Population Health Analytics

We’ve recently been exploring some common misconceptions about population health analytics — and, more specifically, about the ACG System — in our LinkedIn Mythbusting series. In this first post of our three-part blog series, we take a closer look at the assumptions that that often shape discussions about population health analytics and offer the ACG System team’s perspective on what’s reality — and what’s myth.

Myth: Proactive care is still years away.

This is something that we hear quite often — both in the media and in conversation. While banking and other areas of daily life have been digitized for some time, digital health care — and more specifically proactive health care — seems much more fragmented and not part of the daily routine for most people. However, the reality is that the shift towards proactive health care is already happening and many organizations are using tools like the ACG System to provide a range of solutions.

As a comprehensive population health analytics platform, the ACG System is designed to capture the full complexity of patient health. It goes far beyond a single risk score or a simple measure of multimorbidity. By analyzing a much broader set of clinical, utilization and social factors, the ACG System helps identify individuals whose needs are beginning to change — often before those changes escalate into a crisis. This includes assessing stability, understanding how different conditions interact, and recognizing the influence of social or behavioral factors.

These insights can be truly transformational, leading to earlier identification and more targeted action which in turn can reduce avoidable hospitalizations and ease pressure on emergency services. They also help organizations focus limited resources where they will have the greatest impact, improving outcomes both for individuals and for the system as a whole. Proactive care is not a distant goal; it’s already here — and the ACG System is helping organizations put it into practice today!

Myth: Frailty is the best indicator of cost and risk of emergency admissions.

Frailty is often viewed as a key indicator of who may require urgent or unplanned care. Individuals who are frail often do face significant health challenges, and frailty can be linked to increased costs and emergency utilization. But while frailty is an important factor, it is only one part of a much more complex picture.

In reality, multimorbidity is often a stronger driver of costs, patterns of care and future risk — and this holds true across all age groups. A younger person living with multiple long-term conditions may face risk of unplanned hospitalization equal to or greater than someone who is frail but otherwise relatively stable.

Frailty provides useful insight, but it represents only one component of a broader risk profile. Medical complexity, utilization trends and social factors all play a role in shaping a person’s health outcomes. For example, someone managing both physical and mental health conditions may require more intensive support than their frailty score alone would suggest. The ACG System brings these nuances into focus, enabling organizations to identify — and respond to — a fuller range of needs.

The lesson here is clear: frailty is important, but it should not be the only measure. By using multimorbidity as a lens, alongside a more comprehensive view of complexity, health systems can more accurately identify those at risk and tailor interventions accordingly. This approach makes it possible to reach individuals who might otherwise be overlooked, ensuring that resources are directed where they can deliver the greatest impact. Read our frailty blog here to find out more.

Myth: The ACG System is just a risk model.

Another misconception is that the ACG System is a single predictive risk score. In reality, the ACG System is a comprehensive population health toolkit, offering a suite of predictive models tailored to a variety of outcomes. These models do more than estimate future cost or risk of hospitalization — they segment individuals based on clinical complexity, expected resource use and patterns of health care engagement.

Predictive models are just one component of the ACG System. The system also provides insight into not only who is at risk, but also why and how best to intervene. The ACG System integrates a social needs framework, highlighting non-medical drivers of health such as housing, income and other social determinants. Care coordination markers flag potential system navigation challenges, while the Emergency Department classification assesses the likelihood that ED visits could be avoided.

Together, these features offer a much richer understanding of populations — supporting better decisions and more effective action. The ACG System does more than identify risk — it provides the actionable insights needed to design meaningful interventions, create targeted cohorts and manage resources effectively. Calling it “just a risk model” misses its real value: a toolkit for managing population health in all its complexity.

To learn more about how the ACG System can support your organization, 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.