Determining consumer preferences for a cash option: Arkansas survey results.

As long-term care (LTC) expenditures have risen, policymakers have sought ways to control costs while maintaining consumer satisfaction. Concurrently, there is increasing interest within the aging and disability communities in consumer-directed care. The Cash and Counseling Demonstration and Evaluation (CCDE) seeks to increase consumer direction and control costs by offering a cash allowance and information services to persons with disabilities, enabling them to purchase needed assistance. The authors present results from a telephone survey conducted to assess consumer preferences for a cash option in Arkansas and describe how findings from the four-State CCDE can inform consumer information efforts and policymakers.

Introduction

As LTC expenditures have risen, policymakers have sought new ways to control costs while maintaining or increasing consumer satisfaction. Concurrently, there is increasing interest within the aging and disability communities in consumer-directed care (Kapp, 1996; Simon-Rusinowitz and Hofland, 1993; Ansello and Eustis, 1992; Mahoney, Estes, and Heumann, 1986). One such model, “cash and counseling,” offers a cash allowance and information services to persons with disabilities, enabling them to purchase the services, assistive devices, or home modifications that best meet their needs. The CCDE is cosponsored by RWJF and DHHS/ASPE. The demonstration seeks to maximize consumer choice and promote efficiency as consumers who shop for the most cost-effective providers may be able to purchase additional and more individualized services (Kapp, 1996).

In this article, we present findings from a telephone survey conducted to assess consumers' preliminary interest in the cash option versus traditional services in Arkansas, one demonstration State. As this preference survey provides background information for the CCDE, we begin with a description of the four-State demonstration and evaluation to provide a context for the Arkansas survey findings. Although the survey results will guide several aspects of program development, we focus on one immediate application—guidance in developing communications and social-marketing materials to assist Arkansas in its efforts to inform consumers about the CCDE. We also highlight key policy issues addressed by the survey.

Background

Consumer-directed care, which emanated from the disability-rights and independent-living movements, allows maximum consumer choice and control (DeJong, Batavia, and McKnew, 1992). These movements, which primarily involved younger persons with disabilities, have been promoting consumer-directed care for two decades. The aging community began to adopt consumer-direction principles more recently, with a movement to develop a coalition between the aging and younger disabilities communities slowly emerging in the mid-1980s (Simon-Rusinowitz and Hofland, 1993; Ansello and Eustis, 1992; Mahoney, Estes, and Heumann, 1986). Interest in consumer choice has expanded among some leaders in the aging community in the early 1990s, in part because of a belief that consumer-directed care may lead to much-needed cost savings. The emphasis on consumer choice and control in the language of the 1994 Health Security Act (Kapp, 1996) exemplifies this increased interest.

Existing Personal Assistance Service Programs

Personal assistance services (PAS) encompass a range of human and technological assistance provided to persons with disabilities who need help with certain types of activities. These include activities of daily living (ADLs), including bathing, dressing, toileting, transferring, and eating, and/or instrumental activities of daily living (IADLs), such as housekeeping, cooking, shopping, and laundry, as well as managing money and medication. Public or private third-party payers can use any of three PAS financing methods: (1) cash benefits (payments to qualified clients or their representative payees); (2) vendor payments (a case-manager determines the types or amounts of covered services and arranges for and pays authorized PAS providers to deliver these services); and (3) vouchers (clients use funds for authorized purchases). The CCDE will evaluate the impact of cash benefits.

In the United States, most existing public programs that finance PAS—including such major funders as Medicaid's optional personal care services benefit and home and community-based LTC waiver programs—follow a vendor-payment model. That is, the program purchases services for consumers from authorized vendors (i.e., service providers or equipment suppliers). In some programs, the list of covered services and authorized vendors is quite restricted. Other programs may have a broader range of covered services, adding adult day care, transportation, home modifications, and assistive devices. Clients may sometimes hire independent providers (i.e., workers not employed by home health agencies) to be in-home aides.

Until recently, the prohibition on direct payments to Medicaid clients was rarely questioned. However, many State program officials have come to share the concerns of disability-rights advocates who want PAS programs that promote consumer choice and avoid program rules that may foster dependency in the name of consumer protection and/or public accountability (Litvak, Zukas, and Heumann, 1987; Litvak and Kennedy, 1990, 1991). In addition, State officials have a strong interest in achieving program economies. Most Medicaid PAS programs mandate that case managers (registered nurses and/or social workers) assess clients, develop and monitor care plans, and authorize provider payments. Case management can be expensive, and researchers and administrators question whether it should be uniformly required (Jackson, 1994; Geron and Chassler, 1994). Hence, reasons for the growing interest in a cash option are savings on program administration and enhanced consumer empowerment.

Cash-allowance programs are currently very small because they involve “State-only” funds. States cannot use Medicaid to fund cash allowances that permit clients to purchase their own services because of Federal restrictions on direct payments to clients. Consequently, it has not been possible to evaluate large programs with a cash option. This policy-driven demonstration and rigorous evaluation will provide information about the costs, benefits, and implementation issues involved in a cash option, so that State and Federal policymakers can make informed decisions about implementing this LTC model.

Demonstration and Evaluation Design

As the national program office for this large project, the UMCA directs and coordinates the demonstration, oversees the evaluation, and provides technical assistance to the demonstration States. The national program office works in conjunction with the project management team, comprised of RWJF and ASPE project officers, the evaluation team leader from Mathematica Policy Research, Inc., and advisors from the National Council on the Aging, HCFA, and the Social Security Administration.

In the winter of 1996-97, Arkansas, Florida, New Jersey, and New York each received grants of up to $500,000 from RWJF to implement programs offering Medicaid PAS consumers the choice of a cash benefit instead of agency-delivered care. Some major program characteristics were:

States were to include both older and younger adults with disabilities. Florida was also to include children with developmental disabilities.

Arkansas, New Jersey, and New York were to offer a cash alternative to their Medicaid Personal Care Option, while Florida was to include its Medicaid Home and Community-Based Care waivers.

Funds had to be used for personal assistance services, i.e., personal care workers, home renovations, and/or assistive devices. Each participant was to develop a plan for the use of the cash. Funds could be carried over from month to month for large purchases or emergency needs.

Each State would determine the cash payment amount. States were generally planning to follow current assessment and care planning practices, establish the value of the individual care plan, and offer a cash amount approximating the amount consumers would receive in the traditional program. The average monthly benefit in traditional programs varied greatly by State, as demonstrated by the four demonstration States: Arkansas ($320), Florida ($389, weighted average for different programs), New Jersey ($910), and New York ($1,580 in State fiscal year 1996).

Counseling services were an integral part of the demonstration. These services were to help consumers decide whether or not to select the cash option, and for cash-option participants, there was an array of supportive services to help them manage employer responsibilities or locate home-modification subcontractors, etc.

