Feasibility of Expanding Self-Directed Services to People with Serious Mental Illness. 3.3. Spending in Individual Budgets


The total amount of money individuals can spend in SDC is typically capped at values ranging from $1500 to $4000 per participant per year, depending on the program.33 Some programs "cash out" outpatient mental health clinic services, which means that participants' individual budgets include the money that would have been allocated for these services, whereas other programs do not give participants control over this spending. Participants may use the money in their individual budgets to purchase specialty mental health care services (e.g., outpatient individual or group therapy) and may also purchase non-traditional services and products and other costs not covered by their insurance plans, for those who have insurance. Most programs do not stipulate the proportion of the individual budget that participants must spend on specialty mental health care versus other products/services, though some do, particularly for persons who are uninsured. Some SDC programs use suggested formulas such as asking participants to spend a certain proportion of their budget on traditional mental health services, usually defined as those services covered by Medicaid.

Individuals enrolled in Medicaid can utilize Medicaid-covered services with minimal out-of-pocket expense. However, Medicaid benefits in some states may not include some traditional mental health services, such as supported employment or family psycho-education, or Medicaid coverage may not fully cover the costs of care for available providers of these services. In those cases, SDC participants may decide to pay for uncovered mental health expenses using their individual SDC budgets. Uninsured persons are eligible for enrollment in some SDC programs (e.g., Florida SDC). For the uninsured, payments for mental health services are deducted from the individual's SDC budget. In some programs, uninsured participants are also required to spend at least a specified percentage of their SDC budget on clinical services.

In a mental health SDC program in Delaware County, Pennsylvania individual budgets have been used to purchase a wide range of items, such as hearing and vision tests, health club memberships (for weight reduction) and nicotine patches. Figure 2 shows Freedom Funds expenditures during the first year of the program by category. The largest expenditure category was for physical health products and services (36 percent), followed by housing (20 percent), work/other activities (19 percent), education (19 percent), mental wellness (4 percent) and social activities (2 percent).

FIGURE 2. Freedom Funds Purchases in Delaware County SDC
Pie Chart: Housing (20%); Physical Health (36%); Work/Other Activities (19%); Education (19%); Mental Wellness (4%); Social Activities (2%).
SOURCE: Magellan Behavioral Health of Pennsylvania: Report to the Community, 2010.

As pointed out by Alakeson,33 the broad categorization of spending shown in Figure 2 masks the variety of purchases made in mental health SDC programs. Physical health expenditures may be for items such as vitamins and nutritional supplements, health club memberships, vision services, hearing aids and batteries, weight loss program fees, exercise equipment, prescription drug expenses. Housing expenditures could include spending on rent, food, furniture, towels and linens, and moving expenses. Work-related expenditures could include spending on clothing, haircuts, computer software, fees for professional licensure, insurance, or car repair. Education-related expenses could include tuition, but might also include transportation, books, and computer supplies.

Figure 3 shows mean expenditures per person in the Florida SDC for a sample of 80 program enrollees who participated in a survey conducted by Spaulding-Givens.20 The dollar amounts are from the Florida SDC program's administrative databases and correspond to a 12-month period for each respondent sometime during fiscal years 2009 to 2010. The spending categories are those used by the SDC program. Using SDC program records, Spaulding-Givens disaggregated expenditures in a "miscellaneous" spending category into sub-categories for computers/computer accessories, household items/appliances, hobbies, arts/crafts supplies, health/physical fitness, office supplies, and memberships/miscellaneous.

FIGURE 3. Florida SDC, Expenditures per Participant Over a 12-Month Period, by Category
(Fiscal Years 2009-20010, n=80)
Bar Chart: Transportation ($211); Housing ($155); Utilities ($144); Dental Services ($121); Counseling ($117); Computers/Accessories ($110); Medication ($99); Clothing ($91); Food ($77); Medication Management ($74); Wellness Services ($70); Household Items & Applicances ($62); Hobbies ($47); Arts & Crafts ($27); Vision Services ($22); Health & Physical Fitness Products ($20); Membership & Miscellaneous ($17); Education & Training ($16); Office Supplies ($14); Entertainment ($11); Pet Ownership ($3); Personal ($2).
SOURCE: Adapted with permission from Spaulding-Givens, J. 2001. Florida Self-Directed Care: An Exploratory Study of Participants' Characteristics, Goals, Service Utilization, and Outcomes. The Florida State University, College of Social Work: Tallahassee.

Florida SDC participants spent $1509 per person during a 12-month period. This is only the amount paid out of participants' individual program budgets. It does not include health insurance reimbursements to mental health service providers and pharmacies for mental health care provided to participants. As shown in Figure 3, transportation had the largest mean expenditures of any category ($211 per person; 14.0 percent), followed by housing ($155 per person; 10.3 percent), utilities ($144 per person; 9.5 percent), dental services ($121 per person; 8.0 percent), and counseling ($117 per person; 7.7 percent). Medication spending ($99 per person; 6.5 percent) encompasses spending by persons who are uninsured, copayments, and any other medication expenses not covered by insurance. Wellness services ($70, 4.7 percent) include fitness club memberships and weight loss program fees as well as alternative medicine services, such as acupuncture. Although the mean values in Figure 3 may indicate a general spending pattern for the program as a whole, they do not necessarily correspond to any individual participant's spending pattern. In fact, participants' spending totals varied tremendously, from $0 to more than $3300.

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