PCP 1st × Caesar Health · For ACOs, CINs and MSOs
The high-risk, high-cost patient program for ACOs
A high-risk, high-cost patient program is a care model in which an ACO hands a defined group of its most expensive patients to a partner who manages them between visits, with connected devices, monthly care management and same-day follow-up, while each patient keeps their primary care provider.
The ACO picks the patients. PCP 1st runs the care. Caesar Health runs the operations. The first cohort is adults with type 2 diabetes and chronic kidney disease.
Why start with diabetes and kidney disease
Spending is concentrated. In 2022, the top 5% of people ranked by healthcare spending accounted for 49.7% of all US healthcare expenditures, and the top 1% for 21.7% (AHRQ, MEPS Statistical Brief #560).
Type 2 diabetes and chronic kidney disease (CKD) sit inside that group, and they travel together. The CDC estimates that 38% of US adults with diabetes have CKD, and that 87% of adults with CKD do not know they have it (CDC). Diabetes and high blood pressure are the leading causes of kidney failure, accounting for 2 out of 3 new cases (CDC).
In Medicare, beneficiaries aged 66 and older with CKD, not counting kidney failure, accounted for nearly $77 billion in 2021, or 24.1% of Medicare spending in that age group (NIDDK, citing the USRDS).
CMS points at the same patients. The CMMI ACCESS Model began on July 5, 2026, runs for 10 years, and includes a cardio-kidney-metabolic track for diabetes, CKD stage 3a or 3b, and atherosclerotic cardiovascular disease (CMS).
Who does what
| Job | Owner | What it means |
|---|---|---|
| Set the cohort | The ACO | The ACO writes the entry criteria. A common starting set: type 2 diabetes with A1c above 8%, and eGFR below 60 (CKD stage 3a or worse). |
| Find the patients | Caesar Health | Reads the participating practices' EMRs and returns every patient who matches, for the ACO to approve. |
| Enroll and equip | PCP 1st | Enrolls each patient and supplies a blood pressure cuff and a continuous glucose monitor (CGM). |
| Watch the readings | Caesar Health | Pulls readings from the cuff, the CGM and connected wearables every day, and puts out-of-range patients at the top of the morning list. |
| Act on them | PCP 1st | PCP1st care team contacts the patient, completes monthly chronic care management and medication adherence along with plan of care recommendations for the patient's provider. |
| Report | Caesar Health | A monthly cohort report to the ACO: enrollment, reading adherence, escalations and open care gaps. |
The ACO keeps attribution. The patient keeps their primary care provider. PCP 1st co-manages.
How a patient moves through the program
- Cohort. The ACO sets the criteria. Caesar Health returns the list. The ACO approves it.
- Enrollment. PCP 1st calls the patient, records consent and ships the devices.
- Daily readings. Blood pressure and glucose arrive on their own. Each reading is tiered against thresholds the clinicians set. See how Caesar runs RPM alerting.
- Follow-through. An out-of-range reading asks the patient to retake it. A confirmed one becomes a same-day task for PCP 1st's care team to call. Severe symptoms are directed to 911.
- The visit. Before each primary care visit, the provider will have the BP and CGM reading reports to mark reviewed for the patient to confirm that their readings were reviewed.
- Month end. The ACO gets the cohort report.
Built so the ACO keeps control
- The ACO picks the patients. The cohort is the ACO's criteria, applied to the ACO's roster. It is not an open door to chronic care management for every attributed patient.
- The PCP relationship stays. PCP 1st co-manages with the patient's primary care provider, and the provider sees every reading that matters before the next visit.
- Devices are not billed to the ACO. Medicare covers a therapeutic CGM when the patient is insulin-treated or has a history of problematic hypoglycemia (CMS, LCD L33822). Many patients with type 2 diabetes and CKD meet neither test. PCP 1st puts a CGM on them anyway.
- One subscription. The ACO pays Caesar Health a flat platform subscription, sized to the cohort.
Where Caesar Health fits
Caesar Health is a clinic operating system: AI agents that run the phone, the fax and document inbox, device data and follow-up tasks inside the EMR a practice already uses.
For an ACO, it is one layer across many practices. It connects their EMRs, device clouds and payer portals, through the EMR's API where one exists and a browser agent where it does not. It runs the same program the same way at every site, and shows the ACO which practices close flagged gaps and which do not. See EMR integrations and value-based care.
About PCP 1st
PCP 1st provides healthcare solutions for CINs, ACOs, MSOs and individual provider offices: population health programs, chronic care management with care managers, and remote patient monitoring. Its Chief Executive Officer is Yeeny Gonzalez, MD, DNP. Visit pcp1st.com.
Read the launch announcement and the white paper the two companies submitted to CMS QualTech 2026. Meet Dr. Gonzalez and the Caesar Health team at FLAACOs 2026 in Orlando.
Start with a pilot
The program starts as a six-month pilot on one cohort. We size it from your EMR or claims data, agree the entry criteria, and enroll.
Frequently asked questions
What is a high-risk, high-cost patient program?
A high-risk, high-cost patient program is a care model in which an ACO hands a defined group of its most expensive patients to a partner who manages them between visits, with connected devices, monthly care management and same-day follow-up, while each patient keeps their primary care provider. The PCP 1st and Caesar Health program starts with adults who have type 2 diabetes and chronic kidney disease.
Which patients qualify?
The ACO decides. A common starting set is type 2 diabetes with A1c above 8% and eGFR below 60 mL/min/1.73 m², which is CKD stage 3a or worse. Hypertension and heart disease criteria can be added.
Does the patient change primary care provider?
No. PCP 1st co-manages with the patient's existing primary care provider. The provider gets the BP and CGM reading reports before each visit.
Will every attributed patient be enrolled in chronic care management?
No. Only patients who meet the ACO's criteria and appear on the list the ACO approves.
Does PCP 1st's Medicare billing count toward the ACO's spending?
Yes. The Medicare Shared Savings Program rewards ACOs for lowering growth in Medicare Parts A and B expenditures relative to their benchmark (CMS), and monitoring and care-management services are Part B. The ACO sets the cohort, so that spending lands only on the patients the ACO chose, where the target is avoided admissions.
Who pays for the continuous glucose monitor?
PCP 1st supplies it. The device is not billed to the ACO. Medicare covers a therapeutic CGM only for insulin-treated patients or patients with a history of problematic hypoglycemia (CMS, LCD L33822), so many patients in this cohort would not otherwise have one.
Which EMRs does it work with?
Caesar Health connects through the EMR's API where one exists and through a browser agent where it does not, so participating practices keep the EMR they run. See EMR integrations.
What does the ACO pay?
A flat platform subscription to Caesar Health, sized to the number of patients in the cohort. It is quoted once the cohort is known.
How is this different from a remote patient monitoring vendor?
A remote patient monitoring vendor ships devices and watches readings. This program adds a care team that acts on the readings and a monthly report to the ACO. The ACO decides who is in it.
How does an ACO start?
Book a call. We size the cohort from your EMR or claims data, agree the entry criteria, and start a six-month pilot.
Send us the criteria. We will return the cohort.
Book a call with PCP 1st and Caesar Health. We size the cohort from your EMR or claims data and start a six-month pilot.