PACE Outside Specialist Referral Cost Calculator
Yearly outside specialist cost = participants × outside visits per participant × (specialist claim + ride and escort cost). A PACE program with 150 participants, 2 outside visits each per year, a $425 claim and about $600 for the ride, escort, and staff time spends about $307,500 a year. If 65% of those visits could be handled in-center, about $200,000 and 585 participant hours stay with the program.
Inputs
Total outside specialist visits last year ÷ average enrollment.
Van or contracted ride, escort hours, scheduling, and staff time.
Visits a curbside answer, eConsult, or tele-clinic could cover.
Note: This is a planning estimate. Some participants need to see a specialist in person, and that is the right call. In-center options don't replace that. They cover the questions that don't need a trip.
Formula
Visits/year = Participants × Outside visits per participant. Yearly cost = Visits × (Claim + Ride). Visits kept = Visits × In-center %. Dollars kept = Visits kept × (Claim + Ride). Hours saved = Visits kept × 3.
Worked example
A PACE program has 150 participants. Each one sees an outside specialist about 2 times a year: 300 visits. Claims are about $425 each ($127,500) and each trip costs about $600 for the ride, escort, and staff time ($180,000). Total: $307,500 a year. The care team thinks 65% of visits could be handled with a specialist's answer in-center: 195 visits, about $199,875 kept and 585 participant hours saved.
Benchmarks
| Measure | Planning range |
|---|---|
| Outside specialist visits per participant per year | About 1.5–2.5 (varies by program and region) |
| Specialist claim per visit | About $300–$600 (Medicare-based contracts) |
| Ride, escort, and staff time per trip | About $400–$1,000 (wheelchair van, escort hours, scheduling) |
| Specialty questions that can be answered by eConsult | Often 50%–75% in published eConsult studies |
These are editable planning estimates, not national PACE benchmarks. Use your own claims and ride data when you can.
Frequently asked
How much does a PACE program spend on outside specialists?
It depends on enrollment and contracts. A program with 150 participants and 2 outside visits each per year, at about $425 a claim and $600 per trip for rides and staff, spends about $307,500 a year.
Why does PACE pay for every specialist visit?
PACE gets a fixed monthly payment per participant and covers all of their care. Every outside visit, ride, and escort comes out of that same payment.
Which specialist visits can stay in-center?
Many questions just need a specialist's answer: a medicine change, a lab result, an EKG or echo read, a rash. Curbside answers, eConsults, and scheduled tele-clinics cover those without a trip.
Is sending a participant out ever the right call?
Yes. Procedures, exams that need hands-on care, and some new diagnoses need an in-person visit. This tool only counts the visits your team thinks could be handled in-center.
How do I find my own numbers?
Pull last year's outside specialist claims and ride logs. Divide visits by average enrollment. Then ask your primary care team which visits a specialist's written answer would have covered.
References
- 1.Centers for Medicare & Medicaid Services. Programs of All-Inclusive Care for the Elderly (PACE), 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 — a systematic review. 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 calculator is for general planning and educational purposes only and is not clinical, legal, billing, or financial advice. Confirm all reimbursement, regulatory, and financial figures with a qualified professional and your organization's current policies before acting on anything here.
Where Beam fits
Curbside answers, eConsult notes, procedure reads, and tele-clinics from a core team of specialists, at your PACE center.
See PACE specialist care