e-Texas Recommendations

Bienvivir Senior Health Services in El Paso, a Program for All-Inclusive Care for the Elderly (PACE) site, provides an alternative to nursing home care for frail, elderly Texans who qualify for Medicaid nursing home care. PACE saves the state and federal governments an estimated 14 percent compared to the cost of regular nursing home and medical care, and supports community decision-making in designing long-term care options. The state should expand the PACE program throughout the state.

Background

Elderly citizens with serious medical needs must navigate a health care system that offers little or no coordinated care, with their doctors and hospitals often operating independently of their home health care or nursing home facilities.[1] These individuals often have multiple health conditions, an average of three per person entering home health care, which further complicates their medical treatment.[2] Elderly Texans must seek qualified doctors and hospitals for their various conditions, visit multiple agencies for government assistance, and evaluate a bewildering array of long-term care programs.

The Program for All-Inclusive Care for the Elderly (PACE) provides frail elderly citizens and their families in El Paso, Texas and in sites across the nation, with an alternative to nursing home care. PACE provides complete health care services at the community level for frail elderly residents who qualify medically and financially for Medicaid nursing home care. Most PACE participants also qualify for Medicare, the federal health insurance program for the elderly. PACE provides participants with a full range of health care and long-term care services, yet it costs less than traditional Medicaid nursing home programs.

Operating in 25 locations across the nation, PACE allows frail, elderly individuals to live at home instead of entering a nursing home, and involves families in treatment decisions. Mr. and Mrs. Jose Miguel Monzón of El Paso were struggling to continue living in their own home. Mrs. Monzón was taking care of her frail husband, but her own health was deteriorating steadily. Now they are both enrolled in Bienvivir. Mrs. Monzón reports, “...Now all our health care needs are taken care of and, what’s most important, we are no longer depressed, we enjoy the company of other participants, we love the parties and wish we could dance the tango again!”[3]

PACE brings long-term care planning to the community level. Each PACE site chooses a mix of appropriate services for its residents, negotiates with local doctors and hospitals for locally-determined rates, and decides the best way to provide care for its clients. Each PACE site has different affiliations, different service arrangements, and other distinguishing characteristics based on unique community needs.

PACE services are different from standard Medicaid home health care programs. Other Medicaid home care programs are restricted in the type or the amount of services they can provide. These limits are dictated by the terms of the federal approval that Texas receives to operate the programs. PACE can provide participants with all needed services for as long as they are required.

PACE funding is also different from Medicaid home care funding. Medicaid generally reimburses providers a predetermined fee after they have provided a particular service. In contrast, PACE sites receive a set amount of funding, or capitation, each month from Medicare and Medicaid before providing care.[4] PACE programs then provide participants with appropriate services for as long as necessary without federal restrictions.

The PACE team, which includes a staff physician and other medical professionals, assesses participants at the PACE adult day care center or at home to identify and treat medical problems before they require hospital care.[5] If needed, PACE sites provide or contract for medical specialists and hospital or nursing home services. Participants typically visit the PACE adult day care center several times a week.[6]

Each PACE site has a strong incentive to provide needed services promptly and efficiently, because PACE sites are completely responsible for participant health care, including more expensive services that participants may need if their health declines. Except for cases of kidney disease, PACE does not receive additional money for hospitalizations or other expensive care. PACE sites must provide the care using the monthly payments they receive. If the services for a PACE participant are more expensive than the monthly payment, the PACE site must fund the care. If services are less expensive, then PACE sites can keep the money to fund other care or expenses.

Participants enter PACE voluntarily, and they can leave the program at any time and re-enter the regular Medicaid and Medicare programs. In fact, many remain in the PACE program until they die.[7] Under federal law, participants in any PACE project must:

PACE Quality Results

Studies indicate that PACE participants require fewer days of inpatient hospitalization than other Medicare recipients. In 1995, PACE participants required 2,399 days of hospital care per 1,000 enrollees. Medicare beneficiaries, by contrast, required 2,448 days of hospital care per 1,000 participants.[9] PACE enrollees also had shorter hospital stays than elderly Medicare recipients, about 4.1 days compared to 6.6.[10] This is especially significant because PACE enrollees nationwide had an average of 7.8 medical conditions and 2.7 conditions that limit daily activity, while the elderly Medicare population includes healthy adults ages 65 and over.[11]

PACE Savings

PACE savings vary from state to state for many reasons, including different eligibility requirements for nursing home certification, community-based services in the state, and number of Medicaid-eligible recipients.[12] The PACE program in El Paso costs the state and federal governments about 14 percent less than regular Medicaid nursing home care.[13] These savings could be replicated in additional sites throughout Texas.

