The heart-failure monitoring model already running at MercyOne Iowa Heart Center, carried across the 48 acute-care hospitals and the employed cardiology groups behind them. Heart-failure patients only, enrolled two ways: from the cardiology office visit and from the hospital discharge. One engine on one Epic instance: transitional care at every heart-failure discharge, remote monitoring and principal care management for the months after it, and the readmission performance the system's four two-sided ACOs and its preliminary Ambulatory Specialty Model exposure are each paid on.
Two counts, two jobs. The headline is 3,953 unique patients at month 24; the enrollment chart and the Scenario Explorer show 6,035 active program enrollments, because a patient on both remote monitoring and principal care management is one patient and two enrollments.
A heart-failure monitoring program with six months of results inside the system, four Enhanced-track shared savings organizations, an owned Medicare Advantage plan, employed cardiology groups already named on a CMS specialty-model list, and a single Epic instance finishing its rollout this year. What Trinity Health does not yet have is one cardiovascular remote care service line that runs the same way in every region.
MercyOne Iowa Heart Center runs its advanced heart-failure cohort on CoachCare remote monitoring. The six-month evaluation is below. It is the only reference a system-wide program needs, and it is already inside the system.
Trinity Health Integrated Care, Trinity Health Of New England CIN, MercyOne ACO III and Genesis ACO all appear on the CMS PY2026 Shared Savings Program file in the Enhanced track, two-sided risk, covering more than 223,000 beneficiaries. Avoided cardiac admissions are shared savings in all four.
27 heart-failure clinicians across 3 Trinity billing entities are named on the CMS preliminary participant list for the Ambulatory Specialty Model, and 19 Trinity hospitals sit in 11 selected areas. Performance year one is CY2027.
TogetherCare, the single-instance Epic platform, completes its final regional waves in 2026. CoachCare is an Epic integration partner. One integration, built once, serves every region as it comes onto the shared instance.
One structural fact completes the picture: no system-level ambulatory cardiology remote-monitoring program is named anywhere in Trinity Health's public materials. Post-acute home health runs its own monitoring, inpatient units run virtual nursing, and Iowa Heart runs this program. The cardiology clinics in the other fourteen regions are the open ground.
Iowa Heart Center identified 450 of its most complex heart-failure patients, NYHA class III–IV, ACC/AHA stage C and D, from a heart-failure population of more than 9,000, and put them on CoachCare remote monitoring alongside standard advanced heart-failure care. Daily blood pressure, heart rate and weight; real-time alerts to the care team; a monthly call. The panel's own 30-day readmission benchmark before the program was 18%.
The FY2026 Hospital Readmissions Reduction Program file, which is the file that sets the penalty, reports a heart-failure excess readmission ratio for 42 Trinity Health hospitals. 18 are above 1.00, which means each is being paid less on every Medicare inpatient stay because of it. The hospital that runs the Iowa Heart program is at 0.879, well below expected, on 731 heart-failure discharges. That is the compliment that opens the argument: the care inside the buildings holds up everywhere; the thirty days after a cardiac discharge are what differ from region to region.
In CY2024 the system's acute-care hospitals discharged 5,566 traditional-Medicare heart-failure patients. Those discharges, grossed up for the Medicare Advantage share of each market, are the heart-failure panel the Value Analysis below is sized on. The heart-attack and arrhythmia cohorts (4,382 further discharges) are the next wave on the same engine and carry no revenue on this page.
| Hospital | HF excess readmission ratio | HF 30-day readmission rate |
|---|---|---|
| St. Joseph's Health, Syracuse | 1.207 | 23.3 |
| Saint Agnes Medical Center, Fresno | 1.177 | 22.6 |
| Trinity Health Livonia | 1.151 | 21.7 |
| MercyOne Genesis Davenport | 1.137 | 19.8 |
| St. Mary Medical Center, Langhorne | 1.104 | 22.0 |
| Mercy Fitzgerald, Darby | 1.100 | 20.3 |
| St. Peter's Hospital, Albany | 1.099 | 21.2 |
| MercyOne Dubuque | 1.082 | 21.7 |
| MercyOne Des Moines (Iowa Heart) | 0.879 | 19.7 |
FY2026 HRRP hospital file (discharges July 2021 to June 2024) and Care Compare unplanned readmission measures (July 2022 to June 2025). The highlighted row is the hospital behind the Iowa Heart program.
