By Rose Hoban
It’s tough to put in place all the resources to help seniors stay at home as they age, but Kim Schwartz, head of the Roanoke Chowan Community Health Center, felt like she had an answer for many of the folks who live in rural Hertford County, where she works. She wanted to create a PACE program.
PACE stands for Program of All-inclusive Care for the Elderly. The program allows seniors to spend several days per week at a senior center, where they get meals, have activities, and receive all their health care. Participants also get some help at home, perhaps meals or medical equipment to make staying in their own houses easier.
When Schwartz got her idea, about four years ago, she realized her clinic was too small to cover the many costs of creating a PACE program that would cover many counties. So she partnered with a larger neighbor, the Sentara Health System, based in southern Virginia.
“We contacted them… they said ‘we’ve had some conversations with North Carolina, what if we did it collectively?’” Schwartz recounted. “They showed us a map. They knew they needed partners. It came together serendipitously.”
The North Carolina Department of Health and Human Services green-lighted the project, telling Schwartz their letter was about to be approved.
Months passed. Then the word came that no new programs were being approved.
The state had put the brakes on any new applications. Since 2014, there’s been a moratorium on creating new PACE programs and admissions caps for existing ones.
North Carolina has one of the fastest growing populations of seniors in the country, and many don’t want to end up in a nursing home. That’s where PACE programs come in.
The programs are targeted at seniors who are frail and who are low income, frequently known as “dual eligibles,” because they’re eligible for the federal Medicare program, which covers people over 65, as well as Medicaid, which targets the poor.
“Between 92 and 95 percent of our participants are dual eligible,” said Linda Shaw, who runs the North Carolina PACE Association.
The first PACE program opened in Wilmington in 2008 and now the state has eleven programs, serving about 1,800 people. All the programs are clustered in urban areas.
At first glance, the numbers don’t necessarily show that PACE saves, costing about the same annually as nursing home care. Detractors say that not every PACE participant would be placed in a nursing home, so it’s money that would not be spent. But Shaw said that when you take all of the PACE expenditures into account, the programs probably save money for both state and federal payers, because the programs assume all the financial risk.
Covered costs include drugs, transportation, medical equipment, hospitalization, specialty care, dentistry, even, if necessary, the cost of nursing home placement, all at a set cost per month to the state.
As Shaw wrote in a document to DHHS in 2013, “The provider has a cost stake in making sure that health costs stay under control. While providing all that is needed, there is a disincentive for providing unnecessary and overly expensive services.”
In that same report, Shaw presented numbers showing that PACE saved the state as much as $18,400 per person who did not go into a nursing home.
“We keep people healthier and happier longer,” she said in a recent interview.
According to DHHS numbers, PACE has come in under the allocated state budget for the past two fiscal years, and as of Nov. 30, was under budget for FY 2016-17 as well.
For the past two years, existing programs could only add three new participants per month. No new programs have been able to get started. It’s slowed things down to a crawl.
“Nobody is hitting the cap,“ said Shaw. “What I was told was that if anyone does hit the cap, that they can come ask me and I will see if I can get [DHHS] to extend the enrollment. So far we have had one program that was able to do that and they were able to get that extended for one month, so they were able to get an additional three people.”
Shaw has been talking up PACE to anyone who’ll listen.
At an event this past fall at PACE of the Triad in Greensboro, Shaw brought several state legislators, along with local Congressional Rep. Mark Walker. Shaw gave a half hour-long tour to former HHS Secretary Rick Brajer and Medicaid head Dave Richard, both of whom made positive comments.
But, when asked, Brajer was unwilling to commit to pushing legislators to lift the moratorium.
Pick up the pace?
As they prepare for the year’s long legislative session, some lawmakers are starting to warm to increasing the number of PACE slots.
“It’s a very good alternative to high-cost inpatient care in other sites,” said Rep. Donny Lambeth (R-Winston-Salem), a co-chair of the Joint Legislative Oversight Committee on Health and Human Services. “I think we have to figure out what’s the role that they play. And I actually think they play a big role.”
Others are less convinced.
Sen. Ralph Hise (R-Spruce Pine), who is a senate co-chair of the oversight committee, argued the savings are not really there, because not every PACE participant would have ended up in a nursing home.
Even under a new administration, DHHS remains non-committal about when the moratorium may be lifted.
“The state continues to view PACE as an important option in the long-term services and supports array of services and is carefully reviewing all options for supporting Medicaid beneficiaries who meet nursing home level of care,” a department spokeswoman said in an email this week.
“At present we do not have an ETA on the release of [a request for applications] for PACE expansion.”