From Medicaid provisions under H.R. 1 to funding streams for models that remain uncertain, behavioral health leaders are trying to build for the future while the ground keeps shifting under them in 2026.
Becker’s asked 11 health system and payer executives this question: What’s the number one behavioral health issue keeping you up at night, what’s being discussed in your executive and board meetings, and what is your organization doing about it?
Editor’s note: Responses have been lightly edited for clarity and length.
Brad Bivens. CFO of Parkside Psychiatric Hospital and Clinic (Tulsa, Okla.): The biggest issue keeping me up at night is the long-term financial sustainability of behavioral health, particularly for organizations that rely heavily on Medicaid funding.
Demand for services continues to grow, but reimbursement has not kept pace with rising labor, technology, and regulatory costs. At the same time, uncertainty around supplemental Medicaid funding programs creates significant risk for organizations serving vulnerable populations.
Our executive team and board spend a great deal of time discussing how to diversify revenue, improve operational efficiency, strengthen revenue cycle performance, and invest in services that meet community needs while remaining financially sustainable.
Rather than waiting for funding decisions, we are taking proactive steps by evaluating new service lines, optimizing reimbursement, improving documentation and billing processes, implementing new technology, and making data-driven operational decisions. Our goal is to ensure we can continue providing high-quality behavioral health services regardless of future reimbursement changes.
Behavioral health organizations must balance mission with financial discipline. If we fail to build sustainable models today, access to care will become an even greater challenge tomorrow.
Dominique Dietz. Director of Virtual Behavioral Health for OSF HealthCare (Peoria, Ill.): The No. 1 behavioral health issue keeping me up at night is the gap between a patient needing help and actually getting connected to the right care.
This is especially difficult because patients are often reaching out during their hardest moments; after an emergency department visit, an inpatient psychiatric hospitalization, or when a primary care provider identifies a behavioral health need. Yet there can be significant gaps between discharge or referral and that first meaningful connection to care. During that time, we are asking patients and families to navigate a very complex behavioral health system, often with multiple referral options, waitlists, insurance barriers, and uncertainty about where to go next.
I often find myself asking, if someone is reaching out to us when they are at their most vulnerable, are we really supporting them if we simply give them a referral and ask them to navigate the rest on their own?
That is the conversation happening across our leadership and interdisciplinary teams. We are starting by understanding our current gaps and where patients are falling out of the system. From there, we are working to centralize more than 20 behavioral health referral pathways into a single referral process with clear clinical care pathways, making it easier to get patients to the right level of care.
And importantly, we know this cannot be solved by technology alone. We are looking at pairing that streamlined process with human-backed navigation, where non-clinical navigators can help patients understand their options, overcome barriers, and connect to care, with clinical teams available when clinical assessment is needed. This is about making the system easier to navigate and making sure that when a patient reaches out for help, we are there to help them take the next step, not hand them a list and ask them to figure it out alone.
Brittany Evans, DNP. Assistant Vice President of Patient Services for Psychiatry at Cincinnati Children’s Hospital Medical Center: The number one behavioral health issue keeping me up at night is workforce sustainability — not simply whether we have enough people, but whether we are creating the conditions for our workforce to be well, safe, confident, and competent enough to care for patients and families with increasingly complex needs.
I think there’s an opportunity to broaden how we think about workforce challenges beyond the traditional “shortage” narrative. The complexity of behavioral healthcare continues to evolve, as do the needs, expectations and opportunities of the people doing the work. We are caring for patients with greater psychiatric and medical complexity, significant trauma histories, developmental and behavioral needs, and social circumstances that often exceed what traditional care models were designed to address.
At Cincinnati Children’s, our 24-hour behavioral healthcare environments include 99 inpatient beds and 24 residential beds across Qualified Residential Treatment Program and Psychiatric Residential Treatment Facility levels of care. It takes hundreds of people across disciplines to sustain those operations. In team-based, milieu-centered care, the workforce is the care environment. We have to continuously adapt not only to the evolving needs of our patients and families, but also to what our interdisciplinary workforce needs to deliver that care safely and effectively.
That challenge is particularly important as behavioral health professionals have more options for how and where they practice, including virtual and remote models. Those options have expanded access in important ways while also challenging health systems to ask: How do we make the work that must happen in person — particularly inpatient and residential care — sustainable and compelling?
For me, workforce sustainability extends well beyond recruitment and retention. Wellbeing, physical and psychological safety, confidence and competence are interconnected. Together, they determine our workforce’s capacity and capability to care for the patients and families who need us most.
Our executive conversations increasingly focus on both workforce development and system design. We are investing in longitudinal, competency-based development; using immersive and experiential learning to help staff practice complex situations before encountering them in real time; strengthening clinical and leadership development; and exploring how simulation, virtual reality and AI-enabled learning can individualize development.
We are also confronting a harder question: Are we asking our workforce to compensate for systems that were never designed with our most complex patients in mind?
When patients and families do not fit neatly within existing environments, services or program models, the burden of making an ill-fitting system work often falls on the people closest to the patient. We are working to identify those gaps, advocate for underserved populations and develop new approaches to care rather than expecting clinicians to continually absorb that complexity.
Ultimately, workforce sustainability is about building human capacity. We cannot ask people to do increasingly complex work without designing systems that help them feel safe, supported and prepared to do it…successfully and meaningfully. If we get that right, we build both a more sustainable workforce and one more capable of meeting the needs of the patients and families our current systems struggle to serve.
Mike Franz, MD. Executive Medical Director of Behavioral Health for Cambia Health Solutions (Portland, Ore.): If I had to name the behavioral health issue keeping me up at night, it’s this: costs are continuing to rise quickly. We need to make sure that increased spending and utilization are leading to better care, better outcomes and lower total costs over time.
Demand for mental health and substance use disorder treatment continues to rise at an unprecedented pace, and that growth is occurring in an environment marked by workforce shortages, higher-acuity needs, fragmented care and increased reliance on virtual, facility-based, and intensive services. Expanding access remains essential, but access alone is not enough. As utilization grows, we must be equally focused on whether care is evidence-based, matched to the right level of need, coordinated with physical health and improving people’s lives in measurable ways.
In executive and board-level conversations, the issue increasingly centers on affordability and sustainability. Behavioral health costs are growing faster than many other areas of healthcare, adding pressure on employers, health plans, government programs and individuals. The challenge is not to reduce behavioral health investment across the board. Underinvesting in behavioral health can drive even higher costs through emergency department use, inpatient admissions, disability, lost productivity and worsening chronic conditions. The challenge is to distinguish high-value behavioral healthcare from low-value or wasteful utilization and ensure that every dollar spent improves clinical outcomes and reduces total cost of care.
Our strategy must balance three priorities: access, quality and value. We need to help people get to the right care quickly, and that care needs to fit their clinical needs, be delivered by qualified providers, supported by data and connected to measurable outcomes. This includes improving navigation, reducing unnecessary or duplicative services, identifying gaps in follow-up after higher-acuity episodes and helping members transition to the most effective and least restrictive, appropriate level of care.
A major focus is strengthening partnerships with high-performing behavioral health providers and advancing value-based approaches that reward outcomes, coordination and appropriate utilization rather than volume alone. We need greater transparency into what is working, where members are improving, where care is fragmented and where spending is not producing commensurate value. Data, measurement, and accountability are essential to improving care while bending the behavioral health cost trend.
Most importantly, we must view behavioral health as central to total health and total cost of care. Mental health, substance use and physical health are deeply interconnected, and unmet behavioral health needs often contribute to avoidable medical utilization and poorer outcomes. The organizations that succeed over the next decade will invest in behavioral health with discipline: expanding access where it is needed, prioritizing evidence-based and coordinated care, reducing waste and holding the system accountable for outcomes that matter to patients, purchasers and communities. That is the leadership challenge ahead and where we are focused now.
