How PACE Could Cover More Older Adults

Like other care models that primarily serve seniors, the Program of All-Inclusive Care for the Elderly (PACE) has achieved a higher profile following the height of the pandemic.

However, there’s still a larger push to expand PACE across the U.S. Currently, there are only 156 PACE organizations operating in 32 states and the District of Columbia.

One of the loudest voices behind this larger push is the National PACE Association.

Beyond geographic PACE expansion, the National PACE Association also sees a future where the model evolves to reach a larger demographic of seniors, including those that fall outside of the category of Medicaid-eligible.

Traditionally, PACE cares for dual-eligible seniors in a given community.

“We refer to them as Medicare-only. I think there’s a substantial opportunity to really position ourselves as a provider of choice for those individuals that increasingly want to stay at home,” Shawn Bloom, president and CEO of the National PACE Association, said during a recent conversation with Home Health Care News.

During the conversation, Bloom also went into detail about other ways he can see PACE potentially evolving, as well as how he is seeing programs work closely with home-based care providers.

HHCN: Looking back over the past few years, how would you describe the overall progress PACE has seen in the U.S.? Are there any defining moments you’d like to highlight?

Bloom: It’s probably important to begin with the point that, for the greater part of 20-plus years, we’ve recognized the potential that PACE could have in the way of supporting older adults’ ability to live in the community.

We have been very strategically focused on supporting, what we refer to as, expanded access to PACE, which is not only growing new programs, but supporting the growth of existing programs. The progress that we’re excited about the most is probably just what we’re beginning to see as unprecedented growth of PACE.

Over the years, we’ve put in place a variety of different strategies to really support the growth of PACE, but the pandemic really changed the perceptions of states. States are in a very prominent role of determining what services are available to older adults in their states, due to Medicaid payments and the Medicaid long-term care system. We’ve seen a significant shift at the state level, and the we’ve seen a lot of attention at the federal level of really incentivizing states to expand the footprint of community-based, non-institutional options. I think between federal policy and state policy, and obviously changing consumer opinions about what services they would find to be most preferential for them, we’re really seeing a wonderful opportunity to expand access to PACE.

There’s really not one single thing, I think it was the confluence of some very favorable factors. We are beginning to get a lot more attention by the press. There’s an old adage that once you’re exposed to PACE, you really fall in love with its potential. We’re beginning to see a lot of expanded recognition that creates a very positive tailwind for us, with respect to consumers that have expanded awareness, and also with state and federal policymakers.

In your view, what are some things that need to happen in order to further accelerate PACE implementation across the country?

I’d say 90% of people that are currently served by PACE are eligible for Medicaid. These are individuals that are in need of long-term care services, so they have significant need for support and health care services, but they also tend to be very low income.

If you look at the demographics in this country, the vast majority of people that need long-term care are not Medicaid eligible. They have some means by which to fund their own care. It may not be for a lengthy period of time, but at least initially.

I think one of the most important things that could happen to accelerate access to PACE would be to address some legislation that we have pending on Capitol Hill, relating to the Medicare Part D prescription drug premium. In PACE, right now the premium is very high, in some ways to reflect the kind of disproportionate degree of needs and medical complexity of those that we serve.

But we are proposing in the legislation that we want to allow individuals that are in the community, before they enroll in PACE, to bring their existing Part D coverage in, which is a fraction of the cost of what it would cost in PACE.

If we did that, we believe that PACE could really emerge as more of a mainstream long-term care option to individuals other than those eligible for Medicaid.

Along these lines, what things are on the National PACE Association’s legislative wishlist for 2024?

I would put it in probably two different buckets.

We do have legislation pending, it’s called the Part D Choice Act. That’s bipartisan supported legislation and has been introduced in both the House and the Senate. It would accomplish essentially what I mentioned before. It would allow individuals to bring their existing Part D coverage with them. On average, for most older adults, it is roughly $50 to $100 a month, compared to $900 to $1,000 a month when accessed through PACE.

The second one is essentially a package of legislation that’s coming together that would help to address some of what we see as some of the more technical policy barriers standing in the way of growing PACE.

What are some of the key issues the National PACE Association is rallying around this year?

At the state level, we’re really working on cultivating opportunities to open up new states. A lot of people can really relate to PACE when they see it, so we want to continue to expand opportunities to cultivate positive awareness. Those are the two biggest ones externally.

Internally, we’re really trying to support the PACE community to continue to put in place internal quality improvement activities. This is a model of care that’s known for yielding unprecedented outcomes. We’re very good at delivering care with a high degree of satisfaction. We are constantly putting in place new projects and new initiatives to help PACE programs further those efforts.

What are some of the main ways PACE providers should be collaborating with home-based care organizations to help keep seniors healthy?

We do collaborate with external organizations and community-based service providers. For example, we might contract out with hospice agencies for end-of-life care for individuals that have very significant end-of-life care needs.

Another point worth making is, the vast majority of our programs are sponsored by existing health care providers. They run the gamut from hospital systems to long-term care systems. In some cases, they’re area agencies on aging, and in other cases, they’re referred to as FQHCs, or federally qualified health clinics.

I think in the context of PACE, there’s a lot of collaboration and a lot of integration with those sponsor services, as I call them. A good example is FQHCs, which play a very important role of providing primary care to typically low income individuals. Those FQHC sponsors of PACE, often, will identify people that really need more than just a primary care visit. They really need the supplemental wraparound comprehensive services that PACE provides, and we will collaborate with them for referrals.

Are there any organizations that are really excelling at collaborating with home-based care providers that you’d like to highlight? What are some of the things these organizations are doing?

It is worth noting as well, that a number of our programs are sponsored by a community collaboration. I’m thinking of a program in Michigan that’s sponsored by the local hospital. Think of sponsors as individuals that kind of own and operate the program. Another sponsor in this Michigan market is an area agency on aging. There’s a home care agency, and then there’s a long-term care provider. There’s an enormous amount of collaboration between and among all those entities in support of PACE.

In general, what are the biggest opportunities you’re seeing for PACE organizations?

I think in our view, vision, and certainly our hopes, plans and actions, we’re really attempting to create opportunities for PACE to serve expanded types of older adults. I mentioned those that are not Medicaid-eligible, we refer to them as Medicare-only. I think there’s a substantial opportunity to really position ourselves as a provider of choice for those individuals that increasingly want to stay at home. From an economic standpoint, we’re less expensive than a nursing home, yet you can stay home. I think being able to be more of a front of mind community-based service option for individuals that are not Medicaid eligible is a huge opportunity for us.

I also think that the other category is new populations, and while Medicare-only falls into that, there are other categories of individuals that are, either under age 55, which is our current enrollment requirement, or individuals that may not yet be eligible for long-term care, but are very medically complex, and really could benefit from PACE.

The third is a little bit abstract. With PACE programs now, once you are deemed as long-term care eligible, which every state has their own criteria, you can access PACE. If you think about it, there’s kind of a closed context of PACE, in terms of who we serve. I think there’s beginning to be a growing ambition among PACE to really unbundle some of those services and bring them out into the community for individuals that are not yet eligible for, but yet could benefit from some degree of support.

People don’t arbitrarily wake up one day and find themselves long-term care eligible, they have a progression of service needs that escalate. During that phase, I think we have a lot to offer, short of the full PACE benefit. We refer to that as building a PACE service pathway. Those are the three things I’d love to see take shape over the next decade or two.