Population Health Analytics

This year’s ACG System User Conference brought customers, partners and the Johns Hopkins research team together in Orlando, Florida for two days of sessions. Presenters came from integrated delivery systems, health plans, ACOs, employer benefits consulting and technology partners. The use cases varied, but a common thread ran through most of them: organizations are gaining value from the risk scores and ACG System outputs and putting them to work for their organizations, their patients and their missions.  

Below is a look at these valuable sessions. Thank you to every presenter who shared their work with the ACG community. 

Translating Risk Insights into Action  

Several presenters addressed how organizations can move ACG outputs beyond analysis and into the operational workflows where care decisions are made. 

We were grateful to have Jeff Rice and DJ Linde of Geisinger open the conference with their experience adopting the ACG System across both health plan and clinical operations. Their session offered a valuable perspective for integrated delivery systems with multiple data sources. Jeff and DJ emphasized that careful decisions about input data, including which source to rely on for diagnoses and procedures and how to combine claims with clinical data, have a direct effect on the reliability of risk stratification. They also described how Geisinger has connected ACG outputs to its case management program so that changes in patient risk inform timely outreach. 

Amy Salls and Dan Segura of SS&C Health, joined by Kalyani Gopalan of Presbyterian Healthcare Services, examined how pairing ACG stratification with intelligent automation can help organizations extend the capacity of their care teams. Their session outlined an approach in which ACG signals guide automated workflows for well-defined tasks, allowing clinicians and care managers to focus their time on patients who need their direct attention. The presenters placed particular emphasis on keeping care team members involved at key points throughout the process. 

Risk Adjustment & Provider Panels 

Primary care panels are often sized by headcount, and may sometimes be adjusted for age and sex. While these methods may be a useful baseline for expected visit volume, accounting for patient complexity is often more reflective of the level of care a patient requires and better reflects the true makeup of a provider’s panel.  

Kalyani Gopalan of Presbyterian Healthcare Services shared a framework for measuring panel complexity at the provider level using the ACG System. Her team compared demographic weighting, RAF scores, and ACG-predicted risk against encounter volume and provider time, and found ACG risk adjustment offered a clearer picture of where patient volume and clinical effort were misaligned. This approach can give health systems an evidence-based foundation for panel assignment and staffing decisions that reflects the care needs of each provider’s patient population.

Other attendees shared how concurrent risk can also support panel planning for new primary care programs. 

Matching Programs to Population Needs 

Selecting and evaluating programs effectively requires a detailed understanding of who is in a population and what they need. Two sessions showed how ACG outputs support this work for very different populations.  

Bernard Khomenko of Alliant Insurance Services shared an employer perspective on managing the rising cost of employee health coverage, describing how Patient Need Groups (PNGs) can help employers and their advisors identify which segments of a population warrant deeper review. This helps focus analytic effort, and program investments are directed where they are most likely to have an impact

Bernard also raised an important consideration for anyone working with claims-based analytics: members with little or no utilization are not necessarily low risk, and understanding the reasons behind limited claims activity can reveal unmet needs.  

Ryan Kivela and Victoria Tewa of NARBHA-The Alliance ACO and Thrive Health Alliance ACO presented a proactive approach to supporting Medicaid members as eligibility requirements change. Using a focused combination of ACG System outputs with supplemental data, their team identifies members who may be at risk of a coverage disruption, including those who would be especially vulnerable to losing access to care. This work allows them to support both their provider partners and the members they serve with prioritized outreach. 

Preparing for Digital Quality Measurement and AI 

Our partners at SS&C Health contributed two sessions on digital quality measures and AI in healthcare workflows. 

Crystal Brown and Amy Salls discussed the transition to digital quality measures as NCQA and CMS continue to advance this work, and the growing need for health plans to modernize their data and interoperability in response. 

Mylea Dutcher addressed the responsible application of AI in healthcare workflows, with a focus on embedded domain knowledge, model governance, and explainability as the basis for trust and compliance. 

Advancing the ACG System through Johns Hopkins University Research  

We were honored to be joined by our research and faculty partners at the Johns Hopkins Center for Population Health Information Technology (CPHIT) at the Johns Hopkins Bloomberg School of Public Health. Klaus Lemke, Senior Biostatistician and member of the ACG research and development team, presented the latest research behind the System and previewed enhancements planned for the upcoming release. 

Klaus’s session reflects the ongoing commitment of the Johns Hopkins research team to advancing the ACG System. As new research is incorporated into each release, customers gain access to methods grounded in decades of academic work and continued evaluation.  

Thank You!

We extend our sincere thanks to everyone who attended and presented at this year’s conference. The perspectives shared in Orlando reflect the many ways organizations are applying the ACG System to serve their populations, and they will continue to inform our work with the ACG community in the year ahead.

To learn more about the ACG System, visit hopkinsacg.org or contact us at acginfo@jh.edu. If you are a current ACG System customer, please reach out to your Account Manager.