Four Trinity Health organizations sit in the Enhanced track of the Medicare Shared Savings Program, the two-sided track, with more than 223,000 assigned beneficiaries between them: Trinity Health Integrated Care across eight states, Trinity Health Of New England CIN, MercyOne ACO III and Genesis ACO. A heart-failure admission that does not happen is a fee-for-service margin for the service line and, for an assigned beneficiary, a dollar that stays under the ACO's benchmark. The same program writes to both ledgers.
Medicare Shared Savings reconciles total cost of care for assigned beneficiaries against a benchmark once a year. Heart failure is the single largest driver of avoidable inpatient spend in a Medicare population, and the cost sits in the thirty days after a discharge: the readmission, the observation stay, the emergency visit. The forecast on this page is priced on the fee-for-service codes alone. Every admission it prevents among assigned beneficiaries also lowers the number the ACO is measured on, and in the Enhanced track that difference is shared, not just reported.
An ACO's analytics tell it which heart-failure patients are likely to be readmitted. What it does not own is the staffed, device-connected layer that reaches those patients every day: the cuff, the scale, the nurse who sees a three-pound weight gain on Tuesday and adjusts the diuretic before Friday. That layer is what this service line is. Population-level attribution and quality reporting stay with the ACOs; the program supplies the daily contact the reports assume is happening.
$3.55M net to the system over 24 months on the RPM and PCM codes, at a 42.4% margin. This is the ledger the Value Analysis below prices.
The share of enrolled heart-failure patients assigned to one of the four ACOs is a chart question, not a modeled one. Whatever that share is, their avoided admissions land under benchmark in the year they happen.
For heart-failure patients enrolled in Trinity Health's own Medicare Advantage plan, an avoided admission is medical cost the system keeps outright, with no benchmark and no split.
A named service line with its own P&L and scorecard, following the cardiac patient from the discharge home, inside the Epic chart every region is moving onto. The stack is the one Iowa Heart already runs, with the transitional-care and principal-care codes added so the thirty days after discharge and the months after that are both billed.
| Service | Codes | CY2026, Michigan locality 01 | Use across the cohort |
|---|---|---|---|
| Transitional care management | 99495 · 99496 | $220.23 / $298.36 per discharge | Every cardiac discharge; not in the forecast below |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $21.43 setup · $50.52/mo | Heart-failure cohort; 99445 opens 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.64 + $41.64 add'l · $25.98 | Daily review, titration, escalation |
| Principal care management | 99424 · 99425 · 99426 · 99427 | $68.29 + $54.25 add'l (clinical staff) · $88.79 + $62.16 (physician) | Monthly management of the heart-failure patient under the cardiologist |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 48152 (WPS, Michigan locality 01), the basis the Value Analysis below is priced on. Each region bills at its own locality; the rollout table further down carries the range.
Trinity Health finishes its single-instance Epic rollout in 2026. CoachCare integrates with Epic: eligibility flags and orders leave the chart, monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. Built once on the shared instance, the integration serves each region the month it joins.
one Epic integration on the shared instance; each region inherits it as its TogetherCare wave completes, with no regional interface project.
a cardiologist or APP flags an eligible patient and submits the referral from inside Epic; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the system's revenue cycle already runs. The program does not compete for integration capacity during the final waves.
The service line earns its own fee-for-service margin. The same monitoring, the same care management and the same readmission results are also what three CMS programs Trinity Health already sits inside measure and pay on. Each is stated here at exactly the strength the CMS files support.
The Value Analysis shows the program pays. This is how it stays safe across fifteen regions. Every blood pressure, weight and heart-rate reading routes through the same protocol Iowa Heart runs today, so each region's cardiologists see signal rather than noise and keep clinical control.
Chest pain, new shortness of breath, stroke signs, syncope, sudden swelling. CoachCare's urgent and emergent policy supersedes any regional preference. If the patient refuses, the clinic is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse each region designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a clean symptom check closes the loop with a chart note and nothing else. The cardiologist's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the region is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
Every cardiac discharge triggers three touches inside two weeks, and when the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days. That cadence, on the heart-failure cohort, is where the modeled 352 avoided hospitalizations over 24 months come from.
Reach the patient, reconcile medications against the discharge instructions, confirm the cuff and scale are transmitting.
