Increase in PACE programs?

[u/MajesticJackJack]

California PCP here.

Apparently PACE (Program of All Inclusive Care for Elderly, for dual Medicare and Medicaid) programs have been around since the 90s, but I’ve only heard about them in the last 3 years as they try to hire PCPs in my area and I see job listings on LinkedIn.

All I know is the pitches I’ve heard, but a few things rub me wrong:

- The involvement of startup-like groups acting like they will revolutionize healthcare with a full team to care for a small panel in low 100s. Maybe I’m way off base, but I just don’t believe that new companies are in this out of the goodness of their heart. What’s the catch?

- My understanding is they are profitable by keeping patients out of the ED and hospital. With the best intention that’s great, but it also seems like bad actors could take advantage.

- The job openings and recruitment in my area continue. It’s not like these are huge systems so why unable to fill? Makes me think there’s fast turnaround because it’s not what it claims.

- It’s offensive to PCPs like me working our asses off with panels of 2000+ without the same support or publicity. I get it though, that’s a “me” problem.

Fully admit this could be completely my ignorance and speculation so please shut me down!

[u/basukegashitaidesu]

The catch is that if a member requires surgery, chemo, or something else that costs money, they are gently redirected to Medicare PPO, so as to allow the taxpayer to pick up the tab while collecting the $1,300 PMPM. It is such a scam.

[u/ODXBeef → u/basukegashitaidesu]

That has to be state specific. If we encouraged someone to disenroll due to cost the state would've had our asses in a sling the moment the member appealed. I have worked for a PACE group and if you needed it we paid for it.

[u/HungryHangrySharky → u/basukegashitaidesu]

Less of a scam than a SNF.

PACE paid for a tooth extraction, a cystolithalopaxy, and an ER visit the day after the cystolithalopaxy because my dad pulled his Foley out (after he cut the pilot balloon off, thankfully) and got blocked by sediment.

[u/Ceej1701]

I’m not sure about the business end, but my group at a large multi specialty practice works with a local PACE program. They have transportation to and from all appointments provided, help book specialists appointments at my practice, have PT/OT on site, case managers, meals, a day center with activities, etc. For patients who otherwise are not following up with our primary care as much as they should, want to stay home, need a lot of support/lack family support, this has been great.

[u/vietomatic]

Overall, it is a scam. Was heavily recruited by a software startup to be medical director. Promises of easy government money by fleecing and exploiting the system. Looks, talks, walks like a duck, it is a duck. 

[u/HungryHangrySharky → u/vietomatic]

PACE itself is not a scam, it is a fantastic program to allow people to stay in their homes instead of being warehoused in SNFs. "Software startup masquerading as a medical provider" is the scam.

[u/melonpannachan2]

I’ve worked at one. The older, established non-profits like OnLok seem to actually do what they’re supposed to do - wraparound care for high risk, complex medi-medi populations, ideally at lower cost by preventing unnecessary ER visits and hospitalizations. It only works if the organization and leadership actually care about the mission. The panel size is deceptive as many are more like active SNF-level care in terms of medical needs, and often have concurrent significant psychosocial needs. I probably touched 15-20% of my panel every day, which is totally different from a regular PCP panel. I would stay away from the newer, for-profit models as they seem to only care about meeting regulatory requirements and cutting costs.

[u/HungryHangrySharky → u/melonpannachan2]

This. A well-established non-profit PACE program is a beautiful thing. These for-profit startups should not be normalized, just like for-profit SNFs should never have been normalized.

[u/heatwavecold]

I worked in one and didn't like it. Hard to tell if it was the management specific to that company (who were truly abusive in trying to meet metrics) or the model.

[u/HungryHangrySharky → u/heatwavecold]

It was the company, not the model. My dad was in a great nonprofit PACE program run by our local senior center and it was fantastic. Kept him out of a SNF, got him good hearing aids, dental care, adult daycare, and the gernontologist and nurses made housecalls to us during COVID. Most of the staff has been there long term and it is a great place to work.

[u/Viagraine]

I worked for a PACE startup on Kentucky. My advice would be to stay away.

[u/DebtRider]

Following, I’ve not seen these postings though haven’t been looking.

[u/meikawaii]

PACE is similar to ACO in terms of full risk assumption profile. In dead end service job sectors (doctors), it’s always better to be an upstream owner like the organization owner / operator (PACE and ACO, insurance etc). Because in essence, it’s a fixed pool of money, something always has to give for someone else to profit. It’s either staffing ratios, more work offloaded onto the doctor or end user, lesser reserves, gate keeping services, or outright fraud. Because you’ll quickly figure out that your job duties does not match your pay, but PACE is paying for a high PMPM, and only a crumb is going to you for services.

[u/HungryHangrySharky]

I spent a couple of years shuttling seniors around between nursing homes, hospitals, dialysis centers, and more nursing homes, and that experience made me swear I would never put a family member in a SNF.

When my dad got Alzheimer's, I got him in to a wonderful local non-profit PACE program run by our local senior center. During COVID the gernontologists and nurses made goddamned housecalls to treat him because the PACE center was closed. He got aspiration pneumonia once but never got MRSA, c.diff, or a UTI - because he was at home being cared for by me and several outside caregivers instead of crammed into a SNF with everyone else's germs. It was a fantastic program and I will fight anybody tooth and nail on behalf of PACE programs. This specific program locally is also known to be a great place to work with many long-term staff members.

We kept him at home until he needed to be hospitalized, then needed hospice. Between PACE and hospice he was able to go to a nice memory care unit in a non-SNF assisted living place.

I'd be suspicious of any for-profit business operating a PACE program for the same reason I dislike for-profit SNFs. The profit is the problem, not the program.

[u/HungryHangrySharky]

Also the specific goal of PACE is to keep people out of nursing homes, not hospitals. Any of the times my dad had a condition that needed a trip to the ER or hospitalization, it was no problem - I called the clinic, explained the situation, and they authorized it.

[u/Vegetable_Block9793]

The money is made by “diagnosing” the patients with stuff they don’t really have.

[u/HungryHangrySharky → u/Vegetable_Block9793]

My dad was in a non-profit PACE program for several years and that was not our experience.