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98–353 PDF 2005

ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG TREATMENT

HEARING

BEFORE THE

SUBCOMMITTEE ON CRIMINAL JUSTICE,

DRUG POLICY AND HUMAN RESOURCES

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

SEPTEMBER 22, 2004

Serial No. 108–269

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

DOUG OSE, California

RON LEWIS, Kentucky

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

NATHAN DEAL, Georgia

CANDICE S. MILLER, Michigan

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

PATRICK J. TIBERI, Ohio

KATHERINE HARRIS, Florida

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

JIM COOPER, Tennessee

BETTY MCCOLLUM, Minnesota

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY AND HUMAN RESOURCES

MARK E. SOUDER, Indiana, Chairman

NATHAN DEAL, Georgia

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

DOUG OSE, California

EDWARD L. SCHROCK, Virginia

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

PATRICK J. TIBERI, Ohio

ELIJAH E. CUMMINGS, Maryland

DANNY K. DAVIS, Illinois

WM. LACY CLAY, Missouri

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

EX OFFICIO

TOM DAVIS, Virginia HENRY A. WAXMAN, California

J. MARC WHEAT, Staff Director

ROLAND FOSTER, Professional Staff Member

MALIA HOLST, Clerk

TONY HAYWOOD, Minority Professional Staff Member and Counsel

(III)

C O N T E N T S

Page

Hearing held on September 22, 2004 ..................................................................... 1

Statement of:

Curie, Charles G., Administrator, Substance Abuse and Mental Health

Services Administration, Department of Health and Human Services .... 6

Heaps, Melody, president, Treatment Alternatives for Safe Communities;

and Dr. Michael Passi, associate director, Department of Family and

Community Services, city of Albuquerque, NM ......................................... 22

Letters, statements, etc., submitted for the record by:

Cummings, Hon. Elijah E., a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 50

Curie, Charles G., Administrator, Substance Abuse and Mental Health

Services Administration, Department of Health and Human Services,

prepared statement of ................................................................................... 9

Heaps, Melody, president, Treatment Alternatives for Safe Communities,

prepared statement of ................................................................................... 25

Passi, Dr. Michael, associate director, Department of Family and Community Services, city of Albuquerque, NM, prepared statement of ............... 31

Souder, Hon. Mark E., a Representative in Congress from the State

of Indiana, prepared statement of ............................................................... 4

(1)

ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG TREATMENT

WEDNESDAY, SEPTEMBER 22, 2004

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY AND

HUMAN RESOURCES, COMMITTEE ON GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 2 p.m., in room

2247, Rayburn House Office Building, Hon. Mark Souder (chairman of the subcommittee) presiding.

Present: Representatives Souder, Cummings, Norton and

Ruppersberger.

Staff present: J. Marc Wheat, staff director; Roland Foster, professional staff member; Malia Holst, clerk; Tony Haywood, minority

professional staff member; and Teresa Coufal; minority assistant

clerk.

Mr. SOUDER. The subcommittee will now come to order.

Good afternoon and I thank you all for being here.

Today, we will continue the subcommittee’s examination of drug

addiction treatment or as President Bush refers to it in the National Drug Control Strategy, healing America’s drug users. It is

estimated that at least 7 million people in the United States need

substance abuse treatment. Providing treatment is important because it improves the lives of individuals and reduces social problems associated with substance abuse.

Effective treatment, for example, reduces illegal drug use, criminal activity and other risky behaviors while improving physical and

mental health. When tailored to the needs of the individual, addiction treatment is as effective as treatments for other illnesses such

as diabetes, hypertension and asthma.

Last year, President Bush took what I believe to be a very significant step toward assisting the difficult problem of extending

help to those suffering from substance abuse when he unveiled the

Access to Recovery Initiative. Beginning this year the President’s

initiative will provide $100 million to the Substance Abuse and

Mental Health Services Administration to supplement existing

treatment programs. This is intended to pay for substance abuse

treatment for Americans seeking help but can’t get it, many of

whom cannot afford the cost of treatment and don’t have insurance

that covers it.

If fully funded at $200 million per year as requested by the

President, this program could help up to 100,000 or more suffering

from addiction to receive treatment. The program also has enorVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
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mous potential to open up Federal assistance to a much broader

range of treatment providers than currently available today.

The initiative will support and encourage a variety of treatment

options and provide those seeking assistance a choice in treatment

approaches and programs. Providing choices for those in need of assistance allows the individual to select the program that best addresses their personal needs. It has often been said that in order

to help substance abusers, you need to meet them where they are.

This approach goes a step further by allowing those seeking help

to determine themselves where they want this meeting to occur

and with whom.

This new approach to treatment will establish a State-managed

program for substance abuse clinical treatment and recovery support services buildupon the following three principles.

Consumer choice. The process of recovery is a personal one.

Achieving recovery can take many pathways, physical, mental,

emotional or spiritual. Given a selection of options, people in need

of treatment for addiction and recovery support will be able to

choose the programs and providers that will help them most. Increased choice protects individuals and encourages quality.

Outcome oriented. Successfully measured by outcomes, principally abstinence from drugs and alcohol and including attainment

of employment or enrollment in school, no involvement with the

criminal justice system, stable housing, social support, access to

care and retention and services.

Increased capacity. The initial phase of the Access to Recovery

will support treatment for approximately 50,000 people per year

and expand the array of services available including medical detoxification, in-patient and out-patient treatment modalities, residential services, peer support, relapse prevention, haste management and other recovery support services. These funds will be

awarded through a competitive grant process. States will have considerable flexibility in designing their approach and may target efforts to areas of greatest need to areas with a high degree of readiness or to specific populations including adolescents.

The key to implementing the grant program is a State’s ability

to ensure genuine, free and independent client choice of eligible

providers. States are encouraged to support any mixture of clinical

treatment and recovery support services that can be expected to

achieve the program’s goal of cost effective, successful outcomes for

the largest number of people.

Today, we will learn more about the status and the goals of the

Access to Recovery Initiative with the person most responsible for

implementing it, my fellow Hoosier and friend, SAMHSA Administrator, Charles Curie. We will also hear from several experts who

are on the front lines of substance abuse treatment. Melody Heaps

is the president of Treatment Alternatives for Safe Communities in

Chicago, IL, a recipient of Access to Recovery funding. Dr. Michael

Passi is the associate director of the Department of Family and

Community Services in Albuquerque, NM which was a pioneer in

providing choices for those seeking substance abuse treatment.

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Thank you again for being here today and I look forward to hearing more about the Access to Recovery from our experts who are

with us today.

[The prepared statement of Hon. Mark E. Souder follows:]

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Mr. SOUDER. I ask unanimous consent that all Members have 5

legislative days to submit written statements and questions for the

hearing record, that any answers to written questions provided by

the witnesses also be included in the record. Without objection, so

ordered.

I also ask unanimous consent that all exhibits, documents and

other materials referred to by Members and the witnesses may be

included in the hearing record and that all Members be permitted

to revise and extend their remarks. Without objection, so ordered.

[Witnesses sworn.]

Mr. SOUDER. Once again, thank you for your patience and for

your leadership not only here but in your previous State position

in Pennsylvania in advocacy for those who often don’t have advocates. You have been consistent for many years talking about cooccurring dependencies and creative ways to address these problems. Thank you for being here.

STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. CURIE. Thank you so much, Mr. Chairman. It is great to see

you again.

I appreciate the opportunity to testify today. I also request that

my written testimony be submitted for the record.

Mr. SOUDER. So ordered.

Mr. CURIE. I am pleased, Mr. Chairman, that you and the committee have selected the President’s Access to Recovery Substance

Abuse Treatment Initiative as the topic of this hearing. Again, I

am very pleased with your opening statement of support for the

concept and for the program, Access to Recovery.

It is also a privilege for me today to be participating in the same

session with Dr. Michael Passi from Albuquerque which did pave

the way with a voucher type of program and New Mexico happens

to be one of the recipients of Access to Recovery, so we have high

hopes for the implementation there. Also, my friend and colleague

for whom I have such regard, Melody Heaps who has done so much

on behalf of individuals trapped in addiction in the criminal justice

system, bringing hope in her career.

Expanding substance abuse treatment and capacity and recovery

support services is a priority for this administration. There is a

vast, unmet treatment need in America. Too many Americans who

seek help for their substance abuse problem cannot find it. A recently released 2003 National Survey on Drug Use and Health,

known as the Household Survey, provides the scope of the problem.

In 2003, there were an estimated 22 million Americans who were

struggling with a serious drug or alcohol problem. The survey contains another remarkable finding. The overwhelming majority, almost 95 percent of people with substance use problems, do not recognize their problem. Of those who recognize their problem,

273,000 reported that they made an effort but were unable to get

treatment.

To help those in need, SAMHSA supports and maintains State

substance abuse treatment systems through the Substance Abuse

Prevention and Treatment Block Grant. Our Targeted Capacity ExVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
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pansion Grant Program continues to help us identify and address

new and emerging trends in substance abuse treatment needs.

Now, we also have Access to Recovery, ATR. It provides a third

complementary grant mechanism to expand clinical treatment and

recovery support service options to people in need.

ATR was proposed by President Bush in his 2003 State of the

Union Address. It is designed to accomplish three main objectives

long held by the field, policymakers and legislators. First, it allows

recovery to be pursued through many different and personal pathways. Second, it requires grantees to manage performance based on

outcomes that demonstrate patient successes. Third, it will expand

capacity by increasing the number and types of providers who deliver clinical treatment and/or recovery support services.

The program uses vouchers and coupled with State flexibility

and executive discretion, they offer an unparalleled opportunity to

create profound positive change in substance abuse treatment financing and service delivery across the Nation.

The uniqueness of ATR and its program is its direct empowerment of people, of consumers. Individuals will have the ability to

choose the path best for them and the provider that best meets

their needs whether physical, mental, emotional or spiritual. Recovery is a very personal process. If you were to ask 100 people

about their story of recovery, people in recovery, you would get 100

different stories. There would be common elements but each would

have their own pathway.

ATR ensures that a full range of clinical treatment and recovery

support services are available, including the transforming powers

of faith. I had the privilege of joining the President in Dallas when

he announced that $100 million in Access to Recovery grants were

being awarded to 14 States and 1 tribal organization. These first

grantees were selected through a competitive grant review process

that included 66 applications submitted by 44 States and 22 tribes

and territories.

While all applicants had the opportunity to expand treatment options for different target population groups and utilized different

treatment approaches, they all had to meet some specific common

requirements, including the need to ensure genuine free and independent client choice of eligible providers and to report on common

performance measures to illustrate effectiveness.