Other studies indicate that PACE allows frail elderly persons to live at home and receive comprehensive medical care at a 12 to 20 percent savings compared to the federal Medicare and Medicaid programs.[14] State Medicaid agencies estimate that the PACE model costs between 5 to 15 percent less than equivalent nursing home care.[15] A study by Abt Associates, Inc. found that actual PACE Medicare costs were 38 percent less than projected Medicare reimbursement in the first six months following a participant’s enrollment, and 15 percent less for the six subsequent months.[16]

PACE in Texas: Bienvivir Senior Health Services, El Paso

Established in July 1987, Bienvivir Senior Health Services in El Paso is the only Texas PACE program. Bienvivir, a private non-profit organization, operates two senior centers and encouraged the development of a separate non-profit organization called Casa Bienvivir, a 40-unit Department of Housing and Urban Development (HUD) housing operation. Bienvivir also is constructing additional facilities, including a personal care home.[17]

Bienvivir provides comprehensive acute and long-term health care and related services to about 367 elderly Texans who qualify medically and financially for nursing home care, but choose to live in their communities and receive alternative services.[18] At Texas’ Bienvivir site, program participants as of May 2000 had an average of 9.3 medical conditions, and over 80 percent depended on someone to help them prepare meals, take medications, pay bills, or perform other daily activities.[19] Despite the number and severity of participant medical conditions, analysis by the Texas Comptroller’s office indicates that Bienvivir saves the state and federal governments about 14 percent compared to the statewide costs of regular nursing home and medical care for the frail elderly.[20]

PACE sites like Bienvivir in El Paso are patterned after the 20 year-old On Lok Senior Health Services program in San Francisco, California. “On Lok,” meaning “a place of peace and happiness” in Cantonese, was the first program to integrate acute and long-term care services in the US. In 1986, federal legislation mandated ten US sites, including Bienvivir Health Services in El Paso, to replicate the On Lok model. In 1990, federal legislation increased the number of PACE sites to 15.[21]

Twenty-five PACE sites receive monthly funding from both Medicaid and Medicare, while nine sites receive Medicaid funding only. Massachusetts leads the nation with five PACE sites, while California and New York have four sites each. [22]

Reasons to Duplicate Bienvivir’s Successes

Prior to 1997, PACE sites operated under federally approved Medicare and Medicaid waivers.[23] The waivers allowed a limited number of sites to operate under both Medicare and Medicaid programs, and allowed program expansions for states that operated under Medicaid only. The Balanced Budget Act of 1997 (P.L. 105-33) allowed states to adopt PACE as part of their regular Medicaid program, instead of by waiver, and increased the number of possible sites.[24] The legislation restricts the number of eligible PACE sites to 60 provider agreements in the first year after the program’s enactment and 20 each year after that, for a total of 100 in 2000.[25]

According to the US Health Care Financing Administration, the agency which approves new PACE sites, there is “tremendous interest” from states in developing PACE sites. Two states, New Jersey and Washington, already have submitted plans to include PACE in their regular Medicaid program, and according to the National PACE Association, at least 41 organizations are exploring the feasibility of starting PACE sites.[26]

Replicating a model like Bienvivir in other Texas locations would allow the state to meet some of the long-term health needs and increased costs posed by growth in the state’s elderly population. The “baby boomer” generation, which will begin turning 65 in 2011, will increase the size of the nation’s elderly population dramatically. Nationwide, people age 65 and over are projected to increase from 12.8 percent of the total population in 1996 to 20 percent in 2030. In addition, more elderly people are expected to live beyond the age of 85.[27]

By 2025, Texas’ population is expected to grow to nearly 27.2 million.[28] Texas experienced a 46 percent growth in residents age 85 and older between 1980 and 1990.[29] By 2025, Texas likely will rank third among states with the highest number of people 65 and over, moving up from fifth in 1995.[30]

