February 24, 2014

Keeping PACE

At a time when most of the news about health and healthcare is pretty bleak, it’s nice to hear that one program for older patients is doing very well. The PACE program—Program of All-inclusive Care for the Elderly—has been around since the 1970s, when a neighborhood health center in San Francisco called On Lok pioneered a “social HMO,” providing both medical and social services using a capitated model. Since that time, PACE programs appeared in much of the country, each petitioning Medicare and Medicaid for special permission to collect one fee in return for taking care of some of the oldest and frailest patients, those who receive both Medicare and Medicaid and are eligible for nursing home placement. Ultimately, it became so clear that PACE provided high quality care while saving money that in 1997 it lost its experimental status: any integrated program that follows the basic tenets established by On Lok can be designated a PACE site. As of 2013, there were 98 PACE sites in 31 states, according to the National PACE Association. What’s new is that a recent study showed that PACE enrollees go to the hospital far less often than other dually eligible patients (patients receiving both Medicare and Medicaid, a particularly vulnerable and sick population).

The report, published in the most recent issue of the Journal of the American Geriatrics Societyreveals that the hospitalization rate was 79% higher among dually eligible in general than in PACE members (because not all patients are enrolled in PACE for an entire calendar year—they may join at different times or disenroll, usually due to death, before the end of the year—the report actually cites the rate per 1000-person-years, which comes to 539 per 1000 person-years in PACE members and 962 per 1000 person-years in the dually eligible). And when the investigators looked at “potentially avoidable hospitalizations,” admissions related to any of four medical conditions that some authorities believe should be treatable outside the hospital or in which optimal outpatient care should be able to prevent the kind of exacerbations of chronic conditions that trigger hospitalization, they found a similar pattern: the rate of potentially preventable hospitalizations was 2 1/2  times higher in the dually eligibles compared to patients in PACE (100/1000 person-years for PACE patients and 250/1000 person-years for dually eligible patients). Since hospitalization causes all kinds of problems in frail older people, and the cost of hospital care is the biggest piece of the Medicare budget, any program that produces these results deserves our attention.

So how does PACE keep patients out of the hospital? Unfortunately, the new study does not address this crucial question. The authors comment only that there are “many components that may affect hospitalization” and enumerate the unique features of PACE: it is capitated (the program receives a lump sum payment for each member to take care of all his or her medical needs), it provides care via an interdisciplinary team (physician, nurse, social worker, and physical therapists and others as needed), and it centers much of the care it offers in a kind of senior daycare program known as adult day health. 

I suspect that the secret to PACE’s success is twofold. First, the members of the interdisciplinary team spend time with the patient and family to review the big picture—the enrollee’s major health problems and their implications—and, based on this understanding, they come up with a plan of care. Second, the clinicians try to bring services to the patient instead of bringing the patient to the services. That means diagnosing and treating problems in the adult day health center or at home. 

If this sounds familiar, it is the prescription I wrote about in my recent article, “When Frail Elderly Patients Get Sick: Alternatives to Hospitalization” and have blogged about in these pages. If PACE has the master key to the problem that has bedeviled American healthcare—how best to care for its sickest, most vulnerable patients—then maybe it’s time to fashion other similar keys, creating models that will appeal to a frail elders of many ethnic groups, varying socioeconomic status, and in many geographic regions.

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