[Senate Hearing 108-794]
[From the U.S. Government Publishing Office]
S. Hrg. 108-794
PERFORMANCE AND OUTCOME MEASUREMENT IN SUBSTANCE ABUSE AND MENTAL
HEALTH
PROGRAMS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
of the
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
ON
EXAMINING PERFORMANCE AND OUTCOME MEASUREMENT IN SUBSTANCE ABUSE AND
MENTAL HEALTH PROGRAMS, FOCUSING ON THE MISSION OF THE SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION TO BUILD RESILIENCE AND
FACILITATE RECOVERY
__________
JULY 20, 2004
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
----------
SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL
HEALTH SERVICES
MIKE DeWINE, Ohio Chairman
MICHAEL B. ENZI, Wyoming EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada JACK REED, Rhode Island
Karla Carpenter, Staff Director
David Nexon, Minority Staff Director
C O N T E N T S
----------
STATEMENTS
Tuesday, July 20, 2004
Page
DeWine, Hon. Mike, Chairman, a U.S. Senator from the State of
Ohio, opening statement........................................ 1
Kennedy, Hon. Edward M., a U.S. Senator from the State of
Massachusetts, prepared statement.............................. 2
Curie, Charles G., Administrator, Substance Abuse and Mental
Health Services Administration................................. 4
Prepared statement........................................... 6
McLellan, A. Thomas, Director, Treatment Research Institute...... 18
Prepared statement........................................... 20
Goldman, Howard H., Professor of Psychiatry, University of
Maryland School of Medicine.................................... 21
Prepared statement........................................... 22
Tester, Gary, Director, Ohio Department of Alcohol and Drug
Addiction Services............................................. 27
Prepared statement........................................... 28
Medalie, Marsha, Vice President and Chief Operating Officer,
Riverside Community Care....................................... 41
Prepared statement........................................... 42
ADDITIONAL MATERIAL
Victor A. Capoccia, Ph.D., Senior Program Officer, the Robert
Wood Johnson Foundation, Princeton, New Jersey................. 54
Eric Goplerud, Ph.D., Executive Director, Ensuring Solutions to
Alcohol Problems, The George Washington University Medical
Center, prepared statement..................................... 69
PERFORMANCE AND OUTCOME MEASUREMENT IN SUBSTANCE ABUSE AND MENTAL
HEALTH PROGRAMS
----------
TUESDAY, JULY 20, 2004
U.S. Senate,
Subcommittee on Substance Abuse and Mental
Health Services,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:07 a.m., in
Room 430, Dirksen Senate Office Building, Hon. Mike DeWine
(chairman of the subcommittee) presiding.
Present: Senator DeWine.
Opening Statement of Senator DeWine
Senator DeWine. Good morning. Thank you all for being here
today. We are meeting to discuss performance and outcome
measurements in substance abuse and mental health programs.
With so much effort and funding focused on these programs, it
is, of course, crucial to understand the effectiveness of these
services, especially as we work on re-authorizing the Substance
Abuse and Mental Health Services Administration. All SAMHSA
programs are moving towards a core set of performance measures.
Our hearing today will help us understand just how this
will work. It will also help us better understand the
challenges faced by government and providers in making such an
approach work and how these measurements can over time improve
the effectiveness of all substance and mental health services
programs.
To the degree possible at this hearing, we want to look at
the big picture. While we are, of course, interested in
specific effective approaches to substance abuse and mental
health treatment and prevention, our focus today is really on
the overall systems of care and their effectiveness.
According to the Agency for Health Research and Quality,
health care performance measurement is the process of using a
tool based on research, a performance measure to evaluate a
managed care plan, health plan, or program, hospital or health
care practitioner. Performance measures generally are developed
to establish clear standards of accountability that in turn
will lead to efforts to improve the quality of care for people
with specific health problems. Performance also implies that
the responsible health care providing entity can be an
identified, held accountable, and has control over the aspect
of care being evaluated.
Using these sorts of measures can lead us directly to
measuring and understanding the health outcomes associated with
programs. That information then can help policy makers decide
where and at what levels to make program investments.
Unfortunately, as reported by many researchers, development of
performance measures in substance abuse and mental services has
lagged behind similar development for many other chronic
medical conditions. Despite that lag, several organizations and
initiatives are now focused one way or another on performance
and outcome measurement in substance abuse and mental health.
We have heard Mr. Curie, for example, talk about SAMHSA's
seven outcome domains. Organizations involved in recent and or
current efforts in the field include the Institute of Medicine,
the Washington Circle Group, the National Committee for Quality
Assurance, the National Association of State Mental Health
Program Directors and its research institute, the National
Association of Psychiatric Health Systems, Ensuring Solutions
to Alcohol Problems, Joined Together, and, of course, SAMHSA
itself.
So while there is a great deal of recently developed
information out there, there is also still much more work to be
done to fill in the gaps in our knowledge. SAMHSA and the
Administration for several years now have been getting ready to
fully transform the current block grants into performance and
accountability-based programs. We have heard often about the
seven domains I mentioned earlier. I hope that we can get a
clear picture today of exactly where that effort is, more
detail about data strategies, where the current challenges lie,
and what we can expect in addressing these issues as we move
forward on SAMHSA re-authorization. I look forward to hearing
the members of our second panel comment on these issues from
their unique perspective.
For me, all of this boils down to doing what works best for
people with mental health and substance abuse problems. That
means using the best information we have to help guide us in
the implementation, management, and funding of Federal
programs.
At this time, I would like to submit a statement from
Senator Kennedy to be included in the record.
[The prepared statement of Senator Kennedy follows:]
Statement of Senator Edward M. Kennedy
Discoveries in the medical sciences in recent years are
bringing new hope, new treatments, and new cures within reach
of millions of our citizens. The benefits have been well-
documented for physical illnesses such as cancer and diabetes,
but too little effort has been made to document the comparable
benefits that treatment makes for people fighting substance
addiction and mental illness.
It's encouraging therefore that the Substance Abuse and
Mental Health Services Administration has been making a
significant effort to close this gap in recent years.
Working in coordination with State officials, SAMHSA has
led a broad effort to reach agreement on a range of outcome
measurements to demonstrate that treatment and prevention are
working nationwide, improve methods for collecting data, and
make the results widely known.
So far, SAMHSA has taken a number of worthwhile steps.
They initially involved States, providers and consumers.
They decided on seven key outcome measurements to assess the
current state of care in the States. They are moving forward
with Access to Recovery and other grants to test the ability of
providers to measure new outcomes. And they have begun the
process of investing resources in system transformation.
But clearly, more needs to be done to reach consensus and
this hearing is a worthwhile first step. Public debate can help
to resolve lasting questions about how to measure new outcomes
in a way that accommodates existing State efforts and produces
the most useful information about State systems of care as well
as other emerging questions that will surface as this process
moves forward--as it must.
At this point, it makes sense to review SAMHSA's proposed
changes in block grant applications for fiscal year 2005 in
light of State concerns about timing and the cost of newly
proposed mandatory and voluntary reporting requirements.
A recent letter to this Subcommittee from Administrator
Charles Curie acknowledged that ``the process had lost sight of
the ultimate goal and that there are major impediments'' to the
previously agreed-upon plan for transforming the block grants
to a performance partnership. We very much appreciate this
candor.
First and foremost among the impediments are obvious
concerns about the cost of meeting any new requirements.
Currently, SAMHSA is tackling the issue in a piece-meal fashion
by awarding small discretionary grants to States, but we know
from discussions with State Directors that the Federal
contribution will need to be in the millions of dollars
annually.
The SAMHSA reauthorization gives us the opportunity to
consider this issue in detail and I look forward to receiving
and reviewing the agency's Reauthorization Proposal and their
Performance Partnership Grant Report this year. Major changes
to the block grants should take place in the context of
reauthorization and following receipt of these reports, and not
prior.
I look forward to today's testimony by Mr. Curie, and I
commend him for his leadership in moving this process forward
so well since he took office.
We will also hear from Marsha Medalie of Riverside
Community Care in Massachusetts. Riverside is one of our
largest and best providers, and we're proud of all they do to
improve the lives of people with mental illness and substance
abuse addiction. Her testimony emphasizes the fundamental
importance of measuring outcomes as the key to improving the
quality and availability of care.
In addition, Dr. Howard Goldman will discuss the importance
of using this information to aid in the transformation of our
mental health system.
We know that millions of Americans who need treatment for
mental illness never obtain it and those who do are often
forced to navigate a broken system that works for only the most
well-off and knowledgeable.
Our committee has broad jurisdiction and can help to break
down the barriers that keep mental health services out of reach
for millions of Americans of all ages. Some States are making
significant progress, and it should be as broadly available as
possible in all States.
I welcome our witnesses, and I look forward to working with
Senator DeWine and other colleagues in Congress to put the best
ideas into action.
Senator DeWine. Now we will turn to our first panel. We
thank everyone, of course, for joining us today.
For our first panel this morning, I would like to introduce
Charles Curie, Administrator of the Substance Abuse and Mental
Health Services Administration. He has served in this role
since October 2001. He reports, of course, directly to Health
and Human Services Secretary Tommy Thompson and leads $3.2
billion agency responsible for improving the accountability,
the capacity, and effectiveness of our Nation's substance abuse
prevention, addictions treatment, and mental health services.
Thank you very much for being back with us.
Mr. Curie. Thank you.
Senator DeWine. We look forward to your testimony and we
look forward to having the chance to talk with you again.
STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION
Mr. Curie. Absolutely. Well, thank you very much for having
me this morning, Mr. Chairman, and I do request that my written
testimony be submitted for the record.
Senator DeWine. It will be made a part of the record.
Mr. Curie. I am very pleased that you have selected
performance measurement and management as the topic for this
morning. I want to recognize this as a challenging issue, a
complex issue. It is an issue that I have struggled with as
SAMHSA Administrator. In fact, I have struggled because the
SAMHSA I entered had hundreds of measures and millions of
dollars of activities around data collection, analysis, and
reporting, but there was no strategy, no direction, and the
links to agency vision and mission were vague at best.
I am happy to report that we are changing the way we do
business at SAMHSA. We have established a vision at SAMHSA to
life in the community for everyone. Our vision is based on the
precept that all people deserve the opportunity for a life that
includes a job, a home, education, and meaningful relationships
with family and friends, recognizing that these outcomes in the
lives of people who are in recovery also more fully assure that
relapse may not occur. So these are critical outcomes
reflecting recovery.
We have established a mission. It is building resilience
and facilitating recovery. We have established a matrix of
priorities and management principles, and we are finalizing and
implementing a data strategy that is firmly based on the best
of our past activities and linked directly to our vision and
our mission.
Over the years, we have developed through a 16-state pilot
program the uniform reporting system for mental health. It
contains over 20 measures of mental health services, each
reported by States in their block grant. I want to commend the
National Association of State Mental Health Program directors
for their leadership in this process. We have also convened
over 30 State substance abuse agency meetings on performance
measurement and funded two treatment outcome and performance
pilot studies. These studies have resulted in the careful
identification of performance measures for substance abuse
treatment. Many States have been reporting on these measures
voluntarily since 2000, and I personally have seen amazing
things done by the State substance abuse authorities as a
result of these efforts.
Mostly recently, I visited North Carolina, last fall Texas
and last summer in Washington State, and I would recommend to
the committee to be examining their States in particular in
terms of how they are arriving at outcomes which fit within the
seven domains, as well as you will be hearing from Gary Tester
from the Ohio on the work that they have been doing.
As an illustration of our commitment to performance
measurement as well, because we know money is needed,
especially in these tight times, SAMHSA will have invested just
over $277 million in data infrastructure-related technical
assistance to States over the past 5 years, up from 49 million
in Fiscal Year 2001 to a requested 66 million in 2005.
Also, for the first time, we are asking for outcomes to be
measured in our grant programs that reflect the seven domains
and access to recovery, which the applications for that grant
are being reviewed as well as the strategic prevention
framework which is on the road right now in terms of people
responding and us evaluating responses to that application.
These are all concrete examples of our steadfast commitment to
build State data capacity to measure and manage performance.
Our intention at SAMHSA is to keep moving forward with our
partners. We will maintain an open and transparent
relationship. Change comes with challenges. Our data strategy
is simple. We are looking at what data we are collecting. We
are asking why are we collecting it, and we are asking how are
we using it to manage and measure performance, and if we do not
use it, we need to lose it. Since all of our programs are
aligned with our vision and our mission, it only makes sense
that the same outcomes are used across all of our programs. The
tighter our measures become, the more we can prove our
effectiveness. The greater our effectiveness, the greater the
number of people served, the greater the chances for that life
in the community for everyone.
Our emphasis is on a limited number of national outcomes.
This emphasis is built on a history of extensive dialogue with
researchers, providers, colleagues in the States, and most
importantly the people we serve. We have learned that a limited
number of key outcomes will minimize the reporting burden on
the States and others and will promote a more effective
monitoring of client outcomes and system improvements. All of
this leads me to the status of performance partnership grants,
a topic that I know is of both interest and concern to the
subcommittee.
The goal and intent of PPGs were clear, to promote greater
flexibility and accountability in the block grant program;
however, what I discussed when I moved from the State of
Pennsylvania to the Federal side of the PPG equation was that
the process had gotten in the way of achieving the purpose.
Talk and debate and discussion had gone on far longer than
necessary, a decade and multitudes of meetings and workshops on
block grant performance measurement alone. SAMHSA had funded
data-related grant programs and data collection activities.
SAMHSA had analyzed them and reanalyzed them, and SAMHSA made
agreements and then re-made the same agreements.
As a result, performance partnerships had not happened when
I arrived at SAMHSA. Process seemed to have supplanted
progress. The report we were to submit to Congress was drafted,
but its focus was on process and not action. I accept full
responsibility for stopping that report, which I discussed with
the subcommittee staff. We still owe you that report. One of
the reasons this hearing is so important is to help ensure that
we are moving forward together to meet the needs of people with
or at risk for mental and/or substance use disorders.
Dr. Gary Tisler, who served as study director for the
Carter Commission of Mental Health recently observed when he
saw that the results of the New Freedom Commission and the
Carter was similar. He said: ``It seems as though the advances
of science and technology far exceed our abilities to solve
problems related to attitudes, bureaucracies, and the human
condition.'' I think he is on to something. Attitudes,
bureaucracy, and the human condition are what I fear will get
most in the way of our efforts to move forward.
It is time to bring performance measurement and management
to the next level. It is time to begin reporting on what really
needs to be measured. Part of the challenge before us is to
change current attitudes and bureaucracies. Only when we find
common ground can we transcend those old attitudes.
The driving force for our work, as verbalized in our vision
and mission, is the hope of recovering the life in the
community. Through performance measurement and management, we
open ourselves to accountability for the work we do for you,
for our many partners, and most importantly for the people we
serve in this Nation.
Thank you, and I would be very open to and look forward to
having a dialogue and answering any questions.
[The prepared statement of Mr. Curie follows:]
Prepared Statement of Charles G. Curie, M.A., A.C.S.W.
Mr. Chairman and Members of the Subcommittee, good morning. I am
Charles G. Curie, Administrator of the Substance Abuse and Mental
Health Services Administration (SAMHSA), part of the U.S. Department of
Health and Human Services (HHS).
I am pleased to appear before you today to focus on performance and
outcome measurement activities being undertaken by SAMHSA. The issue of
performance and outcome measurement is paramount, particularly since
our budget for fiscal year 2004 totals nearly $3.4 billion and since
the President's fiscal year 2005 budget request for SAMHSA raises that
to almost $3.6 billion. Moreover, they are issues with which we at
SAMHSA have been grappling as a priority matter since I came on board
as its Administrator.
I am happy to report that we are changing the way SAMHSA does
business. Instead of continuing a history of talking about performance
measurement and management, we have taken action to achieve performance
measurement and management across all SAMHSA programs. Through decisive
action--grounded in years of deliberation that have preceded it--we are
poised to hold our discretionary and block grant recipients--and
ourselves--accountable not only for how we spend, but also for how we
serve people with or at risk for mental and substance use disorders.
samhsa vision and mission
We have good reason to believe that, working with our partners at
the Federal, State and community levels, we can achieve SAMHSA's
mission of building resilience and facilitating recovery. We have good
reason to believe that we can realize the SAMHSA vision of a life in
the community for people nationwide with or at risk for substance use
or mental disorders. Both our vision and our mission are consistent
with the President's New Freedom Initiative and with the precept that
all people deserve the opportunity for a life that includes a job, a
home, education, and meaningful relationships with family and friends.
Both research and clinical experience have shown that people with
mental and addictive disorders can and do recover when they receive
timely and effective care in their communities. According to SAMHSA's
2002 National Survey on Drug Use and Health, an estimated 22 million
persons, age 12 or older, needed treatment for an illicit drug problem
or an alcohol problem, or both. In the same year, an estimated 17.5
million people, age 18 and older, had serious mental illnesses. An
estimated 4 million adults experienced co-occurring serious mental and
substance use disorders during the year. Further, in any given year,
about 5 to 9 percent of children and youth have a serious emotional
disturbance.
Unfortunately, we also know that for too many people, the need for
care is not matched by the availability of evidence-based substance
abuse treatment and mental health services to meet those needs. Some
people seek care and cannot get it; others do not seek it at all. Under
either circumstance, their quest for recovery and a life in the
community are frustrated; our mission and vision are not being
achieved.
the samhsa role
As this Subcommittee is well aware, since I became SAMHSA
Administrator, the Agency has been working in partnership with other
Federal agencies, with States and with communities to improve how we
approach substance abuse treatment and prevention and mental health
services delivery. By restructuring our work around the vision and
mission, we have eliminated the functions that were not within our
scope as a services agency.
As a result, our work has become more finely honed and our dollars
more carefully directed--nurturing a few solid redwoods that can endure
over time, instead of cultivating a garden of annuals pleasing for a
season but with little lasting impact.
Further, to refine SAMHSA's program development and resources, we
developed a Matrix of program priorities and crosscutting principles
that pinpoints SAMHSA's leadership and management responsibilities.
These responsibilities and program directions were developed as a
result of discussions with Members of Congress, our advisory councils,
constituency groups, people working in the field, and people working to
obtain and sustain recovery. The content is dynamic--and will change
over time. We'll be able to know when we've reached a change point
through performance measurement and management, both at SAMHSA and in
communities and States across the country.
Today's Matrix priorities are aligned with the priorities of both
President Bush and HHS Secretary Tommy Thompson whose support and
confidence we greatly appreciate. They have recognized that it is time
that program and policy--and America as a whole--recognize that
substance use and mental disorders should be treated with the same
concern and urgency as diabetes, obesity, heart disease, stroke, and
cancer.
