[Federal Register Volume 67, Number 247 (Tuesday, December 24, 2002)]
[Notices]
[Pages 78496-78504]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-32305]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Community Mental Health Services Performance Partnership

AGENCY: Substance Abuse and Mental Health Services Administration 
(SAMHSA), HHS.

ACTION: Notice: Request for comments.

-----------------------------------------------------------------------

SUMMARY: Section 1949 of the Public Health Service Act as amended by 
Public Law 106-310 requires the Secretary of Health and Human Services 
to submit a plan to Congress detailing how the Secretary intends to 
change the current Community Mental Health Services (CMHS) Block Grant 
into a performance partnership. The plan, by statute, must include the 
following:
    A description of the flexibility that would be given to the States 
under the plan;
    The common set of performance measures that would be used for 
accountability;
    The definitions for the data elements to be used under the plan;
    The obstacles to implementation of the plan and the manner in which 
such obstacles would be resolved;
    The resources needed to implement the performance partnerships 
under the plan; and
    An implementation strategy complete with recommendations for any 
necessary legislation.
    Section 1949 requires that the Secretary develop this plan in 
conjunction with the States and other interested parties. SAMHSA has 
been in discussion with the States for several years over this 
proposal. This FRN provides States and other interested parties an 
opportunity to comment on those discussions.

DATES: Comments on the information must be in writing and should be 
sent to: Joseph D. Faha, Director of Legislation/SAMHSA, 5600 Fishers 
Lane, Room 12-95, Rockville, Maryland 20857, by February 24, 2003.

FOR FURTHER INFORMATION CONTACT: Joseph D. Faha, Director of 
Legislation/SAMHSA, 5600 Fishers Lane, Room 12-95, Rockville, Maryland 
20857. Mr. Faha may be reached on (301) 443-4640.
    SAMHSA seeks comments on its proposal to develop a plan for the 
changing of the current SAPT Block Grant from its current emphasis on 
process requirements, financial earmarks, and accountability based on 
narrative documentation of compliance and expenditure reports to a 
system referred to as a performance partnership that offers States more 
flexibility in the expenditure of funds while basing accountability on 
performance and develops a partnership between the Federal Government 
and State governments in the provision of substance abuse prevention 
and treatment services.
    The current SAPT Block Grant program has its origins in the 
Alcohol, Drug Abuse and Mental Health Services Block Grant, first 
legislated in 1981. In its conception, the Federal Government gave 
funds to States based on a formula in statute for the purposes of 
providing substance abuse and community based mental health services 
with minimal programmatic and reporting requirements. Over time, the 
statute authorizing the program was changed to require the States to 
spend certain stipulated amounts on or to emphasize public health 
issues such as HIV, tuberculosis, pregnant addicts and others.
    Performance Partnership Grants (PPG) represent a new paradigm in 
Federal and State relations and cooperation. Under this grant program, 
the Federal Government would acknowledge the ability of States to both 
recognize their own needs and to address them as they relate to the 
provision of substance abuse prevention and treatment services by 
increasing flexibility for the States in their use of block grant 
funds. It would also shift State accountability away from Federal 
monitoring of State processes and related expenditures to identifying 
the strengths of a State's service system and areas where it could be 
improved to the benefit of those in need of such services. The goal is 
``continuous quality improvement.''
    The next section of this notice presents the proposal. The first 
part of this section discusses how the new program will work and the 
second part of this section will share the measures that have been 
agreed to so far in our discussions with the States. This is followed 
by a section that lends some explanation for the changes. Finally, 
there is a section suggesting both general and specific questions to 
which you may wish to respond. Public comments will be taken into 
consideration in developing the plan the Secretary will submit to 
Congress.

Proposal

Operationalization

    Eligibility and Distribution of Funds: SAMHSA proposes that those 
entities which are currently eligible to receive direct funding under 
the SAPT Block Grant would continue to be eligible and that the 
formula, recently revised, would be retained. Eligible entities include 
the 50 States, the District of Columbia, the Territories and the Red 
Lake Indian Tribe of Minnesota.
    Use of Funds: SAPT Block Grant funds would be available as they are 
now for substance abuse prevention and treatment activities and for 
carrying out programs required under section 1924 of the Public Health 
Service Act which deals with early intervention services for HIV and 
with tuberculosis services. Language would be added to clarify in 
statute that funds may be used to train counselors and to collect and 
report performance measurement data.
    In addition, under performance partnerships, SAMHSA proposes

[[Page 78497]]

