ACO Name and Location

Genesys PHO, L.L.C.
3495 S. Center Road
Burton, MI 48519

ACO Primary Contact

Wendy Upthegrove
(810) 424-2016
Wendy.Upthegrove@genesyspho.com

Organizational Information

ACO Participants:

ACO Participants	ACO Participant in Joint Venture
ASCENSION GENESYS HOSPITAL	Y
ASCENSION MEDICAL GROUP GENESYS	Y
BEECHER SURGICAL ASSOCIATES PLLC	N
CHRISTOPHER D TYKOCKI DO PC	N
Consultants In Ophthalmic & Facial Plastic Surgery	N
DOUGLAS M IDDINGS PC	N
David Coriasso	N
EAR, NOSE, THROAT AND PLASTIC SURGERY ASSOCIATES, P.C.	N
Edward Lis	N
FAMILY EYE CARE CTR PC	N
FENTON FAMILY MEDICINE PC	N
FLINT GASTROENTEROLOGY ASSOCIATES PC	N
FLINT NEUROLOGICAL CENTER PC	N
GENESEE HEMATOLOGY ONCOLOGY PC	N
GENESEE LUNG ASSOCIATES PC	N
GENESYS PRACTICE PARTNERS INC	N
GRAND BLANC VISION CLINIC PC	N
GREATER MICHIGAN DERMATOLOGY PLLC	N
HEALTH PARK MEDICAL PRACTICE PC	N
HEMANT T THAWANI MD PLLC	N
HENRY HAGENSTEIN DO PC	N
HOLLY VISION CLINIC PC	N
INTEGRATED VASCULAR VEIN CENTER OF MICHIGAN PC	N
JAMES D WALKER II MD MEDICAL ARTS PLLC	N
JAWAD A SHAH, MD PC	N
LAPEER MEDICAL ASSOCIATES PC	N
LAPEER MEDICAL DIAGNOSTICS PC	N
M AL JABBAN MD PLC	N
MEI OPERATIONS, PLLC	N
MICHAEL D ZERAFA PLLC	N
MICHIGAN GASTROENTEROLOGY CLINIC, PC	N
MICHIGAN NEUROSURGICAL INSTITUTE, P.C.	N
ROBERT JAY ZENDLER II DO PC	N
SILVER LAKE FAMILY PRACTICE LLC	N
SURESH ANNE MD PC	N
SURGICAL ASSOCIATES, PLC	N
SYNTHESIS MEDICAL SPECIALTIES PC	N
TIMOTHY R HARRIS OD PLC	N
Tarik Wasfie	N
UROLOGICAL SERVICES PC	N
VITREORETINAL SPECIALISTS PLC	N
WOMENS SPECIALTY ASSOCIATES, P.C.	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
Herman	JoAnne	Board Member	10	Community Stakeholder Representative	N/A
Bedi	Dr. Dhiraj	Secretary	10	ACO Participant Representative	Ascension Medical Group Genesys
Cobb	Jennifer	Hospital	0	Other	N/A
Chrenka	Paul	Board Member	10	ACO Participant Representative	Ascension Medical Group Genesys
Danic	Michael	Hospital	0	Other	N/A
Meyers	Douglas	Hospital	0	Other	N/A
Edgar	William	Hospital	0	Other	N/A
Hanson	Dale	Board Member	10	ACO Participant Representative	Ascension Medical Group Genesys
Karr	Paul	Hospital	0	Other	N/A
Lepzinski	Julie	Hospital	0	Other	N/A
Piontkowski	Timothy	Board Member	10	ACO Participant Representative	Lapeer Medical Associates PC
Krusniak	Renee	Vice Chair	10	ACO Participant Representative	Ascension Medical Group Genesys
Smith	Bonnie	Other	10	Medicare Beneficiary Representative	N/A
Schaaf	Mark	Treasurer	10	ACO Participant Representative	Ascension Medical Group Genesys
Thomas	Theresa	Board Member	10	ACO Participant Representative	Ascension Medical Group Genesys
Youngs	Kevin	Chair	10	ACO Participant Representative	Ascension Medical Group Genesys

Key ACO Clinical and Administrative Leadership:
ACO Executive: Randy Kummler
Medical Director: Kevin Youngs, MD
Compliance Officer: Wendy Upthegrove
Quality Assurance/Improvement Officer: Jennifer Humphreys