Population growth increases the demand for health care services, which in turn increases costs. According to the Congressional Budget Office, the US spent over $120 billion, or more than 10 percent of national health expenditures, on nursing home and home health care in 1998. In 2000, 7.5 million people age 65 or older (about 21 percent of the elderly population) are expected to require some long-term care help. Of these, 1.5 million will be in nursing homes; 2.2 million will receive care while living in their communities; and the rest may use long-term care services occasionally.[31]

Removing Bureaucratic Barriers to PACE Expansion in Texas

New PACE sites in Texas will face unnecessary barriers to starting operations under current state agency policies. Barriers include a plan to require PACE sites to be licensed as health maintenance organizations (HMOs), excessive estimates of startup costs, and unnecessary state steps to obtain federal approval for new PACE sites.

The Texas Health and Human Services Commission (HHSC) recently decided to make PACE an optional state Medicaid program and approved feasibility studies for three additional PACE sites in Amarillo, Galveston, and Harlingen; however, HHSC and the Department of Human Services (DHS) will require new sites to be registered as HMOs in Texas. According to DHS, the purpose of the HMO requirement is to ensure that new sites have sufficient financial backing to support operations. The Balanced Budget Act requires sites to assume complete financial responsibility for the costs incurred on behalf of PACE participants, while the original PACE sites could share risk with Medicare and Medicaid for three years if costs were higher than government payments.[32] DHS reports that it will not require Bienvivir to become licensed as an HMO.[33]

Federal law does not require PACE sites to be licensed as HMOs; it simply requires them to be financially solvent. In fact, Missouri is the only state that requires HMO licensing for their PACE site. Requiring new PACE sites to be licensed as HMOs will deter potential sites from participating in PACE and will unnecessarily slow the start-up process for new sites.

There are high risk reserve requirements for HMO licensing and lengthy licensing processes. A risk reserve is a pool of funds set aside in case expenses exceed revenues. HMOs are required to set aside a $1 million risk reserve fund to become licensed as limited service HMOs and a $500,000 fund to become single service HMOs. PACE sites likely would become single service HMOs; none are licensed currently in Texas. In addition, applicants could receive their HMO licenses anywhere from 60 days to two years after they submit the required information to TDI, depending on the completeness of their applications.[34]

HMOs and PACE sites have different characteristics and handle financial risks differently. HMOs serve large populations that include healthy people who incur limited medical expenses. They can cover high costs and higher health service use by a smaller portion of their members who are ill, because their financial risk is spread over a larger pool of generally healthy individuals.

By contrast, PACE sites care for frail, elderly individuals who qualify for nursing home care. All of these participants will require intensive services. PACE health care teams manage participant care, focusing on early identification and prevention of health problems, frequent monitoring of participant health, and use of lower cost services at the appropriate time to prevent more serious conditions that could require nursing home care or hospitalization.[35] PACE sites in operation for more than two years serve an average of almost 400 persons each, substantially less than most HMOs.[36]

The goals of HMO licensing and its risk reserve requirements differ from the fiscal solvency goals required for PACE organizations. High HMO risk reserve requirements ensure that HMOs have enough resources to take care of HMO enrollees if the HMOs encounter financial difficulties and leave the market. In the case of HMOs, risk reserves ensure that enrollees will be able to obtain medical care. Continuing care is not a concern for PACE participants, however, because they would be able to return to regular Medicare and Medicaid programs if a PACE site could not meet its financial obligations.

Other states have used different mechanisms to ensure fiscal solvency for PACE sites. Some require new PACE sites to establish risk reserves equivalent to several months’ worth of operating expenses. States also may exempt PACE sites from HMO licensing requirements.[37]

Currently available to PACE sites, purchasing reinsurance, insurance coverage purchased to limit potential losses on a particular risk, is one way for sites to meet federal solvency requirements and help guard against catastrophic costs.[38] Reinsurance reduces the impact of losses on individual PACE sites and is a practical alternative to HMO licensing requirements.