The evaluation is comprised of two components—an experimental design with randomized treatment and control groups, and a process evaluation to study program implementation. The evaluation will compare outcomes for consumers receiving traditional PAS and those receiving the cash option, with respect to cost, quality, and client satisfaction. The evaluation will also examine the impact of the cash option on formal and informal caregivers.

Among the many activities of the project-planning phase (e.g., completing a HCFA-1115 Research and Demonstration Waiver application to allow participants to receive cash payments and pay legally responsible relatives), UMCA conducted background research that will guide program development and social-marketing activities. These activities will be in place prior to the enrolling of consumers in the demonstration, targeted to begin in late 1998.

Assessing Preferences for a Cash Option

Little research exists to indicate: (1) how many consumers (or surrogate decisionmakers) would choose a cash option; (2) what consumer characteristics might indicate who would choose cash versus agency-based PAS; and (3) what cash-option features are attractive or unattractive to consumers and surrogates. This information is essential to help the demonstration States design various cash-option components, (including counseling services) and social-marketing approaches that will enable consumers and surrogates to make informed choices between the cash option and their current program.

The demonstration States' communications and social-marketing tasks are somewhat daunting for several reasons. As indicated by presurvey focus groups, the cash option is quite different from traditional services, and consumers often have difficulty understanding such a new and different concept. For consumers with less than a high school education (the vast majority in Arkansas), this communication effort is especially challenging. In addition, even those consumers who decide they like the cash option and feel qualified to try it will need to overcome fears and concerns about changing a service that is so important to their daily lives.

By their very nature, major social experiments push States to enroll many consumers (to have a sufficient sample size for hypothesis testing) during a short period of time. Under the design proposed by Mathematica, Arkansas has 1 year to enroll 2,500 consumers from approximately 12,000 current clients (plus 1,000 new consumers coming into the Medicaid program). One-half of all enrollees will be randomized to a control group. Consequently, UMCA designed a three-part study to assess consumers' preliminary interest in a cash option. RWJF provided funding to support this additional effort.

Consumer Preferences: Existing Research and Theory

Policymakers, program planners, and others have speculated that age would be a strong indicator of preference—i.e., younger consumers would be more likely to select a consumer-directed cash option. Although research on consumer preferences for consumer-directed services is limited, there is evidence that consumers of all ages—including elders—would like to be more involved in directing their care. In a small study of Minnesota home care clients (20 clients under age 65; 34 clients over age 65), Eustis and Fischer (1992) found that although younger clients were more apt to take charge of their services, about one-third of older clients took charge of their care in at least three ways (e.g., participating in activities such as care plan development, hiring, and training a worker.) Glickman, Brandt, and Caro (1994) surveyed 883 older home care clients to assess their interest in becoming more involved in managing their care. A substantial minority of clients said they would be willing to assume more responsibility in hiring, paying, scheduling, supervising, and firing their workers—ranging from a high of 39 percent willing to schedule their workers to a low of 24 percent willing to fire a worker.

In a study comparing 1,432 California home care clients in independent-provider and agency-contract models, Barnes and Sutherland (1995) found that when consumers of all ages had the amount of management responsibility they wanted, they were happier with their worker's reliability and quality of services. Finally, Doty, Kasper, and Litvak (1996) compared satisfaction with care among 879 older Medicaid personal care clients in 3 States (Michigan, Maryland, and Texas) with varying degrees of consumer direction. Clients were significantly more satisfied with their services in programs that permitted more consumer control. Although these studies indicate some interest in consumer direction among consumers of all ages, there is much more to be learned about age-specific preferences for consumer direction in general, and specifically for a cash option.

In addition to limited knowledge regarding the impact of age on consumer preferences for consumer direction, there is little information regarding other demographic and background characteristics that may influence interest in consumer direction. Glickman and colleagues (1994) provide some guidance: They found an association between client willingness to assume responsibility for directing a home care worker and the following client characteristics: prior experience directing an in-home worker, greater length of time receiving home care services, greater involvement in directing a home care worker, and lower levels of satisfaction with home care services. Research indicating differences in LTC service use and caregiving patterns among some minority groups—greater informal care and less nursing home use among some minority groups compared with their white counterparts—offers reason to speculate that preferences for consumer direction may differ among racial and ethnic groups (Tennestedt and Chang, 1998; Wallace et al., 1998; Rimer, 1998).

However, limited information about consumer preferences for consumer direction, and specifically the cash option, point to the need to further understand many unanswered questions. Most importantly, what types of consumers and surrogates, and how many, would choose the cash option, given the opportunity? In addition, what would their reasons be for this choice?

Preference Study Design and Purposes

A three-part study consisting of presurvey focus groups, telephone surveys, and postsurvey focus groups was developed to: (1) determine preferences for consumer-directed services in general, and specifically for a cash option; (2) determine the percentage of consumers or surrogates choosing the cash option versus traditional services; (3) identify reasons for consumer or surrogate preferences; (4) identify demographic and background characteristics of consumers and surrogates with specific preferences; (5) identify cash-option features that are attractive or unattractive to consumers and surrogates; (6) identify what information consumers and surrogates need to decide whether to choose the cash option; (7) identify consumer and surrogate needs for counseling and support services; and (8) develop strategies to market the cash option.

Methods

Sample

The total population of Medicaid personal care clients in Arkansas in 1996 was approximately 12,000. Based on this population and using the standard error formula to ensure adequate power, a sample of 372 participants was needed. It was assumed that client telephone numbers provided by Arkansas would be 80 percent accurate and that the response rate would be 20 percent, resulting in the need for 2,325 randomly selected names and phone numbers. Arkansas forwarded 2,888 names to the University of Maryland Interdisciplinary Health Research Laboratory (IHRL).

Instrumentation

Survey development was guided by focus-group discussions that took place in two other demonstration States, New York and Florida. The 96 participants were organized into 11 groups, consisting of adult consumers with disabilities under age 65, adult consumers with disabilities over age 65, and adult surrogate decisionmakers. See Zacharias (1997a, 1997b) for a full discussion of focus-group results.

The researchers developed a 139-item instrument to measure consumer and surrogate perceptions of the cash option, using items from other related questionnaires where appropriate. The survey consisted of four primary sections: (1) satisfaction with current personal care services (27 items); (2) perceptions regarding the cash option (33 items); (3) demographic and background variables (44 items); and (4) perceptions and demographics of surrogates (35 items). To explain the cash option, interviewers read a scenario about a woman who needed personal care services. The scenario described several different ways she could use her cash benefits. In addition, subsequent survey items informed respondents about various cash-option features and support services.

The questionnaire contained four attitudinal subscales labeled (1) satisfaction with worker characteristics (6 items); (2) satisfaction with availability of workers (4 items); (3) overall satisfaction with personal care services (9 items); and (4) willingness to assume more responsibility (6 items). Background variables included a measure of functional status based on ADLs, an assessment of overall physical health, one's living arrangement, number of informal caregivers, and experience interviewing, training, hiring, or supervising workers, among others.

