Federal government researchers have predicted that U.S. healthcare expenditures will reach more than $4 trillion by 2016, with about half coming from the federal government. This compares with about $2 trillion overall now and $800 billion in current federal expenditures. A little reflection leads one to ask whether we even can achieve these projected figures, let alone sustain them. A little more reflection leads to questions about the wisdom of our entire approach to financing the U.S. healthcare enterprise.
In this short commentary I am not so bold as to suggest that I have a solution to our healthcare financing dilemma: namely, soaring costs, dismal quality, and about one-fifth of the population with no insurance coverage. Instead, what I describe is an approach to consumer-directed payments, which may hold considerable promise for the future of behavioral healthcare financing and outcomes.
Behavioral healthcare consumers currently have no role in care payments (besides the standard copays). This means that a payer, whether the federal government or a private corporation, makes a payment directly to a provider organization, with virtually no consumer or family involvement. Managed care entities may act on behalf of the payer, but consumers are excluded from the transaction. Yet if we want to move toward recovery-oriented consumer- and family-directed care, this deplorable situation must change.
For the past several years, I have been working on the concept of a “personal independence account” for consumers. (This should not be confused with either the Bush administration's proposal for personal retirement accounts or so-called consumer health plans approved through federal legislation.) Imagine a situation in which a consumer has a debit card that can be used to pay for care, very much like how many pretax medical spending accounts operate. Funds would flow from the payer to the consumer, and then to the provider.
This arrangement would place the consumer directly into the healthcare payment transaction. By itself, this change could do much to promote consumer empowerment and self-esteem. Both are key ingredients of the recovery process, as well as major factors in promoting hope and independence. Personal independence accounts could do much to facilitate provider responsiveness to consumers, because consumers could use their debit card elsewhere if they become dissatisfied with their current care.
Personal independence accounts obviously would require appropriate supports. The first type of support would be a financial trainer who would provide advice on the use of the debit card and who would be available to answer questions. The consumer initially would start in a state of dependence, in which the financial trainer would approve card expenditures. Subsequently, the consumer would move to a semi-independent state, in which the financial trainer would approve exceptional expenditures (determined by dollar threshold or type of purchase). Finally, the consumer would become completely independent, with consultation available from the trainer. I envision the entire process would take 18 to 24 months.
The second type of support would be a quality trainer. Quality training would be guided by the content of the Mental Health Statistics Improvement Program (MHSIP) Consumer Survey, implemented by SAMHSA and the state mental health agencies during the past ten years and recently updated. Other components of this training would include nontechnical, consumer-focused knowledge about psychotropic medications and their primary and secondary effects, evidence-based care, and recommended online sources of nontechnical information. Consumers would be taught how to read and interpret quality and performance measures the field uses. The quality trainer's goal would be to empower the consumer to make good, informed decisions about care quality. Consumers could use this knowledge to select providers, and to change providers if care quality was not deemed adequate.
Advance directives, medical power of attorney, and legal power of attorney would be integral parts of the personal independence account. They would ensure that a consumer's wishes are respected, that someone is available to make medical decisions for the consumer if he/she becomes incapacitated, and that someone is available to commit the resources of the personal independence account at such times.
Providers who deliver quality services would have nothing to fear from personal independence accounts. In fact, they would be empowered by the knowledge that consumers and family members have given a vote of confidence about the services being delivered.
Some work has been done to test various features of a personal independence account. Several demonstrations under way in the Centers for Medicare and Medicaid Services' Cash and Counseling Program show considerable promise. A similar concept is being developed for the United Kingdom.
At a meeting early in the summer of 2006, a consumer remarked that “public care has taken away our hope.” I was particularly struck by this heartfelt comment. If we are to respond effectively, a key feature in transforming public care will be to ensure that consumers have hope about recovery and the future. Personal independence accounts can be an important tool to help make this a reality.
Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm Constella Group, LLC, worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board.