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Carroll ACO (an Accountable Care Organization)

ACO Name and Location

Carroll ACO, LLC
200 Memorial Avenue
Westminster, Maryland 21157

ACO Primary Contact 


Primary Contact Name             Joshua Parks 
Primary Contact Phone Number  410-871-7597 
Primary Contact Email Address  


Organizational Information

ACO Participants

ACO Participants ACO Participant in Joint Venture (Enter Y or N)
Inwha Cho, M.D.   N
Westminster Internal Medicine Association  N
Family Podiatry of Maryland, LLC   N
Michael Davis   N
Dixie Colgan  N
Inwha Cho, M.D.  N
Carroll Health Group, LLC  N
Carroll Regional Cancer Center Physicians, LLC  N
Mid Atlantic Pulmonary, Critical Care and Sleep, PC  N
LifeBridge Multi-Specialty, LLC  N
Smart Pain Management, LLC  N
T&L Optical Supply, Inc.  N
Carroll Hospital Center, Inc.  N
Carroll Primary Care  N
Oral and Maxillofacial Surgery Specialists, P.C.   N
Weintraub and Kessler LLC   N
Carroll Arthritis, PA   N
Airpark Primary Care, LLC    N
Manchester Family Medicine, LLC  N
Carroll Digestive Associates, P.A.  N
Mokhtar Nasir, M.D. PA   N
Carroll County Anesthesia Associates, PA  N
Young J. Cho, M.D., P.A.   N
John C. Baer, M.D. LLC   N
Dr. Wilbur Kuo & Associates Internal Medicine LLC  N
Manchester Medical Center, LLC  N
MDICS at Carroll Hospital Center, LLC  N

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
Galvin, M.D. Todd ACO Participant  1 Chair & Voting Member Carroll Health Group, LLC
Freiji, M.D. Khalil ACO Participant  1 Voting Member Westminster Internal Medicine Association
Green, M.D. Andrew ACO Participant  1 Voting Member Carroll County Anesthesia Associates, PA
Hochuli, M.D. Stephan ACO Participant  1 Voting Member Stephan U. Hochuli, M.D.
Johnston, M.D. Kimberly ACO Participant  1 Medical Director & Voting Member LifeBridge Multi-Specialty, LLC
Kelbly Kevin Hospital Administrator  1 Treasurer & Voting Member  
Leitch Larry Community Member  1 Medicare Beneficiary  
Loeffler, M.D. Sara ACO Participant  1 Voting Member Carroll Health Group, LLC
McClernan Sharon Hospital Administrator   1 Secretary & Voting Member  
McEvoy, M.D. Michael ACO Participant  1 Voting Member Carroll Primary Care
Mendoza, M.D. Ernesto ACO Participant  1 Voting Member Carroll Health Group, LLC
Ozgun, M.D. Bertan ACO Participant  1 Voting Member Advanced Radiology, P.A.
Romans Joyce Compliance Officer  0 Non-Voting Member  
Sikorski, M.D. Stephen ACO Participant  1 Voting Member Carroll Primary Care
Simmons Leslie Hospital Administrator   1 Voting Member  


Key ACO Clinical and Administrative Leadership

Sharon McClernan  ACO Executive 
Kim Johnston, M.D. Medical Director 
Joyce Romans Compliance Officer
Kim Johnston, M.D.  Quality Assurance/Improvement Officer

Associated Committees and Committee Leadership

Committee Name   Committee Leader Name and Position
Clinical and Quality Committee  Kimberly Johnston, M.D., Chair 
Compliance Committee Bertan Ozgun, M.D., Chair 
Finance Committee  Kevin Kelbly, Chair 
Information Technology Committee  Michael McEvoy, M.D., Chair 
Membership Committee  Leslie Simmons, Chair 

Types of ACO participants, or combinations of participants, that formed the ACO:
  • ACO professionals in a group practice arrangement
  • Networks of individual practices of ACO professionals
  • Hospital employing ACO professionals

Shared Savings/Losses

Amount of Shared Savings/Losses
  • First Agreement Period
º Performance Year 2016, $0
º Performance Year 2015, $0

Shared Savings Distribution
  • First Agreement Period
º Performance Year 2016
 Proportion invested in infrastructure: N/A
 Proportion invested in redesigned care processes/resources: N/A
 Proportion of distribution to ACO participants: N/A

º 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

Quality Performance Results

2016 Quality Performance Results:


ACO#  Measure Name  Rate  ACO Mean 
ACO-1 CAHPS: Getting Timely Care, Appointments, and Information 85.00 80.51 
ACO-2 CAHPS: How Well your Providers Communicate 94.01  93.01
ACO-3 CAHPS: Patients' Rating of Provider 92.77 92.25
ACO-4 CAHPS: Access to Specialists 83.63  83.49 
ACO-5  CAHPS: Health Promotion and Education 60.79  60.32
ACO-6 CAHPS: Shared Decision Making 74.89 75.40 
ACO-7 CAHPS: Health Status/Functional Status 72.61 72.30 
ACO-34 CAHPS: Stewardship of Patient Resources 27.12  26.97 
ACO-8 Risk-Standardized, All Condition Readmission  14.18  14.70
ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)  17.73  18.17
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes 48.53 53.20
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure 63.02  75.23
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions   51.94  59.81
ACO-9 Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary
Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)
10.25  9.27
ACO-10 Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention
Quality Indicator (PQI) #8)
10.14 14.53
ACO-11 Percent of PCPs who Successfully Meet Meaningful Use Requirements 67.57  82.72
ACO-39 Documentation of Current Medications in the Medical Record 72.57  87.54 
ACO-13 Falls: Screening for Future Fall Risk 67.61  64.04
ACO-14 Preventive Care and Screening: Influenza Immunization 77.60  68.32
ACO-15 Pneumonia Vaccination Status for Older Adults 70.40  69.21
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up 66.46  74.45
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 93.23  90.98 
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan 51.14 53.63 
ACO-19 Colorectal Cancer Screening 57.77  61.52
ACO-20 Breast Cancer Screening 74.60  67.61
ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and
Follow-up Documented
73.90  76.79 
ACO-42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease  82.33  77.72
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control  10.76 18.24
ACO-41 Diabetes: Eye Exam  62.55  44.94 
ACO-28 Hypertension (HTN): Controlling High Blood Pressure  61.20 70.69
ACO-30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 96.03 85.05 
ACO-31 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 77.14 88.67
ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
- for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%)
71.35 79.67

Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low samples.    

Note: In the Quality Performance Results file(s) above, search for “Carroll ACO, LLC” to view the quality performance results. This ACO can also be found by using the ACO ID A83956 in the public use files on

Payment Rule Waivers

  • No, our ACO does not use the SNF 3-Day Rule Waiver.


The Board of Carroll ACO, LLC has determined that it is eligible for the Participation and Pre-Participation Waivers eligible under the Medicare Shared Savings Program. See MSSP Waivers Disclosure of Arrangements here.