FINAL EP25 PACE === [00:00:00] Welcome to the Mastering Medicare podcast, where we demystify healthcare and Medicare for senior serving professionals and providers with your co hosts, Dr. Alex Moseni and Dr. Amy Shiffman. Visit masteringmedicare. net for show notes, additional episodes, and valuable resources. Amy: Hello, everybody. Welcome to our fall kickoff of our mastering the care podcast. I feel like we kick it off all the time though, Alex, right? Alex: Yeah, for sure. For Amy: sure. But we have a, an amazing podcast today. We are going to be doing a deep dive into what I call an oldie, but goodie type of care delivery model called a pace model, Alex, are you psyched? Alex: I am, I think it's one of the more exciting models out there and it's very interesting and I'm very excited to learn about it. Amy: Yeah, I will, let me just give a little personal anecdote. So I was in the house call space for so long and I honestly had not heard of a PACE program because I think it's really geographical and you [00:01:00] kind of get to know what's in your really close geographical space and sometimes somebody would refer to a PACE program and I would just like nod my head, Oh sure, yeah, PACE, whatever that is. So I think this is really important for people who actually live and breathe in the care delivery space. Not everybody's actually heard of a PACE program. We have two amazing guests here with us. I'm going to let them introduce themselves. They are with a company called My Place Health. I have Dr. Schreiber and Eric Kotzelt, and they are going to teach us about the PACE model. So Dr. Schreiber, would you go ahead and introduce yourself? We'd love to hear a little bit about how you got to doing what you're doing. Rob: Thanks, Amy. And thank you both Alex and Amy for having us. So, my name is Rob Schreiber. I'm a geriatrician internist, and I've been working with older adults my entire career. Been involved with the PACE program. PACE stands for Program for All Inclusive Care for the [00:02:00] Elderly for the last eight years. Previous to joining my place health, where I've been about for the two and a half years, I'd working with the large PACE program in Massachusetts. My career has really been focused on working with multi specialty groups and building and trying to scale programs to successfully, but also doing turnarounds, you know, taking systems that just were not functional and really uprighting them, but then oftentimes having challenges to scale. And the exciting thing about Pace is it is starting to really grow exponentially to your point. That, you know, most people have not heard about it, even though it's been around, like I said, for almost 50 years. So excited to be here and I'll turn it over to Eric to introduce himself. Eric: Hey, Amy and Alex, happy to be here. I'm what you would call a long time listener, first time caller. So I'm really excited to be a part of the show. I've been in Pace for coming up on two years now, been in the healthcare, US healthcare world for almost a decade, largely spent on the payer [00:03:00] side from a business perspective, worked across many different lines of business, both government programs and commercial. Supported many different plans, whether it's blues, other regional plans or national plans, but joined MyPlace beginning of 2023 to support more from a business health plan operations side. So I'm really excited to, to provide that perspective in addition to Rob's clinical expertise from a PACE perspective. So looking forward to the, the show. Amy: Great. Can you just help me out here? What does PACE stand for? It's four letters, but I don't know that we all know what they stand for. Okay. Eric: So PACE stands for the program for all inclusive care for the elderly. So it is a bit of a mouthful and it is helpful to just refer to it as PACE, but yes, it's a national program. It's across 33 States. There's about 170 programs today and it covers about 77, 000 lives. Alex: So one of the things we like to do, Eric and Dr. Schreiber is we like to understand the business model of these sorts of programs, because without understanding that it seems like people don't really understand how these things work. So, so talk to us, [00:04:00] like, how does the PACE program, who pays whom? And then how does this all work operationally? Rob: Yeah. So given the fact it's all inclusive, the way PACE works, it's specifically for a very, very small segment of the population of older adults. Okay. There are criteria in which people have to qualify, and some of it's variable depending on states, but there are four basic principles that people have to hit. 55 years and older, they have to be deemed nursing home certifiable based on the state criteria, and so that can be variable depending on the state. They have to live in a geographically defined area, specific zip codes, so that program can only really market to individuals in those zip codes, and they have to be deemed to be safe with pay services in the community. So these are all people who would be living in nursing homes or at very high risk of being in a nursing home [00:05:00] that instead have opted to choose living in the community. So I just wanted to frame that because it's important to know who we're dealing with. The business case is very interesting and I'm glad you brought that up. Because it is a very challenging environment, I think Eric will go into a little bit more. But I'll sort of lay out how we get paid and sort of start the discussion. The way PACE is paid, in order to qualify, there's a Medicare and Medicaid component. You can be either a dual eligible Medicare and Medicaid, or you can be Medicaid only. And depending on the individuals, there's a different payment stream in terms of the amount of total money. There's also a Medicare D component, a pharmacy benefit that gets paid. You can be Medicare only. But that means if you're a Medicare only individual and you want to be in PACE, you have to also put in your own [00:06:00] money for the Medicaid per member per month fee for the state, as well as the Medicare D payment. So from an individual perspective, it's very hard to be a Medicare only participant unless you have significant money. The business case is it's very expensive to start a PACE program. Just before you even open, depending on where you are in the country, it's a 7 million to 15 million investment just to open up your doors. It takes at least another two years. In order for the organization to break even. So now we're up to at least four to five years and then to pay back the original principle that can take another several years. So you would look at us and say, okay, Dr. Rob and Eric, why are you guys doing this? Because from a business perspective, at least on first glance, it really doesn't make sense. But, you [00:07:00] know, Eric, maybe you can add to sort of really why this does make sense in systems of care and programs of which we are sponsored. We're sponsored by both the SCAN Health Plan and Commonwealth Care Alliance. These are both insurers that really deal with the dual eligible population, and they have really thought this through. And so there really is a business case. Eric, I'll turn that over to you. Amy: Before we get started, Eric, I want to tell you in giant neon lights, all I could say to myself in my brain when you were talking, Dr. Rob was why, why, why in God's name would anyone endeavor to do such a thing? So I am super excited to hear about why. Eric: So I think that the numbers that Rob called out were key there were the 7 just to start it up. So that really is inclusive of the facility build out. So we're talking at a center that would be equivalent to an adult day center with the component of a clinic. So primary care clinic. Additionally, we're talking about vehicles because we do have the transportation [00:08:00] component as well. Those are your primary costs to just start up. From a revenue perspective, this is where you might start to see where the business case can be made. So on