Why specialty care matters so much in PACE
PACE gets one fixed monthly payment for each participant. That payment covers everything: primary care, medicines, hospital stays, and every outside specialist visit [1]. Each outside visit also needs a ride, often an escort, and most of a day for a frail participant.
So a referral is more than one claim. It is a claim, a ride, staff time, and a long day for the participant.
Many visits only need an answer
A lot of outside referrals start with a simple question the primary care team can't answer alone. Studies of eConsult programs show a large share of these questions can be answered in writing, without a visit [2].
| What the team needs | Best fit | Examples |
|---|---|---|
| Quick question | Curbside answer | A medicine dose, a lab value, “should we worry?” |
| Needs a written plan | eConsult note | New diagnosis, treatment change, chart-ready advice |
| Needs a test read | Procedure read | Echo, Holter, PFT |
| Needs to be seen | Tele-clinic | Complex or ongoing problems, seen on video at the center |
| Needs hands-on care | Outside visit | Procedures, hands-on exams, some new problems |
Going out is sometimes the right call
The goal is not zero referrals. Some participants need a procedure or a hands-on exam. The goal is the right care in the right place, so trips happen when they help the participant.
Run your own numbers
Use the free PACE Outside Specialist Cost Calculator. Enter your participants, outside visits, claim cost, ride cost, and the share your team thinks could stay in-center.
See how Beam supports PACE teams with curbside answers, eConsults, procedure reads, and tele-clinics on the PACE page.
Frequently asked
Who pays for specialist visits in PACE?
The PACE organization does. It gets a fixed monthly payment for each participant and covers all of their care, including outside specialists, rides, and escorts.
How many outside specialist visits does a PACE participant have?
Many programs plan for about 1.5 to 2.5 outside specialist visits per participant each year. Your own claims data is the best number to use.
What can be handled at the PACE center instead?
Questions about medicines, lab results, EKG, echo, Holter, or PFT reads, rashes, and follow-ups. A curbside answer, an eConsult note, or a scheduled tele-clinic can cover these.
Should participants ever go out to a specialist?
Yes. Procedures, hands-on exams, and some new problems need an in-person visit. The goal is the right care in the right place, not zero referrals.
What is the difference between a curbside and an eConsult?
A curbside is a quick question and answer. An eConsult is an official written specialist note that goes in the chart.
How do I estimate what my program could keep in-center?
Use the free PACE Outside Specialist Cost Calculator. Enter your participants, visits, claim cost, ride cost, and the share your team thinks could stay.
References
- 1.Centers for Medicare & Medicaid Services. PACE regulations, 42 CFR Part 460. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-E/part-460
- 2.Liddy C, et al. Electronic consultation systems: worldwide prevalence and their impact on patient care. Fam Pract 2016;33(3):274–85. https://pubmed.ncbi.nlm.nih.gov/27075028/
- 3.National PACE Association. What is PACE? https://www.npaonline.org/
This article is for general educational purposes only and is not medical, legal, billing, or coding advice. Reimbursement rules and amounts vary by payer, state, and year — confirm with a qualified billing professional and your payer's current policy before acting on anything here.
See how Beam approaches this in practice
Beam runs same-day specialist consults documented in the chart. The fit depends on your setting and payer mix — happy to walk through it.