[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG
TREATMENT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON CRIMINAL JUSTICE,
DRUG POLICY AND HUMAN RESOURCES
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 22, 2004
__________
Serial No. 108-269
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
______
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky DANNY K. DAVIS, Illinois
TODD RUSSELL PLATTS, Pennsylvania JOHN F. TIERNEY, Massachusetts
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida DIANE E. WATSON, California
EDWARD L. SCHROCK, Virginia STEPHEN F. LYNCH, Massachusetts
JOHN J. DUNCAN, Jr., Tennessee CHRIS VAN HOLLEN, Maryland
NATHAN DEAL, Georgia LINDA T. SANCHEZ, California
CANDICE S. MILLER, Michigan C.A. ``DUTCH'' RUPPERSBERGER,
TIM MURPHY, Pennsylvania Maryland
MICHAEL R. TURNER, Ohio ELEANOR HOLMES NORTON, District of
JOHN R. CARTER, Texas Columbia
MARSHA BLACKBURN, Tennessee JIM COOPER, Tennessee
PATRICK J. TIBERI, Ohio BETTY McCOLLUM, Minnesota
KATHERINE HARRIS, Florida ------
------ ------ BERNARD SANDERS, Vermont
(Independent)
Melissa Wojciak, Staff Director
David Marin, Deputy Staff Director/Communications Director
Rob Borden, Parliamentarian
Teresa Austin, Chief Clerk
Phil Barnett, Minority Chief of Staff/Chief Counsel
Subcommittee on Criminal Justice, Drug Policy and Human Resources
MARK E. SOUDER, Indiana, Chairman
NATHAN DEAL, Georgia ELIJAH E. CUMMINGS, Maryland
JOHN M. McHUGH, New York DANNY K. DAVIS, Illinois
JOHN L. MICA, Florida WM. LACY CLAY, Missouri
DOUG OSE, California LINDA T. SANCHEZ, California
EDWARD L. SCHROCK, Virginia C.A. ``DUTCH'' RUPPERSBERGER,
JOHN R. CARTER, Texas Maryland
MARSHA BLACKBURN, Tennessee ELEANOR HOLMES NORTON, District of
PATRICK J. TIBERI, Ohio Columbia
BETTY McCOLLUM, Minnesota
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
J. Marc Wheat, Staff Director
Roland Foster, Professional Staff Member
Malia Holst, Clerk
Tony Haywood, Minority Professional Staff Member and Counsel
C O N T E N T S
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Page
Hearing held on September 22, 2004............................... 1
Statement of:
Curie, Charles G., Administrator, Substance Abuse and Mental
Health Services Administration, Department of Health and
Human Services............................................. 6
Heaps, Melody, president, Treatment Alternatives for Safe
Communities; and Dr. Michael Passi, associate director,
Department of Family and Community Services, city of
Albuquerque, NM............................................ 22
Letters, statements, etc., submitted for the record by:
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, prepared statement of............... 50
Curie, Charles G., Administrator, Substance Abuse and Mental
Health Services Administration, Department of Health and
Human Services, prepared statement of...................... 9
Heaps, Melody, president, Treatment Alternatives for Safe
Communities, prepared statement of......................... 25
Passi, Dr. Michael, associate director, Department of Family
and Community Services, city of Albuquerque, NM, prepared
statement of............................................... 31
Souder, Hon. Mark E., a Representative in Congress from the
State of Indiana, prepared statement of.................... 4
ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG
TREATMENT
----------
WEDNESDAY, SEPTEMBER 22, 2004
House of Representatives,
Subcommittee on Criminal Justice, Drug Policy and
Human Resources,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2 p.m., in
room 2247, Rayburn House Office Building, Hon. Mark Souder
(chairman of the subcommittee) presiding.
Present: Representatives Souder, Cummings, Norton and
Ruppersberger.
Staff present: J. Marc Wheat, staff director; Roland
Foster, professional staff member; Malia Holst, clerk; Tony
Haywood, minority professional staff member; and Teresa Coufal;
minority assistant clerk.
Mr. Souder. The subcommittee will now come to order.
Good afternoon and I thank you all for being here.
Today, we will continue the subcommittee's examination of
drug addiction treatment or as President Bush refers to it in
the National Drug Control Strategy, healing America's drug
users. It is estimated that at least 7 million people in the
United States need substance abuse treatment. Providing
treatment is important because it improves the lives of
individuals and reduces social problems associated with
substance abuse.
Effective treatment, for example, reduces illegal drug use,
criminal activity and other risky behaviors while improving
physical and mental health. When tailored to the needs of the
individual, addiction treatment is as effective as treatments
for other illnesses such as diabetes, hypertension and asthma.
Last year, President Bush took what I believe to be a very
significant step toward assisting the difficult problem of
extending help to those suffering from substance abuse when he
unveiled the Access to Recovery Initiative. Beginning this year
the President's initiative will provide $100 million to the
Substance Abuse and Mental Health Services Administration to
supplement existing treatment programs. This is intended to pay
for substance abuse treatment for Americans seeking help but
can't get it, many of whom cannot afford the cost of treatment
and don't have insurance that covers it.
If fully funded at $200 million per year as requested by
the President, this program could help up to 100,000 or more
suffering from addiction to receive treatment. The program also
has enormous potential to open up Federal assistance to a much
broader range of treatment providers than currently available
today.
The initiative will support and encourage a variety of
treatment options and provide those seeking assistance a choice
in treatment approaches and programs. Providing choices for
those in need of assistance allows the individual to select the
program that best addresses their personal needs. It has often
been said that in order to help substance abusers, you need to
meet them where they are. This approach goes a step further by
allowing those seeking help to determine themselves where they
want this meeting to occur and with whom.
This new approach to treatment will establish a State-
managed program for substance abuse clinical treatment and
recovery support services buildupon the following three
principles.
Consumer choice. The process of recovery is a personal one.
Achieving recovery can take many pathways, physical, mental,
emotional or spiritual. Given a selection of options, people in
need of treatment for addiction and recovery support will be
able to choose the programs and providers that will help them
most. Increased choice protects individuals and encourages
quality.
Outcome oriented. Successfully measured by outcomes,
principally abstinence from drugs and alcohol and including
attainment of employment or enrollment in school, no
involvement with the criminal justice system, stable housing,
social support, access to care and retention and services.
Increased capacity. The initial phase of the Access to
Recovery will support treatment for approximately 50,000 people
per year and expand the array of services available including
medical detoxification, in-patient and out-patient treatment
modalities, residential services, peer support, relapse
prevention, haste management and other recovery support
services. These funds will be awarded through a competitive
grant process. States will have considerable flexibility in
designing their approach and may target efforts to areas of
greatest need to areas with a high degree of readiness or to
specific populations including adolescents.
The key to implementing the grant program is a State's
ability to ensure genuine, free and independent client choice
of eligible providers. States are encouraged to support any
mixture of clinical treatment and recovery support services
that can be expected to achieve the program's goal of cost
effective, successful outcomes for the largest number of
people.
Today, we will learn more about the status and the goals of
the Access to Recovery Initiative with the person most
responsible for implementing it, my fellow Hoosier and friend,
SAMHSA Administrator, Charles Curie. We will also hear from
several experts who are on the front lines of substance abuse
treatment. Melody Heaps is the president of Treatment
Alternatives for Safe Communities in Chicago, IL, a recipient
of Access to Recovery funding. Dr. Michael Passi is the
associate director of the Department of Family and Community
Services in Albuquerque, NM which was a pioneer in providing
choices for those seeking substance abuse treatment.
Thank you again for being here today and I look forward to
hearing more about the Access to Recovery from our experts who
are with us today.
[The prepared statement of Hon. Mark E. Souder follows:]
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Mr. Souder. I ask unanimous consent that all Members have 5
legislative days to submit written statements and questions for
the hearing record, that any answers to written questions
provided by the witnesses also be included in the record.
Without objection, so ordered.
I also ask unanimous consent that all exhibits, documents
and other materials referred to by Members and the witnesses
may be included in the hearing record and that all Members be
permitted to revise and extend their remarks. Without
objection, so ordered.
[Witnesses sworn.]
Mr. Souder. Once again, thank you for your patience and for
your leadership not only here but in your previous State
position in Pennsylvania in advocacy for those who often don't
have advocates. You have been consistent for many years talking
about co-occurring dependencies and creative ways to address
these problems. Thank you for being here.
STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH
AND HUMAN SERVICES
Mr. Curie. Thank you so much, Mr. Chairman. It is great to
see you again.
I appreciate the opportunity to testify today. I also
request that my written testimony be submitted for the record.
Mr. Souder. So ordered.
Mr. Curie. I am pleased, Mr. Chairman, that you and the
committee have selected the President's Access to Recovery
Substance Abuse Treatment Initiative as the topic of this
hearing. Again, I am very pleased with your opening statement
of support for the concept and for the program, Access to
Recovery.
It is also a privilege for me today to be participating in
the same session with Dr. Michael Passi from Albuquerque which
did pave the way with a voucher type of program and New Mexico
happens to be one of the recipients of Access to Recovery, so
we have high hopes for the implementation there. Also, my
friend and colleague for whom I have such regard, Melody Heaps
who has done so much on behalf of individuals trapped in
addiction in the criminal justice system, bringing hope in her
career.
Expanding substance abuse treatment and capacity and
recovery support services is a priority for this
administration. There is a vast, unmet treatment need in
America. Too many Americans who seek help for their substance
abuse problem cannot find it. A recently released 2003 National
Survey on Drug Use and Health, known as the Household Survey,
provides the scope of the problem.
In 2003, there were an estimated 22 million Americans who
were struggling with a serious drug or alcohol problem. The
survey contains another remarkable finding. The overwhelming
majority, almost 95 percent of people with substance use
problems, do not recognize their problem. Of those who
recognize their problem, 273,000 reported that they made an
effort but were unable to get treatment.
To help those in need, SAMHSA supports and maintains State
substance abuse treatment systems through the Substance Abuse
Prevention and Treatment Block Grant. Our Targeted Capacity
Expansion Grant Program continues to help us identify and
address new and emerging trends in substance abuse treatment
needs. Now, we also have Access to Recovery, ATR. It provides a
third complementary grant mechanism to expand clinical
treatment and recovery support service options to people in
need.
ATR was proposed by President Bush in his 2003 State of the
Union Address. It is designed to accomplish three main
objectives long held by the field, policymakers and
legislators. First, it allows recovery to be pursued through
many different and personal pathways. Second, it requires
grantees to manage performance based on outcomes that
demonstrate patient successes. Third, it will expand capacity
by increasing the number and types of providers who deliver
clinical treatment and/or recovery support services.
