TEAM began January 1, 2026. All three BMC hospitals are mandatory participants, and the model reconciles every Medicare dollar spent in the 30 days after a surgical discharge. This is a remote cardiac care service line built for that window — heart failure, post-MI, post-CABG and structural heart, arrhythmia and device patients — that pays for itself on fee-for-service economics before a single episode is reconciled.
In 2024 Boston Medical Center absorbed two hospitals out of the Steward collapse and became a three-campus system. The cardiovascular service line that resulted is unusual: the academic campus, the system's cardiac surgery and structural heart centre, and the highest-volume heart failure hospital are three different buildings. Everything below is drawn from CMS's own published files.
Circulatory-system discharges across the three hospitals, CY2024 Medicare fee-for-service. CMS suppresses cells under 11 discharges, so this is a floor.
Boston Medical Center (CCN 220031), BMC–Brighton (220036) and BMC–South (220111) — all three mandatory participants for the full 2026–2030 term.
Nearly half of Suffolk County Medicare beneficiaries are dual-eligible — the population with the highest post-discharge risk and the thinnest support between visits.
| Cohort (MS-DRG) | BMC Boston | BMC–Brighton | BMC–South | Combined |
|---|---|---|---|---|
| Coronary artery bypass — the TEAM episode (231–236) | — | 65 | — | 65 |
| Cardiac valve / major cardiothoracic (216–221) | — | 35 | — | 35 |
| Endovascular valve replacement / TAVR (266, 267) | — | 107 | — | 107 |
| Heart failure and shock (291–293) | 163 | 51 | 225 | 439 |
| Acute myocardial infarction (280–282) | 31 | 28 | 165 | 224 |
| Arrhythmia and pacemaker (242, 243, 308–310) | 55 | 44 | 108 | 207 |
| Circulatory disorders with cardiac cath (286, 287) | 40 | 47 | 34 | 121 |
| All circulatory discharges (MDC 5) | 386 | 484 | 732 | 1,602 |
Source: CMS Medicare Inpatient Hospitals — by Provider and Service, data year 2024, queried by CCN. Medicare fee-for-service only — Medicare Advantage discharges are not in this file. Cells below 11 discharges are suppressed by CMS, so every figure is a floor. CY2024 largely predates integration: Brighton and South operated as St. Elizabeth's and Good Samaritan for most of that year.
U.S. News & World Report Best Hospitals, 2025–26 cycle. Cardiology, Heart & Vascular Surgery is one of four BMC specialties ranked in the national top 50.
This is not a greenfield pitch, and it would be dishonest to make one. BMC has run device-based remote patient monitoring inside its own Epic environment since 2022. The results answered the three objections that usually stop a programme like this — and they answered them on BMC's own safety-net panel.
Of 1,000 monitored patients in BMC's remote blood-pressure programme, 98.7% submitted at least one measurement, averaging 17 measurements each. The “our patients won't engage” objection has already been tested here and did not hold.
BMC reported that Black and Hispanic patients sent blood pressure measurements at statistically similar rates to white patients — a result most systems cannot show, and the one that matters most for a panel like BMC's.
The programme launched directly inside BMC's Epic workflow. A third-party remote monitoring application has already been brought into the chart, used by clinicians, and sustained — the technical precedent is set.
| What BMC runs today | Where it stops |
|---|---|
| Brighton Heart Failure Disease Management — a minimum of two telemedicine check-ins, at days 3 and 7 after discharge, explicitly to reduce readmissions. | Two visits, no device data, no daily weights or blood pressures, and it ends on day 7. Structurally it is a transitional-care programme without the monitoring tail — and the TEAM window runs to day 30. |
| Hospital at Home — launched April 2024 with congestive heart failure among its qualifying diagnoses, with round-the-clock monitoring while the patient is admitted. | It covers the patient while they are an inpatient under the CMS waiver. It does not follow them after the discharge, which is where the episode is scored. |
| Complex Care Management — RN- and social-work-led teams with community health workers, pharmacy and housing partners. | Scoped to the Medicaid ACO population. It does not reach the Medicare fee-for-service cardiac panel, and no care-management billing codes are attached to it. |
| Cardiac rehabilitation at the main campus and the Pritikin intensive programme at Brighton, plus the Preventive Food Pantry and Teaching Kitchen, which runs classes specifically for cardiac and hypertension patients. | Strong non-clinical infrastructure with nothing feeding it a daily physiologic signal. A monitored cohort would make these programmes targetable rather than opt-in. |
The Transforming Episode Accountability Model began January 1, 2026 and runs through December 31, 2030. Boston-Cambridge-Newton (CBSA 14460) is a selected mandatory geography, and all three BMC hospitals appear on the CMS participant list as Mandatory — not voluntary.
