ACO Name and Location
ThedaCare ACO, LLC
1 Neenah Center, Neenah, WI 54956 (Corporate)
3 Neenah Center, Neenah, WI 54956 (Office)
ACO Primary Contact
Jennifer Glasheen
Jennifer.Glasheen@thedacare.org
Organizational Information
ACO Participants:
| ACO Participants | ACO Participant in Joint Venture |
| Allergy and Asthma Associates SC | N |
| Appleton Emergency Services SC | N |
| Appleton Plastic Surgery Center SC | N |
| Association of Hospital Anesthesiologists SC | N |
| C. Thomas DeRoche DPM LLC | N |
| Corey W Wesner, DPM SC | N |
| Digestive Healthcare Specialists SC | N |
| Ear Nose & Throat Specialists of Wisconsin SC | N |
| Ear Nose & Throat Surgical Associates SC | N |
| Family Care of the Fox Cities SC | N |
| Farrar and Associates Mental Health SC | N |
| Fox Cities Eye Clinic SC | N |
| Fox Valley Dermatology 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 Plastic Surgery SC | N |
| Fox Valley Pulmonary Medicine SC | N |
| Fox Valley Surgical Associates LTD | N |
| Greenville Foot & Ankle Center LLC | N |
| Hand to Shoulder Center of Wisconsin LTD | N |
| Integrative Pain Management SC | N |
| Kagen Dermatology Clinic SC | N |
| Kaukauna Clinic SC | N |
| Mary McDonald MD SC | N |
| Neal Diabetic Foot & Ankle Center LLC | N |
| Neuroscience Group of NE WI SC | N |
| Northeast Wisconsin Foot & Ankle Associates SC | N |
| Northeast Wisconsin Retina Associates SC | N |
| North Shore Foot & Ankle SC | N |
| Optivision Eye Care LLP | N |
| Pain Relief 1 LLC | N |
| Primary Care Associates of Appleton LTD | N |
| Radiology Associates of Appleton SC | N |
| Radiology Associates of the Fox Valley SC | N |
| Refresh Evolve LLC | N |
| Renard Foot and Ankle LLC | N |
| Sherman Counseling Management LLC | N |
| Surgical Associates of Neenah SC | N |
| ThedaCare Inc. | N |
| ThedaCare Regional Medical Center-Appleton Inc | N |
| ThedaCare Medical Center-Berlin Inc | N |
| ThedaCare Regional Medical Center-Neenah 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 |
| The Center for Aesthetics and Plastic Surgery SC | N |
| The Kagen Allergy Clinic SC | N |
| Torhorst Foot and Ankle Clinic SC | N |
| Valley Eye Associates | N |
| Wisconsin Institute of Urology SC | N |
| Wisconsin Institute of Plastic Surgery SC | N |
| Women’s Care of Wisconsin SC | N |
| Women’s Health Specialists SC | N |
ACO Governing Body:
| Member Last Name | Member First Name | Member Title/Position | Member’s Voting Power (Expressed as a percentage or number) | Membership Type | ACO Participant Legal Business Name and D/B/A, if applicable |
| Bermas | Honnie | MD | 9.1% | ACO participant representative | Fox Valley Surgical Associates LTD |
| Fisher | Cynthia | DO | 9.1% | ACO participant representative | ThedaCare Inc. |
| Werner | Michael | MD | 9.1% | ACO participant representative | Primary Care Associates of Appleton LTD |
| Grunwald | Nathan | MD | 9.1% | ACO participant representative | ThedaCare Inc. |
| Cockley | Mark | MD | 9.1% | ACO participant representative | ThedaCare Inc. |
| Poola | Harsha | MD | 9.1% | ACO participant representative | ThedaCare Inc. |
| Marquardt | Sara | VP | 9.1% | ACO participant representative | ThedaCare Inc. |
| McDonald | Jeannette | Medicare Beneficiary | 9.1% | Medicare beneficiary representative | N/A |
| Eberts | Eric | MD | 9.1% | ACO participant representative | Women’s Care of Wisconsin SC |
| Lang | Tanner | MD | 9.1% | ACO participant representative | Association of Hospital Anesthesiologists SC |
| Iliescu-Levine | Mira | MD | 9.1% | ACO participant representative | ThedaCare Inc. |
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 ACO Quality Committee | Mark Cockley, MD, Chief Clinical Officer |
| ThedaCare Strategy Business Committee | Jennifer Glasheen, Director, Payer Contracting & Provider Relations |
Types of ACO Participants, or Combinations of Participants, That Formed the ACO:
- Networks of individual practices of ACO professionals
- Hospitals employing ACO professionals
- CAHs that bill under Method II
- RHCs
Shared Savings and Losses
Amount of Shared Savings/Losses:
- First Agreement Period
- Performance Year 2022, $3,305,105.02
Shared Savings Distribution:
- First Agreement Period
- Performance Year 2022
- Proportion invested in infrastructure: 0%
- Proportion invested in redesigned care processes/resources: 0%
- Proportion of distribution to ACO participants: 100%
- Performance Year 2022
Quality Performance Results
2022 Quality Performance Results:
Quality performance results are based on CMS Web Interface Measure Set
| Measure # | Measure Name | Collection Type | Rate | ACO Mean |
|---|---|---|---|---|
| Measure #: 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | CMS Web Interface | 3.82 | 10.71 |
| Measure #: 134 | Preventative Care and Screening: Screening for Depression and Follow-up Plan | CMS Web Interface | 90.59 | 76.97 |
| Measure #: 236 | Controlling High Blood Pressure | CMS Web Interface | 86.15 | 76.16 |
| Measure #: 318 | Falls: Screening for Future Fall Risk | CMS Web Interface | 95.40 | 87.83 |
| Measure #: 110 | Preventative Care and Screening: Influenza Immunization | CMS Web Interface | 90.16 | 77.34 |
| Measure #: 226 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | CMS Web Interface | 90.91 | 79.27 |
| Measure #: 113 | Colorectal Cancer Screening | CMS Web Interface | 88.45 | 75.32 |
| Measure #: 112 | Breast Cancer Screening | CMS Web Interface | 88.61 | 78.07 |
| Measure #: 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | CMS Web Interface | 91.23 | 86.37 |
| Measure #: 370 | Depression Remission at Twelve Months | CMS Web Interface | 16.22 | 16.03 |
| Measure #: 479 | Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups | Administrative Claims | 0.1193 | 0.1510 |
| Measure #: 484 | Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions | Administrative Claims | 26.55 | 30.97 |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | CAHPS for MIPS Survey | 84.34 | 83.96 |
| CAHPS-2 | How Well Providers Communicate | CAHPS for MIPS Survey | 90.97 | 93.47 |
| CAHPS-3 | Patient’s Rating of Provider | CAHPS for MIPS Survey | 90.09 | 92.06 |
| CAHPS-4 | Access to Specialists | CAHPS for MIPS Survey | 79.09 | 77.00 |
| CAHPS-5 | Health Promotion and Education | CAHPS for MIPS Survey | 66.23 | 62.68 |
| CAHPS-6 | Shared Decision Making | CAHPS for MIPS Survey | 63.51 | 60.97 |
| CAHPS-7 | Health Status and Functional Status | CAHPS for MIPS Survey | 72.17 | 73.06 |
| CAHPS-8 | Care Coordination | CAHPS for MIPS Survey | 86.71 | 85.46 |
| CAHPS-9 | Courteous and Helpful Office Staff | CAHPS for MIPS Survey | 92.38 | 91.97 |
| CAHPS-11 | Stewardship of Patient Resources | CAHPS for MIPS Survey | 21.91 | 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.
- 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.
