PACE is a fully capitated program in which the

How PACE Reduces Disparities in Health Care

It is no secret that health care disparities exist in the US, and in the State of Michigan and the City of Detroit, no where is it more apparent than other parts of the country. As one of the countries’ most racially segregated metropolitan areas, According to Geronimus, Bound and Waidman (1999) “African American residents in the Detroit metropolitan area have a disproportionately higher risk of mortality compared with that of either white residents of the metropolitan area or whites’ nationally” (cited in Schultz, Williams, Isreal & Lempert, 2002). However one program that plays a key role in reducing health care disparities for the urban elderly is PACE (Programs for All Inclusive Care to the Elderly), an integrated service which focuses on interdisciplinary assessment, care planning and interventions for the elderly has resulted in reductions in nursing home admissions and reductions in health care disparities than those recipients experienced by Social Health Maintenance Organizations (S/HMO) (Willging, 2006). The program’s successes led Congress in 1997 to establish PACE has a provider type under Medicare. PACE has been more effective in targeting recipients and integrating funding and as a result has been more promising in reducing disparities in health care in the elderly populations.

PACE is a fully capitated program in which the Centers for Medicare and Medicaid Services (CMS) pay the Medicare capitation, and each State establishes and pays the Medicaid capitation. These capitated payments are combined at the provider level, creating a flex like funding pool for all primary, acute and long term care services. CMS establishes the Medicare capitation rate for all PACE providers. However, unlike Medicare, no single methodology exists for the development of a Medicaid capitation rate. States have the flexibility to develop a rate method that is reflective of each individual State’s environment. The two approaches currently used by States include the formula-based approach, in which the rate is set at a percentage of a

comparison group’s fee-for-service expenditures, and the cost-based approach, which is based upon the PACE provider’s estimate of the costs that will be incurred in the delivery of PACE services. In essence, PACE is a managed care program (www.npaonline.org). With the interdisciplinary approach to care that PACE provides; the approach is truly geared toward meeting the needs of the person in every aspect of their life. The Center for Senior Independence provides an interdisciplinary approach to care for 220 participants who live in the Detroit area, and just recently expanded to the Eastside of Detroit to provide opportunities for the elderly on the eastside to participate. The PACE team makes life easier for seniors by providing all of the care in one setting. This truly is an integrated approach to health care. Most recently the National Pace Association (NPA), primary care committee has developed a PACE Model of Practice. The model of practice provides relevant diagnostic and treatment recommendations to PACE primary care physicians (PCP). (National PACE Association, 2014). The model practices assume that the goals of care for PACE participants can be divided into three categories: 1) promotion of longevity; 2) optimization of function; and 3) palliative care. This evidenced based model will support research on life expectancy and quality of life indicators for the frail elderly. In a longitudinal study done by Tan, Lui, Eng (2002), examined the relationship between race and mortality in elderly with access to a program providing comprehensive access and coordination of services provided by the PACE program. In a sample of 2,861 patients, 2,002 were White and 859 were Black. The setting included twelve nationwide demonstration sites of the PACE program which provided comprehensive medical and long-term care services for nursing home-eligible residents who lived in the community. The patients were followed from enrollment to death or the end of the follow-up period. Their study concluded that Black patients had a lower mortality rate than White patients and their survival advantage emerged one year after enrollment in the PACE program and may be related to access and coordination of medical and long term care services for the frail elderly.

PACE Grows Nationally Nationally PACE programs have grown to encompass about 17,000 frail seniors- a small fraction of the 70 million Americans who are 55 or older. PACE was started in the early 1970’s in San Fransico’s China Town as a Medicare Demonstration Project. The On Lok model was adopted elsewhere, and since gained permanent federal status in 1990, the number of providers operating a PACE option has grown to 107 in 32 States. Pennsylvania has the most programs with 26, followed by Virginia (14) and California (10), and the State of Indiana just opened its first PACE site (www.npaonline.org). Since the PACE program began in Detroit in 1994, eight other sites in Michigan have started using the model from the Detroit PACE site, Center for Senior Independence which now has two sites, the Northwest and the Rivertown site. An article in the Washington Post, by Susan Jaffe reported the benefits of PACE program in Baltimore, MD with expansions in Northern Virginia. The benefits include a multidisciplinary approach with preventive health care to keep seniors healthy and to avoid expensive hospitalizations or nursing home visits. Virginia has expanded the PACE program including the most recent site in Farmville, VA through Centra Health to assist the rural elderly in Central Virginia. Jaffe reported that Virginia officials estimated that the cost to the State of a person who has both Medicaid and Medicare through PACE is, on average $4200 less per year that that of a similar person getting Medicaid services either at home or in a skilled nursing facility. As PACE programs continue to grow across the country, research has shown that the comprehensive interdisciplinary approach to care has reduced disparities in health care among the elderly and the number of nursing home admissions has declined through the first 20 months of enrollment (www.npaonline.org). Additionally PACE has reduced both nursing home admissions and hospital utilization, with a hospital length of stay of 4.9 days, compared with Medicare average LOS of 7.6. And it had reduced the average of 7.6 medications per resident in a typical nursing facility to 5.5 for

the PACE population (Willging, 2006). In conclusion the PACE program has shown to reduce healthcare disparities in the urban and rural elderly across the country by providing access and preventative care to the elderly and to remain in their homes throughout their enrollment in PACE thus reducing nursing home admissions. However according to Berger (2012) with the rapid expansion of PACE programs across the country, the nursing home model may no longer be financially viable or medically justified especially in light of financial constraints which may affect payments to nursing homes and other long term care providers (Berger, 2012).

References

Berger, J. (Feb 24, 2012). Managed Care Keeping the Frail Out of Nursing Homes. New York Times. Geronimus, A.T., Bound, J., Waidman, T (1999). Poverty, Time and Place: Variation in excess mortality across selected US populations, 1980-1990. Journal of Epidemiology and Community Health, 53, 325-334. Schulz, A., Williams, D., Israel, B., & Lempert, L. (2002). Racial and Spatial Relations as Fundamental Determinants of Health in Detroit. Milbank Quarterly, 80(4), 677-707. Tan, E.J., Lui, L.Y., Eng, C., Jha, A.K., & Covinsky, K.E. (2003). Differences in Mortality of Black and White Patients Enrolled in the Program of All-Inclusive Care for the Elderly. Journal of American Geriatric Society, 51: 246-251. Willging, P.R. (2006). PACE Can Show Us the Way. Nursing Homes, 55(9), 14-22