Content validity of the survey (to ensure that satisfaction with current services and cash-option domains were represented) was established by means of a panel with expertise in aging and disabilities as well as survey design and evaluation (n = 7). In addition, the survey was pilot tested with three disabled and elderly individuals to assess administration time along with acceptability and understandability of the items. Finally, a pilot test with 120 clients was conducted to determine internal consistency reliabilities of subscales and to again assess understandability.

Procedures

The randomly selected potential-participant telephone files from Arkansas were entered into the Macintosh Computer Assisted Telephone Interview (MaCATI) system. Telephone interviews took place between April and June of 1997. On average, interviews lasted 40 minutes. Individuals were called up to six times before they were considered non-respondents. If respondents felt unable to answer survey items themselves, they provided the interviewer with the name and telephone number of a surrogate responder (a friend or relative). A series of questions was then used to identify surrogates and the types of decisions they helped the consumer make (i.e., financial, living arrangements, medical, or all of these). Surrogates were instructed to represent the consumer and respond to survey items with the consumer present, so the consumer could clarify responses if necessary.

Response Rate and Non-Respondent Data

Of the 2,888 randomly selected names and telephone numbers sent to the IHRL, 559 were used in the pilot study, 876 were unusable numbers (i.e., not in service, wrong locale, business phone, person no longer receiving services, etc.), 960 refused to participate, and 491 completed the survey (33.8 percent response rate). Of those who completed the survey, 380 were clients answering for themselves and 111 were surrogates representing a consumer. The primary reasons for not responding included feeling too sick or disabled (30 percent) or being uninterested in answering any survey (26 percent). Twelve percent simply hung up and 10 percent did not give a reason for non-participation.

To determine whether survey respondents were similar to non-respondents (refusers), the researchers compared a sample of these two groups on three items: age, number of months of service over a 6-month period, and average number of hours of billed services per month. There were no statistically significant differences (p > 0.05) between respondents (n = 364) and refusers (n = 740) in number of months of service over a 6-month period or average number of hours of billed services per month. Respondents received 5.8 months of service (standard deviation = 0.81), and refusers received 5.7 months (standard deviation = 0.86). The average number of hours of billed medical service per month for participants was 33.7 (standard deviation = 14.3) and 32.4 (standard deviation = 14.3) for non-participants. However, participants were significantly younger (p < 0.05) than refusers, 78.6 years (standard deviation = 12.7) versus 81.7 years (standard deviation = 11.9).

Findings

Instrument

Adequate internal-consistency reliabilities were obtained for 3 of the 4 attitude subscales (ranging from 0.70 to 0.77), while the overall satisfaction with personal care services subscale had a Cronbach's alpha of 0.64. A factor analysis was subsequently performed with all the attitudinal items using principal components extraction and varimax rotation. Four factors with Eigen values greater than 1 were identified, using a factor loading of 0.50. These four factors were similar to the a priori subscales initially developed and were used to measure consumer attitudes. The new subscales were labeled: (1) dissatisfaction with personal care worker (6 items); (2) willingness to assume responsibility (6 items); (3) availability of personal care worker (3 items); and (4) satisfaction with personal care schedule (2 items).

Description of the Sample

The majority of consumers (n = 491) were female (89 percent), 65 years of age or over (85 percent), had less than a high school education (81 percent), and were widowed (66 percent) (Table 1). Fifty percent were white and 48 percent were black. Fifty-seven percent lived alone, and 43 percent lived with a friend or relative (Table 2). Almost two-thirds of the sample (n = 299, 61 percent) stated that they had informal caregivers (friends or family members who assisted them without being paid). Of those 299 respondents who had informal caregivers, 88 (29 percent) lived with the consumer. Few consumers had experience hiring, firing, or interviewing workers (13 percent) or supervising or training workers (19 percent) (Table 2).

Table 1

Demographic Characteristics of Arkansas Consumers

Demographic Characteristic	Number	Percent
Age
Under 65 Years	67	13.6
65 Years or Over	419	85.3
Do Not Know	5	1.0
Sex
Female	436	88.8
Male	55	11.2
Race/Ethnicity
Black	213	43.4
Biracial	4	0.8
White	222	45.2
Native American or Alaskan Native	3	0.6
Do Not Know	39	7.9
Refused	10	2.0
Education Level
Less Than High School	399	81.3
High School or Equivalent	48	9.8
Trade or Vocational School	1	0.2
Some College	12	2.4
Baccalaureate Degree	6	1.2
Some Graduate School	2	0.4
Graduate Degree	3	0.6
Do Not Know	20	4.1
Refused	1	0.2
Marital Status
Married	59	12.0
Widowed	324	66.0
Divorced	43	8.8
Separated	9	1.8
Single 52	10.6
Living with Partner	1	0.2
Do Not Know	2	0.4
Refused	1	0.2

N = 491

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Table 2

Background Characteristics of Arkansas Consumers

Background Characteristic	Number	Percent
Living Arrangement
Alone	279	56.8
With Spouse and/or Children	139	28.3
With Friend(s), Partner, or Relatives	70	14.3
Other	2	0.4
Refused	1	0.2
Do You Own Your Own Home?
Yes	208	42.4
No	281	57.2
Refused	2	0.4
Do You Have an Informal Caregiver?
Yes	299	60.9
No	190	38.7
Do Not Know	2	0.4
Does Your Informal Caregiver Live with You?
Yes	88	17.9
No	211	43.0
Do Not Know	2	0.4
No Informal Caregiver	190	38.7
Have You Ever Been Employed?
Yes	337	68.6
No	150	30.5
Do Not Know	3	0.6
Refused	1	0.2
Current Employment Status
Employed Full-Time	1	0.2
Employed Part-Time	1	0.2
Unemployed	66	13.4
Retired	265	54.0
Homemaker	6	1.2
Volunteer	1	0.2
Do Not Know	1	0.2
Never Been Employed	150	30.5
Any Experience Interviewing, Hiring, or Firing Any Type of Worker?
Yes	62	12.6
No	422	85.9
Do Not Know	7	1.4
Any Experience Supervising or Training Any Type of Worker?
Yes	95	19.3
No	388	79.0
Do Not Know	8	1.6
Current Overall Physical Health
Excellent	13	2.6
Very Good	39	7.9
Good	95	19.3
Fair	128	26.1
Poor	203	41.3
Do Not Know	13	2.6
Disability Level2
Mild	273	55.6
Moderate	162	33.0
Severe	56	11.4

N = 491

Based on activities of daily living scale; individuals scoring between 0 and 1.5 were considered to be mildly disabled, those scoring between 2 and 3.5 were considered moderately disabled, and those scoring between 4 and 5 were considered severely disabled.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Consumers were asked to rate their overall health status; 67 percent rated it “fair” or “poor,” compared with 30 percent who rated it “good,” “very good,” or “excellent.” A measure of functional status was also obtained based on the five ADLs: bathing, dressing, toileting, transferring, and eating. Consumers were asked if they needed help with each of the tasks, and could respond “yes,” “no,” or “sometimes.” A “yes” response received a score of 1; a “no” response a 0, and a “sometimes” response a 0.5. The functional-status scale could thus range from 0 to 5; 56 percent of consumers scored in the mild-disability category, 33 percent at the moderate level, and 11 percent were considered severely disabled (Table 2).