To that end, they have supported key elements of SAMHSA's matrix:
transforming the mental health care system; improving services for
people with co-occuring disorders; strengthening prevention efforts;
expanding substance abuse treatment capacity; and, critically,
performance measurement and management.
the ace principles
From the perspective of today's hearing, it is also critical that
you know that we are building our priority programs around three key
principles. They are principles that, I am sure resonate with your
interests and concerns about SAMHSA's programs and policy future. I am
speaking of the principles of Accountability, Capacity, and
Effectiveness--ACE.
To promote accountability, SAMHSA tracks national trends,
establishes measurement and reporting systems, develops standards to
monitor service systems, and works to achieve excellence in management
practices in addiction treatment and substance abuse prevention. We are
demanding greater accountability of our grantees in the choice of
treatment and prevention interventions they set in place and in the
ways in which program outcomes meet the identified needs for services.
Increasingly, we are promoting accountability--through performance
measurement and management.
By assessing resources, supporting systems of community-based care,
improving service financing and organization, and promoting a strong,
well-educated workforce that is grounded in today's best practices and
known-effective interventions, SAMHSA is enhancing the Nation's
capacity to serve people with or at risk for substance use and mental
disorders.
Further, SAMHSA also helps assure service effectiveness by
assessing delivery practices, identifying and promoting evidence-based
approaches to care, implementing and evaluating innovative services,
and providing workforce training. For example, our National Registry of
Effective Programs and Practices--with 60 known effective prevention
and early intervention programs in mental health and substance abuse--
provides a foundation on which States and communities can build to meet
prevention needs and reduce treatment needs. Our Treatment Improvement
Protocols (TIPS) bring the latest knowledge about effective
interventions, including treatment for adolescents, co-occurring
disorders, and treatment for older adults, to professionals in the
field. And our mental health services best practices toolkits, on
topics ranging from medication management to assertive community
treatment and from supported employment to illness management and
recovery, are being tested in community-based settings across the
country.
To measure our effectiveness and to be accountable, SAMHSA must
have the capacity to gather and analyze data about our programs. We are
continuing to build on our long history of national surveys, such as
the National Survey of Drug Use and Health (which now includes measures
of mental health and illness), the Drug Abuse Warning Network and the
Drug and Alcohol Services Information System (which includes the
Treatment Episode Data Set (TEDS)). At the same time, we are working
with States to build the infrastructure needed to capture and evaluate
their own measures and to identify and agree upon specific national
outcome measures.
These national outcome measures, to the extent possible, have been
drawn from already tested instruments in use by mental health and
substance abuse authorities across the Nation. Many States are already
reporting or are substantially ready to begin reporting on these
measures, thanks to this work. Data on specific populations, including
women and children, and racial and ethnic minorities, are being and
will continue to be captured by these measures. In this way, the
majority of specific components of each measure already are known to
and in use by many States, and come from existing data sets, discussed
next.
Mental Health Data Sets
Since its inception, SAMHSA's Center for Mental Health Services
(CMHS) has worked with the States to develop a mental health services
data system, including the identification and specification of
performance measures and data. This resulted in the CMHS Uniform
Reporting System (URS) that contains over 20 measures of mental health
services, each reported by States in URS ``data tables'' in their CMHS
Block Grant applications. Today, most States can report on the basic
measures contained in the URS. These measures are indicated as change
measures, since annual totals for these measures will be compared year
to year. Work is underway to develop more refined methodologies that
can demonstrate system change and transformation. Currently, under the
CMHS Block Grant, States will be expected to report on all 20 URS
measures and to establish performance goals and targets for mental
health. In the future, SAMHSA expects that the number of measures the
States will report will be refined as specific measures are agreed upon
for the Mental Health System Transformation effort.
Substance Abuse Treatment Data Sets
During the past several years SAMHSA's Center for Substance Abuse
Treatment (CSAT) convened over 30 SAMHSA/State substance abuse agency
meetings on performance measurement and funded two ``Treatment Outcome
and Performance Pilot Studies'' (TOPPS) that resulted in careful
identification and delineation of performance measures for substance
abuse treatment. The outcome measures identified through TOPPS included
changes in client alcohol and drug use; changes in client illegal
activity; changes in employment status; and, changes in homelessness.
Many States have been reporting on these measures voluntarily since
2000. To add yet another way to help, we have created the Web
Infrastructure for Treatment Services or (WITS) which is an interactive
technology system designed to aid States in data collection. I've seen
and heard about amazing things done through these efforts--most
recently in North Carolina, last fall in Texas, and last summer in
Washington State.
In addition, Federal and State substance abuse treatment data also
build upon the foundation of the TEDS admission data, generally
available for most publicly funded programs throughout the States.
Information produced through a survey conducted by the National
Association of State Alcohol and Drug Abuse Directors (NASADAD)
indicates that most States exceed the minimum specifications of TEDS
and are now collecting many of the relevant variables at discharge and
beyond. To this end, the handful of States that have on-going problems
submitting their TEDS reports will be offered an opportunity to
participate in a pilot State level operation to help determine which
data collection and management system can best generate the most
accurate data on a real-time basis. SAMHSA believes that this will
result in States being fully prepared to report on the same performance
measures regardless of whether they are reporting on the Block Grants
or discretionary grant programs.
Substance Abuse Prevention Data Sets
SAMHSA has also worked carefully over the years with State
substance abuse prevention officials to specify and define performance
measures for substance abuse prevention activities. Since 1990,
SAMHSA's Center for Substance Abuse Prevention (CSAP) and a group of
State prevention officials have met regularly to identify and define
the 30+ performance measures currently being addressed by the States as
part of the State Incentive Grant program (SIG), many of which are
taken from existing data sources, such as CSAP's Minimum Data Set
(MDS). In the future, SAMHSA expects to work with the States also to
identify and finalize a smaller group of environmental measures--
measures that address the impact of programs on the community or
``environmental'' level--that will be used in both discretionary
programs and the prevention portion of the SAPT Block Grant.
These are all concrete examples of our steadfast commitment to
build State data capacity to measure and manage performance. This
foundation has been laid to reorient ourselves to a State-friendly and
consumer-friendly performance environment.
Our intention at SAMHSA is to keep moving forward with our
partners. Change comes with challenges. One of the reasons this hearing
is so important is to help ensure that we are moving forward together
to meet the needs of people with or at risk for mental and or substance
use disorders.
from talk to action: measuring and managing performance
To help us present consistent and reliable information we have been
developing and implementing a data strategy. The strategy is simple:
The tighter our measurements become, the more we can prove our
effectiveness. The greater our effectiveness--the greater the number of
people served, the greater the chances for a life in the community for
everyone. Developing a data strategy is a task that has been hanging
around for years. Now, we have gotten real about doing it.
Our SAMHSA data strategy is a critical building block to achieve
true accountability in a performance environment by transforming the
way we do business. We are looking at what data we are collecting. We
are asking why we are collecting it. And, we are asking how we are
using it to manage and measure performance. If we don't use it, we need
to lose it.
We have learned that a limited number of key outcomes measured in
structured ways can help all of us know how well SAMHSA and its grant
programs are building resilience and facilitating recovery. Our
emphasis on a limited number of national outcomes and related national
outcome measures is built on a history of extensive dialog with our
colleagues in State mental health and substance abuse service agencies
and the people we serve.
While the discussions with States focused specifically on SAMHSA's
block grant programs--something I will address in a bit more detail
later in this testimony--the application of national outcomes and
national outcome measures extends across all SAMHSA grant programs. All
of our programs are about achieving our vision of a life in the
community for everyone and our mission building resilience and
facilitating recovery. So it only makes sense that we use the same
outcomes across our programs. And it only makes sense that we stop
talking about national outcomes and start implementing them.
naming the national outcomes
So let me tell you more about the National Outcomes we have
identified in our deliberations with the States. Together we have
highlighted specific domains of resilience and recovery as National
Outcomes. These are:
Abstinence from alcohol abuse or drug use, or decreased
symptoms of mental illness;
Increased or retained employment and school enrollment;
Decreased involvement with the criminal justice system;
Increased stability in family and living conditions;
Increased access to services;
Increased retention in services (substance abuse) or
decreased utilization of psychiatric inpatient beds (mental health);
and
Increased social connectedness.
These domains are joined by additional outcomes identified by the
OMB Program Assessment Rating Tool (PART) process--for example client
perception of care, cost effectiveness, and use of evidence-based
practices. Together they constitute the National Outcomes that SAMHSA
is applying to its discretionary and block grant portfolio activities.
Already, SAMHSA is implementing these National Outcomes, including them
in the grant announcements for its Access To Recovery Program (ATR),
and its Strategic Prevention Framework (SPF). States have voluntarily
been collecting and reporting performance information on a variety of
measures for SAMHSA's Block Grants and we have required reporting on
many of these measures in our discretionary programs, as is evident in
our fiscal year 2005 budget submission/GPRA plan and report.
Focusing on this handful of National Outcomes will minimize the
reporting burden on the States and other grantees, and will promote
more effective monitoring of client outcomes and system improvements.
SAMHSA has also worked carefully with the States to identify and
agree upon specific performance measures for each of the National
Outcomes. These measures, to the extent possible, have been drawn from
already tested instruments in use by mental health and substance abuse
authorities across the Nation. Now, we need to ensure that we collect
the data in the same way across all of our programs, so that we can
present aggregated results wherever possible.
However, some of the measures are developmental and require further
work by SAMHSA and the States to delineate the best measures to assess
progress toward reporting National Outcomes. For mental health, such
developmental measures include ones for decreased symptomatology,
criminal justice involvement, school attendance, readmission rates, and
number of persons receiving evidence-based practices. For substance
abuse treatment, developmental measures include those for stable living
situation, unduplicated counts, length of stay, and services provided
within cost bands. For substance abuse prevention, developmental
measures include those for returning to/staying in school, decreased
criminal justice involvement, increased stability in family and living
conditions, and cost effectiveness (increase services provided within
cost bands).
Other measures remain to be identified, including those for people
with co-occurring disorders, the presence of both mental and substance
use disorders. Collecting data on co-occurring disorders poses unique
challenges for States--especially for those with separate mental health
and substance abuse treatment systems. These systems will need to work
together to identify measures and methods of measurement that will be
reliable, valid, and non-duplicative, and to share data for reporting.
SAMHSA will continue to work with States to further develop and refine
these measures.
implementing new directions means supporting system change
Critically, the implementation of the National Outcomes is being
accompanied by a real-time infusion of SAMHSA support for the
improvement of the data infrastructures in place at the Federal, State
and local levels to manage this sea change from counting to accounting
for success.
As an illustration of SAMHSA's commitment to performance
measurement, we will have invested just over $277 million in data
infrastructure and related technical assistance to the States over the
past 5 years, up from $49 million in fiscal year 2001 to a requested
$66 million in fiscal year 2005, consistent with the President's fiscal
year 2005 Budget.
The following table provides greater detail regarding SAMHSA's
commitment to States to build the data infrastructure needed to make
performance measurement and management realities in how States do
business with communities and with SAMHSA, and how SAMHSA does business
to achieve its vision and mission for the American people.
SAMHSA Resources for Performance Measurement and Performance Management
[in millions]
----------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
SAMHSA Center Actual Actual Actual Estimate Requested Total
----------------------------------------------------------------------------------------------------------------
CMHS.......................................... $12.2 $12.6 $13.7 $14.9 $15.8 $69.2
CSAP.......................................... 10.1 10.6 8.5 12.3 17.5 59.0
CSAT.......................................... 22.8 25.4 26.8 25.4 28.4 128.8
OAS........................................... 3.9 3.9 4.0 4.1 4.1 20.1
-----------------------------------------------------------------
Total....................................... $49.0 $52.5 $53.0 $56.7 $65.8 $277.1
----------------------------------------------------------------------------------------------------------------
performance partnerships--the block grant programs
All of this leads me to the status of Performance Partnership
Grants (PPGs), one of the topics I know is of both interest and concern
to this Subcommittee. After all, Congress, in its 2000 reauthorization
of SAMHSA, called for the transformation of the existing substance
abuse prevention and treatment block grant and the mental health
services block grants into performance partnership grants.
The goal and intent of PPGs were clear--to promote greater
flexibility and to infuse greater accountability into the block grant
program. I've already described the years of discussion we have had
with State mental health and substance abuse authorities. I have
described the collaboration over that time with them that led to the
identification of the National Outcomes on which our performance
measurement and management focus. And I have described the broad range
of existing data sets and outcome measures--many of which already are
in place.
Yet, what I discovered when I moved from the State of Pennsylvania
to the Federal side of the PPG equation, was that clearly, the PPG
process had gotten in the way of achieving the PPG purpose. Talk and
debate and discussion had gone on far longer than necessary: a decade
and multitudes of meetings and workshops on block grant performance
measurement alone. SAMHSA had funded data-related grant programs and
data collection activities. SAMHSA had analyzed them and reanalyzed
them. And SAMHSA had made agreements and then remade the same
agreements.
As a result, Performance Partnerships still had not happened when I
reached SAMHSA. Process had supplanted progress. The Report we were to
submit to Congress on our progress on Performance Partnerships was
drafted, but its focus was on the process and not on the action. A
recent GAO report reminds us that we owe Congress that report.
In general, the Report delineates how we are changing the
relationship between the Federal and State governments to create more
flexibility for States and accountability based on outcome and other
performance measures.
By using the National Outcomes, we are changing the questions from
``How did you spend the money'' and ``Did you stay within the spending
rules'' Instead, we are asking questions relevant to building
resilience and facilitating recovery, questions like ``How did you put
the dollars to work?'' and ``How did your consumers benefit?''
As the change in questions suggests, our focus is squarely on
National Outcomes and National Outcome Measures. The National Outcomes
are true measures of recovery. They assess whether our programs are
helping people attain and sustain recovery. They show that people are
achieving a life in the community--a home, a job, and meaningful
personal relations.
Clearly, the time for action is long past. Somehow, we lost sight
that block grants are a means to build resilience and facilitate
recovery. Instead, the goal became implementing PPGs solely for the
sake of implementing them and not the implementation of performance
measurement and performance management.
That is why we are moving forward with our National Outcomes and
National Outcome Measures across all of SAMHSA's funding streams. They
will reduce State and community reporting requirements while
simultaneously presenting reliable information to you, to other key
stakeholders and to SAMHSA about the effectiveness of our services and
how they are being applied across the country.
conclusion
As this testimony suggests, SAMHSA has invested a decade preparing
for action, debating about action, and thinking about action. The time
for preparation is over; the time for implementation is now. We have
the knowledge, we have the capacity, and we most certainly have the
obligation to be accountable to the American taxpayer--and to you--to
show that what we do, what we fund, and what we propose in policy are
effective. Beyond this obligation, we have a responsibility to the
millions of Americans who are battling addiction; struggling with a
serious mental illness or emotional disturbance; or are fighting a co-
occurring serious mental and substance use disorder and their families
to put into motion this long-overdue due diligence.
That is why, in our programs, our grant announcements, and our
policies, we are taking that long-overdue action. We have looked to the
past and found the delays unacceptable. And we have looked to the
future and found our direction clear.
It is built on the solid ground of customer service--making
decisions based on the needs of the people we serve, not on the needs
of bureaucracies. The driving force for our work--as verbalized in our
vision and mission--is what people with or at risk for substance use or
mental disorders desire--the hope of recovery and a life in the
community. We must open ourselves to accountability for the work that
we do for you; for our many partners and for the public health of this
Nation.
Substance Abuse and Mental Health Services Administration National Outcome Measures
----------------------------------------------------------------------------------------------------------------
Treatment Prevention
--------------------------------------------------------------------------
Outcome Substance abuse
Mental health Substance abuse prevention
----------------------------------------------------------------------------------------------------------------
Abstinence from Drug Use/Alcohol Not applicable......... Change in percentage of 30-day substance use
Abuse. clients abstinent at (non-use/reduction in
discharge compared to use)\2\
the number/proportion Availability of alcohol
at admission\2\. and tobacco.
Availability of other
drugs.\1\
Percentage of program
participants and
percentage of
population who
perceive drug use as
harmful.\2\
Attitude toward use
among program
participants and among
population at large
Decreased Mental Illness Decreased Not applicable......... Not applicable
Symptomatology\1\. symptomatology\1\.
Increased/Retained employment or Profile of adult Change in percentage of Increase in school
return to /Stay in school. clients by employment clients employed at attendance 1; Decrease
status, increased discharge compared to in ATOD-related
school attendance the percentage at suspensions/expulsions
(children)\1\. admission. 1; Decrease in drug-
related workplace
injuries 1.
Decreased criminal justice Profile of client Change in percentage of Reduction in drug-
involvement. involvement in clients with criminal related crime 1.
criminal and juvenile justice involvement at
justice systems 1. discharge compared to
the percentage at
admission.
Increased stability in family and Profile of clients' Percentage of clients Increase in parent
living conditions. change in living in stable living participation in
situation (including situations at prevention activities
homeless status). discharge compared to 1
the number/proportion
at admission (i.e.,
housing)*1.
Increased access to services (service Number of persons Unduplicated count of Number of persons
capacity). served by age, gender, persons served\1\ \2\. served by age, gender,
race and ethnicity 2. Penetration rate-- race and ehtnicity.
Numbers served
compared to those in
need\1\.
Increased retention in treatment-- Not applicable......... Length of stay\1\...... Not applicable.
substance abuse. Unduplicated count of
persons served*2.
Reduced utilization of psychiatric Decreased rate of Not applicable......... Not applicable
inpatient beds--mental health. readmission to State
psychiatric hospitals
within 30 days and 180
days\1\ \2\.
Increased social supports/Social TO BE DETERMINED TO BE DETERMINED TO BE DETERMINED
connectedness\3\. (Initial indicators (Initial indicators (Initial indicators
and measures have not and measures have not and measures have not
yet been identified). yet been identified). yet been identified).
Client perception of care\2\......... Clients reporting .....................
positively about
outcomes\2\.
Cost effectiveness\2\................ Number of persons Percentage of States Increase services
receiving evidence- providing substance provided within costs
based services \1\ \2\. abuse treatment bands\1\ \2\
Number of evidenced- services within
based practices approved cost per
provided by State 2. person bands by the
type of treatment\1\
\2\.
Use of evidence-based practices\2\... ..................... ..................... Increase services
provided within cost
bands\1\ \2\
Total number of
evidence-based
programs and
strategies funded by
SAPTBG\2\
----------------------------------------------------------------------------------------------------------------
\1\ Developmental.
\2\ Required by OMB PART Review.
\3\ For ATR, Social Support of Recovery'' is measured by client participation in voluntary recovery or self-help
groups, as well as interaction.
Senator DeWine. Thank you very much. I have a question.
Senator Kennedy could not be here today, but he has asked me to
submit this question to you.
According to your testimony, SAMHSA is, quote, moving
forward with the process of implementing national outcomes and
national outcome measures across all of SAMHSA's funding
streams. In light of this significant regulatory movement, what
role do you now envision re-authorization of SAMHSA next year
will play in the PPG transition?
