The fight against substance use disorder (SUD) in America, at times, seems to be a neverending one.

Massive on an economic scale, it is estimated that SUDs cost the nation $600 billion annually. Then, of course, is the emotional and public health toll of the epidemic, measured routinely in numbers published by organizations like the Centers for Disease Control and Prevention (CDC), who track overdose deaths.

On October 13, 2021, the CDC released provisional data showing overdose deaths reaching another year-over-year record, inching ever close to 100,000. The nation has since breached that grim milestone, as one month later, the CDC reported 100,136 overdose deaths having occurred over a 12-month time span ending in April 2021.

With no end in sight, those like Tom Britton are tasked with executing critical responsibilities on both a health care and business level.

Since 2015, Britton has been the president and CEO of the Chicago-based Gateway Foundation, one of the largest non-profit treatment providers in the nation. Founded in 1968, Gateway employs around 1,400 individuals and treats approximately 30,000 individuals annually in Illinois, Delaware, Florida, Michigan, Missouri, New Jersey, Texas and Wyoming.

Providers nationwide have been scaling up operations to meet demand in a treatment market estimated to be worth $42 billion. When it comes to Gateway, Britton said that their top priorities include increasing its virtual presence, leaning into value-based care, investing in technologies and fighting off workforce shortages rampant throughout the behavioral health care spectrum.

Last October — one day after the CDC released its then-latest round of provisional data — Britton was in Chicago attending the inaugural INVEST Conference, hosted by Behavioral Health Business. While there, he took time to talk with BHB, where he shared his thoughts on Gateway’s priorities.

Portions of this interview have been edited for length and clarity.

Inside the C-Suite shines a spotlight on executives in the behavioral health space. Know a top leader who’d like to be profiled in an upcoming Q&A? Drop us a line at [email protected].

BHB: Let’s talk about the state of SUDs. How have the rising rates nationwide impacted Gateway’s business?

Britton: There are three worlds of people that try to access care. You’ve got the high net people that pay for private treatment. You’ve got the middle class with commercial insurance, and you’ve got the uninsured and publicly insured.

The biggest growth for us has been around the population of the uninsured and Medicaid-insured, and for them, that access to care has been very valuable. Our commercial business has stayed about the same. We have about a waiting list right now of 1,000 people that want treatment.

Do you think COVID has had a significant part to do with the demand?

Addiction by nature is a disease of social isolation. The worse one’s symptoms get, the more they isolate. For people in early recovery, a lot of the solution is rejoining the community. It’s why the group model of counseling is so successful.

When suddenly people are forced to be at home and all of the 12-step groups went virtual, and all the counseling groups went virtual, that was a real barrier for a lot of people who didn’t know how to join with others in that way.

Do you think Gateway has risen to meet that challenge, and if so, how?

One of the things Gateway did in reaction to that is that we identified how you develop and train staff, how you develop and train clients to survive better in a virtual environment, and how you design care. We’ve done outcome studies of people receiving services that are face-to-face only, a blend of services, as well as only virtual. In the beginning, there was a meaningful gap between face-to-face and virtual, and we’ve almost eliminated it completely.

Is there a particular SUD that Gateway is treating more of its clientele for at the current time?

Methamphetamine is making a comeback, and it’s more in a rural setting than in an urban setting. Opioids are somewhat flat in urban settings, and I think some of that has been driven by access to the pipeline, with a lot of the heroin and a lot of the opioids coming from Mexico and other parts south of the border. And they didn’t get over the border as easily as they used to.

We’re also seeing an increase in opioid use disorder because, I think, people drink more. There’s a lot of data about how much people drink, and one of the things that we’re also seeing is that there’s a new trend of having more people coming in for first treatment versus repeat people. I think that is a direct result of intensified symptoms that people had during the period of social isolation.

Going forward, do you think Gateway’s services will be more delivered by virtual means?

As we have done de novo growth, we’ve had the calculus of whether there was enough business to open a brick-and-mortar shop. That’s driven a lot of our growth. With virtual services, that changes the calculus. So we have two strategies. One, is providing virtual services to existing clients, even in markets that have brick-and-mortar places. And then a second product is virtual-only for people that either don’t want to — or can’t — get some treatment.

More behavioral health providers are moving to the value-based reimbursement model. Is value-based care a significant part of Gateway’s current service delivery?

That’s been part of our strategy for about four years now. We’ve been saying over and over as an industry for 10 or so years now that, “This is the year, this is the year, this is the year,” and it’s never the year. People are saying that again this year (laughs), but we’re having much more interest from payers moving into risk-shared models.

