Three patient lanes, sorted by who bears the economics. Broad enrollment where AHVI keeps the margin and no ACO benchmark is touched. Selective post-discharge enrollment where care-management spend enters Envoy's benchmark and has to earn its place. One infrastructure that serves fee-for-service today, Envoy's total cost of care now, and the Ambulatory Specialty Model from 2027.
36-month net total-cost-of-care benefit to Envoy Integrated Health ACO. Value to Envoy, not AHVI practice revenue, and excluded from every figure above.
AHVI founded Envoy Integrated Health ACO. That changes the arithmetic of a remote care program. For a patient outside any ACO benchmark, every dollar of RPM and PCM is practice margin. For a patient Envoy is accountable for, the same dollar also raises Envoy's benchmark, and the program has to avoid enough admissions to pay that back. Because AHVI is a specialty practice, patients attribute to their primary care physicians, not to AHVI, so the attributed slice is small and the non-attributed lanes carry the deployment. The deployment below sorts every Medicare heart failure and hypertension patient on that one question first, and the clinical context second.
Retrospective assignment means the operational filter is the referring primary care physician: the six Envoy primary care TINs. Envoy's August 2026 report attributes 809 AHVI beneficiaries, 4.7% of the 17,049-patient heart failure and hypertension panel. Applied across the book, roughly one patient in twenty sits inside the benchmark and the other 95% sit outside it.
Non-attributed heart failure and hypertension patients bill RPM and PCM with no ACO exposure at all. Breadth is free, so these two lanes are staffed to run at full enrollment-specialist capacity from month one.
Only a post-discharge heart failure cohort avoids enough admissions to outrun the care-management spend it adds to Envoy's benchmark. So attributed patients enter through a qualifying discharge, not a panel sweep.
| Lane A · Non-attributed heart failure | Lane B · Envoy-attributed heart failure | Lane C · Non-attributed hypertension | |
|---|---|---|---|
| Population | Non-attributed HF | Envoy-attributed HF | Non-attributed HTN without HF |
| Primary program | RPM + PCM | TCM + RPM + PCM | RPM + selective PCM |
| Enrollment trigger | Eligible HF patient | Qualifying acute discharge | Active HTN management need |
| Deployment posture | Broad | Selective | Broad |
| Primary beneficiary | AHVI | AHVI + Envoy | AHVI |
| Clinical objective | Longitudinal HF management | Fewer readmissions and ED visits | Blood-pressure control and longitudinal management |
| Key economic risk | Enrollment throughput and operating capacity | Care-management spend enters the ACO benchmark | Enrollment capacity, PCM eligibility and documentation |
Broad enrollment makes sense where AHVI captures the economics directly. Attributed beneficiaries require a higher clinical-value threshold, and the model holds Lane B to it.
AHVI's own census: 5,038 Medicare patients with heart failure and 12,011 with hypertension and no heart failure. The two cohorts are mutually exclusive, so nothing here is counted twice. The Envoy split is applied to both.
Medicare heart failure patients, the cohort the Ambulatory Specialty Model will measure AHVI on from January 2027.
Medicare hypertension patients. Heart failure patients are already excluded from this count, so Lane C cannot overlap Lanes A or B.
Each lane connects a population to a program, a posture, and the engine it feeds. The same enrollment specialists, devices, monitoring, and athenaOne integration run all three.
Two dedicated, CoachCare-funded enrollment specialists, each with roughly 80 enrollments a month of capacity. One runs heart failure and staffs the post-discharge window first. The other runs hypertension and nothing else.
Lane B, ~4 a month. Qualifying post-discharge heart failure patients are staffed first. The post-discharge window is perishable, and Lane B is the only lane whose enrollment has to clear an avoided-utilization test, so it gets capacity before anyone else.
Lane A, ~76 a month. Non-attributed heart failure absorbs whatever capacity Lane B leaves, until Lane A reaches its 1,680 ceiling in month 27 and drops to replacement enrollment.
The full specialist runs one lane. Against an 11,440-patient pool and a 3,432 ceiling, 80 a month less attrition reaches about 2,238 active patients by month 36. Lane C becomes capacity-constrained before it becomes population-constrained.
Additional enrollment capacity is a future scale lever, once the economics and clinical performance validate. The population is not the binding constraint.
