ACO Information

If you have questions or concerns, you can talk with your Cotton O’Neil Primary Care physician or call Stormont Vail’s Health Connections at (785) 354-5225 (800) 432-2951 at any time (phones are answered 24/7).

You can also visit www.medicare.gov/acos.html or call 1-800-MEDICARE (TTY users should call 1-877-486-2048). (TTY 785-354-5260)

ACO Name and Location:

Cotton-O’Neil ACO llc
1500 S.W. 10th Ave.
Topeka, KS 66604

ACO Primary Contact:

Todd Lutz
(785) 354-6000
[email protected]

Organizational Information

ACO Participants:

ACO Participants ACO Participant in Joint Venture (Enter Y or N)
STORMONT VAIL HEALTHCARE INCN
Cotton-O’Neil Clinic Revocable TrustN

ACO Governing Body

First Name Last Name Title/Position Member's Voting Power Membership Type ACO Participant Legal Business Name/DBA, if applicable
BradCuttingBoard Member8.33%ACO Participant RepresentativeCotton O’Neil Revocable Trust
ChadYeagerChairman/Secretary8.34%ACO Participant RepresentativeStormont Vail HealthCare, Inc.
ClaytonWoodBoard Member8.33%ACO Participant RepresentativeCotton O’Neil Revocable Trust
CliffJonesBoard Member8.33%ACO Participant RepresentativeCotton O’Neil Revocable Trust
KristenMillerVice Chairman8.34%ACO Participant RepresentativeStormont Vail HealthCare, Inc.
LarryMorrisBoard Member8.33%Medicare Beneficiary RepresentativeN/A
StacieMasonTreasurer8.34%ACO Participant RepresentativeStormont Vail HealthCare, Inc.
MelissaHerrmanBoard Member8.33%ACO Participant RepresentativeCotton O’Neil Revocable Trust
MIkeLexowBoard Member8.33%ACO Participant RepresentativeCotton O'Neil Revocable Trust
TimShultzCompliance8.33%ACO Participant RepresentativeStormont Vail HealthCare, Inc.
ToddLutzBoard Member8.33%ACO Participant RepresentativeStormont Vail HealthCare, Inc.
TraciCuevasBoard Member8.33%ACO Participant RepresentativeCotton O’Neil Revocable Trust

Key ACO clinical and administrative leadership

Title Name
ACO ExecutiveTodd Lutz
Medical DirectorMike Lexow
Compliance OfficerTimothy Shultz
Quality Assurance/Improvement OfficerKristen Miller

Associated committees and committee leadership

Committee Name Committee Leader Name and Position
N/AN/A

Types of ACO participants or combination of participants that formed the ACO:

  • Hospital employing ACO professionals

Shared Savings and Losses

Amount Shared Savings and Losses

  • Third Agreement Period
    • Performance Year 2026, N/A
    • Performance Year 2025, N/A
    • Performance Year 2024, $7,474,895.04
    • Performance Year 2023, $4,472,267.00
    • Performance Year 2022, $4,316,090.32
    • Performance Year 2021, $0
  • Second Agreement Period
    • Performance Year 2021, $0
    • Performance Year 2020, $0
    • Performance Year 2019, $0
    • Performance Year 2018, $0
  • First Agreement Period
    • Performance Year 2017, $0
    • Performance Year 2016, $0
    • Performance Year 2015, $0

Shared Savings Distribution

  • Third Agreement Period
    • Performance Year 2026
      • 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 2025
      • 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 2024
      • Proportion invested in infrastructure:
      • Proportion invested in redesigned care processes/resources:
      • Proportion of distribution to ACO participants:
    • Performance Year 2023
      • Proportion invested in infrastructure: 50%
      • Proportion invested in redesigned care processes/resources: 50%
      • Proportion of distribution to ACO participants: 0%
    • Performance Year 2022
      • Proportion invested in infrastructure: 50%
      • Proportion invested in redesigned care processes/resources: 50%
      • Proportion of distribution to ACO participants: 0%
    • Performance Year 2021
      • Proportion invested in infrastructure: N/A
      • Proportion invested in redesigned care processes/resources: N/A
      • Proportion of distribution to ACO participants: N/A
  • Second Agreement Period
    • Performance Year 2020
      •  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 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
  • First Agreement Period
    • 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
    • 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

Quality Performance Results

2024 Quality Performance Results:

Quality performance results are based on the eCQMs/MIPS CQMs/Medicare CQMs collection type.

Measure # Measure Title Collection Type Performance Rate Current Year Mean Performance Rate (Shared Savings Program ACOs)
321CAHPS for MIPSCAHPS for MIPS Survey6.216.67
479*Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS GroupsAdministrative Claims0.14330.1517
484*Clinician and Clinician Group Riskstandardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)Administrative Claims-37
318Falls: Screening for Future Fall RiskCMS Web Interface--
110Preventative Care and Screening: Influenza ImmunizationCMS Web Interface--
226Preventative Care and Screening: Tobacco Use: Screening and Cessation InterventionCMS Web Interface--
113Colorectal Cancer ScreeningCMS Web Interface--
112Breast Cancer ScreeningCMS Web Interface--
438Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseCMS Web Interface--
370Depression Remission at Twelve MonthsCMS Web Interface--
001*Diabetes: Hemoglobin A1c (HbA1c) Poor ControleCQM20.9428.16
134Preventative Care and Screening: Screening for Depression and Follow-up PlaneCQM76.7354.68
236Controlling High Blood PressureeCQM72.3271.39
CAHPS-1Getting Timely Care, Appointments, and InformationCAHPS for MIPS Survey82.5383.7
CAHPS-2How Well Providers CommunicateCAHPS for MIPS Survey92.9593.96
CAHPS-3Patient?s Rating of ProviderCAHPS for MIPS Survey90.2392.43
CAHPS-4Access to SpecialistsCAHPS for MIPS Survey79.9175.76
CAHPS-5Health Promotion and EducationCAHPS for MIPS Survey67.5765.48
CAHPS-6Shared Decision MakingCAHPS for MIPS Survey57.7162.31
CAHPS-7Health Status and Functional StatusCAHPS for MIPS Survey74.9274.14
CAHPS-8Care CoordinationCAHPS for MIPS Survey85.8185.89
CAHPS-9Courteous and Helpful Office StaffCAHPS for MIPS Survey93.6492.89
CAHPS-11Stewardship of Patient ResourcesCAHPS for MIPS Survey28.3426.98

For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.

*For Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [Quality ID #001], Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups [Measure #479], and Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) [Measure #484], a lower performance rate indicates better measure performance.

*For Clinician and Clinician Group Risk standardized Hospital Admission Rates for Patients with Multiple

Chronic Conditions (MCC) [Measure #484], patients are excluded if they were attributed to Qualifying Alternative Payment Model (APM) Participants (QPs). Most providers participating in Track E and ENHANCED track ACOs are QPs, and so performance rates for Track E and ENHANCED track ACOs may not be representative of the care provided by these ACOs' providers overall. Additionally, many of these ACOs do not have a performance rate calculated due to not meeting the minimum of 18 beneficiaries attributed to non-QP providers.

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.
  • Payment for Telehealth Services:
    • Our ACO clinicians provide telehealth services using the flexibilities under 42 CFR § 425.612(f) and 42 CFR § 425.613.