Mr. Curie. It is an excellent question. What I would
envision is that we will be in a position to be discussing with
the subcommittee what exactly we would need to be doing that
has to be translated in statute which reflect outcomes that we
all have come to consensus reflect those seven domains. We will
have some models to look at. ATR, Access to Recovery, that is
the first grant where we really operationalized outcome
measures reflective of the seven domains, and that will give
us, I think, a good foundation along with strategic prevention
framework to consider what type of outcomes would be required
and how will that impact the block grant.
Obviously, the block grant is the major bulk of what we
fund, and the block grant historically has been viewed as more
of an allocation in practice that goes to the States as opposed
to having what is desired around PPGs, both the flexibility and
accountability. So what we need to look at is how can we assure
that the seven domains are appropriately reflected in the block
grant which are those measures that are germane to all States
while giving States the flexibility to address their
individualized needs and then consider how accountability will
be built in.
We have approached this from the perspective that this is
not a way of penalizing States or trying to put States in an
awkward or difficult position if outcomes are not being
attained, but it needs to be a way of assuring that along with
any regulatory changes we feel need to be made in the re-
authorization process, that we do it in such a way that we have
technical assistance and supports and an understanding of how
those outcomes are going to be used.
Senator DeWine. All right. Senator Kennedy has another
question. What process is in place to consider input on the
developmental outcome measures still under consideration to
ensure that all appropriate stakeholders are involved and
working groups between SAMHSA and State directors represented
here today be reconvened?
Mr. Curie. We are committed to continuing to sit down and
have a dialogue with the directors, both on the substance abuse
side of the equation as well as the mental health side of the
equation, and we recognize that clearly some of these measures
are developmental. One, for example, is connectiveness, which
is the domain which has emerged over the past year as critical
for recovery, but, in all frankness, there are not a lot of
specific measures yet that have been agreed to that reflect
that connectiveness.
So, yes, we will be meeting with on a regular basis State
directors and the appropriate associations to determine how to
approach this from a development perspective, recognizing that
States are all at different levels right now. We have certain
States, States that I mentioned, that have a fairly advanced
approach to demonstrating outcome measures. Other States are
not as far along. Some States have greater capacity than other
States.
So a lot of that discussion also will be along the lines of
how we can use what we have learned from the States and models
that have worked and bring it to scale in other States. So we
are committed to a transparent process, a dialogue. It may not
be necessarily always in the context of an ongoing work group,
but it will be in the context of having ongoing input and
ongoing transparent communication with the appropriate
associations.
Senator DeWine. You point out in your testimony that the
Government Accounting Office just released a report that
reviews several SAMHSA operations. In it, they criticize your
significant delay in reporting to Congress your implementation
plan for performance partnership grants. Why is it late? Are
there some insurmountable policy or other issues which maybe we
should be aware of?
Mr. Curie. I appreciate that, and that is an excellent
question. As I said in my opening remarks, I own responsibility
for that deadline not being met. I made a conscious decision
after reviewing the process of PPGs during my first year,
trying to determine what were we accomplishing, and there was,
as I would put it, a rush to get a report pulled together and
get it submitted to meet that particular deadline.
I was concerned about the fact that it was not tied to any
particular strategy. There was a discussion about measures.
There was still a discussion about it being all very
developmental, and I thought it was very important for us to
embrace those things that we know were being measured already
in the field and bring those things to scale as well as tie it
to an overall data strategy. And the reason that we talk about
the seven domains which we have developed over the past year is
because, for the first time, it begins to put the outcomes into
a structure which will reflect whether the dollars we are
investing are helping people attain and sustain recovery and
helping to build resilience, and it goes to real outcomes in
people's lives; and the PPG report, I thought was critical to
be reflective of strategy and not have, if you will, the tail
wagging the dog, but the PPG itself being more of an outcome we
are looking for. It was important for a data strategy to be
driving the PPG process.
So we met with the members of your subcommittee to indicate
to them what we were examining and that we were looking to
revamp the approach to PPGs in the sense of tying it to that
strategy and that we would not be meeting that deadline, but
that we would continue in dialogue. I am pleased to say that
the PPG report is being vetted at this point through several
Federal agencies, and there is a concrete document from all the
work that has been done which has been taking under
consideration input from stakeholders. We have been also
looking to examine these seven domains in the context of
experts, are these valid, also is there buy-in that this makes
a lot of sense.
So we have been in that process as we have been developing
this report. So the report is on its way, and I would also,
because of the critical aspects of this to our re-
authorization, offer to you that we schedule a briefing with
your committee staff just on this matter of PPGs and
performance measurement on at least an every 60-day basis, that
we sit down and demonstrate the concrete progress we are making
in our discretionary grant process, where we are actually
beginning to take those measurements, and how we begin
translating that to the block grant, and then have discussions
of that report in depth as its submitted.
Senator DeWine. So we should see it initially when?
Mr. Curie. Well, it is in the process of being examined by
appropriate policy and budgetary entities.
Senator DeWine. I understand.
Mr. Curie. So it is going through that process, and if it
was coming just out of my shop, I probably could give you a
more pertinent deadline, but since there is a wide range of
folks looking at it, we have actually gone through preliminary
clearance. It is going through some final clearance at this
point. I would anticipate that it is going to be out hopefully
soon, and it depends how that process is.
Senator DeWine. That would be in my term of office, would
it?
Mr. Curie. I think in terms of definitely soon and
imminent, I know typically are within at least 1 or 2 years.
Senator DeWine. That is what I was afraid of.
Mr. Curie. It is my hope it will be sooner than that, and
that is another reason I would like to convene these meetings
with the staff on a regular basis up until re-authorization, so
we can have discussion about what we anticipate is coming out
in the report, as well as once the report is released, we will
have a venue together to begin to digest it together and
determine a direction.
Senator DeWine. Just for a reference, I have 2 more years
on my term of office.
Mr. Curie. I think it is safe to say soon fits in that
category, but it will be--I think it is on its way.
Senator DeWine. I am a patient man.
Well, we appreciate your testimony. We look forward to
working with you.
Mr. Curie. Thank you, Mr. Chairman.
Senator DeWine. This is very important. We are looking
forward to our testimony of our second panel because they can
give us some of the practical aspects of this. I am interested
in some of the States that you have mentioned, and we will kind
of delve into some of those States.
Mr. Curie. States have done some very good things with the
money we have put out, and I think we have some good models
upon which to build. We are not starting from scratch at all,
and we can really move this along once we have it.
Senator DeWine. You found the States that you mentioned are
doing particularly good work?
Mr. Curie. Yes, absolutely. In fact, the seven domains we
talked about, there are measures related to those, employment,
education, lack of involvement with the criminal justice
systems, and also there are ways States are able to obtain
these outcomes from using the capacities in other State
agencies, being connected to criminal justice, being connected
to labor, being connected to housing and education and cross-
referencing people who have substance abuse issues or who have
a mental illness. So there are models out there that we can
utilize.
Senator DeWine. Let me ask you one final question.
Mr. Curie. Sure.
Senator DeWine. I saw this, and I kind of struggled with
this when I was Lieutenant Governor in Ohio. You want your
agencies always to be accountable, and we would put money out
to county agencies that were doing programming, and we would
want them to be able to tell us that whatever programming they
were doing worked. On the other hand, we did not want to burden
them with so much red tape and have them spend so much of their
programming money on accountability that burned it all up and
spent all their time doing it. How do you do that? How do you
philosophically and practically approach that? How do you go at
it? Because that is the age-old problem. You want to know that
it works. You want to test it so that you know that it works,
and yet you do not want everybody out there spending all their
time filling out what they consider to be very burdensome
paperwork and constantly measuring it so you spend 25 percent
of your money on making sure that the other 75 percent is not
wasted. How do you deal with that?
Mr. Curie. Well, I think, as you described it, it is an
age-old problem. I do think that has been a major obstacle to
this whole thing over the past decade, and I think what is
critical is to have this strategy in place that we have
understanding and consensus around what measures do we really
need to use, number one. In the past, many times measures have
been approached by a grant-to-grant basis or even a county-to-
county basis, and we have not necessarily come to agreement
historically on what are those few measures we need, so trying
to keep it down to a minimum of what we really need.
Second is examine has some of these stuff already been
measured somewhere? Are we already measuring it, and if we are,
let us talk to criminal justice, the other systems that we
talked about that relate to the domains. We may not have to
create a new data infrastructure or we may be able to build on
and have linkages, and I think today with web-based technology
and how we could garner reporting and using what is available
and has not been available in the past, I think there also
could be some breakthroughs to help us find cost effective ways
of gathering the data. And again. I think if we approach this
from a systems perspective, and in North Carolina clearly is an
example of that, of having all the pertinent agencies together
around this, not just the substance abuse authority or just the
mental health authority, but all those agencies that represent
those domains, you also can gain an economy of scale around
that.
But then we have to always keep the provider in mind, and
that is what I think you were describing, the county and
provider, and make sure that what we are requesting is
pertinent. I think during re-authorization, as we look at what
is required in statute, also having discussions with the
Administration ongoing on GEPRA and part scores that we require
in grants, trying to get those all aligned around the measures
that reflect recovery can help reduce a burden.
Also, the struggle is when you go through the process of
trying to reduce a burden, many times it becomes more
burdensome just because you are changing the way you are doing
things. So that is something we need to recognize. Also, in
terms of cost, we typically have tried to allow a certain
percentage in grants to go toward that. Also, as I have
indicated, we have tried to have some separate line items, if
you will, around data infrastructure itself so it would not put
an undue burden on it.
Substance abuse, I am particularly concerned about because
it is a fragile field in some senses in terms of SAMHSA and the
State match pretty much funds the public substance abuse
treatment system, and you are right. If a lot of those
resources are put around evaluation, it already begins to
undercut a system that is trying to grow capacity, and that has
always been its greatest challenge.
Senator DeWine. Okay. We look forward to working with you.
Thank you very much.
Mr. Curie. Thank you Mr. Chairman.
Senator DeWine. Thanks for coming.
Mr. Curie. Thank you.
Senator DeWine. Let me invite our second panel to start
coming up now, and I will begin to introduce you.
First we have Dr. A. Thomas McLellan, an internationally
recognized researcher in the substance abuse field. He is a
psychologist, professor of psychiatry at the University of
Pennsylvania, and Director of the Treatment Research Institute
in Philadelphia. He has published extensively, received many
professional awards, and currently serves as the editor in
chief of the Journal of Substance Abuse and Treatment.
Next we have Dr. Howard Goldman. Dr. Goldman is an
internationally recognized mental health researcher and is a
professor of psychiatry at the University of Maryland School of
Medicine.
Next we have Gary Tester, Director of the Ohio Department
of Alcohol and Drug Addiction Services. In this cabinet-level
position, Mr. Tester oversees a staff of 110 employees and a
budget of $172 million.
Finally, we have Marsha Medalie, who is Vice President and
Chief Operating Officer of Riverside Community Care. She joined
Riverside in 1995, having been the CEO of one of Riverside's
predecessor organizations. She has 30 years of experience in
health care and human services, much of it in leadership
positions and community-based non-profit organizations.
We thank all of you very much for being with us.
Dr. McLellan, we will start with you. And what we are going
to do, we are going to have 5 minutes. We have your written
statements from each one of you. They will be made a part of
the record. We thank you very much for that, and we are going
to stay rigidly to five minutes. So when you get a sign of a
yellow light up here, you have a minute to go, and we will stop
when you get a red light, and we will go to next witness, and
we will go through all four of you, and then we will have the
opportunity to have some questions and kind of discussion maybe
among all four of you.
So, Dr. McLellan, thank you very much.
STATEMENT OF A. THOMAS McLELLAN, DIRECTOR, TREATMENT RESEARCH
INSTITUTE
Dr. McLellan. Thank you very much for asking me. I just
wanted to say that, prior to my testimony, I am not an
advocate. I do not represent any organization that provides
treatment. We do only evaluation, and the work that I will
discuss comes from some of my own work and many studies that
have been reviewed by the scientific community, and it really
is just five simple statements, really. We could talk more if
you want to talk about the specifics.
First, which is quite important with regard to addiction
treatment, it can be evaluated. It is amenable to scientific
inquiry in exactly the same way as all other forms of medicine
and commerce. The same kinds of procedures have been used as
currently used by the FDA to evaluate medication and medication
procedures.
Okay. Two, effectiveness does not mean cure, but it means
more than abstinence. You just heard Mr. Curie. I think the
field would agree with him. The seven domains have been in
existence for 20 years, and they basically revolve around
giving a person a kind of life that they are entitled to and
society the kind of reward, results, that they have paid for.
Effectiveness really means three things. It means
significant reductions, ideally abstinence, from substance use,
improvement in personal health and social function, and
reduction in public health and public safety problems. The
first two are identical to the same dimensions that are used in
the rest of medicine. If you will, there is a holy trinity, and
the holy trinity is abstinence, employment, and no crime. That
is what the public wants. That is what patients want.
Okay. A treatment program consists of many components, and
these components are therapies, various kinds of social and
medical services, and medications. So the truth is that not all
treatment components are effective and not all treatment
programs are competent. Better treatments have the following
characteristics: They are longer, longer duration in an
outpatient setting, more social and medical services, regular
monitoring of the patient, and involvement in the family.
Frankly, most treatment components have not been evaluated, and
many of the things that have been evaluated are not in practice
because of financing and structural issues that I will get to.
Fourth statement: Addiction treatment has changed over the
years, and it has made significant impact on the way it is
evaluated. In the old days, addiction was a bad habit or a sin
or a vile idea. You went away to Shady Acres Treatment Program
for ``X'' number of days and you were expected to emerge
rehabilitated. Evidence of that was lasting sobriety,
abstinence. Well, like the rest of health care--well, first of
all, addiction now is more commonly thought of in the same way
that other chronic illnesses are thought of, and like other
chronic illnesses, addiction treatment is now 90 percent in an
outpatient setting. That is very important. People do not go
away to treatment anymore. They stay in the community and they
are allowed to function in the community, appropriately so.
Meanwhile, the same kinds of evaluation techniques are no
longer appropriate. You do not want to wait a year after the
end of treatment to find out if something is effective. What
you want to do is the same kind of thing that they do in the
rest of medicine, performance monitoring. Monitoring is
pertinent to your last questions. The monitoring is the outcome
and it is done as the routine part of standard care, to manage
the patient and to develop the treatment program. The
evaluation merely collects those measures and uses them and
reports them to maintain accountability. That is the way to
make it efficient. That is the way to keep it out of the
treatment people's hair and at the same time get more pertinent
responsive accountability.
The last statement, all this said, evaluation can happen.
Performance monitoring can occur. It cannot happen in today's
addiction treatment system. The infrastructure of today's
addiction treatment system is so deteriorated that it cannot
sustain. You have program directors all through this country
making less than prison guards and having fewer benefits. The
majority of programs, the great majority of programs, have no
full-time physician, no full-time psychologist, no full-time
social worker, no full-time nurse, none of the traditional
professions that represent health care. It does not look like
health care. It looks like something else.
Okay. Counselor turnover in the United States is comparable
to turnover in the fast food stray industry, and while the fast
food industry has accommodated to this by engineering systems
to allow standardization and ensure quality, we do not. We
could, but we do not. The point here is only that you are not
going to regulate this into higher quality at this point. It is
going to need some resources. It is going to need to earn some
resources. I think it can, but that is my testimony.
That is it.
[The prepared statement of Dr. McLellan follows:]
Prepared Statement of A. Thomas McLellan, Ph.D.
I am Thomas McLellan and I am a researcher in the substance abuse
treatment field from the University of Pennsylvania and the Treatment
Research Institute.
I am not an advocate and neither I nor my Institute represent any
treatment or government organization.
I can offer evidence on the effects of treatments for alcohol,
opiate, cocaine and amphetamine addiction based on my own work of over
400 reviewed studies published in scientific journals--and based on
several reviews of the scientific literature--also reviewed by
organizations such as the IOM.
My testimony contains only five points:
1. Addiction treatment can be evaluated in a scientific manner
using exactly the same procedures and standards presently used by the
FDA to evaluate new medications and devices.
There are over 700 published studies using these methods to
evaluate various types of addiction treatments and the findings show
that--when properly applied--addiction treatments CAN be effective.
Treatment response rates and relapse rates are quite similar to those
seen in other chronic illnesses such as diabetes, hypertension and
asthma.
2. Effectiveness does NOT mean cure--it does mean more than
abstinence. There is no reliable cure for alcohol or drug addiction.
Many people can become abstinent and resume normal lives but once
addicted it is very unlikely that a person can drink or use drugs
socially.
From an evaluation perspective ``Effectiveness'' means three
things:
Significant reduction in substance use;
Improvement in personal health and social function;
Reduction in public health and public safety problems.
3. Not all treatments are effective--not all treatment programs are
competent. Treatments that do NOT work include: Detoxifications not
followed by continuing care; and acupuncture.
Many contemporary treatment components have not been evaluated.
Many evidence based treatments are not in practice--financing &
training issues.
Better treatments have the following characteristics: Longer length
and monitoring--in outpatient setting; Tailored social/medical
services; and Involvement of family.
4. Addiction treatment has changed in concept and delivery over the
past 10 years and it has significant implications for treatment
evaluation. Addiction was considered a bad habit and over 60 percent of
treatment was provided in an inpatient setting. Discharged patients
were expected to emerge ``rehabilitated'' and the evidence was
sustained abstinence measured 6-12 months following treatment
discharge.
Now addiction is considered like other chronic illnesses (evidence
can be briefly reviewed if necessary) and today over 90 percent of
addiction treatments are provided in outpatient settings for
unspecified periods of time.
Consequently, the post-treatment measurement of outcomes in the
traditional way, inappropriate, slow and expensive. Traditional post-
treatment outcome evaluations cannot provide clinicians with
information they need to iteratively improve care--or the policymaker
with evidence of accountability about those issues the public is most
interested in--crime, employment, ER utilization.
The clinical monitoring approaches used in the treatment of other
chronic illnesses are also appropriate in the treatment of addiction.
These approaches stress patient responsibility for disease and
lifestyle management and the early detection of threats to clinical
stability (relapse). These contemporary clinical approaches require
modern information management techniques and systems that provide
standardized, relevant monitoring information to the clinician and to
the payors.
5. The basic infrastructure of the United States addiction
treatment system is in very bad condition. Program closures or
takeovers are over 20 percent per year. Program directors make less
than prison guards and have fewer benefits. The great majority of
programs have no full time physician, no psychologist and no social
worker. Counselor turnover is comparable to that of the fast food
industry. There are no standardized data collection protocols designed
for clinical use in monitoring patients.
Although there are now well-tested medications and therapies that
could be helpful, the present system cannot adopt most of them.