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
Finance, Contracting, Cost Containment Committee	Mark Schaaf, DO, Chair
Information Systems Committee	Kevin Youngs, MD, Chair
Medical Services & Quality Committee	Renee Krusniak, DO, Chair Muhammad Aboudan, MD, Co-Chair
Specialist Quality Improvement & Credentialing Committee	Muhammad Aboudan, MD, Chair
Preferred Panel Specialist Committee	Theresa Thomas, DO, Chair
Medical Directors Committee	Kevin Youngs, MD, Chair

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

• ACO professionals in a group practice arrangement
• 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, $5,708,130
• Performance Year 2022, $1,859,628

• Second Agreement Period
• Performance Year 2021, $3,913,973
• Performance Year 2020, $2,629,258
• Performance Year 2019, $2,460,776
• Performance Year 2018, $5,360,927

• First Agreement Period
• Performance Year 2017, $2,800,594
• Performance Year 2016, $4,540,213
• Performance Year 2015, $2,154,556

Shared Savings Distribution

• Third Agreement Period
• Performance Year 2023
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2022
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%

• Second Agreement Period
• Performance Year 2021
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2020
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2019
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2018
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%

• First Agreement Period
• Performance Year 2017
• Proportion invested in infrastructure: 10%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2016
• Proportion invested in infrastructure: 2.5%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%
• Performance Year 2015
• Proportion invested in infrastructure: 4.1%
• Proportion invested in redesigned care processes/resources: 0%
• Proportion of distribution to ACO participants: 90%

Quality Performance Results

2023 Quality Performance Results:

ACO Quality Measure Number	Measure Name	Rate	ACO Mean
Quality ID#: 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [1]	13.11	9.84
Quality ID#: 134	Preventive Care and Screening: Screening for Depression and Follow-up Plan	64.92	80.97
Quality ID#: 236	Controlling High Blood Pressure	84.29	77.80
Quality ID#: 318	Falls: Screening for Future Fall Risk	85.26	89.42
Quality ID#: 110	Preventive Care and Screening: Influenza Immunization	57.41	70.76
Quality ID#: 226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	90.00	79.29
Quality ID#: 113	Colorectal Cancer Screening	86.51	77.14
Quality ID#: 112	Breast Cancer Screening	79.44	80.36
Quality ID#: 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	87.72	87.05
Quality ID#: 370	Depression Remission at Twelve Months	6.12	16.58
Quality ID#: 321	CAHPS for MIPS [2]	6.71	6.25
Measure # 479	Hospital-Wide, 30-Day, All- Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [1]	0.1729	0.1553
Measure # 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	---	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	86.24	83.68
CAHPS-2	How Well Providers Communicate	95.71	93.69
CAHPS-3	Patient’s Rating of Provider	92.80	92.14
CAHPS-4	Access to Specialists	77.58	75.97
CAHPS-5	Health Promotion and Education	64.39	63.93
CAHPS-6	Shared Decision Making	59.81	61.60
CAHPS-7	Health Status and Functional Status	75.72	74.12
CAHPS-8	Care Coordination	84.86	85.77
CAHPS-9	Courteous and Helpful Office Staff	92.94	92.31
CAHPS-11	Stewardship of Patient Resources	23.19	26.69

Footnotes:
[1] A lower performance rate corresponds to higher quality.

[2] CAHPS for MIPS Survey is a composite measure, so numerator and denominator values are not applicable (N/A). The Reported Performance Rate column shows the CAHPS for MIPS Survey composite score. The CAHPS for MIPS Survey composite score is calculated as the average number of points across scored Summary Survey Measures (SSMs). Refer to Table 5 for details on CAHPS for MIPS Survey performance.

"[3] For PY 2023, the CMS Web Interface measures Quality ID#: 438 and Quality ID#: 370 do not have benchmarks, and therefore, were not scored. They are, however, required to be reported in order to complete the Web Interface measure set. If they are not reported, the CMS Web Interface measure set denominator is increased by 10 points for each measure that is not reported, resulting in a lower health equity adjusted quality performance score. For more information, refer to the Performance Year 2023 APM Performance Pathway: CMS Web Interface Measure Benchmarks for ACOs:

For Previous Years' Financial and Quality Performance Results, Please Visit data.cms.gov.