average, we're talking for a duly eligible member from a revenue perspective on a per member per month reimbursement, it's on average about 9, 500 in some States, it could be as high as 11, 000 revenue, PM, PM for duly eligible for a Medicaid only. So this would be an individual that is just eligible under the Medicaid, Medicaid only status. They are averaged in between 7, 000 to 8, 000 revenue, PM, PM. So it is quite substantial if you compare that to whether it's a Medicare advantage or a DSNIP, a FIDESNIP, HIDESNIP member, those are in the range of between 850 to 3, 000 PM, PM in a revenue basis. So there is substantial revenue on a per member per month basis, which does obviously support the program to, to pay back Alex: some of the early startup costs. Is there a risk adjustment component to the revenue, similar to how there is an MA? It's exactly, Eric: it's, it's [00:09:00] nearly the exact same as, I mean, so if we, if we're thinking through Part C, the Medicare reimbursement component of a PACE member does go through the same risk adjustment process. Many of the starting points for what the initial population would be for a PACE program utilize the same Part C methodology, and then it's really on the clinical and health plan side of the PACE program to continue to find HCC codes and additional components for that risk adjustment. everyone. Rob: And to that point, the risk adjustment, this population has a significant larger number of HCCs compared to a Medicare Advantage population or a special needs plan population. So, it's the sickest of the sick or the most complex of the complex in general. The other piece about the business case. So even though Eric talked about where you can start seeing the business case, if you sit down back of the envelope calculation, it's going to take you, if I'm not mistaken, Eric, right about eight or nine years just to [00:10:00] get your principal investment back. And start making a more, a significant margin, depending on how, what the startup costs are. I think the other piece of that, oftentimes organizations haven't thought about is if you're part of a system of care, right? You have subpopulations, and for different populations, different models of care or different approaches are necessary, right? You have those that are upstream. That older adults that are really sort of well, then you have those who are midstream that are oftentimes engaged in health issues going through the care system and those that are downstream that oftentimes are limited in life expectancy and health status. The PACE population in average is about 76 to 77 years each individual, two thirds are women, and their average life expectancy is about three years. So, and, but these are the, again, you know, we know that in the last six months of life, 50 percent of the Medicare dollars are spent as well as a large amount of [00:11:00] Medicaid dollars, right? So, if you can segment this population and really work with them, take them out of an MA plan or even a special needs plan, they do better. As well as those plans do better. And so, you know, if you have the spectrum of programs, if you can put people in the best program based on their needs and it's also what their goals are, right, in general, you're going to do better. And so there really is a business case. And we have seen a lot of large health systems. Trinity healthcare is one. Ascension Henry Ford hospital has a PACE program. John Hopkins. But also now Kaiser has entered the PACE space for exactly, I think, this reason. Alex: So let's talk a little bit about the, like, what are the services that are actually provided? What is the typical day for a member look like? Eric: So from a comprehensive standpoint, we're talking every type of service that you could receive under Part A, Part B, [00:12:00] Part C, Part D, as well as Medicaid. So a PACE program is required to offer Adult day health services or adult daycare. So that would be the center component of our facility, primary care, home care, and home care encompasses both skilled and unskilled dental lab prescription therapy, and that would include physical therapy, occupational therapy, recreational therapy, nutritional counseling, as well as meals, social work. Transportation. And then from a, a network standpoint, so this doesn't necessarily sit within the PACE program itself, where many of those other services do, where we're employing individuals that provide those services. But from a network perspective, we also then have a network of hospital, ERs, urgent care, potentially other primary care physicians that support the program, specialists, labs, diagnostics, so everything that an individual would need. The PACE program is responsible for providing based on the care plan that Dr. Rob and other clinicians are defining on a daily and weekly basis. Alex: So are you essentially [00:13:00] taking total cost of care risk for these patients? Rob: Yes, it is total cost of care. And just to add to what Eric said, we provide clinical care, right? We're a provider of care. We're also a health plan. So every PACE program is an insurer. And so, yes, we are total cost of care. You know, we've heard about total cost of care, right? And Medicare Advantage being total cost of care. It's really not. We take care of people from the beginning to the end. If they end up in the nursing home, we have to pay for that. If they need services, no matter what those services, we are totally on the hook for those. So it's all inclusive to the points that Eric mentioned. What Medicare and Medicaid require us to do, you know, like what are covered benefits, we have to provide that. But in addition, the way decisions are made are through the interdisciplinary team. So we have 11 people that take care of each individual. So, it's like concierge care for [00:14:00] those who are most needy and most complex. And so, that's the way the decisions are made, but CMS and the state make certain that we're following the rules and regulations, but it is total cost of care. And so, it's really important that we provide the care that the people want, what their goals are, and make certain the care is goal concordant. And not discordant, you know, there's a lot of times care is being given and people don't want it. And we haven't really understood what their ultimate goal is. So it's a really fine line on how this is done. It's, I sort of look at it as almost like the nuclear submarine program. Like you have to be able to do everything well. Well, to run a PACE program, it's really takes that type of overall perspective, but you have to do the health plan operations well, the clinical care, as well as, you know, the community and adult day center. So it's really a wraparound that [00:15:00] requires total integration and collaboration. Alex: Rob, I'm glad you brought the nautical metaphor because when Eric was describing this, there All I could think about is this sounds like a cruise ship, like you got to have everything, right? Like you should create a Pace program that's a cruise ship. And that just has all of Amy: Pace at sea. Pace at sea. That's what it's called. Yeah. There you go. Rob: Yeah. We'll take that back, Eric. I mean, I Amy: just, I just converted from why, why, why to wow, wow, wow. Like that is actually, I'm blown away. I mean, having been a little bit in that sort of what I call the original gangster approach to value based care, which is hospice. It sounds like PACE is even that a little bit on steroids. It's quite amazing. Rob: The other thing I would suggest is what we're doing and what we're trying to do differently is again, you have this interdisciplinary team, but what guides it, right? So if you have one PACE program, the interdisciplinary team works one way. It's not like there's a standardized cookbook [00:16:00] playbook. But what MyPACE Health is trying to do is to develop an evidence based approach by which the interdisciplinary team works. And we're trying not only to put the individual and we call the people we care for participants