Feds propose improvements to PACE

Comments are due Oct. 17 for the new proposal to update and strengthen the federal Program of All-Inclusive Care for the Elderly (PACE). The Centers for Medicare & Medicare Services (CMS) is making the changes to the program to help people meet their health care needs at home rather than in a long-term care facility.

According to CMS, more than 34,000 older adults are enrolled in about 100 PACE organizations in 31 states, and enrollment increased by more than 60 percent since 2011. A Medicare and Medicaid program, PACE provides services to beneficiaries, most of whom are dually eligible for both Medicare and Medicaid benefits, through an interdisciplinary team of providers.

“The focus is on the participant,” said Andy Slavitt, acting CMS administrator, in announcing the new rule August 11. “A team of health care professionals works to make sure that care is coordinated in the home, the community, and at a PACE center.

The goal of the new proposal, Slavitt said, is to strengthen beneficiary protections and provide PACE organizations with more administrative and operational flexibilities so they can better care for patients. “While PACE serves a relatively small number of people today, our proposal is intended to encourage states to further expand these programs,” Slavitt said.


Key Changes

One of the changes in the proposed rule would be to allow members of the interdisciplinary team to participate in more aspects of a participant’s care. Currently, team members can fulfill only one role on the team. The proposed rule would also allow non-physician primary care practitioners to provide some services in a move to improve flexibility and efficiency while ensuring participants’ needs are met.

Additional proposals include:

  • Clarifying that PACE organizations offering qualified prescription drug coverage must comply with Medicare Part D prescription drug requirements;
  • Strengthening sanctions, enforcement actions and terminations to improve CMS’ ability to hold PACE organizations accountable and decrease the risk of harm to patients;
  • Ensuring individuals with convictions for physical, sexual, or drug or alcohol abuse are not employed in any capacity where their contact would pose potential risk to beneficiaries.

The National PACE Association (NPA) approved the CMS proposal, saying the changes would support PACE growth, improve access to the program and increase opportunities for innovation.

“With more than 30 years of experience delivering care, PACE organizations are leaders in the use of highly effective interdisciplinary teams,” NPA president and CEO Shawn Bloom said. “Current regulations require a one-size-fits-all approach to meeting the needs of enrollees. The proposed regulation will allow PACE interdisciplinary teams to function on a more individualized basis.”

He pointed out the rule also would allow community physicians to be involved in the teams, thereby opening the door for greater continuity of care as a senior enrolls in PACE. “By providing more options for how the team delivers primary care, PACE organizations will have more flexibility in customizing care delivery based on individual needs,” he said.

Bloom said the changes in CMS’ program monitoring would shift from relying on in-person inspections to reliance on the organizations’ internal compliance and continuous quality improvement efforts and the use of multiple sources of data for monitoring. On-site visits would focus on programs with the greatest needs.

One goal not advanced by the proposed rule would make it easier for PACE to provie services in a greater range of settings throughout the community, Bloom observed.

“The PACE center will always be a focal point for the PACE team,” he said. “However, in order to support our enrollees’ desire to live as independently as possible, PACE operates throughout the community. From the PACE center to the home, from providing transportation to access specialty care, PACE is a fully integrated system of care and services that is not confined to one place. Providing more flexibility to PACE organizations in developing alternative care settings where a subset of services would be provided away from the center would provide opportunities for faster PACE growth and greater access and efficiency, while offering enrollees more choice in how their care is provided.”


Expanding Eligibility

Meanwhile, the Bipartisan Policy Center (BPS), led by former Senate Majority Leaders Tom Daschle (D-S.D.) and Bill Frist (R-Tenn.), issued a report in September focused on improving health care and long-term services for dual-eligibles. Included was a set of recommendations focused on PACE. BPS said CMS should test:

  • An expansion to individuals, regardless of age, who meet all other PACE criteria and who do not require nursing home level care.
  • An option that permits individuals to enroll in PACE but opt out of adult day services.
  • A new option for individuals who are not eligible for Medicaid and whose income exceeds 300 percent of Social Security income. That option would include both Medicare-covered services and a beneficiary “buy-in” of a limited long-term services benefit less than the full range of Medicaid-covered benefits.

In addition, BPS said CMS should permit PACE organizations to enroll beneficiaries during the month rather than requiring them to wait until the first of the month to enroll and pro-rat the monthly per-capita payment.

However, in a Sept. 22 letter to Slavitt, the Medicare Advisory Payment Commission (MedPAC) cautioned that expanding eligibility to younger participants should be accompanied by changes in payment system reforms to prevent federal expenditures from skyrocketing.

In that letter, MedPAC Chairman Francis J. Crosson, MD, acknowledged that PACE “has shown good results” and more beneficiaries could be served if the eligibility age was lowered. That should not occur until the payment system is reformed, he said.

For more information about PACE, click . To learn more about the proposed rule, click here.

Robert Gatty has more than 40 years of experience in journalism, politics and business communications and is the founder and president of G-Net Strategic Communications based in Myrtle Beach, South Carolina. He can be reached at bob@gattyedits.com.

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