Driving Better Outcomes Through Population Health Management in PACE

The “One Big Beautiful Bill Act,” or OBBBA, represents more than just a policy change; it ushers in a $1 trillion seismic shift in the healthcare landscape, creating significant funding risks for states and, by extension, for the Program of All-inclusive Care for the Elderly (PACE) programs that depend on them. For PACE, business as usual is no longer an option.

The New Reality: Navigating the Post-OBBBA Landscape

The OBBBA threatens the financial stability and operational capacity of every PACE program through significant funding cuts and increased administrative burdens. The squeeze is on. With reduced federal financing, states will be forced to make tough decisions, meaning PACE programs will be competing for a smaller pool of dollars, making it critical to demonstrate a clear return on investment. Furthermore, PACE faces the burden of proof through increased scrutiny and administrative overhead, with more frequent eligibility redeterminations increasing costs and risking census loss. While new Home and Community-Based Services (HCBS) and rural health funding opportunities offer a glimmer of hope, these lifelines will only be extended to the most efficient, effective, and data-savvy programs.

This brings PACE to its most effective response: going on offense. By embracing a robust, data-driven population health management strategy, PACE programs can not only mitigate these looming risks but also resoundingly prove their indispensable value in this new, cost-conscious environment.

The Tactical Response: Why Population Health Is Built For PACE

Population health management is a proactive, data-driven approach to improving outcomes for a defined group. Its goals, often referred to as the “triple aim”, improving health, enhancing the care experience, and reducing healthcare costs, mirror PACE’s mission. PACE’s holistic model, addressing medical, physical, social, and emotional needs while managing complex chronic conditions, already embodies population health principles. The opportunity now is to power this model with integrated data to unlock its full potential.

To put population health into action, PACE programs must first address a common challenge: their reliance on claims data. While claims data tells part of the story, covering diagnoses and costs, it is inherently incomplete. What’s often missing is the subjective data—the participant’s direct experience, their quality of life, and their true burden of illness. 

The solution lies in building a 360-Degree Participant View. This is the core “how-to” for true population health management. It requires integrating essential data sources: 

• Clinical Data from the EHR such as diagnoses, medications, fall incidents, and utilization patterns.
• Administrative Data from claims detailing services used and associated costs.
• Patient-Reported Data, which is often the missing link, providing crucial subjective assessments on health status and quality of life directly from participants. 
• Social Determinants of Health (SDoH)including critical information on factors like housing stability, food security, and transportation.
• Evidence-Based Research to inform and validate successful intervention strategies.

When combined, these insights provide a complete picture, enabling more targeted, effective care.

From Reactive to Proactive Care

This integrated, participant-centered approach shifts care from reactive to proactive, delivering the right care at the right time at the right frequency. It allows PACE to spot high fall risks before incidents occur, act on declines in self-reported quality of life instead of waiting for lab values to change, and address root causes early preventing costly ER visits and hospitalizations. This leads to fewer unnecessary hospitalizations, more appropriate interventions, and care plans that reflect what matters most to the individual. This is precisely how PACE can lower costs and prove undeniable value to the state in the post-OBBBA world.

The Data Strategy Every PACE Program Needs Now

The time to prepare is now. The deadline for states to submit Rural Health Transformation plans is December 31, 2025, and to make their case effectively, they need data.

Every PACE leader is urged to take these crucial steps:

• Assess current data capabilities. Leaders should ask: Can EHR, claims, and patient-reported data be easily integrated today? Is there a clear picture of the SDoH impacting their population? Can ROI be proven with hard numbers?
• Identify technology & strategy gaps. This is complex, and programs don’t have to go it alone. Seek out partners and platforms specifically designed to unify disparate data sources and provide actionable insights tailored to the unique needs of the PACE population.
• Launch a pilot initiative. Start small and make it achievable. Focus on one high-impact area, perhaps the most complex participants, or a specific outcome like reducing hospital readmissions. Then use an integrated data approach to rigorously track interventions, prove the results, and build a powerful case study that showcases value.

The OBBBA presents a formidable challenge, but it is also a powerful catalyst for evolution. The PACE programs that master their data, wholeheartedly embrace true population health, and deepen their commitment to participant partnership will not only weather this storm but will emerge as the undisputed leaders in elder care. They will be the programs that states look to as the model for the future—a future that is efficient, effective, and, above all, profoundly participant-centered. This is an opportunity for PACE to seize the moment and thrive.

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