because they choose to participate in the program. But not only are they in the center, but they're actually directing the care. And our focus is to identify what matters most to them, what their values are, and then what is an achievable goal that they feel they want to achieve. And then we try to align the care. Everybody on the interdisciplinary team looks at that goal, assesses them, and then our goal as a team is to come up with a plan of care That's goal concordant that they agree to, them and their caregivers, and then we have to implement it, and we're actually held to account to see whether or not what we say we're doing is being done by CMS and [00:17:00] the states. So it's a really, it's not only something that we say we're doing, we're actually being held to account, which I think is oftentimes very different than what you see in the healthcare space, you know, in the other different types of programs. Amy: It's like being a polyglot of the entire healthcare ecosystem with a tiny group of people who are high spenders. I mean, it sounds like you're collecting about, just south of about 120, 000 or so dollars per member per year. And that is then supposed to kind of take care of all of it. I have one specific question because you, you did hit on something that I'm always like, huh, you are receiving money for your particular organization through an MA plan and somebody else. Is it possible that any program, whether or not they're an MA plan, whether or not they're just a health system or just a regular old startup that just is not affiliated could possibly do this? Because this is a lot of money, but can this happen from a [00:18:00] groundswell that is disconnected from other entities? Eric: I think one thing just to clarify, so we are contracted directly with CMS and the state Medicaid agency. My place's corporate structure is a bit unique in that we are, we are owned by two non profit health plans. But to your question around who can do this, can any type of provider group, can any type of health plan, can any type of health system participate in this program? The answer is yes, but it does require an extensive application process that is dependent on both the state structure of how they run their program. So for in California, for example, it is more of an open RFP or open application type state where you can. identify or do a study of zip codes and suggest that based on our study, the population here has a gap in pace support. We believe that we can serve X amount of members or X amount of participants and then bid or submit an application to the Department of Health in California with that, with that kind of the evidence based approach to why you should be able to support there. [00:19:00] In other states such as Illinois, Ohio, It's a formal RFP process that is more similar to your traditional Medicaid program, where it's a rolling cycle of either every four or five years, there might be additional licenses up for bid for new service areas. So for Illinois, for example, the program has just launched in the past year. And that went through a formal RFP process where any type of organization could bid on the licenses and service areas being granted. But ultimately only four to five organizations were selected for specific service areas. And those organizations were traditional PACE organizations. So organizations that had PACE programs in other states. It was also included health systems. I know in Southern Illinois, it's OSF Healthcare, which is an established healthcare provider for Inpatient as well as home health. And then in the Chicagoland area, also bidders that were more traditional home health, nursing home facilities that wanted to join the program. So the dynamics and makeups of who the organizations are that are participated in the program are very diverse. It's more so [00:20:00] driven by the state calendar, the state licensing process, and then ultimately getting approval from both the state department of health and Medicaid, as well as CMS from the Alex: Medicare side. Amy, maybe you can answer this. So if in combination, Medicare and Medicaid are paying something like nine, 10 grand a month. What's the typical nursing home cost relative to that? Amy: Sure. I mean, it, I mean, it's interesting because if you're 24, seven in a nursing home, that's about 12 a month. So this absolutely sort of takes care of that south of that. Right. So you're definitely saving money by keeping people in the community. So there's no doubt that this sort of bodes well when you keep people in the community, it saves people money. And obviously, you know, the long term care impact on a state of keeping people in a nursing home who are on Medicaid is, is extraordinary. It's for some states it's up to 50 percent of their cost. So for these very specific patients who sound like they will do okay in the community, at least [00:21:00] initially, this has got to be a cost saver, Rob: right? Yes. Amy: Yeah. In Rob: addition, I want to add though, it's not just about the money, even though oftentimes it's about the money, right? Quality care. Let's talk about that. So to your point, Amy, and to your point, Alex, it's, you know, basically almost a wash. Although there's questions of that, but for the, let's say it's a wash. Well, what about the quality outcomes? Now, unfortunately we've not been able to do a randomized controlled trial now. Because how are you going to tell somebody who certifies for PACE and needs PACE that they have to be in a control group, right? But previously, when PACE became a certified model, it did pass definitely the stator, not only in terms of value, but outcomes. And when you look at previous studies, the hospitalization readmission rate for PACE population compared to Medicaid, Medicare populations was 19%.[00:22:00] This was not risk adjusted versus 22 percent people living. In nursing homes at life expectancy of two years less than those living in PACE programs in the community. Satisfaction rates for individuals, participants, and families, 95%. I don't know about you two, when I used to get evaluated on my satisfaction, if I was in the 70s, I was like in the top 5%, 90%, I did not believe it, but this is truly the case. And so when you look at overall, you know, the outcomes and functionality and the expense, there's no question. Oh, and the ER visits for this population, they're less than one per year per individual, where in a Medicare population. You're talking about twice, and if you have a population like this, it could be two or three [00:23:00] times. So, when you look at the overall dollars, it's been really hard to do that controlled study, but there have been studies that have compared PACE to Special Needs Plan, including Bitey SNPs, and there's no question, I haven't seen the entire methodology, but it's clear from a quality and value base, PACE, You know, does Alex: really lead the way. So Rob, one of the things you mentioned was participant recruitment and certification. So how does that work both from the perspective of the company, like MyPlace Health, what do you guys do to recruit like, or evaluate patients or participants? And then also from the participant angle, what if you are interested in becoming a participant? How do you even do that? How do you approach that? Rob: That's a great question. And that has been one of the challenges. You know, like why if this program is as good as we're talking about, right? Why is it like, why isn't it everywhere? What has been the challenge with growth? And that's one of the pieces. So think about the population [00:24:00] we're caring for. It's really the most complex. They're very oftentimes poor. They've oftentimes been marginalized. Many of them have been traumatized. So this is a group that, you know, and oftentimes there's an issue of equity or a lack of equity for this population. 