Examination of the surrogate sample (n = 111) revealed that the majority were female, 74 percent (n = 82), 64 years of age or under, 68 percent (n = 76) and married, 51 percent (n = 56). Almost one-half had less than a high school education, 49 percent (n = 54), 37 percent (n = 41) were high school graduates, and 12 percent (n = 13) had some college experience. Forty-nine percent (n = 54) of the surrogates were white and 42 percent (n = 47) were black. The majority of surrogates were relatives of the consumer, 78 percent (n = 87).

Interest in the Cash Option

Approximately 29 percent (n = 110) of consumers answering for themselves indicated interest in the cash option, with an additional 26 percent (n = 98) indicating they were not sure of their interest (Table 3). When examining responses of surrogates answering for consumers, 39 percent (n = 37) thought the consumer would be interested, and 19 percent (n = 18) were not sure. Finally, using a slightly different question, surrogates were asked for their own opinion. Fifty-six percent (n = 62) stated that they personally liked the idea of the cash option, and 20 percent (n = 22) indicated they did not know how they felt about it (Table 3). Overall, 32 percent (147 of 470) of consumers (regardless of whether they answered for themselves or a surrogate answered for them) and 56 percent (62 of 111) of surrogates were interested in the cash option.

Table 3

Interest in the Cash Option, by Respondent Status

Respondent Status	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
Consumer Answering for Self	110	29.3	98	26.1	167	44.5
Surrogate Answering for Consumer	37	38.9	18	18.9	40	42.1
Surrogate Answering for Her- or Himself	62	55.9	22	19.8	27	24.3

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Consumers did not significantly differ (p > 0.05) in their interest in the cash option based on their age. There were 62 consumers under age 65 who answered the item regarding interest level, and of these, 44 percent (n = 27) were interested in the option, 18 percent (n = 11) were not certain of their interest, and 39 percent (n = 24) were not interested. Examination of the 403 consumers age 65 and over who answered the item showed 29 percent (n = 118) were interested, 26 percent (n = 103) were not sure, and 45 percent (n = 182) were not interested in the option.

Chi-square analyses were conducted on the demographic and background variables by level of interest in the cash option. Respondents differed significantly in their level of interest on 9 of the 21 variables. Consumers who desired more involvement in determining the amount and type of current personal care services they receive were significantly more likely (p < 0.001) to be interested in the cash option (64 percent), compared with those who desired the same (22 percent) or less involvement (43 percent), as were those who had experience supervising or training any type of worker (50 percent), compared with those who had no such experience (27 percent). Consumers who reported ever having dismissed a personal care worker, having an informal caregiver who lives in, or who had experience hiring, firing, or interviewing workers were significantly more likely (p < 0.01) to be interested in the cash option, compared with those who did not have such experiences (47 versus 27 percent, 43 versus 33 percent, and 51 versus 28 percent, respectively).

Finally, there were significant differences (p < 0.05) in level of interest between black consumers who were more likely than white consumers to be interested (38 versus 26 percent); those with informal caregivers who were more likely than those without to be interested (35 versus 25 percent); those with more years of formal education who were more interested compared with those with less than a high school education (approximately 67 versus 30 percent), and those with 5 or more new personal care workers in the past year who were more interested than those with fewer new workers (approximately 60 versus 28 percent).

Consumer interest in the cash option did not differ significantly (p > 0.05) by gender, marital status, level of disability, health status, living arrangement, or home ownership. Interest level also did not differ significantly by length of time in the home care services program, number of personal care workers, relationship with personal care workers (ranging from “very close” to “hostile”), or previous experience with other personal care programs.

Examination of the surrogate subsample (n = 111) found that they only differed significantly (p < 0.05) on one of the demographic variables (surrogate's living arrangement) by interest level in the cash option. Surrogates who lived with a spouse or children were less likely to indicate they liked the cash option, 45 percent (n = 28) when compared with those who lived with a friend or other relative, 74 percent (n = 26) or those who lived alone, 67 percent (n = 8).

A multivariate analysis Gogistic regression) was conducted to predict consumer interest in the cash option. Predictor variables included: the demographic items race, age, education, and gender; the four attitude subscales; and the variables identified by means of a bivariate analysis as significant predictors of interest. Hosmer and Lemeshow (1989) suggest using 0.25 as the cutoff probability level for inclusion; therefore, the variables entered in the model included the ones already mentioned as significant in the bivariate analysis, as well as current living arrangement (p < 0.12) and level of disability (p < 0.09). Interest in the cash option was collapsed to test for significant differences between those who showed some interest in the option (“interested” and “not sure” respondents) versus those who responded “not interested.”

The primary influence on consumer interest in the cash option was the consumer's willingness to perform tasks associated with managing personal care workers (p < 0.001) (Table 4). These tasks, which comprise the willingness-to-assume-responsibility subscale, included willingness to: (1) hire your own home care worker; (2) show your worker what to do; (3) schedule your worker; (4) supervise your worker; (5) pay your worker; and (6) fire your worker if he or she was not doing a good job. The next most important variable that predicted interest was desired level of involvement with current personal care services (Table 4). Respondents who indicated they wanted more involvement in determining the amount and type of services they currently receive were 4.5 times as likely to be interested in the option, when contrasted with those who desired the same or less involvement with their current services.

Table 4

Variables That Predict Interest in the Cash Option

Variable	Significance	Odds Ratio
Willingness-to-Assume-Responsibility Subscale	0.0000	0.40571
Desired Level of Involvement with Current Services	0.0000	4.5609
Race	0.0066	0.4919
Experience Supervising or Training a Worker	0.0176	2.2636
Have Informal Caregiver(s)	0.0209	1.8228

This variable was continuous, so the odds ratio is a measure of the sensitivity of the measurement, not the increase in odds as one moves from one category to the other (in this case, from the “Interested” or “Not Sure” category to the “Not Interested” category).

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Another variable that predicted interest was race (Table 4). White consumers were half as likely to be interested in the option as were black consumers. Consumers who had experience supervising or training workers were more than twice as likely to be interested in the cash option, compared with those without such experience. Finally, consumers who had informal caregivers (i.e., friends, neighbors, or family members who provide services without pay) were almost twice as likely to be interested in the option when contrasted with those who did not have informal caregivers.

