oversight

Substance Abuse and Mental Health: Reauthorization Issues Facing the Substance Abuse and Mental Health Services Administration

Published by the Government Accountability Office on 1997-05-22.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                          United States General Accounting Office

GAO                       Testimony
                          Before the Subcommittee on Public Health and Safety,
                          Committee on Labor and Human Resources, U.S. Senate




For Release on Delivery
Expected at 9:30 a.m.
Thursday, May 22, 1997
                          SUBSTANCE ABUSE AND
                          MENTAL HEALTH

                          Reauthorization Issues
                          Facing the Substance Abuse
                          and Mental Health Services
                          Administration
                          Statement of Marsha Lillie-Blanton, Associate Director
                          Health Services Quality and Public Health Issues
                          Health, Education, and Human Services Division




GAO/T-HEHS-97-135
Substance Abuse and Mental Health:
Reauthorization Issues Facing the
Substance Abuse and Mental Health
Services Administration
              Mr. Chairman and Members of the Subcommittee:

              We are pleased to be here today to assist the Subcommittee in its
              deliberations on the reauthorization of the Substance Abuse and Mental
              Health Services Administration (SAMHSA). SAMHSA, with an operating budget
              of $1.9 billion in fiscal year 1996, is the Department of Health and Human
              Services’ (HHS) lead agency for substance abuse and mental illness
              prevention and treatment. The work of this agency has been deemed
              critically important to our nation’s efforts to address and reduce the
              problems related to substance abuse and mental disorders. My testimony
              today focuses on SAMHSA’s role in (1) coordinating its efforts with federal
              agencies involved in related research or services; (2) measuring the results
              of its programs or activities, particularly in light of the fact that most of its
              funds are used to support services provided by States and by local
              grantees; and (3) monitoring the impact of the transition to managed
              health care on individuals with mental disorders and substance abuse
              problems.

              The observations I present today are based on our past and ongoing work
              at HHS as well as on conversations with SAMHSA officials and officials at
              other agencies that are engaged in substance abuse and mental
              health-related activities.

              In summary, SAMHSA faces three important challenges in the current
              environment. First, given the many different, yet related, federal agency
              activities in the areas of substance abuse and mental health, it is especially
              important that SAMHSA communicate and coordinate its efforts with
              agencies involved in similar or complementary activities. Second, under
              the Government Performance and Results Act (GPRA), SAMHSA will have to
              show that its funds are used efficiently and effectively. This will present a
              particular challenge for the agency because most of its funds are used to
              support services provided by states and local grantees. Finally, the move
              to managed care in the private and public sectors affords potential
              opportunities for SAMHSA to improve the coordination of care, yet it has
              risks, given the financial pressures to control costs and health plans
              limited experience in setting capitation rates for mental health and
              substance abuse services. These are issues that deserve SAMHSA’s careful
              attention.




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             Substance Abuse and Mental Health:
             Reauthorization Issues Facing the
             Substance Abuse and Mental Health
             Services Administration




             It is estimated that 52 million Americans annually experience a mental
Background   health or substance abuse problem and about half obtain treatment.1 Many
             factors, including perceptions of the need for treatment, account for many
             people not getting care. In addition, insurance coverage has generally been
             more limited for mental health than for physical health services. For this
             reason, public sector (federal and state) resources have provided an
             important safety net for individuals unable to afford the care available in
             the private sector, and we now have a sizable public sector investment in
             mental health and substance abuse services. Private sector resources (for
             example, managed behavioral health plans) have grown, however,
             particularly as more employers have offered mental health and substance
             abuse benefits. Nonetheless, many Americans continue to face barriers in
             obtaining access to mental health and substance abuse services.

             In October 1992, the Congress established SAMHSA under Public Law
             102-321 to strengthen the nation’s health care delivery system for
             prevention and treatment of substance abuse and mental illnesses. Before
             1992, the major federal substance abuse and mental health delivery
             services and research activities were combined under one agency, the
             Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). In the
             1992 legislation, the Congress created SAMHSA to administer the services
             portion of ADAMHA and transferred its research components to the National
             Institutes of Health (NIH) to be carried out by the National Institute on
             Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug
             Abuse (NIDA), and the National Institute of Mental Health.

