PACE can show us the way.
Let's face it; we have a healthcare delivery and financing system for America's elderly that appears largely incompatible with their healthcare needs. It's a delivery system more oriented o·ri·ent
1. Orient The countries of Asia, especially of eastern Asia.
a. The luster characteristic of a pearl of high quality.
b. A pearl having exceptional luster.
3. toward the acute care requirements of younger populations, and a financing system focused on facility-based care (which America's seniors would prefer to avoid). What's more, the funding programs reflect two very different philosophies of public support--one oriented toward a social insurance concept, in which all elderly are eligible, and one toward the concept of means testing means test
An investigation into the financial well-being of a person to determine the person's eligibility for financial assistance.
Noun and benefiting only the impoverished.
These multiple difficulties resulted not from conscious design, but from the unintended consequences For the "Law of unintended consequences", see Unintended consequence
Unintended Consequences is a novel by author John Ross, first published in 1996 by Accurate Press. of programs whose authors were not at all conversant CONVERSANT. One who is in the habit of being in a particular place, is said to be conversant there. Barnes, 162. with the particular healthcare needs of America's elderly. Their solution, therefore, will require that we focus precisely on those needs.
A number of programs have been developed and tested over the past 30 years to better structure the financing and delivery of care, particularly long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. , for America's seniors. Most of these have focused on the need to better coordinate and integrate the services provided. They've done so through one of two basic, but very dissimilar, approaches: case management (the "brokerage" model) or direct provision of services (the "consolidated" model). Brokerage approaches have had only limited success, one reason being the difficulty of identifying high-risk patients for whom home- and community-based services would be most cost-effective, another being these programs' failure to integrate funding sources. Consolidated models, such as Evercare, Social Health Maintenance Organizations (S/HMOs), and Programs of All-inclusive Care for the Elderly (PACE), have done a better job of targeting recipients and integrating funding, and their results have been more promising. But they, too, have their limitations and challenges.
Evercare, for example, is a nursing home-based approach to care integration that manages acute care financing and care delivery for residents. It is appropriately focused on case management and the use of geriatric geriatric /ger·i·at·ric/ (jer?e-at´rik)
1. pertaining to elderly persons or to the aging process.
2. pertaining to geriatrics.
1. specialists and has resulted in a significant decline in hospital admissions. But since its clientele already resides in nursing facilities and the program assumes no responsibility for custodial care Custodial Care
Non-medical care that helps individuals with his or her activities of daily living, preparation of special diets and self-administration of medication not requiring constant attention of medical personnel. , the program is limited in terms of its applicability and is not likely to be a significant solution to the overall problems of long-term care delivery and financing.
S/HMOs don't have that flaw. They were established in 1982 as part of a demonstration to bring both service providers and funding streams (Medicare and Medicaid Medicare and Medicaid
U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. ) together. Unlike Evercare, their services are not oriented toward the institutionalized in·sti·tu·tion·al·ize
tr.v. in·sti·tu·tion·al·ized, in·sti·tu·tion·al·iz·ing, in·sti·tu·tion·al·iz·es
a. To make into, treat as, or give the character of an institution to.
b. recipient of care. Indeed, their problem is the converse (logic) converse - The truth of a proposition of the form A => B and its converse B => A are shown in the following truth table:
A B | A => B B => A ------+---------------- f f | t t f t | t f t f | f t t t | t t ; in setting a limit on annual expenditures for its clientele, the S/HMO cannot cover the typical long-term stay in a nursing facility and, therefore, effectively denies the benefit. It is true that S/HMOs (as incorporated in the Medicare+Choice program in the Balanced Budget Balanced budget
A budget in which the income equals expenditure. See: budget.
A budget in which the expenditures incurred during a given period are matched by revenues. Act of 1997) have shown dramatic reductions in admissions to nursing facilities (by as much as 29% compared with non-S/HMO programs). But their financial limitations make them, like Evercare, unlikely solutions to long-term care financing.
