The Promise and Progress of Cash &
Counseling and Other Opportunities
f Expanding
for
E
di Consumer
C
Choice
Ch i
Randall S. Brown
Academ Health Ann
AcademyHealth
Annual
al Conference
June 28, 2010
Why Isn’t Consumer
Direction the Norm?

Fear of:
–
–
–
–
–

Inadequate, unsafe care of consumers
Exploitation of consumers
Caregiver injuries
Fraud, misuse of allowance
Cost increases
Agency/union opposition
2
Cash and Counseling

I l
Implemented
t d in
i three
th
states
t t (AR,
(AR FL,
FL NJ)

Enrolled Medicaid PCS/HCBS waiver eligibles
(10/98 - 7/02)

Flexible use of benefit allowed

Consumers could hire legally liable relatives, no
Medicaid contracting requirements

N screening
No
i off eligibles
li ibl (representatives
(
t ti
allowed)
ll
d)

Counselors helped develop spending plan,
monitored it

Fiscal intermediaries wrote checks, withheld taxes
3
Study Design and Methods

Randomly assigned applicants

1,700 - 2,000 adults per state, 1,000 children (FL)

Separate analyses by state and age (<18, 18-64, 65+)
Measured Effects on:
Data
Consumers’ well-being
Consumer survey @ 9 months
Caregivers’ well
well-being
being
Caregiver survey @ 10 months
Hired workers’ experience
Worker survey @ 10 months
Medicaid costs
Claims data for 2 years
4
Effects on Hours of Care

Large increase in percentage getting any
paid care (12% to 27%)

More hours of paid care (17% to 25%)

Fewer unpaid hours (7% to 24%)

Slightly fewer total hours of care
– Except AR age 18-64 (-19%), FL 65+ (-12%)

Little measurable effect on other
allowance uses
5
Effects on Consumers’ Well-Being

Large reductions in unmet needs

L
Large
i
increases
in
i satisfaction
ti f ti
with
ith care

Care-related health problems/injuries
same or lower

Satisfaction with life increases g
greatly
y

Works for children, adults < 65, elderly

Only exception—if
exception if few get the allowance
6
Very Satisfied with Way Spending
Life These Days
Percentage
80
Non-Elderly Adults
Children
Elderly Adults
64**
60
56**
52**
50
47**
43**
38**
40
37
36*
28
23
29
25
21
20
0
T C
AR
T C
FL
T C
NJ
T C
AR
T C
FL
*, ** Significantly different from control group at .05,
05 .01
01 level
level, respectively
respectively.
7
T C
NJ
T C
FL
Effects on Unpaid Caregivers

R d
Reduced
d total
t t l hours
h
off care provided
id d

Much more satisfied with consumers’ care,
less worried

Much less emotional/physical/financial
p y
strain
– Fewer adverse effects on work life
– Fewer adverse health effects

Much greater overall satisfaction with life

No effects for group whose hours increased
8
Eff
Effects
on M
Medicaid
di id Costs
C
For cashed out benefits, cost per month received
 Increased for younger adults (all states) and children
– Because control group underserved in AR and NJ
– Because allowance > care plan amount in Florida DD groups

For total cost per beneficiary in study
Personal care costs higher
– Higher cost/month, higher percentage receiving



Other Medicaid costs 4% to 17% lower (mostly longterm care)
Total Medicaid cost 3% to 14% higher
Only AR improved in Year 2
9
Arkansas’s Program Reduced
Nursing Home Use

18% lower NH admits and costs over 3 years

For both recipients
p
of PCS at enrollment and
new eligibles

Medicaid savings on non-PCS:
non PCS:
– Fully offset higher PCS costs for prior recipients
– Offset little of higher
g
PCS costs for new eligibles
g
(few controls received any PCS)
– Effects on access explain difference across states

Savings persist/grow in 3rd and 4th years
10
Conclusions

Can increase access to care

Greatly improves quality of life (all ages)

Caregivers also benefit greatly

States may be concerned about costs
– But have learned how to control them
11
Consumer Direction Today

Waivers no longer required for CD
– 180 CD p
programs
g
nationwide
– Extensive resources available to states
(see cashandcounseling.org)
cashandcounseling org)
– But penetration of CD among 2.8M HCBS
recipients is unknown

C & C in 15 states; 15,000 enrollees
– Only half enroll > 10% of eligibles
12
Why Hasn’t Consumer Direction
Grown Faster?

Cost concerns deter some states

Shortages of enrollment and outreach personnel;
liti l conflicts
fli t and
d changes
h
political

Lack of needed infrastructure for CD
– Budget setting, financial management, counseling

Resistance from stakeholders
– Agencies/unions and casemanagers
See Doty et al. Health Affairs, January 2010
13
How States are Adapting to
Implementation Issues

Cut administrative costs of CD care (e.g.,
budget management costs)

Recognize that waiting lists for HCBS can
increase nursing home entrycost increases

Pursue slow but steady growth to gain
cooperation of other agencies,
agencies resolve kinks

Address CM opposition by enlisting
champions
h
i
14
Transitioning Institutional Residents:
Money Follows the Person

Large federal program in 31 states to transition
people in institutions > 6 months back to the
community
y
– One year of enhanced transitional services
– Federal match to be used for rebalancing

States having difficulties meeting targets
– Lack of affordable housing

New regulations expand eligibility to those in
institutions for 3 months

Major concern: no real increase in transitions
15
New Opportunities for Learning What
Works for Whom in Long Term Care

Center of Excellence in Research on Disability
y
Services, Care Coordination, and Integration
– Two-year ARRA funded study
– Focus on long term support services for
community residents with disabilities

Project objectives
– Comprehensive
p
literature review
– Build linked datasets (Medicare, Medicaid, other
administrative data, surveys)
y )
– Produce new research on comparative
effectiveness of alternative models of care
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Contact Information
Randall S
S. Brown
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543
(609) 275-2393
rbrown@mathematica-mpr.com
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