Evaluation of the Cash and Counseling Demonstration

Consumers | Caregivers | Public Costs | Participation | Implementation |
Enrollment | Data Sources | Publications

Mathematica evaluated Cash and Counseling, a three-state demonstration in which Medicaid enrollees who are frail or have disabilities received a monthly cash allowance to purchase personal assistance and related goods and services (PAS). They also received counseling to help plan these purchases. They were able to purchase personal assistance from sources other than Medicaid providers, such as family members or friends. The primary goal of Cash and Counseling was to increase consumers’ control over their personal care, thereby increasing satisfaction with care and reducing unmet needs, without increasing public costs.

Cash and Counseling was tested in Arkansas, Florida, and New Jersey. The demonstration was 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 evaluation addressed four broad questions: (1) How did Cash and Counseling affect consumers and their caregivers? (2) How did it affect public costs? (3) Who participated in the project? and (4) How was it implemented? The study estimated the size of demonstration effects, determined whether it worked better for some groups than others, and described, in each state, how the project accomplished its goal (or why it failed). To estimate effectiveness, the evaluation randomly assigned 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 provided unbiased estimates of demonstration effects. Evaluation findings will assist policymakers 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 on agencies to provide them, 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 PAS improves, it may also improve independence and disability-related health.

Although the expected effects of the program are to improve consumer outcomes, we also assess whether any outcomes worsen. If consumers cannot manage their cash allowances, the allowances are not sufficient to purchase needed care, or consumers 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.

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 are also investigating 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.

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 may increase or decrease, depending on how the monthly payment rates are set. Costs for other health care also may 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.

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.

Implementation

Our analysis of how Cash and Counseling is implemented in each state includes descriptions of the policy process and reasons states and participating agencies made certain design choices over others. Design elements of particular interest include how the cash benefit amount is determined, permissible uses of the benefit, caregiver training, frequency of counselor-client contact, and fiscal monitoring and quality assurance.

Program Enrollment

Total enrollment in the programs (for treatment and control groups combined) was 2,008 in Arkansas, 1,763 in New Jersey, and 2,820 for Florida, with the larger sample size for Florida reflecting its inclusion of children in the eligible population. These sample sizes ensure a high probability of detecting even relatively small program impacts on the full sample. Separate analyses of subgroups of consumers are being conducted in each state. Key subgroups of interest include groups of consumers defined by age—children (in Florida only), working-age adults (ages 18 to 64), and the elderly (age 65 and older)—and whether the consumer had received PAS prior to enrollment.

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 agreed to participate in the demonstration completed a baseline telephone interview before they were randomly assigned to the treatment or control group. Four months after enrollment, we interviewed treatment group members to learn about their early experiences with the program. Nine months after enrollment, we interviewed treatment and control group members to collect information on satisfaction, unmet needs, 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 were interviewed about their satisfaction, type and amount of care provided, and relationship with the consumer. Samples of paid workers identified in the nine-month survey also were interviewed about earnings and benefits, job satisfaction, and problems encountered on the job. Medicaid and Medicare claims and enrollment data are being 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, we visited state officials and provider agencies to collect information about program implementation. Counselors in each state were asked about their experiences as well. These data will be used to help explain our findings about program effectiveness and differences cross states, and to describe operational processes and problems for the benefit of the demonstration states and other states that are considering self-direction programs.

Publications

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