These five factors predicted with 79-percent accuracy consumers who were either interested or not sure of their interest in the cash option and with 67-percent accuracy those who indicated they were not interested. No other factors or combination of factors were found to significantly improve upon this prediction rate.

Attractive Program Features

Respondent ratings of the importance of various program characteristics were strongly related to their expressed interest in the cash option. Interested consumers and surrogates were significantly (p < 0.05) more likely to consider it important to pay their worker more money than he or she currently receives, to know a group of other consumers involved in the option, and to have the ability to back out of the option and return to their old program if they desired (Table 5). Those who found these program characteristics less important were less likely to be interested in the cash option. In addition, interested consumers were also significantly (p < 0.05) more likely to believe it was important to hire their current worker, compared with those who were less interested, although there was no difference between interested and less interested surrogates on this variable.

Table 5

Consumer and Surrogate Perceptions Regarding the Importance of Cash-Option Characteristics, by Interest Level

How Important Is It To:	Consumers						Surrogates
	Interested		Not Sure		Not Interested		Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Hire the Current Worker
Important	104	72.2	58	52.3	103	*51.5	45	72.6	13	59.1	15	55.6
Do Not Know	16	11.1	40	36.0	39	19.5	9	14.5	5	22.7	2	7.4
Not Important	24	16.7	13	11.7	58	29.0	8	12.9	4	18.2	10	37.0
Pay the Worker More Money
Important	86	60.1	46	41.1	66	*33.0	42	67.7	11	50.0	5	*18.5
Do Not Know	32	22.4	50	44.6	61	30.5	11	17.7	7	31.8	9	33.3
Not Important	25	17.5	16	14.3	73	36.5	9	14.5	4	18.2	13	48.1
Know Others in the Option
Important	114	78.6	61	54.0	66	*33.2	51	82.3	11	50.0	11	*40.7
Do Not Know	14	9.7	35	31.0	49	24.6	4	6.5	6	27.3	1	3.7
Not Important	17	11.7	17	15.0	84	42.2	7	11.3	5	22.7	15	55.6
Be Able to Back Out of the Cash Option If So Desire
Important	125	85.6	80	70.2	122	*61.6	55	88.7	17	77.3	20	*74.1
Do Not Know	10	6.8	30	26.3	38	19.2	1	1.6	5	22.7	0	0.0
Not Important	11	7.5	4	3.5	38	19.2	6	9.7	0	0.0	7	25.9

p ≤ 0.001

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Consumers under 65 and those 65 and over only differed significantly (p < 0.05) on one of the important program features. Consumers under 65 years of age were more likely to consider it important to pay their worker more money than he or she currently receives when compared with consumers 65 and over (60 percent [n = 33] versus 41 percent [n = 168]). There was a significant difference (p < 0.05) between younger and older surrogates as well, although on a different program feature. Surrogates under 65 were more likely to want to know others involved in the cash option, 72 percent (n = 55), compared with those 65 and over, 53 percent (n = 18).

Consumers were asked whether particular program characteristics would make them interested in the cash option. When asked whether the ability to “get services on the days and times you want them” would make them interested in the option, 89 percent (n = 130) of those interested indicated this characteristic was appealing (Table 6). When asked whether the ability to “hire whomever you want to provide personal care services, even a friend or relative” would make the consumer interested in the option, 90 percent (n = 131) of those interested liked this characteristic. Finally, when asked whether the ability to “buy different services” would make the consumer interested in the option, those interested in the option were more likely to be interested in this feature (Table 6).

Table 6

Consumers' Potential Reasons for Interest in the Cash Option, by Actual Interest Level

Which of the Following Makes You Feel Interested in Being Part of the Cash Option?	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
Getting Services on the Days and Times You Want Them
Interested	130	89.0	44	38.6	47	*22.9
Do Not Know	8	5.5	45	39.5	29	14.1
Not Interested	8	5.5	25	21.9	129	62.9
Hiring Whomever You Want to Provide Services, Even a Friend or Relative
Interested	131	89.7	51	45.1	31	*15.3
Do Not Know	7	4.8	40	35.4	34	16.7
Not Interested	8	5.5	22	19.5	138	68.0
Using the Money to Buy Different Services or Make Home Modifications
Important	134	91.2	56	49.1	34	*16.5
Do Not Know	7	4.8	35	30.7	38	18.4
Not Important	6	4.1	23	20.2	134	65.0

p ≤ 0.001

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Surrogates were also asked a series of questions to ascertain reasons for their interest in the cash option; surrogates interested in the option were significantly (p < 0.05) more likely to be interested in specific characteristics, compared with the other two groups (those not sure of their interest and those who were not interested). Ninety-seven percent (n = 60) of surrogates interested in the option liked the idea of being able to interview and hire the worker, and the majority believed receiving cash would offer more flexibility to the consumer, 87 percent (n = 54) and themselves, 84 percent (n = 52) (Table 7). Additionally, 80 percent (n = 50) of the surrogates interested in the cash option believed the consumer would want to participate.

Table 7

Surrogates' Reasons for Interest in the Cash Option, by Actual Interest Level

Reason for Interest	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
Could Interview and Hire the Worker
Agree	60	96.8	5	22.7	5	*18.5
Do Not Know	0	0.0	11	50.0	1	3.7
Disagree	2	3.2	6	27.3	21	77.8
Offers More Choice, Flexibility, and Independence for Consumer
Agree	54	87.1	10	45.5	5	*18.5
Do Not Know	5	8.1	7	31.8	3	11.1
Disagree	2	3.2	5	22.7	19	70.4
Offers More Choice, Flexibility, and Independence for Me
Agree	52	83.9	12	54.5	5	*18.5
Do Not Know	7	11.3	6	27.3	3	11.1
Disagree	3	4.8	4	18.2	19	70.4
I Think the Consumer Would Like to Participate
Agree	50	80.6	1	4.5	2	*7.4
Do Not Know	6	9.7	15	68.2	1	3.7
Disagree	2	6.5	6	27.3	24	88.9

p ≤ 0.001

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Finally, surrogates were asked if they thought the cash option would make it easier or harder on them; 35 percent (n = 39) believed the option would make their job easier, and 32 percent (n = 35) believed it would be harder. Surrogates who were interested in the cash option were significantly (p < 0.05) more likely to believe the option would make things easier for them, 58 percent (n = 36), compared with those who were not sure of their interest, 4 percent (n = 1), and those who were not interested, 7 percent (n = 2). Surrogates who indicated the option would be harder for them were asked if the extra effort would be worthwhile. Those who thought it would be worthwhile or who were not sure if it would be, were significantly (p < 0.05) more likely to be interested in the cash option, compared with the other two groups.

