United States General Accounting Oface H/d I / Testimony GAO . lllllllllIlllll 141271 For Release ,HBS Cannot Currently Measure States' on Delivery Progress in Meeting The Prompt Treatment Expected at 9:45 a.m. EDT Goal for Intravenous Drug Users Monday April 30, 1990 Statement of Linda G. Morra Director of Intergovernmental and Management Issues Human Resources Division Before the Subcommittee on Health and the Environment Committee on Energy and Commerce House of RaDreaentacives I GAO/T-HRD-90-25 GAO Form 160 (12/‘37) Mr. Chairman, we are pleased to testify on the GAO report released today on treatment for intravenous (IV) drug abusers. In September 1989, you asked us (1) to review states' implementation of a section of 'the Anti-Drug Abuse Act of 1988 concerning timely IV drug abuse treatment and (2) to assess the problems women, especially pregnant women, face in receiving drug treatment. As the second study is still ongoing, my remarks today are limited to states' implementation of the IV drug abuse provisions. These federal provisions -require states to ensure, among other things, that local providers receiving alcohol, drug abuse, and mental health services (ADMS) block grant funds will provide treatment to IV drug users within 7 days of request, to the maximum extent practicable. BACKGROUND These provisions are particularly important as IV drug abusers-- drug addicts who use needles to inject themselves with heroin, cocaine, or other illicit drugs --are among those with the highest risk of contracting acquired immunodeficiency syndrome (AIDS). The reported cases of both IV drug abuse and AIDS,in the 1980s indicated public health problems of major proportions. States estimated.that 1.3 million people were IV drug abusers in 1988. About 21 percent of reported AIDS cases are linked to contaminated needles shared among IV drug abusers. Thus, treating IV drug 1 abusers has become.an important strategy in reducing the spread of AIDS. The Congress responded to these health problems when it enacted the Anti-Drug Abuse Act of 1988. Section 2034 requires that, for a state to receive ADMS block grant funds, it must assure the Department of Health and Human Services (HHS) that it will -- first, ensure that local providers receiving ADMS block grant funds, and nearing full capacity, will provide treatment for IV drug abusers within 7 days of request, to the maximum extent practicable; -- second, develop a plan--if HHS requests one--to provide services for all individuals seeking substance abuse treatment (including IV drug abusers1 and estimate the resources needed to provide such treatment; -- third, target ADMS block grant funds earmar'ked for substance abuse treatment to communities with the greatest need for services or the highest prevalence of substance abuse: -- fourth, require local providers receiving ADMS block grant funds to notify the state when they reach or exceed 90 percent of 'their treatment capacity for IV drug abusers; and -- fifth, require local providers receiving ADMS block grant funds to conduct outreach activities encouraging IV drug abusers to seek treatment. You asked that we assess both states' compliance with these five provisions and HHS's role in overseeing their implementation. To do this we visited three states--California, Oregon, and New York--in October and November of last year. We visited 15 local clinics --14 methadone maintenance programs and 1 drug-free elinic-- that had reached 90 percent or more of their treatment capacity. We also discussed HHS's role with officials in the Office for Treatment Imhrovement and with public interest groups involved in drug treatment issues. RESULTS IN BRIEF The three states were generally implementing the five IV drug treatment provisions, but 5 of the 15 local clinics we visited were not meeting the 7-day treatment goal. At those five clinics, some clients waited more than 3 months. HHS has not visited any states to assess compliance with the block grant provisions since 1987. Although in recent months HHS has begun collecting some information, it will not be sufficient to measure the progress of individual states in meeting the 7-day treatment goal. 3 I will summarize our findings for each of the five provisions, related to timely IV drug abuse treatment, and then address HHS's overall role. WAITING PERIODS FOR IV DRUG ABUSE TREATMENT SOMETIMES EXCEEDED 7 DAYS The first provision sets a goal for local clinics to provide treatment to IV drug abusers within 7 days of request. IV drug abusers seeking treatment waited longer than 7 days in three of the five clinics we visited in California and two of the five in Oregon. Some clients waited more than 3, months. One clinic in Long Beach had over 200 people on a waiting list, some of whom had been on the list for over 2 months. Waiting periods did not exceed 7 days in the 5 New York programs we visited because when these local providers reached their capacity, they referred addicts to treatment programs that were under capacity. New York does not have a central intake system to track referrals, but this is generally done informally by providers when they reach treatment capacity. All three states had assured HHS they would provide IV drug treatment within 7 days, to the "maximum extent practicable." The states view the Anti-Drug Abuse Act's timely drug treatment 'provision as a broad goal, rather than a requirement. HHS cannot currently measure individual states' progress toward this goal 4 because it is not obtaining outcome data, such as changes in the length of waiting periods for IV drug abusers seeking treatment. HHS DID NOT REQUEST TREATMENT PLANS, BUT STATES DID HAVE ELEMENTS IN PLACE The second provision stipulates that states must agree to develop a plan for substance abuse treatment services, if requested by HHS. The plans are to identify the magnitude of each state's substance abuse problem and the resources needed to address it. None of the three states had prepared such a plan because HHS has not requested plans from any states. We inquired, however, whether the states were planning to meet the needs of all IV drug abusers seeking treatment. The three states had estimated the number of IV drug abusers