ISSUE BRIEF October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations Sara Karon Molly Knowles Cleo Kordomenos Micah Segelman Senior Health Policy Researcher Research Public Health Analyst Public Health Analyst Health Policy Researcher Aging, Disability, and Long-Term Aging, Disability, and Long-Term Aging, Disability, and Long-Term Aging, Disability, and Long-Term Care Program Care Program Care Program Care Program RTI International RTI International RTI International RTI International ABSTRACT TOPLINES ISSUE: High-need populations benefit from integrated care such as that The Program of All-Inclusive offered by the Program of All-Inclusive Care for the Elderly (PACE) model. Care for the Elderly (PACE) is one of the most successful models Understanding the diversity of high-need populations and where they are of integrating care for high-need located can guide optimal expansion of this model. people requiring acute and long- GOALS: Identify high-need, high-cost (HNHC) populations that may term services and supports. benefit from an expansion of the PACE model and determine the size and geographic distribution of these populations. Even though PACE is restricted to people age 55 and older, younger METHODS: Conduct a literature review and form an expert advisory adults with developmental or panel to identify key HNHC populations. Analyze Medicare and Medicaid physical disabilities also could benefit from the program’s claims data to capture the size and distribution of these populations, and interventions. the extent to which they are particularly high cost. KEY FINDINGS AND CONCLUSIONS: The greatest opportunity for Expanding PACE to adults expansion is to the population currently eligible for PACE programs. with end-stage renal disease Significant opportunities exist to serve other high-need populations, and younger adults with developmental disabilities could some of which are particularly high-cost, and some of which may require help meet the needs of many changing how PACE is structured. Other high-need populations also could high-need, high-cost patients. benefit from PACE if its scope were expanded and if reimbursement rates were appropriately structured to recognize variation in costs. Expanding the PACE Model of Care to High-Need, High-Cost Populations 2 INTRODUCTION Subsets of the five populations were determined to be In recent years, the term high need (HN) has been used both high need and high cost. Understanding the size to describe people who have conditions that require and geographic distribution of these HN and HNHC significant levels of health care; high need, high cost populations can support policymakers and providers in (HNHC) has described those who both have the most focusing on those localities with the greatest potential to need and make the most use of that care. There are benefit from a PACE expansion or other targeted services. several populations that may be identified as HNHC, including people with multiple chronic health conditions, FINDINGS functional limitations, and behavioral health needs. Meeting the needs of these HNHC groups requires three Which Populations Could Benefit from PACE steps: 1) understanding the diversity of the populations; Expansion? 2) identifying integrated care programs that can best meet An advisory group identified five HN populations and their needs at lower cost; and 3) spreading adoption of subsets of those populations that are HNHC as likely to those integrated care programs.1 Integrated care programs benefit from integrated care programs such as PACE. provide efficient coordination of medical and mental In addition to those currently eligible for PACE, the health care as well as long-term services and supports populations include: (LTSS) that these HNHC populations may need, in ways that may be more person-centered than traditional, siloed • younger adults (ages 21–54) with developmental care approaches.2 disabilities (DD) and comorbidities The Program of All-Inclusive Care for the Elderly (PACE) • younger adults (ages 21–54) with physical disabilities is one of the oldest and most successful models of (PD) and comorbidities integrating services for high-need people with acute and LTSS needs. Several studies and evaluations have • adults with behavioral health conditions and demonstrated the positive effects of enrolling in PACE. comorbidities Such benefits include reductions in hospitalization, • adults with end-stage renal disease (ESRD), rehospitalization, and emergency department use; comorbidity, and functional impairment. reductions in long-term nursing facility placements; reductions in mortality; and lower rates of functional decline and better reported health status and quality of life.3 What Are the Opportunities for PACE Expansion? PACE can grow through three means: To date, PACE has been restricted to people age 55 and older who require a nursing home level of care. The PACE 1. Scale: Increasing the number of people served Innovation Act of 2015 enables the Centers for Medicare by current PACE organizations in their current and Medicaid Services (CMS) to authorize demonstrations communities. of PACE programs to serve other HN populations. 