Population Health Analytics

In late December 2025, the Centers for Medicare and Medicaid Services (CMS) announced a landmark $50 billion investment in rural health care, awarding funds to all 50 states through the Rural Health Transformation Program (RHTP). First-year awards averaging $200 million per state are intended to expand access to care, strengthen the rural health workforce, modernize facilities and technology, and support innovative models that bring high-quality care closer to home.

For health systems, providers and payers operating in rural communities, this moment represents both a significant opportunity and a meaningful challenge: how do you deploy resources strategically across a dispersed population? The answer starts with understanding who that population is.

Rural Populations Require a Targeted Approach

Rural communities face a distinct set of health challenges. Chronic disease burden tends to be higher, access to specialists more limited and social determinants of health (SDOH), including transportation, housing and economic stability, often compound clinical needs.

States are focusing their RHTP plans on workforce development, technology and data modernization, behavioral health and substance use disorder treatment, primary care access and facility modernization. Translating these broad categories into effective, accountable programs requires the ability to segment populations, identify high-risk individuals and track outcomes over time to ensure improvement.

A Population Health Analytics Framework for Rural Implementation

The Johns Hopkins ACG System is purpose-built for population health. By analyzing diagnoses, pharmacy claims and demographic data, the ACG System helps organizations understand the full spectrum of need within their populations — from individuals with no current health care utilization to those managing multiple complex chronic conditions.

Several capabilities within the ACG System are particularly well-suited to the priorities outlined in the RHTP:

• Population Segmentation. The ACG System’s Patient Need Groups (PNGs) assign every individual to one of 11 mutually exclusive segments based on their overall health status and complexity. For rural health organizations, this means being able to distinguish between patients who would benefit from preventive programs, those who need chronic disease management support and those requiring intensive care coordination — before resources are deployed.
• Risk Stratification and Predictive Modeling. Identifying which patients are at rising risk for hospitalization or emergency department use allows rural providers to intervene proactively.
• Social Determinants of Health (SDoH) & GeoHealth. The ACG System’s SDoH capabilities, including both Social Need Markers (SNMs) and GeoHealth allow organizations to layer social need data onto clinical profiles, enabling a more complete view of what each patient requires.
• Chronic Disease Management. The ACG System enables organizations to identify cohorts by condition, track medication adherence patterns and monitor care gaps, supporting outcome-driven programs.

Turning Funding into Measurable Impact

One of the RHTP’s defining features is its emphasis on accountability. Continued funding is contingent on states adopting and implementing the policy commitments outlined in their approved plans. This means that the organizations responsible for executing rural health strategies at the local level will need to demonstrate progress, not just activity.

When organizations can leverage population health infrastructure to measure baseline morbidity burden, track changes in utilization and tie interventions to outcomes, they are positioned not only to report on their work but to continuously refine it.

The ACG System is used by health systems, health plans, accountable care organizations and analytics companies across more than 20 countries around the globe because it provides this kind of durable, evidence-based foundation for population health programs. Its methodology is rooted in decades of research at the Johns Hopkins Bloomberg School of Public Health, giving organizations the credibility and rigor that a program of this scale requires.

Organizations that invest now in a robust population health analytics infrastructure will be better positioned to meet RHTP reporting requirements, demonstrate impact to CMS and, most importantly, improve outcomes for the patients they serve.

To learn more about how the ACG System can support your rural health strategy, 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.