How one health tech is helping hospitals navigate CMS’s TEAM model

Healthcare can be disjointed, as physicians don’t always have access to patients’ full medical records or can’t provide cohesive communication with other providers. Rainfall Health, a compliance and reimbursement platform, thinks that AI can be a solution.

Founded in 2019, Rainfall is helping hospitals navigate a new program from the Centers for Medicare and Medicaid Services (CMS) called Transforming Episode Accountability Model, or TEAM, which launched on Jan. 1. The model requires participating hospitals to streamline their surgical processes for five expensive procedures in an effort to reduce Medicare spending and make the patient care experience more cohesive.

Complying with new government mandates can take a lot of time and resources for hospitals. That’s where Rainfall Health comes in, with its cloud-based AI and technology platform that follows a patient through their surgical experience by tracking data and communicating with patients before and after procedures.

“What CMS is asking hospitals to do is something that’s not natural to them, which is to manage care outside their hospital walls,” David Shulkin, a healthcare consultant and former secretary of the US Department of Veteran Affairs, told us.

CMS did not respond to a request for comment. Rainfall declined to share exactly how many hospitals it works with, though it reported that it had a $15 million Series A fundraise led by Two Bear Capital back in February.

No ‘I’ in TEAM

CMS’s TEAM payment model works by defining care “episodes” starting when Original Medicare patients—i.e., the 33.4 million patients on Medicare—get surgery, either inpatient or outpatient. The window continues for 30 days through recovery. The hospitals have to refer patients at or before discharge to primary care services to try to ensure improved long-term health.

TEAM will run for five years and mandates participation from 716 hospitals around the US to better coordinate care for five surgical procedures: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedures.

Through the TEAM program, CMS is looking to reduce often overwhelming and expensive hospital readmissions and emergency department (ED) use, which could also result in cost savings. The federal government reported that in 2021, there were 107.4 million ED visits that cost a total of $80.3 billion.

Each episode has a designated target cost, according to CMS, which is meant to cover the inpatient stay or procedure as well as care after discharge, like skilled nursing facility stays or follow-up visits. The idea is that hospitals will be paid all at once for a holistic care experience so they can designate resources to care both inside and outside of the hospital. Then, if the episode ends up costing less than the target cost, the hospital may receive a payment from CMS. Hospitals may also receive bonus payments or penalty fees for their success or failure to comply with the program.

How Rainfall helps

Using an AI system like Rainfall Health helps hospitals find and condense the health records to show actual results rather than “flying blind” through the program, Shulkin said. A Mayo Clinic facility in Jacksonville, Florida, is one of the hospitals using the program.

Say a patient has a joint replacement scheduled in 60 days. Once the provider puts that patient into Rainfall’s system, the company’s agentic AI care coordinator (which speaks 76 languages) will start checking in with the patient, Ahmed Qureshi, CEO and founder of Rainfall Health, told us. It can ask if the patient has been doing their physical therapy or if they have a ride to their next appointment. The platform continues communication with four to five check-ins during the 30 days after discharge.

The company then takes health records from the hospital, skilled nursing facility, and physical therapy office and merges them so the care team can make decisions with a more holistic understanding of the patient.

“We know that these types of data and technologies make a big difference to the success of the program,” Shulkin said. “In fact, if you try to do it without them, I think it’s going to be very challenging.”

Rainfall doesn’t get paid by a hospital unless the health tech provides meaningful value and outcomes, like ensuring a patient goes to their next appointment. They help the hospital manage the episode, and if they lower the cost below the target price, they get a cut of the CMS bonus.

“It essentially allows us to bring new revenue to the hospital, save Medicare money, and improve patient experience, all in one go—and then we get paid,” Qureshi said.

CMS has created similar programs to TEAM in the last decade, including the Comprehensive Joint Replacement Program, which the agency said yielded $180 million in Medicare savings, and the Bundled Payments for Care Improvement Advanced Model, which it reported saved $800 million.

Rainfall also produced guides to help hospitals comply with the joint replacement program.

Health tech WellSky is also helping hospitals comply with TEAM. Similar to Rainfall, WellSky’s platform helps transition patients between acute and post-acute care, tracks data and reports analytics, and uses AI agents.