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Program of All-Inclusive Care for the Elderly (PACE): A Podcast with Dan Drake and Jay Luxenberg

 



Older adults often turn to institutional settings like nursing homes when they need more help than they can get at home. However, since the 1970s, there has been a program that allows older adults to receive nursing home-level care outside of nursing homes. That model of care is known as the Program of All-inclusive Care for the Elderly, or PACE.

On today’s podcast, we discuss PACE with two leaders in the PACE community, Dan Drake and Jay Luxenberg. Dan is the President and CEO of Trinity Health PACE, the second largest provider of PACE in the country, and Jay is the Chief Medical Officer of On Lok, the very first PACE demonstration site in the nation.

We talk with Dan and Jay about all things PACE, including:

  • What is PACE and what is included in it that makes it able to care for nursing home level care in peoples homes?

  • How is PACE paid for, what does it need to cover, and who is eligible?

  • How did PACE start and what’s the evidence that it works?

  • What are the challenges to PACE implementation and what do they think the future has in store for PACE?

  • Why should you work at a PACE program?


  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who do we have with us today?

Alex: We are delighted to welcome Jay Luxenberg, who is the Chief Medical Officer of On Lok, a program of all-inclusive care for the elderly. And he is a geriatrician in San Francisco. Welcome to GeriPal Podcast, Jay.

Jay: Thank you.

Alex: And we have Dan Drake, who is the President and CEO of Trinity Health PACE, which is the second largest PACE in the country and the largest nonprofit PACE. It's based in nine states, largely in the Mid-Atlantic/Northeast region of the United States. Welcome to the GeriPal Podcast, Dan.

Dan: Thank you for having me.

Eric: So this podcast is all things PACE. We'll talk about what is it, how you guys got interested in it, and what are some of the outcomes and where do we see it going in the future. But before we do, we always have a song request. Who has a song request for Alex?

Jay: I do. I do. I asked Alex to play a song by The Byrds, which was really dear to my heart. When I was in high school, I got a job loading equipment for The Byrds, and that was very influential in me choosing a different career path than being a roadie.

Eric: You actually traveled around with The Byrds?

Jay: Just within New Jersey, but yes.

Eric: That is awesome.

Alex: And Jay has an amazing catalog of all the bands he's seen, including the Grateful Dead some 30-odd times, Rolling stones, among many other incredible bands. Dan, what's your favorite concert?

Dan: Probably there's two of them, Elvis Costello and I saw The Clash at the Tower Theater outside of Philadelphia, a very small venue.

Alex: Oh, great. Great.

Dan: It was a lot of fun.

Alex: Those are great. All right. Well, here's a little bit of Hickory Wind.

Alex: (singing)

Eric: And we'll get a little bit more of The Byrds at the end of the podcast. So let's jump into to PACE. Dan, can you describe a little bit for me, what the heck is PACE?

Dan: I think Jay explained a little bit about it. It's a program for all-inclusive care for the elderly. It is a program that cares for the elderly 55 years and above. The program itself is a Medicare/Medicaid-capitated program. Again, when you look at it, you look at it as an inside out nursing home. We provide everything they provide in a nursing home, but you get to go home every night.

Dan: So think about this. You have socialization at a day center. The physicians come in at the day center. You have an interdisciplinary team made up of nurses, physicians, transportation drivers, therapists, social workers who manage your care plan to help you stay healthy and at home. So we are a home and community-based program that is financed from the state and federal government. So when you look at it as a provider, we're the provider and insurance company.

Eric: Yeah. So we're going to get into some of those topics in a little bit, including what the heck is capitated. But before we do, I'd love to hear from both of you how you ended up where you are in PACE. Jay, you want to describe a little bit about your history with PACE?

Jay: Sure. PACE started at the program that I currently work at, On Lok. It started in 1971. They opened their first center in 1972. I came to visit as a medical student, the first medical student doing the elective at UCF in geriatrics, and I was given a tour of On Lok by Marie-Louise Ansak, who was the developer of the model and also the first executive director.