retaining restrictions on the use of funds as follows:
    For construction and major rehabilitation (unless waived by the 
Secretary as set out in current law) or purchase of major medical 
equipment;
    For inpatient hospital substance abuse treatment, except if the 
treatment is a medical necessity for the individual involved as set out 
in current law;
    To make cash payments to patients;
    To support needle exchange programs;
    To be used as a State match against other Federal programs;
    To provide financial assistance to for-profit private entities;
    To provide treatment in penal and correctional facilities of the 
State beyond what the State spent in 1991; and
    For administrative expenses above 5 percent of the State's 
allocation.
    Plans: States would be required to submit a plan every 3 years for 
the use of the funds including performance objectives for the 3 years 
unless the State or the Secretary believes circumstances dictated the 
need to revise the plan in the interim.
    The plans would include three sections, the first of which would 
describe the system of services in the State including a demographic 
and client characteristic profile, client screening and placement 
procedures, the treatment options that are available, the use of 
Federal and non-Federal funds to provide substance abuse services, how 
the principal agency coordinates with other service delivery systems, 
and how the block grant funds are used.
    A second section would be an analysis of any State or Federal data 
that might be available including performance data to identify the 
strengths of the system and areas where improvement may be needed.
    A third section would propose, for the Secretary's approval, the 
areas the State wants to focus on for the 3 years of the plan to 
further improve the system. The areas that the State may want to focus 
on could be, but must not necessarily be, selected from among the core 
measures being used. For example, the data may show that a large 
percentage of those completing treatment are unemployed at the time of 
discharge and steady employment is a precursor of success in treatment. 
If a State chooses to focus on a particular area not among those 
covered by the core measures, for example, stigma against individuals 
with a substance abuse problem, then the State would be asked to 
identify a performance measure that could be used. If it appears that 
several States are focusing on an area, SAMHSA, the States and other 
interested parties will work together to develop a common measure. To 
clarify, all States will be required to submit data on the core 
measures. This paragraph is only a discussion of what areas a State 
would like to focus on for the sake of the plan. For a more complete 
discussion of the measures, please read that section later in this 
notice.
    Annual Reports to SAMHSA: These reports would serve to keep SAMHSA 
and the States informed of the States' progress in meeting their goals 
and to report on remaining expenditure requirements including State 
maintenance of effort. States also would be required to report on their 
intended use of PPG funds for the next fiscal year. States are 
currently required to submit an annual report to the Secretary as part 
of their application which details how they met the requirements in 
statute.
    Congressional Reports: Each year SAMHSA would submit a report to 
Congress summarizing the programs in each State and the State's 
progress in meeting its objectives. These reports will not compare and 
contrast States. Currently there is no requirement for a report to 
Congress.
    Public Comment: SAMHSA proposes to retain the current requirements 
on seeking public comments which require the State to make the State 
application public in such a manner as to facilitate comment from any 
person during the development of the application. SAMHSA will be 
working with the States to further improve public access and 
participation.
    Incentives: SAMHSA seeks ideas on building incentives into the 
system to encourage States to further improve the service system. 
Currently the system is built on enforcement principles of withholding 
funds and financial penalties for non-compliance with requirements of 
the program.

Particular Requirements in Current Law

    Prevention Set Aside: SAMHSA proposes to retain the requirement 
that a minimum of 20 percent of PPG funds be expended for prevention 
activities. SAMHSA also proposes to change the current definition of 
prevention to one developed by the Institute of Medicine that refers to 
universal, selected and indicated interventions. Universal 
interventions are designed to reach an entire population or large 
audience, for example, a radio message on preventing substance abuse. 
Selective interventions target subgroups who may be at risk to use 
substances, for example, children of alcoholics. Indicated 
interventions identify individuals who are experiencing early signs of 
substance use and other problems.
    Expenditure Requirement for Pregnant Women and Women with Dependent 
Children: SAMHSA proposes to retain the current set aside requirement 
that single State agencies maintain their level of financial support 
for pregnant addicts and women with children at the level the single 
State agency expended in 1994. SAMHSA also proposes to permit the 
Secretary to waive the requirement based on performance criteria to be 
developed.
    Mandatory Services for Intravenous Drug Users: SAMHSA proposes to 
eliminate the requirement in favor of a performance measure related to 
the reduction of HIV transmissions.
    Early Intervention for HIV: SAMHSA proposes to retain the 
requirement that States whose incidence of AIDS is at or greater than 
10 per 100,000 of the general population use between 2 and 5 percent of 
their allocations for HIV early intervention services. SAMHSA also 
proposes to permit a waiver against this requirement with the criterion 
being based on the State's reduction of HIV transmissions among the 
substance abusing population.
    SAMHSA also proposes to permit, but not require, States whose 
incidence of AIDS is below 10 per 100,000 of the general population to 
spend between 2 and 5 percent of their allotment on early intervention 
services if their incidence rate had been at or above the threshold 
level in either of the previous 2 years. This permits a more consistent 
State policy.
    Tuberculosis Services: SAMHSA proposes to retain the requirement 
that States are to ensure that entities which receive block grant funds 
make available tuberculosis services to each individual receiving 
treatment and, if an individual is denied treatment based on lack of 
capacity, will refer the individual to another provider of tuberculosis 
services. SAMHSA also proposes to give the Secretary the authority to 
waive this requirement using performance criteria.
    Group Homes: Currently States have the option as to whether to 
maintain a $100,000 revolving fund to support recovery homes. SAMHSA 
proposes to maintain this as an optional requirement.
    Preference for Pregnant Addicts: SAMHSA proposes to retain the 
requirement that pregnant addicts be given preferential placement in 
funded facilities.
    Improving Referrals/Continuing Education/Coordination of Services: 
SAMHSA proposes to eliminate the requirements that States take 
deliberate steps to improve their referral systems

