Accountable Care Organization

ACO Name and Location                               

ThedaCare ACO, LLC

3 Neenah Center, Neenah, WI 54956

ACO Primary Contact

Jennifer Glasheen

920-454-4212

Jennifer.Glasheen@thedacare.org

Organizational Information

ACO Participants:

ACO Participants	ACO Participant in Joint Venture
Appleton Emergency Services SC	N
Association of Hospital Anesthesiologists SC	N
Family Care of the Fox Cities SC	N
Fox Valley Emergency Medicine SC	N
Fox Valley Nephrology Partners SC	N
Fox Valley Pathologists SC	N
Fox Valley Perinatology SC	N
Fox Valley Pulmonary Medicine SC	N
Fox Valley Surgical Associates LTD	N
Kaukauna Clinic SC	N
Primary Care Associates of Appleton LTD	N
Radiology Associates of the Fox Valley SC	N
Surgical Associates of Neenah SC	N
The Neuroscience Group of Northeast Wisconsin SC	N
Theda Clark OB Hospitalists SC	N
ThedaCare Incorporated	N
ThedaCare Medical Center-Berlin Inc	N
ThedaCare Medical Center-New London Inc	N
ThedaCare Medical Center-Shawano Inc	N
ThedaCare Medical Center-Waupaca Inc	N
ThedaCare Medical Center-Wild Rose Inc	N
ThedaCare Regional Medical Center-Appleton Inc	N
ThedaCare Regional Medical Center-Neenah Inc	N
Valley Eye Associates	N
Women’s Care of Wisconsin SC	N
Women’s Health Specialists SC	N

ACO Governing Body:

Member First Name	Member Last Name	Member Title/Position	Member’s Voting Power (Expressed as a percentage)	Membership Type	ACO Participant Legal Business Name, if applicable
Beth	Krieger	MD	9.09%	ACO Participant Representative	Fox Valley Surgical Associates LTD
Cynthia	Fisher	DO	9.09%	ACO Participant Representative	ThedaCare Incorporated
Michael	Werner	MD	9.09%	ACO Participant Representative	Primary Care Associates of Appleton LTD
Dirk	Steinert	MD	9.09%	ACO Participant Representative	ThedaCare Incorporated
Mark	Cockley	MD	9.10%	ACO Participant Representative	ThedaCare Incorporated
Andrew	Maes	MD	9.09%	ACO Participant Representative	ThedaCare Incorporated
Sara	Marquardt	VP	9.09%	ACO Participant Representative	ThedaCare Incorporated
Jeannette	McDonald	Medicare Beneficiary	9.09%	Medicare Beneficiary Representative	N/A
Ryan	Bly	MD	9.09%	ACO Participant Representative	Surgical Associates of Neenah SC
Tanner	Lang	MD	9.09%	ACO Participant Representative	Association of Hospital Anesthesiologists SC
Mira	Iliescu-Levine	MD	9.09%	ACO Participant Representative	ThedaCare Incorporated

Member’s voting power may have been rounded to reflect a total voting power of 100 percent

Key ACO Clinical and Administrative Leadership:

ACO Executive: Jennifer Glasheen

Medical Director: Mira Iliescu-Levine, MD

Compliance Officer: Robert Reed

Quality Assurance/Improvement Officer: Shelah Bechtel

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
ThedaCare Strategy Business Committee	Jennifer Glasheen, Committee Chair

Types of ACO Participants, or Combinations of Participants, That Formed the ACO:

• Networks of individual practices of ACO professionals
• Hospital employing ACO professionals
• Critical Access Hospital (CAH) billing under Method II
• Rural Health Clinic (RHC)
  

Shared Savings and Losses

Amount of Shared Savings/Losses:

• Second Agreement Period
  • Performance Year 2026, N/A
  • Performance Year 2025, N/A
• First Agreement Period
  • Performance Year 2024, $5,647,535.54
  • Performance Year 2023, $5,849,623.71
  • Performance Year 2022, $3,305,105.02

Shared Savings Distribution:

• Second Agreement Period
  • Performance Year 2026
    • 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 2025
    • Proportion invested in infrastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
• First Agreement Period
  • Performance Year 2024
    • Proportion invested in infrastructure: 0%
    • Proportion invested in redesigned care processes/resources: 0%
    • Proportion of distribution to ACO participants: 100%
  • Performance Year 2023
    • Proportion invested in infrastructure: 0%
    • Proportion invested in redesigned care processes/resources: 0%
    • Proportion of distribution to ACO participants: 100%
  • Performance Year 2022
    • Proportion invested in infrastructure: 0%
    • Proportion invested in redesigned care processes/resources: 0%
    • Proportion of distribution to ACO participants: 100%

Quality Performance Results

2024 Quality Performance Results:

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

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOS)
001*	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9)	CMS Web Interface	3.27	9.44
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	96.02	81.46
236	Controlling High Blood Pressure	CMS Web Interface	84.00	79.49
318	Falls: Screening for Future Fall Risk	CMS Web Interface	95.22	88.99
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	86.67	68.60
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	100.00	79.98
113	Colorectal Cancer Screening	CMS Web Interface	87.50	77.81
112	Breast Cancer Screening	CMS Web Interface	88.16	80.93
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	89.58	86.50
370	Depression Remission at Twelve Months	CMS Web Interface	11.94	17.35
479*	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1201	0.1517
484*	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)	Administrative Claims	–	37.00
321	CAHPS for MIPS	CAHPS for MIPS Survey	7.82	6.67
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	81.95	83.70
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	93.51	93.96
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	92.46	92.43
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	80.13	75.76
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	68.72	65.48
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	69.14	62.31
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	76.09	74.14
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	88.20	85.89
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	94.46	92.89
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	25.35	26.98

*For Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [Quality ID #001], Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [Measure #479], and Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], a lower performance rate indicates better measure performance.

*For Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], patients are excluded if they were attributed to Qualifying Alternative Payment Model (APM) Participants (QPs). Most providers participating in Track E and ENHANCED track ACOs are QPs, and so performance rates for Track E and ENHANCED track ACOs may not be representative of the care provided by these ACOs’ providers overall. Additionally, many of these ACOs do not have a performance rate calculated due to not meeting the minimum of 18 beneficiaries attributed to non-QP providers.

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.