[{"_1":2,"_100":-5,"_101":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,76,88],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},"mediaId",6274834,"mediaKeyId","2778669-eff2e1de28668fae4e03bab0a8d4105f","parentId",2778669,"title","OCA proposes focused behavioral‑health investment benchmark emphasizing outpatient/community care; seeks stakeholder input","audioSeconds",1475,"startMs",3667000,"endMs",5142000,"viewUrl","/Search/View?dp=1&key=2778669-eff2e1de28668fae4e03bab0a8d4105f&start=3667&end=5142","thumbnailUrl","https://assets.pipeline.soar.com/2778669-eff2e1de28668fae4e03bab0a8d4105f/thumbnail_3667000.jpg","articleUrl","/articles/6274834/California/OCA-proposes-focused-behavioralhealth-investment-benchmark-emphasizing-outpatientcommunity-care-seeks-stakeholder-input","mediaUrl","https://secure.pipeline.soar.com/6274834-0ee223bcf58ec813886d00b846514125/orig.mp4?Expires=1773588362&Signature=eqKaspKib-O15zKJDwr0Ww~lI1JOJ2yu42mqajFObQ7eMWLXlS1qN2boPtdD6R2sGL8ipRNFJJli1Y01CR36EkPKMd-JVpEjD-w8x8vugbiUROA0w-kNDI9ZW7SaLOlHihuyiHW6TQnLNA1T5S0RH7KeXuBJng9KstKvB6XRHnxX0SeTdnGGEpt4FNq3vzMO-tzqE~eKnG1zFcSo1s2wbhJ1XzpGnGqgXfOSaGqSuYGVw9FL4Arg7AwbcoH2JQQEC6uMsPz7c9azUcr3JzKDwYaJCyVeC8GU9vZOb-V-46feTYw2YtGh79PCX2wDNL7PZFwDHa6n6ox4aqFPzGVvDw__&Key-Pair-Id=KUT5TJCACFTXG","author","Department of Health Care Access and Information","date","2025-03-26T14:14:45Z","article","Monterey — The Office of Healthcare Affordability on Feb. 25 offered a proposed approach for a behavioral‑health investment benchmark that centers on strengthening outpatient and community‑based services and increasing timely, in‑network access to mental‑health and substance‑use disorder care.

Staff described two distinct but related tasks required by statute: first, measure total behavioral health spending across payers (the broad measurement task); second, set an investment benchmark intended to “sustain infrastructure and capacity” and shift resources toward lower‑intensity settings and improved access. OCA proposed separating the two: use a broad definition for measurement (claims and non‑claims spending across service settings) while using a narrower, policy‑oriented subset of spending for the investment benchmark.

Under the straw model presented to the Board and to the advisory committee, the benchmark would emphasize covered, in‑network outpatient and community‑based behavioral‑health services — for example outpatient facility visits, professional services (including primary‑care screening and treatment when appropriate), mobile crisis and community supports, and telehealth visits delivered by qualified clinicians. Staff proposed excluding pharmaceutical spend from the benchmark calculation (though it would remain part of the overall behavioral‑health spending measurement) to avoid having high pharmacy costs overshadow investments in clinical care and community capacity. The office also noted behavioral‑health services provided in emergency, residential and inpatient settings would be captured in the broader total‑spending measure but would not be part of the focused benchmark.

Staff explained the rationale: a focused benchmark that emphasizes outpatient/community care is intended to expand timely access, encourage in‑network participation and support culturally responsive services, which OCA and stakeholders view as upstream interventions that can reduce demand for higher‑intensity care. Staff noted the proposal aligns with state efforts such as Proposition 1 (behavioral‑health infrastructure and services), SB 855 (parity) and SB 221 (timely access to mental‑health care), and that OCA will coordinate with DHCS, HCAI, counties and other partners to ensure consistent definitions and to avoid duplication.

OCA convened an Investment and Payment work group and reported advisory‑committee feedback in January. Advisory members generally supported a focused benchmark; several members asked for (a) linkage between investments and measurable outcomes, (b) clarity on inclusion of telehealth and technology‑enabled services, and (c) clarification on how the benchmark interacts with Proposition 1 investments in beds and infrastructure. The work group emphasized outpatient access gaps and urged inclusion of screenings and assessment activities. Several advisory‑committee and public commenters cautioned that inpatient and residential capacity remain critical and suggested OCA periodically publish additional analyses of inpatient spending (outside the focused benchmark) to monitor capacity and system effects.

