Substance use disorder (SUD) providers are no strangers to operating under pressure. But right now, the heat has been turned up, the lid is locked, and the steam has nowhere to go.

The policy changes, market shifts, and Medicaid scrutiny driving that pressure aren’t arriving one issue at a time—they’re all hitting at once, and at warp speed. It’s hard just to keep up, let alone know what to do next.

In a recent executive interview hosted by OPEN MINDS, Paul M. Duck sat down with Dr. Denny Morrison, psychologist, longtime behavioral health executive, and Chief Clinical Officer at Eleos, to talk honestly about where SUD care stands today, and what leaders should do now.

Their conversation covered a lot of ground, including: 

We’re breaking down the main points, but if you’re looking for their full conversation, head over to OPEN MINDS to watch the interview.

The Challenges SUD Providers Are Facing Right Now

So, what exactly is turning up the heat on SUD organizations? Quite a bit, it turns out.

The Treatment Gap Is Still Wide Open

Before we get into policy and operations, let’s start with a fact:

Roughly 80% of people in the United States who have a substance use disorder aren’t receiving treatment for it.

That’s not new, but for organizations trying to make the case for investment or growth, the unmet need is enormous. It proves that the challenge isn’t demand, but rather, capacity—and a long-fought battle of addiction treatment stigma. 

And recent policy changes aren’t helping in that area. Medicaid cuts and new eligibility and work requirements will: 

  • Add to the already overly heavy administrative burden on staff; and 
  • Make access to care more difficult for the 1.6 million Medicaid enrollees with substance use disorders.

SUD Workforce Pressure That Predates COVID

Like every other corner of behavioral health, SUD providers are dealing with a workforce that has been stretched thin for years. 

The pandemic only piled on the stress, further accelerating burnout and staff departures. 

To make things even more difficult, behavioral health and SUD don’t have the clinical multipliers—like, say, a dental assistant or a nurse practitioner—to help compensate. 

There is, however, group therapy.

And as Dr. Morrison noted, “Group therapy is a clinical multiplier.”

In fact, group therapy has been proven to be just as effective as individual therapy, and it’s also much more operationally efficient. Realizing that potential, though, requires training and tools that many organizations don’t have.

The Training Problem at the Core of Group-Based Care

About 90% of SUD treatment is delivered through groups. And yet, most providers received the vast majority of their clinical education in individual therapy.

“As a psychologist, I’ll bet you 10% of my training in grad school was in groups. The other 90% was in individual therapy,” Dr. Morrison explained.

The result is that a lot of what passes for group therapy in SUD settings is, as Dr. Morrison put it plainly, “individual therapy with a bunch of people watching.” Providers talk to one person, then the next, then the next. That’s not true, highly effective or efficient group therapy.

Read more about Dr. Morrison’s perspective on why group therapy is often a missed opportunity in behavioral health.

Lack of Evidence-Based Treatments

There’s also tension in parts of the SUD field between peer-experience-based approaches and what the research actually shows.

While peer counselors and people in recovery bring something real and valuable to the work,  relying solely on personal recovery experience—rather than evidence-based treatments—may result in differing patient outcomes. 

The debate over medication-assisted treatment is the clearest example. 

“The data shows that [medication-assisted treatment] is very effective—more effective than just traditional sobriety or abstinence-based programs,” Dr. Morrison explained. 

Resistance to it is, in many cases, rooted in an old-school view of sobriety rather than in data.

Why H.R.1 Is a Double Hit on Community-Based Care (and SUD)

When you add the effects of H.R.1 on top of the challenges SUD providers are already facing, the pressure-cooker analogy starts to feel less like a metaphor and more like reality.

“I think [H.R.1 has] created a lot of uncertainty around funding and a lot of fear,” said Duck, “There’s a ‘sky is falling’ kind of idea, and in some cases, it legitimately is.” 

With 11.8 million people estimated to lose health coverage by 2034, it creates a “double hit” for community-based SUD and behavioral health providers.

  1. A large share of community behavioral health and SUD clients are covered by Medicaid. So, the cuts directly reduce the primary funding source for these organizations.
  2. People lose insurance coverage, but they don’t disappear. They become uninsured and still need care. They’ll return to community providers as indigent clients, driving up uncompensated care when reimbursement is already shrinking.

