Mental health SDC represents both a philosophical and a practical departure from the conventional approach to planning mental health care. Key informants interviewed for this report were asked to offer their perspectives on how mental health SDC differs from traditional public mental health services (i.e., those mental health services that are typically covered by Medicaid programs and states and that are administered by a state mental health authority). This section provides a summary of their comments.
As a result of having greater decision-making control, SDC program participants were thought to be more activated to establish personal goals, to select products and services that reflect their preferences and that are consistent with their goals, and to plan expenditures within a budget. One SDC expert observed that for many consumers, traditional services have not been effective in supporting them to move on in their lives and have left them disempowered and lacking in self esteem and hope. According to one member of the PNFC, SDC gives individuals a "sense of control" and "allows them to operate in the economic system, which is normalizing." The recovery oriented philosophy of SDC programs and the greater control offered by SDC over one's own care appear to be why participants generally prefer SDC to traditional services. As articulated by one SDC participant:
"[SDC provides] the freedom to have a voice and to actively participate in navigating my own personal road to recovery. [Self direction] is the ability to choose the services that will be most effective for me in reaching that destination. Self direction is the freedom to request assistance instead of receiving it based on rigid criteria for treatment. It's a method of testing my potential and responsible limits by allowing me to take ownership of the choices I make...it's about choosing professionals in those fields that will best meet [my] individual needs."
From the perspective of one public mental health system administrator interviewed for this report, SDC also tends to put participants in a position where there is a heightened sense of expectation that they are responsible for the direction of their lives. This opportunity to make one's own decisions, for better or for worse, is an integral element of self-direction. The expectation of self-responsibility is conveyed by giving participants control over an individualized budget and the authority to self-direct the service planning process. As a result, SDC participants may be more motivated to take steps towards independence and recovery than they would be otherwise, especially in comparison to institutional mental health service settings, which put consumers in a position of dependency. Compared to traditional services, SDC consequently may serve to align consumers' personal incentives with the goals of recovery oriented public mental health systems. In the words of one consumer representative:
"People who have choice and control of decisions pertaining to their lives and services are more likely to be motivated. People who are motivated are more likely to be successful."
Another key informant involved with the planning of one SDC program also emphasized the broader set of choices that SDC offers regarding providers and supports: "the whole philosophy of the [SDC] program is to take advantage of community supports not available within the traditional mental health system." These community resources may include access to additional mental health providers and programs, including private practices, and may include access to non-traditional services, such as fitness programs, transportation and education. Community resources also may include products, such as clothing for a job or household products needed to live independently. By contrast, in traditional services, the menu of reimbursable mental health programs and providers is more limited and clients are usually referred to the nearest mental health outpatient program that is accepting new clients rather than given the option to use other providers. As a result, spending in SDC can be shifted toward products, services, and providers that consumers value more highly within the constraints of a budget.
Some key informants to this report emphasized differences between the mental health SDC approach and traditional services that may impede implementation of SDC programs in Medicaid. A chief concern expressed by one key informant was how to ensure that standards for the quality of mental health care would be maintained. In public mental health systems, a minimum quality of care is ensured through provider licensing and training requirements, regulations that define the content of specific mental health services, systems' rollouts of evidence-supported practices, continuing medical education opportunities, independent performance standards, and other administrative policies. In contrast, SDC would allow consumers to select providers and services that may not be bounded by these policies. The implications of this point are discussed in Chapter 4.
Other concerns were raised regarding the much greater scope of goods and services that SDC participants may purchase in comparison to consumers in traditional outpatient mental health programs. One key informant pointed out that one reason Medicaid sets limits on the goods and services that can be purchased is to ensure the integrity of the payment system. Services that are reimbursable are all generally considered standard components of mental health treatment. By contrast, SDC programs would allow some purchases whose legitimacy could be questioned on the basis that other Medicaid recipients and other privately insured consumers may not be reimbursed by their health care plans for similar purchases. This point is further discussed in Chapter 4.
Another key informant with experience in managed behavioral health care contracting raised the concern that most SDC programs do not currently have an adequate administrative infrastructure for approving a large volume of proposed purchases. In most current mental health SDC programs, a program manager or supervisor approves participants' proposed purchases. However, the key informant indicated that if SDC programs are implemented on a much larger scale, the volume and variety of proposed purchases could overwhelm a program manager's ability to properly review each and every purchase. Consequently, in the key informant's opinion, many purchases would not be subjected to any significant review. Implications of this point for SDC program design are discussed in Chapter 4.