THE ACG^® SYSTEM: ONE TOOL, MANY SOLUTIONS

By capturing the morbidity burden of populations, the Johns Hopkins ACG System helps explain and predict how health care resources are delivered and consumed. Some common applications include:

Capitation LEARN MORE
Care Coordination LEARN MORE
Care Density LEARN MORE
Care Management LEARN MORE
Case Management LEARN MORE
Coordination Markers LEARN MORE
Disease Management LEARN MORE
Financial Analysis LEARN MORE
Performance Assessment LEARN MORE
Pharmacy Analysis LEARN MORE
Population Health LEARN MORE
Program Evaluation LEARN MORE
Resource Allocation LEARN MORE
Underwriting LEARN MORE

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GAIN POPULATION HEALTH INSIGHTS

By considering the differences in illness burden among different patient populations, the ACG System allows you to:

Examine variations and trends in disease prevalence
Understand health care needs of a population or subpopulation that differs in age, gender, geographical region, ethnicity or other characteristics
Explain variations in outcome measures

PHARMACY ANALYSIS financial analysis

EVALUATE INTERVENTION PROGRAMS

Once targeted programs are identified and implemented, the ACG System can help determine their success—including patient characteristics associated with successful programs’ outcomes, changes needed, program continuation or termination. These analyses also quantify improvements related to specific interventions, which demonstrates program value to external parties.

MEASURE ROI

STREAMLINE CARE MANAGEMENT

With the ACG System you can identify up to 25% more individuals for care management before they become high utilizers. Optimize your case management and disease management programs by targeting individuals, assessing patient risk, and identifying those who would benefit the most.

LEARN HOW

DISEASE MANAGEMENT CASE MANAGEMENT

IMPROVE OUTCOMES WITH CARE COORDINATION

Reduce Health Care Cost and Improve Patient Health Outcomes

Coordination exerts an important impact on both the efficiency and effectiveness of care. Patients most in need of highly coordinated care include those with multiple chronic medical conditions, concurrent care from several health professionals or many medications, and patients undergoing extensive diagnostic workups or transitions from one setting of care to another.

The ACG System Utilization Profile Report includes many concepts to evaluate population health, including concurrent and prospective risk, risk factors, utilization, disease prevalence, pharmacy adherence, and care coordination risk.

COORDINATION MARKERS CARE DENSITY

ASSESS PHYSICIAN PERFORMANCE

The ACG System performance analysis takes into account the health of the particular population served by a specific clinician or set of clinicians, addressing important differences in case mix and the often stated concern that “my patients are sicker.” Because a disease-based focus may miss important implications of related co-morbidities, we provide a holistic view of the patient rather than the management of specific diseases or episodes.

PERFORMANCE ANALYSIS

The ACG System helps several health plans tackle various issues by understanding their population. Patricia M. Brown, Esq., President, Johns Hopkins Healthcare, highlights this application in a video captured at the ACG System 2016 AcademyHealth Health Services Research (HSR) Award celebration.

ALLOCATE RESOURCES APPROPRIATELY

The ACG System is widely used by health plans and health systems for risk adjustment, setting capitation rates, insurance premiums and for appropriately distributing health care resources within large health systems. The ACG System helps health care providers, payers, and governments worldwide ensure that resources appropriately target populations in greatest need.

RESOURCE ALLOCATION CAPITATION UNDERWRITING

GAIN PROMPT INSIGHTS FROM PHARMACY DATA

Using Pharmacy Data

Prescription drug claims are processed at the point of service and prescribing events often occur with more frequency than physician events, providing more timely and frequent information. Three months of pharmacy claims can often be available immediately at the end of this period whereas medical claims from this same three-month-period may not be available for another three months.

With three months of prescription drug claims, the ACG System can help you:

Predict pharmacy costs
Identify high risk patients
Inform care managers

CATEGORIZE CODES COMBINING DATA POTENTIAL GAP ACG Rx GAPS

IMPACTING MILLIONS OF LIVES WORLDWIDE

The ACG System is the most widely used population-based case mix system in the world. Currently used in close to 20 countries, the System incorporates local cost structures, coding systems, practice behavior, languages and local markers for socio-economic, functionality, living arrangement, or other dimensions. Some international application examples are available by clicking on a specific country.

