Meet the Underdog of Senior Care

Felicia Biteranta struggled when she signed up for the PACE program run by Lutheran Senior Life in Jersey City, New Jersey five years ago.

After the stroke, she found it difficult to eat without choking. She often fell; her diabetes is out of control; she had lung disease and asthma. She could miss her doctor’s visit if she couldn’t order or afford a taxi. Her family lived far away.

In short, she was a candidate for a nursing home. But such a move is what PACE – Comprehensive Elderly Care Program — was designed to prevent.

“The main goal is to allow people to age in place,” said Maria Yavarone, chief executive PACE program in which Ms. Biteranta participates. “No one wants to give up their home. This is where you feel most comfortable. This is where you should stay.

Ms. Biteranta now receives all her medical care through PACE, who closely monitors her, along with 120 other elderly people. PACE also provides much of her social life.

“This is where they make appointments for you,” said Ms. Biteranta, 74, a retired nurse. “They send someone to pick you up and take you home.”

Carpal tunnel syndrome in her wrists and hands makes self-care and housework difficult, so PACE sends an assistant to her home for 12 hours a week. “She cleans and launders my clothes and also does my shopping,” Ms. Biteranta said. “She knows what kind of food I like.”

PACE provided a portable oxygen unit that freed her from having to use the larger oxygen cylinders she uses at home. He organized cataract surgery and regularly refers her to an orthopedist, cardiologist, endocrinologist, and other specialists. It delivers many medicines for free, including asthma inhalers and diabetic testing supplies. A staff social worker helped her apply for and move into an apartment in a subsidized nursing home.

As a Medicaid beneficiary, she pays nothing for this service—no copays, deductibles, or other personal care costs, and no limits on benefits. If she needs more hours of home care or eventually a nursing home, PACE will also cover those costs.

“It’s carefree,” said Ms. Biteranta, who was preparing to have lunch at the PACE Center, as she spoke. “They’re worried about me.”

However, both the state and the federal government are also saving money. The PACE programs receive a set amount each month from Medicare and Medicaid to provide almost everything for people over 55 whose needs allow them to enter a nursing home but who do not want to enter one. This includes doctor visits, tests, procedures, physical therapy, occupational and speech therapy, social workers, home care, transportation, medications, dentistry, and hearing aids. Members typically visit a PACE center, similar to the one in Jersey City, several times a week for meals and social events, as well as treatment and health monitoring.

This monthly payment is on average 15 percent lower than what Medicaid typically pays for care for low-income seniors, the PACE National Association said.

Research has shown that PACE programs reduce hospital admissions, emergency room visits, and stays in nursing homes. Participants survive longer than similar patients in less comprehensive programs. A study was conducted last year by the federal Department of Health and Human Services. noted that the PACE program “stands out from our analysis as consistently ‘highly effective.”

Why, then, are there so few PACE programs and so few older Americans? Nearly three decades after Medicare and Medicaid began funding PACE programs (today there are 144 operating 272 centers in 30 states), according to the National PACE Association, the enterprise serves fewer than 60,000 people in total, according to the National PACE Association.

The association estimates that 1.6 million Medicare recipients may qualify for PACE. As the list of current programs shows however, 21 states do not have a PACE program, and 11 have only one.

Elderly care professionals are usually fans. “Every geriatrician loves this model,” said Mark Luks, co-director of geriatrics and palliative care at Weill Cornell Medicine.

Professionals like Dr. Lahs have complained for years that traditional Medicare will cover costly surgeries to repair broken hips but won’t pay for inexpensive handrails to prevent falls. With PACE flat-rates, “the money may be less, but you can spend it however you want without having to call the phone to get insurance company approval,” Dr. Laks said.

In New York’s ArchCare PACE program, for example, “if a person’s air conditioner breaks during a heatwave, we’ll replace it,” said Walid Michelin, the program’s chief medical officer. “If there’s a snowstorm and they need food, we’ll send it.”

With coordinated care and close monitoring, “you prevent a urinary tract infection before it develops into sepsis,” said Jay Luxenberg, former chief medical officer At Lok PACE program in San Francisco. “Or pneumonia, when it can still be treated with antibiotics before you desperately need a hospital.”

However, growth has been slow. “We’ve had a lot of headwinds over the years,” said Sean Bloom, the association’s chief executive.

Persuading state legislators to expand PACE enrollment or authorize new programs proved to be a difficult task; such moves represent new costs, even if they ultimately reduce costs.

For individuals, the enrollment process, which includes a condition assessment to determine if their medical condition, cognitive status, and functional limitations warrant a nursing home, can take weeks. A family in need of aged care immediately may not be able to wait.

Moreover, agreeing to receive all care from PACE often means waiving a personal physician, and some patients waive this requirement. Programs can get around this barrier by allowing PACE programs to work with local doctors.

But potential patients may not know about PACE at all. “We’re trying to raise awareness, but we don’t have ‘Got Milk?’ budget,” Mr. Bloom said.

However, the pandemic has heightened the desire of older Americans for alternative forms of long-term care. “If people didn’t want to be in nursing homes before Covid, they really don’t want to be there now,” Dr. Lax said. According to the association, Covid deaths among PACE participants are approximately one-third of those in nursing homes.

So PACE’s growth is accelerating, with 45 new programs expected to start enrolling over the next two years, due in part to higher federal incentives. Moreover, commercial companies are beginning to create or acquire PACE programs, although skeptics fear that commercial status will reduce quality.

Several bills introduced in Congress will remove barriers to growth; Veterans Affairs hospitals could be partnered to make PACE more accessible to veterans.

Another intriguing possibility is to encourage middle-class patients, for whom long-term care costs can also be ruinous, to enroll in PACE. Older adults who are not poor enough to qualify for Medicaid can already participate, but few do so because their monthly premiums will be high—$4,000 to $5,000 a month in many states.

But it’s still less than what they would pay for nursing homes or nursing homes in many places. political analysts are looking for ways to cut costs and expand PACE rights to the middle class.

In Jersey City, Ms. Biteranta is doing well, although she misses concerts, Zumba classes, birthdays, and other events at PACE. The administration has scaled down such activities during the pandemic but hopes to resume as Covid rates decline.

“My God, I would be so depressed” without PACE, Ms. Biteranta said. “It gives me life.”

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