This system ultimately could meet the accountability demands of the
public and could adopt the evidence-based treatments developed by NIH--
but ONLY if it gets investment to improve information infrastructure,
basic management training and to attract professional staff.
Senator DeWine. Very good.
Dr. Goldman.
STATEMENT OF HOWARD H. GOLDMAN, PROFESSOR OF PSYCHIATRY,
UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE
Dr. Goldman. Good morning, Mr. Chairman. As you noted, I am
Howard Goldman. I am a professor of psychiatry at the
University of Maryland. I am pleased to appear before you. I am
testifying on behalf of the Campaign for Mental Health Reform.
The campaign was established to advocate for the
recommendations of the President's New Freedom Commission on
mental health to transform mental health care in America. It
was created to serve as the mental health community's united
voice in promoting Federal policy changes that will transform
mental health care from a fragmented, unresponsive, and
inefficiently funded delivery system to one that meets the
needs of service users and their families.
I am pleased to respond to your invitation today to discuss
what we have learned about performance and outcomes in mental
health services and about our capacity to measure effectiveness
of programs for multiple perspectives. My written testimony
presents an elaborate argument about the importance of
accountability through performance and outcome measurement, and
I will not go into the details other than to say that we
outline the prevalence of mental illness and its associated
burden and point out that fewer than half of individuals who
have a diagnosable mental illness, even the most serious
conditions, seek care. This is particularly unfortunate because
we know that treatment is effective and compounding the problem
is that the care that is delivered is not the best that the
advances in science indicate are effective and are likely to
produce the agreed upon outcomes that we have heard about from
Mr. Curie and from Dr. McLellan, such as reduced symptomology,
increased community participation in work in school, for
example. This quality gap, if you will, is the reason that
accountability is so critical.
I want to make two basic points about accountability with
my oral testimony. One focuses on the traditional role of
SAMHSA as the mental health steward for the specialty and
particularly public mental health system, but the other point
is about that role in an unconventional form that will be
necessary if we were to transform mental health care as the
President's commission has suggested. That first point is that
SAMHSA's re-authorization is critical to funding an
infrastructure for performance and for outcomes measurement.
Considerably more than the current level of expenditure is
needed if States are to be able to report to the Federal
Government in an effort to assess the performance of the public
mental health system.
$100,000 to $150,000 grants each year is a start, but more
is needed to make performance measurement work. The performance
partnership grants must build a meaningful infrastructure and
they must require data that will be useful to the States and to
local governments, the counties in particular, as well as to
the Federal Government, or the whole process will be viewed as
too burdensome and will not be effective. This accountability
is a critical element of SAMHSA's Federal stewardship for
mental health. That leadership role for the Nation is critical.
Now, conventional testimony, I would say would end with
this single point, calling for re-authorization of SAMHSA and
increased spending to build the infrastructure for performance
and for outcomes monitoring. We could stop now in a
conventional sense, but that conventional approach will not
stimulate the transformation that is needed and that was at the
heart of the President's New Freedom Commission recommendations
and its vision for recovery.
The second point is that stewardship of mental health must
extend beyond the traditional mental health system to all of
the service systems in which people with a mental illness and a
substance abuse problem are found. The traditional stewards of
mental health have been asked to be responsible for meeting the
many needs of individuals who are affected by mental health
illness, yet they do not control the majority of the resources
needed to accomplish this task. If we are to take seriously our
responsibility for these outcomes for individuals with mental
illness, then we must hold all of the systems accountable for
their performance.
If SAMHSA is to be the Federal mental health steward, then
this stewardship must empower the agency to oversee this broad
accountability process. SAMHSA must be invested with more
authority to work collaboratively with all of the other systems
and agencies.
In short, focusing on SAMHSA and the State mental health
agencies and requiring reporting performance measures in their
programs alone without at the same time looking at the
performance of other programs will merely perpetuate the
fragmentation of the current mental health system and do little
to advance the goals of the President's commission. If we are
serious about recovery and about improving outcomes for adults
and children with mental disorders in all of the systems where
people with these disorders are found, we must empower
leadership. We must hold all of these systems accountable.
Now, intentionally, the report of the President's
commission with its enumerated goals and recommendations left
us with its own set of rudimentary performance measures. We
think that this a serious place to start, and one measure of
the campaign's performance is the re-authorization of SAMHSA.
We appreciate that the committee is approaching the task in the
same vein, and thanks for the opportunity to present before
you. I look forward to future questions.
[The prepared statement of Dr. Goldman follows:]
Prepared Statement of Howard H. Goldman, M.D., Ph.D.
Mr. Chairman, Senator Kennedy, and Members of the Subcommittee:
Good morning Mr. Chairman, Senator Kennedy, and Members of the
Subcommittee. My name is Howard Goldman. I am a psychiatrist and mental
health services researcher at the University of Maryland School of
Medicine and served as the senior scientific editor of the Surgeon
General's 1999 Report on Mental Health and as a consultant to the
President's New Freedom Commission on Mental Health. I am honored to
participate in today's hearing and am proud to be doing so on behalf of
the Campaign for Mental Health Reform.
Our Campaign, galvanized by the call of the President's New Freedom
Commission on Mental Health to transform mental health care in America,
was created to serve as the mental health community's united voice in
promoting Federal policy changes that will transform mental health care
from a fragmented, unresponsive, and inefficiently funded delivery
system to one that meets the needs of services users and their
families, is integrated across programs, and is adequately and
responsibly funded.
I am pleased to respond to your invitation to discuss what we have
learned about performance and outcomes in mental health services and
our capacity to measure effectiveness of programs from multiple
perspectives. I will review what we know about this important topic and
its implications for mental health policy generally and for the Federal
role and SAMHSA leadership in particular. My comments will draw upon
current research and numerous publications, as well as two reports of
the Surgeon General and the reports of the President's New Freedom
Commission on Mental Health.
In the course of a year, about one in five persons has a
diagnosable mental disorder, excluding substance use disorders. Almost
everyone's life has been touched in some way by mental illness--if not
due to one's own impairment, then in caring for family members, close
friends, or colleagues. Unfortunately, notwithstanding the existence of
effective treatments and services and the real prospect for recovery,
the majority of individuals who have a diagnosable disorder do not seek
or find the help they need. This personal tragedy and public health
failing is even worse for members of ethnic and racial minorities.
There are many reasons for this crisis: inadequate funding, lack of
parity in insurance coverage, stigma, shortage of mental health
professionals, and lack of political will to make mental health a
priority. Another relates to the focus of this hearing, namely, the
challenges associated with documenting performance and outcomes of
mental health interventions.
Fortunately, we can do far better. The Surgeon General's 1999
Report on Mental Health established that mental health is fundamental
to health. Mental disorders are real health conditions that impose a
tremendous burden on the population in terms of disability, economic
loss, and human suffering. Yet, recovery--wherein people with mental
disorders are able to live, work, learn, and participate fully in their
communities--is possible, even expected. The literature makes clear
that there is a range of well-researched and efficacious interventions
that successfully treat most mental disorders of adults of all ages,
children, and adolescents.
The hopeful findings concerning scientific advances and recovery
are tempered by the wide gap between science and practice. Evidence-
based services and other valuable though less thoroughly documented
promising and emerging practices are often not available in many
communities, and implementing such practices can be complex and
difficult. Barriers impede their use, including resistance to change by
entrenched and threatened organizational structures, obsolete
reimbursement rules, and, most importantly, lack of resources necessary
to support training and dissemination and to provide incentives for
innovation. The hard reality is that millions of Americans who need
mental health services to achieve positive clinical outcomes do not
receive any and, for many, the care that is furnished is inappropriate,
inadequate, ineffective or obsolete. There are too many stark
manifestations of our system's failure, including the 30,000 lives lost
each year to suicide and the hundreds of thousands of people with a
mental disorder who are homeless, unemployed, or inappropriately
institutionalized or incarcerated.
The promise of recovery combined with the sobering reality of the
enormous gaps in the system of services set the stage for President
Bush's New Freedom Commission on Mental Health. The President, aware of
the promise, sought to reveal and tear down the barriers to appropriate
care and community participation. Following a year of study and
consultation, the Commission transmitted to the President its report
calling for the transformation of mental health in America. The
report--Achieving the Promise--is organized around six goals that
assert that in a transformed mental health system:
1. Americans understand that mental health is essential to overall
health.
2. Mental health care is consumer and family driven.
3. Disparities in mental health services are eliminated.
4. Early mental health screening, assessment, and referral to
services are common practice.
5. Excellent mental health care is delivered and research is
accelerated.
6. Technology is used to access mental health care and information.
Within each goal are specific recommendations designed to transform
mental health care and improve systems performance and individual
outcomes. The Commission recognized and the Campaign for Mental Health
Reform firmly agrees that accountability is fundamental to each of the
goals articulated in the report. An accountable system empowers
consumers and family members by enabling them to make informed
decisions about treatment. It supports policymakers and administrators
who must make informed decisions about planning and resource
allocation. It improves the quality of provider practice and results in
improved clinical outcomes. And it is critical in generating the
political support necessary to fund and maintain the system.
An accountable system is one that can measure both the performance
of its programs and the outcomes achieved by the people it serves. With
such data, policymakers and mental health providers may monitor and
continually refine their programs. They will learn whom they are
reaching (and not reaching), what supports they are providing, what
outcomes they are achieving, and what refinements or modifications are
needed to enhance its effectiveness.
Leaders in the field understand the value of performance and
outcome measurement, and over the last 10 years we have seen tremendous
progress. There is consensus and remarkable consistency across
jurisdictions and stakeholders regarding the outcomes that mental
health systems and services are intended to achieve: reduction in
symptom distress; building social supports; community participation;
improvement in work or, in the case of children and adolescents, age-
appropriate functioning; reduced homelessness and inappropriate
hospitalization; improved general health status; and decreased contact
with criminal and juvenile justice systems. Over the past few years,
States, with only modest Federal support, have worked to develop
performance measurement systems along these lines. A handful of
States--Ohio, Texas, Colorado, Washington, and Oklahoma among them--
have implemented systems to obtain these data on a statewide basis, but
the majority of States are currently in the process of building such
systems.
But implementing these systems is not just a matter of
administrative fiat or will. Identifying and implementing measures for
uses such as planning, budgeting, monitoring, and quality improvement
is enormously complex, expensive, and labor intensive. Resources are
necessary to update or, in some cases, create information technology
systems that would enable States and counties to collect, access, link,
and analyze the relevant data. Investing in infrastructure at a time
when budgets are being slashed and public mental health systems are
already failing to provide the services and supports needed by most
consumers and family members can be difficult for States.
This suggests the critical role that the Federal Government must
play in helping enhance and expand performance measurement systems:
first, in consultation with stakeholders, developing meaningful
measures and definitions; second, ensuring the dissemination and
implementation of these measures; and third, funding States and
counties that are creating performance and outcome measurement systems,
particularly to the extent the measures are federally mandated and
designed to present a national picture. To date, the Federal commitment
has been minimal, with States receiving grants of between $100,000 and
$150,000 per year to move billion-dollar systems. To be sure, SAMHSA
and the States, through changes to the mental health block grant
program, are making progress by placing greater emphasis on performance
and outcome measures, but SAMHSA must be sure that the data it is
requiring the States to report are of value not only to the Federal
Government, but also to the States and counties in planning, quality
improvement, and contracts management. To the extent those goals are
not aligned, the Federal Government must be prepared to cover more of
the financial burden.
Much more needs to be done in the area of mental health performance
and outcomes measures, and we must move quickly: the future of mental
health services in this country depends on our ability to improve the
quality and accountability of mental health systems. But without the
leadership, investment, and defined expectations that the Federal
Government is in a position to provide, the impetus for change in this
area is likely to atrophy.
We cannot, however, end our testimony here. Certainly we must
consider accountability in the context of reauthorizing the programs of
the Substance Abuse and Mental Health Services Administration. But we
already know that SAMHSA programs have value in communities. For
example, SAMHSA programs play a crucial role in piloting and
disseminating information about innovative programming as well as
established best practices. The issue goes far beyond SAMHSA, however,
and we urge that you heed one of the most important observations of the
President's Commission: that transforming mental health care in America
will require fundamental change in all social services settings at
Federal, State, and local levels. Although SAMHSA must be looked to for
its leadership at this time, we must not lose sight of the fact that
the resources it controls are dwarfed by those of the myriad programs
and supports that serve adults and children with mental disorders in
other systems, such as criminal justice, housing, Medicaid, Medicare,
child welfare, vocational rehabilitation, special education, and SSI
and SSDI.
We are encouraged by the seriousness with which this Committee is
responding to the call of the President's Commission. We look forward
to working with you to craft legislation that will translate that call
into bold action. A conventional approach to reauthorizing this agency
will not result in transformation. Indeed, how can the stewards of
mental health care, namely SAMHSA at the Federal level, and State
mental health agencies, remain accountable and properly assess
performance and outcomes when they each control only a small fraction
of the resources needed to address these needs? The lesson of the
Commission is that transforming the mental health system will require
change in social services policy broadly. If SAMHSA is to be tasked
with monitoring performance and outcomes of mental health programs,
then it must be able to work collaboratively with all of the other
systems and agencies whose policies affect individuals with consumers
and their families. That will require an investment of greater
authority in SAMHSA. This, the Campaign believes, would be a sound
investment. Only SAMHSA has as its core mission the delivery of
effective services to people with mental disorders, and with so many
competing interests, its leadership now is more important than ever
before.
In short, focusing on SAMHSA and the State mental health agencies
and requiring reporting of performance measures in their programs,
without at the same time looking to the performance of other programs
will merely perpetuate the fragmentation in the public mental health
system and do little to advance the goals of the President's
Commission. If we are serious about recovery and about improving the
outcomes for adults and children with mental disorders in all systems
where people with mental disorders are found, we must hold all of these
systems accountable. But we cannot do this in good conscience without
empowered leadership and without investing the resources necessary to
achieve our goals.
Intentionally, the report of the President's Commission with its
enumerated goals and recommendations left us with its own set of
rudimentary performance measures. The Campaign for Mental Health
Reform, for example, holds itself accountable for robust policy change
that will achieve the outcomes envisioned by the Commission. We view
the reauthorization of SAMHSA as one measure of our performance. We
appreciate that this committee is approaching its task in the same
vein.
Thank you for the opportunity to appear this morning before you and
your subcommittee. I would be more than happy to answer any questions.
references
Daniels, A.S. & Adams, N. (2004). From Policy to Service: A Quality
Vision for Behavioral Health: Using the Quality Chasm and New Freedom
Commission Reports as a Framework for Change. Pittsburgh, PA: American
College of Mental Health Administration.
Drake, R.E. & Goldman, H.H. (Eds.). (2003). Evidence-Based
Practices in Mental Health Care. Arlington, VA: American Psychiatric
Association.
Executive Order # 13263 Establishing the President's New Freedom
Commission on Mental Health. April 29, 2002. Washington, DC.
Ganju, V., Smith, M.E., Adams, N., & Allen, J., Bible, J.,
Danforth, M. et al. (2004). The MHSIP Quality Report: The Next
Generation of Mental Health Performance Measures. Rockville, MD: Center
for Mental Health Services, Mental Health Statistical Improvement
Program.
Ganju, V. & Lutterman, T. (1998). Five-State Feasibility Study:
Implementing Performance Measures Across State Mental Health Systems.
In Mental Health, United States, 1998 (pp. 45-52). Rockville, MD:
Substance Abuse and Mental Health Services Administration, Center for
Mental Health Services.
Ganju, V. & Lutterman, T. (Eds.). (1998). Recommended Operational
Definitions and Measures to Implement the NASMHPD Framework of Mental
Health Performance Indicators: Report of the Technical Workgroup on
Performance Indicators. Alexandria, VA: National Association of State
Mental Health Program Directors.
Lehman, A.F., Goldman, H.H., Dixon, L.B. & Churchill, R. (2004).
Evidence-Based Mental Health Treatments and Services: Examples to
Inform Public Policy. New York, NY: Milbank Memorial Fund.
Lutterman, T., Ganju, V., Schact, L., Shaw, R., Monihan, K. et al.
(2003). 16 State Study on Mental Health Performance Measures.
Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services.
The President's New Freedom Commission on Mental Health. (2003).
Achieving the Promise: Transforming Mental Health Care in America:
Final Report. Rockville, MD.
The President's New Freedom Commission on Mental Health. (2002).
Interim Report to the President. Rockville, MD.
United States Public Health Service Office of the Surgeon General.
(2001). Mental Health: Culture, Race and Ethnicity: A Supplement to
Mental Health: A Report of the Surgeon General. Rockville, MD:
Department of Health and Human Services, U.S. Public Health Service.
United States Public Health Service Office of the Surgeon General.
(1999). Mental Health: A Report of the Surgeon General. Rockville, MD:
Department of Health and Human Services, U.S. Public Health Service.
______
State Performance and Outcome Measurement Systems: Same Examples
1. ohio mental health consumer outcomes system
The Ohio Mental Health Consumer Outcomes System is a standardized
way of measuring levels of health and well being experienced by
consumers of Ohio's public mental health system. The outcomes being
measured were selected by the Ohio Outcomes Task Force a Hogan, Ph.D,
in September 1996. The measures were pilot tested by a multi-
constituency work group in 1998-1999.
The outcomes System is now in operation in a majority of board
areas in the State and Data in the Department's Outcomes data base have
been used to produce a series of statewide reports for local systems.
These reports and other information about the Ohio Mental Health
Consumer Outcomes System can be found on the Outcomes Web site.
The Ohio system includes measures related to quality of life,
Symptom distress, community functioning, safety, employment and
involvement with the criminal justice system.
2. oklahoma performance and outcome monitoring system
The Performance and Outcomes Monitoring Report for Community Mental
Health Centers has been prepared for use by consumers, advocates,
planners, treatment providers, administrators, and other
decisionmakers. The report consists of two volumes. Volume One contains
performance and outcome and indicators based on a framework adopted by
the National Association of State Mental Health program Directors
(NASMHPD). Volume Two contains service utilization data. Also, a
Statewide Summary is presented.
Both Volumes contain three sections of charts and corresponding
tables that display summarized information for (1) all clients, (2)
adults with a serious mental illness (SMI), and (3) children with a
serious emotional disturbance (SED). Also included are appendices for
definitions, data selection criteria, service categories, and a State
map that depicts community mental health center (CMHC) service areas.
Data for the current fiscal year and the previous fiscal year are
presented for year-to-year comparisons.
3. washington state performance indicates systems
Performance indicates for the Washington State mental health
systems are divided from data from remains data bases and surveys.
Regular quarterly reports are produced which provide data for each
administrative region and allow for comparison crossing regions. The
performance and outcomes measures include: Penetration rates inpatients
and outpatient utilization, follow up after hospital discharge,
employment status, living situation and consumer perceptions of access,
quality of care and outcomes.