Key to achieving our goal of expanding clinical substance abuse

treatment capacity and recovery support services and successfully

implementing ATR is the ability to report on meaningful outcomes.

We are asking grantees to report on only seven outcome measures.

These measures are recovery-based and broader than simply reporting numbers of people served or beds occupied. They get at real

outcomes for real people.

First and foremost is abstinence from drug use and alcohol

abuse. Without that, recovery and a life in the community are impossible.

Two other outcomes are increased access to services and increased retention and treatment related directly to the treatment

process itself. The remaining four outcomes focus on sustaining

treatment and recovery, including increased employment, return to

school, vocational and education pursuits, decreased criminal jusVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
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tice involvement, increased stabilized housing and living conditions

and increased supports from and connectiveness to the community.

These measures are true measures of recovery. It is the first time

we are striving to measure recovery in those terms. They measure

whether our programs are helping people attain and sustain recovery. As a compassionate Nation, we cannot afford to lose this opportunity to offer hope to those fighting for their lives to attain and

sustain recovery. Because the need is so great, the President has

proposed in fiscal year 2005, to double the funding for Access to Recovery to $200 million and to also increase the Substance Abuse

Prevention and Treatment Block Grant by $53 million for a total

of $1.8 billion.

As you know, the President’s fiscal year 2005 budget is before

Congress right now. The President’s proposed substance abuse

treatment initiatives are good public policy and a great investment

of Federal dollars. As the President said, and we all know, our Nation is blessed with recovery programs that do amazing work. Our

common ground is a shared understanding that treatment works

and recovery is real. Now, it is our job to see to it that the resources are made available to connect people in need with people

who provide the services.

I also would like to recognize, in conclusion, Dr. Wesley

Clark,who is with me today, who is the Director of the Center for

Substance Abuse Treatment which is the center primarily responsible within SAMHSA for the implementation and carrying out of

Access to Recovery.

Thank you and I would be most pleased to answer any questions

you may have.

[The prepared statement of Mr. Curie follows:]

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Mr. SOUDER. Thank you very much.

In your testimony, you have four different ways you determined

how people were going to get the grants: client choice, how clients

will be assessed, acquire the supplement and no supplant, the poor,

uncommon performance measurements. Were those all weighted

equally? How did you sort through your applicants and if you can

also add, did it matter whether they had prior experience with this,

like you said Albuquerque did? And give us some feeling that this

wasn’t just darts at the board or something.

Mr. CURIE. That’s a very good question. The peer review committee and the reviewers definitely took their jobs very seriously. We

did give weighting according to what we expected with ATR. There

was clear weighting given to the applicants who had to demonstrate and those who won awards had to demonstrate they did

have an objective assessment process in place, that they did have

the capacity to have an eligible provider list in a way of assuring

that the providers were going to clearly increase capacity.

They also needed to indicate and show how they were going to

assure there was not going to be fraud and abuse for using vouchers. Using electronic voucher approaches by using electronic forms

of vouchers has been a way of doing that in other programs. I think

most of the applicants who won were able to demonstrate they

could do that.

Also, they had to demonstrate that the client would have choice

based upon that assessment, that there was a clear link to the assessment and choice, that the assessment process was an objective

one, that there was no conflict of interest in the assessment process

and the providers they were able to select. They also then had to

demonstrate and give competence to those reviewing, that they had

the capacity to actually carry this out in a timely manner, in other

words that they did have structures in place and would be able to

implement this at least by early 2005 in terms of making the

awards.

Previous experience was definitey a consideration because that

would also show capacity to be able to carry this off successfully.

It is clear though that this is a new way of financing and delivering

services, so there were very few examples across the country of

voucher programs. Wisconsin, which also happened to win a grant,

also had a voucher program in Milwaukee and a track record as

well.

Mr. SOUDER. They are 3 year grants?

Mr. CURIE. Three year grants, yes.

Mr. SOUDER. Are the outcomes reported annually and do you

have a monitoring system for that?

Mr. CURIE. Yes. We are looking for the outcomes to be reported

more frequently than annually. We will be looking and the States

will need to demonstrate that they are beginning to collect outcome

information within the first year. Yes, States need to demonstrate

a capacity and that they would be able to glean the outcome measures from eligible providers. That would be one of the things we

would expect in order for a provider to continue to be an eligible

provider, that they respond to those seven domains.

16

Our role at SAMHSA through CSAT will be to monitor the

States’ overall performance and see to it that the States are holding those provides accountable.

Mr. SOUDER. One of the frustrations of any Congressman who

works at all with grant requests, or at least supports those who do

grant requests, has not known precisely how the measurements are

done and particularly if this is going to expand to more than the

50,000 to 100,000. Did you review with the applicants that you

didn’t choose how to put together better programs or do they have

a way to look at how to do that in the next round? Will you continue as you look at the outcomes that you are getting, do you have

ways to communicate to people who didn’t even apply the first

round what you are looking for and how to make this program reflective of things that don’t work and do work?

Mr. CURIE. I believe the answer to each of those questions is yes.

We do have with all of our grant programs and discretionary grant

programs the ability for an applicant who did not receive an award

to ask for feedback in terms of where did they fall short and they

can examine what their particular score was. We do offer ongoing

technical assistance.

Just as we did in the very beginning with Access to Recovery, we

held five technical assistance sessions and we had a great response

to those TA sessions. One of those five was geared toward tribal

organizations. I know we had over 100 tribal organizations participating as well. I think most if not all of the 50 States participated

in those TA sections.

We would continue that process of outreach to encourage folks to

apply. If we are in that position, it would be very good news because it means the $200 million was being appropriated but we

would be prepared to do that to assue we are continuing to do outreach and expand.

Mr. SOUDER. There isn’t any casual way to say this. As we move

into areas that are say somewhat tinged with controversy such as

voucher programs, faith-based programs, new ways of doing things,

I think complete and total transparency and openness about this

becomes more critical, even in our traditional way.

Normally we just respond when somebody asks for feedback. We

need some sort of systematic way because this is big dollar business in drug treatment and many organizations are very concerned

there is going to be a double standard for those of us who are conservative Republicans who have certain ideas about how this

should be done, and may not hold quite the same rigid standards

to some of the new groups coming in have been held to. I think it

becomes critical to review with everybody maybe in a more systematic form like you did by targeting these different groups to also

continue to do the reviews, make sure all the data becomes available.

Like you say, a lot of these are new providers. They aren’t going

to do it necessarily as efficiently in the beginning, but there are different types of groups. Drug cohorts don’t work as much as we

would like them to work but they still work a whole lot better than

other types of systems and broaden to new approaches.

We have this in the Community Block Grant Initiatives under

the bill that Congressman Portman and Sandra Levin did because

17

that was one of the ones where I sat through the first presentation,

the grant applications and some of the reviews and this is even

more difficult than those.

Do you have any comments on that? I know that is what you are

driving toward but as you well know, doing this all the time, this

is not without some stirring in the treatment community. We have

to make sure they know how we are doing it and why and what

is fair.

Mr. CURIE. I think your observations are accurate in this situation. Clearly, you always have with any grant process, especially

when you are talking a total of $100 million and hopefully $200

million. It gains a lot of attention in the field, gains a lot of attention from the States and from tribal organizations. Just that in

itself, there is a lot of emotion around because the field is, I think

there is general agreement, underfunded. It is a lot of dollars, so

people are very hopeful that they are able to apply and actually receive an award.

Second, you are exactly right about this particular program with

the innovation of trying to bring to a systemic level vouchers and

choice along with expanding the provider base to include recovery

support services for the first time in a clear way which also includes expansion of faith-based providers is a change for the field

as well. That becomes frought with concern and questions being

raised. I think the solution of transparency is exactly the right

course to take, that as we implement ATR that we are transparent

about the outcomes? How it is going? Do we need to make any midcourse corrections? Are there things we are learning?

Also during the process of people who have applied, I heard you

suggest perhaps we want to consider more of a global feedback

overall that would not undercut the integrity of the competitive

process of giving overall feedback of maybe where we saw applications of this type and things to keep in mind as we look ahead. We

can certainly incorporate that into our technical assistance as we

move forward.

Mr. SOUDER. Paticularly since in this category, when you hire

what we call here without meaning it in a derogatory term, a ‘‘beltway bandit,’’ in other words somebody who is trained in grants and

works in a large organization, they will systematically do that.

They will do that, go see who won, try to figure out how to do the

exact adverb and adjective that got the grant of the winners.

But if you are out in a much broader group of people who aren’t

used to writing grants and you are trying to bring new people into

the system, they aren’t probably going to have the same hired people to do that for them in trying to figure out precisely where they

are off becomes more critical and basically helps drive the program.

Also, I remember as one of the principles, batters learn by striking out. If a pitcher is going to throw them curve balls and they

can’t hit it, they had better learn how to hit a curve ball. Publishing what we learn from the first innovative people out there, what

isn’t working, is going to be important and to share that because

it may be that your criteria from the first time may change but you

have to be open in the process or you will have everybody gearing

up to go in one direction and then find there is a shared learning

experience.

18

We have done a series of faith-based hearings around the country. We didn’t do a lot on drug treatment because we are treating

this as a separate thing, but you can’t deal with homelessness, with

job development, with social services, child abuse without winding

up with drugs and alcohol mixed in here and there. One of the

things that was interesting because we always had representatives

from both sides, both pro and against faith-based direct funding,

was in drug and alcohol treatment, the questioning of licensed, traditional type providers versus this difficult question of drugs and

alcohol which you alluded to is also a spiritual, in many cases, not

necessarily in the sense of Christian, but a person has to make

some kind of decision that they are going to be cooperative and

that some of the failure rate in drug treatment programs isn’t actually the providers not doing things right, it is people are mandated

in, their family put them in, they didn’t make the internal commitment and therefore they can go through an effective program and

not be changed because they didn’t change.

The irony here and one of the things we were hearing at the

grassroots is sometimes the training may not be as high in some

of these groups but the outcomes may be better because the person

did a transforming or they were able to reach them in a different

way, such that they dried out or got off of narcotics. Freddy Garcia

is a classic example because he doesn’t even do drug treatment but

the people get off drugs. That clearly wouldn’t be eligible under a

Federal program but there are groups in between there that mix

that and we heard that in at least three to four of the cities in

which we did these hearings and the wide range of how to do this.

It is an interesting thing when you are dealing with the psychology

of drug treatment.

