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Study shows better patient outcomes in CPC+ practices utilizing population health management tools

HEALTHeLINK and the Milbank Memorial Fund collaborate to illustrate improved care and efficiency when both programs are in place at the same time

BUFFALO, NY, October 6, 2022 HEALTHeLINK, the health information exchange (HIE) for Western New York, with support from the Milbank Memorial Fund, conducted a study to examine if population health analytics helped to improve care quality and efficiency in primary care practices enrolled in the Centers for Medicare and Medicaid Services’ (CMS) Comprehensive Primary Care Plus (CPC+) program.

CPC+ is a federal program that provided resources and incentives for primary care providers to improve quality, access, and efficiency of care.

The study results show that when a population health management tool and a value-based payment (VBP) model such as CPC+ are in place at the same time, practices tend to have significantly better outcomes as compared with instances where only one or none of the programs are in place.

“While the CPC+ program creates incentives to reach higher goals, our population health tool – HEALTHeOUTCOMES – provides the means for reaching such goals, with real-time access to how providers are doing against quality measures,” said Dan Porreca, executive director of HEALTHeLINK. “As practices continue to shift towards value-based payment models and population health management, this study confirms practices had better outcomes in the CPC+ program when utilizing HEALTHeOUTCOMES.”

HEALTHeOUTCOMES provides both clinical and claims data from participating providers and payers and enables practices to streamline information from multiple data sources to better identify trends in their practice.

The study assessed data collected from four different groups of practices in the Western New York region, which had similar patient populations. However, only three of the four groups were enrolled in the CPC+ program; only two practices utilized HEALTHeOUTCOMES.

Outcomes among the four groups were measured from January 1 – December 31, 2020. The group consisting of both CPC+ and HEALTHeOUTCOMES practices significantly outperformed their counterparts in various outcomes.

When measuring data, membership in both programs together led to a 24.1% reduction in admission rates and a 21% reduction in outpatient surgery. It also reduced the length of stay in hospitals by 32.7% and the re-admission rate by 30.4% compared with practices that didn’t participate in either CPC+ or HEALTHeOUTCOMES.

“Although the study is small, it raises several important issues,” said Lisa Dulsky Watkins, MD, a program officer at the Milbank Memorial Fund. “The federal evaluation of the CPC+ model looked exclusively at Medicare fee-for-service beneficiaries, not at anybody covered by commercial insurance or Medicaid. This study examines that broader population and adds the impact of a high-functioning health information exchange, facilitating the population health tracking and improvement that CPC+ was designed for. By demonstrating a combined positive impact, it will add to the ongoing conversation about how best to support primary care moving forward.”

To view the full study, “The Impact of Population Health Analytics on Heath Care Quality and Efficiency Among CPC+ Participants,” visit


About HEALTHeLINK: HEALTHeLINK is a collaboration among hospitals, physicians, health plans and other health care providers in the eight counties of western New York State to securely exchange clinical information to improve the quality of care, enhance patient safety and mitigate health care costs. HEALTHeLINK is a certified Qualified Entity and part of the Statewide Health Information Network for New York (SHIN-NY), which enables providers to access their patients’ data from across the state. HEALTHeLINK is also a founding member of Civitas Networks for Health, a national collaborative working to use health information exchange to improve health. Providers and patients can visit or @HEALTHeLINK on both Facebook and Twitter for more information.

About the Milbank Memorial Fund: The Milbank Memorial Fund is an endowed operating foundation that works to improve population health and health equity by collaborating with leaders and decision makers and connecting them with the experience and sound evidence. Visit for more information.