4. texas mental health outcomes systems
Performance and outcomes measures for the Texas mental health
system developed by representatives of stakeholder groups and staff are
used for strategic planning, legislative reports, contracts management
and quality improvement. Data are obtained from all adults and children
and youth receiving services. The performance measurement and outcomes
system includes measures related to: functioning symptoms, employment,
school functioning, involvement with criminal/juvenile Justice system
and implementation of evidence-based practices.
Senator DeWine. Doctor, thank you very much.
Mr. Tester, thank you for joining us.
STATEMENT OF GARY TESTER, DIRECTOR, OHIO DEPARTMENT OF ALCOHOL
AND DRUG ADDICTION SERVICES
Mr. Tester. Thank you for inviting me to testify on this
issue. I am presenting both the viewpoints of the National
Association of State Alcohol and Drug Abuse Directors as well
as the concerns from Ohio regarding this issue.
First of all, I think Administrator Curie was exceptionally
accurate in talking about the partnership that had evolved
around the discussions for the performance partnership grants.
Prior to becoming director of the State Department, I was chief
of Prevention Services for Ohio and served as the State's
National Prevention Network representative. Beginning in early
2001 I had the opportunity to participate in a number of
committee meetings and work group meetings that focused on the
prevention measures in alcohol and other drug issues associated
with the performance partnership grant discussions. Similar
work groups were facilitated through CSAT and SAMHSA with State
directors to discuss the treatment-type issues.
Personally, I found those meetings quite helpful. They
provided a rich dialogue and an opportunity to hear from a
diverse sector of States, from the very large States on my
committee of California, New York, Texas, and Ohio to the very
small States. Rhode Island and Connecticut were two that were
representing the smaller side, and we were able to talk about
the various elements of the infrastructure and the various
concerns we had about how we would meet core measures if we
were to move there. And I think that we should not lose
perspective on just how significant those work groups were and
those conversations were to help us get where we needed to be.
Through that process, we were able to develop a set of what
I will call probable core measures for both prevention and
treatment. Preventionists being as we are, it took us a great
many more measures to feel good about what it is that we wanted
to accomplish, but, nonetheless, we reached what we felt was a
good conclusion about many of the measures and anxiously
awaited then the opportunity to learn about which ones we would
narrow down in order to make sure our States were moving
forward.
As the chief of Prevention Services at this time, I was
challenged by my director at that time, Lucille Flemming, to
begin to create core measures in prevention for Ohio based on
the discretionary grants that the Department of Alcohol and
Drug Addiction Services administers so that we could begin to
align our system with what we anticipated would be the
performance partnership grant process.
With that in mind, one of the difficulties that we
experienced was assessing exactly what it would take from a
cost standpoint to implement the appropriate infrastructure to
make this happen. As you know, Senator, Ohio is a state-funded,
county-administered State. We have furious home rule, and as we
look at our county alcohol and drug boards and we look at our
local providers, one of the issues that we face is we can
assess what it would take at the State level to implement as
Mr. Curie noted. I think the ideal would be a web-based
platform that would allow us to report both prevention and
treatment outcomes; however, in simply looking at what we think
it would take at the State level from the department in order
to get our pieces in place, we are estimating conservatively
about $3.8 million in the first year alone to get us to where
we can accept outcomes from all providers on core measures and
then funnel that information both up to the Federal Government
so it could be used wisely by SAMHSA and in reporting to
Congress, but just as importantly to be able to put that
information back down to local boards and then to the local
providers, because as Dr. McLellan indicated, this information
is critical to helping them understand what processes they are
using. If we know we can keep a client, for example, on the
treatment side of the aisle, if we are doing well for 30 days
post-treatment, but we do not know what happened 60 days post-
treatment, we have to go back and take a look at that, and
right now, our system is not set up to do that.
So we are estimating at the State level alone $3.8 million
for the first year, 1.8 Million for the second year.
Under the current domains or categories that Administrator
Curie has noted, the outcome measures that are proposed do make
intuitive sense, and I agree with Dr. McLellan. He is far more
intelligent on this issue than I, but we do have a good idea of
what it takes. The critical part from a State perspective comes
in what the exact measures will be, because each time we look
at a measure or tweak a measure, we are faced with what it is
that we have to do then at the local provider level to help
them gather that appropriate information from each of the
consumers that they serve, and this becomes then more costly
because we are taking time from clinical folks and we are
putting it into evaluations.
States very clearly, we want to work with SAMHSA. I do not
think there is any question that we agree that this needs to be
an outcome-based system. We just really need to put some things
in place to put the finishing touches on this dialogue so that
we can move forward in an effective model. I think Ohio is a
State that clearly is prepared to move forward with that.
I conclude my testimony and will look forward to your
questions.
[The prepared statement of Mr. Tester follows:]
Prepared Statement of Gary Q. Tester
background
There was a time, when in order to generate more funding for
alcohol and other drug addiction services, I would paint you a
picture--a figurative picture--a compelling picture--of a sick, crack-
addicted mom and her three young children to tug at your heartstrings
and hopefully loosen the purse strings. But we all know that those days
are over. We still care strongly about that mom and her three children,
but today, we want to know more; we must know more.
Did she reach a sustained recovery? Is she employed? Is she going
to school? Has she found safe, affordable housing? Has she been
reunited with her children before the Adoption and Safe Families clock
stopped ticking? Are the children succeeding in school? Is she a good
parent?
How do we know if our services are working to improve lives? We
create performance measures covering many of the categories just
listed.
the children's health act--a roadmap for a performance data system
The National Association of State Alcohol and Drug Abuse Directors
(NASADAD) and other national organizations joined the Substance Abuse
and Mental Health Services Administration (SAMHSA) to support language
in the Children's Health Act of 2000 (P.L. 106-310) triggering a
transition from the current Substance Abuse Prevention and Treatment
(SAPT) Block Grant to a Performance Partnership Grant (PPG). The goal
of the transition is to increase State flexibility in the use of funds
in return for increased accountability based on performance. Both
SAMHSA and NASADAD also agreed that the transition should be based on a
``Continuous Quality Improvement (CQI)'' mechanism versus a punitive
system that could threaten the flow of much needed resources to our
already strained system.
The Act required SAMHSA to work with States to release a report to
Congress, due October 17, 2002, detailing the transition to a PPG,
including: (1) a description of the flexibility that would be given to
States; (2) the common set of prevention and treatment performance
measures that would be used for accountability; (3) definitions for the
data elements to be used under the plan; (4) the obstacles to
implementation of the plan, and the manner in which such obstacles
would be resolved; (5) the resources needed to implement the
performance partnership; and, (6) an implementation strategy complete
with recommended legislative language.
nasadad position statement on ppg transition
NASADAD outlined core priorities pertaining to the transition to
the PPG in a Position Statement released this year. The Position
Statement summarized NASADAD's previous correspondence and testimony
regarding the Association's views. Some core priorities are as follows:
(1) A True State-Federal Partnership.--States must be an equal
partner as the PPG transition is developed and implemented. State input
must be incorporated into (a) legislation addressing the PPG, (b) any
proposed changes to the Block Grant application seeking performance
data, and (c) the timing of the transition and other aspects of PPG
implementation.
(2) Federal Funding For Data Management and Infrastructure.--As
SAMHSA noted in its own December 24, 2002 Federal Register Notice,
``Critical to the collection and reporting on performance measures is
the ability to upgrade the data infrastructure of the State . . .
without improved data infrastructures in States, many will not be able
to collect and report performance measures.'' We could not agree more.
(3) Incentives Yes--Penalties No.--NASADAD agrees with SAMHSA's
statement, also included in its December 24, 2002 Federal Register
Notice, that ``The new partnerships will be built on incentives to
improve services rather than penalties for noncompliance.'' This is
vital.
position paper outlines next steps
NASADAD outlined recommended next steps needed to be taken in terms
of PPG transition, including:
The submission by SAMHSA of a report to Congress, as
required by P.L. 106-310, that provides a suggested roadmap for the
transition,
An assessment of State capabilities and readiness to
report PPG data as required by P.L. 106-310,
Allocation of new and additional resources to assist with
the transition, particularly in terms of data system conversions, and
A process whereby legislation that incorporates State
input is considered and passed.
I have submitted the NASADAD Position Statement to the Committee
for the Record.
ppg activity
Since the Children's Health Act was passed, SAMHSA, NASADAD and its
members, including State directors and National Prevention Network
representatives, worked to develop and refine performance measures that
we all can work toward. States have been preparing to transition from
the current SAPT Block Grant to PPGs for a number of years. SAMHSA
released an excellent overview of the progress on PPG in a December 24,
2002 Federal Register Notice. NASADAD provided comments along with
specific proposed measures and other recommendations.
more recent action
As you know, SAMHSA Administrator Charles Curie recently announced
his Agency's policy that seeks to require SAMHSA grant recipients to
report information on seven core ``domains'' or categories. In general,
NASADAD agrees that the seven categories represent important
information. NASADAD is concerned, however, with some specific
requirements and measures included in some of the categories. For
example, SAMHSA proposed to measure clients' connectiveness to society
or participation in recovery support activities at discharge. We agree
that information pertaining to a client's participation in self-help
groups and other data is important. Much more work is needed, however,
to develop ways to accurately define and measure elements within this
category.
These concerns, along with the principles included in NASADAD's PPG
Position Statement, led NASADAD to oppose SAMHSA's recent proposed
changes to the fiscal year 2005-2007 SAPT Block Grant application that
appeared in the Federal Register on March 30th of this year. In a May
28th letter to SAMHSA opposing the changes, NASADAD President Michael
Couty (Missouri) wrote,
NASADAD supports the use of performance measurement and other
data to help reach our ultimate goal: improving our substance
abuse service delivery system. We applaud and share the
Administration's dedication and desire to improve the lives of
millions across the country who are at risk for or have
substance abuse problems. We also appreciate and share the
Administration's desire to avoid unnecessary delay in
developing a Federal performance measurement system.
However, a review of the Federal Register Notice found (1) no
increase in flexibility, (2) no substantial increase in
resources, (3) no reduction in reporting burden, (4) a
substantial increase in reporting burden and (5) a small set of
performance measures that are inappropriate. As a result, we
look forward to continuing our work with the Substance Abuse
and Mental Health Services Administration (SAMHSA) and others
to change our data reporting system in a manner consistent with
our core principles outlined above.
Support for any data changes in the SAPT Block Grant application is
predicated on the need to provide States with increased flexibility and
resources--along with reduced reporting burden in other aspects of the
application.
timing
It is also important to note that States must submit a completed
SAPT Block Grant application for fiscal year 2005 by September 30th.
This Application is complex and takes many person hours to complete. It
is our understanding that the Office of Management and Budget (OMB)
will consider the initial comments sent to SAMHSA. Subsequently, OMB
will release in the Federal Register the Administration's final
proposal to change the Block Grant application with a 30-day comment
period. As a result, even if the OMB proposal came out today, States
would still not be able to begin to complete the final SAPT Block Grant
application until late August--giving States only 1 month to complete a
large and complex application. This is problematic given (1) the
application could ask for new and expanded data requirements, (2)
States are required to seek and consider public input into the
application, and (3) the sheer person hours required to complete the
application.
As a result, we again recommend that meetings move forward as soon
as possible between NASADAD and SAMHSA in order to achieve consensus on
these key issues. In particular, we believe the existing performance
partnership workgroups from SAMHSA's Center for Substance Abuse
Treatment (CSAT) and Center for Substance Abuse Prevention (CSAP)
jointly meet with NASADAD. To date, meetings to discuss the development
of the prevention and treatment measures have moved forward
separately--with separate work groups. In order to encourage
collaboration and coordination, a joint meeting is imperative.
nasadad outreach and communication
NASADAD has focused on communicating our views regarding the
transition to PPG clearly and consistently. On several occasions,
NASADAD highlighted the benefits of working collaboratively with States
on many aspects of the SAPT Block Grant. For example, NASADAD Executive
Director Lewis E. Gallant, Ph.D., noted the following in a response to
SAMHSA's December 24, 2002 PPG Federal Register Notice:
NASADAD recommends that any changes in the Block Grant
Application and thus reporting related to performance measures,
only begin after the following move forward:
An assessment by the Secretary of HHS of States'
readiness to report PPG data,
The allocation of new and additional resources to
assist with data infrastructure and other administrative costs,
and
A process whereby legislation is passed by
Congress, and signed by the President, that truly reflects the
principles of the PPG--including CQI and a true State-Federal
partnership.
Other examples where NASADAD iterated its position on changing the
Application and other issues pertaining to the PPG transition include:
(1) July 15th, 2003 testimony presented before the Senate Health,
Education, Labor and Pensions' (HELP) Subcommittee on Substance Abuse
and Mental Health Services; (2) discussions held during the June, 2003
SAMHSA-NASADAD PPG workgroup meeting; (3) a December 9, 2003 letter to
Administrator Curie; (4) a January 22, 2004 meeting with Administrator
Curie and staff; (5) a February 4, 2004 letter to Administrator Curie;
(6) a February 17, 2003 meeting with Administrator Curie and staff; and
(7) the NASADAD Position Statement on PPG Transition released February
18, 2004.
ohio-specific efforts
In Ohio, where we're in year 3 of an across-the-board outcomes
framework initiative, we've aligned State and local investor targets
with anticipated Federal PPGs. It is vital that these PPG targets
remain consistent across grant opportunities and Federal reporting
needs so that the ongoing work of Ohio and other States is not in vain.
In October of 2001 ODADAS began a 3-year implementation of its
Outcome Framework Initiative. The results to date have been
significant:
ODADAS has re-designed its discretionary grant application
process which now fully incorporates the investor approach of the
Outcome Framework.
ODADAS staff members have received substantial training
and technical assistance to ensure that they can use investor tools and
practices within ODADAS' outcome management framework.
Over 1000 providers have been trained in Outcome
Management with an emphasis on results and the processes that lead to
them.
Every provider who requested it (over 300) received
technical assistance on how to apply Outcome Management to its
program(s).
All grant-funded providers responded to the grant
application using an outcome management framework with a focus on
results and outcomes.
All boards have attended Board-specific training sessions
which introduced them to investor thinking and practices.
All boards have been invited to participate in technical
assistance sessions with providers.
All boards responded to ODADAS' outcomes questions in
their Community Plans and thus have begun to incorporate outcome
planning and strategies into their planning processes.
Individuals employed by the Department, boards and
providers have received extensive skills training to facilitate ``peer-
to-peer'' training and consultation in order to sustain the effort.
ODADAS continues to progress to a fully integrated outcome
framework in its policies and operations. To that end, the focus has
been on:
Building sustaining capacity within the entire system.--
The Train-the-Trainer component will ensure that there are people
within the system who can provide training and technical assistance as
needed.
Management structure.--Investor thinking and practices are
being integrated into the management system to ensure the focus on
results and outcomes into monitoring activities and contract
management.
Instrumentation.--Reporting structures and content are
being designed to ensure that ODADAS, as well as providers and Boards,
have the appropriate data base for results-focused State and local
strategic planning processes.
Gathering and sharing of learning and best practices
approaches.--Through the use of the Outcome Framework: Investor
Thinking and Practices, Outcome Management, Strategic Mapping and best
practices will be evident to all within the system and can be shared so
that planning and implementation of prevention, intervention, treatment
and recovery services will be effective for Ohioans.
Preparation for Federal direction.--Ohio has planned for
the Federal focus on results and outcomes that will be operationalized
through proposed changes in the Federal Substance Abuse Prevention and
Treatment (SAPT) Block Grant application. The investment ODADAS has and
is making in integrating the Outcome Framework will ensure that the
State SSA is well prepared for this Federal direction.
prevention services and performance measures
ODADAS and its county Alcohol, Drug Addiction and Mental Health
Services/Alcohol and Drug Addiction Services Boards and community
providers recognize the value of an alcohol/drug services system that
is data driven, outcome focused, grounded in evidence-based practices
and continually updated.
Consistent with the Department's Outcome Framework Initiative,
prevention provider grant applicants must address two or more of the
Center for Substance Abuse Prevention's strategies which include:
Information Dissemination;
Education;
Community-Based Process;
Environmental;
Problem Identification and Referral;
Alternatives.
All prevention grantees must develop performance targets that
contribute to the ODADAS investor targets that were developed to
correspond directly to the proposed core prevention measures within the
Performance Partnership Grants. ODADAS investor targets are what define
investor success in a quantitative way.
The challenge for the service provider is to clearly define how
many customers will reach the defined targets and what changes the
provider is committed to achieving for the people they serve. The
prevention investor targets are attached at the end of this testimony
(Table 1).
treatment/recovery services and performance measures
ODADAS has taken a number of steps to ensure that its Outcome
Framework is aligned with the proposed PPG core treatment measures.
These can be divided into three categories: outcomes for grant-funded
programs; outcomes for county boards, and infrastructure to support the
Outcome Framework.
Outcomes for Grant-Funded Programs
Each year, ODADAS provides grants to programs that provide
treatment services. These grants support Ohio's investment in key areas
such as: Women's services, Adolescent services, Drug Courts,
Therapeutic Communities, Juvenile Re-entry services and Treatment
Alternatives to Street Crime (TASC). Ohio has established Investor
Targets that define success. Programs contribute to the Investor
Targets by addressing one or more of them in their funding
applications. ODADAS provides a significant amount of training and
technical assistance to its grant-funded programs each year to insure
understanding of this process.
For State Fiscal Year 2005, investor targets and target area(s) for
treatment programs were established and aligned with the PPG core
treatment measures. A table comparing the PPG, Investor Targets and
Target Areas is listed below (see Table 2).
Outcomes for County Boards
Alcohol, Drug Addiction Services (ADAS) Boards and Alcohol, Drug
Addiction and Mental Health Services Boards (ADAMHS)--the county agents
for the State--are required by Ohio law to prepare and submit to ODADAS
a community plan for the provision of alcohol and other drug addiction
services in their service areas. The plan, which constitutes the
Board's application for funds, is prepared in accordance with
procedures and guidelines established by ODADAS every 2 years.
Among the legislatively mandated responsibilities of the Board are:
(1) assessing service needs and evaluating the need for programs; (2)
setting priorities; (3) reviewing and evaluating substance abuse
programs; and (4) assuring effective services that are of high quality.
The evaluation section of the Community Plan guidelines addresses
outcomes (results) of the previous year's plan. Boards are required to
describe what constitutes success in their systems. In the most recent
iteration of the guidelines, ODADAS incorporated the Outcome Framework
as a means for Boards to comply with the evaluation requirements and to
make sure that the data collected was consistent with the PPG measures.