Staff said the work group will meet monthly through July to refine definitions and to recommend an explicit benchmark value and measurement approach; staff said it plans to bring a formal benchmark recommendation to the Board for consideration in July 2025, with interim updates in April and June. OCA reiterated that Medi‑Cal measurement will be incorporated in collaboration with DHCS and that the office will analyze out‑of‑plan and self‑pay behavioral‑health spending in a separate, parallel work stream.

Public commenters at the meeting expressed a mix of support and concern: unions, consumer advocates and some labor groups urged prompt action and a focus on outpatient access; many hospital commenters urged caution and asked OCA to ensure the benchmark does not undercut investments in inpatient and specialty services or create unintended access consequences for rural and public hospitals.

The Board asked staff to continue coordination across state programs and to return with more detailed definitions, inclusion/exclusion lists (including a treatment of pharmaceuticals), and proposed metrics linking spending to access and outcomes.","mediaType","Video","parentTitle","February 2025 | Health Care Affordability Board Meeting","oneSentenceSummary","Staff proposed a focused behavioral‑health investment benchmark that prioritizes in‑network outpatient and community services and asked stakeholders to help refine definitions, data and the prospective benchmark value.","taxTitle","Department of Health Care Access and Information, Agencies under Office of the Governor, Executive, California","taxId",16207,"location","California","headline","","shortSummary",{"_33":77,"_35":36,"_37":38,"_39":78,"_41":79,"_43":80,"_45":81,"_47":82,"_49":83,"_51":84,"_53":85,"_55":56,"_57":58,"_59":86,"_61":62,"_63":64,"_65":87,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6274846,"OCA recommends adjusted growth targets for 11 ‘high‑cost’ hospitals; opens 45‑day comment period",3288,1902000,5190000,"/Search/View?dp=1&key=2778669-eff2e1de28668fae4e03bab0a8d4105f&start=1902&end=5190","https://assets.pipeline.soar.com/2778669-eff2e1de28668fae4e03bab0a8d4105f/thumbnail_1902000.jpg","/articles/6274846/California/OCA-recommends-adjusted-growth-targets-for-11-highcost-hospitals-opens-45day-comment-period","https://secure.pipeline.soar.com/6274846-750e5a0dc8bf5513a65c36091494fcef/orig.mp4?Expires=1773588362&Signature=mvPaVQBGMBxgb793TqDbKlO~RzhSaJXe3FierAd9fdobMyrb9nuRI-XPbSOpuXnnBvJmYL49zlfxDXZcmbmFtoERN0mNGvkI9Kr2uHL6kk8mfaOrBa16aZmNyDF4h8RoPJIEcEgKuCfDrtnmU77EyxZkgPfZ-ejBM544dwlkXsEz6ti-H7ax5zL0zBJgphrQ-MEBsWo-ZgIBqvP7IZ3QYGIwPfcUHVNk9RTwKyV3k-RzpSzbu9fcJKSh5a~Jp34dpCTc7r3mcUCXRqIqkzdhL8eTlF0Hqn~4iXBq30m4Ngdix1sQf9OQU1GGY9BQzoV8MoE2l8r9UyHfZMqdB72Xdg__&Key-Pair-Id=KUT5TJCACFTXG","OAKLAND/Monterey — The Office of Health Care Affordability on Feb. 25 recommended a methodology and specific adjustment steps to set lower allowable spending‑growth targets for hospitals the agency identifies as “disproportionately high cost.” The agency said it will publish a statute‑required memorandum and opened a 45‑day public comment period ending April 11, 2025, before the Board must set targets by June 1, 2025.

OCA staff told the Health Care Affordability Board the office would identify repeat outliers using two metrics and a persistence rule: commercial inpatient net patient revenue per case‑mix‑adjusted discharge (a unit‑price measure) and a relative‑price measure (commercial to Medicare payment‑to‑cost ratio). Staff proposed labeling hospitals that are above the 85th percentile on both measures for at least 3 of the most recent 5 years as disproportionately high cost. Those hospitals would be eligible for an adjusted, lower growth target than the statewide target.

