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.
A note on how patients are counted. Enrolled Patients are unique individuals — 2,699 at Month 24. Enrolled Services are total program enrollments — 3,348 at Month 24 — because roughly 70% of PCM enrollees also carry RPM, so those patients count once as a patient and twice as a service. Every chart and the Scenario Explorer below report active program enrollments; the headline reports unique patients.
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 enrollments |
| Go / scale decision with full unit economics | Day 90 |
*The modeled months 1–3 network census (54 → 142 → 264 active program enrollments), concentrated at the pilot site during the Larkspur-first phase.
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, 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 that collaborative-care arrangement with Network primary care, 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.
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 — rather than a point solution bolted onto one condition.
| 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 | The single high-risk cardiac condition (HF) ≥3 months — the specialist's care-management code |
| Advanced Primary Care Mgmt | G0556 · G0557 · G0558 | ~$15 / ~$49 / ~$107 | Primary-care side only; bundled monthly payment and ASM collaborative-care substrate. Not modeled below. |
The Value Analysis below uses MAC-locality rates auto-resolved for zip 94939 (Noridian JE, California — carrier 01112 / locality 52).
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.
The Epic integration exists so that patients and providers each work in the tool they already know — which is what keeps a program efficient and sustainable past its first year.
A 24-month forecast for the specialty arm alone — RPM plus PCM across MarinHealth Cardiovascular Medicine's five clinics, ~25 referring providers plus a dedicated on-site enrollment specialist, MAC-locality rates for zip 94939 (carrier 01112 / locality 52), Epic integration. The on-site enrollment specialist is CoachCare's expense and is never subtracted from network margin. TEAM episode upside, avoided-readmission savings, and the primary-care APCM arm are not in these numbers; they are upside on top.
| Program (24-Month) | Net Reimbursement | CoachCare Fees | Network Margin |
|---|---|---|---|
| RPM — remote physiologic monitoring | $3,815,928 | $1,972,144 | $1,843,783 |
| PCM — principal care management | $1,281,218 | $658,152 | $623,065 |
| Implementation, integration & ancillary | — | $99,350 | −$99,350 |
| 24-month total | $5,097,145 | $2,729,646 | $2,367,499 |
| By Year | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| Net reimbursement | $1,251,739 | $3,845,406 | $5,097,145 |
| CoachCare fees | $675,538 | $2,054,108 | $2,729,646 |
| Network margin (after fees) | $576,201 | $1,791,297 | $2,367,499 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value, never subtracted from network margin. | |||
24-month practice margin: 46.4% of net reimbursement (Year 1 46.0%, Year 2 46.6%).
Full model available as a companion workbook.
At the modeled scenario the explorer reproduces the workbook run: Month-24 census of 2,421 RPM · 927 PCM = 3,348 active enrollments (2,699 unique patients), and 24-month net reimbursement of $5,097,145.
Recurring, subscription-like professional-fee volume over 24 months across the RPM and PCM stack.
A continuous clinical picture of the HF, CAD, AFib, and HTN panels between visits.
≈ $2.99M in avoided acute cost at $15K per admission — clinical value, excluded from every revenue figure here, and direct TEAM episode relief.
33,359 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; APCM activated across Network primary care as the ASM collaborative-care engine — fully positioned for January 2027.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs on the platform.
Remote care programs implemented and running.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals and 4 million+ care actions recorded.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. That distinction lands directly on this forecast — PCM carries $1,281,218 of the modeled $5,097,146 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality rather than national averages. Same enrollment, same phasing plan — only the rates move.
Both bars run on the same dollar scale, so the red slice is nearly the same width in each — the same dollars, measured against a larger base. The empty track on the top bar is the care-management revenue RPM alone does not include.
Repriced at this locality's own geographic adjusters. The RPM reductions fall almost entirely on practice expense, so the untouched work component carries more weight in some localities than others; the same repricing at national rates would be −8.8% on RPM.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| In scope — remote physiologic monitoring | ||||
| 99454 / 99445 · device supply | Practice expense recrosswalked | $52.11 | $41.38 | −21% |
| 99457 · management, first 20 min | Direct practice expense removed | $51.77 | $49.59 | −4% |
| 99458 · management, each addl 20 min | Direct practice expense removed | $41.42 | $40.39 | −2% |
| 99453 · setup and patient education | Crosswalked; one-time per patient | $21.71 | $20.03 | −8% |
| Not in scope — the codes the proposal does not reach | ||||
| 99424–99427 · PCM | No structural change proposed | $67.80 | $67.00 | −1% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.