So, let's look at PACE. In PACE (as is also true of S/HMOs), the concept of integrating the services needed by the client into a comprehensive package of care is facilitated by capitating payments to the programs (i.e., a fixed amount per member per month). PACE is clearly more advanced than S/HMOs, in that by focusing on seniors eligible for both Medicare and Medicaid, it receives a single, combined capitated payment from both programs. The dysfunctional dys·func·tion also dis·func·tion
Abnormal or impaired functioning, especially of a bodily system or social group.
dys·func compartmentalization of the elderly occasioned by separate funding streams (and separate management of that funding) is not a problem for PACE-eligibles. This integration of financing gives PACE the flexibility to provide services that are needed, not just those eligible to be reimbursed.
The PACE program's focus on interdisciplinary assessment, care planning, and intervention (delivering services deemed necessary for the client, not just those enumerated This term is often used in law as equivalent to mentioned specifically, designated, or expressly named or granted; as in speaking of enumerated governmental powers, items of property, or articles in a tariff schedule. by obscure regulations) has resulted in even more dramatic reductions in nursing facility admissions than even those experienced by S/HMOs. While PACE clients become so only when certified See certification. by the state as being already nursing home-eligible, there are PACE programs with actual admissions to facilities as low as 5 to 10% of their enrollees. Indeed, the program's successes led Congress in 1997 to establish PACE as a permanent provider type under Medicare, with authorization for establishing 60 such programs across the country.
Yet even PACE has its problems--problems that, despite its documented successes, have kept it from becoming the major player it might yet become in the long-term care arena. Enrollees in most of the 20-plus PACE programs number only in the hundreds each. One of the smallest PACE programs, associated with my university (Johns Hopkins Noun 1. Johns Hopkins - United States financier and philanthropist who left money to found the university and hospital that bear his name in Baltimore (1795-1873)
2. ), has fewer than 150 members. (And, frankly, I'm not sure I could sleep nights were I managing a capitated program in which the risks of potentially high-cost enrollees had to be spread over such a small number of "covered lives"; all it takes is a few long-stay admissions to a nursing facility, at an average annual cost of more than $60,000, to demolish de·mol·ish
tr.v. de·mol·ished, de·mol·ish·ing, de·mol·ish·es
1. To tear down completely; raze.
2. To do away with completely; put an end to.
3. your business plan and court financial disaster.)
Small numbers of enrollees are only one of the four major problems the PACE program faces; failure to address any one of which might lead the program to be relegated to the status of "boutique long-term care." The program has experienced, for example, difficulties in recruiting primary care physicians. Appropriately trained and motivated physicians are indispensable to PACE. While certification in geriatrics geriatrics (jĕrēă`trĭks), the branch of medicine concerned with conditions and diseases of the aged. Many disabilities in old age are caused by or related to the deterioration of the circulatory system (see arteriosclerosis), e.g. is not a requirement for physician involvement in PACE, an understanding of the principles of geriatric care is.
It's certainly no secret that there just aren't enough geriatrics-oriented physicians. The Association of Directors of Geriatric Academic Programs (ADGAP ADGAP Association of Dumfries and Galloway Accommodation Providers (Scotland) ) recently put some stark numbers on the table: The 7,500 trained geriatricians in practice today constitute barely one-half of those needed. And given the geometric growth in America's elderly population, the 14,000 we need today will balloon to 36,000 25 years from now. Worse yet, the number of geriatricians actually in practice is actually diminishing--dramatically so. ADGAP estimates that 2,730 fewer certified geriatricians are practicing today than in 1998, a more than 26% decline.
It gets even worse--we don't have sufficient numbers of academicians necessary to train those few medical students who might have an interest in the field. We need 2,400 of these teachers--we have 900. Also, while the Institute of Medicine suggests that each medical school should have at least nine geriatricians on its teaching staff, ADGAP estimates that only 30% of all schools meet that criterion. Only 27 of the more than 100 non-pediatric residency A duration of stay required by state and local laws that entitles a person to the legal protection and benefits provided by applicable statutes.