2. Spread: Increasing the number of PACE organizations Using a literature review and input from a technical and number of communities served by the current advisory group, we identified five high-need populations PACE model. that may benefit from the types of services offered by 3. Scope: Expanding the range of populations that PACE PACE. We drew from Medicaid claims data to identify can serve. the size of these potential target populations by state. commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 3 Our analyses found that the greatest opportunity for What Are the Cost Implications of Expanding to PACE growth is through scale. In 2012, PACE served Different Populations? approximately 25,000 people. Since then, PACE has more All five populations are high need and may have high costs than doubled in size.4 as well. While adding new PACE programs and spreading them In our analysis, we defined high-cost populations as those to new communities is another strategy to grow PACE, whose total annual costs, either Medicare or Medicaid, such growth may be limited by state policy. Some states were in the top 10 percent for two consecutive years. restrict the number of people who may be enrolled in Modest shares of the current PACE population had high PACE, and some limit the number of PACE programs that costs (Exhibit 2). The same was true for groups with may be established. Other states do not offer PACE. As of behavioral health needs and younger adults with physical March 2020, PACE programs could be found in 31 states.5 disabilities. However, nearly 40 percent of the younger Expansion of PACE to states that do not currently offer population with developmental disabilities and almost such programs would require changes to state policy. 70 percent of those with ESRD had high costs as well as high needs. Expanding the scope of populations served by PACE is another growth strategy (Exhibit 1). Younger adults Because the costs associated with each group differ, (those ages 21 to 54) would be an entirely new population expansion of PACE will require careful development of for PACE. Those with physical disabilities may share capitated payment rates, with appropriate risk adjustment similar physical needs with the current PACE population. that recognizes the variation in need within those groups. However, younger adults with developmental disabilities This will ensure adequate reimbursement for each are less likely to have the same needs as older adults population. currently served by PACE. Cost implications of expansion vary significantly by state. Other HN populations identified, those with behavioral The share of high-need populations that are also high cost health needs and those with ESRD, include adults of all ranged from 6 percent in New Mexico to 24 percent in ages. Many of those age 55 and older may be eligible for New York (Exhibit 3 and Appendix Table 1). Expansion PACE as it currently exists. through the creation of new PACE programs, whether they are to serve the currently eligible or new populations, must consider both the size of the target population and its cost distribution. Exhibit 1. Size of High-Need Populations in States with and without PACE Programs Current Younger adults with Younger adults with Behavioral End-stage PACE developmental disabilities physical disabilities health renal disease Total 9,796,706 223,782 1,104,994 7,782,592 263,570 PACE states 7,601,654 171,786 838,078 6,091,980 205,935 Non-PACE states 2,195,052 51,996 266,916 1,690,612 57,635 Notes: The states without a PACE program in 2012 were: Alaska, Arizona, Connecticut, Georgia, Hawaii, Idaho, Illinois, Kentucky, Maine, Minnesota, Missouri, Mississippi, Montana, New Hampshire, Nevada, South Dakota, Utah, Vermont, and West Virginia, as well as Washington, D.C. “Younger” refers to adults ages 21 to 54. Data: Analyses of the 2012 Medicare–Medicaid Linked Enrollee Analytic Data Source (MMLEADS). commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 4 Exhibit 2 What Share of the High-Need Populations Are Also High Cost? Exhibit 2. What Share of the High-Need Populations Are Also High Cost? 100% 13% 15% 90% 17% 80% 39% 70% 69% 60% HNHC 50% HN, not high cost 87% 85% 40% 83% 30% 61% 20% 31% 10% 0% Current PACE Younger, DD