But there is one potential bright spot in the bill: The Rural Health Transformation Program, which is projected to reinvest roughly $50 billion into the system over five years. It doesn’t offset the Medicaid losses… but it’s something.

The Risk of Waiting It Out

SUD providers have historically taken a “wait and see” approach to major policy shifts. Sometimes that’s been rational. But this moment is different.

The effects of these policy changes are moving too fast, and waiting to react could have dire consequences.

Clinical Layoffs and Service Line Reduction

When funding shrinks and reimbursement tightens, organizations that haven’t been proactive will find themselves in reactive mode—making cuts just to stay afloat.

“If you have to make cuts to your budget, it’s going to involve people since that’s 70% of your top line expenses. You can’t save enough on paper clips.”

Dr. Dennis Morrison, Eleos CCO

But layoffs aren’t the only risk. Organizations that wait too long also end up making rushed decisions about which service lines to cut—often eliminating programs not because it’s the right strategic move, but out of pure financial necessity. 

As Dr. Morrison put it, the organizations that wait will likely “be cutting off chunks of their business” rather than making thoughtful choices about where to focus. The result is an organization that may still be standing, but is a fraction of what it once was.

Mergers and acquisitions (M&A)

To avoid having to make reactive cuts, you could also consider partnering up with another organization. In many cases, M&A can be an opportunity to continue your mission when you aren’t able to operate sustainably on your own. 

Reframing it from organizational survival to mission continuity is what makes M&A feel like a strategy rather than a failure.

But as Dr. Morrison warned, “If you wait too long, you won’t be an attractive dance partner. If you’re merging out of desperation, that’s not a merger—that’s an acquisition.”

So, start making decisions now to prepare for what’s ahead. Otherwise, “you may survive, but you’ll be a shell of what you had been previously,” as Dr. Morrison put it.

The time to make those hard calls is now, while you still have the runway to make them strategically.

Watch our webinar, Executive Strategies for the Post-OBBBA Reality, for additional H.R.1 “pivots” for your organization.

The Documentation Crisis in Group Therapy

Amidst H.R.1 pressures, one of the most strategic moves an organization can make right now is leaning into group therapy—allowing teams to do more with less without compromising care.

As we mentioned earlier, it is one of the few clinical multipliers in behavioral health and SUD care. But even for providers who have had the proper training and are running successful group sessions, there’s still a long-standing operational challenge: Group documentation.

SUD providers run group sessions all day. Each group has seven to ten—or even more—people in it. Each person requires their own individualized note, tied to their treatment plan, compliant with payer requirements, and accurate enough to support continuity of care—along with a group note on top of that.

“If I spend an hour seeing you individually as a client, I gotta write a note for one person,” said Dr. Morrison. “But if I spend an hour in a group of seven people, I now have seven times the amount of documentation to do. So the documentation burden has been really onerous for these folks.” 

And on top of the burden on providers, if you wait until the end of the day to document five or six individual sessions, you’re already losing nuance. It’s hard to recall all the details from the sessions that were earlier in the day. Multiply that by a full day of group sessions, and the documentation is almost inevitably incomplete, inaccurate, or templated.

But the problem isn’t that providers are cutting corners out of indifference. It’s that the system isn’t set up to support the documentation that group-based care actually requires.

“The challenge of [group therapy] documentation, and how providers have just literally tried to plow through it, has obviously had an impact on the treatment planning, quality of the documentation, and the ability to really measure outcomes and progress,” Duck explained. 

That’s a clinical problem. It’s a compliance problem. And increasingly, it’s a financial problem—because as the market shifts toward value-based and risk-based contracting, documentation quality becomes the foundation of whether you get paid, and whether you can prove you’re delivering care that works.

“As the market shifts to paying for value—and ultimately taking on full risk—the documentation issue becomes life and death,” Duck concluded.

But there is a solution. The same technology that’s already reducing documentation time by 70-80% for individual therapy is now being applied to groups.

Where Technology Can Lend a Helping Hand

Dr. Morrison outlined three places where AI—done right—can move the needle for SUD organizations.

1. Ambient AI 

Ambient listening and AI scribes are nothing new at this point, but tools within the space that will work for group therapy certainly are. 

Providers using Eleos for individual therapy sessions have seen documentation time drop from 15 minutes per note to just five. For clinicians who see five to six clients a day, that’s roughly an hour saved every day. It’s the difference between finishing notes during the workday and having to take them home.

