To the Editor: The March 2007 Best Practices column, "Implementation of a Consumer-Directed Approach in Behavioral Health Care: Problems and Prospects," by LaBrie and colleagues (1) identified several important barriers in realizing the potential of consumer-directed behavioral health care.
It is important, however, to differentiate consumer-directed care as successfully initiated with people who have physical or developmental disabilities and with older adults through such approaches as cash and counseling (C&C) from approaches that utilize a health savings account (HSA) model. Although both focus on promoting greater consumer choice and control over services, C&C and similar consumer-directed approaches typically utilize individualized budgeting for Medicaid consumers to self-manage services. As described by LaBrie and colleagues HSAs typically use the high-deductible approaches in private insurance markets (2).
We agree that consumers require comprehensive information on quality as well as costs in order to fully utilize consumer-directed care approaches. Although we have a long way to go in the mental health system to achieve this goal, we do see hopeful signs with efforts such as the initiative by the U.S. Department of Health and Human Services to promote transparency and value-driven health care (www.hhs.gov/transparency).
We do question LaBrie and his coauthors' characterization that mental health consumers lack adequate decision-making and self-care abilities to fully utilize consumer-directed care approaches. The Institute of Medicine (3) stated unequivocally that a "clear majority of individuals with mental illnesses (including those with severe illnesses such as schizophrenia) and substance use illnesses are able to make treatment and other life decisions." Regarding self-care, there is a wealth of evidence of the utility and effectiveness of mental health self-help as cited in both the U.S. Surgeon General's 1999 report on mental health and the 2003 report of the President's New Freedom Commission on Mental Health. Additionally, C&C approaches based on consumer direction have been successful with people who have significant cognitive impairments—including developmental disabilities—when decision-making supports are in place (4). Perhaps, the true barrier remains the stigma—evident in both society and mental health systems—that perpetuates negative stereotyping rather than focusing on the abilities and strengths of those served.
Evidence is now being gathered on the effectiveness of consumer-directed mental health care. An analysis supported by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration examined results of the C&C program for persons who received mental health services. Preliminary findings showed that this approach "works as well as for clients with mental health diagnoses with no discernible adverse effects on safety or health" (5).
Consumer direction holds great promise in transforming how mental health services are delivered. Such approaches, in which consumers' self-identified needs, preferences, and choices are the principal drivers, will help us reach our shared destination—recovery.
Ms. Power is director and Mr. del Vecchio is associate director for consumer affairs of the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, Rockville, Maryland.
LaBrie RA, Browne C, Christensen DE, et al: Implementation of a consumer-directed approach in behavioral health care: problems and prospects. Psychiatric Services 58:300—302, 2007
Benjamin AE, Fennel M: Putting the consumer first: an introduction and overview. Health Services Research 42:353—361, 2007
Institute of Medicine: Improving the Quality of Health Care for Mental and Substance Use Conditions. Washington, DC, National Academies Press, 2006
Carlson L, Foster L, Dale S, et al: Effects of cash and counseling on personal care and well-being. Health Services Research 42:467—487, 2007
Shen C, Mahoney K, Smyer M, et al: Consumer direction for persons with mental health diagnoses: lessons from the New Jersey cash and counseling program. Rockville, Md., Substance Abuse and Mental Health Services Administration, in press