Living in a fee-for-service world, it’s all acute-based. You present with an acute crisis, we deal with the acute crisis, and once you’re stabilized, you’re discharged. There’s really three to six months max with that kind of treatment, when the research says 12 months is what you need.

One of the difficulties providers and payers are having with value-based care is in defining exactly what the successful outcomes are that will be reimbursed. There might also be the difficulty of providers possessing the proper measurement systems to assess outcomes. Does Gateway have a model of its own that it uses to track and measure outcomes?

We have designed a risk-stratified model that — based on acuity presentation — determines what’s on the front end of services. But everybody gets the same back end of services, which involves using digital solutions to engage them for 12 months, case management, peer support and relapse intervention services.

Value-based care is here, and I think in the next 12 to 24 months, there’s going to be much more of a push for it. But the only companies who are going to be successful at it are those who have already built quality outcome measurement systems. Because if you don’t have data, and you can’t track data, you’re dead in the water.

Is Gateway planning to open any facilities in the near future? Are there any particular markets/locations it has its eyes on?

As far as community-based expansion, we’re looking at the whole Midwest, and I think that’s going to be an acquisition springboard strategy. That is unlike some of these folks that have massive capital and buy a $40 million company and try to grow it to $200 million. The core of Gateway Foundation is it being a mission-based organization, and we want to provide care to as many people as possible and the best care possible. Wisconsin, Indiana, Ohio and Michigan — those are our next states.

Gateway had previously expanded into California by establishing an affiliate program with a provider, but has since exited the state. Can you give some insight on why this was the case? Would you consider re-entering the Golden State at some point?

How I’d answer that today, as far as going back into California, I think the answer is probably no. What we become five years from now, maybe that answer changes.

I think with that specific opportunity, it was bad timing. We knew it was an underperforming program. We knew we wanted to do an expansion strategy, and so our first year, we rebuilt the whole program — everything from the clinical product to administrative functions. Right around the time when we finished is when COVID hit. There really were just two people in the facility, and we did the math and asked, “How long do we want to carry this? How much will we lose?” So it was really a timing issue. It was not as much a strategic issue.

I think if COVID hadn’t happened it would have to be different. But now, I think the Midwest is a better opportunity.

There are alot of digital mental health companies out there that have been raising a lot of money for their services. Do you view this as competitive or complementary to Gateway’s services?

For the time being, they have a different strategy than we have. Pear Therapeutics is one, for example, that has designed a therapeutic intervention that’s all digital, and they want to bill the insurance companies $1,500 a month or so to provide that intervention. There’s others that are really designed to become almost a Facebook page. And then there are others that are really just peer support.

Expanding intensive outpatient services is a right strategy for us. But to do that successfully, we really need to stay a brick-and-mortar site — partly for insurance contracting, and partly for other areas like emergency services. I think all of it’s complementary right now.

Has Gateway been making other technological investments beyond telehealth?

What I did when I walked in the door at Gateway in 2015 was to analyze what was the technological infrastructure of the organization, and how it makes people’s jobs harder, easier, etc.

We’ve designed an electronic health record and built into it an outcome tool that we could leverage and get data. We’ve built a phone application that links to that so that we have ongoing outcomes data. And we’ve also looked at the back end stuff to see how we make billing, budgeting and monthly financials easier.

Workforce challenges have also been a problem for the industry. Has Gateway had some problems in filling jobs, and what are some strategies to plug any hole that might exist?

We have some programs that are capped right now, because we don’t have enough staff to fill them. And that’s a huge threat. We’re thinking right now about how do we solve that problem, because we have staff that are getting offered $40,000-$50,000 more bucks to leave, not two or three bucks an hour. So we’re thinking very clearly about that threat.

25% of our workforce will retire in the next 10 years. We’ve got about 1,400 people on staff today, with 300-400 of those people not just going to leave for another job, but retire. We have to be ready for that departure.

During COVID, when the stock market went crazy, a lot of people cashed out early. We had early retirements and we had people leave the industry altogether, because they’re just like, “This is too hard.” We’re in the biggest crisis I’ve ever seen.

We’ve done studies to evaluate and modify our compensation. We’ve improved our benefits, we’ve added educational reimbursement opportunities and we’ve developed a succession culture so that it’s not just C-suite people we’re replacing. It’s about how do we take somebody who works in facilities, for example, and cleans the floors and offer them opportunities to grow professionally? That’s what I see.