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)

                       United States General Accounting Oface         H/d       I /
                                                           . lllllllllIlllll

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
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


                                                                            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


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

abusers         has become.an              important            strategy              in reducing            the     spread            of

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

--    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.


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.

 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.


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

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

because          it     is    not       obtaining            outcome         data,      such as changes                  in    the
length          of waiting              periods        for     IV drug          abusers             seeking       treatment.


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

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.


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

,       .



            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.


            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

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.


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'

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.


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



      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.