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OKA details behavioral-health spending definition and flags carve-outs and measurement limits
Summary
OKA presented its behavioral-health spending measurement principles—primary-diagnosis rule (with screening/assessment exception), NDC-based pharmacy inclusion and allocation rules for non-claims payments—and discussed a possible benchmark focused on outpatient and community-based services while acknowledging carve-outs, county spending and out-of-pocket costs complicate a single statewide benchmark.
Debbie Lindis, healthcare delivery system group manager at OKA, reviewed the agency’s approach to defining behavioral-health spending for measurement and for a potential focused investment benchmark.
Under OKA’s approach, claims are counted as behavioral health when the claim has a primary behavioral-health diagnosis; an exception is made for claims for screening or assessment of mental health or substance-use disorders, which are included regardless of primary diagnosis. Pharmacy claims are assessed using national drug codes (NDCs) to identify mental-health or substance-use disorder medications. Non-claims payments will be classified with an expanded non-claims payments framework and allocated using methods that include attributing 100% of behavioral-health capitation payments to behavioral health and proportionally allocating portions of other capitation and transformation payments.
"All claims with a primary behavioral-health diagnosis will be included in the measurement of behavioral-health spending," Lindis said, adding that OKA recognizes this is a relatively narrow view and that future work could use supplemental data sources to capture out-of-pocket and other non-claims spending.
Work group members pressed on two topics: whether counting only primary-diagnosis claims would miss behavioral-health care provided in medical settings (for example ED or hospital care with a primary physical-health diagnosis) and how to account for county behavioral-health carve-outs and state budget spending. OKA and DHCS representatives said the primary-diagnosis rule was adopted to limit potential overcounting and that medical benchmark development is a separate and longer-term task because county carve-outs complicate attribution. "We recognize medical is a different context because of county carve-outs for severe mental illness and substance-use-disorder benefits," a DHCS representative said.
Participants also urged work on measuring out-of-pocket and self-pay behavioral-health spending; OKA staff said they continue to explore data sources and methodologies but do not yet have a reliable statewide approach. OKA said it will analyze the potential impact of including secondary behavioral-health diagnoses as part of sensitivity analyses and will return results to the work group.
OKA described the benchmark concept as a policy tool to focus investment—one likely to prioritize outpatient and community-based services (mobile clinics, outpatient facilities, professional outpatient care including primary care, and telehealth). The agency will seek additional stakeholder input before finalizing any benchmark recommendation to the board later this year.
