7.4 What strategies other than PACE can generate a MediCaring Community?

Any payment arrangement that will leave savings with an entity that can invest in community services is one that can anchor a MediCaring Community, with adjustments in regulations and patterns of care. PACE is the most appealing, because PACE programs already have so many of the key elements in hand. Traditional Medicare fee-for-service is unable to generate a MediCaring Community delivery and financing arrangement, because this payment pattern cannot generate revenues through savings.

An ACO could decide to sponsor a MediCaring Community by accounting for frail elders in a defined geographic area separately from their overall business and establishing an integrated clinical and LTSS delivery system in that community. The savings harvested from avoiding low-value care would be diminished by the share that goes to Medicare and by whatever was retained by the sponsoring ACO. Savings (or cost overruns) are calculated long after the fact, so the delay in having savings to work with will require more initial investment in start-up costs. The ACO clinical services would need to implement good geriatric practices, including for frail elders to have adequate care plans. The usual ACO has little track record to build upon for constructing a Community Board and for collaboration with LTSS providers, but their communities might have strengths in these areas. ACOs also have substantial barriers to establishing dominance in an area and quality metrics that are not aligned with the priorities of frail elders, so both of these would need accommodation by CMS. Finally, ACOs often have quite limited expertise in geriatric medical care and would need to build strong provider teams quickly.

A managed care organization (MCO) likewise could sponsor a MediCaring Community, parallel to the ACO strategy above. The MCO would collect its PMPM and savings are the profits in hand. The challenges in developing clinical expertise, care plans, connections with LTSS providers, and a Community Board will be fairly similar to the ACO issues outlined above. MCOs also face the challenges of the star rating system for quality. Excellent frail elder care will mean not complying with many of the standard quality metrics, like tight control of diabetes and hypertension and screenings for cancer. This will bring down the MCO star rating, which has a substantial impact upon their Medicare reimbursement. Also, MCOs are not allowed to offer some services to only some patients; they must offer the same package to all beneficiaries. So an MCO cannot offer a MediCaring Community package in one area and not in others without a waiver of this requirement.

Other platforms are plausible but more of a stretch—IAH, hospice, and even bundled payments for a year-long or life-long bundle for persons with complex illness or frailty. These other approaches have more challenges initially than working first with expanded PACE programs. PACE has more of the essential elements in hand and much of the appropriate philosophy. PACE has a good reputation to build on, and most of the programs rooted in their communities. Table 7.2 below gives an overview of the comparison among potential delivery and payment platforms and makes it evident why PACE expansion is so appealing.

Table 7.2: Attributes of Potential Sponsors of a MediCaring Community