Although DHS estimates start-up costs of about $2.5 million to $3 million for each new PACE site, start-up costs for existing PACE sites have ranged from $1 million to 1.5 million, including capital renovation costs and operating deficits during the initial 18 to 24 months of operation.[39]

Currently, DHS plans to request one Medicaid plan amendment for Bienvivir, and additional amendments for each new PACE site.[40] According to the federal government, Texas only needs to submit a single state Medicaid plan amendment. New sites will submit separate applications to the federal and state governments, but additional Medicaid plan amendments are unnecessary.[41]

Recommendations

A. State law should require the Department of Human Services (DHS) and the Health and Human Services Commission (HHSC) to expand the number of Program for All-Inclusive Care for the Elderly (PACE) sites and should outline the way Medicaid funds PACE sites.

PACE provides a cost-effective alternative to nursing home care. Existing medical facilities, such as hospitals or nursing homes with unused capacity, can be converted to PACE sites with minimum conversion or acquisition costs. Legislation should require DHS to reimburse PACE sites under Medicaid with the same Medicaid rate methodology it uses for the Bienvivir program. Bienvivir rates are calculated using nursing home costs in El Paso County, and adjusted for various savings and expenditures. This will ensure state and federal cost savings.

B. State law should mandate DHS and HHSC to require new PACE sites to purchase reinsurance or establish risk reserves to ensure that new PACE sites meet federal solvency standards.

DHS and HHSC should require PACE sites to meet a set amount of risk reserve based on expected monthly costs, or to use reinsurance to meet risk management needs, as directed by the Texas Legislature. Legislation could specify either reinsurance or risk reserves, since both may not be necessary. This requirement will eliminate the unnecessary burdens of an HMO licensing requirement.

C. HHSC, in conjunction with DHS, should streamline the PACE application process and the process of submitting a Medicaid state plan amendment for Bienvivir.

HHSC should submit an initial Medicaid plan amendment with provisions for Bienvivir and subsequent PACE sites, as outlined by federal requirements. A shorter state and federal paperwork approval process would allow Texas to implement additional PACE programs more quickly.

D. State agencies should assist potential sites in designing marketing plans for PACE services. In addition, DHS staff should communicate the availability and advantages of PACE to eligible clients.

Some PACE projects had initial difficulties in enrolling participants, but Texas can assist new PACE sites to market their services appropriately. DHS, the Texas Department on Aging, local Area Agencies on Aging (AAA), and new PACE sites should develop coordinated marketing plans for new PACE sites. Marketing plans should employ techniques used successfully in other PACE sites, including person-to-person contacts and follow-up visits. DHS should develop policies and procedures to ensure that caseworkers and other DHS program staff members are knowledgeable about the PACE program and that they discuss PACE with long-term care clients.

E. HHSC should expand feasibility studies for potential PACE sites and work with other agencies to recruit communities and ensure thorough, accurate evaluations of localities interested in starting a PACE site.

HHSC should expand the number of feasibility studies immediately from three to eight, and work with AAAs and other local groups to identify potential PACE sites. In addition, HHSC and DHS should use resources and assessment tools available from PACE sites across the nation that have formed PACE Technical Assistance Centers to evaluate Texas geographical regions with a high need for nursing home care, or other demographic indicators as potential PACE applicants, and work to foster interest in PACE in those areas.

Sites should fund their own start-up costs to demonstrate their financial solvency, as well as their level of community support.

F. HHSC and DHS should report to the Legislature on additional changes in federal law that are needed to encourage the expansion of PACE sites in Texas.

The Balanced Budget Act of 1997 (P.L. 105-33) limits the number of new PACE sites to 20 each year, with a current limit of 100 total sites. If other states receive federal approval for PACE sites before Texas does, Texas should request a change in federal law to increase the number of PACE sites allowed.

Fiscal Impact

Total savings depends on the rate of future site development and participant enrollment. This fiscal estimate assumes that five new PACE sites will be established by the end of 2002, five more will be added in 2003, and an additional five, for a total of 15, will be added in 2004.

Total savings for the biennium would be $7,099,000 in general revenue and $10,905,000 in federal funds. Total savings for five years would be $32,656,000 in general revenue and $50,163,000 in federal funds. To achieve these savings, $6,953,000 in general revenue and $10,680,000 in federal funds would need to be deducted from the DHS budget, and $146,000 in general revenue and $225,000 in federal funds would need to be deducted from the Texas Department of Health Medicaid budget for the biennium.