70 percent are minority population in PACE. So this is a group that's very vulnerable. So CMS and the states have required that if we're recruiting, there's only certain things we can do. All the marketing materials have to be approved by CMS. If we change anything, they have to okay it. We're not able to advertise on TV unless it's approved. We can't put billboards up. So there's really requirements. People have to either find out about us by they're referred by either, you know, social workers, care managers, area agencies, home care companies, [00:25:00] individuals, because they know about it, or they find out about it through print, whatever. But very, very strict on what we can do. We can use brokers, but brokers have to follow a certain script. So, again, we're really been limited. The other thing is enrollment. We enroll, but there's only in most states, there's a specific time frame. You can only enroll on the first of the month. So you may have somebody who really needs programs that wants to sign up at the beginning of the month. And they have to wait 30 to 60 days sometimes to get certified in order to get in. So there's a lot of barriers. To the growth, where with other plans, oftentimes, depending on where they are, you can sign up and you can get into the plan, although with medicare advantage, there's there's restrictions. So, there are acts in Congress, there's the peace anytime act that would allow people to join at any time. Making it easier to get in. But again, there's just a lot of barriers that have been [00:26:00] set up, some of which make sense so that they will, this population will be protected. And Eric: I think it's helpful to add, because most of the listeners may be more familiar with traditional Medicare and Medicare Advantage and the size of those plans. If you think about a individual PACE program, so that's one PACE program with one center, the optimal or kind of that, that initial breakeven point that that census that you're targeting. Is 150 individuals. So we're not talking thousands. We're talking 150 baseline is when you really begin to be able to scale your fixed costs. And then the larger programs for one center can likely get between 400 to 500 census. So that's over the longterm between five to 10 years on a monthly basis, the growth rates that most PACE programs are targeting on this is on average, it's usually between five to 10 new members per month. So again, this is much smaller than your typical MA enrollment process where they're potentially collecting thousands of members between October and December of [00:27:00] every year during AEP. Alex: So it, let's say I'm the family member of a, of a senior who might qualify for this. What do I do? Do I go on Google and say, place programs near me and start calling, or is there a better mechanism? So I Eric: think to Rob's point, it's heavily regulated for good reason. Each PACE program does employ growth and outreach teams that includes individuals that are going to either community based organizations, faith based organizations, working directly with those community teams that might have relationships or be able to introduce individuals to the PACE program. Many individuals are referred through family members, or if they have neighbors or friends that are in PACE programs, that's another way to do it. But it is very, very human capital or human resource heavy where it is building relationships in the community with organizations, but also directly with the individuals that are interested in enrolling. Overall, the, the process to enroll, it takes several. Weeks, if not months, from education and initial understanding of what the program is, the full [00:28:00] scope of offerings that are included within the program, and then all of the different steps from your Medicaid certification to ensure that you're Medicaid eligible, you're nursing home eligible. So there's many steps to the process that require the PACE program team to really guide you through it, but also educate you on the process so that by the time you get to the point where you are ready to enroll, you're fully understanding what the program entails. For more information, visit www. FEMA. gov And that you are approved by the state and CMS level. Rob: There's only three, well, 32 states in DC that have PACE programs. And every state that has PACE doesn't mean you have access. Remember we talked about zip codes. You have to be within 45 minutes. So even if you want to have PACE, there may not be a PACE program by you at this point. And that's what one of our missions is to help scale PACE so it's accessible everywhere. Amy: What's fascinating about this is I'm, I'm just kind of taking note of all the amazing amount of services. I mean, you've got home health, private duty, you've got hospice, you've got other [00:29:00] specialists. So if I was nearby a PACE program that I know is coming, coming up in this, you know, Oh, there's like a lot of announcements. There's going to be a new PACE program. If I was a, an organization that could serve a PACE program, what do I need to look like? What does that need to entail? Is there a contracting process or do I need to be employed by, can you explain how the peripheral care circle works around PACE? Eric: So if we think about the wraparound partnerships that are available, it could be assisted living facilities, it could be skilled nursing facilities, it could be nursing homes, it could be your typical community based organizations. Anyone can be a part of that wraparound. In many cases, there will be a contract requirement to have in place from compliance and regulatory standpoint, that if you are either interacting with the PACE participant, there are expectations on what that interactions look like from a training perspective, but then also from your standard network perspective, there is sometimes a reimbursement component. So if we're working directly with an assisted [00:30:00] living facility, we may be reimbursing them for the lodging component, the meals component. They might be basically what the care plan defines for our particular participant. The PACE program may have outlined private duty or home health type care to be delivered at that assisted living facility. So there is that typical reimbursement mechanism in place to provide for direct services that those partners are providing. But in the cases that, you know, they have more of a referral relationship, there might just be other types of contracting components involved. Amy: Right. Cause they're not going to bill Medicare directly. They're going to have to send you the bill. Eric: Because we are the health plan as well. Amy: You are the health plan now. I'm a little confused using for people that must be confusing sometimes for people in the community that are not used to pace. Eric: Yeah, I'll add that is one of the major growth issues is that when you go to any types of these potential partners, whether it's a new market or even an established market like California, many of them may not be familiar with what pace is and they are fundamentally confused on how the reimbursement is [00:31:00] changing. We you're the health plan twos, but you're the one providing the care. So there is just general confusion across all these different stakeholders. Alex: I'm a little confused about housing. To what degree do you guys cover or not cover housing in various situations? Rob: So we're not able to pay for housing unless somebody's in a nursing home. Then we have to pay for whatever component of social security doesn't cover, you know, which is just a small amount. We are on the hook for nursing home. Housing wise, we can help individuals try to find affordable housing that we With the state, et cetera, and a lot of our population has been on house. So they may be in transitional housing. They have to be in some type of stable housing, but that cannot be paid for by the Medicaid dollar. What Eric was bringing up is we can pay. However. If somebody's in housing for services, home care services, cleaning [00:32:00] services, food services, transportation, those types of things like in an assisted living or supportive housing, if there are those services, we