A 36-month forecast of the three lanes on AHVI's own census, at Anchorage Medicare rates, net of denials and coinsurance bad debt, after every CoachCare fee. Launch is modeled at January 2027, alongside the first ASM performance year.
| Line | 2027 | 2028 | 2029 | 36-Month |
|---|---|---|---|---|
| Net reimbursement, all lanes | $2,528,971 | $6,524,257 | $9,260,442 | $18,313,669 |
| CoachCare fees, all lanes | $1,346,995 | $3,481,259 | $4,946,488 | $9,774,742 |
| Net to practice (after fees) | $1,181,976 | $3,042,998 | $4,313,954 | $8,538,927 |
| Lane A · non-attributed HF | $615,006 | $1,595,949 | $2,152,492 | $4,363,447 |
| Lane B · attributed HF | $31,107 | $54,817 | $54,906 | $140,830 |
| Lane C · non-attributed HTN | $535,862 | $1,392,231 | $2,106,556 | $4,034,650 |
| Practice margin | 46.7% | 46.6% | 46.6% | 46.6% |
Full model available as a companion Deployment Value Model workbook.
With implementation and integration waived, the deployment is purely variable-cost. Expense scales alongside reimbursable events, so there is no payback period to finance and no modeled month in which cumulative cash is negative. The decision is less about financing a long payback than about validating enrollment throughput, clinical eligibility, reimbursement realization, and operational execution.
Referring providers set the referral supply, at eight referrals a month each and 80% acceptance: the starting 25 providers supply about 160 a month, exactly the two specialists' capacity, so the constraint binds as soon as the provider count falls or a specialist is added. Ramp time scales enrollment capacity up linearly to full pace; the starting 12-month ramp is more conservative than the forecast above, which runs at full pace from month one. Penetration and enrollment rate set each lane's ceiling; the specialists set how fast the lane climbs toward it. Once a lane stops reaching its ceiling inside 36 months, a higher ceiling buys runway past month 36 rather than a larger 36-month total.
Across the two heart failure lanes over 36 months, at a 40% reduction on a 40% annual admission rate. Lane C claims revenue only.
The attributed post-discharge cohort alone, with about 12 emergency department visits avoided beside them.
Cumulative over 36 months, against 140 post-discharge enrollments in Lane B and 2,880 in Lane C.
Monthly for all three lanes, with ASM shown by payment year and Envoy by performance year.
Every Lane B care-management dollar raises Envoy's benchmark. Selective post-discharge enrollment lets the avoided admissions and emergency visits outweigh that spend, so the lane improves Envoy's total cost of care while AHVI still earns positive practice economics on it.
Care-management spend that lands inside the Envoy benchmark: 0.13 points of it, against a 1.5-point budget.
Gross utilization savings from roughly 8 admissions and 5 emergency department visits avoided each year on a ~42-patient census.
$113K over 36 months. About 21 admissions and 12 ED visits avoided across the horizon.
| Principal care management attach on Lane B | 0% | 25% | 50% | 70% · modeled | 100% |
|---|---|---|---|---|---|
| Benchmark drag | 0.08 pts | 0.10 pts | 0.12 pts | 0.13 pts | 0.15 pts |
| Net TCoC benefit to Envoy | +$81K/yr | +$69K/yr | +$57K/yr | +$48K/yr | +$33K/yr |
| Avoided admissions needed per 100 to break even | 8.9 of 20 | 10.7 of 20 | 12.5 of 20 | 13.9 of 20 | 16.1 of 20 |
| AHVI Lane B net | $33K/yr | $41K/yr | $49K/yr | $55K/yr | $64K/yr |
Every point of attach moves both directions at once: it raises what Envoy absorbs and raises the avoided admissions the lane must deliver to pay for itself. The modeled cohort delivers 20 avoided admissions per 100 enrollee-years, so the lane clears at every attach shown, with 1.44× cushion at the modeled 70%.
Total ACO savings must clear the MSR before any savings are shared. Below it, distributable shared savings fall to zero regardless of how well Lane B performs. The cushion is the number to watch.
About 27.8% at Envoy's 71.03 reference score. The same avoided utilization is worth roughly a third less below the threshold, which yields ~$19K of incremental earned savings at the year-three run rate.
After the infrastructure, care-redesign, and participant allocations, AHVI's share of the distribution is minor. The enterprise value sits in total cost of care, not in the distribution check. AHVI gets rich on practice margin.
Fifteen AHVI clinicians appear on CMS's preliminary CY2027 participant list for the heart failure cohort, on a historical Part B base of about $5.91M. From the 2027 performance year, paid in 2029, that base carries a two-sided adjustment that widens every year. The remote monitoring, post-discharge intervention, and longitudinal management the three lanes deliver are the same work ASM measures.
ASM adjustments apply to covered professional Part B reimbursement broadly, not only to remote care claims. That is what makes the exposure base $5.91M rather than the program's own billing.
Fewer inpatient and emergency events, plus better expected-cost capture, from the two heart failure lanes at a 60% ASM-managed share of the census. A direction, not a predicted CMS score.
Only the 2029 payment (~$240K) falls inside the 36-month window, and it is the one ASM figure carried into the total AHVI value above. The maximum downside at a zero score runs $564K in the first payment year.