Mr. SOUDER. Absolutely. In fact, clearly we expected States as

they look at eligible providers, because that is really I think the

key of what we are talking about here, that they ensure the eligible

providers met public safety standards if they are going to be receiving dollars through the vouchers. Also if you hang out your shingle

and call yourself a particular kind of treatment program, if there

is a license for that, you have to engage that; and also there is a

range of recovery support services for which there may not be a

specific State license but again, in terms of public accountability,

the States needing to maintain the list of eligible providers.

Mr. CURIE. You are absolutely correct. Whenever you begin opening that, especially in a field that has really worked hard over the

past 40 years to gain certification, to gain credibility along with the

other health care fields, mental health and other types of primary

health care, it does raise questions and concerns. I think the challenge is how do we operationalize recovery from a public policy and

public finance standpoint. That is really what we are striving to do

for the first time because there are many pathways to recovery. So

we need to be thinking about this as a continuum because there

are people whose lives wouldn’t have been saved if it wasn’t for

that licensed, residential program, they went through a medical

detox, licensed residence, they attained sustained recovery and now

they are on their own personal recovery plan as a result of that.

There are others who have gone through a similar program and

it wasn’t until they engaged the faith-based program that recovery

19

took hold but also I would say probably each of those experiences

added to that person being able to attain recovery some day. So I

think it is clear we need a robust continuum that is available and

when you have a qualified assessment and then a choice involved,

I think you begin to open more of those pathways and the common

denominator among all of those types of providers is holding them

accountable to outcome. If they are held accountable to outcomes

that reflect recovery, we think therein lies the key for public accountability that we have not seen before.

Mr. SOUDER. One of the problems we have in job training is cherry picking, for lack of a better word, that most people who go on

unemployment, get off unemployment and the question is, those

are the easy ones to do because probably they are going to get off

anyway. What you are really dealing with is a temporary situation

and you are trying to move it faster or at least claim credit as opposed to the long term dependency.

It is a little less clear to me how you would do that here but I

can think of a couple types of things. Did you look in your grant

system to see whether any of them were taking harder types of

cases, in other words a program that specialized in taking people

who failed four times?

Another thing would be in co-dependency, it is real interesting in

Vancouver, British Columbia where we were looking at the heroin

distribution, the needles and free heroin from the government, basically. One of the things that happened in downtown Vancouver

is the areas where needles are distributed, people don’t want to be

and so the housing there tends to be the lowest income and people

who used to be institutionalized are released in those areas. So all

of a sudden they are exposed for the first time to illegal narcotics

and you have this huge bump up in co-dependencies of people who

have other problems and all of a sudden they are in a zone that

becomes a drug zone.

I don’t know whether this would be geographic, whether this

would be different people who have co-dependencies, whether it

would be people who failed multiple programs before, but looking

for the real hard programs that really take up a lot of our drug

money. I am not saying we don’t need drug treatment for people

the first time because if you can catch them early, you don’t get

them late. On the other hand, it can give you a false sense if you

say we want to prove this program works, we are only going to

take the people we think we can get at, first-time offenders, parents are there, wife is there, supportive, or husband. That won’t

give us a good read either.

Do you have a mix? Did you work to get that kind of mix?

Mr. CURIE. I am confident that we do have the mix. Again, we

had another discretionary grant program we implemented over the

past year or year and a half called Screening, Brief Intervention,

Early Intervention Program, which is focused on those individuals

who are considered the hard core, long term addict but catching

them early. This program was not focused on that. In fact, this program is focused on individuals who have an addiction that is longer

term. We are looking especially to hit that treatment gap with

those people who are ready for service.

20

I think when it comes to cherry picking, the key thing to keep

in mind here is this is the first time the client picks the provider.

The provider doesn’t pick the client. If someone is issued a voucher

based upon the assessment and if a provider continually turns

down people who bring vouchers, first of all, they are going to lose

out on revenue but second, they have every reason to accept that

client because they are going to get paid.

Second, that is what we are expecting the States to monitor in

terms of provider performance. If a provider is consistently not

working with the program, that would be reason not to keep them.

I think there are some clear safeguards in there but I think fundamentally the objective assessment that is taking place without a

conflict of interest, it is not the provider doing the assessing, and

then a voucher being issued based on the client picking the provider. Again, the only way a provider could cherry pick is to refuse

the client who comes with the voucher.

Mr. SOUDER. Here really it is you monitoring the States to make

sure that they and their eligibility standards aren’t taking the easiest ones first exposed, stable families, middle and upper income

groups, no co-dependencies.

Mr. CURIE. Correct, and the other thing that is very good about

the Access to Recovery, if you look at a profile and I believe we submitted that to you, of the grants that have been awarded, you see

many of them are hooked into drug courts, the criminal justice system, vulnerable populations, adolescent treatment, some very

tough and challenging cases just out of the shoot. So by virtue of

the populations, the high risk populations that States were able to

choose, again, you are not talking necessarily about an easy clientele out of the shoot.

Mr. SOUDER. I thank you for your testimony and willingness to

come today. I wish I could say that the general public and Congress have become more sophisticated in this area but I think we

are moving a little that way because after you put billions year

after year and you hear numbers, it becomes a little bit like the

old Vietnam days where you blow up the bridges and blow up more

bridges and pretty soon you realize you blew up more bridges than

there were to begin with. Sometimes in drug treatment and other

things, it feels like you are pouring in all this money and yet the

problem isn’t going down or you put it into child abuse, put it into

drug prevention in Colombia or wherever and we have to get more

sophisticated in our measurement standards.

When groups come in and say, oh, if we can just put it into this, we will get $17 for every dollar returned and yet the Government

is broke and if we did that, we would be 17 times more broke probably. We need to realize there aren’t instant solutions here. This

is going to be difficult. It is like a drug court but if you can get

25 percent of the people deterred or clean most of the time, it is

much better than what we had before. We have kind of oversold

a lot of these things and I think Congress in trying to analyze the

spending, if we can show both success but reasonable success with

the harder risk groups and people who weren’t able to get it, it may

be easier to get the money in the appropriations bills. I would hope

at least that we are getting more sophisticated with that so we can

avoid what good does it do to put the Government money in anyVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
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way because we do it every year and the problem doesn’t change.

That is our challenge for those of us in oversight and your challenge in administration.

Mr. CURIE. Absolutely. I couldn’t agree with you more. To be able

to paint a picture of success that is based on real numbers I think

will not only benefit us but benefit you in making those decisions,

but most importantly, it is going to benefit those trapped in addiction.

Mr. SOUDER. Thank you very much for coming today.

Mr. CURIE. Thank you.

Mr. SOUDER. If our second panel could come forward: Melody

Heaps, Treatment Alternatives for Safe Communities, Chicago, IL

and Dr. Michael Passi, associate director, Department of Family

and Community Services, city of Albuquerque, NM.

[Witnesses sworn.]

Mr. SOUDER. Thank you, Ms. Norton, for joining us. Would you

like to do a statement before I start the second panel or wait until

after they give their testimony?

Ms. NORTON. Mr. Chairman, the only statement I have is first

to apologize that I have been delayed at another hearing and then

to say how important I think this hearing is which is why I have

run by. There is an introduction of a judge in the Senate I have

to do.

All across the country, I think the link between access to drug

treatment and elimination of crime is absolute. In the District of

Columbia, we have people waiting in line for as far as the eye can

see. Mr. Chairman, as you may know, there are some hard line jurisdictions that have decided to go way beyond where the Federal

Government has dared venture. You have hard line jurisdictions

like California, the three strikes and you are out State which inaugurate the notion of diversion to drug treatment for people caught

with small amounts for the first time. I don’t know how that is

working out. All I know is they found their criminal justice system

was so overcrowded, so costly with people who are not classic felons

or classic criminals, that they have decided, for all their law and

order concerns and innovations, to try something new.

I am interested in this hearing in particular and in what we in

Federal Government can do to increase access to treatment, real

tough treatment. There are all kinds of folks who claim to be able

to treat addiction. I think treating addiction, Mr. Chairman, must

be the most difficult thing in the world to do.

We all know something about addiction. Along about 10 p.m., I

need grapes and it is all I can do to keep from going down to get

some grapes. I have a sweet tooth and if I didn’t exercise, I am not

telling you I have real self control when it comes to the sweet

tooth, but if I didn’t exercise and do a lot of other stuff, I think the

sweet tooth would have taken hold of my body by now.

Try then to analogize to somebody who, for whatever reason, has

a tendency toward an addiction that is even more harmful and I

think that, first of all, we can be more empathetic but then we

know from our own experience that unless we fasten upon treatments that in fact say, there is something approaching carrot and

stick that even the best treatment doesn’t work, so I am here to

be educated and thank you for this hearing, Mr. Chairman.

22

Mr. SOUDER. Thank you for coming.

We will start with Ms. Heaps.

STATEMENTS OF MELODY HEAPS, PRESIDENT, TREATMENT

ALTERNATIVES FOR SAFE COMMUNITIES; AND DR. MICHAEL

PASSI, ASSOCIATE DIRECTOR, DEPARTMENT OF FAMILY

AND COMMUNITY SERVICES, CITY OF ALBUQUERQUE, NM

Ms. HEAPS. Thank you, Mr. Chairman and members of the committee.

First of all, it is a real privilege to have been asked to testify on

Access to Recovery. I particularly find it a privilege because I know

the work that you, Mr. Chairman, have been doing to support

treatment and particularly to look at the issues of reentry and the

impact reentry for criminal justice clients is having on our communities. I applaud your work and applaud the work and interest of

other members of the committee on this very, very serious, serious

problem. Thank you so much.

I am Melody Heaps, the founder and president of TASC Inc.

TASC is a statewide, not for profit organization headquartered in

Chicago. Our primary span of services involves linking drug-involved individuals in the criminal justice system with communitybased treatment and other services. In fact, by statute and administrative rule, we are the designated agent of the State to do so.

We provide the initial screening and assessment to the court, we

facilitate admittance into substance abuse treatment and we incorporate a hands-on approach to providing case management services

through the utilization of community resources that support clients

and help them navigate through their regular social service system

toward recovery. We also work with individuals involved in the juvenile justice system, the child welfare system and the TANF system.

I would like to talk to you today about Access to Recovery and

how it is going in Illinois and how it is being applied, but I also

want to talk more broadly about the implications of the program

for people in recovery, for families and communities and for local,

State and national drug policy. Like many States, Illinois continually grapples with the problems associated with drug use and

crime. In our urban areas, we are among the worse in the Nation

in terms of drug use by arrestees at between 70 and 80 percent.