can supplement and pay for those supplemental services, but not for the direct housing costs at this point. Alex: Got it. So a patient could be paying cash for assisted living and be part of a PACE program, and the PACE program is picking them up every day. They're doing all sorts of activities and seeing their docs and then dropping back off at the assisted living. And there could be even services at the assisted living that the PACE program is paying for. Rob: Correct. So the previous PACE program I was involved with, over a third of our population was in assisted living. Amy: And Rob: so let's say it costs 45, this was several years ago, 4, 500, just throwing numbers out for them to live in assisted living per month. We would supplement that 45 and give the assisted living 1500, let's [00:33:00] say, to cover services, meals, two hours of home care per day. So yes, we can pay for that because think of it, right? This is a group of individuals that require home care, transportation, and food. They have food insecurity. You know, there's issues with social supports. That's why they're in the PACE program. They're all nursing home eligible. Alex: Yeah. Rob: All have. You know, activities, the daily living needs. Alex: So, you know, Amy and I are both ER docs or former ER docs. And very often somebody like yesterday looked relatively okay. But today they look like, Whoa. Bertha, our aunt Bertha cannot go home today, right? So she's in your daycare center today and she's declined and it's Friday evening. What do you guys do? Great question. Rob: That happens all the time. Yeah, I'm sure. It doesn't, not only Friday, it happened yesterday actually. So the nice thing about this is that we know these individuals. [00:34:00] Sometimes they feel horrible and they go to the emergency room and you see them and it's like, oh my gosh, and then we look back. It's like, no, they've done this before. Give them this. Watch them. You know what? Send them out. Either we can have a nurse come and see them on Saturday. We can talk to the family. We can arrange for other alternatives. Or let's say, They really can't go home. Well, then we can have them go to a nursing home for the weekend, and we can, you know, monitor them and then get them into the center and then determine that. The emergency room doctors, once they learn about PACE, are the biggest fans of PACE. I can't tell you how many of them are like, You do what? You're going to own this, you know, and I would sometimes call them back and say, yeah, that's why I, you know, remember, you know, Bertha. Well, guess what? She's doing fine. It's like, oh great. Thanks for the call, you know, because you're looking at them going, you know, I'm worried about this person, but we know them so well And we know what the capability is and i'll [00:35:00] say having done this for many many years And others having done this we're almost always on target. Sometimes, you know, somebody just can't do it But let's give them a chance if they want to go home and we can give adequate support. They oftentimes, as you know, will do better if they're in their home than in a, you know, ER or hospital setting. Amy: So this is an incredibly, as you said, resource intensive from a human resource intensive perspective. What technologies are being built around this? And I, and I asked this in so many different ways. Number one, it's operationally, but number two, this is a really interesting test bed in some ways for how older people who don't have many means are communicating with their provider, with each other, with their family members. How have you seen that evolve? In terms of a technology perspective, if at all. Rob: Yeah, that's a great question. Yeah, so we always look at the people, process, and technology. I would say, you know, just being a geriatrician, the care that, [00:36:00] and we've seen this over the years, it's high touch, generally low tech. I think the technology, though, is becoming much, much more prevalent because of COVID. You know, we didn't talk about COVID and the impact, but that was the accelerator for PACE programs. In COVID, people in PACE had two thirds less deaths and two thirds less hospitalizations compared to nursing home populations. And that's why now there's all this interest in PACE. Because who wants to live in a nursing home? Nobody does, right? But the technology is how you utilize the technology and so we are piloting and trying and actually our model is to develop a virtual home that becomes an alternative care site where people and there's these older adult friendly tablets. That people use them. We use them during COVID where people were given tablets so they could communicate. So technology is being leveraged, but it's a means to an end. It's not the end [00:37:00] to itself. So monitoring, remote monitoring, check ins, people with behavioral health needs that have anxiety that need to talk to somebody, right? There are ways to leverage this. So we're trying to figure out how to integrate technology. AI is also another opportunity to help look at old records, try to identify what we're doing or trends. There aren't things that we're applying, but we're being very cogent of how to utilize technology. But all the things you're seeing. The nice thing is if we employ technology, because we're total cost of care, we can actually do a value proposition and see what the ROI is and we can do it in a holistic way. We're starting new, but we're being very intentional. But technology is going to play a very, very big role, but we want to implement pilot it and study it and see really what the holistic, not only what the outcomes are the quality, but also satisfaction and how we [00:38:00] integrate it. So it does become a burden, but it becomes part of the process. Alex: It's so interesting for me because, you know, when you look at other forms of risk bearing models in healthcare, like the ACO model, the percentage of the total cost of care that's at risk, either up or down risk is so small that it doesn't leave enough room to actually have, like, have financial clay to try things out. Right. But when you're taking full total cost of care, like you guys are. There's a lot more space, financial room, I think to, to try it. Like if there's some service that costs 10 PM, PM, it might be worth it for you guys. Right. Whereas for an ACO, that might be way too much. So I, there's one piece that I S I I'd like to understand a little bit better, which is how do people leave pace? Do people graduate? Can they opt to leave? And is there the option for the PACE program to force a participant to leave? And how does, how does that all look? Rob: So people can leave [00:39:00] PACE. They can leave voluntarily anytime. So if they decide to leave in the, whatever, after the first of the month, we are still obligated to care for them and meet all their needs up until the time they disenroll. We're also obligated to ensure that their care gets transitioned well. It's not like we can just, you know, say, okay, well, we're done with you. So we're still on the book. And again, we really try to do everything possible when we understand people have choices, if they decide to leave, you know, that's their right. And we try to make certain they understand the consequences. They can always come back by the way. So it's not uncommon. We will have people leave and they say, you know, Hey, really didn't appreciate what you had. I don't know what the percentage is, but it's not insignificant or voluntary disenrollment. So there's involuntary disenrollment. Somebody dies or they lose coverage, their Medicaid lapses, or they don't apply. So there's other ways people get removed or they move out of the service area. Or they want to be in a nursing home and [00:40:00] we feel they could provide, you know, be given care. That's more of a voluntary thing, but they can just say, no, I want to, I'm staying in the nursing home and it's like, well, you know, no, we can do this. So they just may say, I'm done. I'm disenrolling, but the