Public Reporting
The Shared Savings Program requires ACOs to create and maintain a dedicated webpage to publicly report required organizational and programmatic information, such as organizational contact information and performance results. CMS provides instructions to ACOs ahead of each public reporting cycle.”
ACO Name and Location
Crystal Run Healthcare ACO, LLC
155 Crystal Run Road
Middletown, New York 10941
ACO Primary Contact
Primary Contact Name | Scott Hines, MD |
Primary Contact Phone Number | 845-703-6381 |
Primary Contact Email Address | shines@crystalrunhealthcare.com |
Organizational Information
ACO participants:
ACO Participants | ACO Participant in Joint Venture (Enter Y or N) |
Crystal Run Healthcare LLP | Yes |
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 | |||
Cheung | Francis | CIO | 12.5% | Employee | Crystal Run Healthcare ACO |
Hines | Scott | Chief Quality Officer | 12.5% | Employee | Crystal Run Healthcare ACO |
Nasser | Jonathan | Chief Clinical Integration Officer | 12.5% | Employee | Crystal Run Healthcare ACO |
Sansted | Doug | Chief Strategy & Legal Officer | 12.5% | Employee | Crystal Run Healthcare ACO |
Spencer | Gregory | CMO | 12.5% | Employee | Crystal Run Healthcare ACO |
Zeng | Steve | CFO | 12.5% | Employee | Crystal Run Healthcare ACO |
Teitelbaum | Hal | CEO | 12.5% | Employee | Crystal Run Healthcare ACO |
Walters | Kenneth | Medicare Beneficiary | 12.5% | Medicare Beneficiary | N/A |
Key ACO clinical and administrative leadership:
Hal Teitelbaum | ACO Executive |
Gregory Spencer | Medical Director |
Katie Owens | Compliance Officer |
Scott Hines | Quality Assurance/Improvement Officer |
Associated committees and committee leadership:
Committee Name | Committee Leader Name and Position |
Value Based Care Committee | Scott Hines, MD; Chief Quality Officer |
Practice Redesign Committee | Jonathan Nasser, MD; Chief Clinical Transformation Officer |
Best Practice Council | Scott Hines, MD Chief Quality Officer |
IT Committee | Francis Cheung; Chief Information Officer |
Types of ACO participants, or combinations of participants, that formed the ACO:
- ACO professionals in a group practice arrangement
Shared Savings and Losses
Amount of Shared Savings/Losses
- Second Agreement Period
- Performance Year 2021, $0
- Performance Year 2020, $2,391,188.71
- First Agreement Period
- Performance Year 2019, $0
- Performance Year 2018, $2,752,398
- Performance Year 2017, $2,740,733
Shared Savings Distribution
Crystal Run Healthcare ACO will distribute all of the shared savings it earned in the following manner: Crystal Run Healthcare plans on using any shared savings to reinvest in the necessary infrastructure to further our mission of improving clinical quality, improving the patient experience, and reducing the cost of care. This will include investments in technology to collect and analyze clinical data, additional care coordinators to coordinate the care of our sickest patients, and capital investments to enhance our facilities. We also plan to use some of this money to incentivize our physicians to embrace the tenets of value based care.
Shared Savings Distribution
Second Agreement Period
- Performance Year 2021
- 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 2020
- Proportion invested in infrastructure: 50%
- Proportion invested in redesigned care processes/resources: 50%
- Proportion of distribution to ACO participants: 0%
First Agreement Period
- Performance Year 2019
- 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 2018
- Proportion invested in infrastructure: 50%
- Proportion invested in redesigned care processes/resources: 50%
- Proportion of distribution to ACO participants: 0%
- Performance Year 2017
- Proportion invested in infrastructure: 50%
- Proportion invested in redesigned care processes/resources: 50%
- Proportion of distribution to ACO participants: 0%
Quality Performance Results
2021 Medicare Shared Savings Program Quality Performance Report
A3452 – CRYSTAL RUN HEALTHCARE ACO, LLC
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 | 71 | 416 | 17.07 | 12.46 | |
134 | Preventative Care and Screening: Screening for Depression and Follow-up Plan | N | 91 | 249 | 36.55 | 74.38 | |
236 | Controlling High Blood Pressure | Y | 176 | 258 | 68.22 | 74.87 | |
318 | Falls: Screening for Future Fall Risk | Y | 173 | 269 | 64.31 | 87.03 | |
110 | Preventative Care and Screening: Influenza Immunization | Y | 225 | 276 | 81.52 | 80.52 | |
226 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | Y | 33 | 53 | 62.26 | 80.97 | |
113 | Colorectal Cancer Screening | Y | 231 | 298 | 77.52 | 73.63 | |
112 | Breast Cancer Screening | Y | 358 | 472 | 75.85 | 75.11 | |
438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | N | 222 | 253 | 87.75 | 84.24 | |
370 | Depression Remission at Twelve Months | N | 4 | 54 | 7.41 | 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 | — | — | 0.1643 | 0.1540 | |
MCC1 | All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)2 | Y | — | — | 37.50 | 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.
Quality Performance Results, continued – CAHPS for MIPS
2021 Medicare Shared Savings Program Quality Performance Report
A3452 – CRYSTAL RUN HEALTHCARE ACO, LLC
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 | 75.53 | 84.67 | |
CAHPS-2 | How Well Providers Communicate | Y | 93.01 | 93.56 | |
CAHPS-3 | Patient’s Rating of Provider | Y | 89.89 | 92.19 | |
CAHPS-4 | Access to Specialists | N | 75.00 | 78.80 | |
CAHPS-5 | Health Promotion and Education | Y | 56.83 | 61.61 | |
CAHPS-6 | Shared Decision Making | Y | 50.31 | 60.89 | |
CAHPS-7 | Health Status and Functional Status | N | 72.49 | 71.78 | |
CAHPS-8 | Care Coordination | Y | 85.24 | 85.66 | |
CAHPS-9 | Courteous and Helpful Office Staff | Y | 87.89 | 91.88 | |
CAHPS-11 | Stewardship of Patient Resources | Y | 15.35 | 24.71 |
Payment Rule Waivers
- Skilled Nursing Facility (SNF) 3-day Rule Waiver:
- No, our ACO does not use the SNF 3-Day Rule Waiver.
- 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.
- Skilled Nursing Facility (SNF) 3-day Rule Waiver:
Fraud and Abuse Waivers
- ACO Pre-Participation Waiver:The following information describes each arrangement for which our ACO seeks protection under the ACO Pre-Participation Waiver, including any material amendment or modification to a disclosed arrangement.[For each arrangement, provide the following information:
- Parties to the arrangement: N/A
- Date of arrangement: N/A
- Items, services, goods, or facility provided: N/A
- Date and nature of any amendments to the arrangement, if applicable: N/A
- ACO Participation Waiver:
The following information describes each arrangement for which our ACO seeks protection under the ACO Participation Waiver, including any material amendment or modification to a disclosed arrangement.[For each arrangement, provide the following information:- Parties to the arrangement: N/A
- Date of arrangement: N/A
- Items, services, goods, or facility provided: N/A
- Date and nature of any amendments to the arrangement, if applicable: N/A