Changes in Infrastructure to Support the Outcome Framework
ODADAS, through its Governor's Advisory Council on Alcohol and Drug
Addiction Services, has taken steps to build on the Outcome Framework
by establishing a standing committee on outcomes issues. Other steps
include expanding the number of individuals who are trained Outcome
Framework trainers and by providing training to county Boards on
outcome-based planning.
The Department's organizational structure has also been altered to
better align State resources for maximum impact on quality, accessible
services for all Ohioans. ODADAS has added a Division of Planning,
Outcomes and Research to spearhead long range quality improvement and
expanded its Division of Treatment and Recovery Services to encompass
all of the continuum of care services that comprise holistic wrap-
around care. All of these efforts have been undertaken in the context
of a connection between enhanced customer service, Ohio's Investor
Targets and the PPGs.
data collection--access to recovery (atr) vs. ppg
While the data elements collected in ATR are going to provide
grantees with good information on their programs, closer alignment and
consistency with PPG measures would be beneficial. The States anxiously
await the joint meetings proposed between NASADAD and SAMHSA to
establish a definitive listing of those measures so that all
preliminary planning can become finalized.
New opportunities such as Access to Recovery are welcomed by every
State. Clearly, ATR performance outcomes, PPGs and State outcome
targets must be consistent and trackable.
implementation costs
Resources are needed to help States build systems that will
collect, track, refine, manage, analyze and disseminate data in
accordance with the anticipated new requirements in the PPG. Funding is
needed to reengineer the business processes in substance abuse
prevention, intervention, treatment and recovery to effectuate a
performance measurement system.
Based on conservative figures, ODADAS estimates that implementation
of the proposed Federal PPG infrastructure would cost the State $3.8
million in the first year alone. The second year and annual costs would
be $1.8 million per year. Should SAMHSA require implementation of the
PPG structure for next Federal fiscal year, Ohio would have to pull at
least $4 million from prevention and treatment services funding. This
amount does not include the local cost to county Boards and service
providers who have staffing and information technology needs that must
be addressed if they are to meet these requirements. A sample of other
State cost estimates, provided by NASADAD, is included below:
California--$6.2 million for treatment data--this does not
include prevention data or out-year estimates;
Texas--$1.9 million initial costs, $1 million each of the
following years to maintain;
Michigan--$2.3 million in new costs;
Washington State--$750,000 to initiate the transition, and
$350,000 each of the following years.
States are not simply asking for Federal assistance without
substantial investments of their own. In a report written in November
2001 by NASADAD for SAMHSA, research found that the total State
expenditures for the operation and maintenance of alcohol and other
drug data delivery systems in a year was over $35 million. As a result,
we know that substantial resources are already being spent by States on
substance abuse data management. It is estimated that millions more
will be required to upgrade State data systems to meet PPG data
requirements. The States fully intend to work with SAMHSA to achieve
the desired goals related to PPG implementation and request Federal
funding support to further existing State efforts.
conclusion
Ohio is ready and willing to partner with the Federal Government in
establishing and working toward well-defined performance measures. We
have been laying the groundwork for the past 3 years. For Ohio and
other States, however, a financial burden comes with a change of this
magnitude. We've all heard the dreaded phrase ``unfunded Federal
mandate.'' I ask you, on behalf of all Single State Authorities, to
carefully consider and review where we are, where we need to be and
precisely how we should all get there. The SSA's, through NASADAD, will
diligently work with Congress and SAMHSA to reach a new level of
accountability and quality performance.
I'll be happy to entertain your questions.
Table 1.--Prevention
------------------------------------------------------------------------
Proposed Federal Performance ODADAS Investor Implementor Target
Partnership Grants (PPGs) Targets Areas
------------------------------------------------------------------------
Youth who have not used ATOD in 1. Programs that a. Increase the
the past 12 months. increase the number of youth
number of and/or adults who
customers who avoid ATOD for a
avoid ATOD use defined period of
and perceive non- time.
use as the norm.. b. Increase the
number of youth
and/or adult who
perceive an ATOD
using lifestyle
unacceptable and
do not use.
c. Increase
involvement of
youth engaged in
ATOD-free
alternative
activities.
d. Increase the
number of youth
who become
positive peer
prevention
leaders.
e. Increase the
number of youth
with enhanced
resistance
skills.
f. Increase the
number of youth
who have more non-
using peers than
using peers
Youth who obtain resistance/ ................
refusal skills.
Youth who understand the risks/ 2. Programs that a. Increase the
harm of use of ATOD. increase the number of youth
number of and/or adults who
customers who have increased
perceive ATOD use knowledge of the
as harmful.. risk and harm of
ATOD use and
avoid ATOD use
for defined
period of time.
b. Increase the
number of women
who have
increased
knowledge of the
risk and harm
from ATOD use and
eliminate use
while pregnant.
c. Increase the
number of women
who deliver a
drug-free baby.
Youth who have favorable ................
attitudes toward non-use.
Youth who have increased 3. Programs that a. Increase the
protective factors. increase the number of
number of families who
customers who provide increased
experience clear consistent
positive family expectations,
management.. rules and
consequences
including non-
acceptance of
ATOD use.
b. Increase the
number of youth
who gain
protective
factors at home,
school and/or
community.
c. Increase the
number of youth
who reside in a
safe and violence-
free home
environment.
Perceived parental attitude..... ................
Reduced availability of ATOD.... 5. Programs that a. Increase the
increase the impact toward
number of reduction or
initiatives that elimination of
demonstrate an ATOD use.
impact on b. Increase the
community laws compliance of
norms.. ATOD- related
laws and
regulations.
c. Increase
productivity,
performance and
attendance at the
workplace.
d. Decrease
accidents and
worker's
compensation
costs and/or
reduce health
care costs, theft
and other losses.
e. Decrease the
availability of
ATOD in the
community.
f. Increase the
number of medical
professionals who
identify at-risk
behavior
concerning the
problematic use
of alcohol and
other drugs.
6. Programs that a. Increase the
reduce the number number of youth
of customers who and/or adults who
misuse demonstrate an
prescription and/ understanding of
or over-the- the proper use of
counter prescription
medications. medications and/
or over-the-
counter
medications.
b. Increase the
number of adults
who demonstrate
and commit to the
monitoring of
prescription
medications in
the home.
------------------------------------------------------------------------
Table 2.--Treatment
------------------------------------------------------------------------
Proposed Federal Performance ODADAS Investor Implementor Target
Partnership Grants (PPGs) Targets Areas
------------------------------------------------------------------------
Abstinence at discharge......... Customers who are Minimum
abstinent for at Requirement:
least 1 year The number of
beyond completion customers who are
of the program. abstinent at
program
completion.
Employed at discharge........... Customers who are Minimum
gainfully Requirement:
employed for at The number of
least 1 year customers who are
beyond completion employed at
of the program. discharge.
No criminal justice involvement. Customers who Minimum
incur no new Requirement:
arrests for at The number of
least 1 year customers who
beyond completion incur no new
of the program. arrests at
program
completion.
Any target that Last year's (SFY
was reported and '04) approved
approved from the target(s)
SFY '04
application that
you wish to
report on this
year.
------------------------------------------------------------------------
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Senator DeWine. Mr. Tester, we appreciate your testimony
very much.
Ms. Medalie, thank you very much for joining us. You are
our last witness.
STATEMENT OF MARSHA MEDALIE, VICE PRESIDENT AND CHIEF OPERATING
OFFICER, RIVERSIDE COMMUNITY CARE
Ms. Medalie. Chairman DeWine, thank you for the opportunity
to present testimony today on behalf of Riverside Community
Care and Mental Health and Substance Abuse Corporations of
Massachusetts. Riverside is a nonprofit behavioral health care
organization serving over 50 communities in eastern and central
Massachusetts. Through more than 60 programs, Riverside
provides a comprehensive system of community-based mental
health care, substance abuse treatment, developmental
disability services, and services to individuals with traumatic
head injuries as well as community crisis response. We employ
1000 people and provide care to over 12,000 people annually.
Over our $33 million budget, about 68 percent of funds are
through contracts with State agencies, cities and towns,
hospital systems, and private foundations. Third-party payers
make up about 28 percent of our funding, and the remaining 4
percent of revenue includes donations and other miscellaneous
income. Mental Health and Substance Abuse Corporations of
Massachusetts is a State association of over 100 community-
based providers. MHSACM's mission is to promote community-based
mental health and substance abuse services as the most
appropriate clinically effective and cost sensitive method for
providing care to those in need.
Riverside values performance and outcome measures to help
inform our quality of care assessment and strategic planning.
Because we are a large organization, we cannot hope to truly
know how we are doing without formal data. Our out-patient
mental health clinics measure outcomes in multiple clinical
spheres such as depression, psychosis, suicidality, and mania.
Our vocational programs measure number employed, length of time
employed, and average wages. Our short-term adolescent day
treatment program uses a homegrown outcome measurement to
survey participants' perception of improvement on a number of
functional measures such as ability to manage anger, get along
with family, communicate feelings and concerns.
State reporting requirements also dictate what data we
collect. Our adult residential programs report on the number of
psychiatric and substance abuse hospital days utilized, number
of consumers who achieve a majority of their treatment plan
goals, and number moving to lower intensity settings. Our out-
patient substance abuse intervention and outreach program
gathers and reports extensive data to the State on a monthly
basis, including many of the seven treatment domains currently
under consideration by SAMHSA, such as arrests, substance use,
etc.
However, it is a constant struggle to balance our data
collection efforts with competing pressures of limited funding
and the myriad of record-keeping and reporting requirements
already imposed by payers and accreditors. In Massachusetts,
the number one complaint from consumers is that staff are kept
so busy with paperwork requirements that they do not have
enough time for direct service. From our 40-plus years as a
provider and our experience with outcome measurements, we
strongly support the movement towards performance measurement
on a uniform national basis, but also note that any change in
funding or in data collection and reporting requirements must
ensure that it will not come at the expense of services, staff
time to serve consumers, or provider viability. This is
especially important for Massachusetts where providers have
been largely level-funded in State mental health and substance
abuse contracts for 14 years despite the fact that our costs
have increased due to inflation and other factors and where
State agencies and some services have also sustained recent
cuts.
Neither providers nor State agencies can afford to divert
resources for further performance measurement programs. So I
respectfully submit the follow recommendations:
Investment in building performance partnerships must come
from new Federal funds specifically for data management
infrastructure, development, and maintenance, rather than
eroding base funding which could dramatically hurt providers
like Riverside. Providers do not have the ability to self-fund
hardware, software, etc., or spend additional staff time that
would be required for data collection and reporting.
Federal funding should require financial support for such
new mandates at the provider level. New mechanisms for
developing Federal block grant funding should not delay
payments to the States. This might delay payments to providers,
many of whom could not survive such a situation.
Until full evaluation of proposed measurements prove their
validity and given the fact that many providers are already
collecting valuable data, proposed national measurements must
be regarded as guidance for further queries rather than
determinants of program's value.
Determining State funding of by outcomes risks incorrectly
penalizing or rewarding programs for results beyond their full
control. Federal funding should not be based on outcomes until
experience is allowed for proper weighting of outside variables
such as the state of the local economy, availability of drugs,
and unemployment statistics as well as the efficacy of the
services being studied.
Performance measurement should support quality improvement
and assist in developing best practices, not create uncertain
funding.
Finally, review of performance measurement programs should
include ongoing feedback from all stakeholders, including
providers like Riverside and consumers of service.
Thank you for your consideration of my testimony.
[The prepared statement of Ms. Medalie follows:]
Prepared Statement of Marsha Medalie, LICSW, ACSW
introduction
Chairman DeWine, Senator Kennedy, and Members of the Subcommittee,
thank you for the opportunity to present testimony on behalf of
Riverside Community Care and Mental Health & Substance Abuse
Corporations of Massachusetts.
Riverside Community Care is an award winning, non-profit behavioral
healthcare organization serving over 50 communities in Eastern and
Central Massachusetts with a service area of one million people.
Through more than 60 programs, Riverside provides a comprehensive
system of community-based mental health care, substance abuse
treatment, developmental disabilities services, services to individuals
with traumatic head injuries, community crisis response and other
health and human services for children, adults and elders.
Mental Health and Substance Abuse Corporations of Massachusetts is
a State association of over 100 community-based providers. MHSACM's
mission is to promote community-based mental health and substance abuse
services as the most appropriate, clinically effective, and cost-
sensitive method for providing care to those in need. Accordingly, the
organization advocates for appropriate public policy and adequate
funding for each service and works with the administration and the
legislature at both the State and national levels to support this goal.
MHSACM serves as a forum for the exchange of information and ideas
among local mental health and substance abuse providers and other
constituents and encourages and supports education, research and
evaluation, technical assistance, professionalism, family/consumer
involvement and outcome-oriented service. Riverside Community Care is
an active member of MHSACM and I personally am a former officer of the
Board of Directors.
To provide some context, Riverside has developed through a series
of mergers of small and medium-sized organization and through creative
new ventures. For example, we have developed unique relationships with
local hospitals to deliver emergency psychiatric services, urgent
behavioral healthcare, and collaboration between medical and behavioral
health services. We are committed to providing community-based
alternatives to institutional care and to offering the same single,
high standard of care to all consumers, whether their care is publicly
or privately funded.
Recent national awards include the Eli Lilly Reintegration Award in
recognition of our employment of people with mental illness, helping
more than 300 adults with mental illness secure and maintain
competitive employment, the Negley Award for Excellence in Risk
Management for our multi-faceted program to safely treat high-risk
consumers, and the National Council for Community Behavioral
Healthcare's Award for Excellence for Community Crisis Response for our
work in the aftermath of local and national disasters.
Our organization employs 1000 full and part-time people and
provides care to over 12,000 people annually.
overview of services provided by riverside community care
Riverside offers an integrated network of services designed to help
individuals and families challenged by behavioral health problems--
including those with dual diagnoses of mental illness and substance
abuse, developmental disabilities, and other disabling conditions to
live and function as independently as possible and to be contributing
members of their own communities. The merger of several organizations
enabled us to gain economies of scale, reduce administrative overhead,
and build a system of care to ensure access to quality services for
consumers needing comprehensive, coordinated treatment. Riverside's
original predecessor organizations began in the 1960's following the
passage of the Community Mental Health Center Act.
Today, Riverside is one of the largest community-based providers in
Massachusetts and is highly regarded for our innovative, high quality
services, progressive and successful employment practices, and positive
relationships with the State Agencies and cities and towns that count
on us to care for their constituents. Our services are organized into
four divisions:
The Family & Behavioral Health Division includes office-based and
community outreach clinical and support services for children,
adolescents, adults and elders. Programs include: six licensed
outpatient mental health and substance abuse clinics; two 24-hour
emergency service programs--the State designated emergency service
providers for their geographies; two crisis stabilization/respite
facilities; one adolescent and four adult psychiatric day treatment
programs; an adolescent substance abuse prevention program; five home
and school-based treatment and outreach programs for youth and their
families; a consultation and treatment program for adults and children
with both developmental disabilities and behavioral disorders; and two
early intervention programs--serving families with children from birth
to age three.
A new addition to this Division is the Urgent Behavioral Care
Center created in conjunction with Milford-Whitinsville Regional
Hospital in Central Massachusetts. This program completes Riverside's
range of services as the behavioral healthcare provider for this
hospital and its large associated physician practice. Riverside
provides the behavioral health emergency services for several other
community hospitals within our core communities and is the contracted
provider for emergency psychiatric and substance abuse assessments for
several managed care organizations.
Programs within the Family and Behavioral Health Division led our
disaster response following national and local tragedies. Staff
provided counseling and support following events such as the workplace
shooting at Edgewater Technologies in Wakefield, the city of Newton bus
accident in which four middle school children were killed while on a
class field trip in Canada, as well as 9/11 which had a devastating
affect on many Massachusetts families and communities. Our staff were
at Boston's Logan Airport immediately after the terrorist attack and we
were part of the MASS Counseling Network, a FEMA funded support network
established by the Massachusetts Department of Mental Health. Riverside
also provided two half-day trainings entitled Caring For Your Staff
While They Care for the Community: What Every Manager Should Know About
Disaster Planning. The trainings were geared to managers of
organizations and local services that directly respond to disasters as
well as agencies that may be indirectly involved because of their role
in the community. The seminars were offered free to participants from
funding provided by the Substance Abuse & Mental Health Services
Administration/Center for Mental Health Services through the Mass.
Department of Mental Health.
The Mental Health Residential Division provides a wide range of
residential services to over 232 adults with serious mental illness.
Many of these consumers are dually diagnosed with both mental illness
and substance abuse problems. Programs range from highly supervised
group homes of four or five individuals with 24-hour staffing to
apartment programs where staff are located within easy reach of
consumers who live in their own apartments to supported living in which
staff are mobile and do outreach to consumers in their own homes or
apartments. These residential options enable us to provide services to
adults across the spectrum of needs, from individuals requiring
intensive help with activities of daily living or those needing
structured treatment environments and supervision to allow them to live
safely with others--including people with serious forensic histories of
violence or sexual offenses, to those who can live more independently
with reliable staff support. Our residential services include a
specialized residence and ``step-down'' outreach program for adults
with mental illness and substance abuse.
Also included within this Division is a Peer Support program run by
and for consumers of mental health services. Peer helpers are hired and
trained to enhance the social support networks and provide guidance in
recovery for consumers who are graduating from residential services.
The Clubhouse and Employment Services Division includes three
psychosocial clubhouse programs that utilize the strength of extensive
peer support and a rehabilitative environment to provide vocational,
social and independent living experiences for individuals who have a
history of mental illness. Currently 683 members are enrolled.
Extensive employment placement services and on-the-job support are
offered. Club housing supports members who need intermittent help with
activities such as budgeting, negotiating with landlords, or getting
along with roommates. Two other Supported Education and Employment
programs, Riverside Career Services, provide comprehensive career
placement services designed to meet the needs of adults whose education
or careers have been interrupted by mental health problems. These
programs offer pre-employment and education assessment and counseling
along with individualized education and career planning, job placement,
access to colleges and job training programs and flexible ongoing
support. They are highly regarded for their success in helping adults
achieve meaningful careers rather than ``dead end'' jobs and for their
employment of staff with their own histories of mental illness and
serve as role models.
Also within this Division is a new Care Management program that
helps caregivers concerned about an aging parent or a family member
with a developmental disability, mental illness, or traumatic brain
injury by providing a thorough assessment and creating and implementing
an appropriate care plan. Plans maximize independence and promote the
family member's safety, community involvement and skill building.