Younger, PD Behavioral Health ESRD Notes: Notes: Younger, Younger, DD = DD = ages adults adults ages 21–54 21–54 with with developmental developmental disabilitiesYounger, disabilities and comorbidities. PD = adults ages Younger, and comorbidities. PD = adults 21–54 with physical ages disabilities and21–54 with physical comorbidities. Behavioraldisabilities and health = adults with behavioral health comorbidities. conditions and Behavioral comorbidities. health = adultsESRD with= adults with end-stage behavioral healthrenal disease, comorbidity, conditions and functional and comorbidities. impairment. ESRD = adults with end-stage renal disease, comorbidity, and Data: Analyses of the 2012 Medicare–Medicaid Linked Enrollee Analytic Data Source (MMLEADS). functional impairment. Data: Analyses of the 2012 Medicare–Medicaid Linked Enrollee Analytic Data Source (MMLEADS). Source: Sara Karon et al., Expanding the PACE Model of Care to High-Need, High-Cost Populations (Commonwealth Fund, Oct. 2020). Exhibit 3. High-Need Population Size and Percentage That Is Also High Cost Varies by State High-need Percentage of high need population (N) that is also high cost Currently PACE-eligible Average 208,441 12.3% Minimum 13,282 6.3% Maximum 823,278 23.9% Younger adults with developmental disabilities Average 5,077 38.7% Minimum 322 16.9% Maximum 20,515 58.3% Younger adults with physical disabilities Average 23,511 17.4% Minimum 1,443 8.9% Maximum 80,911 41.9% Behavioral health Average 165,587 14.2% Minimum 9,895 8.1% Maximum 577,221 28.1% End-stage renal disease Average 5,608 66.9% Minimum 257 54.2% Maximum 27,094 79.5% Note: “Younger” refers to adults ages 21 to 54. Data: Analyses of the 2012 Medicare–Medicaid Linked Enrollee Analytic Data Source (MMLEADS). commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 5 DISCUSSION AND POLICY IMPLICATIONS CONCLUSION The Centers for Medicare and Medicaid Services (CMS) PACE has proven to be a strong model for the population and many states have prioritized improving care it currently serves, and there are significant opportunities and reducing costs of care for high-need, high-cost to expand its scale and scope to others who are currently populations by supporting integrated care models that eligible. PACE also can grow by extending, or spreading, focus on coordinating the delivery of primary, acute, coverage to new populations, but doing so may require and behavioral health care as well as long-term services significant shifts in the PACE model of care. Such shifts and supports. The PACE Innovation Act is intended to may be needed to address the particular care needs of support the growth of PACE by extending its scope to new targeted beneficiaries in a manner that aligns with their populations. Significant opportunities for PACE expansion preferences and goals. also exist by scaling its current programs and spreading Regardless of which beneficiaries they choose to target, programs to new locations. However, the ability to grow policymakers and providers will need to consider that through scale and spread is limited in some states, which the size of their high-need populations and their cost currently impose limits on PACE enrollment or restrict the distributions vary by state. number of PACE organizations in the state. Such policies will need to change before PACE can grow. HOW WE CONDUCTED THIS STUDY While expanding the scope of PACE to new populations This study identified five high-need populations that offers opportunities, it may bring new challenges as could be well served by PACE. A variety of qualitative and well. For example, people with behavioral health quantitative approaches were used to better understand needs, which include mental health and substance use the different types of high-need (HN) populations and disorders, may require specific types of support that are how they are geographically distributed. not a current focus of PACE. Additionally, the service needs of the younger and older adult populations with Identifying Populations of Interest physical disabilities may appear similar, but younger adults may be more interested in supports for educational Several HN populations were identified through an and employment goals, and for community integration. environmental scan. An advisory group reviewed those Providing such supports could require a significant shift populations and recommended five that were most likely from PACE’s current adult day center–based model of to benefit from integrated care programs such as PACE. support. These groups were defined based on combinations of age, disability, and chronic conditions. The advisory group Adequate risk adjustment of reimbursement rates will agreed that