Service and Support Needs

Respondents were asked about their interest in purchasing various services. Again, those interested in the cash option were significantly (p < 0.05) more likely to want to purchase the various services when compared with those not interested or those not sure of their interest level (Table 8). For example, a majority of respondents interested in the option wanted to purchase more hours of service (66 percent), grab bars or shower equipment (56 percent), and transportation services (56 percent) (Table 8).

Table 8

Services Consumers Would Like to Purchase, by Cash-Option Interest Level

Which of the Following Services Would You Like to Buy?	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
More Hours of Home Health Aide Service
Yes	97	66.0	41	35.3	44	*21.3
No	50	34.0	75	64.7	163	78.7
Grab Bars or Equipment for Shower
Yes	82	55.8	52	44.8	39	*18.8
No	65	44.2	64	55.2	168	81.2
Wheelchair or Other Equipment
Yes	69	46.9	46	39.7	43	*20.8
No	78	53.1	70	60.3	164	79.2
Home Modifications (Wider Door, Ramp)
Yes	60	40.8	31	26.7	23	*11.1
No	87	59.2	85	73.3	184	88.9
Exercise Equipment
Yes	46	31.3	17	14.7	10	*4.8
No	101	68.7	99	85.3	197	95.2
Transportation Services
Yes	82	55.8	55	47.4	40	*19.3
No	65	44.2	61	52.6	167	80.7

p ≤ 0.001

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

There was a significant difference (p < 0.05) between the two age groups on only one of the items consumers could purchase. Consumers 64 and under were more likely to want to purchase exercise equipment, 28 percent (n = 19) when compared with those 65 and over, 13 percent (n = 56).

Seven different tasks associated with the cash option were included in the survey, and the majority of consumers wanted assistance or training in each of these areas. However, respondents interested in the cash option (n = 147) were significantly (p < 0.05) more likely to want help or training on each task when compared with the other two groups (Table 9). They were most likely to want help with deciding how much to pay a worker (86 percent). Those not sure of their interest in the option (n = 115) were most concerned about receiving help or training with payroll taxes (66 percent), and those not interested (n = 202) were most concerned about what to do when a worker did not show (53 percent).

Table 9

Consumers Who Want Help or Training with Task, by Cash-Option Interest Level

Would You Want Help in Doing Any of the Following Tasks?	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
Finding Someone to be Home Care Worker
Yes	111	75.5	61	53.5	92	*45.5
Do Not Know	9	6.1	27	23.7	33	16.3
No	27	18.4	26	22.8	77	38.1
Interviewing a Worker
Yes	98	66.7	58	51.3	80	*39.6
Do Not Know	12	8.2	24	21.2	30	14.9
No	37	25.2	31	27.4	92	45.5
Doing a Background Check on a Worker
Yes	115	78.2	63	55.3	95	*47.3
Do Not Know	9	6.1	23	20.2	27	13.4
No	23	15.6	28	24.6	79	39.3
Deciding How Much to Pay a Worker
Yes	127	86.4	67	58.8	91	*45.0
Do Not Know	6	4.1	30	26.3	30	14.9
No	14	9.5	17	14.9	81	40.1
Knowing What to Do If Worker Did Not Come to Work
Yes	121	82.3	69	60.0	105	*52.5
Do Not Know	5	3.4	18	15.7	26	13.0
No	21	14.3	28	24.3	69	34.5
Firing a Worker If Not Doing a Good Job
Yes	99	67.3	58	50.9	81	*40.5	Do
Do Not Know	1	0.7	13	11.4	19	9.5
No	47	32.0	43	37.7	100	50.0
Payroll Taxes and Other Financial Responsibilities
Yes	119	81.0	76	66.1	95	*47.5
Do Not Know	8	5.4	26	22.6	31	15.5
No	20	13.6	13	11.3	74	37.0

p ≤ 0.001

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

No significant differences were found (p > 0.05) in the need for help or training by the age of the consumer, comparing those 64 years and under with those 65 and over. Examination of surrogates' perceptions, when they were answering for themselves (n = 111), found they differed significantly (p < 0.05) on four of the items by interest level. Those interested or not sure of their interest in the cash option were more likely to want assistance or training deciding how much to pay a worker, doing a background check on a worker, knowing what to do when a worker does not show, and help with payroll taxes when compared with those not interested (Table 10).

Table 10

Surrogates Who Want Help or Training With Task, by Cash-Option Interest Level

Would You Want help in Doing Any of the Following Tasks?	Cash-Option Interest Level
	Interested		Not Sure		Not Interested
	Number	Percent	Number	Percent	Number	Percent
Finding Someone to Be a Home Care Worker
Yes	37	59.7	14	63.6	11	40.7
Do Not Know	3	4.8	3	13.6	1	3.7
No	22	35.5	5	22.7	15	55.6
Interviewing a Worker
Yes	37	59.7	11	50.0	7	*25.9
Do Not Know	1	1.6	3	13.6	2	7.4
No	24	38.7	8	36.4	18	66.7
Doing a Background Check on a Worker
Yes	44	71.0	16	72.7	13	48.1
Do Not Know	2	3.2	3	13.6	2	7.4
No	16	25.8	3	13.6	12	44.4
Deciding How Much to Pay a Worker
Yes	45	72.6	14	63.6	14	*51.9
Do Not Know	2	3.2	5	22.7	3	11.1
No	15	24.2	3	13.6	10	37.0
Knowing What to Do If Worker Did Not Come to Work
Yes	42	67.7	15	68.2	12	*44.4
Do Not Know	0	0.0	3	13.6	2	7.4
No	20	32.3	4	18.2	13	48.1
Firing a Worker If Not Doing a Good Job
Yes	26	41.9	7	31.8	4	*14.8
Do Not Know	0	0.0	4	18.2	4	14.8
No	36	58.1	11	50.0	19	70.4
Payroll Taxes and Other Financial Responsibilities
Yes	46	74.2	17	77.3	14	51.9
Do Not Know	4	6.5	3	13.6	4	14.8
No	12	19.4	2	9.1	9	33.3

p ≤ 0.05

p ≤ 0.01

NOTE: N may vary slightly because of missing data.

SOURCE: Simon-Rusinowitz, L., Mahoney, K.J., et al., 1998.

Additional Information Needed

Overall, before deciding to be involved in the cash option, the majority of consumers (regardless of their interest level) wanted more information. However, there were statistically significant differences (p < 0.05) among the three interest-level groups on each of these items—respondents were even more likely to want information if they stated they were interested in the option. Specifically, when asked if they needed to know more financial details, 90 percent of those interested, 78 percent of those not sure, and 60 percent of those not interested answered “yes.” When asked if they needed to know whether their current worker could be retained, 84 percent of those interested, 73 percent of those not sure, and 64 percent of those not interested responded “yes.” When asked if they needed to know how other current benefits they receive would be affected, the percentage breakdown was 96 percent, 84 percent, and 75 percent, respectively. Finally, when asked if they needed to know more about their rights and responsibilities under the cash option, 99 percent of the interested consumers, 83 percent of those not sure, and 73 percent of those not interested responded “yes.”