Weight trend and symptom review, diuretic plan confirmed, follow-up appointment confirmed with the heart-failure clinic.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + PCM stack on heart-failure patients only: 11,661 Medicare heart-failure patients in scope for Year 1, sized from the system's own CY2024 heart-failure discharges and the Medicare Advantage share of its markets, out of a total Medicare panel of 170,400. Enrollment comes from two places: the cardiology office visit, where 295 referring cardiologists and CoachCare's on-site enrollment specialist flag eligible patients, and the hospital discharge, where post-discharge outreach reaches the patient in the first days home. Michigan locality 01 rates and the Epic integration. Shared savings, ASM, TEAM and the health plan's own medical-cost savings are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to system |
|---|---|---|---|
| RPM: devices, data and management | $5,102,980 | $2,922,379 | $2,180,601 |
| PCM: principal care management | $3,268,284 | $1,723,789 | $1,544,495 |
| Implementation, Epic integration and outreach | — | $178,115 | −$178,115 |
| 24-month total | $8,371,265 | $4,824,283 | $3,546,982 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the system and never deducted from its margin. | |||
24-month service line margin: 42.4% of net reimbursement (Year 1 41.2%, Year 2 42.8%).
Year 1 is $859,251 net to the system on $2,084,384 of net reimbursement; Year 2 is $2,687,730 on $6,286,881. Month 1 is −$1,562 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring professional-fee volume over 24 months, generated inside Epic.
Blood pressure, heart rate and weight, a continuous picture of the heart-failure cohort between visits.
About $5.28M in acute-care cost that never gets spent, at $15,000 per admission. In four Enhanced-track ACOs and on the system's own plan, that is savings the system shares in or keeps.
About 75,135 care-team hours of monitoring, outreach and documentation carried by the service line, not by regional staff.
The size of the heart-failure cohort, not enrollment capacity, is what limits this forecast. Widen the cohort and the forecast moves. RPM reaches its ceiling of 3,061 in month 13 and holds there; PCM reaches its ceiling of 2,974 in month 19 and holds there. At month 24 the census is 6,035 active enrollments, 3,953 unique patients, which at 165 patients per care manager is about 24 CoachCare care managers, none on a Trinity Health requisition.
| Program | Enrollment ceiling | How it is defined | Month 24 |
|---|---|---|---|
| RPM | 3,061 | 11,661 in scope × 75% eligible × 35% acceptance | 3,061 |
| PCM | 2,974 | 11,661 in scope × 85% eligible × 30% acceptance | 2,974 |
| At month 24 | — | Active program enrollments = 3,953 unique patients | 6,035 |
Eligibility is set for a heart-failure Medicare cohort. Every point of eligibility or acceptance a region's own chart data supports beyond these raises the ceiling, and the forecast, directly. Year 1 lands at 2,993 unique patients, about 18 care managers.
The forecast is one system-wide number. The program is built region by region, and the order writes itself from the system's own data: heart-failure discharge volume, the readmission ratio in the payment file, the Epic wave date, and where the ASM entities sit. Iowa Heart is the reference site and the training ground; Michigan carries the most heart-failure volume; Albany, Hartford and Boise carry the ASM exposure. The Scenario Explorer above is the sizing tool for each wave: put in the region's cohort and cardiologists, read off its forecast.
The employed primary-care network runs chronic care management and advanced primary care management on the same engine; the COPD and CKD cohorts run RPM and PCM exactly as heart failure does. Heart attack and arrhythmia come first (4,382 traditional-Medicare discharges in CY2024 on the same cardiology bench), then 1,343 COPD, 4,070 renal and 3,184 diabetes discharges. None of that is in the forecast on this page.
CY2024 traditional-Medicare heart-failure discharges by regional ministry, from the CMS inpatient file, with the county Medicare Advantage range each region bills into.
| Regional ministry | States | Hospitals with a CCN | HF discharges, CY2024 FFS | County MA share |
|---|---|---|---|---|
| Trinity Health Michigan | MI | 9 | 1,221 | 56–76% |
| MercyOne (incl. Genesis) | IA · IL | 16 | 945 | 28–61% |
| Trinity Health Of New England | CT | 3 | 355 | n/a |
| St. Peter's Health Partners · St. Joseph's Health | NY | 4 | 586 | 56–63% |
| Trinity Health Mid-Atlantic | PA · DE | 4 | 479 | 34–60% |
| Mount Carmel | OH | 5 | 351 | 56% |
| Loyola Medicine · Saint Joseph Health System | IL · IN | 5 | 479 | 45–58% |
| Saint Agnes | CA | 1 | 366 | 49% |
| Saint Alphonsus | ID · OR | 4 | 181 | 16–63% |
| Holy Cross Health | MD · FL | 3 | 431 | 23–65% |
| St. Mary's Health Care System | GA | 3 | 105 | 44–60% |
| Trinity Health, 58 hospitals | 16 states | 58 | 5,566 | 52.3% weighted |
CoachCare operates as the service line's engine while each region's cardiologists govern protocols and every clinical decision. Full-service delivery means launch needs no new Trinity headcount, the Epic integration is built once on the shared instance, and every subsequent region starts from a running program rather than a blank page.
