Shared Savings Program ACO Public Reporting

ACO Name and Location

Lancaster General Health Community Care Collaborative, LLC
555 North Duke Street
PO Box 3555
Lancaster, PA 17604-3555

ACO Primary Contact

Primary Contact Name	Kevin Bogari
Primary Contact Phone Number	717-544-5511
Primary Contact Email Address	info@lghealth.org

Organizational Information

ACO Participants

ACO Participants	ACO Participant in Joint Venture
Allergy and Asthma Center, P.C.	N
Conestoga Eye, PC	N
Campus Eye Center, LTD	N
Family Eye Group, P.C.	N
Foot & Ankle Associates of Lancaster, LLC	N
Francis J. Manning, MD, PC	N
Henderson Podiatry, LLC	N
Hospice & Community Care	N
Lancaster Otolaryngology	N
Lancaster Skin Center, PC	N
Lancaster Urology, PC (Keystone Urology Specialists)	N
Lancaster Ear Nose And Throat, LLC	N
Lancaster Emergency Associates, LTD	N
Lancaster General Health - Columbia Center (Twin Rose Family Medicine)	N
Lancaster General Hospital	N
Lancaster General Medical Group	N
Lancaster Orthopedic Group, PC	N
Lancaster PET Partnership, LLP	Y
Lancaster Pediatric Associates, LTD	N
Lancaster Radiology Associates, LTD	N
Lancaster Rehabilitation Hospital, LLP	Y
Lancaster Retina Specialists, PC	N
Martin Podiatry, P.C.	N
MRI Group, LLP	Y
Orthopedic Associates of Lancaster, LTD	N
Otolaryngology Physicians of Lancaster, LTD	N
Prime Anesthesia Associates, PC	N
Palliative Medicine Consultants	N
Pulmonary Associates of Lancaster, LTD	N
Quarryville Family Foot Care, P.C.	N
RGAL Anesthesia Services, LLC	N
Regional Gastroenterology Associates of Lancaster, LTD	N
Susquehanna Valley Women's Health Care, P.C. (May-Grant)	N
The Heart Group of Lancaster General Health	N

ACO Governing Body

Member's
First Name	Last Name	Title/ Position	Voting Power - (Expressed as a percentage)	Membership Type	ACO Participant Legal Business Name/DBA, if Applicable
Michael	Ripchinski, MD	Chairperson	5%	ACO Participant Representative	Lancaster General Hospital
Kevin	Bogari, RN	President	5%	ACO Participant Representative	Lancaster General Hospital
John	Wood, MD	Medical Director	5%	ACO Participant Representative	Lancaster General Medical Group
Christopher	Addis, MD	Voting Member	5%	ACO Participant Representative	Lancaster General Hospital
Danielle	Cross, MD	Voting Member	5%	ACO Participant Representative	Lancaster General Medical Group
Sarah	Eiser, MD	Voting Member	5%	ACO Participant Representative	Lancaster General Medical Group
Brian	Young, MD	Voting Member	5%	ACO Participant Representative	Lancaster General Medical Group
Doug	Gohn, MD	Voting Member	5%	ACO Participant Representative	The Heart Group of LG Health
Clair	McCormick	Voting Member	5%	Medicare Beneficiary	N/A
Christopher	Thompson	Voting Member	5%	Community Representative	N/A
Brent	Pawlson, MD	Voting Member	5%	ACO Participant Representative	Lancaster Pediatric Associates
John	Briguglio, MD	Voting Member	5%	ACO Participant Representative	Lancaster Radiology Associates
Corey	Troxell, DO	Voting Member	5%	ACO Participant Representative	Lancaster Orthopedic Group
Craig	Horvat, MD	Voting Member	5%	ACO Participant Representative	Pulmonary Associates of Lancaster
Christopher	Shih, MD	Voting Member	5%	ACO Participant Representative	Regional Gastroenterology Associates of Lancaster, Ltd. / RGi
Robert	Belser, MD	Voting Member	5%	ACO Participant Representative	Lancaster Otolaryngology
Bronwyn	Wilke, DPM	Voting Member	5%	ACO Participant Representative	Martin Podiatry, P.C.
Debra	Vermette	Voting Member	5%	ACO Participant Representative	Hospice & Community Care
William	Andersen, MD	Voting Member	5%	ACO Participant Representative	Lancaster Skin Center, PC
Benjamin	Snell, MD	Voting Member	5%	ACO Participant Representative	Lancaster General Health - Columbia Center (Twin Rose Family Medicine)