Proceed with a three-lane deployment: maximize direct practice economics in the non-attributed populations, selectively manage attributed heart failure patients where acute-utilization savings justify the ACO spend, and use the resulting infrastructure to strengthen AHVI's position as specialty reimbursement moves further toward value.
Validate the actual Envoy attribution overlap.
Validate real enrollment conversion and staffing capacity.
Validate utilization and hypertension management outcomes.
Confirm ASM participation; monitor Envoy's MSR and quality.
Implement remote care infrastructure, activate the two enrollment specialists, launch all three patient lanes, establish the financial and clinical baselines, and operationalize the athenaOne integration.
Enrollment conversion and throughput. Net reimbursement and practice margin. Heart failure admissions, ED utilization, and blood-pressure control. PCM eligibility and documentation. ACO economics and ASM-related heart failure performance.
Add enrollment capacity where realized contribution margin stays attractive, retention validates the assumptions, clinical outcomes support deployment, Lane C demand still exceeds throughput, and AHVI operating capacity supports expansion.
If Envoy prefers no care-management spend inside its benchmark, or Lane B does not clear its avoided-admission test in validation, the referring-physician screen simply excludes every attributed patient. Lane B is switched off, and nothing else changes.
The deployment described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded; 4 million+ care actions enabled.
A remote care service line is a clinical operation that happens to bill. Software companies hand back the care team, staffing companies hand back the technology, device companies hand back the billing, and a multi-vendor stack fails at the seams. In Alaska the seams are a ten-day transit to a village post office, a community without LTE, and an EHR migration in flight. One partner has to carry the whole set.
Platform, proprietary cellular devices and SIMs, end-to-end device logistics, a US-based W-2 care team, the billing engine, and the analytics layer, built and run by CoachCare. Devices arrive configured and paired, transmitting over cellular with no smartphone, app, or home internet, which is what makes the program statewide instead of Anchorage-only.
Cardiology is the core competency, not one vertical among many: 60+ ambulatory cardiology sites, with programs running at Cardiac Solutions, Western Washington Medical Group, MercyOne Iowa Heart, and AMS Cardiology. The protocols carry cardiology defaults, a five-rung escalation ladder, a distinct emergency pathway, and a fixed three-touch post-discharge sequence that AHVI signs before go-live.
Readings, care-plan time, notes, and billing-ready documentation land in the chart the physician already opens. Both athenaPractice and athenaOne are built and supported, so the migration is not a reason to wait. Eligibility flags surface candidates inside the chart; claims generate into athenahealth.
No upfront capital, no hiring plan, no device purchase. AHVI bills under its own NPIs and keeps the payer relationship and the revenue. A named care team belongs to AHVI rather than a shared queue, staffed to AHVI and trained on AHVI's protocols, at a 160:1 care-team ratio rather than the 300:1 common in the market. The two enrollment specialists enroll on site at the point of care, because telephonic outreach alone converts at about 8%. Only two things rise back to an AHVI clinician: the exceptions, and the claim.
Symptom and vitals trends surface progression in monitored aortic stenosis patients between visits for structural heart. Post-discharge weight, pressure, and adherence are tracked through the readmission window after CABG and PCI. Documented, device-captured blood pressure over time is the evidence base a renal denervation referral needs. Daily weights give the heart failure clinic and the APP team a continuous view between titration visits.
Both programs ran on CoachCare with cardiology groups. Hypertension and heart failure are the two conditions in this deployment.
2,738 patients monitored 12 months or longer; 94.8% of Stage 2 patients improved, and the full cohort averaged 6.42 mmHg. High-consistency readers improved more than twice as much as low-consistency readers, which is the argument for the care-team ratio.
450 advanced heart failure patients, NYHA III–IV, enrolled from a 9,000+ HF population, against an 18% readmission benchmark on the same panel: 81 readmissions prevented and 26 GDMT care gaps closed. The same shape as this account, with a complex subset enrolled first.
127 chronic disease patients with heart failure, hypertension, and diabetes: 74% fewer admissions (271 to 70), 85% fewer hospital days, 63% fewer ED visits, measured against the same population's prior six months. Fewer admissions is the mechanism; cost avoidance is the accounting.
One decision this month sets the shape of the deployment. Everything after it is implementation, and the sequence below is the pace a care team can absorb.
Lane B on, or the failsafe: exclude Envoy-attributed patients entirely and run the two non-attributed lanes.
Fee schedule at list, implementation and integration setup waived, per-patient variable pricing.
Eligibility flags, orders, vitals write-back and billing-ready documentation configured in the tenant AHVI already uses.
Two CoachCare-funded specialists hired in Anchorage; soft launch with a limited group of physicians and APPs.
Referral pathways open practice-wide; enrollment climbs toward the two specialists' full pace across all three lanes.