Procedures and policies that SDC programs adopt in relation to participants' purchases may be interpreted as manifestations of programs' commitment, or lack thereof, to the principles of client self-direction and autonomy. Purchasing policies and procedures should consequently be transparent and ideally will reflect substantial input from SDC participants and other community stakeholder groups. However, purchasing procedures and policies may also be interpreted as manifestations of SDC programs' stewardship of public financing for mental health care. Viewed from this perspective, purchasing policies and procedures should reflect input from varied constituencies.
Nearly all of the key informants interviewed for this report agreed that SDC participants should be allowed to purchase essentially any legally obtainable good or service that is consistent with one or more goals of their recovery plan. A former federal program official offered the following principle as guidance: programs should allow any purchases "related to living a full life in the community." However, at least one key informant pointed out that the legitimacy of some items could be questioned by the public even if the item is linked to a valid recovery goal, suggesting the need for some boundaries on purchases of non-traditional items.
According to key informants who have worked in or with SDC programs, proposed purchases rarely have tested the boundaries of legitimacy and denials of proposed purchases have been uncommon. One SDC program administrator said that the most frequently disallowed items are requests to receive outpatient mental health services from a provider whose hourly rate is not affordable within the constraints of the participant's available budget. Insufficient linkage between a proposed purchase and a recovery goal in a participant's recovery plan was the only other reason cited for purchase denials.
Standardization of approvable items and vendors, within a region or state, would seem to be in the interest of all SDC participants. Public controversy regarding the legitimacy of selected purchases in SDC could threaten the perceived legitimacy of the overall SDC program and continued program financing. External authorization of program policies regarding allowable purchases (e.g., as established in state regulations) and a process for auditing approved and actual purchases may encourage such standardization. SDC program coaches also will require training with respect to a program's purchasing policies.
SDC programs could also utilize modern payment technologies to minimize labor expenses associated with managing participants' budgets. For example, SDC participants in Texas SDC are given "cash cards" that have a pre-assigned spending limit and that allow purchases from a pre-specified set of vendors. Such a system would relieve the need for human review and approval of each purchase and would facilitate the monitoring of participants' budgets during a plan year.
In Cash and Counseling programs, fiscal intermediaries provide the Medicaid program with financial accountability and protection against misuse of budgets by participants and their representatives. Yet nearly all Cash and Counseling grantees report having experienced difficulties with fiscal intermediaries.57 Hence, state officials agree that it is critical to develop strong oversight capability to detect and resolve any difficulties in a timely fashion.