voluntary disenrollment rate is incredibly low. Remember I said the 95 percent satisfaction rate. I think if I'm not mistaken, I haven't seen the latest, but it's 2 percent per month disenroll voluntarily or it's 2 percent over the course of the year. So it's pretty unusual. And a lot of peace programs. Individuals are going to disenroll. We try to understand what can we do? Can we meet them halfway? So we really are working to keep people in. Sometimes it's just not a good fit. But in general, the disenrollment right now, I would say in California, it may be a little higher. There's a lot of reasons for that. I don't think it's really the PACE program. I think people are inundated with so many different things. They hear so many, they talk to their neighbors, whatever. Why are you in that program? Oh, I [00:41:00] got, I get this benefit card, but they don't see necessarily the whole picture. So we work very aggressively to meet people where they are to understand and make certain they get handed off, but we try to keep the doors open, but voluntarily, very small percentage, Alex. So it's, it's been, and I couldn't believe it, but it's really true. It really, we do really meet people where they're at. Eric: And I wanted to just quickly emphasize that if you think about the mechanics of if someone were to communicate, you know, I'm interested in disenrolling or leaving the program. Rob had mentioned the 11 different disciplines that are represented. All 11 of those individuals have a direct relationship with that individual. It could be the driver that's picking them up on a weekly or monthly basis. It's beyond just your, your typical primary care physician relationship where it's the PCP and the individual. It's a social worker relationship. So it really is less of a, like a sales pitch to why they should stay, but more so on a personal level to explain kind of, you know, what the benefits have been for the program and it really is that participant and IDT relationship that ultimately drives [00:42:00] that low disenrollment rate. Amy: Okay. This is kind of amazing. I, I always like to take a minute and like go back and forth and just be like, do I understand this? So, in this podcast that we have, we talk about all these different parts of Medicare, and I have been one of those like, oh, there's a Part A, there's a Part B, there's a Part D, that's original Medicare. And there's MA, and that's Part C. But there really is this other fifth form of Medicare at this point, or other type of insurance that you can get through the federal government. So it sounds like there's A, B, C, D, and PACE, all inclusive of all the other ones, all in one little bucket. Alex: Well, kind of like hospice, right? Even though it's under Part A, it really is its own capitated model, and this is its own capitated model. Amy: It is, but true. But I sort of feel like the way that things get billed is very different. With Part A, you were taking all the Part A benefits for hospice, and then, you know, Part B, then, you know, they sort of sometimes send you the bill. But this is actually, it's literally own [00:43:00] everything. Rob: Yes. Amy: That's right. Own everything. It is not part A, it is not part B, it is not C, it is not D, it is PACE. Eric: That's exactly right. And if you think about, so part C is most comparable in that it has Medicare Advantage on one side of the spectrum, and then it goes all the way to your D SNP, your FITE SNP, your HEIDI SNP plans. PACE is then off that spectrum, moving us further to the right, if in the, kind of the, the analogy there. To your point, it is truly its own separate part, not comparable to any of those previous parts within the Medicare spectrum. Alex: Are you guys generating claims for either data or quality reasons or any other reason? Eric: Yes. And that was one of the pieces that I wanted to add to the technology component. So I think from a participant facing technology component, we are limited where we're doing small pilots, given who the individuals are, but on the health plan, business side, provider group side, all of the opportunities that AI, other types of technology are playing in large health plans, large health [00:44:00] systems. We are testing those and working with those. So from a data and analytics standpoint, on our health plan side, we are running claims analytics to try and understand what are the trends that we're seeing from different care plans. From the provider side, we're trying to look through the EHR, do medical record reviews and understand what the patterns are. So all of the types of things that are being tested, I would say, in the larger commercial Medicare Advantage spaces. They are being done at the pace level, just on a much, much more granular scale. But at the same time, if there are opportunities or performance improvement opportunities identified within the health plan or the provider group side, those things are raised and worked not only with IDT, but then also from an educational standpoint to try and understand, Rob: Hey, Eric: is there areas of opportunity within our internal team? Is there opportunities with our network that we could potentially provide additional communications to the ER teams that we work with to say, Hey, when this individual shows up, we would prefer that you call or connect directly to our system and be able to message with us. So we're exploring all of those different opportunities. And it is a lot of the areas that are occurring from an innovation standpoint [00:45:00] within the pay space across the country. Amy: My mind is still blown. Okay. So let's go back to 120, 000 a year. Cause I'm thinking about all this stuff thrown in and I, you know, if we took it, it's sort of like a, a BOGO model, right? You like buy some, you get a lot of other stuff kind of at a very discounted rate because it's highly monitored. If we were to take that individual, their total cost of care and take them out of the PACE program, is it thought to be? double of what a PACE program is able to achieve. Cause you had mentioned hospitalizations as a driving force, you know, decreasing that by 50%, even by a third. ED visits on home care. You're now sort of taking some dollars out of what would be a cost if they weren't going to adult daycare. I'm just sort of thinking about all these different costs. I mean, this is potentially saving 200. I mean, I know this is, we're supposed to be talking quality of care, you know, good care all. I get that. But in terms of cost savings, this could be saving per individual 100 to 200, 000 per year in a total cost of care. [00:46:00] If you individually priced everything out, it Rob: could be, you know, it depends on the crux of the matter. It's very hard to study this, right? Because that would be the definitive study. And that's why we've been sort of stuck. Like, how do you study this? That the problem is that individuals, because they're getting the care and there's a lot of support, yes, it is going to cost less per individual. However, some of these individuals may pass much sooner. Remember I said, two year life expectancy. So people are living longer, more expensive. So like, how do you really compare that? I would say though, you know, in general, MA plans, Medicaid, all try to decrease hospitalization rates. Our average hospitalization rate for the most complex is about 500 per 1, 000 per year. That's pretty damn low for, you know, this population, right? ER visits, we talked about, you know, less than one per person, you know, 0. 8, 0. 