high-cost subgroups should be identified be needed to properly capture the costs of high-need, based on two consecutive years of being high cost (i.e., high-cost populations. This is especially important with costs in the top 10% of Medicare or Medicaid). when considering expanding PACE to some adults with ESRD and to younger adults with developmental In addition to the HN population that is currently eligible disabilities. These two groups have a significant share of for PACE, the advisory group recommended two groups the population who are high cost. They also are the two of younger adults, and two groups of adults regardless of smallest populations. Together, those factors suggest that their age. The younger groups represent new populations these groups may be particularly challenging as a focus for for PACE, as they are not eligible currently on the basis of PACE expansion. age. The younger group with physical disabilities may be similar in needs for support to the older population, but the group with developmental disabilities may represent a new target with different needs. Expansion to the groups with behavioral health needs and with end-stage renal commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 6 disease (ESRD) would mean a targeted outreach to specific FIVE HIGH-NEED POPULATIONS THAT MAY populations. Many people with behavioral health needs BENEFIT FROM ACCESS TO PACE or ESRD may be currently eligible for PACE, and some may already be served. • Currently PACE-eligible • Younger adults with developmental disabilities (DD) and comorbidities Qualitative Methods • Younger adults with physical disabilities (PD) and To identify HN and high-need, high-cost (HNHC) comorbidities populations, we conducted an environmental scan that included information collected from publicly available, • Adults with behavioral health conditions and peer-reviewed literature and grey literature. We also comorbidities reviewed all comments submitted in response to the • Adults with end-stage renal disease (ESRD), comorbidity, PACE Innovation Act Request for Information (RFI) and and functional impairment conducted interviews with key advisors from current PACE programs. An advisory group recommended five Identifying the Populations populations that they believed to be particularly suitable MMLEADS data were used to identify individuals in each for services under the PACE model. of the HN populations selected for study. The authors identified each of these populations using a two-step Quantitative Methods approach similar to that used by Joynt et al.6 This approach Analyses of the 2012 Medicare–Medicaid Linked Enrollee began by identifying HN groups based on chronic health Analytic Data Source (MMLEADS) were conducted to conditions and disabilities, either alone or in combination determine the size and distribution of HN and HNHC with others. populations by state. Additionally, where appropriate, the authors used data on utilization of long-term services and supports (LTSS) Data to identify people with needs for functional supports. MMLEADS data include comprehensive information These data are available only for those who are Medicaid- about the eligibility, enrollment, service utilization, eligible. Functional impairment data also are available expenditures, chronic health conditions, and disabilities only for those who are Medicaid-eligible. Predictive (including 27 chronic conditions and 25 mental health, models, created using data MMLEADS data linked with tobacco, physical, and mental health disability conditions) information from the Medicare Current Beneficiary of people who are enrolled only in Medicare, enrolled Survey, were applied to the full MMLEADS data set to only in Medicaid, or who are enrolled in both Medicare identify those people eligible for Medicare only who were and Medicaid. For those who are enrolled only in likely to meet the functional eligibility criteria. High-cost Medicaid, MMLEADS is limited to those who were eligible populations were those whose Medicare or Medicaid because of disabilities. The data include all qualifying expenditures fell within the top 10 percent for both 2011 individuals during 2012. and 2012. Data exclude four states (Colorado, Idaho, Kansas, and Rhode Island) because of incomplete Medicaid information for this time period. commonwealthfund.org Issue Brief, October 2020 The Commonwealth Expanding the PACE ModelFund Hto of Care ow High Is America’s High-Need, Health Care Cost Burden? High-Cost Populations 7 7 Appendix Table 1. High-Need Populations and Share That Are High Cost, by State Currently eligible Younger, IDD Younger, PD Behavioral health ESRD High need High cost High need High cost High need High cost High need