States have required state residency for a variety of rights, including the right to vote, the right to run for public office, the and fellowship training programs in our medical schools even have a curriculum requirement in geriatric care. (We won't even discuss departments of geriatric medicine--at last count, only six existed in the entire country.)
The third major challenge facing PACE is developmental. Bringing a PACE site up to speed takes time and money. Programs have routinely consumed from three to five years in the development phase, with about $1,500,000 in capital expenditures laid out before enrolling the first client. Because of these financial exigencies, one PACE challenge will be to partner with other providers, with the development phase consisting of repositioning repositioning Laparoscopic surgery The changing of a Pt's position during a procedure to improve access or visualization of the operative field, which may be linked to complications, as it changes anatomic planes of operation. Cf Laparoscopic surgery. existing facilities rather than creating them from scratch.
Finally, the PACE financing structure might well forever limit it to the status of a "welfare program." Is it permanently doomed to be available only to "dual eligibles" (those Americans on Medicare so poor as to qualify for Medicaid, as well)? Well, statutorily it's not--any Medicare recipient can join PACE, rich or poor. But someone has to pay what Medicaid doesn't. The Medicaid contribution has been typically looked upon as a form of PACE copayment co·pay·ment
A fixed fee that subscribers to a medical plan must pay for their use of specific medical services covered by the plan.
n . If Medicaid is precluded from paying because of the resources and/or income available to the beneficiary, then it is the beneficiary who's left holding the bag for private pay--typically close to $2,500 a month. Yes, $2,500 per month is pretty cheap compared with nursing homes rates, which can be twice that. But potential PACE clients aren't living in a nursing home. And when they look at the services that might be available to them at home for that additional money, they just might not find it to be worth it.
Nevertheless, for all these potential problems, programs such as PACE might well carry the seeds of a solution to the current inadequacies of long-term care financing and delivery. PACE has created cohesion cohesion: see adhesion and cohesion.
The tendency of atoms or molecules to coalesce into extended condensed states. This tendency is practically universal. where there was fragmentation. PACE has created awareness where there was confusion. PACE has created access where there were barriers. PACE has shown the value of a coordinated, interdisciplinary approach to providing services to patients whose needs are diverse--it has shown, for example, the value of holistic medicine holistic medicine, system of health care based on a concept of the "whole" person as one whose body, mind, spirit, and emotions are in balance with the environment. , the hallmark of geriatric care. And it has changed the focus of both funding and delivery toward the recipient of service and away from the service provider.
Moreover, PACE exhibits high levels of customer satisfaction, marked by low rates of disenrollment. PACE has reduced both nursing facility and hospital utilization hospital utilization The usage rate of a particular health care facility; a group of statistics referring to a population's use of hospital services , with a hospital length of stay of 4.9 days, compared with the Medicare average of 7.6. And it has reduced the average of 7.6 medications per resident in the typical nursing facility to 5.5 for the PACE population.
So, is PACE the solution? Maybe so, maybe not--but certainly, the concepts incorporated in the PACE program are key to those solutions. Perhaps the greatest lesson to be learned from PACE is this: Treat the client as the focus--indeed, treat the entire client as the focus. Withstand the urge to force the recipient of care into categories comfortable for the practitioner, the bureaucrat, and the financier to deal with. Make the patient more the object than the subject of our attention; i.e., make meeting his or her needs, not ours, the ultimate goal of our endeavors.
Do that, and we just might have a system that works.
To send your comments to Dr. Willging and the editors, e-mail firstname.lastname@example.org.
Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association The American Health Care Association (AHCA) is non-profit federation of affiliated state health organizations, together representing more than 10,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for , Dr. Willging went on to co-found the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living as·sist·ed living
A living arrangement in which people with special needs, especially older people with disabilities, reside in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication. Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.