GERMANY ISRAEL ITALY SPAIN SWEDEN UNITED KINGDOM CANADA UNITED STATES

ACCEPTS LOCAL DATA INPUTS ADAPTS TO LOCAL CONTEXT INCLUDING LANGUAGES

The ACG System’s Success around the World

Chad Abrams, Director of U.S. Operations, describes common challenges around the world such as language differences, data quality, turning data into impact, and misconceptions of local population health, and the ACG System’s ability to turn them into successes.

Adapts to Local Context including Languages

The ACG System is unique in its ability to account for differences in local cost data, practice behavior, additional available data inputs (i.e. socio-economic status, functionality, or living arrangement measures) and other variables that distinguish a given population. In addition, all menus and labels within the program can be easily translated to other languages.

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Accepts Local Data Inputs

Diagnosis Codes
The ACG System is the only case mix system in the world which accepts and integrates International Classification of Primary Care (ICPC) diagnostic codes as an input stream. No mapping of ICPC to ICD codes is needed. In addition, the ACG System works with ICD and Read codes.

Pharmaceutical Codes
The ACG System includes a case mix algorithm which relies solely on pharmaceutical codes to group patients into morbidity categories. Pharmacy information using U.S. National Drug Code (NDC), WHO Anatomical Therapeutic Chemical (ATC) as well as Read codes or from the British National Formulary (BNF) has proven beneficial in situations where diagnosis codes are untimely, of questionable quality or incomplete. Using pharmaceutical information is also helpful to identify potential gaps in data, as well as identify clinicians who may be over prescribing. Click here to read about ACG Rx Gaps.

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Categorize All Available Pharmacy Codes

The ACG System classifies all pharmacy codes into pharmacy-based morbidity groups (ACG® Rx-MGs) using the following clinical criteria:

Morbidity-type: symptom vs. disease
Duration of morbidity: chronic vs. time-limited
Stability of morbidity: stable vs. unstable
Route of administration: oral, inhaled, topical, intramuscular, intravenous
Therapeutic goal: curative, palliative, preventive

All pharmacy codes (NDC, ATC or other national codes) can be classified according to these clinical criteria. An active ingredient count is also made available.

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Combining Medical Claims Data with Pharmacy Claims Data

Get a better understanding of patient need and identify:

Patients taking drugs for conditions not in their medical claims history
Patients with both medical diagnoses and pharmacy indicators
Patients with medical diagnoses and no pharmacy indicators
Unusual pharmacy expenses

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Potential Gap in Availability of Needed Medication for Patients with Chronic Conditions

For a handful of carefully selected chronic conditions where administration of medications is warranted, and where specific medications that should be taken continuously can be identified, the ACG System provides indicators if a patient is receiving treatment and calculates potential gaps in availability of needed medications.

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Disease Management and Wellness Programs

Identifying Patients for Disease Management and Wellness Programs
The ACG System can help identify patients for disease management programs and for wellness programs. The ACG System Expanded Diagnosis Clusters (EDCs) methodology assigns diagnosis codes found in electronic claims or encounter data to one of 282 categories, which enables you to select a specific disease or condition to focus on.

Evaluating Disease Management and Wellness Programs
The ACG System can also be used to evaluate the effectiveness of disease management or wellness programs.The ACG System can segment the population by level of multi-morbidity, enabling you to examine the results of your disease management programs and wellness programs while accounting for co-occurring diseases.

An Example: Disease Management Program for Asthma

Disease Management Program Enrollment Goal
In the population represented in Figure 1, the health plan has a goal to enroll 2,000 members in their asthma disease management program each year.

Measure of Program Success and Health Improvement
One of the key indicators for the population is an improvement in the rate of members dispensed a preferred asthma therapy (a higher overall rate is the desired result.)

