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The Effect of Consumer Direction on Personal Assistance Received in Arkansas

Publication Date

Stacy Dale, Randall Brown, Barbara Phillips, Jennifer Schore and Barbara Carlson

Mathematica Policy Research, Inc.

May 2004

This report was prepared under contract HHS-100-95-0046 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of Maryland. For additional information about the study, you may visit the DALTCP home page at or contact the ASPE Project Officer, Pamela Doty, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is:

Please see "The Effects of Cash and Counseling on Personal Care Services and Medicaid Costs in Arkansas," a November 19, 2003 Health Affairs web exclusive available at for important additional results produced after this report was written. These new results show that when costs for the second year after enrollment are examined, the savings in nursing home and other long-term care costs grow to essentially offset the treatment group's higher costs for personal care.


The traditional system of providing Medicaid personal care services (PCS) through home care agencies gives consumers few choices about how and when their care is provided. Because some agencies do not provide care on weekends or outside business hours, consumers may not receive care when they need it. Moreover, worker shortages make it difficult to ensure that beneficiaries receive all the care they entitled to. This study of Arkansas's Cash and Counseling Demonstration program, IndependentChoices, examines how this model of consumer direction changes the way that consumers meet their personal assistance needs.

Demonstration enrollment, which occurred between December 1998 and April 2001, was open to interested Arkansans who were at least 18 years old and eligible for personal care services under the state Medicaid plan. After a baseline survey, enrollees were randomly assigned to direct their own personal assistance as IndependentChoices consumers (the treatment group) or to receive services as usual from agencies (the control group). IndependentChoices consumers had the opportunity to receive a monthly allowance, which they could use to hire their choice of caregivers (except spouses) or to buy other services or goods needed for daily living. They could also call on counselors for support and advice about managing the allowance.

Outcome measures related to PCS use were drawn from computer-assisted telephone surveys; PCS expenditures and other Medicaid expenditures for the 12 months after enrollment were drawn from Medicaid claims data. Nine months after baseline, we asked consumers about the type, timing, and amount of personal assistance they received as well as any home or vehicle modifications and equipment purchases they made to meet their personal assistance needs. We used regression models to estimate program effects for 473 nonelderly and 1,266 elderly sample members, while controlling for a comprehensive set of baseline characteristics.

For both the elderly and nonelderly groups, IndependentChoices substantially increased the likelihood of receiving any paid personal care and increased the proportion receiving care during non-business hours. For the nonelderly only, it reduced the likelihood of having multiple paid caregivers, and increased the likelihood of receiving assistance with key types of personal care for which we observed a high level of unmet need at baseline. IndependentChoices also altered the way in which nonelderly consumers addressed their needs for assistance, decreasing the hours (both total and unpaid) of personal care they receive, but increasing the likelihood that they would make home or vehicle modifications or assistive equipment purchases.

The much greater satisfaction and fewer unmet needs of consumers in the treatment group (Foster et al. 2003) shows that nonelderly individuals were not disadvantaged by the decline in hours of care received. Consumers may hire more productive workers, decide how and when paid care is delivered, and purchase equipment or make modifications to meet their personal assistance needs--all of which can lead to more efficient care delivery under consumer direction.

IndependentChoices enabled more Medicaid beneficiaries to receive the paid assistance for which they were eligible, and to receive a greater proportion of the hours of care recommended that they would if agency care were the sole option. Because the program improved access to care, PCS expenditures overall and per month of service were higher for treatment group members than for the control group during the 12 months after randomization. Consistent with CMS's budget neutrality requirements, treatment group costs per month of services were roughly equal to the cost that beneficiaries in the control group were expected to incur. However, control group costs per month of service were far lower than expected because they received only about two-thirds of the authorized hours in their care plans instead of the historic average of 86 percent. Medicaid costs for other services (including home health and nursing homes) were lower for the treatment group than for controls, but not enough lower to offset the higher PCS costs attributed to greater service provision. Future research will examine whether these expenditure patterns persisted over a longer follow-up period and will compare findings from Arkansas to those of the other two demonstration states, Florida and New Jersey.

Cash and Counseling Demonstration