There were no statistically significant differences (p > 0.05) in the need for more information by age of respondents. Again, the majority of respondents (74 to 88 percent) wanted additional information regarding each area asked about, regardless of their age.

Discussion and Recommendations

Survey results will guide Arkansas in designing numerous aspects of the cash option; however, this discussion focuses on the implications of survey findings for Arkansas' critical communications and social-marketing efforts. Survey data will help provide answers to three broad questions: (1) How can Arkansas reach those consumers and surrogates most interested in the cash option? (2) What messages should Arkansas emphasize in its communications and social-marketing efforts? (3) What issues need to be explored further in the postsurvey focus groups?

Targeting Consumers and Surrogates

Frequency data help to describe the population, bivariate analyses show correlations that can help pinpoint interested consumers, and multivariate analyses identify variables that predict interest in the cash option. It is important to use all three types of analyses to guide social-marketing efforts.

Some frequency data clearly guide social-marketing efforts. For example, knowing that 81 percent of the population has less than a high school education serves as a blunt reminder that outreach and training materials must be very simple and straightforward (and/or many consumers may need the assistance of surrogates and direct contact with counselors). Frequency data can also assure Arkansas that it can achieve evaluation enrollment targets by focusing on those individuals who indicated an initial interest in the cash option (31 percent of the total consumer sample) along with those who stated that they were unsure whether they would be interested in the cash option (25 percent of the overall sample). Arkansas will need to use data from the survey and followup focus groups to learn more about what information is needed to help the “unsure” population make a well-informed decision to choose the cash option or stay with their current program.

Bivariate analysis indicates that males tend to be more interested in the cash option than females, 39 percent versus 30 percent (p <0.07). In addition, black persons were significantly more interested than white persons (38 percent versus 26 percent). However, the vast majority of the Arkansas sample was female (89 percent), and the population is about equally divided between black and white people. This information guides Arkansas toward those most interested consumers and clarifies areas where State program officials need to learn more (e.g., which cash-option factors do or do not interest women and white persons). The postsurvey focus-group discussions will be designed to learn more about the reasons behind consumer preferences as they vary by race and gender.

One of the survey's major research questions inquires about age as a factor influencing interest in the cash option. Although there was more interest among the younger population than among elders (44 percent versus 29 percent), this was not a statistically significant difference. This lack of significance may be in part because of the small percentage of the sample under 65 (14 percent). However, Arkansas' actual consumer population is primarily elderly (80 percent). This information guides Arkansas to include both age groups in social-marketing efforts; however, program workers need to focus on reaching the relatively small younger population, where interest is strongest, and learning more about the factors that would help uncertain elders feel comfortable with the cash option. The University of Maryland research team will analyze data from other demonstration State surveys and turn age into a continuous variable (as opposed to a dichotomous variable) prior to drawing a conclusion about a correlation between age and interest in the cash option.

Two other key factors require further exploration to guide social-marketing efforts. Survey data indicate the highest level of interest in the cash option—56 percent—is among surrogate decisionmakers when expressing their own views. In addition, the multivariate analysis indicated that the presence of an informal caregiver is a strong predictor of interest in the cash option. It is possible that these two variables are related, as the surrogate decisionmaker is likely to be an informal caregiver. Arkansas needs to learn more about the reasons for surrogates' high level of interest in the cash option, as well as their role in working with a consumer to choose the cash option. The same is true for the role of an informal caregiver—how does the presence of this individual influence a consumer's decision to select a cash option? One possible explanation is that the informal caregiver could serve an emergency backup role if the paid worker does not come to work—an important concern expressed by consumers. Without support from informal caregivers, many consumers may lack the confidence to take on the additional responsibilities required in the cash option. Further understanding of the surrogate and informal-caregiver roles can help Arkansas develop social-marketing messages that address high levels of interest among surrogate decisionmakers and consumers with an informal caregiver.

Communications and Social-Marketing Messages

Survey data offer detailed guidance in developing messages to emphasize in Arkansas' communications and social-marketing materials. Multivariate analyses indicate two issues regarding consumer attitudes that strongly predict interest in the cash option: (1) consumer willingness to perform employer tasks needed to direct their own care; and (2) consumers' desire to be more involved in determining the amount and types of services they receive. At first glance these two characteristics may appear to be quite similar, and possibly proxy indicators for interest in the cash option. However, closer scrutiny illuminates possible differences between these two attitudes. Some consumers may want more say in the types and amounts of services they receive, and at the same time, be unwilling to conduct some or all employer tasks needed to direct their own care. For example, they may feel strongly about being able to specify key aspects of their service (e.g., who provides what service, when, and how much) and want others to carry out some or all of their wishes. Their desire for more involvement may boil down to a desire to assess their own needs and (help) develop a plan that others can implement, as opposed to a wish to carry out employer tasks such as hiring and paying a worker. Once again, the post-survey focus groups can further explore these concepts.

As for surrogates, survey data also offer direction regarding messages to emphasize in social marketing. Surrogates' interest in the cash option was significantly related to their willingness to assume responsibility for employer tasks—a concept to highlight in social-marketing materials. In addition, surrogates' interest in the cash option was significantly related to a belief that this option would make it easier on them. As for those surrogates who thought the cash option would be harder, interest in cash was significantly related to a belief that the extra effort would be worthwhile. To help develop tailored social-marketing messages, the postsurvey focus groups can explore how the cash option can be easier for surrogates, and if extra effort is required of them, what aspects would make the effort worthwhile.

Cash-option characteristics that were attractive to interested consumers provide further direction regarding social-marketing messages (and more importantly, direction for designing the cash option). For example, effective materials would be sure to address the ability to “get services on the days and at the times you want” and “hire whomever you want to provide personal care services, even a friend or a relative” as the vast majority of interested consumers found these program characteristics appealing. The attractiveness of being able to hire one's own worker is consistent with the finding that for consumers (over age 65), interest in the cash option was significantly related to dissatisfaction with their current worker. As the survey addressed the possibility of hiring “a friend or a relative,” the followup focus-group discussion can differentiate between either a friend or relative to learn if consumers find one more appealing than the other. Presurvey focus groups indicated some negative feelings about hiring relatives (Zacharias, 1997a,b).

Interested consumers also found the ability to “buy different services” an attractive program feature. As the majority of consumers interested in the cash option would want to purchase more hours of service, grab bars or shower equipment, and transportation services, these services should be included in social-marketing materials.