The program uses vouchers and coupled with State
flexibility and executive discretion, they offer an
unparalleled opportunity to create profound positive change in
substance abuse treatment financing and service delivery across
the Nation.
The uniqueness of ATR and its program is its direct
empowerment of people, of consumers. Individuals will have the
ability to choose the path best for them and the provider that
best meets their needs whether physical, mental, emotional or
spiritual. Recovery is a very personal process. If you were to
ask 100 people about their story of recovery, people in
recovery, you would get 100 different stories. There would be
common elements but each would have their own pathway.
ATR ensures that a full range of clinical treatment and
recovery support services are available, including the
transforming powers of faith. I had the privilege of joining
the President in Dallas when he announced that $100 million in
Access to Recovery grants were being awarded to 14 States and 1
tribal organization. These first grantees were selected through
a competitive grant review process that included 66
applications submitted by 44 States and 22 tribes and
territories.
While all applicants had the opportunity to expand
treatment options for different target population groups and
utilized different treatment approaches, they all had to meet
some specific common requirements, including the need to ensure
genuine free and independent client choice of eligible
providers and to report on common performance measures to
illustrate effectiveness.
Key to achieving our goal of expanding clinical substance
abuse treatment capacity and recovery support services and
successfully implementing ATR is the ability to report on
meaningful outcomes. We are asking grantees to report on only
seven outcome measures. These measures are recovery-based and
broader than simply reporting numbers of people served or beds
occupied. They get at real outcomes for real people.
First and foremost is abstinence from drug use and alcohol
abuse. Without that, recovery and a life in the community are
impossible.
Two other outcomes are increased access to services and
increased retention and treatment related directly to the
treatment process itself. The remaining four outcomes focus on
sustaining treatment and recovery, including increased
employment, return to school, vocational and education
pursuits, decreased criminal justice involvement, increased
stabilized housing and living conditions and increased supports
from and connectiveness to the community.
These measures are true measures of recovery. It is the
first time we are striving to measure recovery in those terms.
They measure whether our programs are helping people attain and
sustain recovery. As a compassionate Nation, we cannot afford
to lose this opportunity to offer hope to those fighting for
their lives to attain and sustain recovery. Because the need is
so great, the President has proposed in fiscal year 2005, to
double the funding for Access to Recovery to $200 million and
to also increase the Substance Abuse Prevention and Treatment
Block Grant by $53 million for a total of $1.8 billion.
As you know, the President's fiscal year 2005 budget is
before Congress right now. The President's proposed substance
abuse treatment initiatives are good public policy and a great
investment of Federal dollars. As the President said, and we
all know, our Nation is blessed with recovery programs that do
amazing work. Our common ground is a shared understanding that
treatment works and recovery is real. Now, it is our job to see
to it that the resources are made available to connect people
in need with people who provide the services.
I also would like to recognize, in conclusion, Dr. Wesley
Clark,who is with me today, who is the Director of the Center
for Substance Abuse Treatment which is the center primarily
responsible within SAMHSA for the implementation and carrying
out of Access to Recovery.
Thank you and I would be most pleased to answer any
questions you may have.
[The prepared statement of Mr. Curie follows:]
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Mr. Souder. Thank you very much.
In your testimony, you have four different ways you
determined how people were going to get the grants: client
choice, how clients will be assessed, acquire the supplement
and no supplant, the poor, uncommon performance measurements.
Were those all weighted equally? How did you sort through your
applicants and if you can also add, did it matter whether they
had prior experience with this, like you said Albuquerque did?
And give us some feeling that this wasn't just darts at the
board or something.
Mr. Curie. That's a very good question. The peer review
committee and the reviewers definitely took their jobs very
seriously. We did give weighting according to what we expected
with ATR. There was clear weighting given to the applicants who
had to demonstrate and those who won awards had to demonstrate
they did have an objective assessment process in place, that
they did have the capacity to have an eligible provider list in
a way of assuring that the providers were going to clearly
increase capacity.
They also needed to indicate and show how they were going
to assure there was not going to be fraud and abuse for using
vouchers. Using electronic voucher approaches by using
electronic forms of vouchers has been a way of doing that in
other programs. I think most of the applicants who won were
able to demonstrate they could do that.
Also, they had to demonstrate that the client would have
choice based upon that assessment, that there was a clear link
to the assessment and choice, that the assessment process was
an objective one, that there was no conflict of interest in the
assessment process and the providers they were able to select.
They also then had to demonstrate and give competence to those
reviewing, that they had the capacity to actually carry this
out in a timely manner, in other words that they did have
structures in place and would be able to implement this at
least by early 2005 in terms of making the awards.
Previous experience was definitey a consideration because
that would also show capacity to be able to carry this off
successfully. It is clear though that this is a new way of
financing and delivering services, so there were very few
examples across the country of voucher programs. Wisconsin,
which also happened to win a grant, also had a voucher program
in Milwaukee and a track record as well.
Mr. Souder. They are 3 year grants?
Mr. Curie. Three year grants, yes.
Mr. Souder. Are the outcomes reported annually and do you
have a monitoring system for that?
Mr. Curie. Yes. We are looking for the outcomes to be
reported more frequently than annually. We will be looking and
the States will need to demonstrate that they are beginning to
collect outcome information within the first year. Yes, States
need to demonstrate a capacity and that they would be able to
glean the outcome measures from eligible providers. That would
be one of the things we would expect in order for a provider to
continue to be an eligible provider, that they respond to those
seven domains.
Our role at SAMHSA through CSAT will be to monitor the
States' overall performance and see to it that the States are
holding those provides accountable.
Mr. Souder. One of the frustrations of any Congressman who
works at all with grant requests, or at least supports those
who do grant requests, has not known precisely how the
measurements are done and particularly if this is going to
expand to more than the 50,000 to 100,000. Did you review with
the applicants that you didn't choose how to put together
better programs or do they have a way to look at how to do that
in the next round? Will you continue as you look at the
outcomes that you are getting, do you have ways to communicate
to people who didn't even apply the first round what you are
looking for and how to make this program reflective of things
that don't work and do work?
Mr. Curie. I believe the answer to each of those questions
is yes. We do have with all of our grant programs and
discretionary grant programs the ability for an applicant who
did not receive an award to ask for feedback in terms of where
did they fall short and they can examine what their particular
score was. We do offer ongoing technical assistance.
Just as we did in the very beginning with Access to
Recovery, we held five technical assistance sessions and we had
a great response to those TA sessions. One of those five was
geared toward tribal organizations. I know we had over 100
tribal organizations participating as well. I think most if not
all of the 50 States participated in those TA sections.
We would continue that process of outreach to encourage
folks to apply. If we are in that position, it would be very
good news because it means the $200 million was being
appropriated but we would be prepared to do that to assue we
are continuing to do outreach and expand.
Mr. Souder. There isn't any casual way to say this. As we
move into areas that are say somewhat tinged with controversy
such as voucher programs, faith-based programs, new ways of
doing things, I think complete and total transparency and
openness about this becomes more critical, even in our
traditional way.
Normally we just respond when somebody asks for feedback.
We need some sort of systematic way because this is big dollar
business in drug treatment and many organizations are very
concerned there is going to be a double standard for those of
us who are conservative Republicans who have certain ideas
about how this should be done, and may not hold quite the same
rigid standards to some of the new groups coming in have been
held to. I think it becomes critical to review with everybody
maybe in a more systematic form like you did by targeting these
different groups to also continue to do the reviews, make sure
all the data becomes available.
Like you say, a lot of these are new providers. They aren't
going to do it necessarily as efficiently in the beginning, but
there are different types of groups. Drug cohorts don't work as
much as we would like them to work but they still work a whole
lot better than other types of systems and broaden to new
approaches.
We have this in the Community Block Grant Initiatives under
the bill that Congressman Portman and Sandra Levin did because
that was one of the ones where I sat through the first
presentation, the grant applications and some of the reviews
and this is even more difficult than those.
Do you have any comments on that? I know that is what you
are driving toward but as you well know, doing this all the
time, this is not without some stirring in the treatment
community. We have to make sure they know how we are doing it
and why and what is fair.
Mr. Curie. I think your observations are accurate in this
situation. Clearly, you always have with any grant process,
especially when you are talking a total of $100 million and
hopefully $200 million. It gains a lot of attention in the
field, gains a lot of attention from the States and from tribal
organizations. Just that in itself, there is a lot of emotion
around because the field is, I think there is general
agreement, underfunded. It is a lot of dollars, so people are
very hopeful that they are able to apply and actually receive
an award.
Second, you are exactly right about this particular program
with the innovation of trying to bring to a systemic level
vouchers and choice along with expanding the provider base to
include recovery support services for the first time in a clear
way which also includes expansion of faith-based providers is a
change for the field as well. That becomes frought with concern
and questions being raised. I think the solution of
transparency is exactly the right course to take, that as we
implement ATR that we are transparent about the outcomes? How
it is going? Do we need to make any mid-course corrections? Are
there things we are learning?
Also during the process of people who have applied, I heard
you suggest perhaps we want to consider more of a global
feedback overall that would not undercut the integrity of the
competitive process of giving overall feedback of maybe where
we saw applications of this type and things to keep in mind as
we look ahead. We can certainly incorporate that into our
technical assistance as we move forward.
Mr. Souder. Paticularly since in this category, when you
hire what we call here without meaning it in a derogatory term,
a ``beltway bandit,'' in other words somebody who is trained in
grants and works in a large organization, they will
systematically do that. They will do that, go see who won, try
to figure out how to do the exact adverb and adjective that got
the grant of the winners.
But if you are out in a much broader group of people who
aren't used to writing grants and you are trying to bring new
people into the system, they aren't probably going to have the
same hired people to do that for them in trying to figure out
precisely where they are off becomes more critical and
basically helps drive the program.
Also, I remember as one of the principles, batters learn by
striking out. If a pitcher is going to throw them curve balls
and they can't hit it, they had better learn how to hit a curve
ball. Publishing what we learn from the first innovative people
out there, what isn't working, is going to be important and to
share that because it may be that your criteria from the first
time may change but you have to be open in the process or you
will have everybody gearing up to go in one direction and then
find there is a shared learning experience.