The Developmental and Cognitive Disabilities Division offers
services designed to meet the complex needs of individuals with mental
retardation or traumatic brain injury. Over one hundred adults receive
residential services, in small group homes, supported living (where
individuals reside in their own homes and are visited by mobile staff),
and specialized homecare (individuals are placed with families who
agree to foster them, often for a lifetime). Family and individual
support programs provide services such as respite, recreational
activities, provision of adaptive equipment, skill-training and
specialized staff support to adults and children living in the
community with their families or by themselves. Four hundred and fifty
people are served through these support programs.
overview of funding sources
Riverside's fiscal year 2005 annual budget of over $33 million
includes a blend of private and public funding. Approximately 68
percent of funds are through contracts with State agencies, cities and
towns, hospital systems, and private foundations. Riverside maintains
contracts with the Massachusetts Departments of Mental Health, Mental
Retardation, Public Health--Bureau of Substance Abuse Services (BSAS)
and Early Intervention, and the Massachusetts Rehabilitation Commission
(primarily for head injury services). State contract funding includes
State and Federal funds, inclusive of Medicaid Rehabilitation Option
funds and Block Grant funds. Third party payers makes up 28 percent of
Riverside's funding. This includes Medicaid, Medicare, HMO's, insurance
companies, and self pay from clients. Third party payers are the
largest source of revenue for our clinical services such as outpatient
therapy and medication services, emergency services and psychiatric day
treatment. The remaining 4 percent of Riverside's revenue include
donations and miscellaneous income such as donations, interest on
accounts, small grants, and consumer rents.
riverside's performance measurements and quality management
Riverside's senior management highly values meaningful performance
and outcome measurements as well as consumer and payer feedback to help
inform our quality of care assessment and future strategic planning.
Because we are a large and complex organization, we cannot hope to know
how we are truly doing without formal mechanisms to provide data. With
our extensive range of services, the instruments we use need to be
appropriate for the specific programs, so that the feedback we receive
provides meaningful information that our managers can use for quality
improvement efforts.
Our Quality Management Department oversees the organization's
collection of data and measurement of outcomes with the goal of
assessing our effectiveness, efficiency and consumer satisfaction.
Instruments used include standardized, validated tools where available,
performance measurements required by State Agencies, and internally
created measurements tailored to specific service modalities. Our
commitment to ongoing assessment and quality improvement begins each
year with our annual goals and objectives development at the
organization and division levels. Following formal needs assessments in
which consumers, payers and staff are surveyed, measurable goals and
objectives are established. Progress is reviewed at regular intervals
by a senior management committee and ultimately, the Board of
Directors.
We have devoted substantial resources to developing and collecting
quantitative data on our performance (and complying with mandatory
performance data collection), but are mindful of the need to carefully
balance this with competing pressures of limited funding and sizable
staff workloads. The myriad of record keeping and reporting
requirements already imposed by payers, regulators, and accreditors are
highly labor intensive activities. In Massachusetts, we often hear from
consumers that their No. 1 complaint is that staff are kept so busy
with paperwork requirements that they are not available to provide
direct service.
We are very pleased that in our most recent results of consumer and
family satisfaction surveys across Riverside, we yielded a 97 percent
overall satisfaction rating with 98 percent of consumers saying they
would recommend our services to others.
Annual Performance Based Contracting Meetings with our State Agency
funders (such as the Department of Mental Health) have consistently
yielded high praise for the quality and effectiveness of our work.
Massachusetts has instituted measurement requirements for many
contracts with annual contract performance review meetings. Some
specific examples will be presented below.
In addition to these measures of Riverside's success, all recent
accreditation and licensure surveys have been positive. For example,
our organization and our vocational programs are accredited by CARF--
the Rehabilitation Accreditation Commission. Our clubhouses all have
the highest available certification from the International Center for
Clubhouse Development (ICCD). Our residential programs for adults with
mental retardation received 2-year (longest possible) certification
from the Department of Mental Retardation's QUEST survey, and all
mental health and substance abuse programs are licensed by the
Department of Mental Health and/or the Department of Public Health,
where applicable.
examples of performance measurements at riverside
The Treatment Outcome Package (TOP) published by Behavioral Health
Laboratories of Ashland, MA. measures outcomes in multiple clinical
spheres such as depression, psychosis, suicidality, mania, etc. and has
nationally recognized, proven reliability. Riverside has been using the
TOP in our outpatient mental health clinics with adults at the initial
intake session and at an established follow-up time to measure
improvement in clinical outcomes from treatment. Results are
particularly valuable because it is the most widely used instrument of
its kind in Massachusetts, and Riverside's results can be compared to
other similar programs as well as to our own performance. Specific
demographics of consumers can be tabulated to allow comparison of
similar populations as well as global comparisons. Our outcomes
measurements have consistently shown that consumers improve
substantially in all domains. One of our clinics was found to have the
highest rate of improvement in treatment of depression and was asked to
present at a statewide conference on best practices. We also have the
highest rate of follow-up test administration in the State and have
again been asked to share best practices with other organizations. We
believe this is a direct result of our commitment to outcomes
measurements at all levels of the organization. In fiscal year 2005
Riverside will expand the use of this instrument to our psychiatric day
treatment programs and institute the children and adolescent TOP
outcomes measurement in our clinics.
Performance measurements from Riverside's three clubhouses
demonstrate the impressive success being achieved by them and by
clubhouses in Massachusetts in helping adults with mental illness find
employment, despite locally high unemployment rates. For example, our
program in Newton had 113 working members and our program in Norwood
had 74 working members in 2003 compared to a State average of 64 per
program and a national average of 58. Both clubhouses are average size
programs. Additionally, Riverside club members had a job longevity of
about 53 months in independent employment and 37 months in supported
employment, compared to the Statewide averages of 32 and 29 months
respectively. They also earned wages that were slightly higher than the
Massachusetts average.
An example of a ``home-grown'' outcome measurement is the
instrument used in Riverside Lifeskills Program, a short-term
adolescent day treatment program primarily serving youth referred by
the Massachusetts Department of Mental Health. The tool surveys
participants' perception of improvement on a number of functional
measures, such as ability to manage anger, get along with family, and
communicate feelings and concerns. Data is available for the previous 3
years and shows that nearly 100 percent of the adolescents report
improvement on all 13 functional domains.
The Massachusetts Department of Mental Health Performance Based
Contracting requirements designate specific measures for different
service types. Adult residential programs report on the number of
psychiatric and substance abuse hospital days utilized, number of
consumers who achieve a majority of their residential treatment plan
goals, and number moving to lower intensity settings. Our results
consistently meet or exceed contract requirements. While these results
tell part of the picture, the development of quality indicators is
still in relatively early stages and there is potential for identifying
measurements that would further demonstrate the success of these
programs. This is especially important as Massachusetts continues to
move adults with mental illness out of State hospitals and into the
community. For example, a provider that accepts consumers at higher
risk can be under-credited for skill and capability when the measure
solely considers the number of hospitalizations.
Our outpatient substance abuse intervention and outreach program,
funded by the Department of Public Health, gathers and reports
extensive data to the State on a monthly basis. These include many of
the seven treatment domains currently under consideration by SAMHSA
such as arrests/incarcerations, substance use, and living situations.
Our reports also include such measures as number of participants who
completed treatment and who report abstinence at discharge. Our
adolescent substance abuse prevention program that uses environmental
strategies to change community attitudes to reduce youthful substance
abuse also reports extensive information to the Department of Public
Health. This program is measured by how well it achieves agreed upon
benchmarks for such outcomes as decrease in middle school age youth
using alcohol and increase in the number of protective factors
identified by youth. This program converted to a new model during this
past year and results are not yet available.
comments on the proposed performance and outcome measurement programs
From our experience with outcome measurements and our longstanding
work as a provider in Massachusetts, we have come to both respect the
need for performance and outcome studies and the need to proceed
cautiously in their use. Applying our experience to a review of the
proposed measurements for mental health and substance abuse funding we
strongly support the movement toward performance measurement on a
uniform, national basis but also offer several concerns for your
consideration.
First, let me offer some local context. Providers in Massachusetts
have been largely level funded in State mental health and substance
abuse contracts for 14 years, despite the fact that our costs have
increased due to inflation and other factors. In the past few years the
economy in this State has been in critical condition, resulting in cut
backs to some State funding and services at the State Agency and
provider levels. At the same time, community-based providers have
experienced mounting regulations with associated mounting costs. We are
also managing more challenging/high risk consumers in the community who
cost more to serve as State institutions close or downsize, there are
more rapid discharges from community hospitals of under-stabilized
patients due to managed care, and we are experiencing a shrinking
workforce since we are unable to compete for employees as our salaries
fall further behind other industries.
While many organizations in Massachusetts have closed or are in
poor financial condition, Riverside and a number of other providers
have been able to grow through mergers, find economies of scale, reduce
administrative overhead, implement creative business practices and
clinical strategies that identified new funding sources. We have also
worked to improve collection rates, worked to share resources across
programs, and developed other means to stay ahead of costs. However,
even strong providers such as Riverside are now coming to the end of
our ability to continue to deliver high quality services without
funding relief and the entire system of care in Massachusetts is very
fragile. Neither providers nor State Agencies can afford to divert
resources to the development of an infrastructure to support further
performance measurement programs. Therefore, any change in funding or
in data collection and reporting requirements must first ensure that it
will not come at the expense of services, staff time to serve
consumers, or provider viability.
I respectfully submit the following recommendations:
Resources directed to Performance Measurements should not
be taken from existing funding for State Agencies or services. In
Massachusetts, State Agencies have already had major funding cuts and
are already struggling to maintain their commitment to maintain core
services in the community. Therefore, we would hope that the investment
in building Performance Partnerships would arise from new Federal funds
specifically for data management infrastructure development and
maintenance, rather than eroding the base funding now in place, which
could dramatically hurt providers like Riverside.
No unfunded mandates should be passed onto providers.
Providers do not have the ability to self-fund the hardware, software,
retooling or additional staff time that would be required to implement
further management information systems to collect and report new data
to the State. Nor can the consumers who depend on our services afford
to give up staff support that is directly or indirectly diverted to
data collection. In short, changes to Federal funding should
incorporate requirements that ensure funds are provided to support new
mandates at the provider level without reducing current rates or
service levels.
New mechanisms developed for Federal Block Grant funding
should not delay payments to the States. Such delays would ultimately
result in uncertainty and or delay in payment to providers, many of
whom could not survive such a situation.
While the proposed performance measurements appear to be
both reasonable and informative, the certainty that any measures in
behavioral health are true and meaningful indicators requires careful
study over time. Until such full evaluation can be achieved in the
future and the validity of the measurements proven and given the fact
that many providers are already collecting valuable data, we suggest
that proposed national measurements be regarded as useful for informing
further queries rather than determinants of programs' value and that
modifications and refinements be made over time.
Any move to determine State funding levels by demonstrated
outcome improvements risks incorrectly penalizing or rewarding programs
for outcomes beyond their full control. Outcome measurements in mental
health and substance abuse are still in an early stage of development,
with many questions yet to be answered about which results directly
correspond to treatment factors and which are influenced or linked to
outside, unrelated factors. For instance the success of any program, or
State, in reducing substance abuse in a population may be greatly
influenced by the local economy, availability of drugs, unemployment
statistics, etc. as well as the effectiveness of programs being
studied. Similarly, the success of a residential program in graduating
consumers to more independent settings may depend on the availability
of affordable housing, the availability of outpatient and support
services, and consumers' perceptions of opportunities to socialize with
peers and avoid isolation after leaving a program. Therefore, basing
Federal funding levels on outcomes should not be implemented at least
until sufficient measurement experience has allowed for proper
weighting of these outside variables. Even then, it is debatable
whether reducing funding to under-performing States will help them
improve programming or set them further behind. Performance
measurements should support quality improvement and assist in
developing best practices, rather than create variable and uncertain
funding.
The ongoing review of performance measurement programs,
implementation, practices, and applications should include ongoing
feedback from all stakeholders, including providers like Riverside and
consumers of service.
conclusion
As a community-based provider that works daily with thousands of
vulnerable consumers who depend on our services to avoid unnecessary
institutionalization and to recover from their mental health and
substance abuse problems, we support SAMHSA's efforts to evaluate
programs and promote quality practices across the country. Our Nation
needs to invest more in helping individuals and families struggling
with behavioral healthcare challenges. Demonstrating the effectiveness
of services through outcome measurements can be an important step in
increasing public support for funds for behavioral healthcare programs.
Defining best practices and extending them to more people in need is a
valuable aim, as is continuing support for the existing service system.
Therefore, we would hope that current SAMSHA funding would remain
intact and new investment would be added to develop measurements,
infrastructure, and dissemination of what is learned.
Thank you for your consideration of my testimony.
Senator DeWine. Thank you very much.
Ms. Medalie has brought up an interesting point, and of
course that is the point that I brought up previously, and that
is that we all want facts. We all want to know what works, but
no one wants to pay for it. And I think that the point is well
taken that, you know, if we want this data, we ought to pay for
it, but on the other hand, I think we all have to understand
that it all comes out of the same pot anyway. So if the money
was not going to be used for the data, it could be used for
treatment. It goes back to what Dr. McLellan said, that your
description of the treatment situation in the country today was
pretty grim.
So I guess I will start with you, Doctor. How do we get
this balance of that data we want, the information we want,
versus not wasting any of that precious money that you describe
correctly as we do not have enough of for treatment?
Dr. McLellan. If you go to your doctor, and you have, let
us say, hypertension, the first thing--actually, the second
thing. The first thing, of course, is the insurance, but the
second thing they are going to do is they are going to put a
cuff around your arm and they are going to measure your blood
pressure. Now, is that an outcome measure that you ought to pay
for or is that part of clinical management? It is both, and
that is what I am suggesting. For too long, these systems have
been thought to be separate. You need the same kind of
performance measures, patient status measures, to direct and
help a patient achieve self-sustaining care as the Senate and
the finance committees and the insurance companies and
everybody else does. They are, in my view, one in the same.
The testimony of Riverside is really illustrative. So many
agencies want so many different things for so many different
reasons. These programs are, you know, besieged by measurement
and they are in a desert in terms of actual functional
information they can really use.
So I do not think it is a difficult issue. I do not think
it is a costly issue. I think it is an issue of leadership and
agreement on what will be measured and when it will be
reported.
Senator DeWine. Of course in that case, I am not sure I
totally follow you, because in the case of the individual
patient you are tracking, where that patient is, and then how
do you take that so that we know what will work? That is one
patient.
Dr. McLellan. Absolutely.
Senator DeWine. How do I know what is going to work then?
Dr. McLellan. Right. The reason we know what a good blood
pressure is is because across all those individual patients,
across all those individual times they were monitored, you can
see trends in whether they do well or they do not, and they
aggregate to a group level, and you can divide it by age, race,
gender, and other conditions, all those kinds of things. It
seems to be, based on research that has been done, that is the
only viable system. If you cannot get real information into the
hands of, first, the patient about his own condition and,
second, the clinician that is actually charged with treating
that patient and, third, the evaluators that need to report
that information, it is not going to go. It will not be self-
sustaining.
Senator DeWine. Does anybody else on the panel want to take
a shot at my question? What is the balance? What should you
expect to pay? Maybe another way of putting it is what should
you expect to pay? You have got ``X'' number of dollars. What
should research cost you? I mean, maybe that is not a
legitimate question. I have seen research could cost you some
inordinate amount of money.
Doctor?
Dr. Goldman. I was attempting to respond to your earlier
question. When you asked what the amount ought to be, I became
a little more timid. Let me take a shot at it. It is very
difficult to assess precisely what the right amount is, but
everyone can agree what the wrong among and the wrong strategy
is, and the wrong strategy that some people on this panel have
spoken about is the unnecessary inefficient redundancy of the
collection of data that if it were lined up or properly aligned
would not lead to the need for repetitive monitoring or
different measures.
So I think much of what the Federal leadership, the
stewardship we spoke about, what is important and what has been
successful in recent years is overseeing a process of alignment
between the individual person-level measures that a clinician
would use and the way Dr. McLellan has spoken about it to think
about then aggregating those up to become measures of
performance based on outcomes at the local level and have those
measures be the same that the State wishes to know about from
its dependant counties and the same set of relationships
between the Federal Government and its reporting needs be the
same as the State to the county. Now, if we can align those, I
do not think that clinicians and directors of programs will be
as resistant to the collecting of these performance measures if
they are clinically meaningful and useful for planning.
Now, with respect to your more difficult question, what is
the right amount, I have been working in evaluation for a long
time.
Senator DeWine. What is the wrong amount?
Dr. Goldman. I do not even know if I can put the right
dollar amount on the wrong amount, but the point I wanted to
make is I have been working in evaluation for long enough to
remember when the Federal Government set aside 1 or 2 percent
of direct resources for use in evaluation programs. That was
done at the departmental level in health--well, it was done in
Health, Education, and Welfare--I am revealing my age, but more
recently in the Department of Health and Human Services and all
the way along the line, whether it was the community mental
health centers program or other Federal programs, set aside
resources at the 1 to 2 percent level for the performance
evaluation, and that could be used as a benchmark now for the
kind of resources we would need to build this infrastructure.
Senator DeWine. What about the situation where--and I will
go back again. There is nothing worse than a politician who
goes back and says, Well, why was such and such, you know, When
I was a Mayor, but I will do it. When I was Lieutenant
Governor, one of the things I was involved in is I had some
jurisdiction over Mr. Tester's department and some other
departments, and we were involved in drug treatment in our
prisons, and Mr. Tester's predecessor was an advocate for
taking a program of drug treatment that had already been tested
and where she felt had been a model program in other States.
There was a set program, tested, and she convinced me that it
had been used before, model program, had good test results, and
we put it into a few of our prisons. We could not afford to put
it in too many, but we put it into a couple of our prisons.
Now, assuming she was right, and I think she was, there
would be an example or would that be an example of a place
where you would not have to spend much on testing in the sense
that you already had the data? Let us assume you already had
the data of 10 years of testing. No? You still would have to do
the testing?
Dr. McLellan. With respect, I do not think you are getting
it. You do not want to tell people----
Senator DeWine. That is not the first time.
Dr. McLellan [continuing]. With respect, you do not want to
tell people what to do. You tell them what you want. Now, as I
understand it, what you want is people not going back to jail
for drug-related crimes, and that is what you pay for, and one
time-tested empirically validated procedure toward that goal
might be a very good way of getting that, but do not lose sight
of what you want. The fact that you put the miracle cure
program into effect does not necessarily mean that you are
going to get your miracle cures. That has happened over and
over and over and over.
I commend to you the efforts of the State of Delaware.
Senator DeWine. Well, I understand does not mean you are
necessarily going to get it. Maybe you and I are not
communicating. The point is you have got to choose. You are
running a prison. You and I are running a prison. I do not want
to belabor because we will bore everybody else. You and I are
running a prison, and we got a whole bunch of people in there,
and 70 percent of them have got a drug addiction.
Dr. McLellan. Got it. Right.
Senator DeWine. What are you and I going to do? Well, we
are going to spend some money.
Dr. McLellan. Yes. We are going to try something.