Mandatory · 01/01/2026–12/31/2030
All five episode categoriesMandatory · 01/01/2026–12/31/2030
CABG episode sits hereMandatory · 01/01/2026–12/31/2030
All five episode categoriesAn episode runs from admission through 30 days after discharge, and performance is measured on total Medicare Part A and Part B spend across that window — not on the readmission rate alone. Readmissions, ED visits, observation stays and post-acute utilisation all land inside it.
CABG is one of five priced episode categories, alongside major bowel, hip and femur fracture, lower-extremity joint replacement, and spinal fusion.
TEAM's PY1 Composite Quality Score is built on three measures: Hospital-Wide All-Cause Readmission (claims-only in PY1), CMS PSI 90, and the THA/TKA patient-reported outcome measure.
Hospital-Wide Readmission is the measure a post-discharge monitoring programme directly moves — and because it is hospital-wide, it is scored at all three campuses, not just the one performing CABG.
| MS-DRG | Benchmark | Trend factor | Preliminary target price |
|---|---|---|---|
| 231 | $86,534 | 1.0344 | $88,167 |
| 232 | $53,977 | 1.0296 | $54,740 |
| 233 | $69,564 | 1.0374 | $71,084 |
| 234 | $49,061 | 1.0396 | $50,238 |
| 235 | $52,525 | 1.0281 | $53,193 |
| 236 | $37,814 | 1.0386 | $38,685 |
Source: CMS TEAM PY1 Preliminary Target Prices workbook (dated 2025-12-10), New England / Census Division 1, baseline 2022–2024, standardized dollars, CABG discount factor 1.5%. Target prices are published at DRG-by-region level; CMS has not published hospital-level CABG target prices.
Every figure below is from CMS's own Hospital Readmissions Reduction Program and Care Compare files for the 07/2021–06/2024 measurement period, released May 2026. An Excess Readmission Ratio above 1.0000 means CMS observed more readmissions than it expected after adjusting for that hospital's case mix.
| HRRP measure (excess readmission ratio) | BMC Boston | BMC–Brighton | BMC–South |
|---|---|---|---|
| Heart failure | 0.9834 | 1.1383 | 1.1191 |
| Acute myocardial infarction | 0.9834 | 1.2639 | 0.9600 |
| Coronary artery bypass graft | 0.9273 | 1.0527 | not available |
| COPD | 1.0846 | 1.0453 | 1.0515 |
| Pneumonia | 0.9564 | 0.9321 | 1.1044 |
BMC–Brighton — the campus that performs the CABG episode TEAM prices — carries an excess readmission ratio above 1.0 on heart failure (1.1383), acute MI (1.2639) and CABG (1.0527) at the same time. CMS rates its 30-day AMI readmission rate of 16.8% as “Worse Than the National Rate.”
Care Compare's excess-days measure counts all acute care after discharge, including ED visits and observation stays a readmission rate misses. Brighton runs +56.7 excess days per 100 AMI discharges and +31.7 per 100 heart failure discharges; South runs +22.0 on heart failure. Both are rated “More Days Than Average.”
Sources: CMS Hospital Readmissions Reduction Program, Unplanned Hospital Visits and Complications and Deaths datasets, Provider Data Catalog, measurement period 07/01/2021–06/30/2024, released 2026-05-13. Heart failure denominators over the period: 457 (Boston), 249 (Brighton), 682 (South). Excess readmission ratios above 1.0 across all reported measures: 1 of 6 at Boston, 4 of 6 at Brighton, 4 of 5 at South.
The architecture is deliberately narrow: it starts where the risk is highest — the discharge — and hands the patient into longitudinal management without a gap. CoachCare supplies the enrollment engine, the devices, the monitoring team and the billing, so the service line does not depend on BMC hiring into it.
Interactive contact inside two business days, medication reconciliation, and a face-to-face visit inside 7 or 14 days. 99495 / 99496. This is the billable spine of the 30-day TEAM window.
Cellular blood pressure cuff and scale in the patient's hands before they leave. Daily weights and blood pressures reviewed by a monitoring team. 99445 / 99470 — the CY2026 codes that make a partial month billable.
