How Alaska Heart & Vascular Institute turns RPM, CCM, and PCM into a self-funding remote care service line — and the operating model its heart-failure cardiologists will need when CMS's Ambulatory Specialty Model makes them accountable for heart-failure cost and quality on January 1, 2027.
The headline counts 3,737 deduped unique patients in active remote care at Month 24. The enrollment chart and scenario calculator show 5,896 active program enrollments (services), because patients dual-enrolled in RPM plus CCM or PCM are counted once as a patient but more than once as enrollments — mirroring the distinction between Enrolled Patients and Enrolled Services.
CMS's Ambulatory Specialty Model (ASM) is a mandatory, two-sided-risk program that makes cardiologists individually accountable for the cost and quality of the heart-failure patients attributed to them. The first performance year applies a Part B payment adjustment of −9% to +9% and requires an electronic collaborative-care arrangement with primary care. It is not a program AHVI opts into — it is a change in how heart failure gets paid.
Fifteen Alaska Heart & Vascular cardiologist NPIs appear on the live CMS CY2027 preliminary ASM participant list, heart-failure cohort, under the billing legal name “Alaska Heart Institute” — including Gene Quinn, Herman Feringa, William Mayer, Alan Skolnick, and Linda Ireland.
ASM reconciles attributed heart-failure spend and quality against a benchmark. This is two-sided risk from day one — year-one adjustments swing Part B professional revenue by up to nine points in either direction, escalating through 2031.
ASM requires an electronic collaborative-care arrangement with primary care and structured longitudinal management between visits — exactly what a remote care service line operationalizes.
A geography note that changes the door, not the stakes: Anchorage sits outside TEAM but inside ASM. No Alaska CBSA is among the 188 TEAM mandatory-bundle markets, so hospital-side bundling pressure does not apply here — accountability arrives through the cardiology and ambulatory door instead. The wedge is simple: one service line is your ASM heart-failure chassis. The RPM, CCM, and PCM programs modeled on this page are the same infrastructure ASM will demand — continuous physiologic monitoring, protocolized management, and documented care coordination. Build it now, and enter January 2027 with a running program instead of a blank page.
Alaska's dominant independent cardiology group — comprehensive sub-specialty depth, a dedicated Advanced Heart-Failure clinic, and the accountability ASM rewards. The honest read: strong specialty capability and device-level HF monitoring today, with scalable software remote care as open ground.
Fifteen cardiologists on the CMS CY2027 preliminary ASM heart-failure list — the practice already carries the accountability the service line is built to serve. Confirm against the final CMS list (summer 2026).
~28 cardiologists plus ~31 advanced-practice providers (~59 clinicians) across an Anchorage hub and peninsula/Mat-Su sites. Physician-owned by a deliberate independence strategy — no PE or hospital owner. 2020-vintage ownership fact; confirm unchanged in diligence.
A physical Advanced Heart-Failure / CHF clinic led by Duke-trained Dr. Jacob Kelly (Advanced HF & Transplant) — the natural launch cohort for a CCM/RPM overlay. Today's CardioMEMS monitoring (via Providence) is device-specific, advanced-HF only.
An InteliChart patient portal (engagement only) but no general RPM, CCM, or PCM program, chronic-care app, or software telehealth today — clean whitespace on the athenahealth backbone, not a rip-and-replace of a vendor.
Not a point solution bolted onto one diagnosis — a named service line with its own owner, P&L, and scorecard, run by AHVI's cardiologists, following the Medicare patient between visits on the athenahealth backbone. Three billable programs, one shared engine — a cardiology panel, purpose-built for the specialty rather than a primary-care roster.
| Service | Codes | Cardiovascular Use |
|---|---|---|
| RPM setup & device supply | 99453 · 99454 · 99445 (new 2026) | 99445 unlocks 2–15-day post-episode monitoring windows |
| RPM treatment management | 99457 · 99458 · 99470 (new 2026) | Monthly review, titration, escalation |
| Principal Care Management | 99426 · 99427 | Single high-risk condition (heart failure), cardiology-native |
| Chronic Care Management | 99490 · 99439 | Two or more chronic conditions under a cardiac diagnosis |
Rates auto-resolve to AHVI's Alaska MAC locality (Noridian, carrier 02102, locality 01) from the CY2026 Physician Fee Schedule — a locality that carries a statutory work-GPCI floor among the nation's most favorable. Blended net reimbursement per active patient-month, after denials and coinsurance bad debt, is modeled at ~$115.44 RPM, ~$139.38 CCM, and ~$114.10 PCM. Illustrative and modeled — code-level rates and capture are itemized in the companion Value Analysis workbook; verify against the current PFS at contracting.