In addition, yesterday at a meeting with HIDA, we found out that

Chicago ranks No. 1 in heroin deaths and in emergency admissions

to hospitals for heroin. It is a ranking that does not bode well for

our city.

Cocaine and heroin constantly emerge as problems and the Cook

County system alone, the largest of its kind in the country, processes upwards of 55,000 felony cases each year. Most of these involve drugs or drug-related crime. Forty percent of new admissions

to Illinois prisons are for felony drug possession cases. Even despite

a recent attempt, the opening of a 1,000 bed Sheridan treatment

and reentry prison, the large majority of our criminal justice population needs drug treatment but does not get it.

This is a population with a complex set of needs. In addition to

drug use or addiction, some will have mental or physical health

issues, some need housing, most need education and jobs, many

23

have children in our welfare system and most of them will not be

eligible for Medicaid or any other kind of private insurance.

We know if we want to promote long term recovery, promote restoration of citizenship and productivity while at the same time reducing drug use and reducing crime, we have to address all of

these issues. Addiction treatment may be core to the stability of individuals, but if any of these other concerns go unaddressed, their

chances of returning to drug use and crime increases significantly.

It was with this in mind that the State of Illinois in partnership

with TASC decided to apply for the Access to Recovery funds to

support service delivery to individuals sentenced to probation with

demonstrable drug problems. We already have a number of programs in Illinois that have been addressing this. There are the

Statewide TASC services, drug courts, intensive drug probation but

the sheer volume of probationers, over 125,000 at any given time,

means that only a fraction of those needing services will have access to them.

Access to Recovery will predominantly target populations in Chicago and Cook County, two surrounding counties who aren’t otherwise receiving services but we are also piloting it in some rural

areas where the additional challenges like transportation, scarcity

of providers are major barriers to successful service delivery. One

of the key components of the Access to Recovery model is a comprehensive assessment and referral process. Any probationer that

comes into our program will be assessed for needs in a wide array

of behavioral and other social service areas. In fact, we are putting

together what we call an assessment to develop a recovery capital

index. What does the individual have in terms of his own capital?

Does he have a home? Does he have a family? Do they have an

education, so that we will be able to tell the degree of depletion of

these resources in an individual?

Obviously substance abuse is one area. So is mental and physical

health, housing, education, job training, family and life skills. Once

the assessment is complete, we identify qualified providers in the

client’s community and make referrals.

From a service delivery perspective, Access to Recovery represents something that is rarely seen in publicly funded services of

any kind. That is client choice. We know there are core services

that a client in recovery will benefit from like individual and group

counseling but we also know that every individual responds differently. If our goal is individual recovery, then our strategy must

be to help the individual identify the programs and services in the

community that will best help them achieve a place of stability.

Some will benefit from a mentor relationship, some will benefit

from services in a faith-based context that addresses their spiritual

needs as well as their clinical needs. Access to Recovery is truly a

revolution in service delivery because it allows and empowers clients to do what works best for them.

In that regard, I do want to acknowledge the President, his vision, his promotion of and support for the expansion of treatment

in our communities. I also want to acknowledge the leadership of

the Department of Health and Human Services, Substance Abuse

and Mental Health Services Administration, particularly SAMHSA

Administrator, Charles Curie, for taking hold of that vision, conVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
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ceptualizing recovery in the broadest and yet most personal sense

and for pursuing innovative strategies like Access to Recovery.

This initiative has stimulated growth and challenge in our field

that would not otherwise have occurred with a simple increase in

funding. I also acknowledge the work that the Center for Substance

Abuse Treatment has done in developing the proposal and in helping implement this very important program under the leadership

of Dr. Wesley Clark.

Access to Recovery will bring funding to community organizations that might not otherwise have such. TASC has been operating in Illinois for over 30 years. One of the fundamental constructs

of successful recovery has always been getting the community involved with the individual while the individual is getting involved

in the community. Local providers understand local issues. They

know strengths, weaknesses and potential challenges of reintegrating ex-offenders into their community. They are more culturally

and socially aware and they understand the best circumstances

that precipitated the drug use in the first place. When the client

is involved in local programs, it creates a level of trust and comfort

that may not exist if that same client were required to travel

across town or in some instances, across the State.

From a policy perspective, Access to Recovery is important because it breaks down all the traditionally disparate funding

streams and focuses funding on one thing, recovery. Success is

measured by how well you assist an individual in achieving a place

of clinical and social stability. This sounds like common sense but

a program of this size, scope and complexity would have been almost impossible under any other previous funding mechanism.

This move toward recovery focused and client focused funding

started several years ago when many of the major Federal departments pooled resources for the Coming Home initiative. Access to

Recovery represents the natural evolution of that strategy and I

applaud the decisionmakers who were able to accomplish such a

major sea change in funding and policy strategy in so short a time.

Additionally, because Access to Recovery is based on client

choice, it will result in funding efficiencies we have never seen before. The right resources will be applied in the right intensity at

the right time to the right people. The implications are huge. We

will finally be able to start getting a handle on what we need as

towns, States and as a Nation to turn the tide of drug use and drug

crime.

I believe that Access to Recovery is the start of an innovative,

new approach to funding and providing recovery services, an approach that focuses on what we have always been about, a full continuum of services supporting recovery which leads to the restoration of individuals, families and their communities. Right now

there are 14 locations around the country that over the next 3

years will be redefining what it means to provide treatment and recovery services in an effective and efficient way. This is a critical

time and a critical issue.

Thank you for your time and I would be happy to answer any

questions.

[The prepared statement of Ms. Heaps follows:]

25

26

27

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Mr. SOUDER. Thank you.

Dr. Passi.

Dr. PASSI. Mr. Chairman, members of the committee, I am

pleased to be here to speak on behalf of Access to Recovery. I am

particularly pleased that CSAT found something worthy in what

Albuquerque has been doing for the last several years and used our

work to help shape the Access to Recovery program.

Needless to say, we believe in the approach articulated in Access

to Recovery. Having built a system like it using local funds that

will approximate $4 million a year during the current fiscal year,

we will invest more money locally in this treatment system even

while we welcome the resources that will come to us from the Federal Government. We speak here about something to which we

have made a major investment and are happy to share our experiences with you.

The city of Albuquerque’s system is based around two basic elements. First is unbiased assessment and referral using standardized instruments. The second is patient choice among qualified providers with subsidies available to those unable to meet the cost of

care through a voucher system. Both these elements are tied together by an electronic management information system that facilitates assessment, referral, client tracking and billing and by treatment standards that assure quality treatment services.

To assure unbiased assessment and referral, the city has separated assessment from the provision of substance abuse treatment.

Albuquerque Metropolitan Central Intake is a specialized agency

that provides professional assessment of patients presenting for

problems related to substance abuse. The primary tool used for assessment is the well known and standardized Addiction Severity

Index. We administer ASI in both English and Spanish to patients

in the system. For adolescents, AMCI uses the Modified Adolescent

Drug Diagnosis instrument, another well known and standardized

assessment instrument.

Based on the findings of the assessment, patients are referred to

the treatment providers who are best able to meet their needs from

within the city’s provider network. This network currently consists

of 20 different providers ranging from large public agencies to single sole practitioners. The network is open to any provider that

wishes to join and agrees to comply with the city’s clinical standards and reporting requirements. This means we welcome providers that are public and private, for profit and non-profit, secular

and faith-based so long as they meet our clinical standards and are

willing to accept our fees.

Income eligible patients are issued a voucher. It is not a piece

of paper, it is an electronic account effectively established for them,

to assist with the cost of their treatment, if they need such assistance. They are also given referrals to those providers in the network that could offer the services that meet their particular diagnosis. The value of their voucher is determined by the level of care

the patient requires. For example, vouchers for early intervention,

brief therapy and education, are principally for people who don’t

have severe substance abuse problems and many of those are firsttime DWI offenders referred to us through the local courts. That

29

is capped at $390 per patient. For people with more severe problems, vouchers may reach $3,500.

What have we gained from this system? First, we think we have

a better managed system. We have vigorous controls of treatment

related expenses. Authorized units of treatment are based on objective assessments of needs and billed accordingly. We buy what is

needed and pay only for what we buy.

This was not the case in our previous system built around cost

reimbursement contracts with a small group of provider agencies

that independently determined what a client needed. All too often

in these cases, these were agencies whose principal tool was a hammer and for whom the clients’ problems always looked like nails.

Beyond better management, we believe that opening the system

to a broader range of practitioners has increased the likelihood of

matching patients to the treatment approach and treatment setting

that best meets their needs and preferences. Rather than narrow

options to a handful of publicly supported providers, we now offer

a broader range of treatment approaches and treatment settings

that gives a system substantially greater flexibility in meeting different needs.

Most of the providers in the network moreover participate in the

private market for treatment services and are not wholly dependent on the city for their financing. City-subsidized clients at a given

agency in a recent 45 day period, I just picked one at random,

ranged from one or two up to 165. The mean number of city-financed patients at an agency was 17.

Offering clients genuine choice in selection of a provider appears

to affect the process of treatment in a couple of important ways.

First, there is some element of market discipline. The patient is

free to change providers if he or she does not believe that their

needs are being met. We actually have had relatively few patients

electing to change providers in midstream but they are empowered

to do so if they want to and that appears in some way that I

haven’t been able to establish by research to better engage them

in the treatment process.

Moreover, I think and more importantly, simply having choice

from the outset makes the patient an active, empowered participant in the treatment process. They are not just routed there by

government, they are required to commit at least that one initial

act of choosing a provider.

How does this affect their outcomes? I can’t say we are getting

better outcomes now with a differently managed system than we

were before. The only reason I can’t say that is because our data

from the way we operated before was so bad that I have nothing

to compare what we are getting now against. We do have methodologically valid data, however, to show that we are getting positive outcomes, reduction in drug and alcohol use, reduction in binge

drinking, reduction stress, reduction in depression, reduction in

anxiety through the treatment process.

Shortly before ATR was launched, we in fact launched a similar

initiative locally looking at domains of outcomes, establishing three

at least that are similar to CSATs looking at sobriety, employment

and criminal justice involvement. I don’t have the data yet to report to you the results but initial outcome data looks positive for

30

us. I think it is important that we all recognize that outcomes

aren’t driven by the way in which the system is managed alone. It

is also dependent on the quality of the treatment services that are

out there.

Recognizing that, we have allocated about $200,000 a year in

local general funds to support improving treatment to all of those

20 providers within the substance abuse system to try to increase

their knowledge and skill in applying evidence-based treatment

practices.