in their states and identified the number of treatment slots available to serve them. California and New York, however, did not identify the financial and personnel resources required to meet these needs. Oregon's substance abuse agency reflected the level of demand in its agency budget request. HHS is working with states to develop a survey instrument to obtain voluntary information on states' planning for and management of substance abuse services, including IV drug abusers and other special populations. The survey will provide information on, for example, how states prioritize treatment activities in the planning process and how states coordinate with other agencies involved in 5 providing such services. These elements go beyond those described in the statutory planning provision. Many of them are consistent, however, with the requirements for state substance abuse treatment plans proposed last year in H.R. 3630, which would have established separate block grants with respect to substance abuse.and mental health. HHS is pilot-testing this voluntary survey in eight states. It intends to use the information to assess states' progress in providing substance abuse treatment services. STATES TARGET FEDERAL SUBSTANCE ABUSE TREATMENT FUNDS The third provision requires states to target their federal substance abuse block grant funds to communities they determine to have the greatest need for services or the highest prevalence of substance abuse. Each of the three states did so. They target their ADMS block grant funds based on factors such as clinic admissions, the number of drug-related,arrests, and the incidence of communicable diseases. For example, California allocates its ADMS block grant funds for IV drug treatment according to the number of clinic admissions for IV drug abuse and reported AIDS cases. 6 , . . LOCAL CLINICS REPORT TREATMENT CAPACITY The fourth provision requires states to ensure that local providers report to the state substance abuse agency when they reach or exceed 90 percent of treatm ent capacity for IV drug abusers. Each of the three states do so, and all the providers we visited reported the required inform ation. S O M E T IMES STATES, NOT LOCAL PROVIDERS, CONDUCT OUTREACH The fifth provision requires states to ensure those local providers receiving A D M S block grant funds will conduct outreach activities to encourage IV drug abusers to seek treatm ent. Of the three states, only California requires local clinics receiving ADMS block grant funds to conduct outreach activities. However, of the 15 providers we visited across the three states, 12 either conducted their own outreach activities or relied on activities of other agencies to reach IV drug abusers. The other three providers had reached their treatm ent capacity and they believed outreach was not necessary. California requires its local providers to conduct outreach, but the state also conducts areawide outreach activities. New York, like California, conducts areawide instead of clinic-based outreach. For exam ple, New York's substance abuse agency 7 contracts with county agencies to implement regional outreach strategies. California and New York believe areawide outreach is as effective as clinic-based outreach. Oregon did not specifically require its local clinics to conduct outreach; instead, it relied on clinic-based outreach activities that were being conducted before the federal requirement. HHS DOES NOT CURRENTLY MEASURE STATES' PROGRESS TOWARD GOAL OF PROMPT TREATMENT FOR IV DRUG ABUSERS Turning now to HHS's role in overseeing the implementation of these provisions, we found that HHS cannot currently determine the progress that individual states have made toward the federal goal of providing IV drug abusers treatment within 7 days of request. HHS relies heavily on state-reported data from several sources to assure compliance with the federal IV drug abuse provisions. For example, it uses states' annual applications and end-of-the-year reports. These reports provide data on all substance abusers, but they do not specifically identify services for IV drug abusers. HHS also asks eight or nine states each year to assess their compliance with the federal legislation based on an HHS-developed checklist. However, the data states provide to HHS describe procedures in place, and cannot be used to measure states' prbgress. 8 In recent months, HHS has begun to obtain some state-reported data that will provide limited information on progress in providing timely drug abuse treatment. First, HHS will soon have data on the changes in treatment timeliness in about 360 clinics receiving waiting list reduction grants. But these data will cover only about 9,500 IV drug treatment slots. In 1989, there were about 115,000 IV drug abuse treatment admissions nationwide. Second, HHS is also conducting a survey of selected substance abuse treatment providers to describe the national drug abuse treatment system. However, the number of substance abuse treatment providers sampled may be too small to make statements about national progress in providing timely IV drug abuse treatment or show state-by-state progress in providing such treatment. CONCLUSIONS In conclusion, Mr. Chairman, the three states we visited are generally meeting the provisions in the timely IV drug treatment section of the Anti-Drug Abuse Act of 1988. In two of these states, however, some clinics were not yet meeting the goal of providing timely treatment for all IV drug abusers. Further, HHS cannot yet measure states' progress in meeting the 7-day treatment goal. We are, therefore, recommending that the Secretary of HHS revise the Department's reporting system so that it will provide sufficient information to measure individual states' progress in 9 .‘. * meeting the goal of providing IV drug abusers treatment within 7 days of request. Mr. Chairman, this concludes my presentation. I would be happy to answer any questions you may have. Thank you. 10
HHS Cannot Currently Measure States' Progress in Meeting the Prompt Treatment Goal for Intravenous Drug Users
Published by the Government Accountability Office on 1990-04-30.
Below is a raw (and likely hideous) rendition of the original report. (PDF)