At the discretion of the Texas Legislature, these funds could be redirected to fund increased needs for community care or nursing home care.

FiscalYear	Savings/(Cost) to the General Revenue Fund	Savings to Federal Funds	TotalSavings
2002	$1,420,000	$ 2,181,000	$ 3,601,000
2003	$5,679,000	$ 8,724,000	$14,403,000
2004	$8,519,000	$13,086,000	$21,605,000
2005	$8,519,000	$13,086,000	$21,605,000
2006	$8,519,000	$13,086,000	$21,605,000

[1 ] Catherine Eng, James Pedulla, G. Paul Eleazer, Robert McCann, and Norris Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” Journal of the American Geriatrics Society (February 1997), p. 224.

[2 ] US Department of Health and Human Services, Centers for Disease Control and Prevention, Vital and Health Statistics, The National Home and Hospice Care Survey: 1996 Summary (Hyattsville, Maryland, October 1999), p. 2.

[3 ] Cecilia M. Lang, “How an Angel was Sent in Answer to a Prayer,” The Good Life News (Draft, to be published Fall 2000).

[5 ] Eng, Pedulla, Eleazer, McCann, and Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” pp. 225-226.

[6 ] National PACE Association, PACE Profile, 2000, p. 10 (http://www.natlpaceassn.org/education/publications/profile/p10.shtml). (Internet document.)

[7 ] National PACE Association, PACE Profile, 2000), p. 5 (http://www.natlpaceassn.org/education/publications/profile/p05.shtml). (Internet document.)

[8 ] US Health Care Financing Administration, PACE Questions and Answers, May 10, 2000 (http://www.hcfa.gov/medicaid/pace/paceq&a.htm). (Internet document.)

[9 ] Eng, Pedulla, Eleazer, McCann, and Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” p. 229.

[10 ] National PACE Association, Success to Date (San Francisco, California, July 1999), p. 1.

[11 ] Eng, Pedulla, Eleazer, McCann, and Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” p. 229.

[12 ] Telephone interview with Christine Van Reenen, director of Public Policy, National PACE Association, Alexandria, Virginia, May 8, 2000.

[13 ] Calculations based on letter from Kathy E. Hall, rate analyst, Texas Department of Human Services, to Rosemary Castillo, executive director, Bienvivir Senior Health Services, El Paso, Texas, January 20, 2000; letter from Nancy N. Kimble, rate analyst, Texas Department of Human Services, to Ms. Rosemary Castillo, August 31, 2000; interviews with David Cook, Texas Department of Human Services, Austin, Texas, August 7-8 and September 1, 2000; interviews with Nancy N. Kimble, rate analyst, Texas Department of Human Services, Austin, Texas, August 8 and August 29, 2000; memorandum from Sylvia Gomez, Texas Department of Health, to Kathy Hall, rate analyst, Texas Department of Human Services, Austin, Texas, November 3, 1999; interview with Sylvia Gomez, Texas Department of Health, August 28, 2000; telephone interview with Rosemary Castillo, executive director, Bienvivir Senior Health Services, El Paso, Texas, August 15, 2000; telephone interview with Alan White, Abt Associates, Cambridge, Massachusetts, August 9, 2000; and interview with Gerardo Cantu, PACE analyst, Texas Department of Human Services, Austin, Texas, August 31, 2000.

[14 ] Bienvivir Senior Health Services, History and Purpose of the Organization (El Paso, Texas, December 29, 1999), p. 1.

[15 ] Eng, Pedulla, Eleazer, McCann, and Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” p. 230.

[16 ] Abt & Associates, Evaluation of the Program of All-Inclusive Care for the Elderly (PACE): The Effect of PACE on Costs to Medicare: A Comparison of Medicare Capitation Rates to Projected Costs in the Absence of PACE, by Alan J. White (Cambridge, Massachusetts, July 30, 1998), p. 23.

[17 ] Terry Morrison, “Integrated Approaches to Long Term Care Network in Texas,” Texas Journal on Aging (Spring 1999), p. 28.

[18 ] Bienvivir Senior Health Services, Program Status Report, Reporting Period 05/01/2000 through 05/31/2000 (El Paso, Texas, July 13, 2000), p. 1.

[19 ] Bienvivir Senior Health Services, Program Status Report, Reporting Period 05/01/2000 through 05/31/2000, p. 2.