             Since 1992, SAMHSA’s budget has remained relatively stable at about $2
             billion each year. Most of this amount has been in the form of block grants
             to states and local governments. In fiscal year 1996, these grants totaled
             $1.2 billion for substance abuse prevention and treatment services and
             $275 million for mental health services. Combined, these block grants
             accounted for about 80 percent of SAMHSA’s budget (see fig. 1). These funds
             go directly to states and local organizations, which have broad discretion
             in how best to use them, within federal guidelines. The remainder of
             SAMHSA’s budget—$376 million in fiscal year 1996—supports program
             management; data collection, analysis, and dissemination; and a wide
             array of demonstration efforts through the Knowledge Development and
             Application (KDA) program. The KDA program, as described in HHS’ fiscal
             year 1998 budget, supports community organizations and other grantees
             with funding for well-defined demonstrations and other efforts that help

             1
              Institute of Medicine, National Academy of Sciences, Managing Managed Care: Quality Improvement
             in Behavioral Health (Washington, D.C.: National Academy of Sciences, 1997).



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                                     Substance Abuse and Mental Health:
                                     Reauthorization Issues Facing the
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                                     promote strategies to reduce drug use by youth and increase the
                                     knowledge base about issues such as managed care and early childhood
                                     problems.


Figure 1: Amount of SAMHSA’s Total
Budget Authority Devoted to Block
Grants, Fiscal Years 1993-96




                                     Most of SAMHSA’s $1.9 billion budget—75 percent in fiscal year 1996, or
                                     $1.4 billion—funded substance abuse prevention and treatment services.
                                     SAMHSA’s drug abuse budget authority, although sizable, represented only
                                     about one quarter of the federal government’s drug abuse prevention and
                                     treatment budget in fiscal year 1996 (see fig. 2).2 The Department of
                                     Veterans Affairs devoted a similar level of resources, while the
                                     Department of Education, the next largest supporter of these services,
                                     provided about half the level of funding of the other two agencies. Over a

                                     2
                                      The federal government’s drug abuse prevention and treatment budget is prepared by the Office of
                                     National Drug Control Policy (ONDCP). SAMHSA’s budget authority in ONDCP’s budget is
                                     $1.084 billion for fiscal year 1996. This amount excludes SAMHSA funding for alcohol-only programs.



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                                       Substance Abuse and Mental Health:
                                       Reauthorization Issues Facing the
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                                       dozen other agencies with varying roles and responsibilities share in
                                       funding similar or related activities under their respective missions, goals,
                                       and objectives.3


Figure 2: Agencies’ Share of Federal
Funding for Drug Abuse Prevention                                                             Other Departments/Agenciesa
and Treatment, Fiscal Year 1996

                                                                   13.2% •                    Department of Education



                                              • 38.1%
                                                                         24.3% •              Department of Veterans Affairs




                                                            24.4% •                           SAMHSA




                                       Notes: Total funding is $4.4 billion. Funding for alcohol-only prevention and treatment programs is
                                       not included.
                                       a
                                           Other agencies include the Departments of Defense, Justice, and Labor.

                                       Source: ONDCP, The National Drug Control Strategy, 1997: FY 1998 Budget Summary,
                                       (Washington, D.C.: ONDCP, Feb. 1997).




                                       Given the number of federal agencies with related responsibilities in the
Coordination Is                        area of mental health and substance abuse services, SAMHSA is presented
Important to Program                   with a particular challenge as well as an opportunity to coordinate
Results and More                       activities and promote the development of effective linkages. While we
                                       recognize that ONDCP has lead responsibility for coordinating federal drug
Efficient Use of                       abuse supply and demand reduction activities, SAMHSA, nevertheless, has
Federal Funds                          responsibility for coordinating its efforts with agencies involved in similar
                                       or complementary activities.



                                       3
                                        Drug and Alcohol Abuse: Billions Spent Annually for Treatment and Prevention Activities
                                       (GAO/HEHS-97-12, Oct. 8, 1996).