75. So, if you just look at those skilled [00:47:00] nursing facility, even though they're all nursing home eligible, only 5 percent end up living in nursing homes. Because we can't provide the care in the community. So, to your question, Yes, it's not only the fact of the cost, but what about all the time for all the home care agencies, the care coordination, nurses, providers, trying to help people, and they're sliding down the slope and dealing with things in the last, remember, last six months of life. You know, 50 percent of dollars spent that's just wasted first in this population. We're trying to wind their goals of care. So even in the end of life, we're not spending that type of money. So the definitive study needs to be done. It's just not there yet, but we're doing this. It's very clear. It is lower cost and better care. Amy: Amazing. It really is. It boggles my mind because I, I love to, you know, Oh, I'm in post acute and I'm like a subject matter expert and all these things, but pace has forever [00:48:00] eluded me. This is really great. Thank you so much for all of this. I'm not, Alex: are you trying to close up? Cause I still have a few questions. I'm Amy: not, I am keeping going. I have five more questions. What's wrong with you? I, okay. I want to go back to the nursing home eligible portion. Are you saying that. The folks who are in your program really are eligible for 24 7 care. Rob: Yes. Amy: Does that mean that PACE is paying for any time that that person is not in adult daycare for them to be receiving some sort of version of home care or supportive care in their home? Rob: No. Amy: I see. Okay, thank you. Rob: But the question is, how do we do that, right? Amy: Yes. Rob: So, let's talk about an individual, right? There's the dignity of risk. Individuals, if they have capacity, can make the decision of what they do and do not want to do. Now, somebody may need 24 7 care. If they have a family, the family can help, but they can't do 24 7. But they can come into the [00:49:00] center. If they really require that five days a week, we can have home care services come in. They have a medical alert system if they get into trouble and in general We know that people living in their homes that are comfortable that are Sort of older adult friendly, right? So they're set up as such. They can be left alone with appropriate monitoring and support 24 seven. So not to say everybody needs 24 seven, but those that, as they're going down the slope, they're becoming more and more dependent. If their goal is to stay home, we can increase home care services. We can bring them into the center. We can go out into make home visits, you know, like we did in COVID. We became a home based program pasted during COVID. So there's a lot we can do based on what the goal of the individual is and the types of supports. If they really do need the, however, you [00:50:00] need to your point 24 seven, and we can't do that. And their goal is to, you know, they want to stay from a longevity, they still want to continue on, they may make a decision to go into long term care and we would then move them in there. But they still could come into the center, but generally speaking, they're that dependent. R: And didn't, it would be very difficult. Alex: I think that's a brilliant phrase, Rob, the dignity of risk. I love that. You know, one of the toughest things as an ED doc that I experienced repeatedly was this expectation that folks had that they could do whatever they wanted from an unhealthy perspective, eat whatever they wanted, not exercise. And somehow it was on us and the system to provide them a hundred percent guarantee of no risk and no complications. And it's, it was something that just never like sat well with me that that's crazy. Right. The risk is an inherent part [00:51:00] of our lives, of our health. And we need to take some degree of ownership over that. And so anyways, I think that's a fascinating point. I want to touch on hospice a little bit, because I know Amy has a lot of experience there and I don't, I'm trying to understand how does that fit in here? So are there times where a participant is in the PACE program? And then you say, wait a second, this is not a good fit. You should actually leave the PACE program and be in regular hospice. Or do you provide hospice services as part of the PACE program or how does that all work? That is oftentimes R: a confusing point. So we provide end of life care services in the PACE program. As a matter of fact, remember we said we're all inclusive and comprehensive from beginning to end. Hospice is a separate, as we talk about, separate Medicare program. You cannot be enrolled in hospice. And enrolled in pace, right? The PACE program. Remember we have a small number of people, small number of providers, [00:52:00] you know, to your point, Amy, 24 seven, we can't be there in the middle of the night, we just, and you know, it's impossible. So what we can do though is, and what we are doing, and a lot of programs are doing this. Is you can be affiliated and have a contract, a vendor of hospice can be a vendor to a PACE program. So we actually have a contract with a hospice agency and we pay them when somebody goes on hospice. Now what's really cool about this, we could have somebody enrolled in our program getting hospice services, but we pick from the menu of hospice what we don't have the ability to fill, overnight coverage. Weekend coverage, chaplain services. For example, if you're starting out, we may not have that spiritual services. So we can pay a per member. The way we've done is set up a per member per day reimbursement. It's not the full hospice, but to bring hospice in, even if somebody's going [00:53:00] through sort of treatment, that's palliative, that's aggressive, they could still get us the services. In spite of the fact that they're having treatment to ameliorate a condition. So that's the way it is. We can work with hospice, but they cannot be enrolled in hospice and PACE. If they want to be in hospice, they would have to disenroll in PACE. And it doesn't happen often, but it sometimes does. And then they can enroll in the hospice program. Amy: You're bringing in the expertise of hospice where there's gaps in the PACE program. R: And to that point, there's something called the final rule that's updated. Every year, there's updates in terms of what we have to do. This past year, there's been an update that we must contract Remember, we talked 77 years age, three years life expectancy. By definition, Amy, right? And Alex, we're a, you know, a palliative care program. These are people with serious advanced illness. However, CMS said, no, no, no, no. You need to contract with a [00:54:00] palliative care certified provider because some of the programs would put somebody into a palliative end of life program without having a meaningful discussion. And so they were really concerned that people were being denied care. And there was obviously examples because CMS doesn't do this willy nilly, but there were unfortunately a small number of probably organizations where this was happening. So by definition, even now, we just have to have a contract. We don't have to use a palliative care. So, if we have a hospice contract, we already have the palliative care built in, but to your point, Alex, it's filling in the gaps and, you know, again, depending on the organization, the state, whatever, it's better care and they integrate into the interdisciplinary team. But everything goes through, we have the plan of care and we work with hospice, make it worth their while. And also to help improve the outcomes. And I think we actually did this when I was in Massachusetts working with [00:55:00] my organization. And actually we did a ROI and it was very cost Eric: effective R: and guess what, satisfaction was better. Eric: And on that satisfaction point, and Amy, with your background, I know you'll appreciate this. How many times does an individual go into hospice with a week, five days, two weeks left to live, and it's just too late because of how in depth the relationship and understanding of the care plan is from the PACE organization. Dr. Rob, other members in the IDT can identify five, six months in advance that this person is really deteriorating. They need hospice services now. And that allows that person to have those types of services for an extended period of time, as opposed to that acute period where it's. Five days left in their life, and that's all they get for those types of services. Amy: Oh, absolutely. I