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.

Key elements of OCA’s proposal - Follow Milbank’s expanded non‑claims framework as a starting point and align the approach with OCA’s primary care non‑claims methodology. - Include all payments categorized as primary care–behavioral health integration (a2). - Allocate portions of practice transformation (a4) and EHR/HIT infrastructure (a5) payments to behavioral health when they are paid to or specifically support behavioral health providers; OCA is considering applying a percent cap similar to primary care (the primary care approach capped a portion at 1% of total medical expense). - Treat performance incentive payments (category B) as behavioral health only when paid to behavioral health providers or associated with explicit behavioral health programs. - For condition‑based episode/shared savings payments (c3/c4), include the portion tied to behavioral health conditions. - For capitation and full‑risk payments, count all capitation explicitly for behavioral health and apportion professional/global capitation to behavioral health using a fee‑for‑service (FFS) equivalent ratio: behavioral health FFS equivalent encounters ÷ total FFS equivalent encounters × capitation amount. OCA presented numerical examples showing a $250 million professional capitation with $5 million apportioned to behavioral health and a $1 billion global capitation with $10 million apportioned as behavioral health.

Stakeholder concerns and open questions - Data completeness: OCA staff said payers reported they can supply encounter counts and FFS equivalents, but cautioned that the resulting apportionment is an estimate because encounters do not always generate records and payer intentions may not equal provider spending decisions. Catherine Teer of the California Health Care Foundation asked, "Can you walk through how we get or how close we can get to getting these kinds of numbers in order to do this math?" OCA replied that data submitters (payers) have the information but acknowledged gaps and potential undercounting. - Payments to vendors and prevention/well‑being spending: Nicole Stelter of Blue Shield of California asked that OCA consider prevention and upstream well‑being programs that are often paid to vendors rather than providers; she said these programs "may either be a PMPM to a vendor where they are then passing that through to nonclinical staff" and suggested a registry or clearer tracking for such spend. - Community‑defined, culturally specific and nonclinical interventions: multiple participants urged OCA to consider community‑based activities (mindfulness, culturally tailored interventions, peer supports) that may not be billed as clinical services but contribute to behavioral health outcomes. - Social care integration and care management: participants asked how social care integration (screening for social needs, linkages to benefits) and care management that includes behavioral health coordination would be captured; OCA proposed treating social care integration per its expanded framework definitions and said it aims to capture payer‑paid mobile/street services if they are paid via claim or non‑claim.

Limits and caveats OCA noted - Any apportionment method will produce both overcounts and undercounts because most non‑claims payments cannot be tied to specific services or providers. - The data come from payers, not from provider accounting, so apportionment reflects payer intent not granular provider spend decisions. - OCA will need to decide whether to follow primary care’s caps (for practice transformation/EHR) or to set behavioral‑health‑specific limits.

What’s next OCA said it will continue to refine the expanded framework, consider whether to include payments made to vendors and prevention/well‑being programs, and return to the work group with a proposed cap set of codes and allocation rules for public comment.

Ending: OCA staff emphasized the proposal is an initial methodology and that they will iterate the approach with payer feedback and follow‑up analysis before finalizing reporting instructions.