Patty Inacker. Vice President of Behavioral Health and Clinical Director for Penn Medicine and Service Line Administrator for Behavioral Health at Pennsylvania Hospital (Philadelphia): The number one behavioral health issue keeping me up at night is the growing number of adults with profound intellectual and developmental disabilities who are admitted to medical and psychiatric inpatient units because there are no appropriate community placements available. These individuals often remain hospitalized long after they are clinically ready for discharge, not because they require acute medical or psychiatric care, but because the system lacks the specialized residential and support resources necessary to meet their needs. This is unconscionable and borders on criminal.
This challenge is frequently discussed at both executive and board levels because it affects patient outcomes, quality of care, workforce resources, and access to services for others in our communities. Prolonged hospitalizations can be particularly difficult for individuals with profound intellectual disabilities, who often experience increased distress and disruption when living in environments that are not designed for their long-term needs.
We are focused on working collaboratively with state agencies, community providers, and advocacy partners to identify sustainable solutions. We are strengthening care coordination, engaging discharge planning teams earlier, and advocating for increased capacity in specialized residential and community-based programs. We are also exploring innovative partnerships to create more appropriate care pathways for this vulnerable population.
Ultimately, this issue highlights a broader challenge across healthcare: ensuring that individuals with complex intellectual and behavioral health needs have access to the right care, in the right setting, at the right time. Until the gaps in community placement capacity are addressed, hospitals will continue to serve as the default safety net for individuals who deserve more appropriate long-term support and resources.
Pamela Mattel. President and CEO of Coordinated Behavioral Care (New York City): I lead Coordinated Behavioral Care, a New York City-based network of more than 70 behavioral health agencies serving over 350,000 adults and children living in highly distressed communities, many with complex conditions. The network covers the full continuum of care, providing a front row seat on how dozens of agencies are trying to solve the exact same pressure — and a lot of that effort gets duplicated even though we desire to step back and solve it together. On the policy front, we’re watching the downstream effects of H.R. 1’s Medicaid provisions land on top of an already-growing patchwork of state requirements, and honestly, compliance is eating up time that should be going toward better care. Every new reporting requirement, every audit — and we’re fielding them from payers, state agencies, and federal programs all at once now — is pulling people away from the work they actually signed up to do. Mediocrity, not quality, is leading care. That’s the part that is hard to reconcile: we’re being asked for value-based outcomes at the very moment we’re being buried in the paperwork that makes delivering those outcomes harder.
Those are conversations happening amongst the network’s agency executives, touching on the impact on workforce wellbeing and retention — we all know a vacancy isn’t just an HR problem, it’s an access problem — audit fatigue, since we’re getting asked for the same information in a dozen different formats, and fragmentation, since behavioral health just wasn’t built for the kind of integration and data-sharing that value-based care assumes we already have.
Here’s a few things we are doing about it: we’re investing in AI through learning collaboratives, where our agencies test tools together instead of each one reinventing the wheel — including group contracts for ambient documentation with a compliance feature built right in, giving agencies relief without new risk. We’re building better dashboards and opening access to our shared data warehouse, letting agencies lean on network-level infrastructure instead of adding resources to build their own.
We’re pulling in data from our regional health information exchange to get a fuller picture of the people we serve. And we’re coaching agencies on closing gaps in care, which lets them actually capture the incentive payments tied to that work — plus bringing value-based proposals to managed care organizations, backed by our own outcomes data, to make the case that behavioral health is worth investing in, not just managing.
At the end of the day, the pace of change — policy, payer demands, technology — is outrunning most organizations’ ability to adapt. What gives me confidence is scale used well: 70-plus agencies sharing tools and lessons instead of going it alone is how we stay flexible without breaking our people or our model.
