Why Should Nursing Homes Become PACE Providers? Part 1.PACE is intended to keep people out of nursing homes--but opens a door to new 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. possibilities A program known as PACE, the Program of All-Inclusive Care for the Elderly PACE Program of All-inclusive Care for the Elderly PACE programs provide comprehensive health services for individuals over age 55 who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. , has been generating continued interest since the original program in San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden began serving the frail elderly frail elderly, n.pl older persons (usually over the age of 75 years) who are afflicted with physical or mental disabilities that may interfere with the ability to independently perform activities of daily living. in the mid-1970s. Since that time, the program has grown steadily as a federal demonstration program serving 7,000 elderly in 25 programs across the country. As a result of its proven success, the Balanced Budget Balanced budget A budget in which the income equals expenditure. See: budget. balanced budget A budget in which the expenditures incurred during a given period are matched by revenues. Act of 1997 gave the Health Care Financing Administration Health Care Financing Administration, n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. (HCFA HCFA abbr. Health Care Financing Administration HCFA, n.pr See Health Care Financing Administration. ) the authority to issue regulations to make PACE a permanent provider type under Medicare and a state option under Medicaid. Becoming a PACE provider has become a realistic strategic option for any nonprofit organization Nonprofit Organization An association that is given tax-free status. Donations to a non-profit organization are often tax deductible as well. Notes: Examples of non-profit organizations are charities, hospitals and schools. interested in serving the elderly with a community-based, noninstitutional approach. (For-profit organizations will, for now, only be able to participate in a demonstration that was authorized by the BBA BBA abbr. Bachelor of Business Administration of 1997, and which HCFA is now planning.) A number of mission-oriented nonprofit organizations are taking notice--for example: Judy Ryan, president and CEO (1) (Chief Executive Officer) The highest individual in command of an organization. Typically the president of the company, the CEO reports to the Chairman of the Board. of the Evangelical Lutheran Good Samaritan Good Samaritan man who helped half-dead victim of thieves after a priest and a Levite had “passed by.” [N.T.: Luke 10:33] See : Helpfulness Good Samaritan Society, says, "For more than 78 years, the Years, The the seven decades of Eleanor Pargiter’s life. [Br. Lit.: Benét, 1109] See : Time mission of the Evangelical Lutheran Good Samaritan Society has been to share God's love in word and deed by providing shelter and supportive services to older persons and others in need, believing that 'In Christ's love, Everyone is Someone.' Fulfilling this mission in the 2 1st century means continuing to explore alternative ways through which to provide those services. Determining how the PACE program fits within our continuum of care has therefore become one of our top strategic priorities." Fundamentally, a successful PACE provider strives to keep its patients out of nursing homes and in the community with a multitude of supportive services. Why then would any organization that operates nursing homes become a PACE provider? The answer lies in the broader commitment and vision to serve the elderly in the most appropriate and desirable setting, rather than in the short-term goal of filling nursing home beds. For a nursing-home-eligible population over age 55, a PACE program must provide or contract for the full range of healthcare services under 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. (table). Essentially, a PACE provider is both the managed care organization that bears the full financial, risk and the partnering provider that meets the full range of needs (including long-term care) for its enrolled population. Again, there is good reason for facilities to consider making the necessary arrangements. Existing fee-for-service and managed care programs do not fulfill the social and medical needs of the elderly population in need. The traditional Medicare and Medicaid programs, as currently structured, do not adequately fund the provision of social services that are needed by frail adults living in the community. Although, more recently, long-term care providers have been gaining experience in contracting with traditional managed care organizations, they have been frustrated by the limited scope of the long-term care benefits offered. LTC LTC abbr. lieutenant colonel providers know from experience that these traditional managed care organizations only contract with SNFs to avert or reduce 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 . In contrast, PACE is a managed care program that fully integrates financing and care delivery for the frail elderly: * Enrollment: PACE only enrolls older people who are frail and meet nursing home eligibility standards; 55 is the minimum age, but 70% of enrollees are age 75 and older. * Care Management: PACE uses an interdisciplinary team interdisciplinary team, n a group that consists of specialists from several fields combining skills and resources to present guidance and information. approach to manage the complex needs of this patient population. Central to this approach is the adult day health center, which each enrollee attends for 2 to 5 days per week. * Capitated Financing: A capitated payment (i.e., per member per month) is typically obtained from Medicare and Medicaid, although some enrollees who are not financially eligible for Medicaid do pay privately for some of the care. Last November, HCFA issued an interim final regulation that allows interested states and organizations to move forward with PACE development. In general, the regulation remains consistent with the PACE protocol that governs the operation of the demonstration programs. The greatest concern for current and future PACE sites lies in HCFA's decision about how