The patient converts into ongoing chronic care management or principal care management with continued monitoring. 99454 / 99457 / 99490 / 99426. This is where the recurring economics sit.
| Code | What it covers | 2026 rate |
|---|---|---|
| 99453 | RPM set-up and patient education (one-time) | $25.72 |
| 99445 | RPM device supply — 2–15 days of readings (new for 2026) | $62.11 |
| 99454 | RPM device supply — 16+ days of readings, per 30 days | $62.11 |
| 99470 | RPM treatment management — 10–19 min (new for 2026) | $29.32 |
| 99457 | RPM treatment management — first 20 min | $58.29 |
| 99458 | RPM treatment management — each additional 20 min | $45.93 |
| 99490 | Chronic care management — first 20 min | $73.14 |
| 99439 | Chronic care management — each additional 20 min | $56.13 |
| 99426 | Principal care management — first 30 min | $75.14 |
| 99427 | Principal care management — each additional 30 min | $60.47 |
CY2026 Medicare Physician Fee Schedule, non-facility, MAC locality 14212-01 (Massachusetts) — resolved from ZIP 02118. Rates are locality-specific and update annually; confirm against the current fee schedule at contracting.
The programme lives in the Epic environment. Clinicians do not learn a second system, and there is no parallel worklist to maintain — enrollment, readings, documentation and claims all move through workflows the care teams already use.
Enrollment flags and trigger ordering sit inside the clinical workflow. The CoachCare team enrols qualified Medicare patients on BMC's behalf, and enrollment status is visible in Epic in real time.
Bi-directional at intake, so the monitoring team works from the same problem list, medications and history as the clinic.
Device readings land in the chart as discrete vitals — trendable, reportable and usable in flowsheets — not as scanned PDFs.
An integrated care summary writes audit-ready documentation into the record for every billed period.
Claims are generated by the CoachCare billing engine — removing the manual per-patient, per-month claim step that quietly caps most in-house programmes.
Patients begin receiving CCM and RPM services in under five days from the enrollment flag.
Every reading — across RPM, CCM and PCM — routes through one escalation engine. The rules below are the operating standard, not a description of intent, and they are what makes a monitored population defensible to a quality committee.
Chest pain · new shortness of breath · stroke signs · syncope · worst-ever headache · sudden swelling.
Any of these triggers a 911 call with the patient still on the line. If the patient refuses, they are routed to the clinic; if they remain at risk, CoachCare activates 911.
Routed to 911 immediately, with the practice notified.
Routed to a named, agreed member of the BMC care team — defined per campus during implementation.
Documented in the record as an FYI. No interruption generated.
Any ER visit or hospitalisation in the last 60 days triggers a three-touch readmission-prevention sequence. This is the operational mechanism behind the modelled hospitalisations-avoided figure, and it maps directly onto the 30-day window TEAM reconciles.
First contact. Medication reconciliation, symptom check, device set-up confirmed, red flags reviewed with the patient.
Second contact. Adherence, weight and blood pressure trend, follow-up appointment confirmed and barriers to attending it addressed.
Third contact. Stability confirmed, escalation if the trend has turned, and hand-off into longitudinal management.
Modelled on an estimated 2,091 remote-care-eligible cardiovascular patients across the three campuses, at Massachusetts Medicare rates, with one CoachCare-funded on-site enrollment specialist. Illustrative and modelled — verify against BMC's own chart counts.
| Financial summary | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $1,203,050 | $1,481,795 | $2,684,844 |
| CoachCare fees | $708,404 | $856,098 | $1,564,502 |
| Service line margin | $494,645 | $625,697 | $1,120,342 |
| Margin % | 41.1% | 42.2% | 41.7% |
Captured and reviewed over 24 months.
Modelled from RPM patient-months over 24 months.
About 10.7 FTE-equivalents of care management labour.
RPM 377 · CCM 366 · PCM 366 — equal to 732 unique patients after de-duplication.
This calculator runs the same enrollment engine as the Value Analysis and reproduces its 24-month output exactly at the default settings. Move the panel size to the number BMC's own chart counts support — that is the input worth arguing about.
The census shown is total active program enrollments — a patient enrolled in both RPM and CCM counts twice here. The headline “unique patients” figure elsewhere on this page is de-duplicated.
Replace the modelled 2,091-patient estimate with BMC's own counts from Epic: heart failure, post-MI, post-CABG and structural heart, and device patients across all three campuses. Every number in this analysis re-runs off that one input.