Surrogates' reasons for being interested in the cash option also offer messages to include when addressing that group. Materials should be sure to highlight the ability to interview and hire workers, increased flexibility for consumers and surrogates, as well as the cash option's potential benefits for the consumer. Consumers and surrogates interested in the cash option also thought it was important to have peer support from other cash-option consumers. They also want to know that, should they want to, consumers could pay their worker more than the worker currently receives and back out of the option if they wanted to return to the traditional program.

Finally, interested consumers (but not surrogates) considered it important to be able to hire their current worker should they choose the cash option. This information is a strong message that Arkansas needs to address this difficult issue in their social-marketing materials. The Arkansas survey and focus-group data from New York and Florida point to consumers' strong desire to have the ability to hire their current worker. Focus-group participants frequently described problems with former workers, and explained that when they had a worker that they liked, they wanted to continue with that person. Yet, difficult organizational issues are likely to interfere with this consumer preference. Most importantly, provider agencies and/or union contracts may prohibit this practice. In addition, a worker may need full-time employment and only work part-time hours for a specific consumer. This issue is likely to be less important for new consumers entering the Medicaid program, as they would be less attached to an existing arrangement.

Consumers interested in the cash option were more likely to express a need for help or training in employer tasks. Social-marketing materials should be sure to inform consumers that they can have help or training with the most requested tasks. Older and younger consumers did not differ significantly regarding their need for training or help—indicating no need to address this issue differently by age groups.

As the majority of consumers wanted more information before deciding whether to choose the cash option, social-marketing materials and in-person communication should be as specific as possible regarding the following issues: consumer rights and responsibilities under the cash option, how other current benefits would be affected, cash-option financial details, and how the current worker would be affected.

Issues for Postsurvey Focus Groups

Five additional issues need to be explored in Arkansas' followup focus-group discussions. First, successful communications and social-marketing efforts depend on knowing the sources of credible (and unreliable) information for consumers and surrogates. For example, should social-marketing efforts utilize some well-regarded community organizations? Second, it will be very important to test draft materials to be sure they are effective for a population primarily comprised of people with less than a high school education. Third, the timing of presenting various issues will also be important to test. For example, what messages are critical “door openers” to be included in general introductory materials? What information should be included in followup communication? Fourth, it is necessary to learn when consumers and surrogates want hands-on assistance as opposed to training that would allow them to function independently. Finally, Arkansas will need to determine if it is necessary and/or feasible to develop separate materials for specific segments of the population (i.e., according to gender, race, age, surrogate or consumer viewpoint, etc.). Although this decision is related to resources and deadlines, the focus groups can test the need for separate materials.

Policy Issues

The CCDE is a policy-driven project addressing numerous policymaker concerns. Although comprehensive recommendations will not be available until the evaluation is complete, the Arkansas preference survey offers insight into policy issues concerning the importance of offering consumers a choice of PAS options as well as insights regarding potential fraud and abuse and service quality.

The CCDE is based on the premise that the cash option is a choice available to those consumers who want consumer direction. It is not intended to replace traditional services, as the cash option is unlikely to be appropriate for or desirable to all consumers. The Arkansas survey findings support this perspective. Although 34 percent of all respondents expressed a preliminary interest in the cash option (a sizable amount), many were uncertain or not interested.

Fraud and abuse concerns, related to the possibility that consumers and/or their families might misuse the cash benefit or be exploited by others (Doty, 1997), must also be considered. Although the demonstration needs to address these concerns, procedures to minimize fraud and abuse must maintain the consumer-empowerment principles being tested in the CCDE. Overly restrictive measures could negate the effect of the consumer-directed intervention.

Misuse of the cash benefit includes the possibility that consumers might not pay taxes on their workers. Arkansas survey data indicate that these possibilities are limited, as a majority of consumers and surrogates interested in the cash option (81 percent and 74 percent, respectively) said they would want help or training with payroll and taxes. More precisely, most clients are likely to elect to have the payrolling and tax withholding for their workers done for them by accounting professionals. This would greatly reduce the amount of cash that consumers receive and manage (Doty, 1997). Those consumers electing not to use accounting professionals would need to participate in a training program and demonstrate competency in payrolling tasks. Given that 81 percent of the survey respondents did not complete high school, Arkansas is considering a one-to-one training and counseling approach instead of a written training program for this purpose.

One may also question whether the cash benefit will be adequate to provide the level of service that consumers need, especially in States such as Arkansas with a relatively small benefit level. This may be especially pertinent for severely disabled consumers with high levels of need. Although it is not possible to comment on the adequacy of the benefit until the evaluation is complete, it is important to note that the amount of the cash benefit will approximate the dollar amount spent on the consumer's current service plan and will be based on the same assessment process used in the traditional program. The evaluation will compare cost, quality, and satisfaction with service in each option, and will be able to compare adequacy of service in both options.

To prevent consumer exploitation by others (and subsequent suffering of ill effects), the cash option allows and encourages the use of surrogate decisionmakers to represent consumers who are unable to make all decisions independently. (Surrogates are not paid for their assistance.) Although there are many questions to consider regarding surrogate decisionmakers, we know from the Arkansas survey that 23 percent of consumers utilized surrogates and 56 percent of surrogates responding for themselves (versus representing a consumer) were interested in the cash option. In the event of possible exploitation by a surrogate, it is important to note that, under the cash option, counselors will have a role in monitoring all consumers—even those with surrogates.

For those consumers functioning independently, without surrogates, the cash-option training and support services offer further protection against consumer exploitation. When asked whether they would want help or training with various cash-option tasks, the vast majority of consumers who were interested in the cash option wanted these support services.

Arkansas survey respondents found the ability to “hire whomever you want to provide personal care services, even a friend or relative” an attractive feature of the cash option. This finding indicates that consumers are likely to hire friends or relatives as their workers. (As noted earlier, the followup focus groups will explore whether consumers have different views about hiring friends versus relatives.) Policymakers often raise concerns about the quality of care provided by friends or relatives because they may lack formal training. Yet a study of California's In-Home Support Services program (Barnes and Sutherland, 1995) found that consumers rated family members and friends more reliable than workers who were strangers. In addition, a study of elderly Medicaid personal care recipients in Michigan found that client satisfaction was related to several indicators of greater client control and, specifically, to Michigan's policy of encouraging clients to hire family, friends, and neighbors as attendants (Doty, Kasper, and Litvak, 1996). The Arkansas survey indicates that the CCDE will further our understanding about the quality of services when friends and relatives become paid providers.

Summary

The Arkansas telephone survey was conducted as background research to guide CCDE project development Survey findings will guide Arkansas in designing the cash option and developing much-needed communications and social-marketing materials. These efforts are essential to informing Arkansas consumers about the cash option, so they can make informed decisions to choose a consumer-directed option or stay in the traditional program. The authors look forward to continued learning about consumer interest in and satisfaction with a cash option (versus traditional services) when the demonstration is implemented and the choice becomes real, not theoretical.