Eli's Hospice Insider

Influx of for-profit PACE providers may be in the works.

While some parties are leery of PACE changes, others urge CMS to make even more revisions to the program.

When the Centers for Medicare & Medicaid Services changed PACE rules last year to allow for-profit PACE organizations (POs), investors sat up and took notice (see story, p. 11). And one of the big ideas for streamlining PACE care provision — and saving more money/enhancing PO profits — is relying on telemedicine to monitor PACE patients’ care instead of traditional in-person services at the PACE center.

“We understand the need for regulation and strict criteria when caring for seriously ill beneficiaries,” said the National Partnership for Hospice Innovation in its comment letter on the PACE proposed rule. “In hospice, we have seen the proliferation of unscrupulous providers and we do not want to see that experience duplicated in the PACE arena.”

Patients voice similar worries, according to a Kaiser Health News story that ran in the New York Times. One PACE user expressed concerns that new investors will skimp on what outsiders might view as unwarranted services. Another user’s grandson commented that “[a]nytime you involve money, there’s always the concern for greed, especially with the elderly.”

Patients aren’t the only ones concerned. “I’m not wild about every knucklehead running around trying to do PACE,” said former CMS Administrator Tom Scully. “I would rather keep it below the radar,” he told the newspaper.

“For years we were pariahs, and no one wanted anything to do with us,” said Julie Reiskin, executive director of the Colorado Cross-Disability Coalition, a non-profit group that advocates for people with disabilities, many of whom are eligible for PACE. “Now that there’s money involved,” Reiskin told the Times, “everyone is all interested.”

Revamp Is Necessary, Commenters Tell CMS

But while some are worried that PACE program changes go too far, others are worried they don’t go far enough.

PACE is underutilized due to the high barriers to entry to the market, the National Partnership for Hospice Innovation maintained in its comment letter. “These barriers have prevented many of our colleagues from being able to become PACE providers and we applaud CMS for moving towards the expansion of the program through proposing some regulatory flexibility,” said NPHI, which is a coalition of non-profit hospice providers.

In fact: “We do not feel that the proposed rule goes far enough in easing the burdens of the application process,” NPHI insisted.

The Home Care Association of New York State, which represents PACE programs as well as home care and hospice providers, agreed in its comment letter. “If PACE is to continue to exist, increase its membership, and meet changes in the health delivery system, PACE needs to be reformed,” the trade group told CMS.

NPHI urged CMS to streamline the application process and align state and federal deadlines to avoid lengthy delays.

NPHI and HCANYS both expressed strong support for the proposed change to allow nurse practitioners, physician assistants, and community-based physicians, in addition to PACE physicians, to be primary care providers (PCPs) on the PACE interdisciplinary team (IDT), the groups said in their letters. “Currently, more than half of all PACE organizations use nurse practitioners as PCPs on the PACE IDT under waiver authority” already, HCANYS noted. “Nurse practitioners have been very effective partners in this role,” and the trade group expects PAs to be as well.

NPHI urged CMS to “fully integrate community programs like PACE and hospice into discharge planning and other long-term care diversion initiatives,” according to its letter. And the PACE program should take a page from hospice and home care’s book and move even further away from the restriction of the physical PACE center.

PACE Face Time Important

Not everyone is on board with the idea of decentralizing PACE care, however. “Socialization goes a long way to improve the health of the participants we serve,” said Kelly Hopkins, president of Trinity Health PACE, a non-profit health system that operates PACE centers in eight states, according to the Times.

Meanwhile, providers also praised CMS’s move to loosen up personnel qualification requirements. NPHI lauded the “added flexibility” of changing the requirement to hire staff with “one year of experience with a frail or elderly population,” which “had previously excluded staff with experience in hospice. NPHI members believe that the experience staff on hospice interdisciplinary teams (IDT) can and should be transferrable to PACE teams.”

However: “I would suggest that these qualifications be modified to state that the experience be in a professionally supervised setting,” suggested one home health agency commenter from Michigan. “I have managed home health agencies for over 20 years. In times gone by, I would hire staff for our private duty services with similar qualifications as are proposed. I found that those who had a year of experience in setting not supervised by a health care professional, or who only cared for a family-member, did not have adequate training or decision-making skills to care for the frail elderly.”

The home health commenter also asked CMS to require frequent on-site visits. “The vulnerable population served deserves on-site review at a frequency of at least every three years, since off-site review of documentation can be skewed by profit-seeking organizations with good writing skills.”