LalithKumar Solai, MD. Mental Health Chief and Vice Chair for Medical University of South Carolina (Charleston): We as a health system have prioritized expanding behavioral health services across the state of South Carolina. We have been working on this for the past few years with access to behavioral health services as being a number one priority. This means we are focusing on services that do not have proper funding structures and may not be sustainable in the future.
This keeps me up at night a lot. For example, we initiated seven EmPATH units across the state to address emergency psychiatric care needs of our patients, but the funding stream for such a service is still being worked on and very unclear which makes me nervous that if there is no proper funding for this service in the near future, then these services may at risk for closure. This is one example of several such predicaments within mental health payment structure. Other programs such as Collaborative Care Management (CoCM), Primary Behavioral Health Integration and more are at similar risks.
Inpatient hospital reimbursement has been another challenge for academic hospitals, particularly state-supported programs. There is little incentive to provide many of the essential services in behavioral health. Many health systems view behavioral health services as a much-needed service to the patients they serve but also acknowledge that it is a loss leader due to the way reimbursement is structured currently. They continue providing these services while taking on part of the financial responsibility/risks. This could only go on for a certain period of time until it becomes unsustainable. Donor funding and other supports prop up these services for a while but eventually they too dry up leading to closure of them.
What we need is a comprehensive plan that funds essential behavioral health (Inpatient, Emergency Psychiatry, OP, IOP) services in a way it is sustainable.
Jesse Tamplen. Vice President of Acute Care Transitions and Behavioral Health Services for John Muir Health (Walnut Creek, Calif.): The issue keeping me up at night is the growing mismatch between the demand for behavioral health services and the U.S. healthcare system’s ability to provide sustainable access to high-quality care while maintaining the financial viability necessary to serve our communities in the long term.
Demand continues to increase across the continuum, from children and adolescents experiencing psychiatric emergencies to adults and older adults with increasingly complex behavioral and medical needs. At the same time, the economics of providing that care has never been more difficult. Labor, pharmaceutical, facility and supply costs continue to rise, while reimbursement has not kept pace with the cost of care. Behavioral healthcare is underfunded by at least 25% relative to the cost of providing care. Persistent workforce shortages and increasing regulatory requirements add further pressure.
California’s emergency order establishing nurse-to-patient staffing ratios for freestanding acute psychiatric hospitals is a good example of the complexity health systems are navigating and the potential impact on access to 24/7, life-saving inpatient psychiatric treatment across the state. I support the intent of the regulation and its focus on patient safety. At the same time, we have to recognize and address unintended consequences. Hospitals may have to reduce available psychiatric beds or, in some cases, close units or services to meet and financially sustain the new staffing requirements, unintentionally limiting access to care.
From a health system perspective, the consequences extend far beyond behavioral health. When psychiatric capacity is reduced, emergency department boarding increases; acute care capacity and patient flow are affected, and pressure shifts to EMS, law enforcement, community providers and neighboring hospitals. A capacity decision in one part of the continuum ultimately affects the entire healthcare delivery system.
John Muir Health’s executive and board conversations increasingly center on a fundamental question: How do we preserve timely access to safe, high-quality care while building a financially sustainable model capable of serving our communities long term?
At John Muir Health, our strategy spans the continuum:
- Centralizing access and patient flow: We integrated behavioral health into our enterprise Patient Transfer Center, creating a centralized access point with greater visibility into demand and capacity to better coordinate patient movement and optimize capacity across the system.
- Integrating behavioral and medical care: We have embedded behavioral health expertise within our medical centers to support treatment planning, length-of-stay management, care transitions and discharge planning, recognizing that behavioral and physical health cannot be managed in isolation.
- Investing in our clinical workforce: We strengthened our child and adolescent medical staff model and continue to make significant investments in nursing, social work and recreational therapy to support high-quality, multidisciplinary care.
