ACO Public Reporting Information for Southern Illinois

ACO Name & Location

SSM IL ACO, LLC
10101 Woodfield Lane
St. Louis, MO 63132

ACO Primary Contact

Lisa Crouch
618-436-8564
Email: lisa.crouch@ssmhealth.com

Organizational Information

ACO Participants

ACO Participants	ACO Participant in Joint Venture
Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group)	Y
County of Clay (Clay County Hospital)	Y
Washington County Hospital District (Washington County Hospital)	Y
Maamoun Junidi	Y

ACO Governing Body

Member First Name	Member Last Name	Member Title or Position	Member's Voting Power (expressed as a percentage)	Membership Type	ACO Participant Legal Business Name and D/B/A, if applicable
Jayceen	Ensrude	Voting Member & Chair, SSM Health	14.3%	ACO Participant Representative	Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group)
Sudeep	Nair, MD	Voting Member	14.3%	ACO Participant Representative	Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group)
Ralph	Latta, MD	Voting Member	14.3%	ACO Participant Representative	Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group)
Vishnu	Mohan, MD	Voting Member	14.3%	ACO Participant Representative	Physicians Services Corporation of Southern IL, Inc. (SSM Health Medical Group)
Brandon	Cycholl, MD	Voting Member	14.3%	ACO Participant Representative	County of Clay (Clay County Hospital)
Ginger	Fewell, MD	Voting Member	14.3%	ACO Participant Representative	Washington County Hospital District (Washington County Hospital)
Wendy	Lupa	Voting Member	14.3%	Medicare Beneficiary Representative	N/A

Key ACO Clinical & Administrative Leadership

ACO Executive: Jayceen Ensrude
Medical Director: Sudeep Nair, MD
Compliance Officer: Angela Distler
Quality Assurance/Improvement Officer: Lisa Crouch, RN

Associated Committees & Committee Leadership

Committee Name	Committee Leader Name & Position
Finance Committee	John Snodsmith, CFO, Regional Vice President of Finance
Quality Assurance and Improvement Committee	Lisa Crouch, RN-Director, Quality Assurance/Improvement Officer
Compliance Committee	Angela Distler, Director Corporate Responsibility, Compliance Officer

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

ACO professionals in a group practice arrangement
Critical Access Hospital (CAH) billing under Method II

Shared Savings and Losses

Amount of Shared Savings / Losses:

Third Agreement Period
- Performance Year 2022, $1,465,602.01
Second Agreement Period
- Performance Year 2021, $910,954.10
First Agreement Period
- Performance Year 2020, $1,131,015.42

Shared Savings Distribution:

Third Agreement Period
- Performance Year 2022
  - Proportion invested in infrastructure: 60%
  - Proportion invested in redesigned care processes/resources: 0%
  - Proportion of distribution to ACO participants: 40%
Second Agreement Period
- Performance Year 2021
  - 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 2020
  - Proportion invested in infrastructure: 36%
  - Proportion invested in redesigned care processes/resources: 14%
  - Proportion of distribution to ACO participants: 50%

Quality Performance Results

2022 Quality Performance Results

Quality performance results are based on CMS Web Interface Measure Set.

Measure #	Measure Name	Collection Rate	Rate	ACO Mean
0001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	14.10	10.71
134	Preventative Care and Screening: Screening for Depression and Follow-Up Plan	CMS Web Interface	96.79	76.16
236	Controlling High Blood Pressure	CMS Web Interface	67.96	74.87
318	Falls: Screening for Future Fall Risk	CMS Web Interface	85.88	87.803
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	64.07	77.34
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	70.93	79.27
113	Colorectal Cancer Screening	CMS Web Interface	56.28	75.32
112	Breast Cancer Screening	CMS Web Interface	72.3	78.07
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	73.51	86.37
370	Depression Remission at Twelve Months	CMS Web Interface	14.29	16.03
321	CAHPS for MIPS	CAHPS for MIPS Survey	N/A	N/A
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1739	.0151
MCC1	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)	Administrative Claims	36.21	30.97
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	87.25	83.96
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	95.27	93.47
CAHPS-3	Patient's Rating of Provider	CAHPS for MIPS Survey	92.4	92.06
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	81.9	77
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	65.74	62.68
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	66.2	60.97
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	71.3	73.06
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	88.1	85.46
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	95.34	91.97

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.
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.

Fraud and Abuse Waivers

ACO Pre-Participation Waiver: N/A
ACO Participation Waiver: N/A