Working to advance Programs of Allinclusive Care for the Elderly

1
Working to advance Programs of All-inclusive
Care for the Elderly

2
What is PACE?

• An Integrated system of care for the fail
  elderly that is
• Community Based
• Comprehensive
• Capitated
• Coordinated

3
Growing Elderly Population
The Challenge

• Millions 65 and 85

60
50
53
40
30
34
20
10
7
3
0
1990
2020
85
65
4
The Challenge
Problems with the Current System
1. Fragmentation
Institutional Care
Primary Care
In - Home Care
Acute Care
5
The Challenge
Problems with the Current System
HEALTH CARE
Needs
2. Institutional Bias
Tertiary Care Acute Care In - Home Care
6
The Challenge
Problems with Current System
3. Focus on Acute Care
7
The Challenge
Problems with Current System

• Lack of Integrated Non-Institutional
• Financing

8
The PACE Model
PACE Progression -On Lok History
9
The PACE Model
PACE Progression - PACE History
First Program Achieves Permanent PACE Provider
Status
Congress Authorizes Permanent Provider Status
First Demonstration Sites Operational
Legislation Authorizing PACE Demonstration
1986
1990
1997
(Nov) 2001
10
Philosophy
The PACE Model

• Honors what frail elderly want

• To stay in familiar surroundings
• To maintain autonomy
• To maintain a maximum level of physical,
  social, and cognitive function

11
The PACE Model
Who Does It Serve?

• 55 years of age or older
• Living in a PACE service area
• Certified as needing nursing home care
• Able to live safely in the community at the time
  of enrollment

12
The PACE Model
Comprehensive Service Package

• Integrates preventive, acute long-term care
  services
• All Medicare Medicaid services plus community
  long-term care service
• No benefit limitations, co-payments
  or deductibles

13
The PACE Model
Integrated, Team Managed Care
Team Facilitator
Specialists
Primary Care
Home Care
Day Health Nursing Social service OT / PT
Speech Nutrition Recreation Personal care
Pharmacy Transportation
Nursing Home
Hospital
Lab / X-ray Medications / DME
14
The PACE Model
Integrated, Team Managed Care

• An interdisciplinary team
• Team managed care vs. individual case manager
• Continuous process of assessment, treatment
  planning, service provision and monitoring
• Focus on primary, secondary, tertiary prevention

15
The PACE Model
Capitated, Pooled Financing

• Medicare capitation rate adjusted for the frailty
  of the PACE enrollees
• Integration of Medicare, Medicaid and private pay
  payments

16
The PACE Experience
Source of Service Revenue

• PACE Programs receive approximately 2/3 of their
  revenue from Medicaid and 1/3 from Medicare. A
  very small percentage of program revenue comes
  from private sources or enrollees paying
  privately.
• 2002 Median Medicare Rate 1,394
• 2001 Median Medicaid Rate 2,422

17
PACE Participants
Census Growth from 1990 - 2001 PACE and Pre-PACE
18,772 Served as of 12/01
10,082 Census as of 12/01
18
Gender Distribution All PACE Participants as
of 12/01
PACE Participants
Female
Male
73
27
19
PACE Participants
Age Distribution - All PACE Participants as of
12/01
3
10
95
55-64
25
23
55-64
65-74
85-94
65-74
75-84
85-94
39
95
75-84
20
PACE Participants
Racial/Ethnic Distribution
All PACE Participants as of 12/01
5
21
2
33
39
21
PACE Participants
Ten Most Common Diagnoses Among PACE Enrollees
as of 12/2001
61
Coronary Artery Disease
Peripheral Vascular Disease
22
PACE Participants
Prevalence of Activities of Daily Living
Jan. Dec 2001 data for fully-capitated sites
23
PACE Participants
Average Number of
Jan. Dec. 2001 data for fully-capitated sites
24
Use of PACE Services
Acute Hospital Use
(days per year)
2.47
2.23
2.5
2
1.5
1
0.5
0
Medicare 1999
PACE 12/01
25
Types of PACE Sponsors
26
Dual Capitation Sites as of 9/02
Replication of the Model
27
Status of PACE Development as of September 2002

• Twenty-seven organizations are operating under
  dual capitation.
• Ten sites are delivering services under Medicaid
  only capitation.
• Approximately thirty sites are moving forward
  with planning and development of a PACE program.

28
Challenges for Providers . . .

• Begin to think in terms of
  People vs. Sentinel Events.
• Abandon the assumption that more is better.
• Understand that not all aspects of care are
  clinically based, some require simple creativity.
• Embrace the importance of a consistent care
  delivery system over time.

29
PACE Legislation
Balanced Budget Act of 1997

• Creates permanent provider status for PACE.
• Increases number from 15 to 40 the first year
  20 each year thereafter.
• Creates for-profit demo for up to 10 sites.
• Requires new sites to serve a population that is
  comparable to the demo.
• Requires annual recertification of enrollees.

30
PACE Legislation
BBA of 1997

• Creates a three year trial period with more
  detailed reporting criteria to assure that PACE
  providers maintain all elements of the demo.
• CMS to report back to Congress as to the quality
  and cost associated with PACE under provider
  status.

31
What are PACEs Challenges?

• Marketing and enrollment
• Lack of long-term care financing for
  middle-income
• Building partnerships at the federal, state,
  regional and provider levels

32
More Challenges for PACE...

• Maintaining opportunities for on-going innovation
• Expanding availability of PACE services to rural
  areas

33
Why PACE ?

• FOR CONSUMERS
• Comprehensive, preferred method of care
• Stay in the community as long as possible
• One-stop shopping
• FOR PROVIDERS
• Freedom from traditional FFS restrictions
• Focus on the entire range of needs of individual
• FOR PAYERS
• Cost savings predictable expenditures
• Comprehensive service package

34
What are PACEs Opportunities?

• Community rather than institutional focus.
• Only fully integrated comprehensive model of care
  for the frail elderly.
• Applicability to other chronically-ill
  populations.
• Ability to link with other managed and long-term
  care initiatives.

35
What are PACEs Opportunities?

• Ability to provide the full range of needed
  services regardless of reimbursement
• Ability to provide services consistent with
  emerging consumer demands
• Maximum flexibility in service provision tailored
  to meet the specific needs of individuals served