Fragmented payment systems, siloed care models, workforce shortages and more systemic barriers are testing behavioral health providers nationwide. Leaders shared with Becker’s what they see as the most pressing structural issues in behavioral healthcare today — and how they are working to overcome them.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is the biggest structural barrier at the enterprise level that limits behavioral health effectiveness today — and how are you working to change it?
Chris Cargile, MD. Director of Behavioral Health Service Line at University of Arkansas for Medical Sciences Health (Little Rock): The answer to the first question is straightforward; it reflects the same challenge behavioral healthcare has faced for decades: a misaligned and fragmented payment structure that invariably leads to a fragmented treatment system. This separation of payment structures forces patients to navigate disconnected care systems for their co-occurring conditions, which frequently include chronic medical complaints, psychiatric issues, substance use disorders and traumatic brain injuries. Ultimately, this lack of integration leads to poor clinical outcomes and low patient satisfaction. Worsening the problem, continued disparities in reimbursement have resulted in only 50% of psychiatrists accepting third-party payments, which only aggravates the problem.
The second question is more complex, as it requires mutual engagement from stakeholders capable of influencing public and corporate policy. To that end, we have initiated proactive conversations with state and corporate leaders regarding system fragmentation. We are leveraging our expanding database on health outcomes to drive these discussions toward meaningful improvements, including improved access to psychiatric urgent care, primary care co-management models, neuromodulation for mood disorders, and coordinated care for patients with genetic and inflammatory disorders that manifest as behavioral health symptoms.
John Driscoll. President and Chief Executive Officer of Caron Treatment Centers (Berks County, Pa.): The biggest structural barrier limiting behavioral health effectiveness today is that the behavioral health treatment system is still built around episodic, reactive and crisis-driven care, rather than long-term, integrated treatment for chronic conditions. Addiction and co-occurring mental health disorders do not resolve themselves in a single episode of care, yet payer reimbursement, patient access, and care delivery models often fail to support continuity, coordination and long-term follow-up.
At Caron, we’re working to change that by expanding access to integrated, evidence-based care that treats addiction and mental health as chronic, brain-based conditions — combining medical, clinical and long-term recovery support. Reducing stigma and normalizing treatment are also critical because treatment and recovery systems can’t work if patients don’t feel safe seeking care early.
Ken Dunham. Executive Director of Medical Operations for Behavioral Health at Sentara Health (Hampton Roads, Va.): The biggest barrier to effective behavioral health care isn’t clinical knowledge or commitment — it’s that behavioral health has a siloed service history instead of core enterprise infrastructure, so accountability, data and incentives have never fully aligned. This will become more of an issue with the pending impact of OBBA. We are working to resolve as many of these issues as we align ourselves across the system with our communities and behavioral health stakeholders.
Tracey Izzard. Vice President of Behavioral Health at Sentara Health (Hampton Roads, Va.): The most significant structural barrier limiting behavioral health effectiveness in our organization existed at the enterprise level. Historically, behavioral health was separated from core medical, operational, and financial infrastructure, which constrained our ability to deliver fully integrated, whole-person care.
By establishing a service line that spans the health plan, ambulatory and acute care divisions, we took an important first step toward change. Behavioral health is now positioned as a foundational component of population health and overall enterprise strategy. While this milestone marked meaningful progress, we recognize that additional barriers remain — and we are actively addressing them.
At the core of our approach is the belief that behavioral health must not be siloed but embedded across the healthcare system to support the whole person. To that end, we are advancing integration across several key dimensions.
Governance and financial accountability are a primary focus. We are aligning value through coordinated capital prioritization, decision-making and strategic planning across divisions. This includes reframing behavioral health investments in terms of avoided medical costs, improved system capacity and sustainable alternative payment models — such as collaborative care — that support integrated delivery.
