MountainStar Care Partners - ACO

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Public reporting

ACO name and location

MountainStar Care Partners ACO
60 East South Temple Street #1900
Salt Lake City, UT 84111

ACO primary contact

Kelley Frazier
(801) 568-5982
Email Kelly Frazier

Organization information

**ACO Participants**
ACO Participants	ACO Participant in Joint Venture
Andrew Robinson DO	No
ASHLEY VALLEY PHYSICIAN PRACTICE LLC	No
BOISE FAMILY MEDICINE LLC	No
Castleview Hospital	No
CASTLEVIEW PHYSICIAN PRACTICE, LLC	No
EAST FALLS FAMILY MEDICINE LLC	No
Erland Internal Medicine LLC	No
FALL RIVER MEDICAL PLLC	No
GENE HODGES	No
HUNTER MEDICAL CENTER INC	No
JONATHAN BARRUS DO PC	No
JULIAN DEBRUYNKOPS MD PA	No
KATIE A JULIEN MD PC	No
LIVING TREE MEDICAL GROUP	No
MICHAEL D JONES MD PC	No
Miller Medical LLC	No
MOMENTUM MEDICAL GROUP OF IDAHO LLC	No
MOUNTAINSTAR MEDICAL GROUP-OGDEN REGIONAL MEDICAL CENTER LLC	No
MOUNTAINSTAR MEDICAL GROUP-ST. MARKS HOSPITAL LLC	No

**ACO governing body**
Member First Name	Member Last Name	Member Title/ Position	Member's Voting Power	Membership Type	ACO Participant Legal Business Name
Daniel	Young	Board Chair	20%	ACO Participant Representative	MOUNTAINSTAR MEDICAL GROUP-ST. MARKS HOSPITAL LLC
Gene	Hodges	Physician	20%	ACO Participant Representative	GENE HODGES
Michelle	Dahle	Board Member	20%	ACO Participant Representative	HUNTER MEDICAL CENTER INC
Nichole	Munck	Compliance Officer	0%	Other N/A	N/A
Robert	Whipple	Board Member	20%	Medicare Beneficiary Representative	N/A
Samuel	Gardner	Board Member	20%	ACO Participant Representative	STEELE MEMORIAL MEDICAL CENTER

Due to rounding, 'Member’s Voting Power' may not equal 100 percent.

Key ACO clinical and administrative leadership

ACO Executive: Kelley Frazier
Medical Director: Nathan Levanger, Phillip Roberts
Compliance Officer: Nichole Munck
Quality Assurance/Improvement Officer: Kelley Frazier, Nichole Munck

Associated committees and committee leadership

Committee name	Committee leader name and position
N/A	N/A

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

Networks of individual practices of ACO professionals

Shared savings and losses

Amount of shared savings/losses:

First Agreement Period

Performance Year 2026, N/A
Performance Year 2025, N/A
Performance Year 2024, N/A
Performance Year 2023, $0.00

Shared savings distribution:

Our ACO has not yet received financial reconciliation results; therefore, this section is not applicable at this time.

Quality performance results

2024 quality performance results:

Quality performance results are based on the CMS Web Interface collection type.

Measure #	Measure Title	Collection Type	Performance Rate	Current Year Mean Performance Rate (Shared Savings Program ACOs)
321	CAHPS for MIPS	CAHPS for MIPS Survey	6.34	6.67
479*	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.13	0.1517
484*	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)	Administrative Claims	-	37
318	Falls: Screening for Future Fall Risk	CMS Web Interface	80.27	88.99
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	51.21	68.6
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	46.15	79.98
113	Colorectal Cancer Screening	CMS Web Interface	78.95	77.81
112	Breast Cancer Screening	CMS Web Interface	80	80.93
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	83.83	86.5
370	Depression Remission at Twelve Months	CMS Web Interface	17.65	17.35
001*	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	7.26	9.44
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	77.91	81.46
236	Controlling High Blood Pressure	CMS Web Interface	72.16	79.49
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	85.56	83.7
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	92.89	93.96
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	91.19	92.43
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	75.81	75.76
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	63.87	65.48
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	63.6	62.31
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	73.37	74.14
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	85.55	85.89
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	92.36	92.89
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	35.6	26.98

For previous years’ Financial and Quality Performance Results, please visit: Data.cms.gov.

*For Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [Quality ID #001], Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [Measure #479], and Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], a lower performance rate indicates better measure performance.

*For Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], patients are excluded if they were attributed to Qualifying Alternative Payment Model (APM) Participants (QPs). Most providers participating in Track E and ENHANCED track ACOs are QPs, and so performance rates for Track E and ENHANCED track ACOs may not be representative of the care provided by these ACOs' providers overall. Additionally, many of these ACOs do not have a performance rate calculated due to not meeting the minimum of 18 beneficiaries attributed to non-QP providers.

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.

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