Jay: I was simply enamored with it. When I finished my fellowships and came back to San Francisco, I started to volunteer at On Lok, initially on the physicians advisory council and then ultimately our quality and improvement committee. Then I was asked to be on the board of directors. Then very briefly, I was the treasurer, which asking a physician to manage a big checkbook is a big mistake. Then I was brought on as the chief medical officer. And so, I've worked for On Lok for 10 years.

Eric: What enamored you? Out of all the different models out there, why this one, Jay?

Jay: Well, I don't want you to feel very jealous about this, Eric, but when the geriatric fellowship started, there weren't a lot of faculty available in the United States. The UCSF fellowship really was the first west of the Mississippi, second in the United States. So initially they used to send us to England as part of our training. That's what I don't want you to be jealous of. [laughter]

Alex: What?

Eric: What? Don't tell our current fellows. [laughter]

Jay: Yeah, really. I went for a month, and we had a program with the British Geriatric Society that would bring British geriatricians to San Francisco for a month or longer. Then the fellows would go and be able to visit their departments around the country.

Jay: And so, I got to experience what they called day hospital. That was their alternative to nursing home placement. When we would normally have a patient that was too frail or needed more recovery after an acute illness, we would send them to a nursing home.

Jay: But they had this program where they would send you home and then pick you up, bring you to a day center, provide physical therapy, nursing supervision, occupational therapy, and socialization and meals. They would then wean you from that as you recovered. Eventually you were discharged from day hospital and you were back living at home.

Jay: Dan is going to recognize that's very similar to what ultimately became PACE. Indeed, On Lok brought the British geriatrician who had developed that model to San Francisco to help them learn about interdisciplinary teams, which at the time was unheard of, particularly for an outpatient program. I had really, really liked the logic of that when I was in England. Let me explain.

Jay: We would have interdisciplinary team meetings trying to facilitate people staying in their own home. Again, I don't want to date myself a little too much, but people still had outdoor privies on occasion as opposed to indoor plumbing, or they lived in homes where there was no handrail and brick steps to get in. Those two things would be barriers.

Jay: The British national medical system actually at that time was able to say, "We're going to have to pay for a nursing home. It's cheaper for us to put a toilet into the person's home and we'll pay for that. In a month or two, that'll be cheaper than if we had sent them to a nursing home."

Jay: Same thing with the handrail. I saw them ... I didn't actually watch them, but I knew that they installed handrails to make it so somebody could safely get in and out of their house after a stroke or because of arthritis or whatever their physical limitations were. I just said, "This is logical. Our American system is not." Then I came to PACE. I saw PACE and I realized, ah, that's the environment that could actually accomplish this.

Dan: Eric, that's some of the things we do here. If we notice that you're unsafe at home, instead of sending you to a nursing home, we go to your home, we look at your bathroom, your toilet. Is it the right level? Do you need some new flooring in your hallway? Do you need your home decluttered? We have a decluttering service. Or do you need some light washed on?

Dan: Again, for us to come out and do a physical therapy evaluation so you don't have throw rugs everywhere and you're tripping and falling and breaking your hip. That's one of the beauties of our program. We'd go back to that capitated rate. We get one rate and we can spend it any way we want to care for our participants to keep them safer at home.

Eric: Well, can I ask, can we dive a little bit deeper into how a PACE program is actually financed? You mentioned a capitated rate. What's a capitated rate?

Dan: You receive a capitated rate with this. It's set by either state or federal government. So we get a Medicaid, which is your state, and a Medicare rate. Each month, you get paid that for each participant in your program.

Dan: So it's great for budgeting for the state and federal government and it's great for budgeting for us. But we get that pool of money to spend on our participants. If you were in a nursing home and you broke your hip, you would get so many days of therapy.

Dan: Whether you were cured or not at the end of those days, you're off therapy, where our program, you get therapy until you're better. It might be less of a profit margin, of course, because we might keep somebody on 60 days until they're ready, but then they go home and they're thriving at home. We don't have hospital readmissions. We don't have nursing home readmissions. So it really works out for the state, the federal government, and our programs.

