ACUITYhealth™ 100-Point Health Score System
Population Risk Management Scoring
The ACUITYhealth Advantage: Immediate ROI Through CCM Integration
ACUITYhealth leverages Chronic Care Management (CCM) as the stepping stones for provider teams to enter into value-based care arrangements. By embedding CCM as an always-on, billable workflow, our system transforms traditional population health tracking into a real-time revenue generator. It also becomes the template for our Continuous Health Index (CHI) to monitor individuals, bringing actionable insights to provider teams along with real ROI prior to transitioning into VBC.
ACUITYhealth Model
Immediate Revenue- Start billing CCM codes within 30 days
- Generate $40-400+ PMPM immediately
- Scale revenue as you monitor
- Build VBC readiness while earning
Traditional VBC
12-18 Month Wait- Long contract negotiations
- Wait 12-18 months for PMPM awards
- Risk-bearing without revenue
- Delayed ROI on infrastructure
Key Insight: Every patient interaction becomes a billable opportunity through our 5-tier system, creating sustainable revenue streams that fund your transition to value-based care — no waiting period required.
Digital Twin: Personalized Patient Engagement Engine
The ACUITYhealth Digital Twin creates a real-time, personalized health avatar for each patient, transforming complex health data into actionable insights. This AI-powered companion drives engagement, improves outcomes, and generates additional billable touchpoints across all 5 tiers.
Tier-Specific Digital Twin Engagement
- Preventive care reminders
- Wellness challenges & rewards
- Health optimization tips
- Risk progression alerts
- Behavior modification coaching
- What-if scenario modeling
- Daily check-ins & monitoring
- Medication adherence tracking
- Symptom trend analysis
- Crisis prevention alerts
- Care team coordination
- Family member access
- 24/7 monitoring dashboard
- Caregiver support tools
- Advance care planning
Real-Time Insights
Patients see their health score update with each interaction, driving significantly higher engagement rates
Enhanced Billing
Digital twin interactions qualify for multiple care management billing codes, supporting sustainable practice operations
Predictive Interventions
AI-powered insights enable proactive care at transition zones, significantly reducing emergency department visits
Shared Decision-Making
Provider and patient view the same twin, testing treatment scenarios together in real-time
Clinical Impact: The Digital Twin transforms abstract health data into a personalized, visual experience that patients understand and trust. By creating a continuous connection between patients and their care teams, the system enables earlier interventions, stronger treatment adherence, and more informed health decisions — fundamentally changing how patients engage with their own health journey.
5-Tier Population Distribution by Health Score
This distribution shows how a typical patient population segments across the 5 health tiers. The majority (60%) of patients are in Tiers 1-2, representing wellness and emerging risk states where preventive interventions are most effective. The remaining 40% require increasingly intensive care management, with the highest-risk 8% in Tier 5 requiring daily monitoring and comprehensive support. This natural distribution enables practices to allocate resources efficiently while maximizing both clinical outcomes and billing opportunities through appropriate CCM service levels.
Health Score vs. Care Intensity
This graph demonstrates the inverse relationship between patient health scores and care intensity requirements. As health scores decrease from 100 (perfect health) to 0 (critical complexity), both the monthly touch points and care complexity index increase exponentially. The steepest increase occurs at the transition zones (Tiers 2 and 4), highlighting critical intervention points where proactive care escalation can prevent deterioration. This data-driven approach ensures appropriate resource allocation and maximizes billing opportunities at each tier.
5-Tier Health Score Management Protocols
Preventive: 99381-99397
Screenings: G0442, G0444
PCM Monthly: 99426-99427
RPM Setup: 99453
RPM Device: 99454
Behavioral Health: 99484
CCM Complex: 99487
PCM: 99426-99427
RPM: 99453-99458
BHI: 99492-99494
Care Planning: 99483
TCM: 99495-99496
RPM: 99453-99458
Care Navigation: G0506
Prolonged Services: 99417
Home Health: G0162-G0164
Additional CCM: 99490-99491
TCM High: 99496
Critical Care: 99291-99292
ACP: 99497-99498
Prolonged E/M: 99354-99357
Home/Domiciliary: 99341-99350