ACO Public Reporting Information for Wisconsin

ACO Name & Location

SSM WI ACO, LLC
1808 W Beltline Hwy
Madison, WI 53589

Michelle Walker
608-280-4495
Email: michelle.walker@ssmhealth.com

ACO Participants	ACO Participant in Joint Venture
Dean Health Systems Inc.	N
Agnesian Healthcare Inc.	N
The Monroe Clinic Inc.	N
Wildwood Family Clinic SC	N

Member First Name	Member Last Name	Member Title/Position	Member's Voting Power (Expressed as as a Percentage)	Membership Type	ACO Participant Legal Business Name, if Applicable
Brent	Meier, MD	Voting Member & Chair	14.3%	Other	N/A
Shane	Smith	Voting Member	14.3%	ACO Participant Representative	Agnesian Healthcare Inc.
Darren	Pipp, MD	Voting Member	14.3%	ACO Participant Representative	The Monroe Clinic Inc.
Ghulam	Murtaza, MD	Voting Member	14.3%	ACO Participant Representative	Dean Medical Group
Frank	Byrne, MD	Voting Member	14.3%	Medicare Beneficiary Representative	N/A
Paula	Hardgrove, MD	Voting Member	14.3%	ACO Participant Representative	Dean Health Systems Inc.
Sheryl	Green	Voting Member	14.3%	ACO Participant Representative	Wildwood Family Clinic SC

Committee Name	Committee Leader Name and Position
Finance Committee	Matt Kinsella, CFO, Regional Vice President of Finance
Quality Initiatives and Improvement Committee	Michelle Walker, Value Based Contracts Director, Quality Assurance/Improvement Officer
Compliance Committee	Angela Distler, RN, BSN, CHC, Director Corporate Responsibility, Compliance Officer

Partnerships or joint venture arrangements between hospitals and ACO professionals
ACO in a group practice arrangement

First Agreement Period
- Performance Year 2022
  - Proportion invested in infrastructure: 15%
  - Proportion invested in redesigned care processes/resources: 15%
  - Proportion of distribution to ACO participants: 70%

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

Measure #	Measure Name	Collection Type	Rate	ACO Mean
001	Diabetes: Hemoglobin A1C (HbA1c) Poor Control	CMS Web Interface	9.02	10.71
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	84.78	76.97
236	Controlling High Blood Pressure	CMS Web Interface	75.60	76.16
318	Falls: Screening for Future Fall Risk	CMS Web Interface	92.95	87.83
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	84.30	77.34
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	87.18	79.27
113	Colorectal Cancer Screening	CMS Web Interface	85.19	75.32
112	Breast Cancer Screening	CMS Web Interface	85.81	78.07
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	90.91	86.37
370	Depression Remission at Twelve Months	CMS Web Interface	28.57	16.03
321	CAHPS for MIPS	CAHPS for MIPS Survey	N/A	N/A
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1438	0.1510
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims	35.28	30.97

For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.

Skilled Nursing Facility (SNF) 3-Day Rule Waiver:
- Our ACO uses the SNF 3-Day Rule Waiver, pursuant to pursuant to 42 CFR §425.612.
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.