Eric: Dan, for this capitated rate, do you have to cover everything? If they get hospitalized, if they have to go to a nursing home, do you have to cover-

Dan: 100%.

Eric: 100%.

Dan: We are one of the few 100% risk-based healthcare businesses. We are a model for the country at this point. That is the key to this. We try to keep people as healthy and happy as we can in order to keep expenses down, of course, but it's the quality of life we're providing for them that gets much better because we have this capitated rate.

Jay: Well, I want to be clear. We're not responsible for healthcare unless they're in Canada, the United States, or Mexico. So that's pretty broad. We do have patients who end up getting hospitalized in other countries.

Dan: Yes, we do.

Jay: We're financially responsible. But if they're in a different part of the world, then we're not on the hook.

Alex: It's a lot of responsibility. I wonder if you could say ... We used to say that hospices ... Well, we still say, hospices are also paid a certain amount for each patient on a daily basis. I think it used to be $120. Now it's probably like $150, and I think there's some regional variation. But can you give us a sense of what the capitated rate is for PACE enrollees?

Jay: Alex, it actually varies, at least in California, from county to county.

Dan: And in our nine states, it varies drastically, where you have some that are very robust, because they're starting PACE centers. So they need the infrastructure, things like that. Then you have Pennsylvania who has a good Medicaid rate. However, once the infrastructure was put in 25 years ago, they did decrease it. That's what they do with like a Community Health Choices program.

Dan: Any new programs that come in Medicare/Medicaid, at the beginning, they have to pay the provider for the basis of your infrastructure. Once you have that, it normally does go down. But due to other factors like acuity, your Medicare rate looks at acuity and it can go up or down, depending on who's in your program at that time.

Jay: Yeah. For our audience that are physicians, it's not really acuity like a nursing home would judge acuity. It's based on diagnoses. So it's the same HCC mechanism that Medicare Advantage pays. That's why I didn't jump and answer your question, Alex, because the Medicare capitation rate can vary a lot between individuals depending on their diagnoses.

Eric: When we're thinking about ... It sounds like you have to cover everything. Does that include all medications? I know in the news lately we're talking about like $50,000 a year Alzheimer's treatments that probably-

Jay: I really have to say PACE did not start out capitated. In 1980, it became only capitated for the Medicare part. Then in 1983, they added the Medicaid part. That was such an elegant model because the cost of the drugs detracted from the care that you could provide. I remember our medical director at On Lok, when I was sitting in on that quality committee saying, "I don't think we should be providing Cognex," if you remember the first cholinesterase inhibitor.

Eric: The tacrine?

Jay: Tacrine.

Eric: Got it.

Jay: I don't think we should be providing it because it was $4 a day, which really seemed like a lot of money at the time. We could use that same money to provide better food or better activities and get more bang for the buck. So that was very elegant.

Jay: But something broke that model, and that's Medicare Part D, because our drugs are reimbursed through a big mechanism to Medicare Part D. If we include in our bid the cost of things like hepatitis C treatment or this new treatment for Alzheimer's, it gets reimbursed to us essentially through a different mechanism. It changes the capitation rate for drugs in a way that's a little less elegant, because we can treat everybody for hepatitis C and it doesn't detract $1 from the money we have for their food or their transportation. But it does make it a little more complicated.

Dan: Yes, it does. It's basically a pass-through, as Jay had said. So it doesn't affect our Medicare/Medicaid rate. It's a separate rate.

Jay: But 10% of PACE participants nationally don't have Medicare. Then the cost of the drug would entirely be coming through from the Medicaid payment that we get, which is usually considerably lower than the combined payment for Medicare and Medicaid. In those cases, payment for a very, very expensive chemotherapy drug, a monoclonal antibody for Alzheimer's, et cetera, is directly hitting your bottom line.

Eric: Wow! Well, I'm going to move away from drugs and financing to who's eligible for PACE.

Dan: Yeah, eligibility, again, it starts at 55 years of age. I think Jay, it was a little higher in the beginning of the program. They have to be nursing facility-eligible. So they have to be eligible to going to a nursing home.

