Quite simply, Medicare leaders, or the Congress that can direct CMS to take an action, have to enable the first group of communities with good PACE programs interested in expanding PACE on the MediCaring Communities model to get underway. That is the essential element.
Calculating the Medicare and Medicaid payment rates will require some initial and repeated attention in order to estimate the costs in “usual” care, which is an uneven and often imprecise standard. Whether to cap or reinsure for outlier individual costs, whether to work from a historic baseline or to build in frequent updating, and how to deal with the overlap of other innovations in service delivery and finance will require specification. The negotiation between willing community leaders, CMS, and state Medicaid offices, working in the public interest will yield adequate resolutions.
Another critical element is the current drive for sharing the savings with the Medicare Trust Fund. In most cases, the savings shared with the program have been perceived to be incentives to the professional providers, not an investment in ongoing improvement activities or in the well-being of the public served. This framing is obviously out of step with a plan to expand PACE and build a MediCaring Community. The early sharing of savings that is required of ACOs and BPCI conveners is not optimal for supporting the MediCaring Community pilots. The new model has startup risks and costs. Rather than taking back the savings quickly, CMS should encourage the ongoing investment in reform and in meeting initial expenses. In order to learn to provide efficient and effective services to frail elderly people in communities as quickly as possible, we recommend leaving the savings with the programs for the first five years and then reconsidering on the basis of evidence.
In addition to setting payment rates, Medicare should waive certain of their current regulations, especially those that make it time-consuming and burdensome to enroll in PACE. The current quality measures need to align with what is special in PACE.