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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.

Activities of daily living (ADLs) are the basic tasks of everyday life, including eating, washing oneself, dressing, using the bathroom, and moving about. This designation has begun to replace the vaguer notion of the ability to perform a ''major activity.'' Instrumental ADLs, or IADLs, measure more complex work such as maintaining a checkbook or cooking, and tests of cognitive ability measure the competence of those with Alzheimer's and other dementias. Difficulty with one or more ADLs increases with age, although few very old people need help with them. Measurement of ADLs is important because they are strong predictors of nursing home admission, need for paid home care, hospital and physician services, insurance coverage, and death. Questions about ADLs have become as common as those about age, sex and income in research on the elderly. Because not all surveys use the same list of ADLs, and because they phrase the questions differently, there are very large discrepancies among the results. Whether ADLs are measured by level of difficulty, type of assistance, or duration of the problem will affect the results. In addition, the composition of the people surveyed, the data collection methods, and chance all play a role in the results. For insurance companies and government policy, it is important to have accurate numbers in order to predict demand for services of the amount of payout. Policy analysts must remember that measures such as the ADL will never be as accurate as, for example, mortality statistics. When choosing a survey and a set of questions to use, researchers and policy analysts must first ask themselves which questions they are trying to answer. Survey researchers must also avert problems by describing in more detail how ADLs were defined, and which responses they used. (Consumer Summary produced by Reliance Medical Information, Inc.)

Context: Patients with heart conditions in rural areas may have different responses to health promotion-disease Self-management interventions compared to their urban counterparts. Purpose: To estimate the impact of a multi-component health promotion nurse intervention on physical function and total health care expenditures among elderly adults with heart conditions and to examine the impact of rural residence on the intervention effect. Methods: We analyzed data on 281 community-living Medicare beneficiaries with heart conditions from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized controlled trial). We estimated ordinary least squares (OLS) models to determine the effect of the intervention on the change in functional status and log-linear models to determine the impact of the intervention on total health care expenditures over a 2-year period. Results: The OLS models showed that the nurse intervention resulted in fewer impairments in Activities of Daily Living (ADL) (–0.307 on 0-6 scale, P = .055) at the end of 2 years. The effect of the intervention on ADL appeared to be stronger for rural than for urban participants (–0.490 vs –0.162, respectively). However, the difference was not statistically significant (P = .150). The effect of the intervention on Instrumental Activities of Daily Living (IADL) was not significant (P = .321). Average total health care expenditures were 6.5% ($1,981, 95% CI: –$8,048, $4,087) lower in the nurse group. Conclusions: The nurse intervention led to better physical functioning and has potential to reduce total health care expenditures among high-risk Medicare beneficiaries with heart conditions. [ABSTRACT FROM AUTHOR]