Eric: Just for our listeners, what does nursing home-eligible mean?

Jay: Well, first of all, that eligibility criteria would be in the state regulations. So it differs a little bit from state-to-state. But you can think of ... It basically means that you are not capable of being managed in a lower level of care. So if you don't need nursing supervision and a lot of hands-on care 24 hours a day, then you are likely not to be eligible in any state.

Dan: Yeah, your ADLs have to be pretty high in most states and you have to have numerous diagnoses to get into the program. Then you have the financial metrics. You're looking at the Medicaid side. Again, each state is a little different, but you could only have so much in assets and so much in earnings each month. Not everybody ... As Jay said, 10% are not Medicaid eligible. So there is a private pay component also where-

Jay: Nationally, it's not 10% that aren't Medicaid eligible. It's only 1%.

Dan: Oh, that's correct. But, yeah, we have private pay, and we probably have about 2% in all of our programs that are private pay for this program. It's not a big number, I think. Most people do have Medicaid/Medicare, or dual.

Jay: There's a reason. I want to go back to what Dan said in his introduction, that we're a nursing home inside out, and we pay for everything that a nursing home pays for, because that's not really true. When you live in a nursing home, the government, Medicaid, is paying your rent, your room, and board. You're getting three meals a day and rent. Whereas if you're in a PACE program, you still have to pay your rent and you still have to buy your food other than the meals that the PACE program provides, which is often not three a day.

Jay: So really that's what makes it a less attractive deal for people that are privately paying, because, in essence, they're paying the Medi-Cal component, which, if they were in a nursing home, would include their rent and, separately, they're still paying their rent. So financially it's not as attractive, which is why the numbers Dan mentioned of 1% to 2% really is the national experience.

Alex: How do you get patients? I mean do you go out and seek them? Do you have geriatricians or primary care docs who regularly refer to you? Is it social workers who are typically making the referrals?

Dan: Yeah, we have a little of both. But most of it, we rely on our enrollment specialists. We do have enrollment specialists. They go to senior housing. They work often with discharge planners from the hospital where they see somebody rebounding back and forth to the emergency room in the hospital. We have a lot of physicians who feel this program would be better for their patient so that they could live at home. It's that in-between where a family or the patient, they don't want to go into a nursing home and the physicians will recommend our program. We do have some state and county offices that refer to us also. Jay, it might be a little different where you are.

Jay: No, it's the same mix of people. But one category that you mentioned was from geriatricians and other physicians. I can tell you from personal experience, I used to be in private practice and I had a couple that were so right for On Lok, so right for PACE. But I had to convince them to give up me being their doctor, because PACE is an all-inclusive package and generally it means you're going to give up your dentist, your podiatrist, your primary care doctor, and even many of your sub-specialists. So that took some convincing. It is also a barrier for enrollment in PACE.

Dan: It's absolutely a barrier for enrollment. Somebody who has had a physician for 30 years doesn't want to change to join our program, even with the physician's blessing, saying, "This is a good program for you."

Dan: We've had a lot of people come in and then decide, "Yeah, I am going to stay," after a little bit, but we've had a lot of people also come in and say, "I miss my physician,"...

Alex: Yeah. I remember talking to one of the UCSF primary care docs who takes care of ... He's a huge Asian panel. He said many of his patients just ... They don't want to let go and he's not going to push them out. He's pleased that they feel like they have a strong relationship with him and don't want to transition to PACE. So PACE is not for everybody who meets eligibility criteria.

Dan: That's correct.

Alex: Do you want to say a little bit about how PACE has ... Well, actually, I want to go back to the origin story a little bit more. I remember hearing that PACE was started in San Francisco by a social worker who-

Jay: Marie-Louise Ansak.

Alex: That was Louise Ansak. Who was trying to figure out how can we care for ... There's a big need for longterm care in the Chinese community and thought, first, well, maybe we'll build a Chinese nursing home, but that wasn't congruent with the values of the Chinese families-

Jay: That's right.