Over time, the dispensing rate for these therapies is decreasing and is leading management to wrongly conclude that the disease management program is not achieving its goal. However, the results are different if you look at the results by multi-morbidity level.

Modify Program to Exclude Highly Co-morbid Members
Suppose the health plan changed the criteria for acceptance into the asthma disease management program so that highly co-morbid members are excluded. These are patients with, on average, 6 or more chronic conditions.

graphpic2

When you analyze the results by co-morbidity level as in Figure 2, you see that there were modest improvements for each morbidity group in year 2 except in the very high morbidity group where there were no members enrolled in year 2.

Members with lower co-morbidity showed an increase in using the preferred asthma therapy. This demonstrated that the asthma disease management program achieved greater success with individuals with lower co-morbidity. Case mix control using the ACG System is a critical component of evaluating program effectiveness and ROI.

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Case Management Programs

The ACG System helps you target those individuals who might benefit from case management programs. You can perform a quick assessment of an entire health care population or sub-group to identify patients at risk who may not already be identified through other programs. Then you can drill down to patient-specific information to understand an individual patient’s risk factors and resource needs.

Comprehensive Patient Clinical Profile

The ACG System provides a Comprehensive Patient Clinical Profile report containing the following information for you to use during a clinical screening:

Current and predicted medical costs
Predicted resource utilization
Risk of hospitalization
Potential lack of care coordination
Pharmacy adherence/medication compliance and
Other clinical indicators

NOTE: Patients who would typically already be in a case management program due to their diagnosis, such as cancer patients, are excluded from the report.

Sample Information from a Comprehensive Patient Clinical Profile Report

81 year-old male
Current medical costs of $8,367 are predicted to triple in the coming year
Hospital dominant morbidity types – related to complications associated with:
1. Diabetes
2. Acute kidney failure
3. Hypertensive chronic kidney disease
Difficulty walking – triggering the Frailty Flag

While this patient’s current utilization pattern and medical costs may not indicate a need for case management, the significant potential increase in cost indicate that case management interventions may be a cost-effective way to improve care.

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Health Care Resource Allocation

The ACG System helps you allocate health resources in a way that adjusts for morbidity and considers more than age, gender and geography. By incorporating patient clinical characteristics the ACG System improves health care resource allocation by accounting for individuals’ expected medical needs. This ensures an equitable distribution of limited health care resources directing them to those populations who need them most.

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Adjusting Capitation Rates

The ACG System risk adjustment methodology is simple and straightforward and provides a relative population risk index that can be used to adjust capitation rates. It has long been a standard actuarial method for capitation and rate setting. ACG actuarial cells, classify individuals by expected use of health care resources. Covered populations are sorted into these 102 ACG actuarial cells and either national weights or localized weights are applied.

For more than a decade, the ACG System has been used to facilitate the exchange of many billions of dollars within numerous private and public health plans in the United States, Canada and Sweden.

The ACG System’s advantage for capitation:

Simplicity. By classifying the population into ACG cells, it is possible to obtain a risk-adjusted score for the population. Some users have chosen to simplify this approach even further by collapsing the ACGs into smaller homogeneous groupings called Resource Utilization Bands (RUBs).
Less prone to manipulation. Because ACG cells are based on combinations of conditions, it is difficult to alter coding to increase reimbursement.
Stability. The underlying clinical truth captured by ACGs does not change dramatically with each new data set or each new application.
Ease of making local calibrations. It is easy to recalibrate ACG-based actuarial cells to reflect local differences in patterns of practice, benefit structure, and provider fees.

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Underwriting

The ACG System’s rating methodology for setting health care premiums goes beyond demographics and considers individual health. You can set premiums at a fair level that provides more accurate and credible predictions of health care utilization. With more competitive renewal rates you will achieve improved customer retention.

The ACG System Health Plan Rating Methodology:

Provides a risk assessment for every eligible member based on historical claims
Reduces underwriting discretion, allowing for greater consistency among underwriters
Yields reproducible results which are more defensible to customers and regulators
Incorporates an additional source of risk information by using recent data including prescription claims

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ACG System in Germany

Health Care Finance Reform
In 2009, a sweeping overhaul of health care financing implemented a morbidity-based risk adjustment method for transferring funds within the German health care system. This brought to the forefront the need for health care organizations, academic institutions, and government decision makers to understand the variation in disease burden amongst their population.