[20 ] Calculations based on letter from Kathy E. Hall to Rosemary Castillo; letter from Nancy N. Kimble to Ms. Rosemary Castillo; interviews with David Cook; interviews with Nancy N. Kimble; memorandum from Sylvia Gomez to Kathy Hall; interview with Sylvia Gomez; telephone interview with Rosemary Castillo; telephone interview with Alan White; and interview with Gerardo Cantu.

[21 ] Laurence G. Branch, Robert F. Coulam, and Yvonne A. Zimmerman, “The PACE Evaluation: Initial Findings,” The Gerontologist (Washington, DC, 1995), pp. 349-359.

[22 ] National PACE Association, “What is PACE?” July 1999 (http://www.natlpaceassn.org/overview/pace/locations_dual.shtml). (Internet document.)

[25 ] Telephone interview with Christine Van Reenen, director of Public Policy, National PACE Association, Alexandria, Virginia, May 15, 2000.

[26 ] Telephone interview with Sandy Khoury, Texas PACE project officer, US Health Care Financing Administration, Baltimore, Maryland, September 12, 2000.

[27] US Bureau of the Census, 1997 Population Profile of the United States (Washington, DC, 1998), p.50.

[28] US Bureau of the Census, Economics and Statistics Administration, Population Projections: States, 1995-2025 (Washington, DC, May 1997), p. 3.

[29 ] US Bureau of the Census, Economics and Statistics Administration, 65+ in the United States, by Frank B. Hobbes with Bonnie L. Damon (Washington, DC,1996), p. 5-3.

[30 ] US Bureau of the Census, Population Division, Populations Projections Branch, Population Projections for States by Age, Sex, Race and Hispanic Origin: 1995 to 2025, by Paul R. Campbell (Washington, D.C., October 1996) (http://www.census.gov/population/www/projections/ppl47.html). (Internet document.)

[31 ] US Congress, Congressional Budget Office, Budget Options, by Joseph Antos, Sandra Christensen, Ralph Smith, and Bruce Vavrichek, (Washington, D.C., March 2000) (http://www.cbo.gov/showdoc.cfm?index=1545&sequence=2). (Internet document.)

[32] Interview with Gerardo Cantu, Department of Human Services, Austin, Texas, May 8, 2000; Letter from Becky Beechinor, assistant deputy commissioner for Long Term Care Services, Texas Department of Human Services, to The Honorable Carl Isett, Texas House of Representatives, July 31, 2000.; and “PACE Demos Await Permanent Reg; HCFA Approves Seattle Offering,” Managed Medicare & Medicaid (August 3, 1998).

[33 ] Letter from Becky Beechinor to The Honorable Carl Isett, Texas House of Representatives, July 31, 2000.

[34 ] Telephone interview with Blake Broderson, director of the HMO Division, Texas Department of Insurance, Austin, Texas, August 15, 2000; and Telephone interview with Wanda Perez, HMO Licensing, Texas Department of Insurance, Austin, Texas, August 16, 2000.

[35 ] Eng, Pedulla, Eleazer McCann, and Fox, “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing,” p. 225.

[36 ] Calculation based on National PACE Association, “PACE Cross-Site Comparison, January – December 1999,” (Alexandria, Virginia, May 9, 2000) (DataPace standard reports.)

[37 ] California Health and Safety Code, Section 1343.1, Division 2, Chapter 2.2, Article 1, (2000), Deerings California Codes Annotated, Title 26 Human Services Code, Art. 4, Part 1, Subpart 2, Colorado Revised Statutes, 26-4-124 (7), Title XXX, Social Welfare, Florida Statutes 430.707, (1999), and 320 Illinois Compiled Statutes Annotated 40/15 (2000).

[38] Memorandum from Ellen Tishman to National PACE Association Members, November 16, 1998; and On Lok Senior Health Services, PACE Reinsurance, Request for Proposal (San Francisco, California, 1998).

[39] Interview with Gerardo Cantu, May 8, 2000; and State Work Group on PACE, National PACE Association, “Site Selection and Application Process for PACE,” Alexandria, Virginia, April 1, 1999, p.12.

Expand the Use of an Effective Long-term Care Program

Summary