ACO Public Reporting Information for Southern Illinois
ACO Name & Location
SSM IL ACO, LLC
12800 Corporate Hill
St. Louis, MO 63131
ACO Primary Contact
Lisa Crouch
618-436-8564
Email: lisa.crouch@ssmhealth.com
Organizational Information
ACO Participants
| ACO Participants | ACO Participant in Joint Venture |
| Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group) | Y |
| County of Clay (Clay County Hospital) | Y |
| Washington County Hospital District (Washington County Hospital) | Y |
| Maamoun Junidi | Y |
ACO Governing Body
| Member First Name | Member Last Name | Member Title or Position | Member's Voting Power (expressed as a percentage) | Membership Type | ACO Participant Legal Business Name and D/B/A, if applicable |
| Jayceen | Ensrude | Voting Member & Chair, SSM Health | 16.7% | ACO Participant Representative | Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group) |
| Sudeep | Nair, MD | Voting Member | 16.7% | ACO Participant Representative | Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group) |
| Ralph | Latta, MD | Voting Member | 16.7% | ACO Participant Representative | Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group) |
| Brandon | Cycholl, MD | Voting Member | 16.7% | ACO Participant Representative | County of Clay (Clay County Hospital) |
| Ginger | Fewell, MD | Voting Member | 16.7% | ACO Participant Representative | Washington County Hospital District (Washington County Hospital) |
| Beth | Likens | Voting Member | 16.7% | Medicare Beneficiary Representative | N/A |
Key ACO Clinical & Administrative Leadership
- ACO Executive: Jayceen Ensrude
- Medical Director: Sudeep Nair, MD
- Compliance Officer: Angela Distler
- Quality Assurance/Improvement Officer: Lisa Crouch, RN
Associated Committees & Committee Leadership
| Committee Name | Committee Leader Name & Position |
| Finance Committee | John Snodsmith, CFO, Regional Vice President of Finance |
| Quality Assurance and Improvement Committee | Lisa Crouch, RN-Director, Quality Assurance/Improvement Officer |
| Compliance Committee | Angela Distler, Director Corporate Responsibility, Compliance Officer |
Types of ACO Participants, or Combinations of Participants, that Formed the ACO:
- ACO professionals in a group practice arrangement
Critical Access Hospital (CAH) billing under Method II
Shared Savings and Losses
Amount of Shared Savings / Losses:
- Third Agreement Period
- Performance Year 2022, $1,465,602.01
- Second Agreement Period
- Performance Year 2021, $910,954.10
- First Agreement Period
- Performance Year 2020, $1,131,015.42
Shared Savings Distribution:
- Third Agreement Period
- Performance Year 2022
- Proportion invested in infrastructure: 60%
- Proportion invested in redesigned care processes/resources: 0%
- Proportion of distribution to ACO participants: 40%
- Performance Year 2022
- Second Agreement Period
- Performance Year 2021
- Proportion invested in infrastructure: 15%
- Proportion invested in redesigned care processes/resources: 15%
- Proportion of distribution to ACO participants: 70%
- Performance Year 2021
- First Agreement Period
- Performance Year 2020
- Proportion invested in infrastructure: 36%
- Proportion invested in redesigned care processes/resources: 14%
- Proportion of distribution to ACO participants: 50%
- Performance Year 2020
Quality Performance Results
2022 Quality Performance Results
Quality performance results are based on CMS Web Interface Measure Set.
| Measure # | Measure Name | Collection Rate | Rate | ACO Mean |
| 0001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | CMS Web Interface | 14.10 | 10.71 |
| 134 | Preventative Care and Screening: Screening for Depression and Follow-Up Plan | CMS Web Interface | 96.79 | 76.16 |
| 236 | Controlling High Blood Pressure | CMS Web Interface | 67.96 | 74.87 |
| 318 | Falls: Screening for Future Fall Risk | CMS Web Interface | 85.88 | 87.803 |
| 110 | Preventative Care and Screening: Influenza Immunization | CMS Web Interface | 64.07 | 77.34 |
| 226 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | CMS Web Interface | 70.93 | 79.27 |
| 113 | Colorectal Cancer Screening | CMS Web Interface | 56.28 | 75.32 |
| 112 | Breast Cancer Screening | CMS Web Interface | 72.3 | 78.07 |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | CMS Web Interface | 73.51 | 86.37 |
| 370 | Depression Remission at Twelve Months | CMS Web Interface | 14.29 | 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 | 0.1739 | .0151 |
| MCC1 | All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC) | Administrative Claims | 36.21 | 30.97 |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | CAHPS for MIPS Survey | 87.25 | 83.96 |
| CAHPS-2 | How Well Providers Communicate | CAHPS for MIPS Survey | 95.27 | 93.47 |
| CAHPS-3 | Patient's Rating of Provider | CAHPS for MIPS Survey | 92.4 | 92.06 |
| CAHPS-4 | Access to Specialists | CAHPS for MIPS Survey | 81.9 | 77 |
| CAHPS-5 | Health Promotion and Education | CAHPS for MIPS Survey | 65.74 | 62.68 |
| CAHPS-6 | Shared Decision Making | CAHPS for MIPS Survey | 66.2 | 60.97 |
| CAHPS-7 | Health Status and Functional Status | CAHPS for MIPS Survey | 71.3 | 73.06 |
| CAHPS-8 | Care Coordination | CAHPS for MIPS Survey | 88.1 | 85.46 |
| CAHPS-9 | Courteous and Helpful Office Staff | CAHPS for MIPS Survey | 95.34 | 91.97 |
For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.
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.
- 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.
Fraud and Abuse Waivers
- ACO Pre-Participation Waiver: N/A
- ACO Participation Waiver: N/A