Subsequently, two German sickness funds licensed the ACG System to aid with population comparisons, cost projections, identification of potential high-cost members, and cost controlling. Cost controlling is achieved by establishing profiles of member groups, tracking changes in costs over time, and controlling budgets.

The sickness funds are also applying the ACG System in innovative ways to manage patients with psychosocial disease clusters in order to avoid expensive inpatient care. They are also exploring a similar approach for other disease clusters such as diabetes and hypertension.

Custom Code Sets for Germany
To better meet the needs of the sickness funds, the ACG System Team created new code sets based on the German adaptation of ICD-10 codes, as well as two new Risk Assessment Variable Sets (RAVS) that are based on the sickness fund’s own data.

The ACG System provided a more comprehensive assessment of morbidity and resource use at the patient level.

Read more about our Collaborator in Germany Lohman & Birkner

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ACG System in Israel

For almost a decade the ACG System Team has collaborated with Israel’s largest health fund to better understand its members’ needs and characteristics. This not-for-profit government-mandated insurer and health care provider (of primary, secondary and tertiary care) has more than 4 million enrollees and covers 53% of the population.

Examining Differences in Health Care Utilization
The ACG System was instrumental in proving that age and gender adjustments yield an inaccurate positive association between low socioeconomic class and diagnostic tests as well as specialty care use. Moreover, the results demonstrated the superiority of the ACG System in comparison with the Charlson Index in measuring this correlation. The study was part of this health fund’s all-encompassing disparity reduction program and helped direct policy decisions regarding resource use.

Identifying Opportunities for Quality Improvement
Another study conducted as part of this research collaboration examined the association between co-morbidity, as measured by the ACG System, and quality of care. The study showed that, process measures rather than outcome measures were associated with morbidity level and provided a valuable tool for identifying patient groups for which quality of care could be improved.

Identifying High-Risk Users
The ACG System has also been used in Israel to identify high-risk users who could benefit from targeted care management interventions. This method was more accurate than locally developed data-mining tools. The ACG System Team is working with this same health fund to examine the incorporation of information from this health fund’s extensive database (including a comprehensive chronic disease registry, full EMR coverage in all community clinics, and data on social support and functional status); to improve the predictive capabilities of high-risk case identification tools; and test the use of continuity of care tools.

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ACG System in Italy

Veneto, a northern Italian region, uses the ACG System to perform detailed assessments of its population’s morbidity burden and identify future health care needs based on patient data. During the first year of the project Local Health Units including the Italian cities of Verona and Padua participated. The following year, the project expanded to four additional Local Health Units: Feltre, Alto Vicentino, Vicenza and Treviso. In its third year, the project involves all Local Health Units across the Veneto Region.

The Veneto Region project demonstrates the ACG System’s underlying principle that diseases and their distribution are the main determinants of the population’s health care needs.

Insights from Inpatient and Outpatient Data
The ACG System detects disease patterns in patients by not solely utilizing inpatient data, but also by focusing on patients who receive most of their care outside the hospital setting. The ACG System’s first application in Italy validates the Veneto Regional Health Service’s focus on innovation, quality and sustainable methods to ensure the best care is provided to its citizens.

Geographic Disease Concentration
Utilizing existing data from the Local Health Units, the ACG System examines the population’s morbidity burden in order to improve health outcomes, provide more appropriate care, and more equitably allocate health care resources based on need. At its core, the ACG System identifies greater and lower disease concentration levels in different geographical areas. A map will show the “safe areas” and the “hot areas” (those with higher risk patients). Each group is measured by their illness level—single or multiple—and because their health needs and risks have been properly identified, patients can receive better, more targeted health services.

