[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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.]

                                    

      
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