CHESS Innovation ACO Information

ACO Governing Body

Member	Title/Position	Member’s Voting Power	Membership Type	ACO Participant TIN Legal Business Name/DBA
Jason Kihneman, MD	Chair & Voting Member	9.09%	ACO Participant	Catawba Valley Medical Group
Scott Polster, MD	Voting Member	9.09%	ACO Participant	Catawba Valley Medical Group
Dennis Johnson	Voting Member	9.09%	ACO Participant	Catawba Valley Medical Group
Kelly Singer, MD	Voting Member	9.09%	ACO Participant	Fletcher Hospital, Inc.
Christy Sneller	Voting Member	9.09%	ACO Participant	Fletcher Hospital, Inc.
Steven Burroughs	Voting Member	9.09%	ACO Participant	Fletcher Hospital, Inc.
CD Haddock	Voting Member	9.09%	Medicare Beneficiary	N/A
Heather Spry, MD	Voting Member	9.09%	Other	CHESS
Emily Volk	Voting Member	9.09%	ACO Participant	Northern Hospital District of Surry County
Shawn Lambert	Voting Member	9.09%	ACO Participant	Northern Hospital District of Surry County
Marcia Cox	Voting Member	9.09%	ACO Participant	Northern Hospital District of Surry County

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