In the final days of the Obama administration, the Center for Medicare & Medicaid Services provided a parting gift to the PACE community by issuing a Request for Information seeking stakeholder input on the design and implementation of a broad range of PACE pilots.
The PACE Innovation Act of 2015 provided CMS with the necessary waiver authority to undertake pilots that would allow organizations to provide PACE-like services to new and expanded populations.
The RFI contained detailed parameters for a five-year pilot of a Person-Centered Community Care Model (referred to as P3C) for adults with physical mobility impairments. CMS also requested comments on additional populations that could benefit from enrollment in PACE-like models and the adaptations in PACE that would be necessary. The complete RFI can be found at this link.
Clearly, it is unknown whether PACE expansion and innovation will be of interest in the Trump Administration. However, given the PACE program’s long track record of delivering cost-effective, patient-centered care, there is a reasonable expectation that this RFI will ultimately proceed. The PACE community, including new organizations interested in providing PACE-like services, should utilize this opportunity to articulate the parameters of a PACE program that can scale, is financially sustainable and can remain competitive with other models of care in a re-reformed, value-based delivery system.
The CMS view of PACE Innovation
The original PACE model serves a nursing home eligible population over the age of 55 that is dually eligible for Medicare and Medicaid by integrating the delivery of long term support services (LTSS), acute care, and social services through use of an interdisciplinary care team (IDT) and a PACE center. A threshold issue for policymakers and the PACE community is the extent to which PACE requirements can be modified or eliminated until the program is no longer PACE.
For example: Should a PACE program be required to operate a PACE center or can services be provided in alternative settings? In this P3C model, CMS has indicated that the starting point is a traditional view of PACE, while welcoming stakeholder comments on many aspects of implementation. Specifically, CMS has initially designed a model that:
Offers the P3C model to persons with specific mobility-related diagnoses who are also nursing home eligible
Retains a day center requirement in a P3C center while encouraging the use of community based providers in various settings that are appropriate for a younger population
Retains all 11 members of the IDT team (primary care physician, RN, master’s level SW, PT, OT, RT, dietician, PACE center manager, home care coordinator, personal care attendant, driver). Flexibility is contemplated for team members to serve on an ad hoc basis; team members to fill multiple roles; allowing both contracted and employed primary care providers. New types of IDT members such as employment support counselors are also contemplated.
Develops alternative payments (including risk corridors and stop loss provisions) payments to ensure that spending does not increase under Medicare or Medicaid
Which additional populations should be served by PACE?
CMS has requested comments on a future PACE pilot for additional populations with complex medical needs who currently receive suboptimal care from our health care delivery system. Among the many populations that CMS has identified include: (1) Medicare beneficiaries who are at risk of nursing home placement and not yet Medicaid eligible (2) Medicare and/or Medicaid beneficiaries with intellectual and developmental disabilities (3) and persons living in rural areas who could benefit from PACE expansion. CMS has asked the PACE community to offer the parameters of these additional pilots.
What is your vision of PACE Innovation?
Now is the time to express your view of PACE innovation as future CMS action under the Trump administration will determine if PACE can grow beyond its origins as a center based program serving dually eligible and nursing home eligible persons over the age of 55.
Even with the growth of alternative types of managed care programs, PACE remains the most comprehensive, person-centered, capitated model available for geriatric populations. Since the passage of the PACE Innovation Act, enthusiasm has been running high that PACE can move beyond its initial target population and serve broader high cost, high need populations, including Medicare only beneficiaries at risk of nursing home placement. Important issues for comment include identifying other flexibilities that are essential for scale and sustainability and setting priorities among the possible pilots under consideration.
Comments must be submitted to CMS by February 10, 2017.
Jade Gong, MBA, RN, is Principal of Jade Gong and Associates and is a strategic adviser to PACE programs.