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 Participants

ACO Participant in Joint Venture

Gundersen Clinic, Ltd.

Gundersen Lutheran Medical Center, Inc.

Tri-County Memorial Hospital, Inc.

St. Joseph's Health Services, Inc.

Palmer Lutheran Health Center, Inc.

Memorial Hospital of Boscobel

Moundview Memorial Hospital and Clinics, Inc.

Saint Elizabeths Hospital of Wabasha, Inc.

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.
Todd	Kowalski	Medical Director Non-Voting Member	0%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Jim	Bugge	Voting Member	11.111%	Medicare Beneficiary Representative	N/A
Andrea	Werner	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Bryan	Erdman	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Bill	Farrell	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Steve	Little	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Heather	Schimmers	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Lisa	Sheldon	Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Dawn	Thorsten	Quality Assurance / Improvement Officer Voting Member	11.111%	Participant Representative	Gundersen Lutheran Medical Center, Inc.
Naomi	Wedin	Voting Member	11.111%	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.

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

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Todd

Kowalski

Medical Director

Non-Voting Member

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Jim

Bugge

Voting Member

11.111%

Medicare Beneficiary Representative

N/A

Andrea

Werner

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Bryan

Erdman

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Bill

Farrell

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Steve

Little

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Heather

Schimmers

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Lisa

Sheldon

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Dawn

Thorsten

Quality Assurance / Improvement Officer

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Naomi

Wedin

Voting Member

11.111%

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Dan

Lilly

Non-Voting Member

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Maria

Ludwigson

Non-Voting Member

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Chris

Elfner

Non-Voting Member

Participant Representative

Gundersen Lutheran Medical Center, Inc.

Lisa

Harton

Non-Voting Member

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: Todd Kowalski, 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	Steve Little, Chief Financial Officer

Committee Name

Committee Leader Name and Position

QPI Committee

Dawn Thorsten, Director, Quality & Patient Safety

Finance Committee

Steve Little, 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; N/A

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

2022 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	8.26	10.71
Quality ID# 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	93.91	76.97
Quality ID# 236	Controlling High Blood Pressure	CMS Web Interface	80.11	76.16
Quality ID# 318	Falls: Screening for Future Fall Risk	CMS Web Interface	98.45	87.83
Quality ID# 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	85.69	77.34
Quality ID# 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	66.10	79.27
Quality ID# 113	Colorectal Cancer Screening	CMS Web Interface	81.95	75.32
Quality ID# 112	Breast Cancer Screening	CMS Web Interface	86.88	78.07
Quality ID# 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	93.35	86.37
Quality ID# 370	Depression Remission at Twelve Months	CMS Web Interface	13.49	16.03
Measure# 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1]	CMS Web Interface	0.1300	0.1510
Measure# 484	Clinician and Clinician Group Risk - standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	CMS Web Interface	26.78	30.97
CAHPS-1	Getting Timely Care, Appointments, and Information	CMS Web Interface	76.28	83.96
CAHPS-2	How Well Providers Communicate	CMS Web Interface	92.57	93.47
CAHPS-3	Patient’s Rating of Provider	CMS Web Interface	91.59	92.06
CAHPS-4	Access to Specialists	CMS Web Interface	72.72	77.00
CAHPS-5	Health Promotion and Education	CMS Web Interface	67.56	62.68
CAHPS-6	Shared Decision Making	CMS Web Interface	58.96	60.97
CAHPS-7	Health Status and Functional Status	CMS Web Interface	74.85	73.06
CAHPS-8	Care Coordination	CMS Web Interface	87.03	85.46
CAHPS-9	Courteous and Helpful Office Staff	CMS Web Interface	94.96	91.97
CAHPS-11	Stewardship of Patient Resources	CMS Web Interface	23.90	25.62

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.