Shared Savings Program Public Reporting Template

ACO Name and Location

Gundersen Health Accountable Care Organization, LLC

1836 South Avenue

La Crosse, WI 54601

ACO Primary Contact

Dawn Thorsten

(608) 775-9174

[email protected]

Organizational Information

ACO Participants

ACO Participants	ACO Participant in Joint Venture
Gundersen Clinic, Ltd.	N
Gundersen Lutheran Medical Center, Inc.	N
Tri-County Memorial Hospital, Inc.	N
St. Joseph's Health Services, Inc.	N
Palmer Lutheran Health Center, Inc.	N
Memorial Hospital of Boscobel	N
Moundview Memorial Hospital and Clinics, Inc.	N
Saint Elizabeths Hospital of Wabasha, Inc.	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
David	Krueger	Executive Director Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Kimberly	Hardy	ACO Medical Director Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Jim	Bugge	Voting Member	10%	Medicare Beneficiary Representative	N/A
Todd	Kowalski	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Andrea	Werner	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Bryan	Erdman	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Bill	Farrell	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
John	Ceelan	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Heather	Schimmers	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Lisa	Sheldon	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Dawn	Thorsten	Quality Assurance / Improvement Officer Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Naomi	Wedin	Voting Member	10%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Dan	Lilly	Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Maria	Ludwigson	Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Chris	Elfner	Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Lisa	Harton	Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
*Due to Rounding, 'Member Voting Power' may not equal 100 percent.

Key ACO Clinical and Administrative Leadership

ACO Executive: David Krueger, MD
Medical Director: Kimberly Hardy, MD
Compliance Officer: Kari Adank
Quality Assurance/Improvement Officer: Dawn Thorsten

Associated Committees and Committee Leadership

Committee Name	Committee Leader Name and Position
QPI Committee	Dawn Thorsten, Director, Quality & Patient Safety
Finance Committee	John Ceelan, Chief Financial Officer

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

Networks of individual practices of ACO professionals
CAH’s that bill under Method II
RHC’s

Shared Savings and Losses

Amount of Shared Savings/Losses:

First Agreement Period

Performance Year 2022, $0
Performance Year 2023, $0

Shared Savings Distribution:

First Agreement Period

Performance Year 2022
- 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: N/A
- Proportion invested in redesigned care processes/resources: N/A
- Proportion of distribution to ACO participants: N/A

Quality Performance Results

2023 Quality Performance Results:

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

Measure #	Measure Name	Collection Type	Rate	ACO Mean
Quality ID# 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1]	CMS Web Interface	8.24	9.84
Quality ID# 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	90.04	80.97
Quality ID# 236	Controlling High Blood Pressure	CMS Web Interface	79.29	77.80
Quality ID# 318	Falls: Screening for Future Fall Risk	CMS Web Interface	98.56	89.42
Quality ID# 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	81.67	70.76
Quality ID# 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	80.43	79.29
Quality ID# 113	Colorectal Cancer Screening	CMS Web Interface	81.20	77.14
Quality ID# 112	Breast Cancer Screening	CMS Web Interface	90.11	80.36
Quality ID# 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	91.94	87.05
Quality ID# 370	Depression Remission at Twelve Months	CMS Web Interface	22.76	16.58
Quality ID#: 321	CAHPS for MIPS [2]	CAHPS for MIPS Survey	6.23	6.25
Measure# 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1]	CMS Web Interface	0.1316	0.1553
Measure# 484	Clinician and Clinician Group Risk - standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	CMS Web Interface	---	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	CMS Web Interface	81.59	83.68
CAHPS-2	How Well Providers Communicate	CMS Web Interface	93.35	93.69
CAHPS-3	Patient’s Rating of Provider	CMS Web Interface	91.05	92.14
CAHPS-4	Access to Specialists	CMS Web Interface	71.15	75.97
CAHPS-5	Health Promotion and Education	CMS Web Interface	66.64	63.93
CAHPS-6	Shared Decision Making	CMS Web Interface	63.76	61.60
CAHPS-7	Health Status and Functional Status	CMS Web Interface	75.27	74.12
CAHPS-8	Care Coordination	CMS Web Interface	87.78	85.77
CAHPS-9	Courteous and Helpful Office Staff	CMS Web Interface	94.20	92.31
CAHPS-11	Stewardship of Patient Resources	CMS Web Interface	23.26	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.