PCP 1st and Caesar Health Launch a High-Risk, High-Cost Patient Program for ACOs

PCP 1st and Caesar Health today launched a joint program for accountable care organizations. It takes an ACO's highest-cost patients with type 2 diabetes and chronic kidney disease and manages them between visits, while each patient keeps their primary care provider.

The ACO picks the patients. PCP 1st runs the care. Caesar Health runs the operations.

How the program works

• The ACO sets the cohort. It writes the entry criteria, for example type 2 diabetes with A1c above 8% and eGFR below 60, and approves the list.
• Caesar Health finds the patients. It reads the participating practices' EMRs and returns every patient who matches.
• PCP 1st enrolls and equips them. Each patient gets a blood pressure cuff and a continuous glucose monitor. PCP 1st's care managers run monthly care management and call when a reading needs it.
• The primary care provider stays informed. Before each visit, the provider gets one page with the readings, lab trends, CGM summaries and open care gaps.
• The ACO gets a monthly report on enrollment, reading adherence, escalations and open care gaps.

Full details: the high-risk, high-cost patient program for ACOs.

Why these patients

In 2022, the top 5% of people ranked by healthcare spending accounted for 49.7% of US healthcare expenditures (AHRQ). The CDC estimates that 38% of US adults with diabetes have chronic kidney disease, and that 87% of adults with CKD do not know they have it (CDC). CMS's ACCESS Model, which began in July 2026, includes a cardio-kidney-metabolic track for the same conditions (CMS).

What the founders said

"ACOs already have tools that identify their high-risk patients. The question is what happens next," said Yeeny Gonzalez, MD, DNP, Chief Executive Officer of PCP 1st. "We act on what is found, for exactly the patients the ACO chooses."

"ACOs tell us they run too many tools that don't talk to each other," said Shoukri Kattan, Chief Executive Officer of Caesar Health. "Caesar connects the practices' EMRs, the devices and the care team, so one program runs the same way at every site."

The policy work behind it

The program builds on work the two companies have done with CMS this year:

• September 3, 2026: PCP 1st and Caesar Health jointly submitted the white paper AI-Enabled Annual Wellness Visits: Closing the Loop from Risk Detection to Delivered Care to the CMS CCSQ QualTech 2026 showcase.
• September 11 and 13, 2026: Caesar Health and PCP 1st each filed a public comment on the AI request for information in the CY 2027 Physician Fee Schedule proposed rule (CMS-1848-P). Both called for clinician-supervised AI and for measuring whether findings lead to completed care, rather than counting visits. Read Caesar Health's comment, PCP 1st's comment and our summary.

Meet us at FLAACOs 2026

Dr. Gonzalez is a panelist on The High-Cost Patient Playbook at the FLAACOs 2026 Annual Conference: Monday, November 9, 12:45 PM ET, JW Marriott Orlando Bonnet Creek. Find us there, or book a 30-minute discovery call.

About PCP 1st

PCP 1st, based in Boca Raton, Florida, provides healthcare solutions for CINs, ACOs, MSOs and individual provider offices, including population health programs, chronic care management with care managers, and remote patient monitoring. pcp1st.com

About Caesar Health

Caesar Health is a clinic operating system. Its AI agents run the phone, the fax and document inbox, device data and follow-up tasks inside the EMR a practice already uses. caesarhealth.com

Media contact: Shoukri Kattan, shoukri@caesarhealth.com