Six PACE Predictions for 2026

This article was originally published on McKnights Home Care.

The mission of the Program of All-inclusive Care for the Elderly (PACE) isn’t changing in 2026, but the mechanics behind payment and measurement are. Leaders will face tighter risk scoring, higher expectations for defensible diagnosis submission, and Medicare Part D redesign effects that can change pharmacy operations and partner behavior.

Takeaway: In 2026, risk scoring and diagnosis integrity can’t live in a silo. Strong programs will coordinate across clinical, coding, compliance and pharmacy — and use medication management to validate diagnoses and reduce compliance risk, not just manage cost.

Prediction 1: Risk scoring tightens. Documentation gaps will have consequences.

For 2026, PACE risk scores will use a blend: 10% from the 2024 CMS HCC model (V28) and 90% from the 2017 model, with a full transition expected by 2029. Even during the blend, scoring becomes more sensitive to documentation quality and timely, clean submission. The practical shift is operational: maintain a traceable thread from assessment → diagnosis → care plan → treatment → outcomes → submission, so each submitted diagnosis is clinically supported and defensible.

Prediction 2: Diagnosis capture becomes a year-round discipline.

Diagnosis capture will move from annual “campaigns” to an operating cadence. Conditions must be supported in the record, reflected in the care plan, and consistent with treatment intensity and longitudinal clinical reality. More organizations will adopt monthly or quarterly integrity checks to reduce end-of-year scramble, improve audit readiness, and prevent both “phantom acuity” (conditions listed without support) and “missing acuity” (conditions treated but not clearly documented). Integrity becomes shared work because everyone touches the evidence chain: assessments, notes, orders, care plans, medication regimens and submissions.

Prediction 3: Encounter-based reporting raises the bar on defensibility.

As the industry shifts toward encounter-based diagnosis reporting and tighter validation, PACE teams will need clearer governance around what gets submitted and why. “Problem list hygiene” won’t be enough; encounter documentation must show evaluation, monitoring, or treatment that supports the diagnosis and aligns with the care plan. Programs will standardize documentation expectations for high-impact conditions, define when a diagnosis should be removed or downgraded, and use targeted chart review for exceptions rather than broad, last-minute sweeps.

Prediction 4: The med list becomes a primary integrity signal.

The medication profile is an underused integrity tool. Regimens often reveal clinical complexity more clearly than problem lists — especially when therapy intensity changes, high-risk classes appear, or polypharmacy signals instability. By 2026, more PACE programs will formalize medication-to-diagnosis reconciliation so discrepancies surface early for clinical validation: Is the documented condition still accurate and supported? Does the care plan match what the regimen suggests? Are treated conditions missing from documentation, or documented conditions not reflected in therapy?

Prediction 5: Medication management becomes a readiness strategy, not just cost control.

Medication management influences avoidable hospitalizations, adherence, participant experience and the stability that makes documentation defensible. Readiness questions for 2026: Do you have a closed-loop process to identify regimen risk and intervene early? Is pharmacy integrated with the IDT in a measurable way (shared goals, documented interventions, feedback loops)? Can you show alignment among meds, diagnoses, and care plans across time — not just at recertification or year-end? Important note: This is about accuracy and stability — not revenue optimization. Pharmacists can surface discrepancies; clinicians and coders make diagnosis and coding decisions.

Prediction 6: Part D redesign reshapes pharmacy partnerships and day-to-day operations.

Part D redesign continues to shift incentives and operational reality. Even when participant affordability improves, access friction can increase (PA, specialty distribution, network shifts), and partners may adjust service models. Dispensing-only models become less sufficient. PACE will increasingly favor partners that deliver predictable operations, support adherence and complexity, and provide transparency and analytics that help teams detect access barriers and utilization changes early.

Preparing for 2026: What PACE leaders should do now

• Assign clear ownership for diagnosis integrity and set a recurring cadence (monthly or quarterly).
• Define minimum documentation standards for high-impact diagnoses and an escalation path when support is insufficient.
• Implement medication-to-diagnosis reconciliation to flag discrepancies for clinical validation and care plan alignment.
• Strengthen encounter and diagnosis submission workflows plus data visibility (including PBM/claims signals) so issues surface early.
• Reevaluate pharmacy and PBM partners for clinical integration, delivery reliability, transparency, and analytics – not just dispensing.
• Run legal/compliance review on programs and messaging to ensure positioning reflects accuracy, defensibility, and participant safety.

In 2026, the strongest PACE programs won’t treat risk scoring, diagnosis integrity and medication management as parallel workstreams. They’ll connect them — within compliance boundaries — into an integrated, auditable operating system that supports stable care and defensible submission.

Scott Sosso is senior vice president at Grane Rx, a leading Program of All-inclusive Care for the Elderly (PACE) and long-term care pharmacy provider. With nearly two decades in the long-term care industry and deep specialization in PACE, he helps programs deliver better pharmacy outcomes for the seniors they serve.