That, members of the committee, is the Albuquerque system. I

would be happy to answer any questions you have.

[The prepared statement of Dr. Passi follows:]

31

32

33

Mr. SOUDER. Thank you.

Let me make sure I understand precisely how this is working.

Dr. Passi, you are in the city of Albuquerque and the State of New

Mexico received a grant and then it went to your organization in

the city of Albuquerque?

Dr. PASSI. Mr. Chairman, the Albuquerque system was developed

using local funds prior to ATR. When CSAT was looking at designing ATR, our system was one that they looked at as a system that

uses a voucher-based program in order to finance drug treatment.

So we have been doing this for about 6 years, entirely with local

funds.

Mr. SOUDER. Have you received any Federal funds from this new

program at this point, Access to Recovery?

Dr. PASSI. We are a partner with the State of New Mexico. We

have not yet received funds. The funds have not been released to

us as yet.

Mr. SOUDER. Because New Mexico is listed as one of the recipients, when you say you are a partner, it means you will be one of

the groups that most likely will receive funds from the State of

New Mexico or are you designing the State of New Mexico program

or a mix thereof?

Dr. PASSI. I think it is a mix thereof, Mr. Chairman.

Mr. SOUDER. Because you do have experience with it, you are unusual. I understand that. I am just trying to figure out how it

works.

Dr. PASSI. I believe the New Mexico State proposal to CSAT was

to expand treatment in Albuquerque using funds and particularly

in our case, we want to expand and support recovery activities in

relationship to treatment. Moreover, we would work with the State

to help other communities, namely Santa Fe, Las Cruces and one

of the Indian Pueblo groups implement a system comparable to

ours using our methods and our electronic processing systems.

Mr. SOUDER. So the State grants can be used both for actual

treatment for those who are addicted and for setting up programs?

Dr. PASSI. It will be necessary to do some work in setting up programs, I believe, in every one of these grants. In the case of New

Mexico, I think we will be able to move more quickly because Albuquerque has a system in place with a web-based way in which

screening and assessment can be done and communicated to providers, a billing system whereby accounts can be created for patients and billing done.

Mr. SOUDER. Ms. Heaps, the State of Illinois got a grant and

then you were picked as one of their recipients?

Ms. HEAPS. The State of Illinois asked us to help them come together to design the program because we are a designated agent

of the State working with the criminal justice system. The decision

was made to target probationers within that system. So we sat

down together to design the program.

The funds come to the State of Illinois, a portion of which will

come to us for the work we do, the diagnostic assessment, the referral to treatment, the case management and the information

technology that will trigger vouchers. The State retains the dollars

for the treatment and will through the electronic management system be funding the programs that do take our clients.

34

Mr. SOUDER. And then in setting up the system, are you setting

up predominantly for Chicago or for all of Illinois?

Ms. HEAPS. Because of the vast numbers we are dealing with and

obviously limited resources, we targeted Cook County as the primary seat because of the vast numbers of probationers that are

there. We also added two what is known as color counties which

essentially are suburban/urban areas and then added some rural

areas, two rural counties, so that we could see how this pilot would

be were it to be expanded statewide.

Mr. SOUDER. In a metro area as big as Chicago, individuals have

vouchers, but how many providers would you guess there are in

Chicago?

Ms. HEAPS. Around the State, there are 140 providers with about

462 sites. Probably at least three-fourths of those are within the

Chicago metro community. We, as TASC, have developed a provider network with actually every one of the 140 licensed treatment providers and also have been working in terms of recovery

with many of the faith-based and other institutions job programs

that would help our clients in the past. So we have a network already in existence but it has not been systematized, it has not been

fully funded and this gives us an opportunity to do so.

Mr. SOUDER. In addition to those in the system trying to track

new people, do you have a process for clearing them for approval

to make sure they are adequately licensed?

Ms. HEAPS. Yes. We have a set of standards we developed with

the State. They just be licensed and certified as treatment providers. If they are not direct treatment providers but perhaps recovery

support people, do they have a license if they are treating people

in terms of safe buildings, etc. Is it a corporation not an individual,

do they have a sound fiscal mechanism, do they have a set of

standards for providing the service they have, do they have experience in dealing with this population? In order to make sure of that,

we will also have and are engaging now an orientation program,

a training program for those providers that are not used to being

more sophisticated perhaps as you were talking about earlier with

Mr. Curie, in dealing with Federal funding. So we will have an ongoing training program actually facilitated by the addiction technology transfer centers that are a part of CSAT but are locally

based.

Mr. SOUDER. Before I yield to Ms. Norton, let me see if I can

make one more kind of global picture or sense out of something.

The sheer volume of probationers, you said over 125,000 at any

given time, not in the course of a year but at any given time?

Ms. HEAPS. Any given day, right.

Mr. SOUDER. That is Chicago and Cook County or statewide?

Ms. HEAPS. It is statewide but 80,000 I believe are in Cook County.

Mr. SOUDER. Of those 80,000 probationers, how many would you

say are drug and alcohol related?

Ms. HEAPS. The research suggests that we are dealing with 60

to 70 percent that have some issues.

Mr. SOUDER. So 60,000, it looks like?

Ms. HEAPS. Exactly.

35

Mr. SOUDER. So you have 60,000 people there. Do you know how

many of the percentage of the mix of 80,000 are juvenile adults?

Ms. HEAPS. We are dealing with the adult population in that

number. We are not dealing with the juvenile population. We will

only be focusing on adults courts.

Mr. SODER. So in your Chicago area program, you are only going

to be dealing with adults?

Ms. HEAPS. Yes.

Mr. SODER. And only dealing with adults on probation?

Ms. HEAPS. Yes, that is right.

Mr. SODER. And only drug and alcohol?

Ms. HEAPS. That is right.

Mr. SODER. So we are probably at around the 60,000 number?

Ms. HEAPS. Yes, 50,000 or 60,000.

Mr. SODER. Do you have a criteria that the person has to have,

as we talked about earlier, whether it is some risk or some ability

to show an interest or is it that they are high risk? You are not

going to have the dollars to do all 60,000?

Ms. HEAPS. No, we are not.

Mr. SODER. If we were looking at 50,000 in the whole Nation, it

is unlikely that you are going to get 60,000 in Chicago?

Ms. HEAPS. That is quite clear. Again, because we have been

working with probation for so long and have been working with

them in terms of their screening mechanisms, we are going to take

advantage of what they do in terms of screens. We are going to use

the idea of people want to volunteer for treatment. We are also

going to be looking at probation initial screens that suggest there

is some activity perhaps in probation compliance, perhaps the hard

cases you were talking about that indicate this individual may

have a serious drug problem. He then would be referred to us for

a full diagnostic assessment and if found drug or alcohol addicted

or abusing, move into the treatment of their choice.

Mr. SOUDER. Thank you.

Ms. Norton.

Ms. NORTON. Thank you, Mr. Chairman.

Ms. Heaps, as I listened to you describe the licenses, I think I

heard all kinds of licenses but I am not sure I heard any kind of

license or certification for professional proficiency in treating people

with drug or alcohol addiction. Is there any such certification of licensing in the State of Illinois attached to your program or to this

particular program that is under review here today?

Ms. HEAPS. By administrative rule in the State of Illinois, all licensed programs must have certified addictions counselors and

there is a certification training program and annual training they

just comply with. So all licensed programs have individuals treating individuals who are certified in addictions counseling.

Ms. NORTON. Can programs that are not licensed get the funding

that is under discussion today?

Ms. HEAPS. Absolutely. We estimate that programs that are not

licensed, programs that will do the recovery support, whether it is

the spiritual counseling or the jobs or education, who will not or

may not be licensed as a treatment program will, through our program, be able to get support, will be able to get the voucher paid

for their services. We will do so based on a set of standards that

36

I was talking about, bringing them in for training and orientation.

In a mechanism, we are projecting that by the end of the second

year, almost 40 to 50 percent of the dollars will be going to other

recovery support service programs, not simply licensed treatment

programs.

Ms. NORTON. I tell you what, Ms. Heaps, I am very fortunate

with my children. If I had a son or a daughter who had an alcohol

or drug problem, one of the first things I would look to would be

to see the level of professional proficiency. I raise this only because

I look at the series of things that HER uses, those are the things

you look to, abstinence I don’t know for how long, stable housing,

social connectiveness. I am very troubled by programs that are unlicensed or uncertified, very frankly, because I see them all around.

They hover around these communities. The communities that have

the greatest drug addiction have all kinds of programs springing up

with people who are just like me, they don’t know anything except

they claim to have the ability to treat people with what I regard

as the hardest of all things to treat. Give me cancer or heart disease, the causal relationship I think has worked out there better

than an addiction.

I just want to indicate my skepticism not of what you are doing

but of the very idea and I speak from seeing the programs that

abound. For example, if any religious program can get money, I

happen to know that people who are most affiliated with a church

are most likely to be able to be drug free. We have many ministers

who have mentoring programs here quite unrelated to whether the

Federal Government has dollars to hand out or not because they

understand the relationship between faith and drawing people from

addiction. Alcoholics Anonymous, for example, has often been faithbased.

I have been very troubled by some of these folks who claim to

be able to meet standards like this, particularly since the standards see so amorphous. I just want to indicate that skepticism here

because these programs have grown up so often in the AfricanAmerican community and it is very easy, particularly if you are a

religious-based program, to show a tiny group of folks who were affiliated with your church or who you can show in fact met these

standards. So much for that.

The most of those affiliated with your two programs come out of

the criminal justice system. Do most of them in one fashion or another have some contact with the criminal justice system?

Dr. PASSI. Representative Norton, about 60 percent of the patients that flow through Albuquerque Metropolitan Central Intake

are referred to it from the criminal justice system.

Ms. NORTON. About 60 percent?

Dr. PASSI. The other 40 percent are self-referred or come from

other referral sources.

Ms. HEAPS. Under our program, it will be 100 percent. They will

be under the jurisdiction of the probation department coming to

our program.

I concur with your concern that drug treatment be delivered by

licensed professionals and I think the State of Illinois worked very

hard to make sure and has a very rigorous licensure program in

place. So we are using them for treatment but we also recognize

37

that we are dealing now with partnerships and that there are job

programs, faith-based organizations out there that need to welcome

these individuals in the community and surround them with support.

Ms. NORTON. That is very good if you are a job program but if

you are in the business of helping people free themselves from addiction, you are in a very tough business and I think you have to

be able to show some proficiency. The standard I use for the people

in poor communities is the standard I use for my son and I don’t

see that as the standard if people can get government money who

don’t have that kind of professional proficiency.

Your 60 percent and your 100 percent also tells me that the best

way, which I think is very typical, to get drug abuse or alcohol

abuse treatment is to knock somebody in the head or commit a

crime. I just think we have to face that. There are all kinds of folks

waiting in line saying catch me before I kill. I know I am a crack

head. In fact, if you are virtually possessed with this addiction, the

notion of having to go to jail first is very troublesome. I don’t know

what to do with that except that they are waiting in line. We can

get hold of them but we are not doing that.

I would like to know, finally, your evaluation of drug courts and

what you know about drug courts. That is not a choice exactly. We

have one here that is very successful. It is a kind of choice because

you do choose to deal with your addiction and the crime that may

be associated with it or you have made another choice, the choice

to go through the traditional criminal justice system. I wonder

what you think of that choice, the drug court or if there are drug

courts in your jurisdiction with which you are familiar?

Ms. HEAPS. Yes, Representative Norton. In fact, we run six drug

courts in the State of Illinois or are affiliated with them. TASC is

a precursor to drug courts. It was set up in the early 1970’s to be

a sentencing alternative to incarceration for individuals involved

with drugs. So much of the drug court protocols emerged from what

had been TASC protocols but concentrated now on an individual

courtroom where case processing of drug cases were to alleviate

much of the overwhelming drug cases that were coming into the

justice system practically shutting it down.

Our experience in the criminal justice system as a leverage for

successful outcomes I think follows what research was done particularly by UCLA which because we know addiction is a disease

of denial, when the choice is treatment or jail, and the individual

not always, not always chooses treatment, I can’t tell you the number of our clients who would rather go to jail knowing they will get

out in 4 to 6 months or maybe a year rather than go into treatment

where if they fail, the consequences will be severe. People are more

likely to succeed, be retained in treatment if there is some jurisdictional hammer as it were over their head. So drug courts can be

a very effective mechanism for moving people into recovery and retaining them in treatment. We know that the longer you can retain

an individual in treatment, the better chances for recovery.

Dr. PASSI. Our experience in Albuquerque has been similar. We

do have a drug court and in fact we worked closely with the local

district court in establishing their treatment protocols. All evidence

is as Ms. Heaps suggests that for a certain portion of the criminal

38

population, this is an effective way for us to get them into treatment and second, to retain them in treatment.

Ms. NORTON. I will just say in closing, Mr. Chairman, I think

both of you have indeed targeted the group I am talking about. We

can’t get to most people ahead of time. It is naive to think when

we don’t get to people that all you have to do is arrest them and

that will deal with it.

I have been very impressed by what judges have said about the

effectiveness of drug courts. I very much endorse the notion of

choice. I think the first choice you have to make in order to free

yourself from addiction is that you want to do it. That is kind of

the ABCs of how to proceed. That is why so many people don’t

make it time and time again. Of course if you make that decision

and you have a choice and you find a particular program that suits

you, that would be even better.

I suppose I am most concerned with the place, and Chicago

would know all about this, where addiction almost comes naturally

because you are in neighborhoods where people are surrounded by

addicted people, by the selling of drugs, and if we know that is

going to be the case, it does seem to me that we have to face the

fact that once that first drug related crime is committed, we have

a magic opportunity to get hold of that person in a carrot and stick

way and therefore that the drug court may be one of the best approaches or devices that we have been able to use at least for those

who are most likely to come in contact with the worse kind of addiction.

I do note and was fascinated, Dr. Passi, that you said alcohol addiction was more prevalent in your program than drug addiction.

So all these things have to be very much tailored to the jurisdiction.

Thank you, Mr. Chairman.

Dr. PASSI. Multiple addictions really are increasingly the character of the patients that we see. They may be present for alcohol

abuse but subsequent analysis I think shows that most people use

a fair panoply of chemical substances from time to time or on an

ongoing basis.

Ms. NORTON. Mr. Chairman, not only with grapes but grapes, ice

cream and cookies. [Laughter.]

Mr. SOUDER. We have been joined by Mr. Ruppersberger as well

as our distinguished ranking member, Mr. Cummings. I will yield

next to Mr. Ruppersberger.

Mr. RUPPERSBERGER. Thank you.

Sorry, it seems we had a lot of hearings at the same time today,

so if I ask a question that has already been asked, let me know.

First, if specific services are not available in one area, are patients allowed to be transferred to other areas or even other States

under the program?

Ms. HEAPS. Not other States, but certainly in the city of Chicago,

other areas and maybe in the instance of the color counties or the

rural counties, we would be able to allow them to access services

in another area, yes.

Mr. RUPPERSBERGER. As far as the actual patient, drug addiction

is an ongoing battle. If a patient fails in one area or regimen of a

treatment, does that mean that it is a one shot deal or can they

39

be involved and stay in the program until they get what they think

they need?

Ms. HEAPS. I believe there will be different answers because of

the nature of our population. In the instance of our population,

which is under the jurisdiction of the probation department, if an

individual fails in treatment, doesn’t comply with what the court

or probation order says, then through a case management conference with probation, TASC and treatment, we will look at the

individual and say, can this person benefit from a different treatment, from a different placement? We may try that but if the probation office says we think this person is a threat to the community, we may not be able to offer them a second chance.

We at TASC have consistently tried to offer people second

chances, particularly looking at their case and what may need to

be modification of the initial treatment. We would hope to be able

to give them a second chance as long as we are not jeopardizing

community safety in doing so.

Dr. PASSI. In Albuquerque, we presume that substance abuse is

a chronic and a recurring illness and that patients are highly likely

to have one or more relapses in the course of their recovery. How

that might affect their relationship with the criminal justice system

has to be dealt with differently than how it affects the relationship

to the treatment system. Rather like those cigarette ads you see on

the Metro in Washington, DC, don’t stop quitting, I believe that we

would welcome patients back into the system again and again.

Mr. RUPPERSBERGER. I am going to get a little parochial and I

know you are from different States. I represent, along with Congressman Cummings, the Baltimore metropolitan area and Baltimore City. We do have a serious problem as does Chicago and

other areas. It is my understanding that our State has not either

made application to get the moneys that are available for these

programs. What suggestions would you have for the State of Maryland or any State that really hasn’t taken advantage of this program to move forward and to get the benefits?

Ms. HEAPS. That is a very good question. Knowing a little bit

about the work that Maryland has done. Maryland has a drug

court, I believe, and you have had TASC programs. So obviously

from my standpoint, the first thing is to look at the client population that does not now have access to treatment and decide where

and how you will isolate that population and give them access. Do

you want to move criminal clients into treatment, do you want to

make it broader, what level of treatment do you have in the community if you do make it broader?

It seems to me that the State needs to partner with local or

statewide private agencies as Illinois did with us to conceptualize

the system and designing the system so that you might be able to

apply next year. I am surprised, quite frankly, that Maryland did

not apply. It would seem to me it is a classic case, much like Chicago is, and that some of the same decisionmaking processes would

be potentially successful given your experience, given the breadth

of your treatment, and given the fact that I know Baltimore has

worked on this issue before. Hopefully you would be able to do so

and I would be happy to talk with anyone in Maryland or the city.

Mr. RUPPERSBERGER. That is good and we might followup.

40

If you were to go somewhere to get involved in this program for

the State of Maryland and Baltimore, if you were me, where would

you go, to the Governor, to the Mayor? What I am trying to find

out is how we get started because there are a lot of resources here

that may be very useful.

Ms. HEAPS. The State must apply for these grants. So it is the

State, the Governor’s office that must do the application, submit

the application. Obviously the Governor’s office has to work with

your single State agency for substance abuse and potentially with

leading providers in the community and/or criminal justice system.

Mr. RUPPERSBERGER. So the mayor?

Ms. HEAPS. Yes.

Dr. PASSI. I would echo that and I would say the city of Albuquerque has had a fairly good relationship with the Baltimore substance abuse systems since the time we were both target cities

under CSAT. I believe that Baltimore has in place the basic structure to make an ATR system work. I think it is a matter of getting

the Governor together with the mayor and utilizing what I at least

the last time I was looking at it was a very strong structure. It

may have simply been a choice to wait as some States did.

Mr. RUPPERSBERGER. For what reason?

Dr. PASSI. That the commitment to just building one of these systems is fairly major and I know there are some States that have

elected to wait for an additional round of funding to see what happens with the initial grantees. Indeed, the manager of our system

could not be here today because she is in Utah working with the

State of Utah to assist them in preparing an application for a future round.

Mr. RUPPERSBERGER. Just one more question because my time is

up. It is my understanding that Maryland did apply, did not get

the grant, so if that is the case, what happened, not Maryland but

generally. When States are not given the grant, what is the reason?

Ms. HEAPS. I can answer that to some extent because I am a

member of the Center for Substance Abuse Treatment Advisory

Council. Because of this grant, all advisory council members must

vote on applications that come into the center. Access to Recovery

was one. Because we were part of an application, I had to recuse

myself.

However, in the previous testimony by Mr. Curie and from what

I understand, there was a peer review committee that ranked the

proposals according to proficiency, identification of the population,

the ability to develop an independent voucher system, information

system, the ability to show you have a large network of providers

out there, both licensed treatment providers and other recovery

support providers. So there are a series of standards which I think

are objective and you could easily obtain through the Center for

Substance Abuse Treatment.

Mr. RUPPERSBERGER. Does the State put in the application or the

city?

Ms. HEAPS. The State of Maryland would.

Mr. RUPPERSBERGER. Thank you.

Mr. SOUDER. Thank you.

I will now yield to our distinguished ranking member, Mr.

Cummings.

41

Mr. CUMMINGS. First of all, thank you all for being here and

thank you, Mr. Chairman, for calling the hearing. I am going to be

very brief. Because of another meeting I did not get here earlier.

I am interested in data collection. One of the things Ms. Norton

was alluding to was how these folks pop up and I just think whenever government has money to give out, there is going to always

be some persons or entities that pop up and decide that they want

to be a part of the process and sometimes they are not qualified.

I agree with Ms. Norton and I know you agree with her too that

drug addiction is a very, very, very tough thing to deal with. I have

seen in my district in Baltimore people who have been off for 15

years, clean, go back. I have also seen something that is of great

concern and that is that the people who are out there, the recovering addicts, they know the good programs which is interesting.

They will tell you in a minute which programs are I don’t want to

say fraudulent, but that aren’t effective.

I am just wondering, is data collection a real challenge for you

and how do you measure the progress? You may have answered

this earlier but it is something that is very important to us because

we spend a lot of time in this subcommittee trying to address the

issue of effectiveness and efficiency with regard to treatment and

of course, the spending of Federal dollars. What happens is I think

it is criminal to put somebody through a program that is not a program that effectively deals with them, then they go through a process, they are not in a position for maximum potential for recovery

and then they go back on the street. The next thing you know, they

sometimes end up worse off than they would have been if they had

never entered the program because they are so frustrated and they

have been bamboozled. I am just wondering how do you address

those issues?

Ms. HEAPS. Again, both of us probably have very similar and a

little disparate ways of doing it. In the instance of our program, we

have an information system and a hands-on case management system that will track a number of things. Did the client show up for

treatment, does the client comply with treatment? We will be in

the program checking the client files, meeting with the counselor,

recording that and that then gets played into an information system data base which gets reported to the State and gets fed back

to the treatment provider and the client, by the way. It is important that the client see what their record and compliance is.

There are on top of that the outcomes that have to be measured

as a part both of the Federal program but even if the Federal program weren’t there, there are outcomes we have always measured

in terms of is the client complying with treatment, are they moving

in treatment, are they drug free, is their status drug free, are they

looking or is there a stable living arrangement, is there family or

social engagement, do they have education or a job, are they crime

free? So there are a series of outcomes which are frankly not rocket

science. They are basic to what we know it means to be a citizen

in our communities. Those outcomes are applied to every individual

case, the data is collected, it is again transmitted to the various

parties.

In addition, there are data required that look to do treatment

providers open their doors, do the individuals have access to treatVerDate 11-MAY-2000 11:58 Mar 03, 2005 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6633 D:\DOCS\98353.TXT HGOVREF1 PsN: HGOVREF1
42

ment, what is the number of treatment providers, who is licensed

to do the treatment versus who is a recovering support service in

Illinois’ system? The money that will go to licensed providers and

to recovery support services will be tracked again with hands-on

case management and data collection. So we will know very, very

detailed, per case what is happening in that individual’s recovery.

To the issue that has been raised and you raised again, it is true

that money can bring a lot of folks to the table, many of whom really have a client’s recovery in mind and many of whom do not but

I think each of us has had to set up standards for participation in

this program. I have a list here which I would be happy to provide

for you, a faith-based organization that has had experience in the

community, that is a legitimate organization that knows how to

handle the population can offer the kinds of support and services

that are critical to support recovery.

Dr. PASSI. We are getting pretty good at tracking process. Our

system works really well at making sure we are getting what we

pay for and we are paying for what we need according to an assessment instrument, but I think you are looking beyond that and that

is where I think CSAT is making remarkable strides with the ATR

program. That is to say, let us just stop measuring process, let us

start measuring outcomes. I think the domains that they lay out,

abstinence, employment, crime and criminal justice, family living

conditions and social support are really the things that we have to

start measuring and that we can measure. It is not real easy.

There are some problems that we have run into in measuring

criminal justice involvement. You can’t rely solely on self report obviously and matching records from the criminal justice system with

patients in the treatment system and confidentiality issues that get

in the way but those issues are overcomeable.

I now believe we are making major strides toward being able to

say is patient X abstinent for a month, a year, 5 years after treatment; are they not arrested; are they arrested once; are they arrested weekly; did they get a job, did they not get a job; did they

get housing or are they on the street? Those are the things ultimately that I think the addiction treatment system is aiming to affect. We are not simply in the business of providing treatment, we

are in the business of buying abstinence, of buying employability,

of buying recovery, I think is the concept that goes with it. Those

are objective things, things that can be measured and those are

things that we should be measuring.

The city of Albuquerque started that before ATR in baby steps.

We think ATR will push us to look at all of those domains, measure those domains and ultimately reward practitioners for their

ability to produce positive outcomes in those domains.

Mr. CUMMINGS. Before I came to Congress, I was in the State

Legislature and I also practiced law. A group of mainly gentlemen

in my neighborhood, professional men, got together voluntarily and

worked with a lot of people who were coming out of our boot camp

program on Saturdays in a self help program, and didn’t get a dime

from the government. I looked at one of these evidence-based domains, social connectiveness. I don’t know exactly what that means

and I am sure you will tell me.

43

We did this program for about 3 years and we noticed there were

people who were socially connected but they were connected to the

same people that sent them to prison. I can tell you one of the

things we noticed too was the people who found a whole new set

of friends and/or reoriented themselves toward loving their family,

it may have been a child, it may have been a wife, they may get

married or something like that, those were the guys I see on the

street today who never went back.

A lot of this was drug related, things they had been in boot camp

for. They never went back and were living productive lives and almost everybody who went back to the social group they were from

are back in prison and usually have committed much more serious

offenses.

When we talk about social connectiveness, what does that mean?

Does that mean going to church?

Ms. HEAPS. You actually, I think, defined it yourself. This idea

of family, getting back with a child, reinvolvement with the family,

going to church, going to peer support, AA, Winners Circle, a number of communities. We aren’t talking about social connectiveness

going back to the gang. We are talking about changing perhaps

patterns of social connectiveness that are constructive, that are

supportive, that are healthy. That we have to look at and there are

ways to be doing that. That is where I think faith-based organizations have a huge role in this. In some of our communities, they

are the only institutions, especially for people in some of our communities with huge reentry. I think the faith-based community has

a wonderful role in helping develop social connectiveness.

Mr. CUMMINGS. You would agree, I am sure, with Ms. Norton, if

you are going to do the faith-based, you also have to make sure you

have the professional piece in there. As the son of two preachers,

I have all faith but I also know you need to have some professionalism in there too.

Ms. HEAPS. Yes.

Mr. CUMMINGS. One of the things I know, I know about people

who have been addicted. They are first of all, usually some of the

best manipulators. I couldn’t help but think about a good friend of

mine who borrowed my lawnmower, said he was going to cut some

grass and wanted to make a few dollars and I never got my lawnmower back but I did see it at a used lawnmower place about 3

weeks later, on sale for about one-tenth of what I paid for it.

I guess what I am trying to get to, I just think for people who

may be naive with regard to recovery and there is another piece.

One of the things I have noticed is that people will come to my office and say to me because they have been through a 12-step program and may have 6 or 7 years being clean, and will say, I want

to start a program as if they now have become the experts because

they have sat in the 12-step meetings, gone through the anniversaries with different people and for a lot of folks, it is a way to get

into business.

They may have good intentions, but again, they may not have

the support systems and all that. On the other hand, one of the

things I have noticed is a lot of people who have come before us

in this committee have had histories of drug addiction problems

and have clearly made some tremendous strides and are being very

44

effective, or at least appear to be very effective and efficient in

what they are doing.

How do you make sure you guard against all of that? That is

tough.

Ms. HEAPS. I know the depth of concern here. I can hear it obviously and it is not the first time I have heard it. I don’t mean to

minimize it but it really isn’t rocket science. It is called partnership. In Chicago, our licensed, certified treatment counselors at

TASC go and work with the faith-based organizations or other organizations, go into their facilities, talk with them, orient them, try

and orientate them, try and work with them, look at what resources they have to offer, construct a program that would make

sense for the clients we see in a community that need to be reintegrated fully. So it is possible to do in partnership.

I agree with you, there has to be people who know the business

of treating drug offenders or drug addicted individuals as a part of

the process. What we have learned is when we just use that in

terms of addiction and didn’t deal with the other issues, people

were falling away. They had finished the drug treatment and then

they would reoffend and get back on their addiction patterns because we weren’t using the other supports in the community,

weren’t dealing with the spiritual aspects, the job aspects and this

program does in a unique way allow us to very effectively integrate

both in an efficient manner.

Mr. CUMMINGS. Last but not least, Mr. Chairman, as you were

talking, I could not help but think you know I am always fascinated by Starbucks and how Starbucks has become so popular. I

think one of the reasons why Starbucks has become so popular is

people need a social place to go. If they don’t want to go to a bar,

they need some place to go. I think you are right with regard to

faith-based organizations. I think it is a great place for people to

go. They go to church, they have all kinds of functions, dances, singles ministry and all this kind of thing, but I just want to make

sure that we are very, very careful.

You may be listening to me and may be saying he is concerned

about the money but I am concerned about something even more

important than the money, the credibility of treatment because up

here if people don’t feel that treatment is working, then the money

is not going to come from the Federal Government. That is the

problem. When people believe that it is working and we have made

some tremendous strides thanks to the chairman and many others,

toward treatment. The more we know there is some accountability,

the more we know it is working, I think the more Members of Congress are open to seeing those funds are flowing into those programs. It is just a win-win when we do have that accountability.

Dr. PASSI. If I might weigh in on that for just a second, Congressman. The first question you ask your oncologist if you have cancer

is not are you a recovered cancer patient, you ask what is your

training as an oncologist. If the oncologist happens to have recovered from cancer, that may make him a more sympathetic physician.

I think increasingly we have to ask the same kinds of questions

of drug treatment providers and in the city of Albuquerque we certainly are doing that. We are first of all demanding the highest

45

standard of licensure that we can under State regulations. More

than that, we are investing local funds to increase the level of skill

of those practitioners in evidence-based treatment practices. Professor Bill Miller who is an outstanding substance abuse treatment

researcher happens to be at the University of New Mexico and I

think Bill estimates that something like 80 percent of the money

we spend, not just public money but all of our money, is being

spent on practices that we know don’t work and 20 percent of our

money is being spent on practices that we know work.

I think that the approach that we have adopted in Albuquerque,

and I think the approach implicit in Access to Recovery, is going

to try to shift that balance because this is not just about getting

people into any treatment. It is getting people into the right treatment and the right treatment has to be those modalities that we

know will succeed.

It ain’t rocket science. We know a bunch of stuff that is out there

that is working. We just have to start paying people for doing it.

Mr. CUMMINGS. I have to ask you this and then I am finished.

You said something that just hit me, just struck me. When we

are talking about quality, do we have anything anywhere to your

knowledge, like lawyers and teachers, you have to go back for certification if there is a new method. You need to know what is up

to date. Do we have anything like that in Albuquerque, for example, so you keep the people who are doing the treatment right on

the cutting edge of what it is that works and are constantly showing them these examples like you have a place right up the street

which is extremely effective because they use this method and we

believe this is the best practice? Are there actually mechanisms to

do that?

When you say 80 percent of the money is being spent on things

that don’t work, if that program was being funded by the Federal

Government, it would have some real problems, I am just telling

you.

Dr. PASSI. I think there is a real slow knowledge transfer process

that takes place and almost every State as a mechanism for doing

training with its providers. We in Albuquerque believe that can

happen more quickly, especially when we keep in mind that it is

largely money provided by the Congress and by the taxpayers that

is funding research that tells us what are the best ways to approach these.

Mr. CUMMINGS. The key is getting that research to the people

who are doing the treatment.

Dr. PASSI. I agree.

Mr. CUMMINGS. Do you all have any recommendations on that?

Ms. HEAPS. There are two national bodies that I am aware of but

forgive me, my brain being dead, I don’t remember exactly the

names but there are counselor certification boards that work with

individual States to develop. Illinois, for instance, has a State certification board that requires counselors to get annual training,

there are standards, there is a course of activity based on the research coming out of NIDA. I will be happy to get you that information so that you have some comfort level that there is certainly

going on a new professionalism in this counseling arena.

46

Dr. PASSI. And I think CSAT has immense resources and knowledge on this that you can tap to find ways to bring best practices

to providers in the field.

Mr. SOUDER. I want to ask a few more technical questions but

I want to weigh in with a slightly different approach leading to a

question. Both of you alluded to this and that is we in this country

have to be careful we don’t get so credential obsessed that we forget the point here is outcome. When I was a senior in high school,

I took a program called exploratory teaching where we could go

teach a class and because I had a lot of stuff going on, I couldn’t

get over to the elementary building and they put me in an eighth

grade history class. It was clear that I loved history and all of a

sudden the teacher disappeared and I had this class for the whole

semester and I was just a senior in high school.

An amazing thing happened. Because I loved history, four of the

kids who were getting an F turned to A students and the teacher

suspected that they were cheating and she retested them and that

they turned around. I didn’t have any experience in teaching. What

I did was I loved the subject. The question is, are we going to

measure the outcomes or are we going to be obsessed in the

credentialing?

If the credentialing is correct, presumably they will get better

outcomes and much of this is medical in drug and alcohol treatment and therefore, it would be logical that the outcomes would reflect the training. But in this country to some degree, credentialing

and I am going to make a statement that seems kind of role reversal but some of it is who you know and whether you have enough

income to get the credential.

Some of our problem in some of our urban areas is minorities get

excluded, lower income people get excluded and people who can

often relate to the people are in the problem. I know there can be

a street hustle part of this but you also have to be careful you don’t

get an elitism in the credentialed profession that is a disconnect

with the actual problems the individuals are facing at the street

and community level.

That leads to this question. How do you feel, because Director

Walters has been here a number of times and we talked about this

and some of the programs, that some of the funds wouldn’t be delivered to the group that is providing the services until there is

some feedback on the outcome, say they get 75 percent of the funds

and there is a 3 or 6 month delay?

Dr. PASSI. Congressman, we are currently exploring ways in

which to incentivize both outcomes and training. As to the question

of credentialing, I think there has to be some base level of

credentialing. There just are some things people have to know but

it is less an issue of the credential of the practitioner than of the

practice that they utilize, the overall approach to treatment. I

think if we simply emphasize the credential, then we get the easy

part rather than ensuring that what is happening in those clinicians’ facilities reflects the cutting edge of treatment, what we in

fact know works. If it does work, rewarding the outcomes is going

to be in the long run the best incentive for getting people to find

out how to do those things.

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Mr. SOUDER. How did you feel about delaying some of the benefits, the funds?

Dr. PASSI. I think some form of incentivizing payments to practitioners based on outcomes is a direction in which we certainly want

to proceed.

Mr. SOUDER. It really makes you focus on whether the outcomes

are justified and balanced outcomes and will lead to tremendous

manipulation of those outcomes. When I was in the graduate business program at Notre Dame and when you did case studies, I was

the one who did the measurements because once I defined the

measurements, then you start to define the problem, how you are

going to address the problem and if those measurements have real

dollar consequences, then indeed we will follow the outcomes. Otherwise, we will tend to stay at the process level.

Ms. HEAPS. I am very bad at analogies but for some reason this

came into my head about that suggestion. It is as if we are building

a plane and we decide we are only going to give you 70 percent of

the cost to build the plane which may mean you don’t get wings

but the outcome will be can it fly. There is a caution here which

is to say this is such a new endeavor that the need to build the

system to not only treat the client and give the client choice, get

the resources and the network there, develop the voucher system

and move to assessing outcomes is such that you need to fund it,

you need to get the plane built to see if it flies.

Having seen it and tested it and seeing it fly, the question is,

how long a duration and how efficient. Now you can begin to look

at perhaps funding in terms of providers and vouchers, individual

providers who may not have outcomes as good for reasons having

to do with quality of service, failure to integrate with others. There

are standards you could set up but I think one has to be very cautious when one is building a new plane and a new system to make

sure that you have everything you need and then begin to look at

how we can incentivize.

Mr. SOUDER. We will exclude all small providers and there will

only be big ones and the cash-flow.

Ms. HEAPS. Exactly.

Mr. SOUDER. At the same time, I believe that some incentives are

appropriate and obviously not without the wings. In military contracting and so on because of the overruns we have seen and because of obsession with the lobbying and the contractors as opposed

to making sure the weapons system can actually fire, that we have

had to put outcome based things in.

I wanted to ask a couple technical questions to Dr. Passi since

you have actually had a program. What percentage of your existing

program was administrative versus actually cost of treatment? Do

you know roughly?

Dr. PASSI. Our administrative costs are very low. I don’t know

that I can give you a figure.

Mr. SOUDER. Under 10 percent?

Dr. PASSI. I think it is under 10 percent. There is a fairly large

cost in the assessment and in the system. Do you count the assessment itself as administrative? We don’t, it is a clinical service and

probably could be billed separately.

Mr. SOUDER. Is that 5 or 10 percent or is that higher?

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Dr. PASSI. The assessment cost probably is running somewhere around $500 per assessment and I think that is about standard for

clinicians everywhere. Our system is in fact administered by four

people and it is about $4.5 million in treatment services.

Mr. SOUDER. You are saying each of you gets $1 million?

Dr. PASSI. We each get $1 million. In terms of the actual administrators of the program, we pay four people to do it and that might

be probably $250,000.

Mr. SOUDER. Plus overhead of the office.

When you give out the vouchers, how many of those who you give

these vouchers to don’t redeem them?

Dr. PASSI. In fiscal year 2003, we actually gave out 2,870 vouchers. Of those, 2,631 were actually activated.

Mr. SOUDER. So less than 10 percent?

Dr. PASSI. So we lost a couple hundred.

Mr. SOUDER. Do you have a utilization review process to monitor

whether they are actually spending the dollars in the vouchers?

How do you determine the dollar of the voucher?

Dr. PASSI. The dollar amount of the voucher is based on the outcomes of the assessment. The assessment will say this person

needs so much of this level of care.

Mr. SOUDER. And the voucher is then estimated for the full cost

of that program?

Dr. PASSI. The voucher is then estimated for the full cost of that

program. The patient is then given referrals to a practitioner who

can provide those services. The voucher is activated when the patient engages in service. The provider bills then on a fee for service

basis for services that are authorized under the voucher. One hour

of counseling, actually counseling is in 15 minute units, but 1 hour

of counseling will generate a unit of service payment that will then

be deducted from the total amount of the voucher until the voucher

is exhausted. It could be multiple units of different kinds of service.

A heroin addict on methadone might get x units of service for counseling, x units of services for the actual dosing.

Mr. SOUDER. Does the dollar amount that you give them for the

services calculate in whether they are eligible for Medicaid, have

any insurance of their own and assure that the treatment provider

doesn’t in effect double bill?

Dr. PASSI. Generally we attempt to take care of that with the

screening and assessment. Our assessment process doesn’t say

come in, get assessed and get a voucher. It says, come in and get

assessed. So in that same fiscal year where we administered 2,800

vouchers, we actually did 3,300 assessments and about 200 of those

assessments were for people who got referrals without a voucher.

That is, they had some form of third party coverage or could afford

to pay for the cost of their care individually.

The bulk of our patients are single, young males who in New

Mexico are not eligible for Medicaid and therefore, billing to Medicaid is almost not an issue in our system, but several hundred patients a year probably do have some form of third party coverage

through their employer that we then refer them to somebody who

accepts that kind of insurance.

Mr. SOUDER. And you are balancing that so that there isn’t, in

effect, double billing?

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Dr. PASSI. That person would not get a voucher until that third

party coverage has exhausted.

Mr. SOUDER. The same on mental health coverage, is a voucher

eligible for mental health coverage?

Dr. PASSI. No. At this point, this is for substance abuse treatment services only. If the assessment indicates a co-occurring disorder, the patient is referred to a local mental health provider to

have those problems assessed and then a determination made

about how that treatment will be financed.

Mr. SOUDER. Ms. Heaps, in Chicago, you are dealing with just

adults on probation, so any nuisances different?

Ms. HEAPS. Slightly. Because the State of Illinois retains the dollars and the voucher payment, it will double check against Medicaid rolls and treatment provider rolls to see if indeed an individual

has Medicaid as an insurer, so there won’t be double payment. I

think that is a pretty important thing that States have to guarantee against.

I am sorry I blanked on the last piece you talked about.

Mr. SOUDER. Mental health.

Ms. HEAPS. Yes, thank you. Many of our clients of course have

co-morbid situations and we believe mental health has to be a part

of the recovery process, so we will be using our voucher system

where a treatment provider cannot provide both substance abuse

and mental health to access mental health services as well.

Mr. SOUDER. I thank you for your efforts. I sure hope we can get

the Portman bill moved through. At the very least, we have a

marker out this time because long term, if we are going to hold

people accountable and put them in prison, which is our highest

risk population, we have to figure out as they are coming out that

they don’t come out more hardened criminals than they started and

figure out how to deal with this. A lot of this as you pointed out

and we hear hearing after hearing is drug and alcohol at least aggravated if not caused.

I appreciate your work in that field and will be very interested

to see the probation results in Chicago, although our numbers will

be small compared to the overall part of your problem. It is so frustrating as you see the juvenile probation officers with 260 people

and can’t possibly know their names let alone track them all. It is

an overwhelming problem and I appreciate New Mexico’s pioneering of this. We will continue to watch yours because you will be basically a step ahead of the rest of the country as we watch for the

numbers.

Thank you very much for coming.

With that, the subcommittee hearing stands adjourned.

[Whereupon, at 4:15 p.m., the subcommittee was adjourned.]

[The prepared statement of Hon. Elijah E. Cummings follows:]

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