13 ACO Participant Representative Liberty Doctors, LLC
Donald Hanna MD Board Member 13 ACO Participant Representative Liberty Doctors, LLC
Douglas Gleaton MD Board Member 13 ACO Participant Representative Liberty Doctors, LLC
John Forney MD Board Member 13 ACO Participant Representative Liberty Doctors, LLC
David Price MD Board Member 6 Medicare Beneficiary Representative N/A
James Martin Jr MD Board Member 13 ACO Participant Representative James T Martin Jr., LLC
Jeffrey  Kramer MD Board Member 13 ACO Participant Representative Internal Medicine of Walterboro

KEY ACO CLINICAL AND ADMINISTRATIVE LEADERSHIP:

Lissa Lara ACO Executive
Hugh Durrence Medical Director
John Park Compliance Officer
Katherine Hill Quality Assurance/Improvement Officer

Associated committees and committee leadership:

Committee Name Committee Leader Name and Position
Finance Committee Lissa Lara, CEO
Hugh Durence, RPh, MD, Medical Director
Quality Committee Lissa Lara, CEO
Hugh Durence, RPh, MD, Medical Director
Katherine Hill, Quality Assurance, Improvement Officer
Compliance Committee Lissa Lara, CEO
Hugh Durence, RPh, MD, Medical Director
John Park, Compliance Officer

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

  • Primary Care Physicians
  • Obstetrics and gynecology

Shared Savings and Losses

Amount of Shared Savings/Losses:

  • Third Agreement Period
    • Performance Year 2021, $2,563,470

    Second Agreement Period

    • Performance Year 2020, $2,960,193
  • First Agreement Period
    • Performance Year 2019, $921,888.92

 

Shared Savings Distribution:

  • Third Agreement Period
    • Performance Year 2021
      • Proportion invested in infrastructure: 16%
      • Proportion invested in redesigned care processes/resources: 9%
      • Proportion of distribution to ACO participants: 74%

    Second Agreement Period

    • Performance Year 2020
      • Proportion invested in infrastructure: 30%
      • Proportion invested in redesigned care processes/resources: 10%
      • Proportion of distribution to ACO participants: 60%

    First Agreement Period

    • Performance Year 2019
      • Proportion invested in infrastructure: 37%
      • Proportion invested in redesigned care processes/resources: 10%
      • Proportion of distribution to ACO participants: 53%

 

Quality Performance Results

2021 Quality Performance Results:

Table 1. Summary Information
Reporting Mechanism1 (A) MIPS Quality Performance Category Score (B) Quality Performance Standard Score2 ACO Quality
Performance Score3
SSP EUC Policy Applied Quality Performance Standard Met
CMS Web Interface 87.49 61.69 87.49 N Y
eCQMs/MIPS CQMs
[1] Cells are populated for the respective reporting mechanism. If quality was reported via only 1 mechanism, then values are displayed as — for the mechanism through which quality was not reported.
[2] The PY 2021 Quality Performance Standard is the 30th percentile MIPS QPC score based on the unweighted distribution.
[3] ACO Quality Performance Score is capped at 100% and is used to determine shared losses and eligibility for shared savings for the purposes of the Shared Savings Program. This is the higher of the MIPS QPC score (A) for a given reporting mechanism and the Quality Performance Standard score (B).

 Table 2. APP – CMS Web Interface Measure Set
Measure # Measure Name Eligible For Scoring1 Numerator Denominator Reported Performance Rate Current Year Mean Performance Rate (SSP ACOs)
001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control2 Y 35 292 11.99 12.46
134 Preventative Care and Screening: Screening for Depression and Follow-up Plan N 148 269 55.02 74.38
236 Controlling High Blood Pressure Y 247 320 77.19 74.87
318 Falls: Screening for Future Fall Risk Y 227 257 88.33 87.03
110 Preventative Care and Screening: Influenza Immunization Y 147 262 56.11 80.52
226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention Y 8 16 50.00 80.97
113 Colorectal Cancer Screening Y 177 318 55.66 73.63
112 Breast Cancer Screening Y 213 317 67.19 75.11
438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease N 508 655 77.56 84.24
370 Depression Remission at Twelve Months N 6 45 13.33 15.50
321 CAHPS for MIPS3 Y N/A N/A N/A N/A
479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups2 Y 0.1632 0.1540
MCC1 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)2 Y 24.58 33.99
[1] For PY 2021, measures #134, #438, and #370 do not have CMS Web Interface benchmarks and are not scored as a result.
[2] A lower performance rate corresponds to higher quality.
[3] CAHPS for MIPS is a composite measure, so numerator, denominator, and performance rate values are not applicable (N/A). See Table 4 for details on CAHPS for MIPS performance.
Table 3. APP – eCQM/MIPS CQM Measure Set
Measure # Measure Name Eligible For Scoring1 Numerator Denominator Reported Performance Rate Current Year Mean Performance Rate (SSP ACOs)
001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control2 Y
134 Preventative Care and Screening: Screening for Depression and Follow-up Plan Y
236 Controlling High Blood Pressure Y
321 CAHPS for MIPS3 Y N/A N/A N/A N/A
479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups2 Y
MCC1 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)2 Y
[1] For PY 2021, all six measures in the eCQM/MIPS CQM Measure set are eligible for scoring.
[2] A lower performance rate corresponds to higher quality.
[3] CAHPS for MIPS is a composite measure, so numerator, denominator, and performance rate values are not applicable (N/A). See Table 4 for details on CAHPS for MIPS performance.

 Table 4. APP – CAHPS for MIPS Measures
Measure ID Measure Name Eligible For Scoring Reported Performance Rate Current Year Mean Performance Rate (SSP ACOs)
CAHPS-1 Getting Timely Care, Appointments, and Information Y 84.84 84.67
CAHPS-2 How Well Providers Communicate Y 93.53 93.56
CAHPS-3 Patient’s Rating of Provider Y 91.80 92.19
CAHPS-4 Access to Specialists N 82.18 78.80
CAHPS-5 Health Promotion and Education Y 65.74 61.61
CAHPS-6 Shared Decision Making Y 66.69 60.89
CAHPS-7 Health Status and Functional Status N 71.23 71.78
CAHPS-8 Care Coordination Y 87.37 85.66
CAHPS-9 Courteous and Helpful Office Staff Y 89.57 91.88
CAHPS-11 Stewardship of Patient Resources Y 32.02 24.71

2020 Quality Performance Results:

 

ACO Quality Measure Number Measure Name Rate ACO Mean
ACO-43 Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91)) 0.81 0.95
ACO-13 Falls: Screening for Future Fall Risk 81.27 84.97
ACO-14 Preventive Care and Screening: Influenza Immunization 66.13 76.03
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 76.47 81.67
ACO-18 Preventive Care and Screening: Screening for Depression and Follow-up Plan 66.67 71.46
ACO-19 Colorectal Cancer Screening 53.23 72.59
ACO-20 Breast Cancer Screening 60.53 74.05
ACO-42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 79.62 83.37
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 13.38 14.70
ACO-28 Hypertension (HTN): Controlling High Blood Pressure 70.94 72.87

 

“Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size. The Centers for Medicare & Medicaid Services (CMS) also waived the requirement for ACOs to field a CAHPS for ACOs survey for PY 2020 through the Physician Fee Schedule Final Rule for Calendar Year 2021. Additionally, CMS reverted ACO-8 Risk-Standardized, All Condition Readmission and ACO-38 Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions to pay-for-reporting, given the impact of the coronavirus disease 2019 (COVID-19) public health emergency (PHE) on these measures.”

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.