Alaska is the national Medicare Advantage outlier — roughly 1–3% MA penetration, the only state with essentially no individual MA plans, because insurers cannot build low-cost networks in a high-cost state. AHVI's Medicare panel is therefore ~99% traditional fee-for-service. No MA carve-outs, no network exclusions: every RPM, CCM, and PCM code bills across essentially the whole Medicare population — and it is the same population ASM attributes.
Where the national Medicare book is now more than half Medicare Advantage, Alaska is the inverse — a ~99% traditional fee-for-service book. Every code bills across that population with no MA network to carve out.
Care-management codes bill across the full Medicare population; nothing is excluded to a Medicare Advantage network. The billable base and the attributed base are the same people.
Near-pure FFS today with ASM as the single downside-risk exposure — an unusually clean story where one infrastructure bills fee-for-service and de-risks ASM.
AHVI serves a vast, dispersed state and already travels to its patients. In a place where distance and weather gate access, continuous physiologic monitoring is not a convenience — it substitutes for weather-dependent travel and catches decompensation between the visits that are hardest to schedule.
The hardest question this program has to answer is not clinical — it is logistical: does remote monitoring actually work in the bush? AHVI serves dispersed communities where terrestrial fiber and traditional Wi-Fi do not exist, and where a device that assumes a home router and a wall outlet fails on arrival. This is the connectivity, hardware, and delivery model built for that reality.
Kotzebue, Noorvik, Kiana, Selawik, Point Hope, and Point Lay — coastal and river communities reached from a single regional hub.
Bethel, Toksook Bay, Hooper Bay, Emmonak, and Chevak — among the most connectivity-constrained communities in the state.
Utqiaġvik (Barrow), Nuiqsut, and Wainwright — the northernmost patient geography in the United States.
CoachCare's own community-level connectivity audit (2026). GCI is the foundational carrier across all 22 communities, occasionally alongside ASTAC, OTZ, or Bristol Bay. Ten communities (~45%) have no 4G LTE at all and run entirely on legacy 2G/3G — yet indoor home-signal coverage stays strong, several at 100%. That contrast is exactly what determines which kit a patient receives.
| Community | ZIP | Homes w/ Indoor Signal | 4G LTE | Kit Implication |
|---|---|---|---|---|
| Strong indoor coverage · no 4G LTE — legacy 2G/3G only | ||||
| Hooper Bay | 99604 | 100% | 0% | Store-and-forward kit; cached readings flush on signal |
| Toksook Bay | 99637 | 99.9% | 0% | Store-and-forward kit; cached readings flush on signal |
| Point Lay | 99759 | 94.5% | 0% | Store-and-forward kit; cached readings flush on signal |
| Emmonak | 99581 | 79.8% | 0% | Store-and-forward kit; clinic-based backstop |
| Full 4G LTE — standard cellular kit | ||||
| Mountain Village | 99632 | 100% | 100% | Standard cellular kit |
| Kotzebue | 99752 | 99.8% | 99.6% | Standard cellular kit |
| Dillingham | 99576 | 99.8% | 99.0% | Standard cellular kit |
| Petersburg | 99833 | 98.5% | 98.3% | Standard cellular kit |
| Nome | 99762 | 99.4% | 97.8% | Standard cellular kit |
| Bethel | 99559 | 94.3% | 94.3% | Standard cellular kit |
A representative extract of the 22-community audit, selected to show the coverage contrast that drives kit selection. Figures are CoachCare audit percentages (2026), refreshed quarterly.
Embedded SIM, battery-powered. No wall outlet, no home router, no Wi-Fi credentials, no Bluetooth pairing. Wrap the cuff, press one button, and the data pushes on its own — built for off-grid dry cabins and “sync in town” portability.
For patients on more than one vital — blood pressure plus pulse oximetry — in homes with reliable in-home cellular reception.
