Community Health Care Systems controls hypertension better than the average health center in America — 73.3%, up nineteen points since 2021 — across registries of 7,732 hypertensive and 4,063 diabetic patients. Behind those registries sits a Medicare panel of 5,299 patients, 2,099 of them dual-eligible, that has held steady for four years while the whole panel ages into it. Since January 1, 2026, the between-visit work that moves these measures bills code-by-code, on top of the PPS visit. This is the business case for building that layer now.
The headline counts 1,311 unique patients in active remote care at Month 24. The enrollment chart and the Scenario Explorer show 2,145 active program enrollments (services): CCM and APCM cannot be billed for the same patient in the same month, so the 636 CCM and 556 APCM enrollments are 1,192 distinct care-management patients. Most of the 953 RPM enrollments sit inside those cohorts as a second program on the same patient, and the balance are monitoring-only — together, 1,311 unique patients. Program enrollments are never labeled “patients.”
Health centers report clinical quality to HRSA every year and are ranked against every health center in the country. The CY2025 report card for Community Health Care Systems: above the national average on both flagship chronic-disease measures, top national quartile on three more, and five federal quality badges — including National Quality Leader in Diabetes Health.
Against a 69.1% national health-center average — and up from 54.1% in 2021. A nineteen-point climb in four years, earned visit by visit.
Lower is better, and the health center beats the 26.3% national average. Down from 34.0% in 2021 — and HRSA named it a National Quality Leader for Diabetes Health in 2026.
Aspirin therapy for vascular disease (90.6%), depression screening with follow-up (89.8%), and BMI screening with follow-up (87.5%) all rank in the best-performing national quartile.
A Section 330 grantee since 1993, spanning clinic, school-based and mobile care across a middle-Georgia footprint about the size of Connecticut.
Voluntarily accredited, recognized as a Patient-Centered Medical Home, and carrying HRSA badges for diabetes health, health IT, high value care and preventive health.
Patient-support and enabling services reached 2,522 patients last year — four times the 2021 count — alongside school-based clinics, two mobile units and a 340B pharmacy program.
A nineteen-point hypertension climb came from better visits: capture, titration, follow-up. Past the national average, the marginal point stops coming from the exam room, because the disease is decided in the ninety days between appointments. That is where continuous data works — and where these registries give the health center more cohort scale than any practice in its counties.
The one flagship measure in the bottom national quartile — and it is the one that runs on between-visit outreach rather than exam-room care. A monthly care-management touch is a screening reminder with a billing rail under it.
Up from 16.7% in 2021 — a point a year, every year. The panel is aging into Medicare, so every ceiling in this plan rises on its own.
Steady between 5,155 and 5,299 for three straight years: a stable, deep base — 26% of the whole panel — on which every program below bills.
G0511 — the single bundled code that paid health centers one flat amount for roughly twenty distinct care-management services — is gone. Since January 1, 2026, federally qualified health centers bill the individual CCM, RPM and APCM codes, each separately payable in addition to the PPS encounter rate.
PPS still pays for the visit. Care management and remote monitoring pay on top of it rather than folding into it, so a remote-care program does not cannibalize the encounter.
Health centers bill these codes at one national rate, at every site. This forecast is modeled at the lower Georgia locality schedule — four to twelve percent under the national card, code by code — so the rate assumption sits beneath what the rules actually pay.
Each program now needs its own time capture and its own documentation, every month, for every enrolled patient. That is the operational cost of the change, and it is the part CoachCare absorbs.
Since January 1, 2024, Community Health Care Systems has participated in the Medicare Shared Savings Program through ACME Health Partners ACO — built entirely of Georgia community health centers, seven organizations, with this health center holding the board chair. The ACO runs the ENHANCED track, where total cost of care is the scoreboard in both directions. In performance year 2024 it earned $941,299 in shared savings, and four-fifths of that was distributed to the participating health centers.
Medicare assigns beneficiaries to the ACO based on where they receive primary care — and monthly care management, APCM among the qualifying services, is documented primary care twelve times a year. A patient managed monthly is a patient whose attribution stays home.