We have done a series of faith-based hearings around the
country. We didn't do a lot on drug treatment because we are
treating this as a separate thing, but you can't deal with
homelessness, with job development, with social services, child
abuse without winding up with drugs and alcohol mixed in here
and there. One of the things that was interesting because we
always had representatives from both sides, both pro and
against faith-based direct funding, was in drug and alcohol
treatment, the questioning of licensed, traditional type
providers versus this difficult question of drugs and alcohol
which you alluded to is also a spiritual, in many cases, not
necessarily in the sense of Christian, but a person has to make
some kind of decision that they are going to be cooperative and
that some of the failure rate in drug treatment programs isn't
actually the providers not doing things right, it is people are
mandated in, their family put them in, they didn't make the
internal commitment and therefore they can go through an
effective program and not be changed because they didn't
change.
The irony here and one of the things we were hearing at the
grassroots is sometimes the training may not be as high in some
of these groups but the outcomes may be better because the
person did a transforming or they were able to reach them in a
different way, such that they dried out or got off of
narcotics. Freddy Garcia is a classic example because he
doesn't even do drug treatment but the people get off drugs.
That clearly wouldn't be eligible under a Federal program but
there are groups in between there that mix that and we heard
that in at least three to four of the cities in which we did
these hearings and the wide range of how to do this. It is an
interesting thing when you are dealing with the psychology of
drug treatment.
Mr. Souder. Absolutely. In fact, clearly we expected States
as they look at eligible providers, because that is really I
think the key of what we are talking about here, that they
ensure the eligible providers met public safety standards if
they are going to be receiving dollars through the vouchers.
Also if you hang out your shingle and call yourself a
particular kind of treatment program, if there is a license for
that, you have to engage that; and also there is a range of
recovery support services for which there may not be a specific
State license but again, in terms of public accountability, the
States needing to maintain the list of eligible providers.
Mr. Curie. You are absolutely correct. Whenever you begin
opening that, especially in a field that has really worked hard
over the past 40 years to gain certification, to gain
credibility along with the other health care fields, mental
health and other types of primary health care, it does raise
questions and concerns. I think the challenge is how do we
operationalize recovery from a public policy and public finance
standpoint. That is really what we are striving to do for the
first time because there are many pathways to recovery. So we
need to be thinking about this as a continuum because there are
people whose lives wouldn't have been saved if it wasn't for
that licensed, residential program, they went through a medical
detox, licensed residence, they attained sustained recovery and
now they are on their own personal recovery plan as a result of
that.
There are others who have gone through a similar program
and it wasn't until they engaged the faith-based program that
recovery took hold but also I would say probably each of those
experiences added to that person being able to attain recovery
some day. So I think it is clear we need a robust continuum
that is available and when you have a qualified assessment and
then a choice involved, I think you begin to open more of those
pathways and the common denominator among all of those types of
providers is holding them accountable to outcome. If they are
held accountable to outcomes that reflect recovery, we think
therein lies the key for public accountability that we have not
seen before.
Mr. Souder. One of the problems we have in job training is
cherry picking, for lack of a better word, that most people who
go on unemployment, get off unemployment and the question is,
those are the easy ones to do because probably they are going
to get off anyway. What you are really dealing with is a
temporary situation and you are trying to move it faster or at
least claim credit as opposed to the long term dependency.
It is a little less clear to me how you would do that here
but I can think of a couple types of things. Did you look in
your grant system to see whether any of them were taking harder
types of cases, in other words a program that specialized in
taking people who failed four times?
Another thing would be in co-dependency, it is real
interesting in Vancouver, British Columbia where we were
looking at the heroin distribution, the needles and free heroin
from the government, basically. One of the things that happened
in downtown Vancouver is the areas where needles are
distributed, people don't want to be and so the housing there
tends to be the lowest income and people who used to be
institutionalized are released in those areas. So all of a
sudden they are exposed for the first time to illegal narcotics
and you have this huge bump up in co-dependencies of people who
have other problems and all of a sudden they are in a zone that
becomes a drug zone.
I don't know whether this would be geographic, whether this
would be different people who have co-dependencies, whether it
would be people who failed multiple programs before, but
looking for the real hard programs that really take up a lot of
our drug money. I am not saying we don't need drug treatment
for people the first time because if you can catch them early,
you don't get them late. On the other hand, it can give you a
false sense if you say we want to prove this program works, we
are only going to take the people we think we can get at,
first-time offenders, parents are there, wife is there,
supportive, or husband. That won't give us a good read either.
Do you have a mix? Did you work to get that kind of mix?
Mr. Curie. I am confident that we do have the mix. Again,
we had another discretionary grant program we implemented over
the past year or year and a half called Screening, Brief
Intervention, Early Intervention Program, which is focused on
those individuals who are considered the hard core, long term
addict but catching them early. This program was not focused on
that. In fact, this program is focused on individuals who have
an addiction that is longer term. We are looking especially to
hit that treatment gap with those people who are ready for
service.
I think when it comes to cherry picking, the key thing to
keep in mind here is this is the first time the client picks
the provider. The provider doesn't pick the client. If someone
is issued a voucher based upon the assessment and if a provider
continually turns down people who bring vouchers, first of all,
they are going to lose out on revenue but second, they have
every reason to accept that client because they are going to
get paid.
Second, that is what we are expecting the States to monitor
in terms of provider performance. If a provider is consistently
not working with the program, that would be reason not to keep
them. I think there are some clear safeguards in there but I
think fundamentally the objective assessment that is taking
place without a conflict of interest, it is not the provider
doing the assessing, and then a voucher being issued based on
the client picking the provider. Again, the only way a provider
could cherry pick is to refuse the client who comes with the
voucher.
Mr. Souder. Here really it is you monitoring the States to
make sure that they and their eligibility standards aren't
taking the easiest ones first exposed, stable families, middle
and upper income groups, no co-dependencies.
Mr. Curie. Correct, and the other thing that is very good
about the Access to Recovery, if you look at a profile and I
believe we submitted that to you, of the grants that have been
awarded, you see many of them are hooked into drug courts, the
criminal justice system, vulnerable populations, adolescent
treatment, some very tough and challenging cases just out of
the shoot. So by virtue of the populations, the high risk
populations that States were able to choose, again, you are not
talking necessarily about an easy clientele out of the shoot.
Mr. Souder. I thank you for your testimony and willingness
to come today. I wish I could say that the general public and
Congress have become more sophisticated in this area but I
think we are moving a little that way because after you put
billions year after year and you hear numbers, it becomes a
little bit like the old Vietnam days where you blow up the
bridges and blow up more bridges and pretty soon you realize
you blew up more bridges than there were to begin with.
Sometimes in drug treatment and other things, it feels like you
are pouring in all this money and yet the problem isn't going
down or you put it into child abuse, put it into drug
prevention in Colombia or wherever and we have to get more
sophisticated in our measurement standards.
When groups come in and say, oh, if we can just put it into
this, we will get $17 for every dollar returned and yet the
Government is broke and if we did that, we would be 17 times
more broke probably. We need to realize there aren't instant
solutions here. This is going to be difficult. It is like a
drug court but if you can get 25 percent of the people deterred
or clean most of the time, it is much better than what we had
before. We have kind of oversold a lot of these things and I
think Congress in trying to analyze the spending, if we can
show both success but reasonable success with the harder risk
groups and people who weren't able to get it, it may be easier
to get the money in the appropriations bills. I would hope at
least that we are getting more sophisticated with that so we
can avoid what good does it do to put the Government money in
anyway because we do it every year and the problem doesn't
change. That is our challenge for those of us in oversight and
your challenge in administration.
Mr. Curie. Absolutely. I couldn't agree with you more. To
be able to paint a picture of success that is based on real
numbers I think will not only benefit us but benefit you in
making those decisions, but most importantly, it is going to
benefit those trapped in addiction.
Mr. Souder. Thank you very much for coming today.
Mr. Curie. Thank you.
Mr. Souder. If our second panel could come forward: Melody
Heaps, Treatment Alternatives for Safe Communities, Chicago, IL
and Dr. Michael Passi, associate director, Department of Family
and Community Services, city of Albuquerque, NM.
[Witnesses sworn.]
Mr. Souder. Thank you, Ms. Norton, for joining us. Would
you like to do a statement before I start the second panel or
wait until after they give their testimony?
Ms. Norton. Mr. Chairman, the only statement I have is
first to apologize that I have been delayed at another hearing
and then to say how important I think this hearing is which is
why I have run by. There is an introduction of a judge in the
Senate I have to do.
All across the country, I think the link between access to
drug treatment and elimination of crime is absolute. In the
District of Columbia, we have people waiting in line for as far
as the eye can see. Mr. Chairman, as you may know, there are
some hard line jurisdictions that have decided to go way beyond
where the Federal Government has dared venture. You have hard
line jurisdictions like California, the three strikes and you
are out State which inaugurate the notion of diversion to drug
treatment for people caught with small amounts for the first
time. I don't know how that is working out. All I know is they
found their criminal justice system was so overcrowded, so
costly with people who are not classic felons or classic
criminals, that they have decided, for all their law and order
concerns and innovations, to try something new.
I am interested in this hearing in particular and in what
we in Federal Government can do to increase access to
treatment, real tough treatment. There are all kinds of folks
who claim to be able to treat addiction. I think treating
addiction, Mr. Chairman, must be the most difficult thing in
the world to do.
We all know something about addiction. Along about 10 p.m.,
I need grapes and it is all I can do to keep from going down to
get some grapes. I have a sweet tooth and if I didn't exercise,
I am not telling you I have real self control when it comes to
the sweet tooth, but if I didn't exercise and do a lot of other
stuff, I think the sweet tooth would have taken hold of my body
by now.
Try then to analogize to somebody who, for whatever reason,
has a tendency toward an addiction that is even more harmful
and I think that, first of all, we can be more empathetic but
then we know from our own experience that unless we fasten upon
treatments that in fact say, there is something approaching
carrot and stick that even the best treatment doesn't work, so
I am here to be educated and thank you for this hearing, Mr.
Chairman.
Mr. Souder. Thank you for coming.
We will start with Ms. Heaps.
STATEMENTS OF MELODY HEAPS, PRESIDENT, TREATMENT ALTERNATIVES
FOR SAFE COMMUNITIES; AND DR. MICHAEL PASSI, ASSOCIATE
DIRECTOR, DEPARTMENT OF FAMILY AND COMMUNITY SERVICES, CITY OF
ALBUQUERQUE, NM
Ms. Heaps. Thank you, Mr. Chairman and members of the
committee.
First of all, it is a real privilege to have been asked to
testify on Access to Recovery. I particularly find it a
privilege because I know the work that you, Mr. Chairman, have
been doing to support treatment and particularly to look at the
issues of reentry and the impact reentry for criminal justice
clients is having on our communities. I applaud your work and
applaud the work and interest of other members of the committee
on this very, very serious, serious problem. Thank you so much.
I am Melody Heaps, the founder and president of TASC Inc.
