Payers could be better aligning their incentives with behavioral health patients and providers by giving parity more room to breathe within their organizations.

Payers often bury the duty of ensuring behavioral health-physical health parity in a compliance or legal department. Such a structure prevents the necessary cultural and strategic alignment that payers need to establish to ensure that parity’s objective of increased access and diminished barriers to care becomes a reality, Brett Hart, vice president of behavioral health and mental health parity at Blue Cross Blue Shield of Minnesota, said during a fireside chat at VALUE 2025.

“I think the actions that flow out of a parity-driven mindset around value look different than, for example, if it’s strictly a profit-driven motive,” Hart said. “I think what happens in [profit-driven] organizational structures is parity becomes about passing an audit. It’s about checking the boxes to make sure you’re not going to get in trouble with your regulators, but it’s not necessarily permeating what the organization does.”

Blue Cross Blue Shield of Minnesota named Hart to his role in October 2023. He said during the fireside chat that the payer previously put parity under the purview of other executives. Part of his arrival at Blue Cross Blue Shield of Minnesota included merging parity and compliance efforts within the behavioral health arm of the organization.

Big picture, the move was also intended to help Blue Cross Blue Shield of Minnesota, according to Hart, prioritize behavioral health issues more. Since then, it has helped the organization view behavioral health as a source of value generation and not just a cost center.

Referring to a now famous Milliman study, Hart pointed out that patients that experience behavioral health challenges account for a disproportionate amount of spending on services. Specifically, the study found that 27% of an observed population with behavioral health issues accounted for 56.5% of all health care spending. Depending on the condition, behavioral health patients had health care spending that was 2.8 to 6.2 times higher than those without behavioral health conditions.  

“That’s why behavioral health then suddenly becomes so important,” Hart said. “As I tell customers when I meet with them, if you’re not addressing behavioral health, you’re not addressing your total cost of care. It’s just that simple. If you’re leaving 57% of your spend on the table, you’re really failing to manage cost overall.”

In the health payer world generally, Hart said that behavioral health today is somewhat dismissed as “small potatoes,” as it can account for as little as 6% of a payer’s overall spending. That narrow view of behavioral health can lead to the industry’s increased relevance being considered “peripheral” and “trendy,” Hart said.

He added that the health insurance industry also doesn’t look at behavioral health as a big money maker. He said it’s typical for health plans to generate between 0.5% and 1% on behavioral health benefits.

That lack of incentive for payers — and a parallel low-margin, low-interest trend in physical health systems — begs the need for systemic realignment of how the system works, Hart said, without pushing for specific proposals.

He also said that the collective health care system needs to develop much more sophisticated care delivery models before health plans can join in in developing payment models that reflect higher value and make parity more of a reality.

“I’ll say selfishly, from a payer perspective, we want to be paying for outcomes, not time,” Hart said. “I mean, that’s that, and I think most patients want to see that as well.”

But within the context of behavioral health alone, a greater focus on parity will have the outcome of increasing access to care for members. He sees access as the “outcome variable” for a greater realization of parity. The parity-led mindset inspires greater consideration of practices such as co-pays, benefit designs and session limits.

When asked about the change in administration, he said that he and the rest of the market is waiting to see what the Trump administration will do with the matter. So far, other priorities have taken the forefront of health care oversight under the regime.

Near the end of the Biden administration, the White House released a new parity enforcement and compliance rule. The ERISA Industry Committee, better known as ERIC, filed the suit in the U.S. District Court for the District of Columbia on Jan. 17, seeking to have the rule thrown out. How the Trump administration wants to handle suit could have huge ramifications for parity enforcement.

Not much has happened since the filing of the suit. A BHB review of court documents finds the only major action came at the end of March — a squabble over how much time the federal government ought to have to file a response.

At the end of its typical 60-day time frame to respond, the government asked for more time to file its response. The departments named in the suite — U.S. Departments of Health and Human Services (HHS), Labor and Treasury — want another 90 days. ERIC opposes the move.

“In these circumstances, the Departments’ request for a three-month delay is self-evidently unreasonable,” ERIC said in its response to the government’s motion. “Instead, absent a stay, the litigation should move forward expeditiously.”