- Building a broader continuum: We are expanding outpatient and interventional psychiatry services and leveraging telehealth and hybrid models to connect behavioral health expertise with primary care and other clinical settings, anchored by specialized acute inpatient services across the lifespan.
- Advocating for sustainable policy: We are engaging elected officials, regulators and industry partners on how reimbursement, workforce requirements and regulation affect both access and long-term sustainability.
- Leveraging philanthropy for innovation: We are partnering with our generous community to accelerate whole-person care and innovative services beyond what traditional reimbursement models support.
Ultimately, access, quality, safety, workforce and financial sustainability are interdependent. Our responsibility as leaders of nonprofit healthcare systems is to make decisions today that strengthen the entire healthcare delivery system, preserve access to essential services and ensure our ability to serve our communities for generations to come.
Robert Trestman, MD, PhD. Chair of Psychiatry and Behavioral Medicine for Carilion Clinic and Virginia Tech Carilion School of Medicine (Roanoke, Va.): The biggest issue for us right now is the number of people losing insurance coverage. Our ability to continue to provide care is being threatened by so many different risks that are continuing to rapidly evolve. The costs of care continue to rise at a greater rate than compensation for that care. Our patients present with increasing medical complexity and comorbidities. The demand and need for care continues to rise, but the ability for people to pay for the care is diminishing. We have coped with challenges over the years, but they’ve now reached a point where we may no longer have the flexibility to continue to provide appropriate care. Unless we come up with an alternative approach to equitable care delivery, we are creating a profoundly untenable and unsustainable situation.
Arpan Waghray, MD. CEO of Providence’s Well Being Trust (Renton, Wash.): Access remains the behavioral health issue that demands our greatest attention. Across the country, too many people are unable to receive the right level of mental health care at the right time. The barriers are familiar — geography, stigma, workforce shortages, cost and gaps in the care continuum — and the consequences are significant: delayed treatment, worsening acuity, avoidable emergency department utilization and increased strain on patients, families and caregivers.
This requires more than adding capacity. We must integrate behavioral health into whole-person care, build sustainable models across the continuum, support the workforce, and partner with trusted community organizations that can reach people before they are in crisis.
Since 2016, Providence’s Well Being Trust has partnered with behavioral health leaders throughout Providence and community organizations to expand access, alleviate suffering and save lives. Together, this work has supported 1 million individuals, advanced depression care with an 85% improvement in treatment response, supported nearly 30% of Providence caregivers (healthcare workers) through Providence’s No One Cares Alone well-being program, and strengthened 65 mission-aligned partnerships, including seven school-based initiatives that promote community-led mental health solutions building healthier, more resilient communities.
We remain committed to building a more connected, sustainable system of care that expands access, alleviates suffering and helps ensure every person can find compassionate support, hope and healing when and where they need it.
Tobias Wasser, MD. Chair of Psychiatry and Behavioral Health for Hartford HealthCare’s Fairfield Region (Fairfield, Conn.): The greatest challenge we face in our current environment is our reimbursement models and the subsequent impacts on access to care. In our existing fee-for-service environment, behavioral health services are woefully reimbursed compared to many of our peers in medicine. As a result, it is incredibly challenging to expand existing services or develop new ones. Further, the fiscal environment favors high intensity services (inpatient, PHP, IOP), which is helpful for those who need it, but we recognize as a field that the vast majority of individuals in our communities need an outpatient level of care.
The financial constraints on outpatient behavioral health service reimbursements disincentivize organizations from building out such services, leaving many individuals in need of care unable to access the treatment they need. While there have been advancements in telehealth that have helped improve access, it’s been insufficient to meet the need and doesn’t address the qualitative difference in virtual vs. in-person care. We know that our services provide both enormous benefits to our patients and value to the greater healthcare ecosystem, but until we have financial models that support that structure at scale, we will continue to exist in a world of the “haves” and the “have-nots,” with only the wealthiest and most underserved able to access care, and a large chasm in the middle of individuals unsure where to turn.
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.
