OCA finds commercial behavioral‑health claims rose but recommends delay in setting investment benchmark

The Office of Health Care Affordability (OCA) briefed the advisory committee on June 16 about behavioral health spending trends and recommended deferring adoption of a statewide behavioral‑health investment benchmark until OCA completes further data collection and analysis. What OCA found: Using a Milbank/Federal consensus code set applied to HPD commercial claims, OCA's preliminary analysis showed behavioral health spending in the commercial market rose from 6.6% of total claims spending in 2018 to about 8.2% in 2023. Much of the increase was concentrated in in‑network outpatient professional and facility services—"outpatient non‑primary care professional services" grew from about 33% to 43% of behavioral health spending during that period. Methods and limits: OCA and committee members emphasized that the HPD analysis covers the commercial market and voluntary self‑insured submitters; it does not yet include Medi‑Cal or fee‑for‑service Medicare. The analysis suppresses cells with fewer than 30 claims to protect privacy, and the Milbank approach counts a claim as behavioral health if the primary diagnosis is a behavioral health code or the claim includes specific behavioral health screening/assessment service codes; pharmacy claims are counted if the NDC is on OCA's behavioral drug list. Benchmark recommendation and rationale: OCA had earlier proposed a two‑phase benchmark that would require payers to increase spending on in‑network outpatient and community‑based behavioral health by specified annual percentages beginning with a 2025 baseline. After the May work group and the board discussion, OCA recommended delaying formal adoption of a benchmark until spring 2028, with a possible reassessment in 2026 if HPD analyses provide sufficient evidence. The stated reasons: (1) payer starting points vary; (2) HPD and payer submissions need further validation and refinement; and (3) several state behavioral‑health reforms (e.g., children and youth behavioral health initiatives, CalAIM changes) are being implemented now and will affect spending patterns. Committee input: Members raised several concerns: measurement gaps where behavioral health is embedded in primary care visits (secondary diagnoses and coding practices may undercount primary‑care–delivered behavioral health); the need to include county specialty mental health (Medi‑Cal specialty services) and corrections/county care where relevant; the importance of distinguishing mental health from substance use disorder (SUD) spending; and the desire to compare California to other states (Massachusetts, Rhode Island) that measure behavioral health spending. OCA next steps: OCA will continue HPD analyses, coordinate with DHCS to include Medi‑Cal specialty mental health where feasible, finalize a behavioral‑health definition and code set with the investment & payment work group in July/August, publish those definitions for public comment, and return to the committee in September with a refined measurement proposal. The agency also plans supplemental analyses (drivers, diagnoses, price vs. utilization, payer variation) before resetting any long‑term benchmark.