OCA outlines method to count non‑claims behavioral health spending, flags limits and data gaps

The Office of Health Care Affordability on a work group call presented a proposed methodology to measure behavioral health spending that is not captured in provider claims, proposing rules to include primary care–behavioral health integration payments, apportion portions of practice‑transformation and EHR/HIT payments, and a formula to allocate professional and global capitation to behavioral health.

The framework is intended to let OCA capture payments that do not generate a standard provider claim and therefore would be missed if measurement relied on claims alone. Mary Jo Condon, principal consultant with Friedman Health Care, said, "OCA recommends including all of the payments in subcategory a2, primary care and behavioral health integration. These payments would also be included in the behavioral health and primary care module." She added that portions of practice transformation and EHR infrastructure payments should be counted only when tied to behavioral health use cases.

Why this matters: non‑claims payments are common in California because of high capitation levels and are increasingly used for alternative payment models, integration, and vendor‑run wellness programs. Omitting non‑claims payments would underestimate actual payer investment in behavioral health and could skew the Office's benchmark and reporting.

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