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
Wisconsin Institute of Urology SC	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
Nathan	Grunwald	MD	9.09%	ACO Participant Representative	ThedaCare Incorporated
Mark	Cockley	MD	9.09%	ACO Participant Representative	ThedaCare Incorporated
Harsha	Poola	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

Due to rounding, ‘Member’s Voting Power’ may not equal 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 2025, N/A
• First Agreement Period
  • Performance Year 2024, N/A
  • Performance Year 2023, $5,849,623.71
  • Performance Year 2022, $3,305,105.02

Shared Savings Distribution:

• Second Agreement Period
  • 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: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
  • 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

2023 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)
Measure #: 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9)	CMS Web Interface	4.41	9.84
Measure #: 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	92.97	80.97
Measure #: 236	Controlling High Blood Pressure	CMS Web Interface	85.27	77.80
Measure #: 318	Falls: Screening for Future Fall Risk	CMS Web Interface	96.42	89.42
Measure #: 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	83.40	70.76
Measure #: 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	100.00	79.29
Measure #: 113	Colorectal Cancer Screening	CMS Web Interface	86.40	77.14
Measure #: 112	Breast Cancer Screening	CMS Web Interface	90.91	80.36
Measure #: 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	91.69	87.05
Measure #: 370	Depression Remission at Twelve Months	CMS Web Interface	11.45	16.58
Measure #: 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups	Administrative Claims	0.1345	0.1553
Measure #: 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims	–	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	86.26	83.68
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	94.04	93.69
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	91.71	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	78.11	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	68.91	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	63.59	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	73.77	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	87.20	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	92.56	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	30.39	26.69

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.