Identifying Patients for Case Management Programs
After identifying patients with complex care needs, the ACG System identifies individuals who would benefit from specialized case management programs, such as Guided Care®, an innovative patient-centered care model that integrates the general practitioner, local nurses, and the patient’s family to improve care coordination and health outcomes.

Learn more about this project at the Veneto Region website.

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ACG System in Spain

“We believe the ACG System provides us with a valid, relevant and meaningful measure of the population’s health status. With its assistance we can ensure equitable funding and distribution of health resources, accurate evaluations of the quality of care patients receive and fair assessments of the professionals who serve them.”
Gabriel Mª Inclán Iribar
Minister of Health; Basque Region

Provider Performance Assessment
Together with our local collaborator, Iasist, the ACG System Team has been working with several regional governments in Spain since 2005 to provide the tools necessary to assess primary care doctors’ performance. The ACG® System allows primary care managers to compare performance results from one primary care setting to another, and use this information to determine where practice improvements are needed.

Meeting the Needs of Integrated Care
The ACG System has already been adopted as the primary care case mix tool by three regional governments in Spain, while several other regional authorities are currently piloting the system. In the face of the growing interest for integrated care in Spain, there is increased need for other ACG System applications, such as the assessment of the morbidity risk of individual patients to determine resource allocation to different areas and help with risk-stratifying strategies. The ACG System’s predictive models are also being considered for their ability to identify individuals that could benefit from case management strategies.

Read more about our Collaborator in Spain lasist

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ACG System in Sweden

Historically in Sweden, allocation of funds for health care resources was based on diagnostic codes at the hospital level, and on age and gender at the primary care level. After Sweden passed legislation allowing patients to choose their primary care provider, the Freedom of Choice Act, a model that accounted for the variance in morbidity was needed.

Risk-Adjusted Resource Allocation
When Sweden tested the ACG System for risk-adjusted resource allocation, it was able to explain over 60% of the variance in concurrent patient costs. The ACG System is now used for over 95% of the Swedish population and has been customized to the Swedish health care system. The ACG system has been adapted to recognize Swedish ICD10 codes and incorporates standard Swedish weights. County councils are currently running the Swedish ACG System model based on the latest patient data and 15 months of historical diagnosis data.

Incorporating Pharmacy Data
In addition, the ACG System furthered its success in Sweden by partnering with a health care government agency. With access to its national drug register database, the ACG System Team was able to test the pharmacy based predictive model’s (Rx-PM) validity as a risk adjustment tool in the Swedish context. The year-long study, conducted on a database capturing the entire Swedish population, showed that the Rx-PM model not only works very well for Swedish pharmaceutical data, but it could potentially be applied to assess performance.

Read more about our Collaborator in Sweden Ensolution

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ACG System in Canada

Performance Assessment
At the beginning of the 21st century, the government of a western Canadian province started holding physicians accountable for their overall billing patterns, with the annual reporting of each physician’s practice profile. This allowed physicians to compare their practice patterns with others, but it also provided the government with a guide to detect outliers suspected of fraud and abuse. In addition, it increased the need to use risk adjustment tools to ensure that physicians were being evaluated fairly.

Detecting Fraud, Waste and Abuse
Prior to the introduction of the ACG System, audit results showed that, in 3 out of 4 cases, high health care expenses were justified by a sicker patient pool. After the ACG System was extensively evaluated in this particular Canadian province, it became accepted as the gold standard case mix adjustment method for physician profiling. Subsequent audit results enabling more targeted evaluation then showed that unjustified health care expenses were actually confirmed in 3 out of 4 cases identified. The ACG System continues to be successfully used for physician profiling and the detection of fraud and abuse in this province.

The ACG System has been widely adopted in Canada and is currently being used in hundreds of projects across the country.

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Overview | Medicaid | Medicare | Health Insurance Exchange

ACG System in the United States

The ACG System has been helping improve the health care of entire populations in the United States –millions at a time– for more than 30 years. It is used by commercial health plans, employers, Medicare, Medicaid, academic research organizations and more.

Amy Salls, Director of Population Health Strategy at DST Health Solutions, provides a summary on the applications of the ACG System in the United States.

