Geriatric Medicine Training and Practice in the United States at the ...

participants. Geriatricians have been integral to the development
and implementation of many of these programs. Reviews of these
programs’ impact have been published (Weiner & Skaggs, 1995;
Weissert, Cready, & Pawelak, 1988).
An example of an innovative service demonstration program is
the Program of All-Inclusive Care for the Elderly (PACE). PACE includes
a comprehensive service delivery system for Medicare and Medicaid
eligible elders living in the community. The program is funded on a
capitated basis by Medicare and Medicaid. PACE is modeled on a
system of acute- and long-term care services developed by On Lok
Senior Health Services in San Francisco. In 1986, the Robert Wood
Johnson Foundation provided funding for six sites to develop PACE
programs to see if the successful program developed under the
leadership of Marie Louise Ansak in the Chinatown area of San
Francisco could be replicated in other communities. Based on the
success of these demonstration programs, the Balanced Budget Act
of 1997 approved the granting of provider status to PACE programs
under Medicare and gave states’ Medicaid agencies the option to
include PACE as a Medicaid benefit. PACE programs are now in the
process of transitioning from demonstration sites to permanent
provider status under Medicare (Center for Medicare Education, 2001).
The scope of current PACE sites is very small. In 1996, there were 12
PACE sites serving approximately 4,800 individuals. In October 2001,
25 Medicare-Medicaid PACE sites were operating and 11 Medicaid
only PACE sites were open. In December 2000, the nationwide client
census was 7,956 (National Pace Association, 2002) and by March 1,
2002 there were 26 PACE programs in 15 states (Personal
communication, Robert Greenwood, May 17, 2002). Each site serves
an average of 200 enrollees, whose average age is 82.
PACE services include an interdisciplinary team that assesses
participant’s needs, develops care plans,
and delivers all necessary services
(including acute care services and when
necessary, nursing facility services). These
services are integrated to achieve seamless
provision of comprehensive care. PACE
programs provide social and medical
services primarily in adult day health
centers, supplemented by in-home and
referral services in accordance with the
participant’s needs. The PACE service
package must include all Medicare- and
Medicaid-covered services and other
services deemed necessary by the
multidisciplinary team. PACE providers
receive a monthly capitated payment
consisting of a lump sum from Medicare
combined with either Medicaid or a
participant’s private pay resources;
Medicare participants who are not eligible
for Medicaid pay monthly premiums equal
to the Medicaid capitation amount, but no
deductibles, co-insurance, or other type of
Medicare or Medicaid cost-sharing apply
(Center for Medicare Education, 2001). The
capitated payment is used to provide the comprehensive services
required by the participant. PACE providers assume full financial risk
for participants’ care without limits on amount, duration, or scope of
services (HCFA, PACE Quarterly Report, 1999).
A 1998 evaluation report of the impact of PACE on participant
outcomes concluded that PACE participants, as compared to matched
controls, had lower rates of nursing home and hospital use, higher
utilization of ambulatory services, better health status and quality of
life during the first-six months of enrollment, as well as a lower
mortality rate. The benefits of PACE were greater for participants with
high levels of physical impairment. As noted, the expansion of the
PACE model has been slow, and each site serves a small number of
older adults (Chatterji, Burstein, Kidder et al., 1998).
Health of Older Adults
The most common chronic health care conditions affecting older
Americans are listed in Table 4.2. Although limitations in activity
associated with these chronic conditions have been declining in
recent years, they remain significant. In 1999, 6.3% of adults age 65
and over reported at least one limitation in Activities of Daily Living
(ADL), and 12.4% reported at least one limitation in Instrumental
Activities of Daily Living (IADL). Sex, race, and poverty status appear to
be related to the occurrence of functional limitations, with women,
non-whites, and the poor all reporting higher rates of ADL and IADL
deficits (Table 4.3). The most common reasons older adults saw
physicians in the office in 1991 and the final diagnoses associated
with these visits, are shown in Table 4.4. The leading causes of death
for adults age 65 and over in the United States are listed in Table 4.5
for both 1980 and 1999.
Table 4.4 Most Common Reasons for Office Visits and Most Common Final Diagnoses
Among Older Patients, All Physicians, 1999
Age 65 – 74
Age 75 and Over
Reason for Visit Progress visit Progress visit
General medical exam
General medical exam
Hypertension
Hypertension
Diabetes mellitus
Leg symptoms
Cough
Cough
Knee symptoms
Blood pressure test
Medication
Low back symptoms
Back symptoms
Test results
Test results
Medication
Final Diagnoses Hypertension Hypertension
Diabetes mellitus
Diabetes mellitus
Chronic IHD 1 Chronic IHD 1
Osteoarthritis
Osteoarthritis
Lipid disorders
Heart failure
Bronchitis
Special examinations
Special examinations
Cardiac dysrhythmias
COPD 2
Back disorders
General medical exam
Disorders of the urinary track
Allergic rhinitis COPD 2
1
IHD – Ischemic Heart Disease
2
COPD – Chronic Obstructive Pulmonary Disease
Source: US Department of Health and Human Services, 2001
27