Senator DeWine. We are going to try something. Well, we can
do the A, B, C, or D, and E is something that has worked, and
A, B, C, and D had never worked before because we never tried
it before. We have got E. Why shouldn't we try E that has
worked before?
Dr. McLellan. Now, you are right. You better try the thing
that has worked someplace.
Senator DeWine. The problem with E is that it costs a
little more money than the others.
Dr. McLellan. Well, that is a whole separate problem.
Senator DeWine. Well, we decided to try E because we
thought it would probably work better.
Dr. McLellan. So what you want to make sure, though, is
that it actually is giving you the outcomes that you want.
Senator DeWine. You are not going to know that for 10 years
because you are not going to know whether these people are
recidivists. I am not going to know that for 10 years, because
I am not going to know if they come back. I understand that.
Dr. McLellan. Well, about 50 percent of all recidivism
occurs within the first year.
Senator DeWine. Well, I am going to know something in the
first year, but I am not going to know----
Dr. McLellan. Okay.
Senator DeWine [continuing]. I can measure that. The point
is I have got to make a decision initially.
Dr. McLellan. Right, and I would say, my own view is, that
you are using the right criteria to the make your decision. If
somebody else has shown it to be effective and it has been
effective by the standards that you are looking for in your own
State and it has been independently evaluated, that is your
best guess.
I used in my testimony the word ``earn'', because I think
with respect to the addiction treatment system, it ought to be
given the opportunity to earn additional revenue by defraying
costs of re-arrest and re-incarceration and improved welfare
status and things like that and have some of the money, the
savings that are measured, go back into the system that
produces them. At this point, that is not the case.
Mr. Tester. Senator, I just wanted to add Dr. McLellan
earlier in his testimony talked about hypertension and he
talked about both the clinical management and the outcome
piece, and I think the dialog you are having now with Dr.
McLellan around what we would do in prisons is very much part
of the process that Ohio has looked to implement through what
we call our outcome framework initiative. It is both a quality
improvement process and an outcome process.
The quality improvement or in this case management piece is
clinical. There are certain junctures during a treatment
process and a prevention process where we know where we want
our client or consumer to be, and if we can tell at that
juncture that they are on target, then we can continue to move
forward, and quite frankly, when we talk about how do we know
what the right balance is in terms of the money that we invest
in this, I think the bottom line--and I will just speak from my
Ohio perspective. We are in the process of using the Federal
information that we have worked on through the PPG process, and
we are having dialogue with consumers, providers, and boards to
talk exactly about what it is that we can measure at the
provider level with the consumer to make sure that we are doing
the right thing.
From there, if we have designed a system that meets the
needs of the consumer and takes into account what providers are
in a position to be able to address comfortably, comfortably
financially without dedicating too many resources to the other
side, then that should give me the information I need from both
the county board perspective and a State perspective to
understand what our system is doing, and in order for me to
make that work in Ohio, I have to have my consumers, providers,
and boards sitting with me in the dialogue, and I think that is
part of what you are hearing here. We have had that dialogue
with SAMHSA. We have had periods of very good dialogue, and we
just need to finish that so that we know where we are headed,
and then from there, I think we are in a position where,
ideally, I would like to invest more prevention and treatment
and out of that have the provider determine what part of that
they need in order to make these measures work. That is where
we seem to be stubbing our toe, if you will.
Senator DeWine. Well, how likely is it in all this
discussion that you are going to get that kind of either
mandate or guidance from the Federal Government, or are you
better off just doing it yourself?
Mr. Tester. In Ohio, Senator, we have concluded that right
now we are going to move ahead on our own, and we think the
body of literature is sufficient that we have a good
understanding. We think that the dialog with SAMHSA has given
us a foundation, and through NASADAD with the other States, we
have a good feel for where we ought to head, and then what I
have told folks in the State is when we get to the process
where we know what the block grant or the PPG is going to
require, we will do our darnedest to line up what Ohio has
concluded; but quite frankly, because we are committed to the
process of clinical management and outcomes, we need to put
some things in place now.
It is not nearly as sophisticated as what we had
envisioned. If we were going to take that big first step at the
right time, that is where those infrastructure dollars do come
into play.
Senator DeWine. Now, I am saying this almost in jest, but,
of course, to the counties, you are the Federal Government.
Mr. Tester. That is exactly right.
Senator DeWine. You are sort of like the Federal Government
is. So they look at you and say, Oh, those guys up in Columbus,
they are making us do this, this, and this.
Mr. Tester. You are absolutely correctly, and that,
Senator, is why I have those folks sitting at my table through
the Governor's Advisory Council, and, quite frankly, having
dialog with a diverse group of providers, consumers, and boards
is critical to my success, and I think that is what you have
heard us talk about this morning, and I think Administrator
Curie talked about that too. It is just that we encourage a
more formalized process to make sure that we have a clear
perspective on where we are headed.
Senator DeWine. Okay.
Ms. Medalie. I wonder if I might add something.
Senator DeWine. Jump right in.
Ms. Medalie. I think from the provider perspective, it is
important to note that we truly do value performance
measurements and even uniform performance measurements so that
we can, first of all, prove to the general public, if to nobody
else, that what we do really does work and that it really is
worthy of being supported. And we also are quite willing to
collect data. The problem is that much of the data that is even
being looked at is already collected. It is already in the
medical record.
In our dreams, we have electronic medical records so once
it is in there, you do not have to spend additional resources
to then aggregate it, but, frankly, we are a long way from that
happening. I see it, you know, maybe before I retire and maybe
not. But it is in there, and the things that we collect now are
things that are clinically meaningful to both the provider, to
the clinician, and to the consumer and most meaningful when it
is shared, and we are happy to share that if could have
assistance in being able to do the aggregating and the
reporting. It is that intermediate step that is really very,
very difficult without the additional funds.
And, finally, also, for us as providers, the devil is
always in the details, what happens with the information. When
we get information, when we provide information for performance
measurements that is then given back in a way that is
clinically useful, that really does help inform treatment, that
is useful. We value it. Our clinicians value it. It is shared
with the consumers and it has impact on the programs. But when
the information is either used in some aggregate way that never
translates back to something that is clinically meaningful to
help actual program choices or individual clinical choices with
consumers or, even worse, if the detail is let out so that
something--there is some gross measurement being made, but it
leaves out the details that would really say, Yes, it looks
this, but that is because of the special population and special
circumstances, you know, such as measuring hospital usage of
people in residential programs coming out of State hospitals, a
low hospital readmission rate would seem to be good except for
what about when you it is a specialized program and you are
taking folks that are very high-risk people and you are really
succeeding in identifying when the risk starts to go up. You
would think that in year 1, you would probably see more
hospitalization if your good clinicians are recognizing this
and intervening before there is a safety breach, and maybe in
years 2 and 3, you would see it go down; but if the measures
are not detailed enough, then it might be measuring something,
but it may not be measuring something that is meaningful for
the program that is being looked at.
Senator DeWine. Okay. Listen, I appreciate your testimony.
It has been very, very helpful. I look forward to working with
all of you.
Thank you for coming in.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Victor A Capoccia, Ph.D.
Mr. Chairman and Members of the Committee, thank you for
the opportunity to present a written statement to the Committee
on the topic, ``measuring performance and outcomes in addiction
and mental health programs.'' This statement will primarily
discuss improving performance and outcomes in addiction
treatment settings. I believe however that the basic principles
described in the statement are also applicable to treatment in
mental health as well as prevention settings.
Up until recently, measuring performance and outcomes in
addiction treatment was often a function more informed by
belief than by science, with little regard toward empirically
validated standards of success. In consideration of the
mismatch between what works for treating addiction disorders
and what is practiced, the Robert Wood Johnson Foundation
embarked on a strategy to improve the quality of addiction
disorder treatment by implementing programs that encourage the
use of evidence-based approaches that can be measured by
standardized definitions of success.
Our plan to accomplish this objective involves several
partnerships that include: the Substance Abuse Mental Health
Services Administration (SAMHSA), National Quality Forum, State
Mental Health and Addiction Authorities and Medicaid agencies,
purchasers, and providers of addiction treatment services.
There are three basic strategies that we will follow:
We will work with Federal partners, researchers,
providers, and purchasers (including States) through a
consensus process guided by the National Quality Forum to
develop preliminary and simple measures that indicate the use
of proven practices in treatment settings. For example are
medications used in this setting? Are patients admitted quickly
after first contact? How long are patients retained in a
treatment or aftercare activity?
We will work to remove and minimize the policy and
practical barriers that discourage the more than 14,000
publicly oriented treatment programs in this country from using
scientifically informed treatment approaches. For example, is
the admission process organized to encourage same or next day
appointments? Are levels of care sufficiently linked to promote
seamless transition by patients from more to less intense
interventions without re-admission delays?
We will work with States to use the considerable
purchasing and licensing authority that they have to encourage
the use of treatment based on science not belief. For example,
a State might establish that 80 percent of calls for admission
receive appointments within 3 days. Such a standard would
reduce no shows and take advantage of the specific window of
opportunity presented by the call for help, and quickly closed
by the next neuro-biologically based need to continue using
alcohol and or drugs.
In partnership with the Center for Substance Abuse
Treatment, one of our current initiatives to improve quality is
the Network for the Improvement of Addiction Treatment (NIATx).
NIATx is supported by $9.5 million from the Robert Wood Johnson
Foundation's Paths to Recovery program and $7.7 million from
the Center for Substance Abuse Treatment's Strengthening
Treatment Access and Retention (STAR) program. NIATx is a
vehicle for improving quality in the addiction treatment field
that is equivalent to the role the Toyota Production System
plays for the Pittsburgh Regional Health Improvement Initiative
or that the Institute for Health Care Improvement plays for
America's acute health care services.
Research demonstrates that organizational factors are more
significant barriers to admitting and retaining patients into
treatment than are personal or policy-related factors.
Therefore, the overall goal of NIATx is to make improvement of
organizational functioning an integral part of the work of
addiction treatment agencies. The specific aims of the NIATx
are to:
reduce the time between a client's first request
for service and their first treatment session;
reduce the percentage of client no-shows;
increase admissions; and
increase the treatment continuation rate.
These four aims translate into measures of performance
improvement and are consistent with the measures developed by
the SAMHSA-sponsored Washington Circle Group.
How does it actually work? The National Program Office
(NPO) at the University of Wisconsin provides 29 grantee
agencies with an expert process improvement coach and resources
for building their organization's capacity to apply, spread,
and sustain successful changes within their organization.
Within each organization, there must be a committed executive
sponsor, a powerful change leader and a dynamic change team
using an improvement model that allows for changes to be
rapidly tested and implemented. The improvement model is based
on five key principles drawn from extensive empirical research
that separate successful from unsuccessful organizations: (1)
thoroughly understand what it is like to be a customer/user of
the process you are trying to improve; (2) select processes to
improve that, if successful, will help senior leaders achieve
important overarching goals; (3) have only powerful and
respected change agents; (4) engage external expertise to
provide ideas and pressure to improve; and (5) quickly and
repetitively test and (based on those tests) revise solutions
before full-scale implementation.\1\ \2\
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\1\ Gustafson D, and Hundt A (1995). ``Findings of Innovation
Research Applied to Quality Management Principles for Health Care.''
Health Care Management Review 20(2), pp 10-27.
\2\ Gustafson DH (2002). ``Designing Systems to Improve Addiction
Treatment: The Foundation.'' Alcoholism and Drug Abuse Weekly. 14(42).
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In 8 months of NIATx participation, these 29 agencies have
made impressive improvements in treatment access and retention,
developed ideas and tools to share with the rest of the field,
and begun to create the groundwork needed for fundamental
change in their agencies. For example, a subset of
participating programs, through using rapid change cycles, have
reduced wait times to get into treatment by 68 percent, reduced
the number of no-shows for treatment by 29 percent, increased
admissions by 64 percent for inpatient and 142 percent for
outpatient treatment settings, and increased treatment
continuation by 7 to 17 percent depending on the level of care.
Programs are demonstrating that dramatic change may be a lot
simpler and take less time than is often presumed. They are
proving that, when faced with seemingly insurmountable hurdles,
addiction treatment providers find innovative ways of getting
more from existing resources.
Behind the numbers are a variety of specific changes that
began after members conducted a walk-through of their own
agency where they experienced the barriers to treatment faced
by their clients. The barriers identified by the applicant
organizations led to the categorization of nine main areas in
need of systemic improvements: (1) outreach; (2) first request
for service; (3) intake and assessment; (4) therapeutic
engagement; (5) levels of care; (6) paperwork; (7) scheduling;
(8) social support systems; and (9) maximizing revenue sources.
Examples of changes in these areas include: central admission
centers; guaranteed next day appointments; expanded evening,
weekend and morning hours; reduced barrier transition between
levels of care; elimination of ``prove you are ready''
requirements; and targeted reminder and follow up contacts.
Attached to this statement you will find a document that
summarize specific accomplishments of the 29 agencies.
We welcome your questions and interest in this work. Thank
you for this opportunity.
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Prepared Statement of Eric Goplerud, Ph.D.
While SAMHSA is just beginning to implement performance
measurements and outcome measurements to ensure accountability, the
private sector has been utilizing performance measurements in
behavioral health for several years. The model provides accountability
at the plan level and an Ensuring Solutions to Alcohol Problems
analysis has shown how attention to a particular measure can ensure
quality improvements. Ensuring Solutions is a research-based initiative
that examines barriers to access to alcohol treatment.
performance measurement is a first step in quality improvement
Addiction specialists have made tremendous progress in performance
measurement. In just 5 years, they have developed a core set of
measures and incorporated several into tools already familiar to health
care purchasers. The inclusion of these measures alongside those for
treating other chronic illnesses--asthma, diabetes and high blood
pressure--gives addiction to alcohol and other drugs a place on the
Nation's health care agenda that is commensurate with its devastating
impact on individuals, families and communities.
Improving the quality of alcohol treatment serves everyone's
interests. Alcohol problems are the third leading cause of preventable
death, killing 100,000 Americans annually. They drain $185 billion from
the Nation's economy by reducing productivity and increasing health
care costs. Despite these enormous costs, however, the quality of
treatment for alcoholism ranks dead last when compared to treatment for
the Nation's 25 leading causes of illness, death, hospitalization and
doctor's visits. In fact, RAND researchers have found that only 10
percent of Americans with alcoholism receive evidence-based care.
private sector takes performance measure initiative
The National Committee for Quality Assurance (NCQA), a nonprofit
accreditor for managed care organizations, developed and maintains a
leading tool to measure health care value and improve quality--the
Health Plan Employer Data and Information Set (HEDIS). Almost 90
percent of America's health plans now use HEDIS to measure performance
on important dimensions of care and service for many different health
conditions, making it possible to compare the performance of health
care providers in both the private and public sectors on an ``apples-
to-apples'' basis.
Public reporting on performance by NCQA and other entities has
improved the delivery of care for a variety of health conditions.
Holding health care providers accountable for their treatment of
patients with hypertension, for example, has helped increase blood
pressure control efforts substantially over the past 3 years. On
average, private health plans in 1999 helped just 39 percent of their
patients who had been diagnosed with hypertension keep their blood
pressure within limits specified by a performance measure; by 2002 that
average increased to 58 percent. The best performing health plans
assisted 68 percent of their hypertensive patients in controlling their
blood pressure. While there still is room for significant quality
improvement, if every health plan performed at least this well,
researchers estimate that 28,000 lives would be saved and 50,000 fewer
Americans would suffer from strokes.
a milestone in monitoring care
NCQA's announcement that it will begin to measure performance in
treatment for alcohol problems has heightened expectations for quality
improvement in addiction treatment. These measures, developed with the
Washington Circle, a group focused on performance measurement in
addiction treatment, mark a milestone: health plans will be asked for
the first time to account for their success at both initiating and
engaging treatment for alcohol problems once they have been identified.
Public reporting of performance measurement is key. NCQA, for
example, publishes an annual report on the State of health care in
America and provides tools for purchasers and consumers to evaluate
health care. Public reporting increases the pressure on health care
providers to perform at least as well as their competitors or risk
losing market share. This pressure can lead to quality improvement by
encouraging heath care providers to identify problem areas and take the
necessary administrative or clinical actions to fix them.
Performance measurement also increases purchasers' leverage in
negotiating health care contracts. In 1996 the largest business
coalition in the Nation, the Pacific Business Group on Health,
negotiated a contract with 13 of California's largest health plans that
put $8 million in premium income at risk if the plans didn't meet
specific performance measure targets. Poor performance in childhood
immunization resulted in a $2 million refund for the employers on whose
behalf the coalition had been negotiating. A financial penalty of this
kind provides the strongest possible incentive for a health plan to
improve performance and enables employers to get maximum value from
their health care investment. Within a year, all of the health plans
had brought the quality of care up to the business group's standard,
demonstrating the power of objectively measured performance tied to
financial incentives.
a national business initiative
Performance measurement for addiction treatment also has begun to
take root in other areas of the private sector, including the National
Business Coalition on Health (NBCH). Through its membership of 90 State
and regional coalitions, NBCH represents more than 7,000 employers--
including several of the Nation's largest--who provide insurance for an
estimated 34 million workers and their families. Since 1999, NBCH has
offered these and other interested groups a Web-based tool called
eValue8 that enables them to conduct a uniform, annual assessment of
the quality of care for a wide range of health conditions. Independent
analysis of the results permits comparison of health plan performance
on a local, regional and national basis.
In 2003 eValue8 featured, for the first time, an alcohol module
that includes several of the Washington Circle performance measures.
This development is significant for two important reasons:
1. Health plans are likely to respond to eValue8 because purchasers
use the tool to assess health plan quality directly. For example, when
the Pacific Business Group on Health (which uses eValue8 and is the
largest business health coalition in the country), requests that a plan
complete eValue8, the health plan has a strong incentive to comply
because of the coalition's enormous purchasing power.
2. About half of the participating employers offer financial
rewards to high performing plans or provide employees with financial
incentives to choose these plans for their health care needs. Employers
can use these rewards and incentives to drive quality improvement in
addiction treatment.
a critical first step
Performance measurement can improve the quality of addiction
treatment but it will lead to positive change only if everyone with a
stake in health care actively looks for ways to accomplish this. The
development of a core set of performance measures for addiction
treatment is a critical first step. Now that stakeholders at every
level of health care delivery have real tools at their disposal,
quality improvement in alcohol treatment is moving from theory into
practice. It is essential that the Federal Government through the
Substance Abuse and Mental Health Services Administration (SAMHSA) be
actively engaged with both the public and private sectors to support
publicly reported common measures of quality care.
Working with policymakers, employers and concerned citizens,
Ensuring Solutions provides research-based information and tools to
help curb the avoidable health care and other costs associated with
alcohol use and improve access to treatment for Americans who need it.
The project is supported by a grant from The Pew Charitable Trusts.
[Whereupon, 11:20 a.m., the subcommittee was adjourned.]