[[Page 78498]]

and that States ensure that substance abuse services are coordinated 
with other social service programs. States will be submitting 
information in the first section of the State plan on how they assess 
and refer individuals in need of treatment and how they coordinate with 
other service delivery systems. Because of the need to improve the 
skills of substance abuse counselors, SAMHSA proposes to retain the 
requirement on continuing education and as has been previously stated 
to affirm that block grant funds may be used for training.
    Maintenance of Effort: SAMHSA proposes to retain the current 
requirement that States be required to spend State funds for the single 
State agency of the State responsible for substance abuse services at a 
level at least equal to the average that the State spent in the past 2 
years. The penalty is a loss of a dollar of allocation under the 
program for each dollar the State is short in meeting its requirement. 
SAMHSA proposes to retain current statutory provisions which authorizes 
the Secretary to waive the requirement for a State experiencing 
``extraordinary economic conditions.'' SAMHSA also proposes to retain 
the recently passed exclusion from calculation for one time 
expenditures for a single purpose.
    Audits: SAMHSA proposes to retain the current audit requirement.
    Independent Peer Review: SAMHSA proposes to eliminate the 
requirement that States ensure that 5 percent of facilities funded 
under the program are independently peer reviewed to assess the 
quality, appropriateness and efficacy of treatment services.

Performance Measures

    SAMHSA and the States have been working for some time on a set of 
measures that would give both the Federal Government and the State 
government a view of how well the service system is doing in achieving 
its goal of providing access to quality services. SAMHSA expects to 
have a more complete list of such measures in June of 2003 after 
further discussion with the States and consideration of public 
comments.

Treatment Measures

    The following table summarizes the preliminary measures that SAMHSA 
proposes to use in the performance partnership. The measures are 
divided into two categories: core and developmental. Core measures are 
those the States are committed to submitting. There is still work that 
needs to be done to further define and standardize the measures which 
will be completed prior to the submission of the plan to Congress. 
Measures for vulnerable populations or public health issues including 
pregnant women and women with children, HIV transmission, tuberculosis 
and co-occurring populations will be added to the core measures. These 
measures will be completed in time for the submission of the plan to 
Congress. The measure on individuals with a co-occurring substance 
abuse and mental health disorder will be developed jointly with State 
mental health commissioners and directors of substance abuse services 
and in the context of the previously mentioned Co-occurring Report.
    Developmental measures are those which require additional work to 
ensure both the Federal Government and the State governments that these 
measures are necessary, provide the information that both levels of 
government need and are practicable. SAMHSA is committed to concluding 
work on these measures by October of 2003. If, after discussions with 
the States and public comment, any and or all of these measures prove 
to be helpful in understanding the service system, they will be added 
to the list of core measures.
    SAMHSA is applying the principle of ``continuous quality 
improvement'' to the measures as well. SAMHSA will continuously 
evaluate whether certain areas of inquiry are helpful in determining 
the efficiency and effectiveness of the system of services, whether 
specific questions are providing the information needed and whether 
there might be other areas of inquiry that should be taken.
    In the table below, there are two domains: effectiveness and 
efficiency. Effectiveness is measured by examining changes that have 
occurred in the individual with regard to their physical and mental 
health, their employment status and social functioning, living status, 
penetration rates, social support systems and general health. 
Efficiency will be measured by the percentage of clients who complete 
treatment and the average length of stay in treatment.
    SAMHSA is managing the Office of National Drug Control Policy's 
National Treatment Outcome Management System (NTOMS) intended to assess 
on a national level treatment effectiveness of various modalities of 
treatment in terms of such outcomes as drug use, criminal behavior, 
health, employment and other factors through the interviewing of 
individuals entering and leaving some 200 treatment facilities 
nationwide. The performance measures being used in this performance 
partnership focus on the effectiveness of the State system using as 
areas of inquiry many of these same factors.

                                                  Core Measures
----------------------------------------------------------------------------------------------------------------
              Domain                  Indicator area      Specific indicator         Basis of measurement
----------------------------------------------------------------------------------------------------------------
Effectiveness....................  Health Status--       AOD Use............  One measure for alcohol and one
                                    Physical.                                  measure for other drugs
                                                                               (marijuana, cocaine, opiates,
                                                                               methamphetamines). For ``other
                                                                               drugs,'' take the highest
                                                                               frequency reported among all
                                                                               drugs used. Report frequency of
                                                                               use in past 30 days at admission
                                                                               to AOD treatment setting and
                                                                               discharge:
                                                                              no past month use (0 days),
                                                                              1--3 times/month (2 days),
                                                                              1--2 times/week (6 days),
                                                                              3--6 times/week (18 days),
                                                                              Daily (30 days).
                                   Economic Self-        Employment Status..  Employment status at admission to
                                    Sufficiency.                               AOD treatment setting and at 6
                                                                               months post-admission.
                                                                              --Employment (full and part-time
                                                                               or in school if under 18),
                                                                              --Unemployed,
                                                                              --Not in Labor Force (homemaker,
                                                                               student, disabled, retired, or
                                                                               looking in last days,
                                                                               institutionalized).
                                                                              This measure is the percent
                                                                               employed at admission and at 6
                                                                               months post-admission.

[[Page 78499]]

 
                                   Social Functioning..  Criminal Justice     Number of arrests during the past
                                                          Involvement.         6 months at time of admission to
                                                                               AOD treatment setting and at 6
                                                                               months post-admission.
----------------------------------------------------------------------------------------------------------------
*Core measures will be developed on pregnant addicts and women with children, HIV transmission, tuberculosis and
  co-occurring populations to be added to the plan to be submitted to Congress.


                                             Developmental Measures
----------------------------------------------------------------------------------------------------------------
              Domain                  Indicator area     Specific indicator          Basis of measurement
----------------------------------------------------------------------------------------------------------------
Effectiveness....................  Health Status......  ....................  ..................................
                                   Social Functioning.  Living Status.        ..................................
                                                        Social Support.       ..................................
Efficiency.......................  Access.............  Penetration Rates.    ..................................
                                   Treatment Retention  Length of Stay.       ..................................
                                                        Treatment             ..................................
                                                         Completion.
----------------------------------------------------------------------------------------------------------------

    It is expected that some States will be able to report on the 
performance data in time for the FY 2005 application. Other States will 
be asked for a plan of implementation on the collection and reporting 
on the data.

Prevention Measures

    The States will submit data with regard to those programs supported 
in whole or in part with funding under the prevention set aside of the 
new PPG. The performance measures will cover three areas: capacity, 
process and outcomes. The outcome measures are sorted by whether an 
activity is focused on the individual, peers, schools, families or 
communities. States will collect outcome data from each of the 
activities supported in whole or in part with PPG prevention set aside 
funds and aggregate that data for submission to SAMHSA. Each activity, 
however, will only submit outcome data to the State that is appropriate 
to the focus of the activity. For example, if the funded activity 
focuses on schools, the activity must supply the State with information 
designated in the table below.
    SAMHSA is particularly interested in your thoughts and comments on 
the Capacity measures.
    The measures that are being used conform with the measures 
currently being used under the State Incentive Grant prevention program 
though they have been pared down to focus on those that are most 
important and to reduce the costs associated with implementation. They 
include attitudes toward health risks and attitudes regarding social 
acceptance.

                                               Prevention Measures
----------------------------------------------------------------------------------------------------------------
                 Area                           Domain                 Indicator                 Measure
----------------------------------------------------------------------------------------------------------------
Capacity.............................  .......................  Coalition Building.....  (Coalitions are
                                                                                          community based
                                                                                          organizations that
                                                                                          have as their mission
                                                                                          the reduction of
                                                                                          substance abuse in a
                                                                                          comprehensive and long
                                                                                          term manner, with a
                                                                                          primary focus on youth
                                                                                          in the community.
                                                                                          These coalitions are
                                                                                          made up of community
                                                                                          leaders in all aspects
                                                                                          of community life.)
                                                                Workforce Development..
                                                                Technological Capacity.
                                                                Ability to Assess Need.
                                                                Ability to Conduct
                                                                 Exemplary Programs.
                                                                Ability to Evaluate and
                                                                 Report.
Process..............................                           Name and type of
                                                                 program, number of
                                                                 prevention services
                                                                 rendered, service type
                                                                 by strategy and type
                                                                 of service.
                                                                Demographic Information
                                                                 (Age groups, gender,
                                                                 race ethnicity, number
                                                                 of participants
                                                                 completing program.
Outcome..............................  Individual.............  Attitude toward drug     How wrong do you think
                                                                 use.                     it is for someone your
                                                                                          age to drink beer,
                                                                                          wine or hard liquor
                                                                                          regularly?
                                                                                         How wrong do you think
                                                                                          it is for someone your
                                                                                          age to smoke
                                                                                          cigarettes?

[[Page 78500]]

 
                                                                                         How wrong do you think
                                                                                          it is for someone your
                                                                                          age to smoke
                                                                                          marijuana?
                                                                Perceived risk/harm....  How wrong do you think
                                                                                          it is for someone your
                                                                                          age to use LSD,
                                                                                          cocaine, or
                                                                                          methamphetamine?
                                                                                         How much do you think
                                                                                          people risk harming
                                                                                          themselves (physically
                                                                                          or in other ways) if
                                                                                          they smoke one or more
                                                                                          packs of cigarettes
                                                                                          per day?
                                                                                         How much do you think
                                                                                          people risk harming
                                                                                          themselves (physically
                                                                                          or in other ways) if
                                                                                          they try marijuana
                                                                                          once or twice?
                                                                                         How much do you think
                                                                                          people risk harming
                                                                                          themselves (physically
                                                                                          or in other ways) if
                                                                                          they try marijuana
                                                                                          regularly?
                                                                                         How much do you think
                                                                                          people risk harming
                                                                                          themselves (physically
                                                                                          or in other ways ) if
                                                                                          they take one or two
                                                                                          drinks of an alcoholic
                                                                                          beverage (beer, wine,
                                                                                          liquor) nearly every
                                                                                          day?
                                                                Resistance skills        To be determined.
                                                                 (social/life skills).
                                       Peer...................  Perceptions of peer      To be determined.
                                                                 alcohol, tobacco or
                                                                 other drug use.
                                       School.................  School bonding.........  How often do you feel
                                                                                          that the school work
                                                                                          you are assigned is
                                                                                          meaningful and
                                                                                          important?
                                                                                         How interesting are
                                                                                          most of your courses
                                                                                          to you?
                                                                                         How important do you
                                                                                          think the things you
                                                                                          are learning in school
                                                                                          are going to be for
                                                                                          your later life?
                                                                                         Now thinking back over
                                                                                          the past year in
                                                                                          school--
                                                                                         How often did you enjoy
                                                                                          being in school?
                                                                                         How often did you hate
                                                                                          being in school?
                                                                                         How often did you try
                                                                                          to do your best in
                                                                                          school?
                                       Family.................  Perceived parental       How wrong do your
                                                                 attitudes.               parents feel it would
                                                                                          be for you to drink
                                                                                          beer, wine or hard
                                                                                          liquor regularly?
                                                                                         How wrong do your
                                                                                          parents feel it would
                                                                                          be for you to smoke
                                                                                          cigarettes?
                                                                                         How wrong do your
                                                                                          parents feel it would
                                                                                          be for you to smoke
                                                                                          marijuana?
                                                                Parenting skills/        My parents ask if I've
                                                                 practices/bonding.       gotten my homework
                                                                                          done.
                                                                                         My parents want me to
                                                                                          call if I'm going to
                                                                                          be late getting home.
                                                                                         Would your parents know
                                                                                          if you did not come
                                                                                          home on time?
                                                                                         When I am not at home,
                                                                                          one of my parents
                                                                                          knows where I am and
                                                                                          who I am with?
                                                                                         The rules in my family
                                                                                          are clear?
                                                                                         My family has clear
                                                                                          rules about alcohol
                                                                                          and drug abuse.

[[Page 78501]]

 
                                       Community..............  Perceived availability.  If you wanted to get
                                                                                          some beer, wine or
                                                                                          liquor, how easy would
                                                                                          it be for you to get
                                                                                          some?
                                                                                         If you wanted to get
                                                                                          some cigarettes, how
                                                                                          easy would it be for
                                                                                          you to get some?
                                                                                         If you wanted to get
                                                                                          some marijuana, how
                                                                                          easy would it be for
                                                                                          you to get some?
                                                                                         If you wanted to get a
                                                                                          drug like LSD, how
                                                                                          easy would it be for
                                                                                          you to get some?
                                                                Community norms........  How wrong would most
                                                                                          adults in your
                                                                                          neighborhood think it
                                                                                          was for kids your age:
                                                                                          --to use marijuana?
                                                                                          --to drink alcohol?
                                                                                          --to smoke cigarettes?
                                                                                         If a kid drank some
                                                                                          beer, wine, or hard
                                                                                          liquor in your
                                                                                          neighborhood, would he
                                                                                          or she be caught by
                                                                                          the police?
                                                                                         If a kid smoked
                                                                                          marijuana in your
                                                                                          neighborhood, would he
                                                                                          or she be caught by
                                                                                          the police?
----------------------------------------------------------------------------------------------------------------

    All States will begin submitting some of the prevention information 
for the FY 2005 application, and all States will be able to submit all 
the data by FY 2006 applications.

Explanation

    The performance partnerships for the Substance Abuse Prevention and 
Treatment program are built on three principles:
    1. That the Federal Government and the State governments are 
partners in the provision of substance abuse prevention and treatment 
services and that our shared goal is ``continuous quality improvement'' 
of the service system.
    2. That States understand the needs of their population and should 
have more flexibility in the use of Federal grant funds.
    3. That accountability should be based on performance and not 
entirely on expenditures.
    The first principle is reached in this proposal when both the 
Federal and State governments identify the strengths and weaknesses of 
various systems of service and work in tandem to improve those systems. 
The new partnerships will be built on incentives to improve services 
rather than penalties for noncompliance.
    The second principle is achieved in this proposal by reducing the 
number of requirements, simplifying the planning process, giving 
greater freedom in the use of the funds to States, and reducing 
administrative costs and burden.
    The shift to performance measures provides a focus on the 
efficiency and effectiveness of services and, therefore, helps both the 
State and the Federal Government to identify how to improve the system 
of services. For example, the measures will enable us to determine 
whether pregnant addicts are being effectively served. Currently, all 
we know is that States are giving pregnant addicts preference in 
treatment and spending the required amount on pregnant addicts and 
women with children.
    Eligibility for the block grant and the formula for the 
distribution of the funds will not be affected by the changes.
    The use of funds is not being changed except to make it clear that 
PPG funds may be used for training and to develop the data 
infrastructure necessary to collect and report on performance measures.
    The plans bring a new dimension to this block grant. Currently, 
State plans have more to do with the expenditure of funds. The proposed 
plan calls for the State to describe the current system, present data 
on how well the system is giving access to quality care for individuals 
in need of substance abuse services, requires the State to focus on 
issues related to prevention and treatment that need to be addressed to 
improve the system of services, and finally to set performance 
objectives. SAMHSA is recommending a 3-year cycle on plans for several 
reasons: first, 3-year plans give States a chance to do more long range 
planning and they reduce the administrative burden of both the State 
and the Federal Government permitting resources to be better used to 
improve access to quality care. Recognizing that there will 
occasionally be the need to revise plans, the Secretary is authorized 
to consider changing the plans either at his/her request or the request 
of the State.
    States will continue to be responsible for providing the Secretary 
with annual reports detailing their progress in meeting their 
performance objectives and for providing necessary expenditure data to 
demonstrate compliance with such provisions as maintenance of effort, 
the set-aside for women with children, and others.
    The Annual Report to Congress is not part of current law. SAMHSA 
and its predecessor agency, the Alcohol, Drug Abuse and Mental Health 
Administration were on occasion required to submit a report to Congress 
on block grant activities. The last such report was provided in 1994. 
The proposed annual report will serve to demonstrate to Congress that 
the funds are being used efficiently and effectively and that the State 
systems are improving. The report will not compare and contrast State 
systems. SAMHSA believes this would be counterproductive to our goal of 
continuing quality improvement as States would present themselves in 
the best of light.
    States are currently required to ensure that individuals have an 
opportunity to review and comment on the State plan.

[[Page 78502]]

SAMHSA proposes to continue this requirement but at the same time to 
elicit ways of improving public participation.
    SAMHSA is not interested in penalizing States for not meeting 
performance objectives choosing instead to work with them to further 
improve the service system. However, there would remain a few statutory 
requirements which the States would have to comply with by law. In the 
case of the Synar provision and maintenance of effort, the penalties 
are clearly defined and the procedures for penalizing a State 
stipulated in statute. There are other requirements that would be 
retained as well including early intervention for HIV, tuberculosis, 
set aside for substance abusing pregnant women and women with children, 
and others for which States may be penalized if they failed to meet.

Specific Requirements

    With regard to specific requirements in the statute, SAMHSA 
proposes to maintain the requirement that States spend a minimum of 20 
percent of their allocation on prevention but permit the funds to be 
used for prevention as defined by the Institute of Medicine which used 
the universal, selected and indicated criteria. Using these criteria 
would permit for a better continuum of services.
    Universal interventions are designed to reach an entire population 
or large audience, for example, a radio message on preventing substance 
abuse. Selective interventions target subgroups who may be at risk to 
use substances, for example, children of alcoholics. Indicated 
interventions identify individuals who are experiencing early signs of 
substance use. Some have registered concern that this definition does 
not include environmental efforts; however, SAMHSA believes that 
environmental efforts are incorporated under Universal.
    SAMHSA proposes that both the set-aside for women with children and 
the requirement that pregnant addicts be given preferential 
consideration for placement in a treatment facility that is receiving 
block grant funds be retained. While both populations have improved 
access to services since these provisions were first put in statute, 
they remain a very vulnerable population that can benefit from such 
requirements.
    The current statute requires that States carry out outreach 
activities to locate intravenous drug users and to provide treatment 
within a given period of time or the State incurs an obligation to 
provide them with interim services. The emphasis on the intravenous 
drug population arose in 1992 largely because of the concern for the 
transmission of HIV. SAMHSA proposes, however, to address the issue 
differently by having a core measure related to the transmission of HIV 
instead of the expenditures.
    HIV among the substance abusing population remains a public health 
concern. To ensure that States maintain their effort to address this 
public health concern, SAMHSA proposes to retain the requirement that 
States having an incidence of AIDS at or above 10 per 100,000 of 
general population be required to spend between 2 and 5 percent of 
their allotment on HIV early intervention services.
    SAMHSA realizes that most of the HIV services would be provided by 
an agency of the State government other than the single State agency 
and thus holding the State to a performance measure on HIV transmission 
would be difficult. Nonetheless, because of the importance of the issue 
and the requirement of the statute at section 1949(a)(2) of the Public 
Health Service Act a performance measure will be added as a core 
measure for all States to report on.
    SAMHSA also proposes that the Secretary be granted the authority to 
waive this requirement for States whose performance is good in reducing 
the transmission rates.
    SAMHSA also proposes to permit, but not require States whose 
incidence of AIDS is below 10 per 100,000 of general population to 
spend between 2 and 5 percent of their allotment on early intervention 
services if their incidence rate had been at or above the threshold 
level in either of the previous two years. This will permit States 
whose incidence rates are at or near 10 per 100,000 to provide more 
consistent services.
    The same concern for the transmission of tuberculosis among the 
substance abusing population leads SAMHSA to retain the requirements 
with regard to tuberculosis. SAMHSA recognizes that in the case of 
tuberculosis, as in the case of HIV, another agency of the State 
government is responsible for providing these services. Despite this, 
because the public health issue is so important and because the statute 
at section 1949(a)(2) requires that a performance measure be developed 
on tuberculosis, a core measure will be added that focuses attention on 
tuberculosis. SAMHSA does propose, however, that the Secretary be 
authorized to waive the requirement for a State that demonstrates that 
tuberculosis rates among the substance abusing population are 
decreasing.
    Current statute permits but does not require States to maintain a 
revolving fund to support recovery homes. SAMHSA proposes to retain the 
current statute so that States can maintain such funds if needed.
    SAMHSA proposes to eliminate the requirement to improve referral 
systems. States will in their plans discuss the process for determining 
placement for treatment. Whether this system is working will surface as 
SAMHSA and the States review the effectiveness of treatment. SAMHSA 
also proposes to eliminate the requirement to coordinate services. The 
need to coordinate services is a well established principle of 
prevention and treatment. States will be required to discuss how the 
substance abuse service system coordinates with other service systems 
in section 1 of the plan.
    SAMHSA proposes to retain the requirement for continuing education 
of counselors. With the ever increasing amount of information that is 
being accumulated on how best to provide prevention and treatment 
services, there needs to be a mechanism to ensure that counselors are 
kept informed. Continuing education is one mechanism.
    Maintenance of Effort presents an economic burden on States 
especially in these times where the State budgets are running in the 
red and they are looking for ways to reduce spending. SAMHSA, however, 
proposes to retain the requirement. The Federal Government's 
contribution to the provision of substance abuse prevention and 
treatment services through the block grant accounts for over 50 percent 
of State expenditures. In 1995 the block grant accounted for 38 
percent. Since the requirement does not require the States to increase 
their expenditures to match Federal allocations but only to maintain 
their level of support, SAMHSA does not believe it is over burdening 
the States. To address issues of the economies of the States, SAMHSA 
placed criteria in the regulation issued in 1993 on when the Secretary 
would exercise his authority to waive such requirements.
    SAMHSA proposes to eliminate the requirement that States 
independently peer review 5 percent of facilities under the program 
each year to assess the quality, appropriateness and efficacy of 
treatment services. While this specific provision was added with the 
Anti-Drug Abuse Act of 1988, there had always been a provision in 
statute requiring States to evaluate the performance of facilities 
receiving funds under the Block Grant program. The Department has 
monitored the usefulness of the

[[Page 78503]]

requirement and believes that it has not achieved the purpose for which 
it was included in statute largely because the States, while they 
fulfilled their obligation under the provision, did not use it to 
improve performance. In addition, the Department believes that this 
provision not only requires that it be done but that it stipulates the 
way it should be done when there is nothing to suggest that an 
independent peer review is the best way to accomplish the goal of the 
provision.
    The Department is extremely interested in improving the quality of 
services. This is one of the purposes of the whole Performance 
Partnership program--continuous quality improvement. It is our belief, 
however, that the State analysis that has to be done as part of the 
second section of the plan will identify where the State, as a whole, 
needs to improve if the system is to improve. The only way that States 
have of improving their system is to work with the individual 
providers. As an example, the analysis may very well identify that 
programs are not using evidenced based practices. If this is true, the 
Department can work with the States to share the findings from National 
Institute on Alcohol Abuse and Alcoholism and National Institute on 
Drug Abuse services research programs, the findings from National 
Treatment Outcome Management Survey, knowledge gained from other States 
or communities, findings from the Department's own programs, 
information from the technical assistance centers that the Department 
supports and from other sources. It would naturally be in the best 
interest of the State to ensure that the providers are actually then 
using those practices. The end result is that the State undertakes 
activities in support of its own interests and not because of a 
requirement in statute.

Performance Measures

    The performance measures used in this program have been developed 
after considerable consultation with experts in the field and State 
directors. Their acceptance, however, is largely based on what we know 
today. In one to two years after some experience SAMHSA and the States 
may find that the measures need to be revised or replaced. Therefore, 
the performance partnership program must have built into it the ability 
to change the core measures.
    SAMHSA has also considered the practicality of the measures that it 
has been and will be developing. The collection and reporting of data 
on individuals, most of whom are not living in facilities, is a very 
expensive undertaking and administratively burdensome. So while SAMHSA 
is interested in getting a picture of the service system, SAMHSA wants 
to accomplish this without incurring a significant financial and 
administrative burden. SAMHSA believes that it has accomplished that 
goal. In giving comments, SAMHSA asks that you keep this criterion in 
mind.
    Critical to the collection and reporting on performance measures is 
the ability to upgrade the data infrastructure of the State. This 
involves ensuring that each prevention and treatment program begins to 
collect the data that is needed and has the infrastructure to record 
it. It also assumes that States have the ability to receive and analyze 
that data. This remains an issue of critical importance. Without 
improved data infrastructures in States, many will not be able to 
collect and report on performance measures.
    States will begin to submit performance data according to their 
ability to do so. Their ability to do so, in many cases, will be 
dependent on the resources available to develop the data infrastructure 
needed to collect and report on such data.
    With time SAMHSA expects the States to report common data elements 
for each of the measures. In the meantime, SAMHSA expects the States to 
use generally accepted methodological principles.

Questions for You To Consider in Making Your Comments

In General

    1. Please comment in general about the benefits and challenges of 
converting to performance partnership grants. What areas of greater 
flexibility are needed in the administration of the SAPT PPG and what 
measures of accountability are needed in the performance of the program 
and for the overall community based service system?
    2. SAMHSA through the creation of a performance based system is 
developing a partnership with the States in the provision of substance 
abuse services. Do you support this partnership? Are there other ways 
that the Federal Government and State governments could partner in the 
provision of substance abuse services?

Operationalization

    1. Under this proposal, SAPT Block Grant funds would be available 
as they are now for substance abuse prevention and treatment activities 
and for carrying out programs required under section 1924 of the Public 
Health Service Act which deals with early intervention services for HIV 
and with tuberculosis, for training of counselors and for data 
infrastructure development. Do you agree with this approach? If not, 
why not?
    2. SAMHSA is proposing to continue current statutory restrictions 
on the use of the funds as outlined previously in the notice. Do you 
agree with these proposals?
    3. SAMHSA proposes to retain the set aside for women and children 
and the requirement that pregnant addicts be given preferential 
consideration in being given the opportunity for treatment. In addition 
it is our proposal that specific performance measures be established 
for both populations as a way of ensuring that women with children and 
pregnant addicts will receive the services they may require. If you 
have any comments on this or proposals for measures that could be used, 
please forward your comments.
    4. States would be required under this proposal to develop a 3-year 
plan on how they intend to use the funds and how they intend to improve 
access to quality care. Do you agree that 3-year plans are appropriate?
    5. Under the proposal, States would be required to submit yearly 
reports showing their progress in meeting their goals under the 
program. SAMHSA would then use this information to create a report for 
Congress to demonstrate how each State is using the funds efficiently 
and effectively to provide access to quality care. The report to 
Congress would not be a comparison of States but a presentation on the 
programs in each State and what steps the States are taking to further 
improve their system of services. Do you agree with this approach and 
can you recommend alternative, effective approaches to public 
disclosure of developments in State drug treatment and prevention?
    6. SAMHSA proposes to eliminate several current requirements for 
intravenous drug users. Do you believe that these vulnerable 
populations will receive the services they need under this new 
approach?
    7. While SAMHSA proposes to retain the set aside for prevention, we 
are proposing that the set aside be used for prevention as defined by 
the Institute of Medicine as universal, selected and indicated as 
explained earlier in the notice. Do you agree with this expansion of 
the use of the set aside?
    8. SAMHSA proposes to continue the current maintenance of effort 
requirement including the exclusion from the calculation for one time

[[Page 78504]]

expenditures of a single purpose. Do you agree with this proposal?
    9. Do you agree with the concept of ``continuous quality 
improvement'' and do you have any ideas on how to build in incentives 
for States to improve their system of services?
    10. Do you agree with eliminating certain requirements in favor of 
performance measures which would clarify whether the goals of the 
requirements are actually being met?

Performance Measures

    1. Core and developmental measures are listed for treatment and a 
set of core measures for prevention. Please comment about the benefits 
and challenges on using this information to describe performance by 
individual States and to describe the overall accountability, capacity, 
and effectiveness of the service system.
    2. If you could, how would you improve them keeping in mind the 
need to minimize the costs of data collection? Provide specific 
information of the shortcomings of the measures and how you would 
improve them. In responding to this question consider whether there are 
measures listed above that should be improved, why they need 
improvement and how you would improve them. If you believe additional 
measures are necessary, please explain what is missing and what you 
would add to the list of core measures.
    3. With the States, SAMHSA will be developing measures for 
vulnerable populations and for specific public health issues such as 
pregnant addicts, women with children, transmission of sexually 
transmitted diseases, and the co-occurring population. Do you have any 
recommendations for these measures?
    4. Do you agree that States can and should begin submitting 
performance data as part of their FY 2005 application?
    5. SAMHSA has developed a matrix of program priorities and cross 
cutting principles that now guides the agency's daily operations and 
overall program and management decisions. Programs and issues 
prioritized in this matrix include: Co-occurring disorders; substance 
abuse treatment capacity; seclusion and restraint; prevention and early 
intervention; children and families; New Freedom Initiative (including 
the President's Mental Health Commission); terrorism/bio-terrorism; 
homelessness; aging; HIV/AIDS and Hepatitis C; and criminal justice. As 
we move forward in measuring the extent to which the agency has been 
successful in these 11 areas, we are asking the public to comment on 
how to begin work on ways to measure progress by the States in these 
and other program areas.

Economic Impact

    We have examined the impact of this notice as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), as 
amended by Executive Order 13258 (February 2002, Amending Executive 
Order 12866 on Regulatory Planning and Review) and the Regulatory 
Flexibility Act (RFA) (September 19, 1980; Public Law 96-354), the 
Unfunded Mandated Reform Act of 1995 (Pub. L. 104-4), and Executive 
Order 13132 (August 1999, Federalism). Executive Order 12866 (the 
Order), as amended by Executive Order 13258, which direct agencies to 
assess all costs and benefits of available regulatory alternatives and, 
if regulation is necessary, to select regulatory approaches that 
maximize the benefits (including potential economic, environmental, 
public health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in 1 year). We 
have determined that the proposed rule is consistent with the 
principles set forth in the Order, and we find that the proposed rule 
would not have an effect on the economy that exceeds $100 million in 
any one year. In addition, this rule is not a major rule as defined at 
5 U.S.C. 804(2).
    In accordance with the provisions of the Order, the rule was 
reviewed by the Office of Management and Budget.
    It is hereby certified under the RFA that this proposed regulation, 
will not have a significant economic impact on a substantial number of 
small entities. This proposed rule applies only to States.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditure in any 1 year by State, 
local, or tribunal governments, in the aggregate, or by the private 
sector, of $100 million. As noted above, we find that the proposed rule 
would not have an effect of this magnitude on the economy.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have reviewed the proposed rule under the threshold 
criteria of Executive Order 13132, Federalism, and have determined that 
this proposal does not impose substantial direct requirement costs on 
State and local governments, preempt State law, or otherwise has 
Federalism implications. On the contrary, the proposal provides for 
more flexibility for the States in the use of Federal funds, and 
establishes a working relationship between the Federal and State 
governments that will help the States improve access to quality care 
for those individuals in need of substance abuse or mental health 
services.

Paperwork Reduction

    This proposal would assume information collection requirements that 
would be subject to review by the Office of Management and Budget under 
the Paperwork Reduction Act of 1980. This Federal Register Notice, 
however, is only seeking comment on proposed information collection and 
is not establishing a collection requirement. Therefore, doing a 
Paperwork Reduction Act analysis would be premature. The Department 
will comply with the requirements of the Paperwork Reduction Act when 
determinations have been made on the information to be collected and in 
advance of requiring the submission of that information.

    Dated: November 18, 2002.
Charles G. Curie,
Administrator, Substance Abuse and Mental Health Services 
Administration.
    Dated: December 18, 2002.
Tommy G. Thompson,
Secretary.
[FR Doc. 02-32305 Filed 12-23-02; 8:45 am]
BILLING CODE 4162-20-P