High cost High need High cost State (#) (%) (#) (%) (#) (%) (#) (%) (#) (%) AK 13,282 18% 322 56% 1,600 27% 9,895 19% 381 72% AL 218,564 11% 3,981 29% 32,122 10% 144,752 14% 5,962 63% AR 134,643 10% 2,513 34% 18,340 9% 92,810 12% 2,739 62% AZ 136,709 8% 1,369 18% 10,282 12% 105,555 9% 3,914 66% CA 823,278 13% 18,592 36% 70,101 21% 553,238 16% 25,816 74% CT 137,212 19% 3,359 54% 10,764 28% 100,233 23% 2,842 76% DC 18,877 24% 907 55% 2,330 42% 15,201 28% 1,003 79% DE 41,044 14% 725 43% 4,526 17% 30,843 15% 1,215 71% FL 729,469 14% 13,082 37% 63,444 19% 577,221 17% 16,149 69% GA 291,380 10% 6,925 32% 41,865 15% 215,002 12% 11,060 70% HI 20,351 9% 360 31% 1,646 17% 12,663 9% 980 65% IA 129,310 10% 2,827 43% 9,475 20% 100,751 13% 2,210 64% IL 478,586 11% 10,682 41% 37,485 21% 349,291 14% 12,450 69% IN 242,152 10% 6,636 39% 32,330 16% 195,172 13% 5,564 67% KY 203,335 11% 5,360 30% 39,687 9% 179,887 12% 4,204 64% LA 168,754 15% 4,905 48% 22,696 18% 200,196 15% 5,851 71% MA 236,329 18% 7,203 41% 24,746 18% 225,934 18% 4,006 75% MD 201,211 14% 4,868 46% 21,556 23% 151,886 18% 6,410 71% ME 63,011 10% 1,703 39% 8,641 13% 54,661 11% 853 69% MI 405,139 12% 12,412 23% 53,980 12% 399,439 13% 10,523 70% MN 107,529 11% 5,036 53% 14,889 28% 82,666 16% 2,958 65% MO 234,289 10% 6,890 37% 32,355 17% 193,384 12% 5,396 67% MS 147,232 14% 2,789 27% 21,829 10% 99,848 17% 4,731 69% MT 35,253 10% 680 22% 3,274 12% 24,072 11% 568 54% NC 362,167 10% 8,494 30% 49,118 14% 320,609 11% 10,716 68% ND 27,927 13% 485 50% 1,651 23% 18,378 16% 557 55% NE 66,294 10% 1,358 43% 4,967 22% 50,720 12% 1,234 62% NH 53,564 10% 1,057 37% 6,268 13% 45,343 12% 698 68% NJ 334,946 15% 6,953 46% 25,593 21% 225,674 19% 8,747 72% NM 63,260 6% 1,554 41% 8,304 14% 51,830 8% 2,244 64% NV 57,459 11% 1,287 33% 7,411 17% 40,637 13% 1,819 65% NY 605,709 24% 20,515 57% 58,873 27% 454,337 26% 15,471 74% OH 382,363 15% 14,142 46% 56,642 19% 329,561 17% 10,487 68% OK 152,084 10% 3,529 41% 19,642 15% 121,878 12% 3,484 63% OR 90,064 8% 1,844 17% 10,528 10% 73,880 9% 1,957 66% PA 410,657 15% 9,412 41% 37,948 18% 371,045 15% 9,711 69% SC 180,751 10% 3,883 36% 21,850 13% 138,603 11% 5,449 69% SD 33,098 8% 715 38% 2,560 20% 21,532 10% 637 63% TN 237,028 15% 5,264 40% 39,008 13% 200,600 17% 5,984 65% TX 720,403 12% 16,202 37% 80,911 18% 557,843 15% 27,094 71% UT 44,759 10% 908 42% 4,390 15% 36,228 12% 978 60% VA 265,271 10% 5,984 36% 29,660 15% 199,867 11% 7,621 66% VT 26,176 13% 600 44% 2,483 14% 21,089 14% 374 59% WA 179,006 10% 3,046 34% 19,438 14% 165,745 11% 4,310 69% WI 176,739 10% 4,183 22% 19,186 13% 127,730 12% 4,167 66% WV 92,950 12% 2,652 36% 17,157 11% 83,425 13% 1,789 60% WY 17,092 12% 412 58% 1,443 25% 11,438 15% 257 58% Notes: Data exclude four states (Colorado, Idaho, Kansas, and Rhode Island) because of incomplete Medicaid information. “Younger” refers to adults ages 21 to 54. IDD = intellectual or developmental disabilities. PD = physical disabilities. ESRD = end-stage renal disease. Data: Analyses of the 2012 Medicare–Medicaid Linked Enrollee Analytic Data Source (MMLEADS). commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 8 NOTES 1. David Blumenthal et al., “Caring for High-Need, 4. Ghosh, Orfield, and Schmitz, Evaluating PACE, 2014; and High-Cost Patients — An Urgent Priority,” New England National PACE Association, PACE in the States (NPA, Apr. Journal of Medicine 375, no. 10 (Sept. 8, 2016): 909–11. 2020). 2. Peter Long et al., Effective Care for High-Need Patients: 5.NPA, PACE in the States, 2020. Opportunities for Improving Outcomes, Value, and Health (National Academy of Medicine, 2017). 6. Karen E. Joynt et al., “Segmenting High-Cost Medicare Patients into Potentially Actionable Cohorts,” Healthcare 3. Pinka Chatterji et al., Evaluation of the Program of 5, no. 1–2 (Mar. 2017): 62–67. All-Inclusive Care for the Elderly (PACE) Demonstration: The Impact of PACE on Participant Outcomes (Health Care Financing Administration, July 1998); Pamela Nadash, “Two Models of Managed Long-Term Care: Comparing PACE with a Medicaid-Only Plan,” Gerontologist 44, no. 5 (Oct. 2004): 644–54; Robert L. Kane et al., “Variations on a Theme Called PACE,” Journal of Gerontology: Series A 61, no. 7 (July 2006): 689–93; Louise A. Meret-Hanke, “Effects of the Program of All-Inclusive Care for the Elderly on Hospital Use,” Gerontologist 51, no. 66 (Dec. 2011): 774–85; Darryl Wieland et al., “Hospitalization in the Program of All-Inclusive Care for the Elderly (PACE): Rates, Concomitants, and Predictors,” Journal of the American Geriatrics Society 48, no. 11 (Nov. 2000): 1373–80; Micah Segelman et al., “Hospitalizations in the Program of All-Inclusive Care for the Elderly,” Journal of the American Geriatrics Society 62, no. 