TASC is a statewide, not for profit organization headquartered
in Chicago. Our primary span of services involves linking drug-
involved individuals in the criminal justice system with
community-based treatment and other services. In fact, by
statute and administrative rule, we are the designated agent of
the State to do so.
We provide the initial screening and assessment to the
court, we facilitate admittance into substance abuse treatment
and we incorporate a hands-on approach to providing case
management services through the utilization of community
resources that support clients and help them navigate through
their regular social service system toward recovery. We also
work with individuals involved in the juvenile justice system,
the child welfare system and the TANF system.
I would like to talk to you today about Access to Recovery
and how it is going in Illinois and how it is being applied,
but I also want to talk more broadly about the implications of
the program for people in recovery, for families and
communities and for local, State and national drug policy. Like
many States, Illinois continually grapples with the problems
associated with drug use and crime. In our urban areas, we are
among the worse in the Nation in terms of drug use by arrestees
at between 70 and 80 percent. In addition, yesterday at a
meeting with HIDA, we found out that Chicago ranks No. 1 in
heroin deaths and in emergency admissions to hospitals for
heroin. It is a ranking that does not bode well for our city.
Cocaine and heroin constantly emerge as problems and the
Cook County system alone, the largest of its kind in the
country, processes upwards of 55,000 felony cases each year.
Most of these involve drugs or drug-related crime. Forty
percent of new admissions to Illinois prisons are for felony
drug possession cases. Even despite a recent attempt, the
opening of a 1,000 bed Sheridan treatment and reentry prison,
the large majority of our criminal justice population needs
drug treatment but does not get it.
This is a population with a complex set of needs. In
addition to drug use or addiction, some will have mental or
physical health issues, some need housing, most need education
and jobs, many have children in our welfare system and most of
them will not be eligible for Medicaid or any other kind of
private insurance.
We know if we want to promote long term recovery, promote
restoration of citizenship and productivity while at the same
time reducing drug use and reducing crime, we have to address
all of these issues. Addiction treatment may be core to the
stability of individuals, but if any of these other concerns go
unaddressed, their chances of returning to drug use and crime
increases significantly.
It was with this in mind that the State of Illinois in
partnership with TASC decided to apply for the Access to
Recovery funds to support service delivery to individuals
sentenced to probation with demonstrable drug problems. We
already have a number of programs in Illinois that have been
addressing this. There are the Statewide TASC services, drug
courts, intensive drug probation but the sheer volume of
probationers, over 125,000 at any given time, means that only a
fraction of those needing services will have access to them.
Access to Recovery will predominantly target populations in
Chicago and Cook County, two surrounding counties who aren't
otherwise receiving services but we are also piloting it in
some rural areas where the additional challenges like
transportation, scarcity of providers are major barriers to
successful service delivery. One of the key components of the
Access to Recovery model is a comprehensive assessment and
referral process. Any probationer that comes into our program
will be assessed for needs in a wide array of behavioral and
other social service areas. In fact, we are putting together
what we call an assessment to develop a recovery capital index.
What does the individual have in terms of his own capital? Does
he have a home? Does he have a family? Do they have an
education, so that we will be able to tell the degree of
depletion of these resources in an individual?
Obviously substance abuse is one area. So is mental and
physical health, housing, education, job training, family and
life skills. Once the assessment is complete, we identify
qualified providers in the client's community and make
referrals.
From a service delivery perspective, Access to Recovery
represents something that is rarely seen in publicly funded
services of any kind. That is client choice. We know there are
core services that a client in recovery will benefit from like
individual and group counseling but we also know that every
individual responds differently. If our goal is individual
recovery, then our strategy must be to help the individual
identify the programs and services in the community that will
best help them achieve a place of stability.
Some will benefit from a mentor relationship, some will
benefit from services in a faith-based context that addresses
their spiritual needs as well as their clinical needs. Access
to Recovery is truly a revolution in service delivery because
it allows and empowers clients to do what works best for them.
In that regard, I do want to acknowledge the President, his
vision, his promotion of and support for the expansion of
treatment in our communities. I also want to acknowledge the
leadership of the Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration,
particularly SAMHSA Administrator, Charles Curie, for taking
hold of that vision, conceptualizing recovery in the broadest
and yet most personal sense and for pursuing innovative
strategies like Access to Recovery.
This initiative has stimulated growth and challenge in our
field that would not otherwise have occurred with a simple
increase in funding. I also acknowledge the work that the
Center for Substance Abuse Treatment has done in developing the
proposal and in helping implement this very important program
under the leadership of Dr. Wesley Clark.
Access to Recovery will bring funding to community
organizations that might not otherwise have such. TASC has been
operating in Illinois for over 30 years. One of the fundamental
constructs of successful recovery has always been getting the
community involved with the individual while the individual is
getting involved in the community. Local providers understand
local issues. They know strengths, weaknesses and potential
challenges of reintegrating ex-offenders into their community.
They are more culturally and socially aware and they understand
the best circumstances that precipitated the drug use in the
first place. When the client is involved in local programs, it
creates a level of trust and comfort that may not exist if that
same client were required to travel across town or in some
instances, across the State.
From a policy perspective, Access to Recovery is important
because it breaks down all the traditionally disparate funding
streams and focuses funding on one thing, recovery. Success is
measured by how well you assist an individual in achieving a
place of clinical and social stability. This sounds like common
sense but a program of this size, scope and complexity would
have been almost impossible under any other previous funding
mechanism. This move toward recovery focused and client focused
funding started several years ago when many of the major
Federal departments pooled resources for the Coming Home
initiative. Access to Recovery represents the natural evolution
of that strategy and I applaud the decisionmakers who were able
to accomplish such a major sea change in funding and policy
strategy in so short a time.
Additionally, because Access to Recovery is based on client
choice, it will result in funding efficiencies we have never
seen before. The right resources will be applied in the right
intensity at the right time to the right people. The
implications are huge. We will finally be able to start getting
a handle on what we need as towns, States and as a Nation to
turn the tide of drug use and drug crime.
I believe that Access to Recovery is the start of an
innovative, new approach to funding and providing recovery
services, an approach that focuses on what we have always been
about, a full continuum of services supporting recovery which
leads to the restoration of individuals, families and their
communities. Right now there are 14 locations around the
country that over the next 3 years will be redefining what it
means to provide treatment and recovery services in an
effective and efficient way. This is a critical time and a
critical issue.
Thank you for your time and I would be happy to answer any
questions.
[The prepared statement of Ms. Heaps follows:]
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Mr. Souder. Thank you.
Dr. Passi.
Dr. Passi. Mr. Chairman, members of the committee, I am
pleased to be here to speak on behalf of Access to Recovery. I
am particularly pleased that CSAT found something worthy in
what Albuquerque has been doing for the last several years and
used our work to help shape the Access to Recovery program.
Needless to say, we believe in the approach articulated in
Access to Recovery. Having built a system like it using local
funds that will approximate $4 million a year during the
current fiscal year, we will invest more money locally in this
treatment system even while we welcome the resources that will
come to us from the Federal Government. We speak here about
something to which we have made a major investment and are
happy to share our experiences with you.
The city of Albuquerque's system is based around two basic
elements. First is unbiased assessment and referral using
standardized instruments. The second is patient choice among
qualified providers with subsidies available to those unable to
meet the cost of care through a voucher system. Both these
elements are tied together by an electronic management
information system that facilitates assessment, referral,
client tracking and billing and by treatment standards that
assure quality treatment services.
To assure unbiased assessment and referral, the city has
separated assessment from the provision of substance abuse
treatment. Albuquerque Metropolitan Central Intake is a
specialized agency that provides professional assessment of
patients presenting for problems related to substance abuse.
The primary tool used for assessment is the well known and
standardized Addiction Severity Index. We administer ASI in
both English and Spanish to patients in the system. For
adolescents, AMCI uses the Modified Adolescent Drug Diagnosis
instrument, another well known and standardized assessment
instrument.
Based on the findings of the assessment, patients are
referred to the treatment providers who are best able to meet
their needs from within the city's provider network. This
network currently consists of 20 different providers ranging
from large public agencies to single sole practitioners. The
network is open to any provider that wishes to join and agrees
to comply with the city's clinical standards and reporting
requirements. This means we welcome providers that are public
and private, for profit and non-profit, secular and faith-based
so long as they meet our clinical standards and are willing to
accept our fees.
Income eligible patients are issued a voucher. It is not a
piece of paper, it is an electronic account effectively
established for them, to assist with the cost of their
treatment, if they need such assistance. They are also given
referrals to those providers in the network that could offer
the services that meet their particular diagnosis. The value of
their voucher is determined by the level of care the patient
requires. For example, vouchers for early intervention, brief
therapy and education, are principally for people who don't
have severe substance abuse problems and many of those are
first-time DWI offenders referred to us through the local
courts. That is capped at $390 per patient. For people with
more severe problems, vouchers may reach $3,500.
What have we gained from this system? First, we think we
have a better managed system. We have vigorous controls of
treatment related expenses. Authorized units of treatment are
based on objective assessments of needs and billed accordingly.
We buy what is needed and pay only for what we buy.
This was not the case in our previous system built around
cost reimbursement contracts with a small group of provider
agencies that independently determined what a client needed.
All too often in these cases, these were agencies whose
principal tool was a hammer and for whom the clients' problems
always looked like nails.
Beyond better management, we believe that opening the
system to a broader range of practitioners has increased the
likelihood of matching patients to the treatment approach and
treatment setting that best meets their needs and preferences.
Rather than narrow options to a handful of publicly supported
providers, we now offer a broader range of treatment approaches
and treatment settings that gives a system substantially
greater flexibility in meeting different needs.
Most of the providers in the network moreover participate
in the private market for treatment services and are not wholly
dependent on the city for their financing. City-subsidized
clients at a given agency in a recent 45 day period, I just
picked one at random, ranged from one or two up to 165. The
mean number of city-financed patients at an agency was 17.
Offering clients genuine choice in selection of a provider
appears to affect the process of treatment in a couple of
important ways. First, there is some element of market
discipline. The patient is free to change providers if he or
she does not believe that their needs are being met. We
actually have had relatively few patients electing to change
providers in midstream but they are empowered to do so if they
want to and that appears in some way that I haven't been able
to establish by research to better engage them in the treatment
process.
Moreover, I think and more importantly, simply having
choice from the outset makes the patient an active, empowered
participant in the treatment process. They are not just routed
there by government, they are required to commit at least that
one initial act of choosing a provider.
How does this affect their outcomes? I can't say we are
getting better outcomes now with a differently managed system
than we were before. The only reason I can't say that is
because our data from the way we operated before was so bad
that I have nothing to compare what we are getting now against.
