Cost and cost-effectiveness of abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder

Abstract

Background: Alcohol use disorder, unemployment, and risk of homelessness are linked and often co-occurring, but most interventions do not address both alcohol use disorder and unemployment. The Abstinence-Contingent Wage Supplement (ACWS) model of the Therapeutic Workplace offers participants stipends or wage supplements contingent on both their abstaining from alcohol and engaging with an employment specialist or working in a community job. Wearable biosensors continuously tracked alcohol use. Methods and data: The study randomized participants to Usual Care (UC) (n = 57) and ACWS (n = 62). We used micro-costing methods to identify the resources and costs of the 6-month ACWS intervention. The study team tracked the cost of incentives for wearing biosensors, stipends, and wage supplements. We used 6-month cost and effectiveness data to calculate incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. Results: Over the 6-month study period, average intervention costs per participant were $7282, with contingent stipends and wage supplements accounting for 50 % of intervention costs. We also reported average per participant costs for healthcare (UC: $17,785; ACWS: $26,734), justice system (UC: $131; ACWS: $153), and public welfare (UC: $1107; ACWS: $1275). The incremental cost-effectiveness ratios (ICERs) at 6 months were $80,911 for an additional participant abstinent, $3894 for an additional drinking free day, $22,756 for an additional participant employed, and $1514 for an additional day worked. Conclusions:The ACWS intervention for adults with an alcohol use disorder and experiencing homelessness increased costs and improved alcohol use and employment outcomes compared with Usual Care. For policymakers seeking a solution to alcohol use and unemployment with populations experiencing homelessness, ACWS may be a cost-effective solution.