Alex: ... who wanted their loved ones to be at home with them, their older adults to remain embedded in the communities. And so, they developed this PACE model. Is that something close to-

Jay: That's really true, except that she talked to the seniors themselves, and they didn't want to go to a nursing home. Yeah, if they had to go to a nursing home, they'd want them to speak their language and serve food that was culturally appropriate. But really they wanted to stay at home whether they had nearby family or not.

Jay: That's always been the challenge of PACE. It's a lot easier to care for somebody who's living with family than somebody who's living, for example, in a single-occupancy hotel or a small apartment. But PACE always has been there to serve both.

Alex: At least in San Francisco, there's been this effort to maintain some community cohesion within the PACE. So, for example, I've visited the centers that have more of a Chinese American focus. I've visited the center that has a more African-American focus and the center that has a more Latino focus. I'm interested in thoughts behind that, maintaining that community cohesion within the PACE model. Then after that, from Dan, whether that's true in other places in the country.

Jay: Well, you live in the Bay Area. You know that we're truly a melting pot of different languages and cultures, particularly in the seniors. That becomes a real challenge because building a PACE center, I'm sure Dan is going to support this, is very expensive.

Dan: Yes.

Jay: And so, you can't build a PACE center for every language and ethnic community that you care for. You need to be able to integrate people, but retain cultural continuity and language ability as best you can. We have centers, for example, in San Jose, where we serve people that speak six different languages in addition to English, or instead of English.

Alex: Wow!

Jay: It really becomes very difficult. You can just imagine finding qualified geriatricians who coincidentally speak Mandarin and Spanish. We do have such people, but they're not easy to find, and it is every member of the IDT. Imagine trying to get speech therapy from a speech therapist that doesn't speak your language.

Jay: Then there's things beyond what you might routinely think of as culture. We have centers that were initially based in convents and we serve a large group of religious devotees, whether they're sisters or nuns. It's a big community, and these people need help. But we also had a contract with the veterans system to integrate veterans in.

Jay: So just imagine the activities that are equally of interest to retired teachers that are nuns and a group of male veterans. I want to please them both. I wanted a man-cave with football on the TV and beer, but it's hard to please everybody.

Jay: And so, those are the challenges that are part of longterm care in general. I know Dan has a background in the longterm care industry prior to PACE. It's as challenging in a nursing home environment as it is within PACE.

Dan: It is, and it sounds very similar. San Francisco sounds like Philadelphia, believe or not, where we have North Philadelphia, West Philadelphia, and South Philadelphia, where you have an Italian neighborhood, an African American neighborhood, and a Hispanic neighborhood. Then we have Saint Joseph University priests, we have the sisters at Immaculata, the sisters at McAuley House, and Assisi House.

Dan: Programming at each one of them is different. Really our physicians at each one of them are a little different. We really try to work with physicians who can speak the language of our center. We're very fortunate. We're living in Philadelphia and are able to do that. You're not always as fortunate when you have a location that might be in an area that doesn't have the diversity we do.

Dan: But it's a challenge, and it's a fun challenge, though, going to different locations and seeing the rec therapy that's going on, that you would go into one and you'd see something and you'd be amazed. We have the amazing Jimmy Wells who comes into West Philadelphia and things ... And he's like James Brown. He does this act that you wouldn't believe for us.

Dan: Well, some of our other center said, "Why doesn't Jimmy Wells come to our center?" We started to book him at each of the different ... And he was as big as a hit everywhere, which was wonderful for everybody. So even though you have a diverse population, great music is great music.

Eric: Yeah. So when I think about PACE, it goes back to what Jay was saying when he went to England. You put up a railing on the stairs. It just makes common sense.

Dan: It does.

Eric: It makes common sense. However, do we have any outcome data on PACE? Do we have any data around how people do with PACE or outcomes of it?

Jay: My primary outcome variable is a Kaplan-Meier survival curve, because everybody is eligible for a nursing home placement at the time they enroll in PACE. And so, I look at how long can we keep them in the community. I become very strict at my definition of the community.

Jay: I'm not including assisted living, which we can provide, even though it's not normally a Medicaid benefit. I don't count the convents as true community because it's so easy to keep people there. They're such great resources. It's not enough of a challenge.