System service-line charter, P&L and scorecard; one clinical protocol adopted from the Iowa Heart program; Epic integration built on the TogetherCare instance; revenue-cycle configuration for the TCM, RPM and PCM families.
Iowa Heart extends from the advanced cohort to the wider heart-failure population; Trinity Health Michigan's cardiology division launches across its nine hospitals, the largest heart-failure volume in the system. CoachCare's enrollment outreach working both.
Albany, Hartford and Boise, where the preliminary ASM entities sit, ahead of the CY2027 performance year; then Syracuse, Fresno, Davenport and Langhorne, where the readmission ratio is costing the most. Monthly system scorecard to the executive team.
Remaining regions as their Epic waves settle; re-validate eligibility against chart data; align reporting with the four ACOs' quality and cost measures; decide the primary-care, pulmonary and renal sequencing on real enrollment data.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, priced at the Detroit-locality amounts the forecast itself uses rather than national averages.
The proposals reach the remote-monitoring family only. Principal care management is not in them, and on this forecast PCM carries $3,268,284 of the $8,371,265 in 24-month net reimbursement. Its own amounts move by about two points through the conversion factor, so $26,188 of the $485,122 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an MSO-style arrangement in which CoachCare manages the staffing while the health system owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. For a system that already runs four two-sided-risk ACOs and its own Medicare Advantage plan, that shift lands on ground Trinity Health has already prepared.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars are drawn on one shared dollar scale, so the green can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at WPS Michigan locality 01 (Detroit) amounts, non-facility, on this forecast's own billing mix. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B, so the movement can be read without a locality in the way. The repricing above uses Detroit amounts; the two bases do not reconcile to the dollar, by design.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $21.71 | $20.03 | −7.7% |
| 99445 | Device supply, 2–15 days | $52.11 | $41.38 | −20.6% |
| 99454 | Device supply, 16–30 days | $52.11 | $41.38 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $51.77 | $49.59 | −4.2% |
| 99458 | Treatment management, each additional 20 minutes | $41.42 | $40.39 | −2.5% |
| 99470 | Treatment management, first 10 minutes | $26.05 | $20.69 | −20.6% |
| Not in scope: principal care management | ||||
| 99426 | Principal care management, first 30 minutes (clinical staff) | $67.80 | $67.00 | −1.2% |
| 99427 | Principal care management, each additional 30 minutes | $54.11 | $54.52 | +0.8% |
| 99424 | Principal care management, first 30 minutes (physician) | $87.51 | $84.40 | −3.6% |
| 99425 | Principal care management, each additional 30 minutes (physician) | $61.46 | $59.11 | −3.8% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than CY2028.
Comments on CMS-1848-P are due September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
The service line on this page runs on infrastructure already proven at national scale, and already running inside Trinity Health.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this partnership fits Trinity Health specifically, not remote care in general.
The program is running at MercyOne Iowa Heart Center with six months of results. The protocol, the device kit, the escalation engine and the enrollment playbook already exist in Trinity Health's own language. Every other region starts from that, not from a pilot.
CoachCare integrates with Epic. On a single-instance platform the integration is built once and inherited by every region as its wave completes, which is the only way a fifteen-region program avoids fifteen interface projects during a year when integration capacity is spoken for.
Enrollment outreach, care managers at about 165 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. A service line that runs at a 42.4% margin without a single Trinity requisition is a different conversation from one that asks each region to hire.
In the Enhanced track, fewer cardiac admissions among assigned patients are shared savings. The monthly touches that generate remote-monitoring and care-management revenue are the same touches that produce them. One program, both ledgers, with the fee-for-service margin funding it.
The heart-failure quality and cost measures in the Ambulatory Specialty Model are what this program produces: guideline-directed therapy closure, blood-pressure control, fewer admissions. The regions named on the preliminary list get it first, with a year of data before the first performance year.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If a region's census does not build, CoachCare does not get paid for it, which is why every wave is measured before it goes to paper. The forecast, the Disclosures and the workbook behind this page are Trinity Health's to keep either way.