ACO Public Reporting Information for Wisconsin

ACO Name & Location

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

ACO Primary Contact

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

Organizational Information

ACO Participants

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

ACO Governing Body

Member First NameMember Last NameMember Title/PositionMember's Voting Power (Expressed as as a Percentage)*Membership TypeACO Participant Legal Business Name, if Applicable
BrentMeier, MDVoting Member & Chair12.50%OtherN/A
DanielleMitchell, MDVoting Member & Medical Director12.50%
ACO Medical DirectorDean Health Systems Inc.
ShaneSmithVoting Member12.50%
ACO Participant RepresentativeAgnesian Healthcare Inc.
FrankByrne, MDVoting Member12.50%
Medicare Beneficiary RepresentativeN/A
PaulaHardgrove, MDVoting Member12.50%
ACO Participant RepresentativeDean Health Systems Inc.
JasonHampton, MDVoting Member12.50%
ACO Participant RepresentativeWildwood Family Clinic SC
KatieMarti, DNPVoting Member12.50%
ACO Participant RepresentativeThe Monroe Clinic Inc. 
JilaineBolek-Berquist, MDVoting Member12.50%
ACO Participant RepresentativeDean Health Systems Inc. 


*Due to rounding, Member’s Voting Power may not equal 100%

Key ACO Clinical & Administrative Leadership Personnel

  • ACO Executive: Brent Meier, MD
  • Medical Director: Danielle Mitchell, MD
  • Compliance Officer: Angela Distler, RN, BSN, CHC
  • Quality Assurance/Improvement Officer: Michelle Walker, MSN, RN

Associated Committees and Committee Leadership

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


Partnerships or joint venture arrangements between hospitals and ACO professionals:

  • Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings / Losses:

  • Third Agreement Period
    • Performance Year 2024, $10,533,536.01
  • Second Agreement Period
    • Performance Year 2023, $8,138,432.30
  • First Agreement Period
    • Performance Year 2022, $5,030,630.23

Shared Savings Distribution:

  • Third Agreement Period
    • Performance Year 2024
      • Proportion invested in infrastructure: 15%
      • Proportion in redesigned processes/resources: 15%
      • Proportion of distribution of ACO participants: 70%
  • Second Agreement Period
    • Performance Year 2023
      • Proportion invested in infrastructure: 15%
      • Proportion invested in redesigned care processes/resources: 15%
      • Proportion of distribution to ACO participants: 70%
  • 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

2024 Quality Performance Results

Quality performance results are based on the eCQM collection type.

SSM WI ACO Quality Results for Public Reporting

Measure #Measure NameCollection TypeRateACO Mean
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)eCQM17.9328.16
134Preventive Care and Screening: Screening for Depression and Follow-up PlaneCQM
71.2754.68
236Controlling High Blood PressureeCQM78.5171.39
321CAHPS for MIPSCAHPS6.116.67
479Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician GroupsAdministrative Claims0.13250.1517
484Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic ConditionsAdministrative Claims--37
CAHPS-1Getting Timely Care, Appointments and InformationCAHPS for MIPS Survey80.39883.7
CAHPS-2How Well Providers CommunicateCAHPS for MIPS Survey94.4293.96
CAHPS-3Patient's Rating of ProviderCAHPS for MIPS Survey93.2692.43
CAHPS-4Access to SpecialistsCAHPS for MIPS Survey68.3575.746
CAHPS-5Health Promotion and EducationCAHPS for MIPS Survey64.2665.48
CAHPS-6Shared Decision-MakingCAHPS for MIPS Survey56.3562.31
CAHPS-7Health Status and Functional StatusCAHPS for MIPS Survey74.2974.14
CAHPS-8Care CoordinationCAHPS for MIPS Survey87.2985.89
CAHPS-9Courteous and Helpful Office StaffCAHPS for MIPS Survey94.9492.89
CAHPS-11Stewardship of Patient ResourcesCAHPS for MIPS Survey24.4626.98

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 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.