Jay: Then we do own some housing, not in our PACE program but On Lok as a corporation has different branches. We do have housing that we provide for some of the PACE participants. It's too easy to keep people in our own housing.

Jay: I mean people who really live in what you and I would consider the community, how long can we keep them there? I can look at that parameter over time and see are we succeeding in our primary goal, which is to assist people to take some risk and stay in the community because that's what they want to do. [crosstalk 00:29:43].

Dan: A lot of this depends on the family. We have some wonderful family and community members that enable participants to stay in their home happy and healthy. If we didn't have them, a lot more people would transition to the nursing home.

Dan: Again, I don't think, Jay, both of us are very positive about nursing homes. There is a need for nursing homes. We're not saying anything negative about them. But if you had the option or the choice and you could to live at home, what would you rather do? Live at home.

Dan: I mean my parents are in their 80s. They live at home with assistance. My sister comes over Monday through Friday, and she's a godsend. If it wasn't for her, we'd have to look at other options. But you have services that can provide home health. You talked about hospice, palliative care. There's a lot going on out there.

Dan: I think with the Biden administration really coming out and supporting home and community-based programs and rebalancing from the majority of the people in nursing homes to the majority of people over the next ... And it's not going to happen in four years, but in the next 20 years to make it 50-50. We'll have to see how that works, but I'm very confident. It's a start.

Eric: Dan, do you know how many PACE sites there are in the US?

Dan: I really don't. I wish I have that-

Jay: I do.

Eric: Jay, what's the number?

Jay: As of last month, 272 PACE centers sponsored by 139 organizations.

Dan: Very good.

Jay: So On Lok has seven centers, but we're one organization.

Eric: Is it a rapid growth, Jay? Are we plateauing? Where are we on this growth curve for PACE?

Jay: It's a remarkably rapid growth over the last few years for a number of reasons, one of which is they changed the law and began to allow for-profit programs. Even though I'm quite nervous about that prospect compared to the non-profits that Dan and I work for, it has driven growth, which was probably why Congress authorized it.

Dan: I agree with you. I'm hesitant about some of the things, but guess what? They both have more centers and are able to serve more underserved people. Due to them opening it, we have been able to get capital funding through our organization and we have opened one center a year, which, again, that's a lot, believe it or not. We just today received capital permission to open another center in Florida.

Dan: So it's benefited us in one way and in other ways, we'll have to see what the longterm effect is with the for-profits in the industry. But they have the same requirements as we do. They have the same quality requirements and financial requirements. So it's a level playing field other than they have private equity money to start more sites.

Jay: Yeah. I can say the number of people enrolled in PACE has doubled in the last 10 years.

Alex: Wow!

Jay: So that's a pretty rapid growth.

Alex: Yeah. Now, as we said before, PACE isn't for everybody. But it's a key piece of the puzzle of how we care for older adults who are losing function, need assistance from other people, who have multiple chronic conditions. Where should PACE be? I mean do you think that PACE should be continuing to grow? It should be twice, three times, four times the size? Should it be the dominant paradigm for caring for older adults in this country? What-

Jay: Alex, the finances is predicated on nursing home eligibility. Otherwise, it makes no sense to the government to spend as much as PACE costs. Even though I'd love to have some of the services available through PACE for my parents who are in their 90s, luckily they're not nursing home eligible.

Jay: And so, that's the challenge of how do you expand the model beyond nursing home eligibility? The other barrier would be, okay, I think we all agree that the interdisciplinary team is part of the success of the model, and having the medical care be part of that interdisciplinary team is part of the success, but Dan mentioned people who are reluctant, you mentioned people who were reluctant to join PACE because they don't want to give up their primary care. The question is how do you provide this kind of model, but allow people to retain their own primary care?

Jay: There are examples of that, for example, in western Colorado, where it's such a geographically spread out low-population density area around Grand Junction, that they've come up with a model where people retain their primary care doctor and they have a nurse practitioner at the PACE center.