We do have methodologically valid data, however, to show that
we are getting positive outcomes, reduction in drug and alcohol
use, reduction in binge drinking, reduction stress, reduction
in depression, reduction in anxiety through the treatment
process.
Shortly before ATR was launched, we in fact launched a
similar initiative locally looking at domains of outcomes,
establishing three at least that are similar to CSATs looking
at sobriety, employment and criminal justice involvement. I
don't have the data yet to report to you the results but
initial outcome data looks positive for us. I think it is
important that we all recognize that outcomes aren't driven by
the way in which the system is managed alone. It is also
dependent on the quality of the treatment services that are out
there.
Recognizing that, we have allocated about $200,000 a year
in local general funds to support improving treatment to all of
those 20 providers within the substance abuse system to try to
increase their knowledge and skill in applying evidence-based
treatment practices.
That, members of the committee, is the Albuquerque system.
I would be happy to answer any questions you have.
[The prepared statement of Dr. Passi follows:]
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Mr. Souder. Thank you.
Let me make sure I understand precisely how this is
working. Dr. Passi, you are in the city of Albuquerque and the
State of New Mexico received a grant and then it went to your
organization in the city of Albuquerque?
Dr. Passi. Mr. Chairman, the Albuquerque system was
developed using local funds prior to ATR. When CSAT was looking
at designing ATR, our system was one that they looked at as a
system that uses a voucher-based program in order to finance
drug treatment. So we have been doing this for about 6 years,
entirely with local funds.
Mr. Souder. Have you received any Federal funds from this
new program at this point, Access to Recovery?
Dr. Passi. We are a partner with the State of New Mexico.
We have not yet received funds. The funds have not been
released to us as yet.
Mr. Souder. Because New Mexico is listed as one of the
recipients, when you say you are a partner, it means you will
be one of the groups that most likely will receive funds from
the State of New Mexico or are you designing the State of New
Mexico program or a mix thereof?
Dr. Passi. I think it is a mix thereof, Mr. Chairman.
Mr. Souder. Because you do have experience with it, you are
unusual. I understand that. I am just trying to figure out how
it works.
Dr. Passi. I believe the New Mexico State proposal to CSAT
was to expand treatment in Albuquerque using funds and
particularly in our case, we want to expand and support
recovery activities in relationship to treatment. Moreover, we
would work with the State to help other communities, namely
Santa Fe, Las Cruces and one of the Indian Pueblo groups
implement a system comparable to ours using our methods and our
electronic processing systems.
Mr. Souder. So the State grants can be used both for actual
treatment for those who are addicted and for setting up
programs?
Dr. Passi. It will be necessary to do some work in setting
up programs, I believe, in every one of these grants. In the
case of New Mexico, I think we will be able to move more
quickly because Albuquerque has a system in place with a web-
based way in which screening and assessment can be done and
communicated to providers, a billing system whereby accounts
can be created for patients and billing done.
Mr. Souder. Ms. Heaps, the State of Illinois got a grant
and then you were picked as one of their recipients?
Ms. Heaps. The State of Illinois asked us to help them come
together to design the program because we are a designated
agent of the State working with the criminal justice system.
The decision was made to target probationers within that
system. So we sat down together to design the program.
The funds come to the State of Illinois, a portion of which
will come to us for the work we do, the diagnostic assessment,
the referral to treatment, the case management and the
information technology that will trigger vouchers. The State
retains the dollars for the treatment and will through the
electronic management system be funding the programs that do
take our clients.
Mr. Souder. And then in setting up the system, are you
setting up predominantly for Chicago or for all of Illinois?
Ms. Heaps. Because of the vast numbers we are dealing with
and obviously limited resources, we targeted Cook County as the
primary seat because of the vast numbers of probationers that
are there. We also added two what is known as color counties
which essentially are suburban/urban areas and then added some
rural areas, two rural counties, so that we could see how this
pilot would be were it to be expanded statewide.
Mr. Souder. In a metro area as big as Chicago, individuals
have vouchers, but how many providers would you guess there are
in Chicago?
Ms. Heaps. Around the State, there are 140 providers with
about 462 sites. Probably at least three-fourths of those are
within the Chicago metro community. We, as TASC, have developed
a provider network with actually every one of the 140 licensed
treatment providers and also have been working in terms of
recovery with many of the faith-based and other institutions
job programs that would help our clients in the past. So we
have a network already in existence but it has not been
systematized, it has not been fully funded and this gives us an
opportunity to do so.
Mr. Souder. In addition to those in the system trying to
track new people, do you have a process for clearing them for
approval to make sure they are adequately licensed?
Ms. Heaps. Yes. We have a set of standards we developed
with the State. They just be licensed and certified as
treatment providers. If they are not direct treatment providers
but perhaps recovery support people, do they have a license if
they are treating people in terms of safe buildings, etc. Is it
a corporation not an individual, do they have a sound fiscal
mechanism, do they have a set of standards for providing the
service they have, do they have experience in dealing with this
population? In order to make sure of that, we will also have
and are engaging now an orientation program, a training program
for those providers that are not used to being more
sophisticated perhaps as you were talking about earlier with
Mr. Curie, in dealing with Federal funding. So we will have an
ongoing training program actually facilitated by the addiction
technology transfer centers that are a part of CSAT but are
locally based.
Mr. Souder. Before I yield to Ms. Norton, let me see if I
can make one more kind of global picture or sense out of
something. The sheer volume of probationers, you said over
125,000 at any given time, not in the course of a year but at
any given time?
Ms. Heaps. Any given day, right.
Mr. Souder. That is Chicago and Cook County or statewide?
Ms. Heaps. It is statewide but 80,000 I believe are in Cook
County.
Mr. Souder. Of those 80,000 probationers, how many would
you say are drug and alcohol related?
Ms. Heaps. The research suggests that we are dealing with
60 to 70 percent that have some issues.
Mr. Souder. So 60,000, it looks like?
Ms. Heaps. Exactly.
Mr. Souder. So you have 60,000 people there. Do you know
how many of the percentage of the mix of 80,000 are juvenile
adults?
Ms. Heaps. We are dealing with the adult population in that
number. We are not dealing with the juvenile population. We
will only be focusing on adults courts.
Mr. Soder. So in your Chicago area program, you are only
going to be dealing with adults?
Ms. Heaps. Yes.
Mr. Soder. And only dealing with adults on probation?
Ms. Heaps. Yes, that is right.
Mr. Soder. And only drug and alcohol?
Ms. Heaps. That is right.
Mr. Soder. So we are probably at around the 60,000 number?
Ms. Heaps. Yes, 50,000 or 60,000.
Mr. Soder. Do you have a criteria that the person has to
have, as we talked about earlier, whether it is some risk or
some ability to show an interest or is it that they are high
risk? You are not going to have the dollars to do all 60,000?
Ms. Heaps. No, we are not.
Mr. Soder. If we were looking at 50,000 in the whole
Nation, it is unlikely that you are going to get 60,000 in
Chicago?
Ms. Heaps. That is quite clear. Again, because we have been
working with probation for so long and have been working with
them in terms of their screening mechanisms, we are going to
take advantage of what they do in terms of screens. We are
going to use the idea of people want to volunteer for
treatment. We are also going to be looking at probation initial
screens that suggest there is some activity perhaps in
probation compliance, perhaps the hard cases you were talking
about that indicate this individual may have a serious drug
problem. He then would be referred to us for a full diagnostic
assessment and if found drug or alcohol addicted or abusing,
move into the treatment of their choice.
Mr. Souder. Thank you.
Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
Ms. Heaps, as I listened to you describe the licenses, I
think I heard all kinds of licenses but I am not sure I heard
any kind of license or certification for professional
proficiency in treating people with drug or alcohol addiction.
Is there any such certification of licensing in the State of
Illinois attached to your program or to this particular program
that is under review here today?
Ms. Heaps. By administrative rule in the State of Illinois,
all licensed programs must have certified addictions counselors
and there is a certification training program and annual
training they just comply with. So all licensed programs have
individuals treating individuals who are certified in
addictions counseling.
Ms. Norton. Can programs that are not licensed get the
funding that is under discussion today?
Ms. Heaps. Absolutely. We estimate that programs that are
not licensed, programs that will do the recovery support,
whether it is the spiritual counseling or the jobs or
education, who will not or may not be licensed as a treatment
program will, through our program, be able to get support, will
be able to get the voucher paid for their services. We will do
so based on a set of standards that I was talking about,
bringing them in for training and orientation. In a mechanism,
we are projecting that by the end of the second year, almost 40
to 50 percent of the dollars will be going to other recovery
support service programs, not simply licensed treatment
programs.
Ms. Norton. I tell you what, Ms. Heaps, I am very fortunate
with my children. If I had a son or a daughter who had an
alcohol or drug problem, one of the first things I would look
to would be to see the level of professional proficiency. I
raise this only because I look at the series of things that HER
uses, those are the things you look to, abstinence I don't know
for how long, stable housing, social connectiveness. I am very
troubled by programs that are unlicensed or uncertified, very
frankly, because I see them all around. They hover around these
communities. The communities that have the greatest drug
addiction have all kinds of programs springing up with people
who are just like me, they don't know anything except they
claim to have the ability to treat people with what I regard as
the hardest of all things to treat. Give me cancer or heart
disease, the causal relationship I think has worked out there
better than an addiction.
I just want to indicate my skepticism not of what you are
doing but of the very idea and I speak from seeing the programs
that abound. For example, if any religious program can get
money, I happen to know that people who are most affiliated
with a church are most likely to be able to be drug free. We
have many ministers who have mentoring programs here quite
unrelated to whether the Federal Government has dollars to hand
out or not because they understand the relationship between
faith and drawing people from addiction. Alcoholics Anonymous,
for example, has often been faith-based.
I have been very troubled by some of these folks who claim
to be able to meet standards like this, particularly since the
standards see so amorphous. I just want to indicate that
skepticism here because these programs have grown up so often
in the African-American community and it is very easy,
particularly if you are a religious-based program, to show a
tiny group of folks who were affiliated with your church or who
you can show in fact met these standards. So much for that.
The most of those affiliated with your two programs come
out of the criminal justice system. Do most of them in one
fashion or another have some contact with the criminal justice
system?
Dr. Passi. Representative Norton, about 60 percent of the
patients that flow through Albuquerque Metropolitan Central
Intake are referred to it from the criminal justice system.
Ms. Norton. About 60 percent?
Dr. Passi. The other 40 percent are self-referred or come
from other referral sources.
Ms. Heaps. Under our program, it will be 100 percent. They
will be under the jurisdiction of the probation department
coming to our program.
