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Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to $250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. Findings: The voucher was associated with a 32.4% (P less than 0.01) increase in the probability of choosing agency providers and a 12.5% (P = 0.03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. Conclusions: This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.

Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health promotion/disease self-management program that included 766 elderly Medicare beneficiaries from western New York, West Virginia, and Ohio. Physical function was measured by changes in self-reported dependencies in activities of daily living over the study period. Total health care expenditures were measured by aggregating expenditures from major sources (acute, postacute, and long-term care). We used ordinary least squares models to examine the effects of the intervention on both physical function and cost outcomes during the 22-month period. Results: The results indicated that the intervention reduced physical functional decline by 54% (p = 0.03) in the study sample. Stratified analyses showed that the intervention effect was much stronger in the rural sample. Mean total health care expenditures were 11% ($3,100, p = 0.30) lower in the intervention group. The effects of the intervention on average health care expenditures were similar among urban and rural participants. Implications: The intervention offered a promising strategy for reducing decline in physical function and potentially lowering total health care expenditures for high-risk Medicare beneficiaries, especially for those in rural areas. Future studies need to investigate whether the findings can be replicated in other types of rural areas through a refined intervention and better targeting of the study population.

Purpose: We estimated the effect of a voucher benefit on the demand for personal assistance by Medicare beneficiaries aged 65 years or older who had functional disabilities. Design and Methods: We performed a secondary data analysis on 645 Medicare beneficiaries from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized controlled trial) between August 1998 and June 2000. We estimated a two-part model to determine the effect of the voucher on out-of-pocket personal assistance expenditures. The model controlled for individual health and functional status variables, sociodemographics, prior health care utilization, and state fixed effects. Results: A modest experimental Medicare personal assistance voucher benefit (that reimbursed 80% of up to $250 of eligible expenses per month) increased the likelihood of any out-of-pocket spending for assistance (by 12%, p less than 0.05), but it did not increase the amount of personal assistance expenditures among users (p = 0.94). Overall, the voucher benefits increased average annual expenditures by 10% ($5,304 for the voucher group vs $4,836 for the control group). However, this effect did not reach statistical significance (p = 0.66). Implications: The voucher benefit provided a small incentive to use personal assistance for older Medicare beneficiaries with functional disabilities. Thus, if Medicare were to implement such a benefit, Medicare expenditures may increase. Further research is needed to determine if the increased personal assistance use leads to better health outcomes and whether it is associated with offset cost savings for Medicare-covered services. (Contains 4 tables.)

Purpose: We describe the impact of two interventions, a consumer-directed voucher for in-home supportive services and a chronic disease self-management-health-promotion nurse intervention, on the probability of use of two types of home care-skilled home health care and personal assistance services-received by functionally impaired Medicare beneficiaries. Design and Methods: The Medicare Primary and Consumer-Directed Care Demonstration was a randomized controlled trial in 19 counties in New York, West Virginia, and Ohio with four groups: disease-management-health-promotion nurse, consumer-directed voucher, combination (nurse plus voucher), and control. We estimated a bivariate probit model for the 1,394 individuals aged 65 or older who had no private long-term-care insurance. Results: Whereas the nurse intervention alone had no effect on the probability of using either type of home care, the voucher alone increased the probability of personal assistance services use by 13% (p = .002) but not that of skilled home health care use. The combination of the two interventions increased the probability of personal assistance services use by 18% (p < .001). Implications: The implementation of disease-management-health-promotion nurse interventions should not lead to a greater probability of skilled home health care or personal assistance services use, whereas the provision of consumer-directed vouchers should result in an increased probability of personal assistance services use, as intended.

Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers. [ABSTRACT FROM AUTHOR]