PACE: A Better Model for Elder Care?

In a recent podcast, I talked with Dr. Anthony Zizza, medical director of Element Care, about the Program for All-Inclusive Care for the Elderly (PACE) that provides comprehensive care to low-income older adults. Unlike the piecemeal approach of most healthcare in the United States, participants in PACE receive one-stop-shopping for all their health needs.

PACE is available to patients who have both Medicare and Medicaid (MassHealth in Massachusetts, where Element Care is located) and agree to receive all their care through the PACE program. Medicare and Medicaid pay a fixed amount per participant, which gives the program a financial incentive to keep them healthy and living in the community. As a result, many PACE programs offer nonmedical as well as medical care.

While PACE has existed since 1971, it only expanded from a couple of dozen programs nationwide after 1997 when it became a permanently recognized provider type under Medicare and Medicaid. By 2023, there were 151 programs serving 68,000 participants in 32 states and the District of Columbia.

Here are some excerpts from our conversation:

Risking Old Age in America (ROA): What is PACE?

Dr. Anthony Zizza: PACE is a Medicare and Medicaid model for adults 55 and older who need a nursing home level of care, but can still live safely in the community with the right support.

We call the people receiving care “participants” as opposed to “patients” because they really do participate in their care. With PACE, it’s not just a clinic visit and you go home. It’s a full care model. We have 14 different [services that] deliver high quality, coordinated person-centered care so these older adults can remain in their homes and communities as long as possible.

ROA: How do you make that happen?

Zizza: The system really should wrap around the older adult and not force the older adult and family to chase the system. That’s what traditionally you see for a lot of geriatric patients. We have transportation, therapy, social work, physicians, nurse practitioners, medication support, dieticians, an adult day health center and also home-based services that we coordinate through our whole team. And we also do palliative care as well as urgent care.

We’re also able to take outside-the-box steps. I’ll give you an example: We had a…participant who had a disease called COPD. It’s a disease that usually longtime smokers get. They have trouble oxygenating their blood and clearing carbon dioxide. So, they are prone to a lot of what we call exacerbations or infections, and they need hospitalization. Many times they go on a ventilator. It’s a very serious disease, especially as it progresses.

For our patient, we noticed that every summer he would have four or five exacerbations. In the winter, it calmed down. So we bought the patient an air conditioner, and that did the trick.

Once they’re enrolled in our program, we are committed to doing the right thing for them from the moment they enroll until the last breath that they take. We will do everything we can to keep them in the home, including sometimes having 24-hour services in the home.

ROA: How can you afford that level of service?

Zizza: Yes, it’s a lot of money. But these patients would cost the system a lot more if we weren’t involved. We’re preventing emergency room visits, preventing inpatient hospitalizations, and delaying long-term care. All of those things saves the system quite a bit of money.

ROA: Is PACE available nationwide?

Zizza: It could be, but it’s not. Some states do not have PACE programs. Even the states that have them, it’s not as if it’s available in the whole state. It’s quite a convoluted process to establish a PACE program. The organization has to make applications both through CMS as well as through the state Medicaid agency.

The state will grant you certain ZIP codes, which would be your service area, and that has to be approved by CMS. One thing about PACE that I would love to see changed or at least improved, is to reduce the tremendous amount of regulation and red tape that is involved right now [for] programs.

ROA: One of the earlier points you made was that to qualify you have to be clinically eligible as well as financially eligible. What do you mean by clinically eligible?

Zizza: The idea of PACE is to think about it as a nursing home without walls, which means that the participants need to be nursing home eligible. Now, what qualifies you to be nursing home eligible? You need to have a dependence on an ADL or on assistance for an activity of daily living. You may need help with bathing; you may need help with dressing or with feeding. If you need assistance and can’t live alone without it, then you very likely clinically would be eligible for PACE.

You can learn more about PACE by listening to our whole conversation here.

For more from Harry Margolis, check out his Risking Old Age in America blog and podcast.  He also answers consumer estate planning questions at AskHarry.info.  To stay current on the Squared Away blog, join our free email list.