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Monitoring Outcomes: Our New and Permanent Challenge

— Andrew M. Mecca, Dr.P.H., former Director of the California Department of Alcohol and Drug Programs, also chaired the California Governor's Policy Council on Drug and Alcohol Abuse. He served as president of the National Association of State Alcohol and Drug Abuse Directors from 1993-95. He is currently working with the California Mentoring Foundation.

Those of us in the alcohol and other drug (AOD) field will be dealing with treatment outcomes for the rest of our professional lives. There are three reasons why I make this assertion.

• Scarce public sector resources. As money sources tighten, Federal and State legislatures demand greater assurance that we are devoting those resources to the most effective programs.

• Public demands for accountability. Two-thirds of all American workers have jobs where part of their pay is based on their performance. These workers are increasingly go-ing to demand that funding be linked to performance in social programs.

• The ethical focus on client well-being. Monitoring treatment outcomes is ethically preferable to monitoring what agencies do because it makes client well-being the primary value.

These accountability concepts are much more than the latest management fad. The emphasis on client outcomes as a basis for improving governmental and nonprofit performance is a concept expanding rapidly in ways that extend well beyond the AOD field. Heightened attention to outcomes is apparent across many sectors of U.S. society — in more than half the States, in the implementation of the Government Performance and Accountability Act of 1993, in new work under the leadership of United Way of America, and in work being done by most of the major foundations.

AOD Balancing Acts

For the AOD field, using outcomes at the State and local levels to assess the performance of treatment programs is often a challenge of paradoxes. We need to develop outcome measures and monitoring systems that can satisfy conflicting — even contradictory — forces. We need:

• To pay attention to fiscal and client outcomes simultaneously.

• To phase in the use of outcomes carefully. This measured change will be occurring in a climate of urgency.

• To focus on outcomes for special populations and to set much clearer priorities than ever before.

• To lead from the public sector, while tapping the best that the nonprofit and for-profit sectors have to offer, to ensure that no one sector dominates — that leadership is balanced across all three sectors.

• To develop cross-agency accounting concepts that capture the paradox of cost-offsets. Successful outcomes achieved by an AOD agency often result in major cost savings to other agencies. These savings result from decreased recidivism, fewer child welfare cases, reduced health care costs, and increased employment.

• To market our services and to build constituencies that support AOD prevention and treatment, yet move away from resource allocations driv-en more by politics than by need.

Each of these paradoxes requires a balancing act. Framing the trade-offs will be a crucial challenge in monitoring outcomes in the AOD field. For example, managed care moves us to ward a focus on fiscal outcomes. Yet we have seen that overemphasizing fiscal outcomes — without devoting adequate attention to client outcomes — can lead to a backlash against managed care itself.

In the long term, the best fiscal outcomes are also the best client outcomes. It is only in the short run that the two come into conflict. As one policy analyst put it, "cheaper ain't better." To choose the lowest cost provider — regardless of client satisfaction, the impact on special populations, the well-being of the client's family, or the capacity of the system to deliver services — is to ignore important client issues as though fiscal issues are the only ones that matter.

A second balancing act has to do with reorganization, some of which will focus on the AOD agency. Other reorganization will reflect the need to work across all agencies affected by AOD issues. If agencies don't share concrete outcomes for the clients they have in common, then it will no longer be convincing to talk of "interagency collaboration." Collaboration without the glue of shared outcomes is just a lot of meetings.

Increasingly, State and local AOD agencies will be asked how much money they shifted last year from their least effective to their most effective programs. That clear, simple question is asked annually in the private sector, and any chief executive officer who can't answer it is in trouble. In the public sector, the question is less frequent. But AOD agency leaders who wish to make their own decisions about priorities will need a ready answer. Otherwise, these leaders may find that decisions about AOD treatment priorities are being made by their legislatures or budget offices.

Outcomes at Different Levels

In discussing outcomes, it is important to recognize the potential for confusion. Outcomes can be addressed at six different levels: