Hongdao Meng, Ph.D., Stony Brook University Brenda Wamsley, Ph.D., West Virginia State University

1. Impact of a Voucher Program on Consumer Choices of Personal Assistance Providers: Urban-Rural Differences 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. 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)

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

5. 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.

6. 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

7. 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)

8. 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

9. Analytical Strategies • Descriptive statistics • Multivariate logistic regression adjusting for the following co-variates: • Age, gender, education, income, MediGap, Medicaid, caregiver status • ADLs, IADLs, Cognitive Performance Scale • Prior health services use

10. 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% ER 23% Nursing home 10% Home care 52% Baseline Descriptive Results

11. PAS Use Over Two Years

12. PAS Use, Control Group

13. PAS Use, Voucher Group

14. Odds Ratio for PAS Use, by Provider Type Adjusted for covariates

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

16. Summary of Key Findings • Overall, the voucher program increased the probabilities of using both types of PAS providers. • In urban areas, the voucher effect is primarily on the use of agency-employed workers. • In rural areas, the voucher effect is primarily on the use of privately-hired workers.

17. Limitations • Generalizability • Definition of rural

18. Policy Implication • A voucher program for PAS promotes its use moderately. • Consumer behavior under the voucher program differs substantially between urban and rural participants. • The availability of agency and private workers may explain part of the observed differences. • These differences should be taken into account in promoting the use of consumer-directed models.