1. Impact of a Voucher Program on Consumer Choices of Personal Assistance Providers: Unintended Consequences Hongdao Meng, Ph.D., Stony Brook University Brenda Wamsley, Ph.D. West Virginia State University

2. Acknowledgments Funding agency: Centers for Medicare and Medicaid Services (# 95-C-90467/2-01) Monroe County Long Term Care Program, Inc., Rochester, NY. Center for Aging and Healthcare in WV, Inc., Parkersburg, WV.

3. Key Findings Voucher increased probability of using agency-employed as well as privately- hired personal assistance workers. Voucher promoted use of agency- employed workers in urban areas and of privately-hired workers in rural areas.

4. Background Personal Assistance Services (PAS) help people with long-term care needs to live independently in their homes. PAS is delivered via: –“Agency-directed” model (ADM) –“Consumer-directed” model (CDM)

5. Background Benefits of CDM: –Flexibility –Autonomy –Potential cost-savings –Expanded care worker pool Concerns of CDM: –Cognitive impairment –Hiring of family members –Quality assurance

6. Objectives To examine the impact of a voucher program on consumer choices of PAS providers (ADM or CDM). To assess urban-rural differences in these choices.

7. Study Design Randomized controlled trial: –Control group: regular Medicare –Nurse group: health promotion nurse home visit –Voucher group: $200 monthly PAS benefits –Combination group: Nurse + Voucher

8. Sample 1605 participants who meet the inclusion criteria of this study: –Community-dwelling (NY, WV, OH) –Medicare Parts A and B enrollee, and –2+ ADLs or 3+ IADLs, and –Had prior health services use (ER, hospital, NH, or home care)

9. Data Baseline assessment data –Socio-demographics –Health and functional status –Prior health services use PAS utilization data over two years –Personal care aide –Home health aide –Respite care

10. Analytical Strategies Descriptive statistics Multivariate logistic regression

11. Baseline Descriptive Results Mean age 77 –27% age 85+ 69% female 96% White 33% income < $10k 73% had caregiver 38% lived alone 11% had Medicaid 3% had LTC insurance Mean # of ADLs 2.3 Mean # of IADLs 3.5 Mean # of chronic conditions: 4.4 Prior service use: –Hospital 63% –ER23% –Nursing home 10% –Home care52%

12. PAS Use Over Two Years

13. PAS Use, Control Group

14. PAS Use, Voucher Group

15. Odds Ratio for PAS Use, by Provider Adjusted for covariates

16. Odds Ratio for PAS Use, by Provider and Urban-Rural **: p < 0.01, adjusted for covariates

17. Summary Voucher increased probability of using agency-employed as well as privately- hired personal assistance workers. Voucher promoted use of agency- employed workers in urban areas and of privately-hired workers in rural areas.

18. Policy Implication Financial subsidy for PAS would promote its use moderately. Differences in consumer choices in urban and rural areas should be taken into account to achieve intended goals of promoting consumer- directed model. Differences in the supply of PAS in urban and rural areas need to be considered.