I concur with your concern that drug treatment be delivered
by licensed professionals and I think the State of Illinois
worked very hard to make sure and has a very rigorous licensure
program in place. So we are using them for treatment but we
also recognize that we are dealing now with partnerships and
that there are job programs, faith-based organizations out
there that need to welcome these individuals in the community
and surround them with support.
Ms. Norton. That is very good if you are a job program but
if you are in the business of helping people free themselves
from addiction, you are in a very tough business and I think
you have to be able to show some proficiency. The standard I
use for the people in poor communities is the standard I use
for my son and I don't see that as the standard if people can
get government money who don't have that kind of professional
proficiency.
Your 60 percent and your 100 percent also tells me that the
best way, which I think is very typical, to get drug abuse or
alcohol abuse treatment is to knock somebody in the head or
commit a crime. I just think we have to face that. There are
all kinds of folks waiting in line saying catch me before I
kill. I know I am a crack head. In fact, if you are virtually
possessed with this addiction, the notion of having to go to
jail first is very troublesome. I don't know what to do with
that except that they are waiting in line. We can get hold of
them but we are not doing that.
I would like to know, finally, your evaluation of drug
courts and what you know about drug courts. That is not a
choice exactly. We have one here that is very successful. It is
a kind of choice because you do choose to deal with your
addiction and the crime that may be associated with it or you
have made another choice, the choice to go through the
traditional criminal justice system. I wonder what you think of
that choice, the drug court or if there are drug courts in your
jurisdiction with which you are familiar?
Ms. Heaps. Yes, Representative Norton. In fact, we run six
drug courts in the State of Illinois or are affiliated with
them. TASC is a precursor to drug courts. It was set up in the
early 1970's to be a sentencing alternative to incarceration
for individuals involved with drugs. So much of the drug court
protocols emerged from what had been TASC protocols but
concentrated now on an individual courtroom where case
processing of drug cases were to alleviate much of the
overwhelming drug cases that were coming into the justice
system practically shutting it down.
Our experience in the criminal justice system as a leverage
for successful outcomes I think follows what research was done
particularly by UCLA which because we know addiction is a
disease of denial, when the choice is treatment or jail, and
the individual not always, not always chooses treatment, I
can't tell you the number of our clients who would rather go to
jail knowing they will get out in 4 to 6 months or maybe a year
rather than go into treatment where if they fail, the
consequences will be severe. People are more likely to succeed,
be retained in treatment if there is some jurisdictional hammer
as it were over their head. So drug courts can be a very
effective mechanism for moving people into recovery and
retaining them in treatment. We know that the longer you can
retain an individual in treatment, the better chances for
recovery.
Dr. Passi. Our experience in Albuquerque has been similar.
We do have a drug court and in fact we worked closely with the
local district court in establishing their treatment protocols.
All evidence is as Ms. Heaps suggests that for a certain
portion of the criminal population, this is an effective way
for us to get them into treatment and second, to retain them in
treatment.
Ms. Norton. I will just say in closing, Mr. Chairman, I
think both of you have indeed targeted the group I am talking
about. We can't get to most people ahead of time. It is naive
to think when we don't get to people that all you have to do is
arrest them and that will deal with it.
I have been very impressed by what judges have said about
the effectiveness of drug courts. I very much endorse the
notion of choice. I think the first choice you have to make in
order to free yourself from addiction is that you want to do
it. That is kind of the ABCs of how to proceed. That is why so
many people don't make it time and time again. Of course if you
make that decision and you have a choice and you find a
particular program that suits you, that would be even better.
I suppose I am most concerned with the place, and Chicago
would know all about this, where addiction almost comes
naturally because you are in neighborhoods where people are
surrounded by addicted people, by the selling of drugs, and if
we know that is going to be the case, it does seem to me that
we have to face the fact that once that first drug related
crime is committed, we have a magic opportunity to get hold of
that person in a carrot and stick way and therefore that the
drug court may be one of the best approaches or devices that we
have been able to use at least for those who are most likely to
come in contact with the worse kind of addiction.
I do note and was fascinated, Dr. Passi, that you said
alcohol addiction was more prevalent in your program than drug
addiction. So all these things have to be very much tailored to
the jurisdiction.
Thank you, Mr. Chairman.
Dr. Passi. Multiple addictions really are increasingly the
character of the patients that we see. They may be present for
alcohol abuse but subsequent analysis I think shows that most
people use a fair panoply of chemical substances from time to
time or on an ongoing basis.
Ms. Norton. Mr. Chairman, not only with grapes but grapes,
ice cream and cookies. [Laughter.]
Mr. Souder. We have been joined by Mr. Ruppersberger as
well as our distinguished ranking member, Mr. Cummings. I will
yield next to Mr. Ruppersberger.
Mr. Ruppersberger. Thank you.
Sorry, it seems we had a lot of hearings at the same time
today, so if I ask a question that has already been asked, let
me know.
First, if specific services are not available in one area,
are patients allowed to be transferred to other areas or even
other States under the program?
Ms. Heaps. Not other States, but certainly in the city of
Chicago, other areas and maybe in the instance of the color
counties or the rural counties, we would be able to allow them
to access services in another area, yes.
Mr. Ruppersberger. As far as the actual patient, drug
addiction is an ongoing battle. If a patient fails in one area
or regimen of a treatment, does that mean that it is a one shot
deal or can they be involved and stay in the program until they
get what they think they need?
Ms. Heaps. I believe there will be different answers
because of the nature of our population. In the instance of our
population, which is under the jurisdiction of the probation
department, if an individual fails in treatment, doesn't comply
with what the court or probation order says, then through a
case management conference with probation, TASC and treatment,
we will look at the individual and say, can this person benefit
from a different treatment, from a different placement? We may
try that but if the probation office says we think this person
is a threat to the community, we may not be able to offer them
a second chance.
We at TASC have consistently tried to offer people second
chances, particularly looking at their case and what may need
to be modification of the initial treatment. We would hope to
be able to give them a second chance as long as we are not
jeopardizing community safety in doing so.
Dr. Passi. In Albuquerque, we presume that substance abuse
is a chronic and a recurring illness and that patients are
highly likely to have one or more relapses in the course of
their recovery. How that might affect their relationship with
the criminal justice system has to be dealt with differently
than how it affects the relationship to the treatment system.
Rather like those cigarette ads you see on the Metro in
Washington, DC, don't stop quitting, I believe that we would
welcome patients back into the system again and again.
Mr. Ruppersberger. I am going to get a little parochial and
I know you are from different States. I represent, along with
Congressman Cummings, the Baltimore metropolitan area and
Baltimore City. We do have a serious problem as does Chicago
and other areas. It is my understanding that our State has not
either made application to get the moneys that are available
for these programs. What suggestions would you have for the
State of Maryland or any State that really hasn't taken
advantage of this program to move forward and to get the
benefits?
Ms. Heaps. That is a very good question. Knowing a little
bit about the work that Maryland has done. Maryland has a drug
court, I believe, and you have had TASC programs. So obviously
from my standpoint, the first thing is to look at the client
population that does not now have access to treatment and
decide where and how you will isolate that population and give
them access. Do you want to move criminal clients into
treatment, do you want to make it broader, what level of
treatment do you have in the community if you do make it
broader?
It seems to me that the State needs to partner with local
or statewide private agencies as Illinois did with us to
conceptualize the system and designing the system so that you
might be able to apply next year. I am surprised, quite
frankly, that Maryland did not apply. It would seem to me it is
a classic case, much like Chicago is, and that some of the same
decisionmaking processes would be potentially successful given
your experience, given the breadth of your treatment, and given
the fact that I know Baltimore has worked on this issue before.
Hopefully you would be able to do so and I would be happy to
talk with anyone in Maryland or the city.
Mr. Ruppersberger. That is good and we might followup.
If you were to go somewhere to get involved in this program
for the State of Maryland and Baltimore, if you were me, where
would you go, to the Governor, to the Mayor? What I am trying
to find out is how we get started because there are a lot of
resources here that may be very useful.
Ms. Heaps. The State must apply for these grants. So it is
the State, the Governor's office that must do the application,
submit the application. Obviously the Governor's office has to
work with your single State agency for substance abuse and
potentially with leading providers in the community and/or
criminal justice system.
Mr. Ruppersberger. So the mayor?
Ms. Heaps. Yes.
Dr. Passi. I would echo that and I would say the city of
Albuquerque has had a fairly good relationship with the
Baltimore substance abuse systems since the time we were both
target cities under CSAT. I believe that Baltimore has in place
the basic structure to make an ATR system work. I think it is a
matter of getting the Governor together with the mayor and
utilizing what I at least the last time I was looking at it was
a very strong structure. It may have simply been a choice to
wait as some States did.
Mr. Ruppersberger. For what reason?
Dr. Passi. That the commitment to just building one of
these systems is fairly major and I know there are some States
that have elected to wait for an additional round of funding to
see what happens with the initial grantees. Indeed, the manager
of our system could not be here today because she is in Utah
working with the State of Utah to assist them in preparing an
application for a future round.
Mr. Ruppersberger. Just one more question because my time
is up. It is my understanding that Maryland did apply, did not
get the grant, so if that is the case, what happened, not
Maryland but generally. When States are not given the grant,
what is the reason?
Ms. Heaps. I can answer that to some extent because I am a
member of the Center for Substance Abuse Treatment Advisory
Council. Because of this grant, all advisory council members
must vote on applications that come into the center. Access to
Recovery was one. Because we were part of an application, I had
to recuse myself.
However, in the previous testimony by Mr. Curie and from
what I understand, there was a peer review committee that
ranked the proposals according to proficiency, identification
of the population, the ability to develop an independent
voucher system, information system, the ability to show you
have a large network of providers out there, both licensed
treatment providers and other recovery support providers. So
there are a series of standards which I think are objective and
you could easily obtain through the Center for Substance Abuse
Treatment.
Mr. Ruppersberger. Does the State put in the application or
the city?
Ms. Heaps. The State of Maryland would.
Mr. Ruppersberger. Thank you.
Mr. Souder. Thank you.
I will now yield to our distinguished ranking member, Mr.
Cummings.
Mr. Cummings. First of all, thank you all for being here
and thank you, Mr. Chairman, for calling the hearing. I am
going to be very brief. Because of another meeting I did not
get here earlier.
I am interested in data collection. One of the things Ms.
Norton was alluding to was how these folks pop up and I just
think whenever government has money to give out, there is going
to always be some persons or entities that pop up and decide
that they want to be a part of the process and sometimes they
are not qualified.