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                     Substance Abuse and Mental Health:
                     Reauthorization Issues Facing the
                     Substance Abuse and Mental Health
                     Services Administration




                     The relationship between SAMHSA and the NIH institutes that once were a
                     part of ADAMHA is an important partnership to maintain. The NIH research
                     institutes support the development of new knowledge and technologies in
                     prevention and treatment of substance abuse and mental illness. Linkages
                     between researchers and practitioners are critical for new research
                     initiatives to be grounded in real world problems and for new
                     programmatic initiatives to reflect current knowledge in the field. Since
                     one of SAMHSA’s major goals is to support the application of innovative
                     treatment and prevention approaches, working with the research institutes
                     to identify projects that could serve as models for innovation is very
                     important. There are probably many such opportunities for collaboration
                     across agencies.

                     SAMHSA  also has the opportunity to work with agencies such as the
                     Departments of Veterans Affairs and Justice that serve populations in
                     which mental health and substance abuse problems are great. Despite the
                     value of such relationships, we found that in the past, SAMHSA, along with
                     NIDA and NIAAA, had no process to link its expertise with that of the Indian
                     Health Service (IHS),4 an agency that serves a population in which abuse of
                     alcohol and other substances is a major problem. We recommended that
                     IHS and the other HHS agencies work together to develop a plan to address
                     substance abuse-related problems among Indian populations. In 1996, HHS
                     developed and implemented such a plan, which should help it strategically
                     allocate limited federal resources to address a major public health
                     problem in IHS service areas.


                     Another major challenge for SAMHSA is to measure how well its programs
Emphasis on          are working. Given that most of SAMHSA’s dollars are distributed to states
Accountability for   through its block grant program, the agency faces the additional challenge
Meeting Program      of balancing the flexibility it affords states to set priorities on the basis of
                     local need against its own need to hold the states accountable for
Goals Is Essential   achieving SAMHSA’s goals. While this may have always been a daunting task,
                     the passage of GPRA in 1993 now requires SAMHSA, along with other federal
                     agencies, to show that the use of their funds is yielding results.5

                     Under GPRA, every major federal agency—and, in many cases,
                     organizations within each agency—must now answer some basic

                     4
                      Indian Health Service: Basic Services Mostly Available: Substance Abuse Problems Need Attention
                     (GAO/HRD-93-48, Apr. 9, 1993).
                     5
                      Managing for Results: Using GPRA to Assist Congressional and Executive Branch Decisionmaking
                     (GAO/T-GGD-97-43, Feb. 12, 1997).



                     Page 5                                                                       GAO/T-HEHS-97-135
Substance Abuse and Mental Health:
Reauthorization Issues Facing the
Substance Abuse and Mental Health
Services Administration




questions: What is our mission? What are our goals, and how will we
achieve them? How can we measure our performance? How will we use
performance information to improve? GPRA forces federal agencies to shift
their focus from such traditional concerns as staffing and activity levels to
a single overriding concern: results.

Specifically, GPRA directs agencies to consult with the Congress, obtain the
views of other stakeholders, and clearly define their missions. It also
requires agencies to establish long-term strategic goals as well as annual
goals linked to the strategic goals. Agencies must then measure their
performance according to their goals and report to the President and the
Congress on their success. In addition to ongoing performance monitoring,
agencies are expected to identify performance gaps in their programs and
to use information from these evaluations to improve programs.6

GPRA  requires that federal agencies develop strategic plans for a period of
at least 5 years and submit them to the Congress and the Office of
Management and Budget (OMB) no later than September 30, 1997. These
plans must identify the agencies’ long-term strategic goals and describe
how the agencies intend to meet these goals through their activities and
resources. GPRA also requires agencies to submit an annual performance
plan to OMB that links the strategic goals in their plan to managers’ and
employees’ daily activities. This plan should include the annual
performance goals for the agencies’ programs as listed in their budget, a
summary of the resources to conduct these activities, the performance
measures that will gauge the progress toward those goals, and a discussion
of how the performance information will be verified.

