7.7 After the first set of PACE expansion initiatives, how might MediCaring Communities develop?
The first set of communities should probably include about twelve to twenty communities. They should be connected by an improvement collaborative and technical assistance, both to accelerate their progress and to build tools and advisories to help the next set of communities. Some of these will be convincing successes within two years, and the insights from studying their progress should help shape the next cohort. Assuming that the trend is strongly favorable, the next cohort should be 50-75 communities starting about 2.5 years after the first cohort, and they should have the benefit of established pathways for clinical care, Community Board activation, savings calculation, expansion timing, and a dozen other elements of the work. A higher proportion of them will succeed convincingly within two years, and again there should be technical assistance and collaboration that builds the expertise to succeed more quickly and reliably. Depending upon the enthusiasm of communities and the results to date, a third cohort starting about 5 years after the first cohort would include perhaps 250-300 communities, and at this point, the demonstration would become a regular part of Medicare with conditions of participation and established quality reporting.
Assuming that the first cohort succeeds and attracts attention, during the second cohort, other kinds of health care providers will probably demand to expand the participating platforms. Some will want to establish new PACE programs that immediately expand PACE and rapidly take on the responsibilities of MediCaring Communities. Some will want to build MediCaring Communities on an ACO or MCO platform, which will require new waivers and demonstration authorities. Some communities that want and need a MediCaring approach will have many challenges to organizing any Community Board. Some may want to organize MediCaring Communities as a for-profit endeavor. Much of the evidence that will guide policy at that point is yet to be garnered in those first pilots. With the advantages of established methods and metrics, entirely new PACE programs can probably come up to speed quickly enough to allow them to be expansion population providers from the start. Adapting to ACO or MCO financing is easily done with a few critical waivers, if management and clinical leaders are committed to the clinical service reforms and the community can generate a strong Community Board. As MediCaring Communities become more widespread, policy will have to tackle the more challenging communities, and having technical assistance and collaboration would help achieve successes. The characteristics that make a community challenging for a MediCaring Community program are not those that usually make communities vulnerable, such as poverty or minority race and ethnic groups. Instead, MediCaring Communities are predicted to be more difficult in communities that have little tradition of joint action among coalitions, that have densely overlapping medical care and aging network providers, or that have very large or very small populations.
If for-profit management is to be allowed, the returns on investment probably need to follow a social impact bond structure, since having investor interests compete with the needs of elders and the interests to protect the Medicare Trust Fund and public financing generally would be destructive to public trust and potentially raise costs.
The first five components of MediCaring Communities would continue into the future: targeting frail elders in a geographic community, generating individual care plans for each, ensuring geriatric medical care, buttressing social and supportive services, and developing and adhering to the priorities of the community as to investments. However, the financing model will begin to become inadequate as the numbers of frail elders keeps increasing and the standards of MediCaring medical care become more widespread. Financing will come to rely upon a combination of social insurance and enhanced savings (as personal savings or as long-term care insurance), as outlined in Core Component #6 (page 103) so that the improved care system that MediCaring Communities develops is able to expand to serve a larger number of elders.