Staff presented the underlying numbers the office used to compute a combined “cost relativity” for the group it identified. For the 11 hospitals staff flagged as repeat outliers, the pooled weighted average commercial inpatient net patient revenue per case‑mix adjusted discharge was roughly $40,200 versus about $20,200 for other comparable hospitals (a 2.0 relativity). For the commercial‑to‑Medicare payment‑to‑cost ratio the pooled averages were roughly 350% for the outliers and 200% for other hospitals (a 1.8 relativity). Averaging the two relativity values produced a combined relativity of 1.9, which staff used to scale the statewide target for the identified group.

Using that combined relativity as the adjustment factor, staff calculated proposed adjusted growth values that would apply to the identified hospitals if the Board adopts the recommendation: a 1.8% allowable growth rate for 2026, about 1.7% for 2027–28 and about 1.6% for 2029. Staff also presented a stylized projection showing that, at those slower growth rates, the outlier group would converge toward the 80th percentile value in roughly 20 years under the modeled assumptions.

The Board did not vote on targets on Feb. 25. Chair Sandra Hernandez and staff framed the recommendation as the beginning of a formal rulemaking and public comment process. The Board opened the 45‑day comment period (ending April 11, 2025) and noted staff will return with final recommendations before the statutory deadline to set targets in June.

Public commenters at the meeting and on the phone included hospital executives, trade groups, patient advocates and labor representatives. Hospital speakers and trade associations warned the proposed adjustments would threaten access in communities with high Medi‑Cal and Medicare shares and cited high capital and operating costs (for example seismic retrofit requirements and local wage levels). Salinas Valley Health, Scripps Health, Dignity Health, Cottage Health, Stanford Health Care, Marshall Medical Center and other hospitals urged staff to consider health system‑level finance, payer mix, capitated Medicare Advantage accounting, and recent improvements when identifying outliers. Community advocates, labor unions and health‑care affordability groups urged prompt action and supported the staff approach as a way to begin curbing what they described as excessively high provider pricing.

Staff told the Board they will continue one‑on‑one meetings with hospitals to collect additional feedback in March and planned follow‑up Board and advisory‑committee briefings. OCA staff emphasized the methodology is modifiable after public comment and that exclusions apply to noncomparable entities (for example, Kaiser facilities and certain long‑term state hospitals as listed in Health and Safety Code §1250 or where submitted data are not comparable). The office said it will not apply a separate “discharge” size cutoff after hearing hospital input.","The Office of Health Care Affordability proposed on Feb. 25 to identify hospitals that are repeatedly high cost using both a unit‑price metric (commercial inpatient net patient revenue per case‑mix‑adjusted discharge) and a relative‑price metric (commercial to Medicare payment‑to‑cost ratio), and to set slower allowable spending growth for those hospitals; the Board opened a 45‑day public comment period that closes April 11, 2025.",{"_33":89,"_35":36,"_37":38,"_39":90,"_41":91,"_43":92,"_45":93,"_47":94,"_49":95,"_51":96,"_53":97,"_55":56,"_57":58,"_59":98,"_61":62,"_63":64,"_65":99,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6274839,"OCA previews baseline spending report, updates data submission guide and APM/primary‑care reporting timeline",367,2925000,3292000,"/Search/View?dp=1&key=2778669-eff2e1de28668fae4e03bab0a8d4105f&start=2925&end=3292","https://assets.pipeline.soar.com/2778669-eff2e1de28668fae4e03bab0a8d4105f/thumbnail_2925000.jpg","/articles/6274839/California/OCA-previews-baseline-spending-report-updates-data-submission-guide-and-APMprimarycare-reporting-timeline","https://secure.pipeline.soar.com/6274839-44787f67ae741756e7a8b4351e4bcd73/orig.mp4?Expires=1773588362&Signature=dwUbSIhKlQvqJpKl66K5d-XvYbG~lfs~mJOV~DgIr-sMoouLvrOySthp2dMndwmSkrgkigZUi4auiGkhBa-RYLBFo2oEv2DCa9DD8UK5WxMgGNof3hBR7LkJ~i5DquJRuXLUW7FDSyOHZpHzcWkNimqKnisPuvgyqEBNpFYAGYczb335sg2AqI0pL2QN2ZPYdPlkdhIpgX0Pn7OHqWbJKOEa3ptcqxZOwndzPFPS8SG2yMBQQFyDAPuHjo~07cTT3PHyKSs~JAIFU6U9FhroNNXcA9u077GfavPl~y8P0inaL6bv1mGkB6iEMu7-biAKjH8Dnv21FdBjaDYh-~X3wg__&Key-Pair-Id=KUT5TJCACFTXG","Monterey — Office of Healthcare Affordability staff told the Board on Feb. 25 that the agency will publish a baseline report, due by June 1, 2025, using calendar‑year 2022–23 data to show statewide total medical expense (TME) and enrollment by payer and to disaggregate spending by service category and region.

