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

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.