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 NameScott Hines, MD
Primary Contact Phone Number845-703-6381
Primary Contact Email


Organizational Information

ACO participants:

ACO ParticipantsACO Participant in Joint Venture (Enter Y or N)
Crystal Run Healthcare LLPYes


ACO governing body:

MemberMember’s Voting PowerMembership TypeACO Participant TIN Legal Business Name/DBA, if Applicable
Last NameFirst NameTitle/Position
CheungFrancisCIO12.5%EmployeeCrystal Run Healthcare ACO
HinesScottChief Quality Officer12.5%EmployeeCrystal Run Healthcare ACO
NasserJonathanChief Clinical Integration Officer12.5%EmployeeCrystal Run Healthcare ACO
SanstedDougChief Strategy & Legal Officer12.5%EmployeeCrystal Run Healthcare ACO
SpencerGregoryCMO12.5%EmployeeCrystal Run Healthcare ACO
ZengSteveCFO12.5%EmployeeCrystal Run Healthcare ACO
TeitelbaumHalCEO12.5%EmployeeCrystal Run Healthcare ACO
WaltersKennethMedicare Beneficiary12.5%Medicare BeneficiaryN/A 

Key ACO clinical and administrative leadership:

Hal TeitelbaumACO Executive
Gregory SpencerMedical Director
Katie OwensCompliance Officer
Scott HinesQuality Assurance/Improvement Officer


Associated committees and committee leadership:

Committee NameCommittee Leader Name and Position
Value Based Care CommitteeScott Hines, MD; Chief Quality Officer
Practice Redesign CommitteeJonathan Nasser, MD; Chief Clinical Transformation Officer
Best Practice CouncilScott Hines, MD Chief Quality Officer
IT CommitteeFrancis 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 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 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

2020 Quality Performance Results:

ACO#Measure NameRateACO Mean
ACO-43Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91))1.110.95
ACO-13Falls: Screening for Future Fall Risk60.6884.97


ACO#Measure NameRateACO Mean
ACO-14Preventive Care and Screening: Influenza Immunization68.1876.03
ACO-17Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention90.3281.67
ACO-18Preventive Care and Screening: Screening for Depression and Follow-up Plan31.771.46
ACO-19Colorectal Cancer Screening73.3772.59
ACO-20Breast Cancer Screening76.0574.05
ACO-42Statin Therapy for the Prevention and Treatment of Cardiovascular Disease83.6683.37


ACO#Measure NameRateACO Mean
ACO-27Diabetes Mellitus: Hemoglobin A1c Poor Control15.9414.7
ACO-28Hypertension (HTN): Controlling High Blood Pressure63.3572.87

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.

Note: In the Quality Performance Results file(s) above, search for “Crystal Run Healthcare ACO, LLC” to view the quality performance results. This ACO can also be found by using the ACO ID A3452 in the public use files on


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.