ACO Governing Body

Member	Title/Position	Member’s Voting Power	Membership Type	ACO Participant TIN Legal Business Name/DBA

Key ACO Clinical and Administrative
Leadership

Associated Committees and Key Leadership
Personnel

Types of ACO Participants, or Combinations of Participants that formed the ACO

• ACO professionals in a group practice arrangement
• Hospital employing ACO professionals

Shared Savings/Losses

Amount of Shared Savings/Losses:

First Agreement Period:

• Performance Year: 2023, $1,204,585.21
• Performance Year: 2022, $1,159,637.73

Shared Savings Distribution:

First Agreement Period

Performance Year 2023

• Proportion invested in infrastructure: 5%
• Proportion invested in redesigned care processes and other resources necessary to improve outcomes and reduce Medicare costs for Beneficiaries: 35%
• Proportion of distribution to ACO Participants and Preferred Providers: 60%

Performance Year: 2022

• Proportion invested in infrastructure: 5%
• Proportion invested in redesigned care processes and other resources necessary to improve outcomes and reduce Medicare costs for Beneficiaries: 35%
• Proportion of distribution to ACO Participants and Preferred Providers: 60%

Quality Performance Results

2023 Quality Performance Results

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate (SSP ACOs)
Quality ID#: 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)  [1]	CMS Web Interface	5.58	9.84
Quality ID#: 134	Preventive Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	87.50	80.97
Quality ID#: 236	Controlling High Blood Pressure	CMS Web Interface	82.72	77.80
Quality ID#: 318	Falls: Screening for Future Fall Risk	CMS Web Interface	85.89	89.42
Quality ID#: 110	Preventive Care and Screening: Influenza Immunization	CMS Web Interface	51.28	70.76
Quality ID#: 226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	63.16	79.29
Quality ID#: 113	Colorectal Cancer Screening	CMS Web Interface	83.95	77.14
Quality ID#: 112	Breast Cancer Screening	CMS Web Interface	84.07	80.36
Quality ID#: 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	88.61	87.05
Quality ID#: 370	Depression Remission at Twelve Months	CMS Web Interface	2.53	16.58
Quality ID#: 321	CAHPS for MIPS [2]	CMS Web Interface	8.08	6.25
Measure # 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [1]	CMS Web Interface	0.1445	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	CAHPS for MIPS	86.36	83.68
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS	93.57	93.69
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS	94.53	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS	80.12	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS	75.71	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS	59.96	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS	75.84	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS	87.57	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS	93.00	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS	30.89	26.69

For previous years’ Financial and Quality Performance Results, please visit: Data.cms.gov

Payment Rule Waivers

Our ACO does not utilize any payment rule waivers.

Medicare Shared Savings Program Fraud and Abuse Waivers

ACO Participation Waiver:

The following information describes each arrangement for which our ACO seeks protection under the ACO Participation Waiver, including any material amendment or modification to a disclosed arrangement. 

For each arrangement, provide the following information:

• Parties to the arrangement: CHESS Innovation, LLC and Circulation, Inc.
• Date of arrangement: 04/27/2022
• Items, services, goods, or facility provided: Transportation services (see link below)
• Date and nature of any amendments to the arrangement, if applicable: N/A

CHESS Innovation Transportation Assistance Program