Jay: So there are ways that this can be tweaked to serve different populations, including people who are not quite nursing home-eligible and also different geographic areas that aren't right for the normal PACE model.

Dan: Right. We see another barrier as housing, where we are in the cities where there's not affordable housing. We have people in the Philadelphia area that are in nursing homes. They're nursing facility-eligible. They would thrive in our program, but there's no housing that they can live in.

Dan: That is a big initiative of ours to go into senior housing and try to find some sort of solution, because it's sad when you visit somebody who left a house in Philadelphia, wanted to stay in our program, went to the nursing home, when they came back, the house was no longer there or was repossessed or it's not livable in. We try to do anything to get them out. However, where are they going to go with the gentrification of Philadelphia to housing prices and you're in San Francisco? So I don't have to tell you, but the prices are going crazy at this point.

Alex: Crazy.

Dan: That has really limited our enrollment also, where they don't have a place to live. It's really sad.

Eric: I wonder, as you think about the next five or 10 years for PACE, where do you see PACE in 10 years?

Dan: Well, I think Jay had talked about the growth. Did you say in 10 years it's doubled? Is that what-

Jay: Yeah.

Dan: I think you're going to see that in five years. It's going to double because a bunch of states have just ... Right after Biden was elected, we received information on potential PACE sites in Mississippi, Maryland, new zip codes in Pennsylvania.

Dan: When you look at the opportunity to serve more elderly, who wants that the most? The government. The state governments really want these elderly served. So they are looking at this as a program, this, Community HealthChoices, and a couple other programs, where you live at home and you're happier, you're healthier, you live longer, you live more productive, and you benefit your community. So I do think it's like anything else, that was 10 years it doubled, maybe it's going to double in five years.

Eric: Dan, I also hear you talk about ... I know we talked about with Jay some metrics around his Kaplan-Meier curve around sitting at home. Do we have any metrics around do people live longer, or are there other quality measurements that are better in PACE than a nursing home?

Dan: I'll tell you my prejudice. This is the problem, that people in PACE are a little healthier than a nursing home population. So, yes, they live considerably longer than the average lifespan of somebody in a nursing home. I just don't think it's a fair comparison because these people are not being randomized to PACE or nursing home placement.

Eric: Yeah. However, if you were a drug company, you would just do some post-talk analysis and-

Eric: ... figure out that there's some signal of positivity and the FDA would totally approve. [crosstalk 00:38:03].

Dan: There's correlation. I mean I think that the truth is, in 1997, when they authorized PACE as a Medicare benefit, they were convinced by the data that was available. Then in 1999, there was an article in the New England Journal by Tom Bodenheimer that used the PACE model and had an economic analysis. Now we all know a lot about the economics have changed since the year 1999, but at that time they could very much show that the savings on the Medicare side made it cheaper to care for somebody in PACE than the same person in a nursing home environment.

Eric: Jay, 10 years, where do you see PACE?

Jay: Okay. I think that geriatrics in general, longterm care, is faced with a demographic challenge, and that is the people of working age that can work on the hands-on care, whether that's CNAs in nursing homes or home health aides in PACE, is not growing as fast as the population that's elderly and needs the care.

Jay: So I always look to Japan because they're ahead of us in that demographic imperative, and I see PACE having to incorporate more technology. In fact, if you go on YouTube and you do care robots, pretty much what you'll see is from Japan, the big ones that can do the transfer from a wheelchair to a bed or toilet or whatever. Those have to be really big robots. It's not like a little seal that's going to be good companionship, but it's certainly not going to help you get to the bathroom.

Jay: That's going to have to happen for PACE, because everything that we learned in our first economics class is going to mean that the labor to provide the hands-on care is going to become unaffordable for government programs like PACE.

Alex: I'm just having this vision of some giant robot helping a patient transfer. I guess I didn't [crosstalk 00:40:19].

Jay: Alex, you've got to look at those videos. They always have young models being transferred, because you could never get an older, particularly demented, person to cooperate for the video.

Dan: It would scare the heck out of them, faced with all that machine coming.