2 (Feb. 2014): 320–24; Jody Beauchamp et al., The Effect of the Program of All-Inclusive Care for the Elderly (PACE) on Quality (Centers for Medicare and Medicaid Services, Feb. 2008); Arkadipta Ghosh, Cara Orfield, and Robert Schmitz, Evaluating PACE: A Review of the Literature (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Jan. 2014); and Micah Segelman et al., “Transitioning from Community-Based to Institutional Long-Term Care: Comparing 1915(c) Waiver and PACE Enrollees,” Gerontologist 57, no. 2 (Apr. 2017): 300–8. commonwealthfund.org Issue Brief, October 2020 Expanding the PACE Model of Care to High-Need, High-Cost Populations 9 ABOUT THE AUTHORS Cleo Kordomenos, B.A., is a public health analyst in RTI’s Sarita (Sara) Karon, Ph.D., is a senior health policy Aging, Disability, and Long-Term Care Program. She is a researcher in RTI International’s Aging, Disability, and member of qualitative and quantitative teams for projects Long-Term Care Program. She has more than 25 years of funded by the Centers for Medicare and Medicaid Services professional experience in the study of issues related to and has contributed to primary data collection, data long-term services and supports (LTSS) for elderly and analysis, and report writing. Her work includes collecting working-age adults with disabilities and chronic illness. data from PACE plans (using the Health Outcomes Survey– Her work covers access to, expenditures for, and quality Modified) to measure the frailty of their enrollees. Prior to of LTSS services for people with disabilities provided in joining RTI in 2017, Ms. Kordomenos translated research both institutional and community-based settings. Dr. findings into proposed health care legislation while serving Karon’s work draws upon many sources of data, including as junior legislative aide to Assemblywoman Elizabeth Medicaid and Medicare claims data and data from assorted Maher Muoio of New Jersey’s 15th Legislative District. surveys, to understand the needs and experiences of Micah Segelman, Ph.D., is a health policy researcher in people with disabilities and chronic health care needs. RTI’s Aging, Disability, and Long-Term Care Program. He She has previously led projects related to PACE costs has more than seven years of experience utilizing health and opportunities for PACE expansion, funded by the services research methods to inform policy, particularly Centers for Medicare and Medicaid Services (CMS) and in the areas of long-term care and care for the elderly. Dr. for the Office of the Assistant Secretary for Planning and Segelman has expertise in quantitative methods, including Evaluation (ASPE). developing risk-adjusted quality measures and designing Mary (Molly) Knowles, M.P.P., is a research public health and conducting evaluations of policy interventions. analyst with RTI’s Aging, Disability, and Long-Term Care He studied the impact of PACE, the degree to which Program. She has extensive experience in Medicaid, community-based long-term services and supports Medicare, health, and LTSS policy analysis and research. are effective in delaying nursing home admissions for She has conducted qualitative research projects on frail elderly beneficiaries, hospitalizations and hospital several Medicaid issues, including Medicaid managed readmissions of nursing home residents, and the quality care, the effect of the changing Medicaid delivery systems of hospice care. Much of his work has been funded by the for enrollees with long-term care needs, delivery of care Centers for Medicare and Medicaid Services. systems for individuals dually eligible for Medicaid and Medicare, and health care coverage for nonelderly ACKNOWLEDGMENTS low-income adults. As a former senior analyst at the The authors acknowledge the participation and input Medicaid and CHIP Payment and Access Commission, of the National PACE Association (NPA). The views Ms. Knowles has considerable experience working on expressed here are those of the authors only and do not issues related to the Medicaid program, contributing necessarily reflect those of the Commonwealth Fund to several reports to Congress and providing technical or NPA. assistance to congressional staff on Medicaid policy issues. With support from ASPE, she has compared outcomes for PACE enrollees to those receiving services in other Editorial support was provided by Laura Hegwer. ways, explored opportunities to expand PACE to younger populations, and identified barriers to PACE growth. For more information about this brief, please contact: Sarita (Sara) Karon, Ph.D. Senior Health Policy Researcher RTI International skaronrti.org commonwealthfund.org Issue Brief, October 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.