The track carries real downside alongside the highest sharing rate in MSSP. What earns savings is exactly what remote care produces: blood pressure that stays controlled, exacerbations caught early, and the post-discharge cadence behind the 78 avoided hospitalizations in this forecast.
The ACO's public quality reporting and the UDS report card flag the same gap: colorectal screening. That number moves through between-visit outreach — which is what a care-management layer does every month, with a billing rail under it.
Modeled across the 5,299 Medicare and dual-eligible patients in the CY2025 federal report — the population where these codes pay at Medicare rates. CoachCare supplies the devices, the enrollment staff, the monitoring hours and the documentation. The health center supplies the panel and the clinical decisions.
Remote physiologic monitoring. Cellular blood-pressure cuffs and glucose meters that transmit on their own — 99453 setup, 99454 device supply, 99457 and 99458 treatment management, plus the CY2026 short-window codes 99445 and 99470. Reaches 65% of the in-scope panel and stacks with either care-management rail.
Chronic care management. Monthly non-face-to-face management for patients with two or more chronic conditions — which, in a panel where nearly half carry hypertension and a quarter carry diabetes, is most of the Medicare population. 99490 and 99439.
Advanced primary care management. No minute thresholds and no time sheets — a monthly per-patient payment tiered by complexity. G0556, G0557 and G0558, where the top tier pays most for qualified Medicare beneficiaries who also carry Medicaid. 2,099 of the 5,299 Medicare patients — 39.6% — are dual-eligible, and that mix is what feeds the top tier.
Twenty-four sites, fourteen counties, two mobile units, and school-based clinics. Devices ship cellular-connected — they work in the parts of the footprint where home broadband does not — and no clinician adds a task: the on-site specialist works the highest-volume sites while telephonic outreach covers the rest.
Community Health Care Systems runs on eClinicalWorks, and CoachCare's integration uses eCW's own built-in workflows — the care team enrolls and monitors patients without learning a second system. Readings, documentation and claims land in the chart the clinicians already work in.
Enrollment flags and trigger ordering by service sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on the health center's behalf, enrollment status shows in eCW in real time, and patients begin receiving CCM and RPM services in under five days from flag.
Bi-directional at intake, so the care team starts with the same problem list, medications and history the clinic has.
Blood pressure, weight and glucose readings post as structured data on the patient record rather than as attachments nobody opens.
Evidence of Care, vitals and care plans attach to the patient's chart monthly. Under the CY2026 individual-code rules each program needs its own time capture and its own documentation, and this is what substantiates the billed time when a payer asks.
Claims are created by the CoachCare billing engine. CoachCare is the only care-management application integrated with eClinicalWorks that generates claims automatically, which removes the manual per-patient, per-month claim step entirely.
The economics prove the service line pays. This is what keeps it safe — and what lets a lean clinical bench delegate monitoring without inheriting noise.
The care team retakes it and screens for symptoms before anything escalates. A single high number is a measurement; a confirmed one is a finding.
A patient who feels fine with a critical reading still escalates. Feeling well is not a reason to wait.
Three readings at least an hour apart for blood pressure or glucose, or three within seven days for heart rate. Not a judgment call, and not a different threshold depending on who is working.
Voicemail and a callback attempt are logged, and a critical value or confirmed trend escalates anyway. Silence never closes a case.
Emergencies go to 911. Non-critical findings go to a named member of the practice team. Stable and resolved goes into the record as an FYI, so the clinic is not paged for readings that resolved themselves.
Vital, findings, method of contact, who was reached, outcome, and follow-up. That record is also what substantiates the billed time.
A 24-month forecast across the 5,299-patient Medicare and dual-eligible population, 15 referring adult-medicine clinicians, one CoachCare-funded on-site enrollment specialist, telephonic enrollment, and Georgia physician fee schedule rates. Health centers actually bill these codes at the national rate card, which runs four to twelve percent higher — that gap is left out of every number here, along with Medicaid revenue, 340B pharmacy effects, shared-savings distributions and the dollar value of avoided admissions.
| Program | Year 1 | Year 2 | 24‑Month |
|---|---|---|---|
| RPM net reimbursement | $263,736 | $808,428 | $1,072,164 |
| CCM net reimbursement | $272,059 | $760,583 | $1,032,642 |
| APCM net reimbursement | $240,507 | $377,656 | $618,163 |
| Total net reimbursement | $776,302 | $1,946,667 | $2,722,969 |
| CoachCare fees (incl. one-time) | $458,006 | $1,103,350 | $1,561,356 |
| Net to the health center | $318,296 | $843,317 | $1,161,613 |
| Margin to the health center | 41.00% | 43.32% | 42.66% |
Roughly $1.18 million of avoided acute cost over 24 months. That value accrues to payers and to the ACO's total-cost result rather than to the health center's revenue line, so it is excluded from every figure above.