Start where the evidence points: the post-discharge cohort at one campus. Brighton concentrates the surgical episode risk; South concentrates heart failure volume. Either is a defensible first site, and the choice is BMC's.
Epic integration, escalation routing agreed per campus, devices staged, and the CoachCare-funded enrollment specialist on site. Patients begin receiving services within five days of the first enrollment flag.
Track 30-day readmissions and excess days in the monitored cohort against the campus baseline. Once the engine is running, extending it to the second and third campus — and to the next service line — is incremental.
Across more than 400 managed conditions.
Committed to remote care excellence.
Successful in-market programme launches.
Care plan coding and billing at scale.
Physiologic readings captured and reviewed.
Enabled through the platform.
Sized from CMS Medicare Inpatient Hospitals — by Provider and Service (data year 2024), queried by CCN for all three BMC hospitals. Circulatory-system discharges (MDC 5, DRG 215–316) totalled 1,602, plus 11 ECMO discharges. The remote-care-eligible subset — heart failure, acute MI, cardiac surgical and structural heart, arrhythmia and device, circulatory disorders with catheterisation, hypertension and other circulatory diagnoses — totalled 1,316; syncope, chest pain, peripheral vascular disorders, amputation and other vascular procedures were excluded.
Because the CMS file contains fee-for-service discharges only, the figure was grossed up for Medicare Advantage at the catchment penetration of 37.05% (Suffolk and Plymouth counties, weighted by each county's BMC discharge volume; CMS Medicare Monthly Enrollment, April 2026), giving an estimated 2,091 eligible patients and a total cardiovascular Medicare population of about 2,562.
This is a discovery-stage estimate and almost certainly a floor. CMS suppresses discharge cells under 11, and inpatient discharges capture only the fraction of an ambulatory cardiology panel admitted in a given year. It is the single input most worth replacing with BMC's own chart counts.
All CPT rates resolve from ZIP 02118 to MAC locality 14212-01 (Massachusetts) against the CY2026 Medicare Physician Fee Schedule, non-facility. Massachusetts is a comparatively high-reimbursement locality. Net reimbursement is modelled after denials, coinsurance and bad debt, not gross charges. Rates are locality-specific and revised annually.
Enrollment is driven by three pathways: provider referral (8 referrals per provider per month at an 80% acceptance rate), one CoachCare-funded on-site enrollment specialist (80 enrollments per month at capacity), and telephonic outreach. All three ramp over the first four months. Monthly attrition is 1.5%. Conversion is 30% for RPM and 25% for CCM and PCM, applied to program-specific eligibility of 60% (RPM) and 70% (CCM and PCM). Enrollment begins in month 1 — there is no onboarding delay in the model.
Program ceilings are reached at month 4 (RPM), month 5 (CCM) and month 8 (PCM), after which the census holds flat.
At month 24 the model carries 1,109 active program enrollments — RPM 377, CCM 366, PCM 366. Because a patient may carry both a monitoring and a care-management enrollment, these are de-duplicated to 732 unique patients. Charts and the Scenario Explorer show enrollments; the headline figure shows unique patients.
Hospitalisations avoided are modelled from RPM patient-months using the workbook's standard reduction assumption, and are an illustrative projection, not a guarantee or a clinical claim. Care team hours saved are modelled from task volumes and converted to FTE at 2,080 hours per year.
TEAM. Verified against the CMS TEAM Participant List (June 2026 rendition, hospital data as of April 15, 2026) on two gates: CBSA 14460 (Boston-Cambridge-Newton) is a selected mandatory geography, and CCNs 220031, 220036 and 220111 each appear individually as Mandatory participants for 01/01/2026–12/31/2030. All three CCNs were independently confirmed against the CMS Hospital General Information dataset. CMS refreshes the participant list quarterly.
Readmissions. CMS Hospital Readmissions Reduction Program and Unplanned Hospital Visits datasets, measurement period 07/01/2021–06/30/2024.
Ambulatory Specialty Model. Checked and found not applicable. Boston-Cambridge-Newton is not on the CMS ASM mandatory geography list, and no BMC clinician appears on the CY2027 participant file. No ASM content appears anywhere in this analysis.
Every financial figure is illustrative and modelled from public CMS data and published fee schedules — not a quotation, a contract, or a guarantee of results. It has not been reconciled against BMC's internal volumes, payer mix, contracts or cost structure. Pricing is indicative and subject to contracting.