Alex: I'm sure. Many of our listeners are trainees. They may be earlier stage in their career. I've heard that PACE is a good place to work for doctors, for nurses, social workers. I just want to open it up as a pitch. I'm sure PACE isn't for everybody in terms of a place of employment, but speaking to our listeners now, do you have anything to say in terms of why work at PACE?

Jay: I do. I was in private practice and I worked with home care agencies. Occasionally was able to find a social worker to be working with my patient. But one of the just frustrating challenges of being a geriatrician in a resource-poor environment is you can't get what your patients need. I can treat their blood pressure, I can treat their diabetes, but I can't provide them what they really need.

Jay: In PACE, you're managing a very complicated panel, but usually around a hundred patients is your whole panel. And yet you're busy because you're helping provide the longterm care that they need. It's really complicated, but it's so much fun.

Jay: I'll tell you that I hired one of my friends who had been a trainee in the geriatrics program back when I ran it. She started to work for On Lok. About a month later, I asked her how things were going and, "What do you think?" She told me such a poignant anecdote. She said, "If I ever thought that when I hospitalize somebody, I have to worry about who's going to feed their cat, I would say, 'You're crazy.' But the reality is if that cat died while my patient was in the hospital, my patient would have no reason to stay at home. They'd have no reason to live."

Jay: And so, the PACE program had to come up with like how are we going to feed the cat while this person is hospitalized? She said, "I love it." And so, I think it's a fabulous job for people that like the big picture of geriatrics.

Dan: Yeah, and we have a lot of satisfaction with our colleagues, especially nurse practitioners, because they're really able to work to the extent of their license. Social workers, physical therapists, and nurses are very happy. Then you have to look at a lot of our caregivers who used to work at nursing homes and had to work double shifts just to make their salary.

Dan: We're here. Not that we're a 9:00 to 5:00. We start at 6:00 and then at 5:00, and then we'll have people on call. But it's Monday through Friday, normally. They can pick up other hours on the weekend. They're not as burnout. Everybody goes home. So from the program, they go home at the end of the day. So they're a little happier to work with also.

Dan: So we do have a lot of positive colleague engagement and satisfaction because of the fact that the participants go home also. So it makes everybody happy. Go into your own house? That's pretty good.

Eric: It's great. All right. Last question. Lightning question. You got a magic wand. You can make one change, let's say from a policy perspective, or really any perspective around pace. What are you going to use that magic wand for?

Jay: Oh, me.

Eric: Jay?

Jay: Housing. Our society needs to address the availability of housing, because we all say that we'd like to be cared for at home if we could be. But, as Dan mentioned, if you lose your home or societal changes mean you can no longer afford to live in your home. There's got to be a solution to that because, honest to goodness, the medical stuff is easy. We can always treat diabetes, hypertension. It's how do you keep somebody at home?

Dan: Yeah. I think that would have been mine also. So my number two is financing-

Eric: Financing.

Dan: ... that we can be properly financed for growth and for new facilities throughout the country.

Eric: Well, Jay and Dan, thank you. I just want to say for housing, I mean how much is a studio in Philly?

Dan: Well, we are right near University of Pennsylvania, at one location. So it varies.

Eric: Yeah. Let's aim on the higher. Probably like $2,000 a month.

Dan: Yeah, for a studio.

Eric: $2,000 times 12. That's what? $24,000 a year.

Eric: That's only half the cost of one year's of aducanumab. It's made its third appearance in this podcast.

Jay: Well, that's true, but it's also significantly less than a nursing home cost. The nursing home is such an inefficient way of dealing with this problem. Dan is absolutely right. There are people living in nursing homes who could live at home, but they've lost their house. The nursing home-

Eric: Well, before I bring up aducanumab for the fourth time, I want to be respectful of the time. Alex, do you want to give us a little bit more of The Byrds?

Alex: A little bit more Hickory Wind. (singing)

Eric: Jay, Dan, big thank you for joining us on this GeriPal Podcast.

Jay: Thanks for inviting us.

Eric: Thanks. Thank you as always, Archstone Foundation, for your continued support and to all of our listeners. Have a wonderful day.

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