I agree with Ms. Norton and I know you agree with her too
that drug addiction is a very, very, very tough thing to deal
with. I have seen in my district in Baltimore people who have
been off for 15 years, clean, go back. I have also seen
something that is of great concern and that is that the people
who are out there, the recovering addicts, they know the good
programs which is interesting. They will tell you in a minute
which programs are I don't want to say fraudulent, but that
aren't effective.
I am just wondering, is data collection a real challenge
for you and how do you measure the progress? You may have
answered this earlier but it is something that is very
important to us because we spend a lot of time in this
subcommittee trying to address the issue of effectiveness and
efficiency with regard to treatment and of course, the spending
of Federal dollars. What happens is I think it is criminal to
put somebody through a program that is not a program that
effectively deals with them, then they go through a process,
they are not in a position for maximum potential for recovery
and then they go back on the street. The next thing you know,
they sometimes end up worse off than they would have been if
they had never entered the program because they are so
frustrated and they have been bamboozled. I am just wondering
how do you address those issues?
Ms. Heaps. Again, both of us probably have very similar and
a little disparate ways of doing it. In the instance of our
program, we have an information system and a hands-on case
management system that will track a number of things. Did the
client show up for treatment, does the client comply with
treatment? We will be in the program checking the client files,
meeting with the counselor, recording that and that then gets
played into an information system data base which gets reported
to the State and gets fed back to the treatment provider and
the client, by the way. It is important that the client see
what their record and compliance is.
There are on top of that the outcomes that have to be
measured as a part both of the Federal program but even if the
Federal program weren't there, there are outcomes we have
always measured in terms of is the client complying with
treatment, are they moving in treatment, are they drug free, is
their status drug free, are they looking or is there a stable
living arrangement, is there family or social engagement, do
they have education or a job, are they crime free? So there are
a series of outcomes which are frankly not rocket science. They
are basic to what we know it means to be a citizen in our
communities. Those outcomes are applied to every individual
case, the data is collected, it is again transmitted to the
various parties.
In addition, there are data required that look to do
treatment providers open their doors, do the individuals have
access to treatment, what is the number of treatment providers,
who is licensed to do the treatment versus who is a recovering
support service in Illinois' system? The money that will go to
licensed providers and to recovery support services will be
tracked again with hands-on case management and data
collection. So we will know very, very detailed, per case what
is happening in that individual's recovery.
To the issue that has been raised and you raised again, it
is true that money can bring a lot of folks to the table, many
of whom really have a client's recovery in mind and many of
whom do not but I think each of us has had to set up standards
for participation in this program. I have a list here which I
would be happy to provide for you, a faith-based organization
that has had experience in the community, that is a legitimate
organization that knows how to handle the population can offer
the kinds of support and services that are critical to support
recovery.
Dr. Passi. We are getting pretty good at tracking process.
Our system works really well at making sure we are getting what
we pay for and we are paying for what we need according to an
assessment instrument, but I think you are looking beyond that
and that is where I think CSAT is making remarkable strides
with the ATR program. That is to say, let us just stop
measuring process, let us start measuring outcomes. I think the
domains that they lay out, abstinence, employment, crime and
criminal justice, family living conditions and social support
are really the things that we have to start measuring and that
we can measure. It is not real easy. There are some problems
that we have run into in measuring criminal justice
involvement. You can't rely solely on self report obviously and
matching records from the criminal justice system with patients
in the treatment system and confidentiality issues that get in
the way but those issues are overcomeable.
I now believe we are making major strides toward being able
to say is patient X abstinent for a month, a year, 5 years
after treatment; are they not arrested; are they arrested once;
are they arrested weekly; did they get a job, did they not get
a job; did they get housing or are they on the street? Those
are the things ultimately that I think the addiction treatment
system is aiming to affect. We are not simply in the business
of providing treatment, we are in the business of buying
abstinence, of buying employability, of buying recovery, I
think is the concept that goes with it. Those are objective
things, things that can be measured and those are things that
we should be measuring.
The city of Albuquerque started that before ATR in baby
steps. We think ATR will push us to look at all of those
domains, measure those domains and ultimately reward
practitioners for their ability to produce positive outcomes in
those domains.
Mr. Cummings. Before I came to Congress, I was in the State
Legislature and I also practiced law. A group of mainly
gentlemen in my neighborhood, professional men, got together
voluntarily and worked with a lot of people who were coming out
of our boot camp program on Saturdays in a self help program,
and didn't get a dime from the government. I looked at one of
these evidence-based domains, social connectiveness. I don't
know exactly what that means and I am sure you will tell me.
We did this program for about 3 years and we noticed there
were people who were socially connected but they were connected
to the same people that sent them to prison. I can tell you one
of the things we noticed too was the people who found a whole
new set of friends and/or reoriented themselves toward loving
their family, it may have been a child, it may have been a
wife, they may get married or something like that, those were
the guys I see on the street today who never went back.
A lot of this was drug related, things they had been in
boot camp for. They never went back and were living productive
lives and almost everybody who went back to the social group
they were from are back in prison and usually have committed
much more serious offenses.
When we talk about social connectiveness, what does that
mean? Does that mean going to church?
Ms. Heaps. You actually, I think, defined it yourself. This
idea of family, getting back with a child, reinvolvement with
the family, going to church, going to peer support, AA, Winners
Circle, a number of communities. We aren't talking about social
connectiveness going back to the gang. We are talking about
changing perhaps patterns of social connectiveness that are
constructive, that are supportive, that are healthy. That we
have to look at and there are ways to be doing that. That is
where I think faith-based organizations have a huge role in
this. In some of our communities, they are the only
institutions, especially for people in some of our communities
with huge reentry. I think the faith-based community has a
wonderful role in helping develop social connectiveness.
Mr. Cummings. You would agree, I am sure, with Ms. Norton,
if you are going to do the faith-based, you also have to make
sure you have the professional piece in there. As the son of
two preachers, I have all faith but I also know you need to
have some professionalism in there too.
Ms. Heaps. Yes.
Mr. Cummings. One of the things I know, I know about people
who have been addicted. They are first of all, usually some of
the best manipulators. I couldn't help but think about a good
friend of mine who borrowed my lawnmower, said he was going to
cut some grass and wanted to make a few dollars and I never got
my lawnmower back but I did see it at a used lawnmower place
about 3 weeks later, on sale for about one-tenth of what I paid
for it.
I guess what I am trying to get to, I just think for people
who may be naive with regard to recovery and there is another
piece. One of the things I have noticed is that people will
come to my office and say to me because they have been through
a 12-step program and may have 6 or 7 years being clean, and
will say, I want to start a program as if they now have become
the experts because they have sat in the 12-step meetings, gone
through the anniversaries with different people and for a lot
of folks, it is a way to get into business.
They may have good intentions, but again, they may not have
the support systems and all that. On the other hand, one of the
things I have noticed is a lot of people who have come before
us in this committee have had histories of drug addiction
problems and have clearly made some tremendous strides and are
being very effective, or at least appear to be very effective
and efficient in what they are doing.
How do you make sure you guard against all of that? That is
tough.
Ms. Heaps. I know the depth of concern here. I can hear it
obviously and it is not the first time I have heard it. I don't
mean to minimize it but it really isn't rocket science. It is
called partnership. In Chicago, our licensed, certified
treatment counselors at TASC go and work with the faith-based
organizations or other organizations, go into their facilities,
talk with them, orient them, try and orientate them, try and
work with them, look at what resources they have to offer,
construct a program that would make sense for the clients we
see in a community that need to be reintegrated fully. So it is
possible to do in partnership.
I agree with you, there has to be people who know the
business of treating drug offenders or drug addicted
individuals as a part of the process. What we have learned is
when we just use that in terms of addiction and didn't deal
with the other issues, people were falling away. They had
finished the drug treatment and then they would reoffend and
get back on their addiction patterns because we weren't using
the other supports in the community, weren't dealing with the
spiritual aspects, the job aspects and this program does in a
unique way allow us to very effectively integrate both in an
efficient manner.
Mr. Cummings. Last but not least, Mr. Chairman, as you were
talking, I could not help but think you know I am always
fascinated by Starbucks and how Starbucks has become so
popular. I think one of the reasons why Starbucks has become so
popular is people need a social place to go. If they don't want
to go to a bar, they need some place to go. I think you are
right with regard to faith-based organizations. I think it is a
great place for people to go. They go to church, they have all
kinds of functions, dances, singles ministry and all this kind
of thing, but I just want to make sure that we are very, very
careful.
You may be listening to me and may be saying he is
concerned about the money but I am concerned about something
even more important than the money, the credibility of
treatment because up here if people don't feel that treatment
is working, then the money is not going to come from the
Federal Government. That is the problem. When people believe
that it is working and we have made some tremendous strides
thanks to the chairman and many others, toward treatment. The
more we know there is some accountability, the more we know it
is working, I think the more Members of Congress are open to
seeing those funds are flowing into those programs. It is just
a win-win when we do have that accountability.
Dr. Passi. If I might weigh in on that for just a second,
Congressman. The first question you ask your oncologist if you
have cancer is not are you a recovered cancer patient, you ask
what is your training as an oncologist. If the oncologist
happens to have recovered from cancer, that may make him a more
sympathetic physician.
I think increasingly we have to ask the same kinds of
questions of drug treatment providers and in the city of
Albuquerque we certainly are doing that. We are first of all
demanding the highest standard of licensure that we can under
State regulations. More than that, we are investing local funds
to increase the level of skill of those practitioners in
evidence-based treatment practices. Professor Bill Miller who
is an outstanding substance abuse treatment researcher happens
to be at the University of New Mexico and I think Bill
estimates that something like 80 percent of the money we spend,
not just public money but all of our money, is being spent on
practices that we know don't work and 20 percent of our money
is being spent on practices that we know work.
I think that the approach that we have adopted in
Albuquerque, and I think the approach implicit in Access to
Recovery, is going to try to shift that balance because this is
not just about getting people into any treatment. It is getting
people into the right treatment and the right treatment has to
be those modalities that we know will succeed.
It ain't rocket science. We know a bunch of stuff that is
out there that is working. We just have to start paying people
for doing it.
Mr. Cummings. I have to ask you this and then I am
finished.
You said something that just hit me, just struck me. When
we are talking about quality, do we have anything anywhere to
your knowledge, like lawyers and teachers, you have to go back
for certification if there is a new method. You need to know
what is up to date. Do we have anything like that in
Albuquerque, for example, so you keep the people who are doing
the treatment right on the cutting edge of what it is that
works and are constantly showing them these examples like you
have a place right up the street which is extremely effective
because they use this method and we believe this is the best
practice? Are there actually mechanisms to do that?
