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A high-risk, high-cost patient program for ACOs. The ACO picks the patients. We start with adults who have type 2 diabetes and chronic kidney disease, and the patient keeps their primary care provider.
Why 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 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).
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).
Who does what
| Set the cohort | The ACO. You write the entry criteria. A common start: type 2 diabetes with A1c above 8%, and eGFR below 60. |
|---|---|
| Find the patients | Caesar Health platform. Reads participating practices' EMRs and returns every match for you to approve. |
| Enroll and equip | PCP 1st. Enrolls each patient and supplies a blood pressure cuff and a continuous glucose monitor. |
| Watch the readings | Caesar Health platform. Pulls readings daily and puts out-of-range patients at the top of the morning list. |
| Act on them | PCP 1st. RN case managers call the patient, run monthly chronic care management and adjust the plan with the patient's provider. |
| Cardiac work-up | PCP 1st. Holter monitoring and echocardiograms, without a separate specialist referral. |
| Brief the PCP | Caesar Health platform. Readings, lab trends, CGM summaries and open care gaps in front of the provider before each visit. |
| Report | Caesar Health platform. A monthly cohort report to the ACO: enrollment, reading adherence, escalations, open care gaps. |
The ACO keeps attribution. The patient keeps their primary care provider. PCP 1st co-manages.
How a patient moves through it
- Cohort. The ACO sets the criteria and approves the list. Nobody outside it is enrolled.
- Enrollment. PCP 1st calls the patient, records consent and ships the devices.
- Daily readings. Blood pressure and glucose arrive on their own, tiered against thresholds our clinicians set.
- Follow-through. A confirmed out-of-range reading becomes a same-day task for our care team, who call. Severe symptoms are directed to 911.
- The visit. Before each primary care visit the provider gets one page: readings, labs, CGM reports and open care gaps.
- Month end. The ACO gets the cohort report.
Built so the ACO keeps control
- The ACO picks the patients. It is not an open door to chronic care management for every attributed patient.
- The PCP relationship stays. We co-manage, and the provider sees every reading that matters.
- Devices are not billed to the ACO. We put a CGM on patients Medicare would not otherwise cover.
- Starts as a six-month pilot on one cohort.
Questions
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. We co-manage with the patient's existing provider, who gets the readings, lab trends and CGM summaries before each visit.
Will every attributed patient be enrolled?
No. Only patients who meet the ACO's criteria and appear on the list the ACO approves.
Who pays for the continuous glucose monitor?
PCP 1st supplies it. It is not billed to the ACO. Medicare covers a therapeutic CGM only for insulin-treated patients or those 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?
The platform connects through the EMR's API where one exists and through a browser agent where it does not, so practices keep the EMR they run.
How is this different from a remote monitoring vendor?
A monitoring vendor ships devices and watches readings. This adds a care team that acts on them, a cardiac work-up, a one-page brief for the provider before each visit, and a monthly report to the ACO.
How does an ACO start?
Get in touch. We size the cohort from your EMR or claims data, agree the entry criteria, and start a six-month pilot.