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US Medicaid

US Medicaid
In the United States the ACG System is used by various Medicaid health plans and state governments to improve health outcomes for underserved populations. The ACG System provides insight into health care utilization and health care resources allocation.

Health Care Utilization

Inappropriate emergency department use
High probability of a unplanned hospitalization or readmission
Consistently high annual health care costs

Health Care Resources Allocation

Allocation of funds to sicker populations
Geographical variations in morbidity burden
Getting the right patients to the right doctors

East Baltimore: Managing High Risk Populations. Linda Dunbar, Vice President of Population Health Care

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US Medicare

Medicare Advantage plans use the ACG System to identify patient morbidity burden not captured in the encounter data used to determine CMS hierarchical condition categories (HCCs).

Plans are able to identify members with high health service needs who will benefit from care coordination and case management programs.
Instances of irregular coding intensity and imprecise diagnosis coding practices can be identified and addressed to improve accuracy and minimize audit risk.
Errors and omissions in patient diagnoses can be identified and verified by medical record review. Gaps in care can be identified and patient diagnoses corrected to more accurately reflect the disease burden of the population.

On February 20th, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the use of the ACG System Pharmacy Defined Morbidity Groups™ (Rx-MGs™) methodology as a means to assess coding intensity. For detailed information read the entire CMS 2016 Draft Call Letter: February 20, 2015.

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US Health Insurance Exchange

The “ACG-HIE” software is based on the advanced and widely used Johns Hopkins ACG System risk adjustment methodology that has been in use for over three decades. The ACG System is currently employed to help finance and manage the care of millions of individuals in public and private health plans and agencies across the U.S. (including 16 Medicaid agencies) and by the governments and private delivery systems in close to 20 countries. The ACG-HIE version builds on the experience of the ACG-Medicaid version, and is available subject to the following terms and conditions:

License allows limited use for purposes of rate setting (or validation) within State Health Insurance Exchange programs;
Support is not included;
Ensure that the Johns Hopkins University is properly indemnified as allowed by state law.

It is recommended that consultants knowledgeable in the use and application of the ACG System assist with proper software implementation.

Amy Salls, 866-287-9243, is DST Health Solution’s contact regarding ACG-HIE and can answer questions about the software and obtaining a license.

Care Coordination

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Care Density

Research at the Johns Hopkins Bloomberg School of Public Health hypothesized that patients seen by clinicians who share patients more frequently have higher levels of communication and information sharing. The results demonstrated that through a better understanding of how patients are shared amongst clinicians, rates of hospitalization could be reduced and potential cost savings achieved. The following studies explore this in detail.

3Pollack, et.al, (2013) Care Density and Costs of Care, J Gen Intern Med 28(3):459-65. LEARN MORE
4Pollack, et.al, (2015) Patient sharing and quality of care: measuring outcomes of care coordination using claims data. LEARN MORE

The ACG System provides a measure of patient sharing, termed “Care Density Score” based on this research. This patient-level measure indicates how much of the care of that patient is shared among clinicians.

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Care Coordination Markers

Patients with poorly coordinated care have worse clinical outcomes and higher medical expenses than those with coordinated care. The ACG System developed Coordination Markers to identify populations at risk for poorly coordinated care.

ACG System Coordination Markers:

Management Visit Count: Number of face-to-face doctor visits with an eligible specialty.
Majority Source of Care (MSOC): Assesses the participation levels of doctors providing care to the patient.
Unique Provider Count: Number of doctors providing care to the patient.
Specialty Count: Number of specialty types (not number of specialists seen) that provided care to the patient.
Generalist Seen: Indicates generalist’s participation in the care of the patient.

A coordination risk measure combines these markers to determine whether a person has a “likely,” “possible,” or “unlikely” coordination issue. A care density ratio quantifies patient sharing based on outpatient face-to-face visits with eligible physicians.

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United Kingdom: Sollis

sollis_website_logo

Sollis has been delivering business intelligence and health care analytics solutions to the UK National Health Service (NHS) for 20 years.