Blood pressure, weight and glucose readings arriving between visits, where the hypertension and diabetes measures are decided.
Coded, documented and submitted with the time capture the CY2026 individual-code rules require.
About 8.9 full-time equivalents of care-management capacity, added without the health center hiring anyone.
The forecast above covers the 5,299 Medicare and dual-eligible patients — 26% of the 20,188 people this health center cares for. Everything the service line builds is the same device fleet, the same enrollment staff and the same escalation engine. What changes over time is how much of the footprint it serves, and who pays for it.
Georgia Medicaid does not pay for remote patient monitoring as a separate service, and care management sits inside the encounter. That is exactly why the sequencing starts with Medicare — the rail that pays code-by-code from month one, at every site, in all fourteen counties.
The state's GREAT Health program is deploying $218.9 million of federal rural-health money in its first year — $1.43 billion over five — with funded strategies that name health centers, care coordination, telehealth, and clinical technology that supports care coordination. None of that money is in this forecast. A running remote-care service line is the kind of infrastructure those strategies describe.
Patients 65 and over went from 16.7% of the panel in 2021 to 23.2% in 2025 — a point a year. Every program ceiling in this plan is set by the Medicare line, and the Medicare line's future is already sitting in the waiting room. Better adherence also fills the scripts the 340B pharmacy program dispenses.
Pull the exact Medicare and dual-eligible count — and the traditional-Medicare split — from eClinicalWorks, and agree which sites start. The Sandersville specialty hub and the highest-Medicare clinics are natural candidates; the mobile units extend reach from day one.
Enrollment flags and trigger orders built into the existing workflow, discrete vitals mapped to the chart, escalation routing set to the health center's own contacts, documentation templates mapped to the CY2026 individual-code requirements, and cellular device kits staged for a footprint where home broadband cannot be assumed.
Enrollment begins in month 1 — there is no dormant onboarding period. The CoachCare-funded on-site specialist works the flagship site while telephonic outreach covers the other thirteen counties from the start.
APCM reaches its eligible population in month 9 and CCM in month 18. RPM is still enrolling at month 24 — and by then the conversation has moved to the ACO's next performance year, the colorectal screening number, and the panel that ages into Medicare every year.
Over 400 managed conditions.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline, and this is what they do to the forecast in this document — priced at Community Health Care Systems' own Georgia locality amounts, not at national averages.
The proposals reach the remote-monitoring family only. Chronic care management and advanced primary care management are not in them — and on this forecast those two programs carry $1,650,805 of the $2,722,969 in 24-month net reimbursement. Their own amounts move by less than a percentage point to two points, so $27,618 of the $124,675 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement — SaaS platform, device logistics and program enablement priced separately — and an MSO-style arrangement in which CoachCare manages the staffing while the health center 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. Fee-for-service code cuts and that shift are the same policy argument — pay for results rather than for device-months.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars below are drawn on one shared dollar scale, so the red can be compared directly across them — and the same reduction lands against far more.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Palmetto GBA Georgia locality amounts (Rest of Georgia), non-facility, on this health center'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 Georgia locality amounts; these two bases will 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 — care management | ||||
| 99490 | Chronic care management, first 20 minutes | $66.13 | $64.04 | −3.2% |
| 99439 | Chronic care management, each additional 20 minutes | $50.44 | $49.92 | −1.0% |
| G0556 | Advanced primary care management, level 1 | $16.37 | $16.09 | −1.7% |
| G0557 | Advanced primary care management, level 2 | $53.78 | $53.20 | −1.1% |
| G0558 | Advanced primary care management, level 3 | $117.24 | $116.91 | −0.3% |
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 therefore 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.