mean, the engagement that precedes a patient's death is so highly correlated with how well any organization is perceived, be they an organization that's palliative or hospice or way upstream. I mean, if you have a longstanding relationship and are not just like, you want some morphine and a chaplain maybe to come and [00:56:00] maybe a nurse a couple of times and then it's over. I mean, the patients, the family members. Are not getting the full flavor of whatever services can be provided through the hot. I'd say the R: other piece, though, I want to point out the human side of this because we had. Circumstances that I also, unfortunately, was involved just because you have hospice doesn't mean it's going to be, you know, it's going to all work. However, oftentimes people feel they don't need hospice services. Oh, we got to cover it. And then. When that last 24 hours of comes, we say, look, you don't have to use it. We're going to just have it there in the event something goes wrong. And so I think having that backup gives people the assurance that even though they think they can do it, you know, watching a loved one die. Is a very difficult thing, no matter how well you think. And just because you've been through a once doesn't mean you're going to do it well the next time. Right. I mean, you, we all know this. So I think that piece of that support and to Eric's point, we can do this very upfront, you know, so [00:57:00] it's not on average, you know, whatever, 11 days, seven, whatever the number is these days, and maybe that's even a lot, but really get people so that they can get closure in their life. They can ask for forgiveness, you know, make the, heal those broken relationships, wrap up loose. And so when they leave this, this earth, they leave it in a better state of mind and at peace. Amy: And it's a unique skill set, right? If, if somebody who works for P. A. C. E. That may have been a social worker in a hospital doing discharge planning or a social worker who worked in the community. This is a unique job to be a social worker in a PACE program because you are taking people who are all the way through almost to the point of being a hospice social worker in some ways. Eric: Yes. Amy: Talking about goals of care and existential things and non existential things and reality checking and you know, all of those things. This is a very unique job. How do people get trained to do this? R: Yeah, that is such a great point and, you know, I'm glad you brought that up. Obviously, you [00:58:00] understand what social workers do and I think it's probably with your hospice background. They're really advocates for the individual. They make certain that the individual's voice gets heard. You know, our social worker at our PACE program, the ones I've worked with, were incredibly engaged and really understanding. And so some of it is understanding the role, but being empowered for the social workers to do the job that they know how to do, that they're actually supported to be the advocate for these individuals. And so like, oftentimes they'll push back. Like the thing about, remember, we talked interdisciplinary team. Well, even though I may be a doctor and a senior doctor, I'm only 10 percent of that team. I'm taught no more than 10 percent of the time. That social worker is an advocate and we have to make certain that what they're advocating for is we're addressing and then we have to go back to the individual to validate it. So I think one is you have to have the [00:59:00] ability to do this and willingness, but it's also the support of the IDT to ensure that what they're being, you know, that they're being listened to and supported. And I think It's, it's the part of the secret sauce. Alex: I'd love to understand a little bit more about this human component, because we, we spent a lot of time on like the operations and the finances, which I like to understand too, but talk to me a little bit about joy and delight and fun and how we make these last few years of people's lives more beautiful and touching, and is there anything special in the PACE program that helps foster that more than other models? R: That is a really great point and question. And, you know, as you were talking about, I'm just sort of getting the chills thinking about all of the, all the stories. I would say the joy is, you look at this population, many of these individuals have had very little joy, if any joy in their lives. A lot of times, these individuals have incredible [01:00:00] stories, trauma, etc. Their joy may be just being able to have a day where they're not, in distress, or they have more better days than bad days. And it may not be joyful. Some of these individuals, they're just not having anxiety attacks or the anxiety is not as much, but for the most part, even those individuals become attached to the PACE team. As Eric said, 11 people know intimate details. They bond with individuals, and I will tell you, the PACE staff become part of their family. They become part of the PACE family. And again, here you have a family that is accepting of who you are, where you've been, and we try to understand, remember we talked about what matters most, and what their goal is? Our job is to help you reach that goal. And if your goal is to be independent, well, and you stay independent in your home, and you're going to do that through activities, you're going to [01:01:00] do things you want to do personal connections, people end up realizing and they live long. Why are they living longer? They have a sense of purpose. They have a sense of belonging. It's incredible, but we've had many testimonies. We have, you know, we just opened 67 months ago. The stories we're getting from individuals have how their wives have transformed because they people that care about them that actually meet them where they're at. I mean, we have people that came in that literally just tell us thank you and are crying because they've not had this type of care ever. And so not to say we have all those types of stories, but in general, those stories are very common. And that's why the satisfaction rate is so high because we are able to help people find their purpose and their meaning and what is really important to them. That's where we're trying to build. This is really. It's about you. How do we as a team help you reach your goal? Where does that happen? And by the way, has [01:02:00] your provider or have, you know, do we ask normally, what matters most to you and what's your goal and what can we do today to help you reach that? Think about that. That does not happen. So how would you not have joy if we're really working for you to do what's most important for you in your life? Wow. Alex: It's almost like adoption at the end of life instead of adoption at the beginning of life. Correct. That's Amy: beautiful. Well said. Wow. Alex: Well said. Amy: Yeah. Wow. Alex: Wow. I'm, I'm blown away. Amy: Right. I'm blown away that you were like, I was wrapping up. I just keep going back to like, I'm blown away. I'm blown away. Yeah, Alex: it really is. You know, it really is amazing that we have so much experimentation. You know, the U. S. healthcare system gets so much criticism. But there are lots of different models. There are experiments going on, you know, in our state of Maryland, there's this global budget revenue model for hospitals to experiment with. I mean, it is really cool to see that people are trying different things and learning [01:03:00] and seeing what works. And I just hope that. Amazing models like the PACE model can get the funding and infrastructure and attention they need to continue to evolve and grow because this is amazing. I'm blown away. Rob and Eric, thank you so much for teaching us and sharing all of this amazing information with us. R: Thanks for having us. Yeah, Amy: this is great. Thank you again. Wow. Wow. Wow. Not why, why, why? You have been listening to the Mastering Medicare podcast. Visit MasteringMedicare. net for show notes, additional episodes, and valuable resources.