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Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences


  • We wish to acknowledge the Centers for Medicare and Medicaid Services for funding the Medicare Demonstration (CMS # 95-C-90467/2-01; Project Officers: Carolyn M. Rimes, Tamara Jackson-Douglas, and Don Sherwood). We thank all project staff at the Monroe County Long Term Care Program, Inc. (ACCESS) and the Center for Aging and Healthcare in West Virginia, Inc. for their contributions. We would also like to thank all participants, their informal caregivers, and primary care physicians for participating in the study. We thank Dr. David Oakes for his comments on an earlier draft of this manuscript. A draft of this paper was presented at the 2008 Academy Health Annual Meeting in Washington, DC. For further information, contact: Hongdao Meng, PhD, School of Aging Studies, University of South Florida, 4202 E. Fowler Ave. MHC 1349, Tampa, FL 33620; e-mail


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 < .01) increase in the probability of choosing agency providers and a 12.5% (P= .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.

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