We have a long and established relationship with the Johns Hopkins University where we have successfully integrated the ACG® System into our health care business intelligence software – Clarity Patients.

We believe that our collaboration with the world renowned Johns Hopkins University has resulted in one of the most advanced clinically based commissioning decision support systems available to the UK health care system.

Sollis Clarity Patients is the largest implementation of the Johns Hopkins ACG System in the UK.

Today, Clarity Patients combined with the ACG System processes records for approximately six million patients, having been implemented in three large Commissioning Support Units (CSUs):

NHS South CSU
NHS Central Southern CSU
NHS South East CSU

It currently supports 29 Clinical Commissioning Groups (CCGs) and 868 GP Practices.

In 2013, Sollis collaborated with the ACG International Team and NHS Central Southern CSU to recalibrate the predictive models in Version 10i of the ACG System to better reflect the NHS context. This enables the ACG System to more accurately capture the morbidity patterns within the NHS as well as the factors that contribute to increased risk within the local population. Central Southern CSU and Sollis agreed to make this enhancement available free of charge to other non-Sollis NHS implementations.

We continue to further develop Clarity Patients while integrating the ACG System to support service transformation and outcomes based commissioning for the UK NHS.

To find out how Sollis can help you please call our sales team on 01372 847525 or visit our website www.sollis.co.uk.

Read more about a Sollis-ACG System collaborative success story. LEARN MORE
Access the Sollis Case Study on Central Southern CSU’s ACG implementation LEARN MORE

Improving Care with Performance Analysis

With only one year of diagnostic and/or pharmacy codes, the ACG System performance metrics provide the information needed to drive change at the organizational level and to influence voluntary changes in clinician behavior. These reports can be used to:

Facilitate process and practice improvements
Tie quality and outcomes to financial incentives
Identify rare cases of inappropriate billing and potential fraud

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Measure ROI on care management programs

The example below demonstrates how the ACG System controls for case mix differences and also risk-adjusts the population enrolled in a program.

Focusing on high-risk patients, results show that those enrolled in the intervention program experienced reductions in cost that far exceeded the high-risk, no intervention group.

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Target Individuals for Case Management and Disease Management

With a total disease burden perspective, the ACG System focuses on commonly occurring patterns of morbidity and assesses all types of medical need to achieve significant administrative efficiencies in the care management process, patient risk assessment and in patient targeting. This comprehensive approach has repeatedly proven superior to other case mix adjustment methodologies, especially those using complex data-mining or artificial intelligence algorithms where no two patients are categorized in the same manner.

Assess Patient Risk with Available Data

The ACG System uses both pharmacy and electronic medical record data sources to select individuals based upon program-specific criteria, allowing care managers to spend more time with patients and less time on analysis. The clinical markers produced automatically eliminate the need to review records manually. The care manager is then able to understand a patient’s disease and morbidity profile; and select only the patients that truly warrant a detailed chart review.

Identify Individuals for Care Management Early

The ACG System Predictive Models can identify up to 25% more individuals in need of care management intervention before they become high utilizers, compared to traditional methods based on prior utilization such as hospital concurrent review and emergency department utilization reports. By emphasizing developing patterns of morbidity, the ACG System helps identify individuals with a high disease burden—those seeing multiple clinicians and taking multiple prescriptions, as they may benefit from improved coordination of care.

Greater insight about the convergence of risk, medical utilization and prescribing patterns can be captured by combining risk defined by diagnoses with risk defined by retail pharmacy claims.

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ACG^® Rx Gaps

Patient adherence with therapy represents a major impediment to assessing clinical performance and contributes substantively to patient care costs and outcomes. The ACG RxGaps methodology was developed to capture patients with adherence issues and thereby improve their care management. Pharmacy benefits managers have made available refill patterns of patients to help identify potentially non-adhering patients who may warrant interventions by care managers. Unfortunately, the signal to noise ratio of these warnings is not high; there are many instances where gaps in adherence are expected, especially when medications are used acutely or as needed.