Data and performance measurement are equally critical. Behavioral health outcomes have traditionally been underrepresented in enterprise analytics, which is why we are building quality dashboards that assess program performance through a value-based lens. Behavioral health metrics are now being integrated into enterprise dashboards, including access, length of stay, readmissions, emergency department boarding and downstream medical utilization. Our goal is to clearly demonstrate system-wide impact, not just behavioral health unit performance.
Care delivery integration has been another major area of advancement. Behavioral health care has often been episodic and reactive, so we have focused on embedding services into primary care, emergency departments, inpatient settings and post-acute transitions. Through shared workflows, staffing models and escalation pathways, we have strengthened alignment across emergency departments, inpatient units, primary care and specialty services.
Our teams continually design services around patient flow and population need, supported by ongoing workforce and care model evaluation. A notable example is the successful implementation of a behavioral health navigation program that spans all divisions, aligns community partners and supports continuity of care beyond the emergency department.
While programmatic growth remains important, our primary emphasis has been on structural integration. Behavioral health will achieve its greatest impact not through isolated programs, but through a coordinated continuum of care embedded throughout the enterprise. This is the transformation we are driving and moving behavioral health from the margins to the center of how we deliver, measure and finance care.
Vicky Martin. Chief Executive Officer of Oak Hills Behavioral Health Solutions (Moberly, Mo.): One of the biggest structural barriers limiting behavioral health effectiveness today is workforce gaps. Many primary care managers have significant caseloads and limited knowledge of specific behavioral health interventions and medications. This is understandable, as primary care managers are generalists who cover a wide range of care needs.
To address this, OHBHS offers workshops for primary care providers led by our psychiatric provider, a specialist with decades of experience. Additionally, we provide internships for psychology students and graduate students in counseling and psychiatric nursing. These internships offer exposure to various providers who take the time to explain the logic behind specific interventions. Through these initiatives, we support the professional development of future providers, encourage continued learning for current practitioners, and strengthen community relationships.
Lindsey Mortenson. Executive Director of University Health and Counseling, Chief Mental Health Officer for Student Life at Michigan Medicine and University of Michigan (Ann Arbor, Mich.): Enterprise bottom-line pressures and documentation burden can result in clinicians having less time to spend with patients and families. This can increase the risk that the true drivers of suffering are overlooked, that the hard questions aren’t asked, that the range of potential solutions is more limited and that suffering is prolonged. Many common causes of mental health distress do not surface in quick appointments and on standard screening tools. Examples from my own practice this year include gambling-related financial losses, behavioral addictions, loneliness, a lack of purpose and mattering and relationship stress.
Matthew Ruble, MD. Chief Medical Officer of Discovery Behavioral Health (Irvine, Calif.): The biggest structural/systems barrier is funding. “Follow the money” is the famous quote from the movie “All the President’s Men.” This is the guidance that Deep Throat speaks to Bob Woodward, the investigative journalist who breaks the Watergate scandal with Carl Bernstein for The Washington Post. Yes, this is overly reductionistic, and no, I’m not comparing behavioral health disparity to Watergate. That said, mental health conditions and substance use disorders have a morbidity burden that is 31.8% higher than that of the top four noncommunicable diseases combined. In contrast, mental health conditions only receive 2% of domestic government healthcare funding globally, resulting in an annual funding gap of $200 billion to $350 billion. Discovery Behavioral Health is working to fill the funding gap by integrating our services into the communities and integrating with physical health providers.
Tobias Wasser, MD. Chair of Psychiatry and Behavioral Health at Hartford Healthcare Fairfield Region (Conn.): The biggest barrier to care is access. Our models and pathways for getting individuals in need into care are antiquated and overburdening typical medical models of care. In our system, we’re working to tackle this by developing direct care pathways that bypass emergency services, reducing emergency department boarding and increasing access to higher-level inpatient care. Simultaneously, we’re expanding ambulatory service line capacity at different levels of care (outpatient, IOP, PHO) and adding interventional services. This strengthening of the continuum of care enhances patient throughput and helps make increased access to care sustainable.
