Research Context

As states work to measure primary care investment, as part of larger efforts to increase investment in primary care, some — though not as many — have taken similar steps to measure investments in behavioral health care (i.e., care related to mental health and substance use disorders). Such measurement takes on particular importance, given the high level of unmet need for behavioral health services within and outside of primary care.

Despite significant expansions in behavioral health policy, including eligibility expansions through state and national parity laws and the Affordable Care Act, behavioral health care remains elusive for many. Among California with any mental illness, only 37% of adults received care for that condition. About the same percentage of adolescents with major depression received care. Access to substance use disorder treatment (SUD) is worse: Only an estimated one in 10 people with an SUD receives treatment. At a time of rising need for these services, the behavioral health workforce is stretched thin.

California is working to measure behavioral health investment, along with investment in primary care. Senate Bill 184, which was signed into law in June 2022, requires the state’s Department of Health Care Access and Information to calculate the percentage of total health care expenditures allo­cated to both primary care and behavioral health. In this paper, Freedman HealthCare (FHC) looks across states to identify national best practices in the collection and reporting of behavioral health invest­ment data — a similar analysis to that found in Investing in Primary Care: Lessons from State-Based Efforts, in which FHC provided similar guid­ance related to primary care. While this new paper is focused on California imple­mentation, the analysis and recommendations should also be valuable to agencies, planners, and policymakers in other states working toward measuring and reporting behavioral health investment.

Key Findings

FHC identified 13 states that measure behavioral health investment, and reviewed measurement specifications and methods used by each state. (The majority of these states measure some behavioral health services as part of primary care. Only two — Massachusetts and Rhode Island — measure behav­ioral health investment across all clinical services.)

In its analysis, FHC identified three categories of invest­ment — clinical care, social supports, and “other,” which includes workforce development and other admin­istrative costs. This paper discusses the ways in which states have measured and reported on these three categories, as well as the data sources used to document and measure investments. The authors identify key questions and trade-offs for states and other purchasers that include:

• Should states focus the measurement of behavioral health investment on clinical services, or should it also include social supports or other behavioral health initiatives such as workforce expansion?
• Which data sources should be used to supple­ment the all-payer claims database?
• What best practices should states consider incor­porating into measurement and reporting of behavioral health investment?

The authors suggest that states may want (or need) to design an iterative approach to addressing these questions, starting with clinical services paid through the claims system, and expanding over time to services outside the claims system and expenditures beyond traditional care delivery. Initial measurement efforts can inform next steps, including whether to set a target for behav­ioral health investment.

The paper is available for download below. Appendix B to the report is also available below at a separate link. It documents the Current Procedural Terminology, Place of Service and taxonomy, and International Statistical Classification of Diseases and Related Health Problems codes that each state uses to define behavioral health care for measurement and reporting.