Recognizing this challenge, HHS is transforming its SAMHSA block grants into
Performance Partnership Grants (PPG). Under PPG, an arrangement
between the state and federal governments will be negotiated that
identifies specific objectives and performance measures in terms of
outcomes, processes, and their capacity to be achieved over 3 to 5 years.
This appears to be a promising strategy because it gives states greater
control over their funding decisions while encouraging them to accept
greater accountability for results.

One of the many difficulties in implementing PPGs, however, will be
developing and reaching agreement with individual states on their
measures of performance. A panel of experts, convened by the National

6
 Executive Guide: Effectively Implementing the Government Performance and Results Act
(GAO/GGD-96-118, June 1996) and Managing for Results: Using GPRA to Assist Congressional and
Executive Branch Decisionmaking (GAO/T-GGD-97-43, Feb. 12, 1997).



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                        Reauthorization Issues Facing the
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                        Research Council at the request of HHS, was asked to recommend a set of
                        performance measures for ten public health areas of concern that states
                        and the federal government could use to negotiate PPG agreements and
                        monitor performance. Included in these areas of concern are substance
                        abuse, mental health, chronic disease, and sexually transmitted diseases.
                        The panel’s final report on this first phase of its work is expected to be
                        released by mid-June 1997. A final report on the second phase of the study,
                        which will include recommendations for improving state and federal
                        surveys and data systems, is expected to be released by the end of
                        calendar year 1998. Consequently, implementation of PPGs will occur later
                        than fiscal year 1998, as earlier projected.


                        Another challenge facing SAMHSA is its role in restructuring public sector
Issues in the           mental health and substance abuse services, given the growth of the
Transition to Managed   private sector managed behavioral health care industry. The forces driving
Behavioral Health       the move to managed care for physical health services are also in
                        operation in the mental health specialty sector. Employers’ concerns
Care                    about the high costs of mental health and substance abuse services have
                        prompted them to adopt a number of managed care strategies. According
                        to HHS, about 60 percent of Americans with private insurance were
                        enrolled in a managed behavioral health plan in 1995. Similarly, the public
                        sector, through the Medicaid program—which is administered by the
                        Health Care Financing Administration (HCFA)—has looked to managed
                        care to improve access to a comprehensive range of services while also
                        reducing costs. As states have enrolled increasing numbers of Medicaid
                        beneficiaries in managed care plans, they have found themselves having to
                        make choices about payment and care arrangements for mental health
                        services. While some states are integrating behavioral health and physical
                        health services into a single managed care program, others are either fully
                        or partially carving out mental health benefit packages under separate
                        contractual arrangements.

                        The move to managed care, particularly when driven by pressures to
                        control costs, has raised concerns about access to and quality of mental
                        health and substance abuse care. Managed care has the potential to
                        improve access to a comprehensive range of benefits for a population with
                        multiple and chronic behavioral health care needs; yet it also has risks,
                        given financial incentives to limit costs and the health care system’s
                        limited experience in setting capitation rates for services needed by this
                        population. People with mental health and substance abuse problems may
                        need a combination of different types of care, such as outpatient services,



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               inpatient hospital care, and long-term institutional or residential care.
               SAMHSA has established an Office of Managed Care, which funds a project
               that is monitoring the impact of the transition to managed care on public
               mental health and substance abuse providers and the people served. In
               addition, SAMHSA is supporting a number of managed care policy and
               demonstration grants that focus on specific issues or populations, such as
               people who are homeless or seriously mentally ill or who live in rural
               communities. Knowledge gained through these efforts should be useful in
               working with HCFA to develop oversight and performance standards for
               Medicaid’s move to mental health managed care. Given the major
               transitions occurring in health care delivery and financing of physical and
               mental health services, it will be important for SAMHSA to continue to give
               attention to developments in the field.


               Mr. Chairman this concludes my statement. I will be pleased to answer any
               questions you or Members of the Subcommittee might have.


               For more information on this testimony, please call Bernice Steinhardt,
Contributors   Director, Health Services Quality and Public Health, (202) 512-7119.




(108332)       Page 8                                                     GAO/T-HEHS-97-135
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