Daily weight tracking for fluid retention — the core congestive-heart-failure protocol, and the measurement that ties this section directly to AHVI's heart-failure focus.
Where: Anchorage bowl, Mat-Su, Kenai, Fairbanks, Juneau — roughly 75% of the state's population.
Transit: 1–3 business days.
Kit: Standard cellular, dense LTE/5G; no special handling.
Where: Bethel, Nome, Kotzebue, Utqiaġvik, Dillingham, Sitka, Ketchikan, King Salmon, Unalakleet.
Transit: 2–5 business days on daily jet mainline, with a same-day option available.
Kit: GCI LTE native; cellular with Wi-Fi fallback.
Where: ~200 roadless villages served from the hubs by bush carriers.
Transit: 3–10 business days, weather-buffered.
Kit: Coverage-checked; store-and-forward or Wi-Fi/Starlink where there is no cellular; clinic-based backstop.
The model is designed to work with Alaska's existing tribal health system — ANTHC (AFHCAN telehealth), YKHC, Norton Sound, and Maniilaq — using village clinics as local activation points, with Community Health Aides as force multipliers for delivery confirmation, hands-on patient activation, and troubleshooting. Billing is configured for rural FQHC, RHC, and tribal facility reimbursement rules. No partnership or affiliation with these organizations is in place or implied.
Regional fiber and satellite investment continues to raise the floor underneath this program — AIRRAQ, TERRA, Quintillion, and Starlink bonded gateways are all extending usable bandwidth toward the hubs and villages.
CoachCare's supply-chain leadership comes from medical-device and life-science backgrounds, including global supply-chain work for organizations such as Medtronic and Boston Scientific, with direct supplier oversight and Pan-Pacific sourcing experience. This describes the team's prior experience only — not a partnership, endorsement, or affiliation.
Every reading runs through a documented protocol — not ad hoc triage. In a state where the nearest emergency room can be a bush flight away, what happens when a reading goes wrong matters more here than anywhere. Every RPM, CCM, and PCM reading is governed by CoachCare's documented Care Management Standard Operating Procedures (v. March 2026) — exactly the escalation discipline a risk-bearing ASM heart-failure program has to be able to show.
Every RPM, CCM, and PCM reading runs the same decision logic, so escalations are consistent rather than subjective — and a critical value escalates regardless of symptoms.
A vital arrives from the patient's cellular device — blood pressure, weight, or pulse oximetry — into the monitoring queue.
A critical value escalates regardless of symptoms. An out-of-range value first gets a retake plus a symptom check before anything reaches the practice.
A trend is defined objectively — 3 consecutive out-of-range readings ≥1 hour apart (blood pressure / glucose), or 3 within 7 days (heart rate) — never a single stray number.
If the patient can't be reached, the care team leaves a voicemail with a callback line and still escalates a critical value or out-of-range trend. Every escalation documents vital, findings, method, contact, outcome, and follow-up.
Any of these, reported live during outreach, moves straight to the emergency pathway:
For a dispersed Alaska panel, this is the guarantee that matters most: the emergency response does not wait on a callback from the office.
Clinical changes split three ways, so physicians are not paged for what does not need them — a real consideration for a busy cardiology group.
Active emergent symptoms follow the emergency pathway immediately — the clinic is informed, but the response never waits on it.
A non-critical clinical change is routed to a defined member of the practice's care team for review and follow-up — the right person, not a broadcast page.
A stable or resolved reading is documented as an FYI in the record — visible for continuity, without interrupting anyone.
Any ER visit or hospitalization in the last 60 days triggers a fixed three-touch sequence — the concrete readmission-prevention loop behind this account's hospitalizations-avoided number. Each touch documents and escalates per protocol, and heart-failure decompensation is exactly what it is built to catch early.
Identify precipitating factors, reconcile medications, confirm a PCP or specialist follow-up in 7–14 days, and assess symptoms.
Verify medication adherence, re-evaluate triggers, confirm the follow-up appointment happened, and verify labs.
Review medications and risk, review the outcomes of the completed visit, and re-assess symptoms.
Every element ASM will require of a heart-failure program is an element this service line already runs. Build once for reimbursement today; be ready for accountability in 2027.