When you say 80 percent of the money is being spent on
things that don't work, if that program was being funded by the
Federal Government, it would have some real problems, I am just
telling you.
Dr. Passi. I think there is a real slow knowledge transfer
process that takes place and almost every State as a mechanism
for doing training with its providers. We in Albuquerque
believe that can happen more quickly, especially when we keep
in mind that it is largely money provided by the Congress and
by the taxpayers that is funding research that tells us what
are the best ways to approach these.
Mr. Cummings. The key is getting that research to the
people who are doing the treatment.
Dr. Passi. I agree.
Mr. Cummings. Do you all have any recommendations on that?
Ms. Heaps. There are two national bodies that I am aware of
but forgive me, my brain being dead, I don't remember exactly
the names but there are counselor certification boards that
work with individual States to develop. Illinois, for instance,
has a State certification board that requires counselors to get
annual training, there are standards, there is a course of
activity based on the research coming out of NIDA. I will be
happy to get you that information so that you have some comfort
level that there is certainly going on a new professionalism in
this counseling arena.
Dr. Passi. And I think CSAT has immense resources and
knowledge on this that you can tap to find ways to bring best
practices to providers in the field.
Mr. Souder. I want to ask a few more technical questions
but I want to weigh in with a slightly different approach
leading to a question. Both of you alluded to this and that is
we in this country have to be careful we don't get so
credential obsessed that we forget the point here is outcome.
When I was a senior in high school, I took a program called
exploratory teaching where we could go teach a class and
because I had a lot of stuff going on, I couldn't get over to
the elementary building and they put me in an eighth grade
history class. It was clear that I loved history and all of a
sudden the teacher disappeared and I had this class for the
whole semester and I was just a senior in high school.
An amazing thing happened. Because I loved history, four of
the kids who were getting an F turned to A students and the
teacher suspected that they were cheating and she retested them
and that they turned around. I didn't have any experience in
teaching. What I did was I loved the subject. The question is,
are we going to measure the outcomes or are we going to be
obsessed in the credentialing?
If the credentialing is correct, presumably they will get
better outcomes and much of this is medical in drug and alcohol
treatment and therefore, it would be logical that the outcomes
would reflect the training. But in this country to some degree,
credentialing and I am going to make a statement that seems
kind of role reversal but some of it is who you know and
whether you have enough income to get the credential.
Some of our problem in some of our urban areas is
minorities get excluded, lower income people get excluded and
people who can often relate to the people are in the problem. I
know there can be a street hustle part of this but you also
have to be careful you don't get an elitism in the credentialed
profession that is a disconnect with the actual problems the
individuals are facing at the street and community level.
That leads to this question. How do you feel, because
Director Walters has been here a number of times and we talked
about this and some of the programs, that some of the funds
wouldn't be delivered to the group that is providing the
services until there is some feedback on the outcome, say they
get 75 percent of the funds and there is a 3 or 6 month delay?
Dr. Passi. Congressman, we are currently exploring ways in
which to incentivize both outcomes and training. As to the
question of credentialing, I think there has to be some base
level of credentialing. There just are some things people have
to know but it is less an issue of the credential of the
practitioner than of the practice that they utilize, the
overall approach to treatment. I think if we simply emphasize
the credential, then we get the easy part rather than ensuring
that what is happening in those clinicians' facilities reflects
the cutting edge of treatment, what we in fact know works. If
it does work, rewarding the outcomes is going to be in the long
run the best incentive for getting people to find out how to do
those things.
Mr. Souder. How did you feel about delaying some of the
benefits, the funds?
Dr. Passi. I think some form of incentivizing payments to
practitioners based on outcomes is a direction in which we
certainly want to proceed.
Mr. Souder. It really makes you focus on whether the
outcomes are justified and balanced outcomes and will lead to
tremendous manipulation of those outcomes. When I was in the
graduate business program at Notre Dame and when you did case
studies, I was the one who did the measurements because once I
defined the measurements, then you start to define the problem,
how you are going to address the problem and if those
measurements have real dollar consequences, then indeed we will
follow the outcomes. Otherwise, we will tend to stay at the
process level.
Ms. Heaps. I am very bad at analogies but for some reason
this came into my head about that suggestion. It is as if we
are building a plane and we decide we are only going to give
you 70 percent of the cost to build the plane which may mean
you don't get wings but the outcome will be can it fly. There
is a caution here which is to say this is such a new endeavor
that the need to build the system to not only treat the client
and give the client choice, get the resources and the network
there, develop the voucher system and move to assessing
outcomes is such that you need to fund it, you need to get the
plane built to see if it flies.
Having seen it and tested it and seeing it fly, the
question is, how long a duration and how efficient. Now you can
begin to look at perhaps funding in terms of providers and
vouchers, individual providers who may not have outcomes as
good for reasons having to do with quality of service, failure
to integrate with others. There are standards you could set up
but I think one has to be very cautious when one is building a
new plane and a new system to make sure that you have
everything you need and then begin to look at how we can
incentivize.
Mr. Souder. We will exclude all small providers and there
will only be big ones and the cash-flow.
Ms. Heaps. Exactly.
Mr. Souder. At the same time, I believe that some
incentives are appropriate and obviously not without the wings.
In military contracting and so on because of the overruns we
have seen and because of obsession with the lobbying and the
contractors as opposed to making sure the weapons system can
actually fire, that we have had to put outcome based things in.
I wanted to ask a couple technical questions to Dr. Passi
since you have actually had a program. What percentage of your
existing program was administrative versus actually cost of
treatment? Do you know roughly?
Dr. Passi. Our administrative costs are very low. I don't
know that I can give you a figure.
Mr. Souder. Under 10 percent?
Dr. Passi. I think it is under 10 percent. There is a
fairly large cost in the assessment and in the system. Do you
count the assessment itself as administrative? We don't, it is
a clinical service and probably could be billed separately.
Mr. Souder. Is that 5 or 10 percent or is that higher?
Dr. Passi. The assessment cost probably is running
somewhere around $500 per assessment and I think that is about
standard for clinicians everywhere. Our system is in fact
administered by four people and it is about $4.5 million in
treatment services.
Mr. Souder. You are saying each of you gets $1 million?
Dr. Passi. We each get $1 million. In terms of the actual
administrators of the program, we pay four people to do it and
that might be probably $250,000.
Mr. Souder. Plus overhead of the office.
When you give out the vouchers, how many of those who you
give these vouchers to don't redeem them?
Dr. Passi. In fiscal year 2003, we actually gave out 2,870
vouchers. Of those, 2,631 were actually activated.
Mr. Souder. So less than 10 percent?
Dr. Passi. So we lost a couple hundred.
Mr. Souder. Do you have a utilization review process to
monitor whether they are actually spending the dollars in the
vouchers? How do you determine the dollar of the voucher?
Dr. Passi. The dollar amount of the voucher is based on the
outcomes of the assessment. The assessment will say this person
needs so much of this level of care.
Mr. Souder. And the voucher is then estimated for the full
cost of that program?
Dr. Passi. The voucher is then estimated for the full cost
of that program. The patient is then given referrals to a
practitioner who can provide those services. The voucher is
activated when the patient engages in service. The provider
bills then on a fee for service basis for services that are
authorized under the voucher. One hour of counseling, actually
counseling is in 15 minute units, but 1 hour of counseling will
generate a unit of service payment that will then be deducted
from the total amount of the voucher until the voucher is
exhausted. It could be multiple units of different kinds of
service. A heroin addict on methadone might get x units of
service for counseling, x units of services for the actual
dosing.
Mr. Souder. Does the dollar amount that you give them for
the services calculate in whether they are eligible for
Medicaid, have any insurance of their own and assure that the
treatment provider doesn't in effect double bill?
Dr. Passi. Generally we attempt to take care of that with
the screening and assessment. Our assessment process doesn't
say come in, get assessed and get a voucher. It says, come in
and get assessed. So in that same fiscal year where we
administered 2,800 vouchers, we actually did 3,300 assessments
and about 200 of those assessments were for people who got
referrals without a voucher. That is, they had some form of
third party coverage or could afford to pay for the cost of
their care individually.
The bulk of our patients are single, young males who in New
Mexico are not eligible for Medicaid and therefore, billing to
Medicaid is almost not an issue in our system, but several
hundred patients a year probably do have some form of third
party coverage through their employer that we then refer them
to somebody who accepts that kind of insurance.
Mr. Souder. And you are balancing that so that there isn't,
in effect, double billing?
Dr. Passi. That person would not get a voucher until that
third party coverage has exhausted.
Mr. Souder. The same on mental health coverage, is a
voucher eligible for mental health coverage?
Dr. Passi. No. At this point, this is for substance abuse
treatment services only. If the assessment indicates a co-
occurring disorder, the patient is referred to a local mental
health provider to have those problems assessed and then a
determination made about how that treatment will be financed.
Mr. Souder. Ms. Heaps, in Chicago, you are dealing with
just adults on probation, so any nuisances different?
Ms. Heaps. Slightly. Because the State of Illinois retains
the dollars and the voucher payment, it will double check
against Medicaid rolls and treatment provider rolls to see if
indeed an individual has Medicaid as an insurer, so there won't
be double payment. I think that is a pretty important thing
that States have to guarantee against.
I am sorry I blanked on the last piece you talked about.
Mr. Souder. Mental health.
Ms. Heaps. Yes, thank you. Many of our clients of course
have co-morbid situations and we believe mental health has to
be a part of the recovery process, so we will be using our
voucher system where a treatment provider cannot provide both
substance abuse and mental health to access mental health
services as well.
Mr. Souder. I thank you for your efforts. I sure hope we
can get the Portman bill moved through. At the very least, we
have a marker out this time because long term, if we are going
to hold people accountable and put them in prison, which is our
highest risk population, we have to figure out as they are
coming out that they don't come out more hardened criminals
than they started and figure out how to deal with this. A lot
of this as you pointed out and we hear hearing after hearing is
drug and alcohol at least aggravated if not caused.
I appreciate your work in that field and will be very
interested to see the probation results in Chicago, although
our numbers will be small compared to the overall part of your
problem. It is so frustrating as you see the juvenile probation
officers with 260 people and can't possibly know their names
let alone track them all. It is an overwhelming problem and I
appreciate New Mexico's pioneering of this. We will continue to
watch yours because you will be basically a step ahead of the
rest of the country as we watch for the numbers.
Thank you very much for coming.
With that, the subcommittee hearing stands adjourned.
[Whereupon, at 4:15 p.m., the subcommittee was adjourned.]
[The prepared statement of Hon. Elijah E. Cummings
follows:]
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