Programs for the All-Inclusive Care of the Elderly (PACE) is a long-term care model that uses a interdisciplinary health care approach to assess the needs of each member and deliver a comprehensive array of services. All of this with one goal in mind: keep seniors healthy and living in their own communities for as long as possible.
Driven by directives from The Centers for Medicare & Medicaid Services (CMS), PACE programs provide seamless, coordinated health care services with improved efficiency and better outcomes. It is the only program of its kind that integrates Medicaid and Medicare under a collaborative contract between state agencies and the PACE organization. This fully integrated model of care allows for greater service flexibility, coordination, and continuity of care.
Benefits and Challenges
On one hand, PACE gives states a powerful tool to meet Medicaid long-term care goals. These programs can help states rebalance nursing facility and home and community-based services, while simultaneously helping to extend seniors’ time in their own communities. On the other, this program’s complexity, where the multi-faceted needs of seniors intersect with regulatory, medical, social, and health care delivery concerns, means that implementing a PACE program is a significant undertaking. Federal law requires that rates be less than what would otherwise have been paid under the State plan if participants were not enrolled in PACE. The rates should account for frailty of participants, be set at a fixed amount, and can be renegotiated on an annual basis. Although most states have developed PACE programs, the model remains unique enough to present uncommon challenges that public administrators may not have previously encountered.
Choosing the Right Partner: Development and Implementation
Creating and launching a PACE program – a multifaceted, dynamic, and sometimes challenging process – requires a sound understanding of the model; an organizational assessment; program planning; calculation of capitated rates; stakeholder engagement; the submission of a PACE provider application; and readiness reviews.
Myers and Stauffer can help bring a big-picture focus to PACE program development through market analysis and knowledge of how PACE can complement traditional Medicaid programs. Our key competencies in the PACE arena include market analysis, feasibility studies, program applications and financials reviews, provider procurement tools development, and federal requirements compliance reviews. We offer:
- Planning, Feasibility Studies, and Rate Calculations. We can provide dynamic, adaptable guidance on the development and launch of a PACE program. Detailed feasibility studies – market analyses, including review of census data – help assess potential PACE enrollment and locations. The creation of the PACE upper payment limit and capitation rates requires an in-depth analysis of fee-for-service claims data and/or managed care encounter data, as well as in-depth understanding of Medicaid and Medicare program coverage and reimbursement policies.
- Stakeholder Engagement. We have designed and conducted extensive and diverse stakeholder engagement strategies and have decades of experience working with providers and provider organizations, advocacy groups, community-based organizations, Medicaid agency leadership, and contracted vendors.
- Requests for Proposals (RFPs). We know the complexity of PACE RFPs. We have experience supporting states with procurements, including drafting of the RFP and contract requirements, and supporting the RFP evaluation. We have prepared public announcements and timelines, as well as executive briefing documents. We have prepared scoring tools, as well as coordinated and supported states through the scoring and evaluation process.
- Readiness Reviews. We support clients in the state readiness review process to ensure the PACE organization meets the regulatory requirements. We can help states review these applications from administrative, financial, and operational perspectives and offer constructive feedback. Our on-site readiness review services include vital clinical evaluation to ensure the centers comply with CMS guidelines.
- Pay for Performance. We support our clients with pay for performance initiatives to improve health outcomes by working with POs on metrics that encourage integrated care, care coordination, and incentives for high quality care in a financially sustainable delivery system.
- Post-Implementation Monitoring. We conduct financial reviews of approved PACE organizations and participate in the federal review process. Regular financial reviews of the PACE organizations are particularly important to ensure the entities remain financially sustainable. Post-implementation monitoring of quality metrics is also critical to long-term success of a PACE program. Our experience in this area offers unique insight into quality compliance with CMS.
Experience has taught us what is critical: established, methodical processes governed by strict adherence to standards and regulations. We can apply best practices, emerging trends, and state specific objectives to guide our work. Our disciplined, repeatable processes incorporate the rigor necessary to generate the defensible results clients need and the meticulous quality they expect. We bring this same philosophical orientation and technical execution to every engagement.
Refer to our blog post about the components of pace and to understand why your state needs a skilled partner for proper support and guidance.
Contact the subject matter experts for further information:
Jared Duzan, CFE
Vicki Bartlett, RN, CCM, COC
Health Care Senior Manager
Renae Blunt, CPA
Rose Anne Howland, RN, MS, CFE, CHC, CPHQ, LFACHE