The study, focused on PPA’s Medicare Shared Savings Program and ACO REACH populations, highlights the efficacy of Annual Wellness Visits as a primary catalyst for engagement. Patients who completed these visits showed superior health outcomes compared to those who did not, validating the organization’s strategy of using wellness screenings as an entry point for long-term care management.

Data from the analysis points to clear performance gains: healthcare costs dropped to $947 per member per month, compared to $1,014 for the control group. Readmission rates fell by 44%, and emergency department utilization decreased to 272 per thousand patients. Furthermore, the organization achieved a 70% HCC recapture rate, up from 57%.

Lisa Bloder, Executive Director of Population Health at Primary Partners of Florida, noted that the technology provides the visibility necessary for independent practices to remain sustainable in a value-based environment. By identifying care gaps and streamlining documentation, the 251 providers within the network can prioritize direct patient interaction. Supported by the nonprofit Alliance for Community Health, PPA’s model underscores how data-informed outreach transforms fragmented care into a coordinated, proactive system.