require recipients to do something that the proposer viewed as salutary. It was clear, however, that many treatment providers believe that money with strings can make it harder for them to successfully compete in an increasingly difficult world, and when that was the case they rejected the concept.

The discussion and deferral of plans to link federal funding for substance abuse treatment to performance objectives under the Performance Partnership Grants (PPG) Program illustrates the problem. In the opinion of the National Association of State Alcohol and Drug Abuse Directors and a National Academy of Sciences panel, performance measures for public health, substance abuse, and mental health are not ready for prime time. Both concluded that the science of performance measurement and the data available to support such a link are major stumbling blocks (Gustafson and Sheehan, 1997).

Recognizing that data resources and measurement methods need improvement, the panel recommends that DHHS continue to work with states toward several infrastructure goals: developing common definitions and measurement methods; encouraging efficient development of data resources that support multiple public health, mental health, and substance abuse needs; incorporating state data priorities in national infrastructure development efforts; and promoting states' data collection and analytic capabilities.

Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health, Phase 1 Report; NRC (1997)

One top-down model that was discussed would have suggested changes in the incentives that currently are attached to the state block grant money used to support treatment programs in most communities. The block grant program has requirements that states pass on to service providers. For example, states are required to assure expenditures for services to pregnant and parenting women, to injection drug users, and to provide access to HIV and TB services for testing and medication (GAO, 1995). In order to meet the requirements, states may offer treatment programs additional funds to deliver new services and to serve consumers with specified characteristics (e.g., using injection drugs, caring for children). States could also use funding strings to promote collaborations among community-based organizations and research groups. The Department of Veterans Affairs approach includes a money-with-strings strategy (see Box 3.2).

The introduction of managed care into the drug abuse treatment field has produced a new, and particularly difficult, set of requirements. Most treatment providers already are quite concerned with the "strings" that come with managed care money, but the quick response by treatment pro-



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