The baseline will combine claims‑based TME with plan administrative costs and profit where available, showing aggregate TME, per‑capita/TME per member per year measures, and year‑over‑year changes. Staff said commercial, Medicare Advantage and many Medi‑Cal managed‑care figures will be included though OCA is still working to consolidate Medi‑Cal MCO data with DHCS. Staff recorded that 2022 commercial and MA files are already in hand and that OCA will incorporate Medi‑Cal managed‑care MCO data with assistance from the Department of Health Care Services.

Staff explained what will not appear in the initial baseline: physician‑organization level reporting and APM/primary care breakdowns are not yet ready for the first baseline because provider attribution (mapping payer records to provider tax‑IDs) remains incomplete. OCA said it intends to collect tax‑ID information and require payers to attribute major physician organizations in the September 2025 reporting cycle; the office will include physician‑organization results in a subsequent annual report once attribution confidence increases.

OCA also reviewed proposed changes to the Data Submission Guide (DSG) and a revised schedule for DSG2. Key points included:
• License‑level reporting: OCA will require plan/insurer reporting at the licensed entity level (consistent with Health Care Payments Data Program and DMHC/CDI licensing distinctions).
• Claims run‑out and reconciliation: OCA will keep the currently prescribed minimum (180 days) claims run‑out but will analyze submission completeness and potential effects from run‑out timing using the 2024–2025 cycle data.
• Member responsibility (out‑of‑pocket) fields will be retained on statewide TME files for consistency across datasets.
• Physician‑organization attribution: OCA plans to focus initially on larger physician organizations (those with ~5,000+ attributed members in commercial/MA in 2023) while working to expand the universe; staff said the top identified organizations plus the unattributed population accounted for roughly 90% of covered lives in the 2023 sample.
• APM and primary‑care files: OCA will require submitters to report alternative‑payment models and primary‑care spending in the 2025 submission cycle (due Sept. 1, 2025). Medi‑Cal MCOs will have a phased reporting approach with DHCS to avoid duplicative burden.

Staff also summarized public comments on the DSG2 draft. Submitters asked for clarifications about market‑category classification for commercial partial benefits, treatment of Medicare Advantage capitation in the relative‑price measure, how to count non‑claims payments and shared‑savings reconciliations, and how to treat retail‑pharmacy payments and vaccines in primary‑care calculations. OCA said it will clarify instructions and data‑field definitions in the final DSG2 and hold additional training webinars and one‑on‑one sessions with submitters.

Board members pressed staff on consumer affordability measures and administrative costs; staff said member out‑of‑pocket payments are available in the TME files and will be reported; staff also agreed to pursue additional cross‑checks and contextual comparisons (for example, comparing OCA’s measured TME against other statewide totals such as CMS estimates) and to present affordability framing in the baseline report.

Staff noted the schedule for DSG2 that opens submitter registration in May, allows test submissions in June, requires final files by Sept. 1, and contemplates a June 2026 annual report using the 2025 data. The draft DSG2 and related regs remain subject to the public rulemaking timeline.","OCA staff previewed the baseline report that will present 2022–2023 total medical expense (TME) data by payer, region and service category; described where physician‑organization attribution and primary‑care/APM data will fit into future reporting; and summarized public comments on the revised data submission guide (DSG2) and timelines.","actionData","errors"]

Article not found

OCA proposes focused behavioral‑health investment benchmark emphasizing outpatient/community care; seeks stakeholder input

OCA recommends adjusted growth targets for 11 ‘high‑cost’ hospitals; opens 45‑day comment period

OCA previews baseline spending report, updates data submission guide and APM/primary‑care reporting timeline