Dr. Roy Baker helped adapt NASA telemetry so a moving ambulance could transmit an EKG to the emergency room. Seven decades later, Medicare finally pays — every month — for exactly that idea: continuous remote care for heart failure, coronary artery disease, atrial fibrillation, and hypertension. This is the plan to claim it.
Baker-Gilmour is not being asked to adopt someone else's idea. The founder's signature achievements — EKGs transmitted from moving ambulances, cardiac patients in small rural hospitals monitored from metropolitan coronary care units — are the direct ancestors of today's remote physiologic monitoring and chronic care management. The only thing missing is the modern program.
Dr. Roy Baker opened his Jacksonville practice in 1953 — the founding of a cardiovascular institution now in its eighth decade of independent practice.
Dr. Baker helped adapt the NASA technology that monitored astronauts' EKGs into systems transmitting EKGs from moving ambulances to emergency rooms.
He developed remote cardiac patient monitoring — connecting patients in small rural hospitals to coronary care units in larger metropolitan hospitals.
No remote physiologic monitoring or chronic care management program is marketed anywhere on the practice's site today. The founder's category sits unclaimed, in his own practice.
Dr. Kay E. Gilmour — Jacksonville's first female critical care practitioner and the first female Chief of Cardiology at Memorial Hospital — extended that legacy of firsts. The 2026 opportunity is to be first again: the independent cardiology group in Northeast Florida that runs remote care as a governed, margin-positive service line.
Since January 1, 2026, CMS's Transforming Episode Accountability Model (TEAM) holds hospitals financially accountable for 30-day surgical episode cost and quality. Both hospitals where Baker-Gilmour's cardiologists practice are mandatory participants — and a 2026 billing change makes the operational answer newly reimbursable.
HCA Florida Memorial Hospital (CCN 100179) — where a Baker-Gilmour physician directs the electrophysiology laboratory — and Flagler Hospital (CCN 100090) in St. Augustine are both mandatory TEAM participants in the Jacksonville CBSA (27260), model window 2026–2030. Their surgical episodes, including CABG, now reconcile against CMS target prices with 30-day spend and readmissions on the line.
New CPT codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the 16-day floor that used to block episodic monitoring — making post-discharge and post-procedure windows cleanly billable for the first time.
The Jacksonville office is directly across the street from HCA Florida Memorial; the St. Augustine office sits on the Flagler Hospital campus. The discharges those episodes are judged on walk past your front door — a structural position no other independent group can copy.
Hospital TEAM participation verified by CCN against published renditions of the CMS selection list (Aug 2024 vintage); re-confirm both CCNs against the current CMS participant file at decision time.
Not a device pilot bolted onto one condition — a named service line with its own P&L and scorecard, run on CoachCare's engine and governed by Baker-Gilmour's physicians, following the Medicare patient between every office visit.
| Service | Codes | CY2026 Magnitude | Cardiovascular Use |
|---|---|---|---|
| Transitional care management | 99495 · 99496 | ~$200 / ~$280* | Every HF and post-procedure discharge from Memorial and Flagler |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · $50.00/mo | 99445 unlocks the 2–15-day post-discharge window |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.12 + $41.22 add'l | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $65.97 + $50.16 add'l | Multi-condition Medicare cardiac patients |
| Principal care management | 99426 · 99427 | $67.57 + $53.69 add'l | Single high-risk condition (HF, resistant HTN) ≥3 months |
Dollar figures are CY2026 Physician Fee Schedule amounts auto-resolved for zip 32216 (Florida carrier 09102, locality 99), as used in the Value Analysis below. *TCM shown at illustrative national non-facility magnitude — not included in the modeled forecast. Verify all rates against the current fee schedule.
The same infrastructure — enrollment, devices, alerts, outreach, documentation, billing — is the connective tissue for the TEAM episodes your hospitals now own, and for every other lever the practice cares about. Build once, reuse everywhere.
Baker-Gilmour runs a Veradigm ambulatory environment, with patients already using the FollowMyHealth portal. CoachCare's integration catalog includes Veradigm: the program is designed to work from the chart your team already lives in, not beside it.
Eligible patients are identified and enrolled from practice data — no separate registry to maintain, no new system for your staff to learn.
Cellular device readings and care-team documentation return to the practice as structured data — a continuous record between visits, not a stack of faxed PDFs.
Time logs, care plans, and consent capture are generated automatically to the standard each code family requires.
CoachCare's billing engine assembles claim-ready detail for every enrolled patient, every month — the capture-rate discipline that decides program economics.
Integration scope and the exact Veradigm ambulatory product configuration are confirmed in contracting; patients keep the FollowMyHealth experience they already know.
A 24-month forecast for the practice: an estimated 2,200-patient Medicare panel across both offices, six referring providers plus a dedicated on-site enrollment specialist funded by CoachCare, CY2026 rates auto-resolved for zip 32216 (Florida carrier 09102, locality 99). TEAM episode upside and avoided-readmission savings are not in these numbers — they are upside on top. All figures are illustrative and modeled; verify against practice data.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $239,993 | $449,170 | $689,163 |
| CCM net reimbursement | $250,912 | $509,668 | $760,580 |
| PCM net reimbursement | $100,256 | $314,562 | $414,818 |
| Total net reimbursement | $591,162 | $1,273,400 | $1,864,561 |
| Practice margin (after fees) | $192,262 | $437,685 | $629,947 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value already reflected in the fees above, never deducted from your margin. | |||
Figures are illustrative and modeled — verify against practice data. Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the HF, CAD, AFib, and HTN panels between visits.
≈ $721K in avoided acute cost at $15K per admission — and direct relief on your hospitals' 30-day episodes.
17,101 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 Baker-Gilmour's physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new practice headcount: the on-site enrollment specialist is staffed at CoachCare's expense, and your medical assistants and front desk keep their current workflow.
Named physician owner, P&L, scorecard; Veradigm integration and billing configuration; protocol sign-off for the HF, CAD, AFib, and HTN pathways; panel validation against practice chart counts.
Heart failure and post-procedure discharges from Memorial and Flagler, plus the device-clinic population — first billable enrollments by day 45, outreach within two business days of discharge.
Jacksonville and St. Augustine panels enrolling to ceiling pace; hypertension cohort deepens; monthly scorecard — census, capture rate, revenue per patient-month, readmission signal — to practice leadership.
Program results packaged for your hospital partners: documented 30-day support on their reconciled episodes — the evidence that makes Baker-Gilmour the indispensable cardiology partner in the model era.
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 data. The key assumptions: