[Federal Register: December 24, 2002 (Volume 67, Number 247)]
[Notices]
[Page 78496-78504]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr24de02-120]
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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.
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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
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Domain Indicator area Specific indicator Basis of measurement
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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.
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*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
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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.
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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
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Area Domain Indicator Measure
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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?
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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