Key ACO Clinical and Administrative Leadership

ACO Executive:	Kevin Bogari
Medical Director:	John Wood, MD
Compliance Officer:	Elizabeth Katz
Quality Assurance/Improvement Officer:	John Wood, MD

Associated Committees and Committee leadership

Committee Name	Committee Leader Name and Position
Quality Committee	Rebecca Shepherd, MD - Chair
Finance Committee	Jeffrey Rittenhouse, MD - Chair
Clinical Integration Committee	Fernando Gutierrez, MD - Chair

Types of ACO Participants, or Combinations of Participants, That Formed the ACO

Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

Third Agreement Period:

Performance Year 2023, $0
Performance Year 2022, $0
Performance Year 2021, $4,204,652
Performance Year 2020, $2,856,740

Second Agreement Period:

Performance Year 2019, $0
Performance Year 2018, $0
Performance Year 2017, $0

First Agreement Period:

Performance Year 2016, $0
Performance Year 2015, $0
Performance Year 2014, $0

Shared Savings Distribution:

Third Agreement Period:

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
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 2021
- Proportion invested in infrastructure: 15%
- Proportion invested in redesigned care processes/resources: 15%
- Proportion of distribution to ACO participants: 70%
Performance Year 2020
- Proportion invested in infrastructure: 15%
- Proportion invested in redesigned care processes/resources: 15%
- Proportion of distribution to ACO participants: 70%

Second Agreement Period:

Performance Year 2019
- 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 2018
- 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 2017
- Proportion invested in infrastructure: N/A
- Proportion invested in redesigned care processes/resources: N/A
- Proportion of distribution to ACO participants: N/A

First Agreement Period:

Performance Year 2016
- 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 2015
- 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 2014
- 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

2023 Quality Performance Results

Quality performance results are based on CMS Web Interface collection type.

Measure #	Measure Name	Collection Type	Reported Performance Rate	Current Year Mean Performance Rate
Measure #: 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	5.93	9.84
Measure #: 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	66.83	80.97
Measure #: 236	Controlling High Blood Pressure	CMS Web Interface	76.89	77.80
Measure #: 318	Falls: Screening for Future Fall Risk	CMS Web Interface	86.89	89.42
Measure #: 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	81.38	70.76
Measure #: 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	72.73	79.29
Measure #: 113	Colorectal Cancer Screening	CMS Web Interface	83.67	77.14
Measure #: 112	Breast Cancer Screening	CMS Web Interface	82.22	80.36
Measure #: 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	80.88	87.05
Measure #: 370	Depression Remission at Twelve Months	CMS Web Interface	13.18	16.58
Measure #: 321	CAHPS for MIPS	CAHPS for MIPS Survey	7.78	6.25
Measure #: 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.14	0.16
Measure #: 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims	---	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	86.16	83.68
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	96.77	93.69
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	95.02	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	76.12	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	64.85	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	61.33	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	77.16	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	87.08	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	95.40	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	24.05	26.69

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.

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.

Parties to the arrangement: ACO Participants
Date of arrangement: 01/01/2017
Items, services, goods, or facility provided: Blood pressure cuffs, scales and pulse oximeters for patients with uncontrolled hypertension and congestive heart failure and blood pressure cuffs and a text-based remote monitoring solution for postpartum women at risk for worsening hypertension
Date and nature of any amendments to the arrangement, if applicable: 07/12/2019 amended to include downside risk.

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