AHVI's EHR is athenahealth — currently on athenaPractice (the legacy on-prem platform, formerly GE Centricity), actively migrating to athenaOne (cloud EHR / practice management / RCM). athenahealth is one of CoachCare's integrated ICP EHRs, and CoachCare integrates natively with athenaOne. The athenaPractice→athenaOne cutover is the native moment to stand up remote care — build it into the new cloud platform instead of bolting onto the system you are leaving.
Enrollment, discrete vitals, care-management documentation, and claim-ready charges flow between CoachCare and athenaOne — clinicians and billers never leave their workflow.
Standing up remote care during the athenaPractice→athenaOne cutover means it is native from day one — not a retrofit onto a platform AHVI is retiring.
athenahealth sits among CoachCare's core integrated EHRs — AHVI is an integrated-EHR account, so the interface is a configured integration, not a custom build.
A 24-month forecast for the cardiology service line — an estimated ~21,276-patient Medicare panel (a discovery-stage estimate to validate against AHVI's chart counts; Alaska's ~99% traditional-FFS book means essentially the whole panel bills fee-for-service), across AHVI's Anchorage hub and peninsula / Mat-Su sites, 33 referring providers, 1 CoachCare-funded on-site enrollment specialist, telephonic enrollment, Alaska MAC-locality rates, and native athenaOne integration. ASM episode performance and avoided-admission savings are not in these numbers; they are upside on top.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $980,591 | $3,034,725 | $4,015,316 |
| CCM net reimbursement | $892,220 | $2,766,657 | $3,658,877 |
| PCM net reimbursement | $330,689 | $1,024,874 | $1,355,563 |
| Total net reimbursement | $2,203,500 | $6,826,257 | $9,029,757 |
| Net to practice (after fees) | $1,006,334 | $3,161,158 | $4,167,492 |
| Delivered full-service — telephonic enrollment, devices, 24/7 monitoring, and billing handled by CoachCare; no new practice headcount required. | |||
Figures are illustrative and modeled — verify against practice data. Per-program year splits are allocated from the 24-month totals by each program's enrollment ramp. Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the heart-failure, CAD, and hypertension panels between visits.
≈ $3.48M in avoided acute cost at ~$15K per admission — a system-level, indirect benefit.
≈ 31.0 FTE-years 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 AHVI cardiologists govern protocols and every clinical decision. Full-service delivery means launch requires no new headcount; the staffing model formalizes as census grows.
Named owner, P&L, scorecard; athenaOne integration and billing configuration; attribution policy for shared patients; protocol sign-off for the heart-failure, CAD, and hypertension pathways.
The decompensation-risk heart-failure panel first — RPM plus PCM, protocolized GDMT titration, telephonic enrollment, and TCM at discharge for the highest-acuity patients.
Extend RPM to CAD and hypertension across the peninsula, Mat-Su, and rural echo footprint; activate CCM for the multi-condition population; monthly scorecard reporting to service-line governance.
Formalize electronic collaborative-care arrangements, harden the titration production process, and enter January 2027 with a running program. ASM participation is preliminary — confirm against the final CMS list (summer 2026).
AHVI already operates a dedicated Advanced Heart-Failure clinic under Dr. Jacob Kelly — the natural launch cohort. The heart-failure patients attributed to the fifteen ASM-listed cardiologists are exactly the population ASM will hold the practice accountable for. Starting there concentrates enrollment where the clinical and financial stakes converge, and produces the internal evidence — census, capture rate, revenue per patient-month, decompensation signal — that makes the panel-wide rollout a data decision, not a leap.
| Milestone | Target |
|---|---|
| athenaOne integration + protocol sign-off | Day 30 |
| First billable enrollments | Day 30–45 |
| RPM device-connectivity rate | ≥ 85% |
| Documented GDMT titration touch, per patient/mo | ≥ 1 |
| Active enrollments by Day 90* | ~466 enrollments |
| Go / scale decision with full unit economics | Day 90 |
*The modeled month-3 total active census (~223 RPM + ~167 CCM + ~76 PCM ≈ 466 active program enrollments) for the whole service line, concentrated in the Advanced HF cohort during the pilot phase. Enrollment begins in month 1. Illustrative and modeled — 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 and CMS data. The key assumptions — including what remains to be confirmed in discovery: