By Monica E. Oss, Chief Executive Officer, OPEN MINDS
August 1, 2024

The U.S. addiction problem seems intractable. And the health care system appears ill-prepared to tackle the problem. According to a 2024 review published in the Journal of Addiction Medicine, many physicians remain reluctant to provide addiction treatment, often pointing to a lack of institutional support. The top reasons cited for reluctance were insufficient skill (74%), lack of cognitive capacity to manage a certain level of care (74%), inadequate knowledge (72%), and the institutional environment (59.2%). 

But it isn’t just the preparedness of the medical community that’s at issue. Of the 49 million people in the U.S. estimated to have at least one substance use disorder, based on the 2022 National Survey on Drug Use and Health, only 13 million received treatment in the past year. Among those who did receive care, just 25% were treated with medications for opioid use disorder. 

To address addictions, professionals in the field are looking to new medications as a solution (despite the low uptake). For example, there is anecdotal evidence that consumers taking specific GLP-1 receptor agonists have reduced cravings for alcohol, nicotine, gambling, and other compulsive behaviors.  The pipeline of new pharmaceutical agents to treat addictions is robust, with ongoing research into medications for alcohol use disorder, as highlighted in Current Research in Medications Development; new additions to the World Health Organization’s Essential Medicines List for smoking cessation; and expanded treatments for opioid use disorder, as outlined in recent resources on medications for opioid use disorder (MOUD). We recently reported on a Nebraska’s Mid-Plains partnership with Genoa Healthcare that will integrate pharmacy services directly within the Mid-Plains clinic. 

One model for treating addictions, the therapeutic community (TC), is making a comeback. We had the opportunity to learn more about the model and the team that is updating it for the new challenges in the market in our recent Executive Roundtable, An Opportunity for Exponential Growth: The RSG Case Study. The session featured Paul W. Sobey, M.D., Chief Medical Officer and Principal, and Elizabeth Loudon, Chief Clinical Officer for Corrections, at ROSC Solutions Group (RSG). 

TCs were first launched in the United States in 1958 as an alternative form of rehabilitation for consumers with substance use disorders. They are long-term, evidence-based residential programs for the treatment of addiction that use community-as-method as the primary instrument to achieve outcomes.  The length of stay is usually at least one year. 

There are currently 3,000 TC programs in communities and in prison environments in 65 countries. Despite its popularity around the world, and particularly in Europe, this model had fallen out of favor in the U.S. 

Why bring the model back? For one, it can deliver the outcomes that payers are looking for. Studies have shown that at nine months, 68% of participants remain abstinent, and both alcohol and drug dependence scores are reduced by over 60%, according to findings from The Benefits of Therapeutic Communities and Effective Model in Addiction Recovery and Return to Full Community Living. Consumers who complete the program are 26.4% less likely to recidivate. Additionally, TCs have been shown to deliver a big return on investment—the range of the benefit-to-cost ratio is between 2.5:1 and 4:1. 

The team at RSG is focused on bringing the TC model of care back to Canada and the U.S.—and they are operating TC programs in Alberta, Canada. In March 2023, RSG received a $21.4 million grant to set up the model in Alberta (a process that includes staffing, choice of sites, training programs, fidelity maintenance, and a strategic plan going forward) for an expansion of the program to all Canadian provinces over the next 18 to 24 months. They also have plans to expand into multiple U.S. states. 

RSG is using an innovative “hub and spoke” centralized system to speed the adoption of the TC model. Instead of a lot of small, individual TCs, RSG is building a large therapeutic correctional center that will include centers of excellence and a webinar-based training model for professionals working in the system; a long-term (one year) recovery village; recovery coaches in prisons, homeless shelters, and emergency rooms; and a “front-line expert team” to advise government entities on service optimization. This centralization provides scale for infrastructure, quality management, and growth. 

The TC concept is important to provider organization executives to pay attention to as payers look for options for meeting the needs of high-needs consumers, particularly consumers with health-related social needs (HRSNs). For a large proportion of consumers with addictions, current models do not have positive outcomes—and those consumers use a disproportionately high amount of medical resources. For housing-insecure consumers and families involved in the child welfare system, the therapeutic community (TC) model offers the stability needed for successful recovery, as highlighted in the study Effectiveness of Therapeutic Community Program on Resilience and Change in Lifestyle in People With Alcohol Use Disorder And with the changes at CMS for using Medicaid funding to pay for HRSN, the TC model—reimbursed with some form of alternative payment methodology—could be an attractive proposal to Medicaid health plans.  

Right now, there is an opportunity to introduce new models for treating addictions (whether the TC model or something else) to payers and health plans. This is particularly true for those populations that have not been served with success in the current delivery system. But to introduce any new model in the current competitive and value-driven market, executive teams need to have a clinically sound model, understand the cost parameters for providing the service, estimate the performance improvements from the model (clinical, financial, and experiential), and create cost-benefit estimates for potential health plan partners, as discussed in Pushing the Social Service Line and How to Develop a Sustainable Social Supports Service Line. 

My colleague, OPEN MINDS Senior Associate, Carol Clayton, brought a great perspective to the revival of the therapeutic community concept in the health and human service delivery system, “Programmatic elements of the therapeutic community model have broad application for any person recovering or living with trauma and looking to maintain life in the community. The principles of self-help, recovery orientation, peer support and community commitment are key elements of healthy and safe lifelong living for many vulnerable populations. This includes people with an SMI, young transition-aged youth leaving foster care and headed toward independent living, women leaving a domestic violence situation, persons with HIV/AIDS, and persons in recovery from substance use disorder who have had interactions with the criminal justice system.” 

“The TLC model embodies the elements of a whole person approach—health, life, social engagement, employment and social and civic engagement—all components of meaningful life. What’s old is new again!”