How MarinHealth and its Medical Network cardiology group convert a five-star franchise into continuous care for heart failure, coronary artery disease, atrial fibrillation, and hypertension — and get paid for it under TEAM today and ASM in 2027.
This is not a turnaround story. MarinHealth enters the payment-model era with a five-star quality rating and a cardiovascular institute most community systems can't match. The strategic question is how to defend that position — and monetize it — as Medicare shifts from rewarding the procedure to rewarding accountability over time.
Current 2026 Care Compare release — the quality halo that TEAM and ASM reconciliation math now puts at financial stake.
America's 250 Best Hospitals (2024–2025) — plus hospital-wide readmissions already better than national (13.7%).
Renamed June 2026: cardiac surgery in-house (2025), structural heart (TAVR, TEER, WATCHMAN), high-volume EP, women's heart health, hypertension program, Oak Pavilion procedural platform.
Symplicity Spyral renal denervation offered since Dec 2023 — a hypertension growth lane whose CMS coverage pathway is built on BP remote monitoring.
One more structural advantage: the Medical Network's five cardiology clinics — Larkspur, Novato, Petaluma, Sonoma, Napa — run on the shared UCSF-powered Epic/MyChart instance. One record, one in-basket, one billing layer. That is precisely the substrate a remote care service line needs. What's missing is the service line itself: no RPM, CCM, PCM, or TCM program is marketed anywhere in the system today.
Two mandatory-era CMS models now put MarinHealth's cardiovascular economics on the line — and a 2026 billing change makes the operational answer newly reimbursable.
MarinHealth Medical Center appears on the CMS TEAM participant list (San Francisco–Oakland–Fremont CBSA). Since January 1, 2026, every CABG episode is reconciled against a CMS target price with a quality adjustment — 30-day spend and readmissions now flow to the bottom line. The remote-care answer: TCM at discharge plus a first-14-day RPM bundle.
The Ambulatory Specialty Model makes cardiologists individually accountable for heart failure cost and quality, with first-year Part B swings of −9% to +9% — and requires an electronic Collaborative Care Arrangement with primary care. The service line, plus the CCM/APCM primary-care arm, is the ASM operating model built two years early.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) make post-TAVR, post-CABG, and transitional monitoring windows cleanly billable — removing the 16-day floor that previously blocked episodic remote care. Marin's demographics amplify the case: the Bay Area's oldest county, with a majority Traditional-Medicare payer mix favorable to FFS care-management billing.
Not a point solution bolted onto one condition — a named, governed service line with its own owner, P&L, and scorecard, following the Medicare patient across the whole system on the shared Epic backbone.
| Service | Codes | ~CY2026 Magnitude | Cardiovascular Use |
|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every HF, CABG, and procedure discharge |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 unlocks 2–15-day post-procedure windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 + ~$41 add'l | Monthly review, titration, escalation |
| Principal Care Management | 99426 · 99427 | ~$60 + ~$50 add'l | Single high-risk condition (HF) ≥3 months |
| Chronic Care Management | 99490 · 99439 | ~$60 + ~$47 add'l | Primary-care arm, 2+ chronic conditions |
| Advanced Primary Care Mgmt | G0556 · G0557 · G0558 | ~$15 / ~$49 / ~$107 | Bundled monthly payment; ASM collaborative-care substrate |
Illustrative national non-facility magnitudes. The value analysis below uses MAC-locality rates auto-resolved for zip 94939 (Noridian JE, California). Verify against the current CY Physician Fee Schedule.
The same infrastructure — enrollment, devices, alerts, navigation, titration, billing, analytics — powers each strategic lever MarinHealth already cares about. Build once, reuse everywhere.
MarinHealth's UCSF-powered Epic instance is the single biggest accelerant for this service line. CoachCare integrates directly and bi-directionally with Epic — practices enroll and monitor remote-care patients inside built-in Epic workflows, without learning a new system. The whole program lives in the Epic environment.
from enrollment flag to a patient receiving billable RPM and care-management services.
CoachCare is the only care-management platform integrated with Epic that provides automated claims creation via its billing engine.
"Key to achieving a program that is efficient, effective and sustainable, is creating a seamless, intuitive user experience for the patient and provider, and that's what our integration with Epic accomplishes."
A 24-month forecast for the specialty arm alone — MarinHealth Cardiovascular Medicine's five clinics, ~25 referring providers plus a dedicated on-site enrollment specialist, MAC-locality rates for zip 94939, Epic integration. TEAM episode upside, avoided-readmission savings, and the primary-care APCM arm are not in these numbers; they are upside on top.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $594,848 | $1,814,837 | $2,409,685 |
| CCM net reimbursement | $503,336 | $1,576,387 | $2,079,723 |
| PCM net reimbursement | $193,623 | $606,273 | $799,896 |
| Total net reimbursement | $1,291,807 | $3,997,496 | $5,289,304 |
| Network margin (after fees) | $608,354 | $1,918,577 | $2,526,931 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value already reflected in the fees above. | |||
Figures are illustrative and modeled — verify against practice data. Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the HF, CAD, AFib, and HTN panels between visits.
≈ $1.9M in avoided acute cost at $15K per admission — and direct TEAM episode relief.
36,891 care-team hours of monitoring, outreach, and documentation handled by the service line.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while Haynes Heart & Vascular Institute physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new headcount; the pilot staffing model (RN navigators, 0.5–1.0 clinical pharmacist, an APP lead, a cardiology medical director at 0.1–0.2 FTE) formalizes as census grows.
Named owner, P&L, scorecard; Epic integration and billing configuration; attribution policy for shared patients; protocol sign-off for HF, CAD, AFib, HTN pathways.
HF discharges and post-CABG high-risk patients — TCM contact within 2 business days, first-14-day RPM bundle, pharmacist-led GDMT titration under protocol.
All five cardiology clinics enrolling; structural-heart same/next-day discharge pathway live; balanced scorecard reporting monthly to service-line governance.
Hypertension RPM feeding the renal denervation program; CCM/APCM activated across Network primary care as the ASM collaborative-care engine — fully positioned for January 2027.
The Medical Network's flagship cardiology clinic at 2 Bon Air Road is the natural pilot site — one road from MarinHealth Medical Center and the Haynes Heart & Vascular Institute, so the highest-acuity discharges, the structural-heart and EP recovery pathways, and the cardiology clinic that follows them all sit within the same campus loop, on the same Epic instance.
A Larkspur-first launch concentrates enrollment where discharge volume already flows, lets one clinic's physicians and MAs shake out the workflow, and produces the internal evidence — census, capture rate, revenue per patient-month, readmission signal — that makes the Network-wide rollout a data decision, not a leap.
| Milestone | Target |
|---|---|
| Epic integration + protocol sign-off | Day 30 |
| First billable enrollments | Day 30–45 |
| 48-hour TCM outreach rate | ≥ 90% |
| 7-day post-discharge follow-up rate | ≥ 70% |
| Active remote-care census by Day 90* | ~260 patients |
| Go / scale decision with full unit economics | Day 90 |
*The modeled months 1–3 network census (54 → 142 → 264 active patients), concentrated at the pilot site during the Larkspur-first phase. Illustrative — the pilot's actual funnel is set in protocol design.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers committed to remote care excellence.
Successful program implementations.
Care plan coding and billing generating over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Every number on this page traces to the CoachCare Value Analysis workbook or cited public data. The key assumptions: