Targeted Population Health Management for Under 55-Year-Olds Qualifying for LTC Services

Historical Background

PACE has its roots in the founding of an adult day and health care center in San Francisco, California, in 1971. Providing care to older adults in the community setting rather than in a nursing home, PACE has grown from a small initiative to 116 programs serving more than 30,000 beneficiaries in 32 states.

Over time, the model's outcomes have been researched multiple times and studies show the ability PACE programs have in improving the quality of life and health care of its beneficiaries. From reducing the amount of preventable hospitalizations to minimizing the length of hospital stays, PACE continues to show that a community-based interdisciplinary approach better serves its beneficiaries. ^2,3 PACE programs do this under a capitated model, assuming all risks associated with taking care of its enrollees—essentially helping to reduce Medicare's health care expenditures. Programs receive a set amount from Medicaid and a frailty-modified amount from Medicare.

Because of the positive outcomes and the growing demand for models of care that can decrease expenses, health care policy makers have worked to replicate the PACE program's success with the development of programs such as the Wisconsin Partnership Program, the Assisted Living Model, and other HCBS programs. ⁴ Although these programs have been successful, the significant limitation is that applicants must be 55 years of age or older in order to enroll.

Currently, PACE has strict enrollment criteria established by the Centers for Medicare & Medicaid Services. The age requirement is now becoming an issue as PACE continues to see an influx in enrollment of individuals who are 55–65 years old—something that was not the norm 10 years ago. This trend indicates younger individuals will continue to access the health care system more often, and those with multiple chronic conditions, hospitalized and readmitted multiple times for the treatment of their diseases, will continue to drive up health care expenditures in our nation.

According to Machlin, ⁵ 25% of adults in the United States live with 1 or more chronic conditions. If left untreated, these conditions result in poor patient outcomes, subsequent higher costs, and an even higher burden on the system. Furthermore, individuals living with multiple chronic conditions require advance care coordination, which is not usually available in a primary care clinic setting.

It is because of this that there is now a general consensus that PACE will benefit younger adults living with multiple chronic conditions or major physical disabilities—delaying their institutionalization in nursing homes and helping them cope with their illnesses in the community. According to the National PACE Association, policy makers have been supportive of expanding PACE because the program has proved to be effective in providing a high quality of life for participants and saving taxpayer dollars by minimizing the use of institutional care.

Policy Background

In May 2014, under the 113^th Congress, Representative Christopher Smith (R-NJ) introduced H.R. 4543. At the time, this bill was known as the PACE Pilot Act of 2014. Although H.R. 4543 received major support from the National PACE Association and other organizations, the bill failed to pass. Nonetheless, lobbying in favor of PACE legislation continued for months after and a group of senators and representatives continued to work on measures to expand PACE and promote its adaptation for younger, sicker patients.

The PACE Innovation Act of 2015

Following the support for H.R. 4543, Representatives Christopher Smith, Earl Blumenauer (D-OR), Kevin Brady (R-TX), and Jim McDermott (D-WA) reintroduced the PACE bill during the 114^th Congress as H.R. 3243. This new bill became known as the PACE Innovation Act. Its purpose is to expand PACE to younger individuals with disabilities who at the time did not meet PACE eligibility criteria, primarily because of their age. It has been estimated that 5 organizations will participate in this pilot study. So far, only 1 organization has revealed its plan for implementation.

The Inglis Foundation, an organization providing care to hundreds of persons living with disabilities in the Philadelphia area for more than 100 years, plans to start their PACE pilot early in 2016. ⁶ Inglis's current nursing home model of care for patients with major physical disabilities is no longer viable. The cost associated with caring for these individuals is substantial, as younger adults living with disabilities account for 57% of Medicare and Medicaid expenses. Inglis has estimated that it will save the Commonwealth of Pennsylvania $50,000 per year per member or about $2 million over the lifetime of an enrollee. Furthermore, there could possibly be significant Medicare savings related to the reduced rates of preventable hospitalizations and readmissions.

