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HPD reanalysis: outpatient professional services now the largest share of commercial behavioral-health claims spending
Summary
Using OKA’s definitions, Friedman Healthcare and OKA re-ran HPD analyses and found outpatient professional non-primary-care services rose from ~33% to 44% of commercial claims-based behavioral-health spending (2018–2023); mental health comprises ~88–89% of BH spending while substance-use disorder spending (~11–12%) is more concentrated in inpatient/residential care.
Vanayak Sinha, a senior consultant with Friedman Healthcare, presented results of a Healthcare Payments Data (HPD) reanalysis using OKA’s behavioral-health definitions. Comparing the Friedman/Milbank specifications to OKA’s expanded diagnosis and NDC lists, analysts found minimal differences in the overall measurement for commercial claims-based behavioral-health spending (no more than 0.1 percentage point of total medical expense).
Key findings for commercial claims-based spending (2018–2023): outpatient professional non-primary-care services represented the largest and fastest-growing share of behavioral-health spend, increasing from roughly 33% to 44% of the total. Pharmacy and inpatient facility spending together accounted for about one-third of behavioral-health spend. Mental-health spending made up roughly 88–89% of total behavioral-health spending, with substance-use disorder (SUD) accounting for about 11–12% and a larger share of inpatient and residential SUD services.
Analysts cautioned that results can be affected by whether a plan has behavioral health carved out; HPD includes data for commercial plans, carved-in plans and behavioral-health-only plans, so OKA is reviewing plan-level reporting to identify which plans report full-service (carved-in) behavioral health so that plan-level benchmarks are comparable. "Because of carve-outs and reporting differences, we're identifying which plans have behavioral health carved in so we can produce accurate plan- and payer-level estimates," Sinha said.
Participants asked whether pharmacy trends should be analyzed by utilization versus unit-price changes and whether high-cost services such as Applied Behavioral Analysis (ABA) can be pulled out; analysts said HPD contains NDC-level and taxonomy-level data that can support future analyses of utilization, generic versus brand dynamics, and diagnosis-specific subcategory breakdowns. OKA said it will pursue further HPD analyses to inform the behavioral-health benchmark, including the potential impact of counting claims with secondary behavioral-health diagnoses.
The work group asked for follow-up analyses on (1) identifying plans with behavioral-health carve-outs, (2) separating pharmacy-price versus utilization effects, and (3) examining high-cost subcategories such as ABA by provider taxonomy and diagnosis codes.