RxGaps employs innovative methods that increase the ability to detect genuine adherence problems by careful selection of conditions where chronic administration of medications is warranted, by the careful identification of specific medications that should be taken continuously, by capturing prescribing patterns that introduce potential noise, and by identifying medications that may be validly substituted without introducing gaps in adherence. Generally, measurement strategies have targeted specific possession events (i.e., gaps) or average possession of time expressed as a ratio (supply over prescribing period). The RxGaps employs markers using both of these strategies as they address different dimensions of adherence. Gaps capture acute occurrences and may represent a therapeutically significant event that could be overlooked if only averages are considered. Averages represent how well medication is supplied over a span of time (i.e, one year) and are a good summary indicator of possession in assessing the overall status of a patient but may be less amenable to direct clinical action.

To see the ACG System in action and speak to a Team member about your specific needs, request a demo today.

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THE ACG® SYSTEM: ONE TOOL, MANY SOLUTIONS

GAIN POPULATION HEALTH INSIGHTS

By considering the differences in illness burden among different patient populations, the ACG System allows you to:

EVALUATE INTERVENTION PROGRAMS

STREAMLINE CARE MANAGEMENT

IMPROVE OUTCOMES WITH CARE COORDINATION

Reduce Health Care Cost and Improve Patient Health Outcomes

ASSESS PHYSICIAN PERFORMANCE

ALLOCATE RESOURCES APPROPRIATELY

GAIN PROMPT INSIGHTS FROM PHARMACY DATA

Using Pharmacy Data

With three months of prescription drug claims, the ACG System can help you:

IMPACTING MILLIONS OF LIVES WORLDWIDE

The ACG System’s Success around the World

Adapts to Local Context including Languages

Accepts Local Data Inputs

Categorize All Available Pharmacy Codes

The ACG System classifies all pharmacy codes into pharmacy-based morbidity groups (ACG® Rx-MGs) using the following clinical criteria:

Combining Medical Claims Data with Pharmacy Claims Data

Get a better understanding of patient need and identify:

Potential Gap in Availability of Needed Medication for Patients with Chronic Conditions

Disease Management and Wellness Programs

An Example: Disease Management Program for Asthma

Case Management Programs

Comprehensive Patient Clinical Profile

The ACG System provides a Comprehensive Patient Clinical Profile report containing the following information for you to use during a clinical screening:

Sample Information from a Comprehensive Patient Clinical Profile Report

Health Care Resource Allocation

Adjusting Capitation Rates

The ACG System’s advantage for capitation:

Underwriting

The ACG System Health Plan Rating Methodology:

ACG System in Germany

ACG System in Israel

ACG System in Italy

ACG System in Spain

ACG System in Sweden

ACG System in Canada

ACG System in the United States

The ACG System has been helping improve the health care of entire populations in the United States –millions at a time– for more than 30 years. It is used by commercial health plans, employers, Medicare, Medicaid, academic research organizations and more.

US Medicaid

Health Care Utilization

Health Care Resources Allocation

US Medicare

Medicare Advantage plans use the ACG System to identify patient morbidity burden not captured in the encounter data used to determine CMS hierarchical condition categories (HCCs).

US Health Insurance Exchange

Care Coordination

Care Density

Care Coordination Markers

ACG System Coordination Markers:

United Kingdom: Sollis

Today, Clarity Patients combined with the ACG System processes records for approximately six million patients, having been implemented in three large Commissioning Support Units (CSUs):

To find out how Sollis can help you please call our sales team on 01372 847525 or visit our website www.sollis.co.uk.

Improving Care with Performance Analysis

With only one year of diagnostic and/or pharmacy codes, the ACG System performance metrics provide the information needed to drive change at the organizational level and to influence voluntary changes in clinician behavior. These reports can be used to:

Measure ROI on care management programs

Target Individuals for Case Management and Disease Management

Assess Patient Risk with Available Data

Identify Individuals for Care Management Early

ACG® Rx Gaps

THE ACG^® SYSTEM: ONE TOOL, MANY SOLUTIONS

ACG^® Rx Gaps