Established PACE organizations have not come forward with plans to participate in the pilot project. Because their focus is on multiple chronic conditions and not on disabilities, PACE organizations may not all jump in to partake. It is unclear if major physical disabilities will be a requirement for enrollment for those younger than age 55 and it seems the pilot is catered to those organizations already taking care of these individuals, such as the Inglis Foundation.

Influential Factors

Several stakeholders could benefit from the PACE Innovation Act: patients, PACE organizations, prospective PACE organizations, and the state and federal government. The benefits for patients are obvious; they get increased access to services that otherwise would be challenging and fragmented. They will most likely see positive health care outcomes and will continue to live in the community for a longer time, maintaining their independence and comfort. This alone is a significant cultural and social factor as policies and programs that strengthen social, family, and community networks lead to increases in quality of life and general well-being.

On the other hand, the benefits for PACE and prospective PACE organizations are still indistinct. From a practical factor, current PACE programs are not equipped to care for younger enrollees, particularly those with major physical limitations. Although PACE programs would benefit from expanding services to younger individuals, they will need to reconsider their human resources as the majority of PACE clinicians specialize in geriatrics. Because of this, established organizations servicing young adults with disabilities and chronic conditions, such as the Inglis Foundation, likely would benefit the most. These organizations already have the human resources, could easily transform their sites into fully operational PACE programs, and would profit from reduced expenses in program operations and management.

From an economics factor, the state and federal government would benefit tremendously from this initiative. The savings associated with expanding PACE to younger, sicker adults, will most likely reflect positively in the short term for state Medicaid programs that are already at a financial risk. At the federal level, Medicare savings can be significant when you take into consideration the reduction in hospital admissions and readmissions. Furthermore, the capitated model PACE operates under would reduce overall Medicare expenditures. This factor alone is a major driver behind support for this bill.

Addressing the Problem and Future Recommendations

The PACE Innovation Act of 2015 seems simple enough, amending the Social Security Act section 1115 A to authorize the Secretary of Health and Human Services to waive certain requirements in order to establish demonstration projects using PACE. But the bill is far from simple. Under the PACE Innovation Act, the Secretary cannot waive certain other Medicaid requirements that relate to enrollment and disenrollment from the program. In fact, while H.R. 3243 waives the age requirement, it is still not clear whether a minimum age will be required to enroll. The bill's wording and all documentation in relation to it state that PACE should be available to individuals younger than 55 years of age; the bill did not set a minimum age.

Those individuals aged 18–55 who have multiple chronic conditions or disabilities are the ones who are targeted by the PACE Innovation Act, but it should be described as such. The bill's wording for specific enrollment and disenrollment criteria should be more clear. Currently, being eligible for nursing facility level of care is a requirement for enrollment. The interpretation of this requirement is vague in some states and too strict in others. For example, an individual with chronic obstructive pulmonary disease might be eligible for a nursing facility in Pennsylvania but not in Florida. This bill should have allowed the Secretary to waive this requirement, as by the time an individual qualifies for a nursing home level of care it might be too late.

Another enrollment requirement not waived by this bill is the geographical requirement. PACE enrollees must live within a PACE organization's catchment area. Although this makes sense for enrollees who need the adult day center on a daily basis, it limits potential enrollees who live around the perimeter of PACE organizations and do not need an adult day center. So is the case for those younger than 55 years of age, who most likely would not attend the adult day center as other PACE enrollees do.

Although the PACE Innovation Act makes progress in advancing the long-term care agenda, it falls short in many areas as waiving only 1 enrollment requirement does not seem enough. Furthermore, the nursing facility level of care is a misapprehension that was initially established to control enrollment into the program and, with it, growth. There are many individuals who belong to subpopulations of long-term care enrollees who would benefit from PACE, such as individuals with chronic mental illness.

Conclusion

As the expense of caring for individuals with multiple chronic conditions takes an increasing toll, the development of efficient and effective targeted population health management models of care will become ever so critical. The PACE Innovation Act of 2015 is an attempt to extend the successful PACE model of care to a population of younger individuals with multiple chronic conditions and major disabilities. This Act is intended to benefit this unique population suffering the consequences of a fragmented, complicated, and expensive system through the expansion of PACE, a proven targeted population health management program.