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