Multiply those five to six sessions by seven to 10 notes per group, and the hours saved are staggering.

And on top of time savings, there’s an unexpected clinical benefit: One organization found a 35% increase in evidence-based treatments after implementing Eleos. 

It wasn’t that providers suddenly started doing more EBTs. Most were already doing them, but forgetting to document them. Eleos captured what was happening in the session and prompted providers to include it—ensuring the note reflected the care that was actually delivered, before sign-off.

2. Compliance at Scale

The second tier is compliance review. Rather than the industry-standard 5–10% random note sampling, AI can review 100% of notes before they go out—flagging golden thread issues, copy-pasting, and payer compliance gaps before they become denials or audit risk.

Instead of quality teams spending their time searching for issues and reviewing notes that are already good to go, they can focus on resolving only the issues surfaced by AI. 

And Eleos takes it a step further, checking notes in real time and prompting for missing elements before sign-off—preventing the 10-15% of notes that would typically be rejected and delay reimbursement.

“So you’ve got two tiers of compliance processing,” said Dr. Morrison. “It prevents a bad note from going out from a payer perspective, but also helps the provider write a better clinical note.” 

3. Revenue Cycle Management (RCM)

The third opportunity is applying that same AI infrastructure to the billing side of the house. Clinical and billing teams often operate as if they’re throwing work over a wall. 

They’re not—it’s one continuous pipeline. 

AI RCM tools that help billing departments work more efficiently, catch issues upstream, and reduce denials extend the same logic that’s already working in clinical documentation.

Find out how Eleos is expanding into a system of action for community-based care.

What Separates the Organizations That Will Thrive

As Dr. Morrison put it, “We have three responsibilities in this business: Clinical excellence, fiscal accountability, and customer service.”

The landscape in SUD right now is forcing leaders to think strategically to continue to do all three. 

Here’s where Duck and Dr. Morrison recommend you focus your efforts.

Rethink what business you’re in. 

The organizations that survive—and grow—will be the ones that can clearly articulate what they do best and are willing to stop doing what they don’t. 

Invest in technology now, not later. 

It may feel like the wrong time to make new investments when margins are shrinking. But Dr. Morrison’s view is the opposite: This is exactly when those investments matter most. 

“You can use this to make your providers more productive, and you can make them happier so they’re less likely to leave,” Dr. Morrison explained. “And you can use it as a differentiator when you recruit: ‘We’ve got tools that can help you do your documentation faster than the place you just left.’” 

It shouldn’t be technology for its own sake, though. Choosing the right technology partner and using it to support providers, reduce burnout, and recruit and retain staff is exactly the strategic investment SUD organizations need right now.

Build toward interoperability. 

As H.R.1 forces organizations to think strategically about their service lines and hone in on certain specialties, the ability to share data across systems becomes essential. Your patients will likely be seeing multiple providers, so interoperability and sharing data seamlessly will be crucial.

Invest in group therapy. 

As the workforce stays thin, group therapy becomes not just a smart clinical choice but an operational necessity for both SUD and behavioral health organizations.

And if your staff could use a brush-up on their group skills, the American Group Psychotherapy Association (AGPA) has practice guidelines available on their website—a concrete starting point for organizations that are serious about improving their group competency. 

Make measurement real. 

Evidence-based treatment and measurement culture go hand in hand. If organizations are doing EBTs, they’re already collecting data. The work is building systems that make that data visible and actionable—especially as value-based contracts start demanding it.

The SUD Care Environment Bottom Line

SUD providers are facing the most consequential set of pressures many of them have seen in their careers. The temptation to wait and see—to ride out the uncertainty before making moves—is understandable. But the window to act from a position of strength is now.

“Think about this as a strategic opportunity—not just a death and gloom kind of situation,” Dr. Morrison concluded. “Yeah, it’s hard, but now’s not the time to sit and wait. Now’s the time to think strategically and to take action.”

The organizations that come out ahead will be the ones that use this moment to get sharper about their mission, smarter about their operations, and more honest about where they are leaving revenue on the table.

That’s not a comfortable conversation to have. But it’s the right one.

Interested in learning more about how Eleos supports SUD and behavioral health organizations? Request a demo to learn more.

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