One of the rationales for the SDC approach is that giving participants the freedom to make choices, whether good or bad, encourages personal responsibility and independence. As a result, some participants in SDC may use individual budgets to select treatment interventions that psychiatrists and psychologists would consider misguided or potentially harmful. Others may spend their individual budgets in ways that they later regret. Although such outcomes are a predictable and perhaps necessary consequence of self-direction, SDC programs should seek to minimize them by offering education and decision-making supports.
Ensuring that SDC participants obtain care that is no worse in quality than the care they would have received in traditional mental health programs and instituting standards that encourage quality improvement are critical to the long-term sustainability of mental health SDC. Quality and accountability have become guiding principles of efforts to improve mental health services and the health outcomes of individuals with SMI,21, 50 just as autonomy and choice are guiding principles in the design of SDC. One concern is that many participants will purchase ineffective or unneeded products and services or will be exploited by product and service vendors. Another concern is that SDC will undermine the successful dissemination of evidence-based practices (EBPs), mental health services and clinical practices whose clinical benefits have been demonstrated in rigorously designed research studies or demonstration trials (e.g., Supported Employment). If mental health SDC programs do not establish clear standards that address these concerns, their legitimacy may be challenged and sustained financing for SDC may be put at risk.
Efforts to ensure adequate quality and accountability have often involved creating standards and payment policies that serve to reduce natural variations in service delivery and practice. In managed care health plans and Medicaid fee-for-service plans, the concern that consumers will purchase ineffective or unneeded products and services is addressed by limiting health plan reimbursement to those providers, products, and services that satisfy regulatory standards or that have been vetted for quality. Training providers to provide EBPs51, 52 and instituting payment policies, such as accountable care organizations,53 that financially reward adherence to quality indicators are leading examples of strategies states have used to achieve greater quality and accountability in health care.3
In SDC, the pursuit of autonomy and choice could conflict with the pursuit of quality and accountability. SDC participants may or may not elect to use interventions and services that are supported by evidence and may select services that raise concerns among participants' health care providers or family members. The issue of quality may be addressed through a shared decision-making process and/or by providing decision-making supports, as discussed above (Section 4.2). SDC coaches, who assist SDC participants in developing their individual service plans, can be trained to provide information and guidance about providers and services and to support shared decision-making. Such training could include education on EBPs and information about the locations where EBPs are offered within a service region. Over time, SDC coaches may also compile a more global assessment of the quality of providers in their service region based on the feedback they receive from mental health consumers, and consequently SDC coaches may be able to provide qualitative assessments of provider quality to SDC participants.
The concern that SDC programs could undermine the dissemination of EBPs raises several unresolved issues. One likely benefit of implementing SDC on a larger scale is that participants' service choices may yield new information about their preferences for various EBPs. Some EBPs may be preferred to similar non-EBP services, and in those cases SDC would likely accelerate EBP use and implementation. An evidence base is being developed for several innovative interventions that are recovery oriented, including stigma-reduction interventions,54 wellness recovery interventions,55 and peer-led illness self-management programs.56 Innovative recovery oriented interventions could be especially attractive to participants in SDC.
Some SDC participants may report a mismatch between available EBPs and the types of services they would like to have available. Such information could result in modifications of existing EBPs or the development of new EBPs. The least attractive outcome would be if policymakers and providers favored the dissemination of an EBP that SDC participants did not want to use. In such cases, implementing a shared decision-making process to enable assessment of the costs and benefits of the EBP would be critical.
One key informant to this report emphasized that it is essential for either the state or the managed care company or fiscal intermediary serving as the state's agent to ensure that information is available and that choices are made among a set of products, services, and providers that have been vetted for quality. According to this informant, allowing people to make choices from a selected menu of providers and services is a reasonable method to control quality. Whether or not programs limit choices among providers or services, programs should be able to communicate in an understandable way their policies regarding allowable services and products to participants, some of whom may have low literacy.