to risk-adjust the Medicare capitation. The risk-adjustment methodology that will be applied to traditional managed care plans uses inpatient utilization as a key factor. This factor would be inappropriate, however, for the PACE population, since the emphasis is on averting inpatient utilization. In any event, application of the risk-adjustment methodology will be delayed until January 2002 at the earliest. Meanwhile, the key to understanding how the program can achieve financial success lies in understanding how the PACE monthly capitation is established today. For now: * Medicare capitation rates are based upon the methodology that is used to pay other managed care plans, with payments adjusted for the frailty of this population. This Medicare capitation is set to provide at least 5% savings to the Medicare program. * Medicaid capitation rates are set by each participating state and developed based upon the state's estimate of the costs for a comparable population. The Medicaid capitation has typically built in a 5 to 15% savings. In general, PACE programs receive approximately two-thirds of their revenue from Medicaid and one-third from Medicare. Statistically, the result of the current methodology is as shown in the figure. How is the capitation dollar spent? The figure shows how the premiums are spent on the care of PACE participants, and the surprisingly low proportion of the capitation dollars that are spent on inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital and nursing home care. Reducing hospital utilization is a key to providing care within the capitation amount. Typically, the PACE interdisciplinary team is housed in an adult day health center and sees the patients (called participants) several times a week. This care-delivery model is central to managing the capitation dollars with the flexibility to provide a full range of care and services. While there is great variation across states, PACE is successful in reducing inpatient utilization. Hospital utilization is very similar to the general Medicare population, although PACE serves a much frailer population. Statistically: * In 1998, 2,224 inpatient days per thousand were utilized by PACE enrollees, as compared to 2,014 for all Medicare beneficiaries age 65 and over. * In 1998, the average length of stay for a PACE enrollee was 4.7 days, as compared to 6.4 days for all Medicare beneficiaries age 65 and over. Similarly, PACE is successful in maintaining enrollees in the community and avoiding permanent nursing home placement. PACE enrollees receive adult day care, long-term care provided at home and supportive housing to achieve this low rate of permanent institutionalization Institutionalization The gradual domination of financial markets by institutional investors, as opposed to individual investors. This process has occurred throughout the industrialized world. . Only about 7% of PACE enrollees are nursing home residents. If a PACE enrollee does eventually require permanent institutionalization in a nursing home, the PACE provider must fill this need from its capitation payment. Nevertheless, nursing homes with today's broader perspective on long-term care should take a look at joining the PACE movement. If you are contemplating becoming a PACE provider, here are some self-assessment questions to answer: * Are the goals of the organization consistent with PACE? * Do you have the support of senior management to secure the resources necessary? * How will a PACE program relate to your organization's existing programs? Will they compete or complement them? * Has your organization provided services to the frail elderly in the community? * Has your organization had experience assuming or sharing risk? * Is your organization in a position to undertake development of a new program such as PACE? * If not, should you partner with another organization to pursue PACE development? These are profound questions that require careful thought. Part 2 of this series will explore the issues involved in determining whether your organization is a good candidate for becoming or joining a PACE program, including how to undertake a feasibility study "A Feasibility Study" is an episode of the original The Outer Limits television show. It first aired on 13 April, 1964, during the first season. It was remade in 1997 as part of the revived The Outer Limits series with a minor title change. . Jade Gong is a senior advisor to the Health Dimensions Consulting Group in St. Paul, Minnesota. She is based in Arlington, Virginia, and can be reached at (703) 243-4202. Susan McCarthy is director of the Technical Assistance Center at Community Care Organization's PACE program in Milwaukee, Wisconsin. Services provided by PACE. [*] PACE Center Services Physician/Nurse Practitioner * Nursing * Social Work * Physical Therapy Occupational Therapy * Speech Therapy * Recreation Therapy Nutrition Counseling * Personal Care * Chore Services * Transportation Meals * Escort Service In-Home Services Home Healthcare * Personal Care Homemaker/Chore Services * Meals Specialist Services Medical Specialists * Audiology audiology /au·di·ol·o·gy/ (aw?de-ol´ah-je) the study of impaired hearing that cannot be improved by medication or surgical therapy. au·di·ol·o·gy n. Dentistry * Optometry optometry (ŏptŏm`ətrē), eye-care specialty concerned with eye examination, determination of visual abilities, diagnosis of eye diseases and conditions, and the prescription of lenses and other corrective measures. * Podiatry podiatry (pōdī`ətrē, pə–), science concerned with disorders, diseases, and deformities of the feet, also called chiropody. Podiatrists treat such common conditions as bunions, corns and calluses, and ingrown toenails. Other Medical Services Prescriptions * Lab Tests/Procedures * Radiology Services/Procedures Durable Medical Equipment Durable medical equipment is a term of art used to describe certain Medicare benefits, that is, whether Medicare may pay for the item. The item is defined by Title XVIII the Social Security Act: * Outpatient Surgery * Emergency Room Care Medical Transportation Inpatient Services Hospital * Nursinq Home * Inpatient Specialists * Source: National PACE Association, PACE Profile, 1999 |
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion