Mathematica Policy Research (MPR) is evaluating Cash and Counseling, a three-state Medicaid demonstration in which beneficiaries with disabilities receive a monthly cash allowance to purchase personal assistance services (PAS) and related goods, and counseling to help plan these purchases. They may purchase personal assistance from sources other than Medicaid providers, such as family members or friends. The primary goal of Cash and Counseling is to increase consumers' control over their personal care, thereby increasing satisfaction with care and reducing unmet needs, without increasing public costs. Cash and Counseling is being tested in Arkansas, Florida and New Jersey.
MPR's evaluation will address four broad questions about Cash and Counseling: (1) How does it affect consumers and their caregivers? (2) How does it affect public costs? (3) Who participates in the project? and (4) How was the project implemented? The evaluation will estimate the size of demonstration effects, determine whether it worked better for some groups than others, and describe, in each state, how the project accomplished its goal (or why it failed). To estimate effectiveness, the evaluation randomly assigns interested, eligible beneficiaries to either receive Cash and Counseling in lieu of traditional Medicaid services (the treatment group) or to receive personal assistance services as usual from Medicaid-certified providers (the control group). Differences in outcomes between the two groups therefore will provide unbiased estimates of demonstration effects. Evaluation findings will assist policy makers in determining whether and how to develop ongoing consumer-directed programs in the demonstration states and other locales.
Effects on Consumers
Cash and Counseling is expected to affect consumers' use of, unmet need for, and satisfaction with PAS. As a result it may also affect their health and functioning. Because consumers purchase PAS on their own, rather than relying solely on agencies, they are likely to have more control over who provides their PAS, and how and when these services are delivered. Consumers may use different amounts or mixes of services than they would have received under traditional Medicaid PAS. They may also use their funds to buy equipment or devices to increase their independence. The greater flexibility afforded by the cash allowance should reduce unmet need and improve satisfaction with PAS. If the quality of their PAS improves, it may also improve independence and disability-related health.
Although the expected effects of the program are to improve consumer outcomes, we will also assess whether any outcomes worsen. If consumers can not manage their cash allowances, if the allowances are not sufficient to purchase needed care, or if consumers either hire people who provide poor care or cannot find workers to hire, unmet need will increase and satisfaction will decline. Consumers could also be abused or neglected, and health and functioning may suffer. [ Back to top ]
Effects on Caregivers
Cash and Counseling could affect unpaid caregivers in a number of ways. Family and friends providing unpaid care to consumers prior to enrollment in the demonstration could face fewer demands on their time if the consumer hires attendants or uses the cash allowance for assistive devices. If the consumer mismanages the allowance, however, unpaid caregivers may need to provide more care than they did before. Likewise, unpaid caregivers' emotional stress may decrease (for example, if they are more satisfied with the consumer's care as a result of the program) or increase (if the consumer begins to pay some informal caregivers but not others, for example).
We will also investigate the experience of caregivers who are hired and paid under the demonstration. The working conditions, job satisfaction, and physical and emotional strain experienced by paid caregivers will be measured and compared to that of agency workers providing care to control group members. [ Back to top ]
Effects on Public Costs
The evaluation will estimate Cash and Counseling's effects on Medicaid costs for personal assistance services alone and for all costs paid by Medicaid and Medicare. Costs for personal assistance also may increase or decrease, depending on how the monthly payment rates are set. Costs for other health care may also increase or decrease. If consumers receiving the cash allowance are more likely to get care when they need it, they may have fewer falls or pressure sores (for example), and thus have lower costs. On the other hand, if recipients of the cash allowance hire workers who are less well-trained than agency workers, consumers' health may suffer, resulting in higher costs. [ Back to top ]
Participation
One measure of the importance and success of the program is consumers' willingness to participate in Cash and Counseling. Therefore, we will examine consumers' reasons for participating or not participating, and the differences in characteristics between those who participate and those who do not. The evaluation will also present the reasons participants drop out of the program, and the differences between those who drop out and those who do not. Trends in the statewide use of PAS before and during the demonstration will be investigated for indirect evidence that the demonstration itself may be increasing demand for PAS. [ Back to top ]
Implementation
Our analysis of how Cash and Counseling is implemented in each state will include the reasons states and participating agencies made decisions about the design and implementation of the demonstration. Design elements of particular interest include how the cash benefit amount is determined, permissible uses of the benefit, assistance with caregiver training, frequency of counselor-client contact, fiscal monitoring, and quality assurance. [ Back to top ]
Enrollment Targets
The current target sample size (for treatment and control groups combined) is 2,000 each for Arkansas and New Jersey, and 3,000 for Florida, with the larger sample size for Florida reflecting its inclusion of children in the eligible population. Actual program enrollment will have to be slightly larger than these target study sample sizes, because a small proportion of individuals complete the client consent forms but are ineligible for inclusion in the study sample. (For example, some enrollees will have moved out of state or into a nursing home, lost eligibility for Medicaid, changed their mind, or died by the time attempts are made to complete a baseline interview with them and assign them to the treatment or control group. Others who enroll in the demonstration may be excluded from the study sample because we include only one individual from each household in our analyses.)
These sample sizes ensure a high probability of detecting even relatively small program impacts on the full sample. Separate analyses of subgroups of consumers will be conducted in each state if sample sizes for these subgroups are sufficient to yield adequate precision. Key subgroups of interest include groups of consumers defined by age -- children (in Florida only), working-age adults (age 18-64), and the elderly (age 65 or older)-- and by whether the consumer had received PAS prior to enrollment, because program effects on these subgroups may differ. For example, disabled working-age adults and parents of disabled children may be better able than elderly adults to direct their personal assistance, resulting in more favorable effects on their unmet needs and satisfaction. Prior experiences with PAS could give consumers greater awareness of the benefits of self-direction, leading to greater increases in reported satisfaction and other outcomes. [ Back to top ]
Major Data Sources
The main sources of evaluation data are telephone surveys with demonstration participants and their caregivers, and Medicare and Medicaid enrollment and claims data. Individuals who agree to participate in the demonstration must complete a baseline telephone interview before they can be randomly assigned to the treatment or control group. Four months after enrollment, MPR will interview treatment group members to learn about their early experiences with the program. Nine months after enrollment, MPR will interview treatment and control group members to collect information on satisfaction, quality of care, quality of life, use of other formal and informal care, and health and functional status. Around the same time, unpaid caregivers identified at baseline will be interviewed about the type and amount of care the unpaid worker provides, their relationship with the consumer, and their satisfaction with the paid care the consumer receives. Samples of paid workers identified in the nine-month survey will also be interviewed about earnings and benefits, job satisfaction, and problems encountered on the job. Medicaid and Medicare claims and enrollment data will be used to study the cost of personal care services, the use and cost of medical services, and the participation rate in personal assistance programs.
In addition to data for impact analyses, MPR will visit state officials and provider agencies to collect information about program implementation. Counselors in each state will also be asked about their experiences. These data will be used to help explain our findings about program effectiveness and differences across states, and to describe operational processes and problems for the benefit of the demonstration states and other states that are considering self-direction programs. [ Back to top ]
Reporting Results
Interim reports on findings from the consumer surveys are being prepared for each state, based on findings for early samples of treatment group members. Final reports on each state will be available beginning in 2003, followed by a report that synthesizes and compares findings from all three demonstrations. [ Back to top ]
FOR MORE INFORMATION
For more information about the demonstration evaluation or to request evaluation reports as they become availabe contact:
Randall S. Brown, Project Director
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543-2393
Phone Number:(609) 275-2393
Email rbrown@mathematica-mpr.com
Cash and Counseling is a national demonstration jointly funded by the Robert Wood Johnson Foundation and the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The national program office for Cash and Counseling is the Center on Aging at the University of Maryland. General information about the demonstration can be obtained by contacting the National Program Director, Dr. Kevin J. Mahoney, at (617) 552-4039. Information about Mathematica can be obtained by visiting our web site at www.mathematica-mpr.com. [ Back to top ]
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