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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs 6 Public- and Private-Sector Policy Support CHAPTER SUMMARY Policies set by public and private purchasers, oversight bodies, and other health care leaders shape how health care is accessed, what services are delivered, and the manner in which they are delivered. Many of these policies already support the provision of some psychosocial health care. The decision by Medicare and leading purchasers in the private sector to pay for behavioral health assessments and interventions is a strong example of these policies, as is Medicare’s recent decision to increase payment levels for patient evaluation and management services. However, other reimbursement policies have not kept pace with the evidence for the strong influence of psychological and social problems on health care and outcomes set forth in Chapter 2. Reimbursement approaches for care coordination for individuals with complex needs are not well articulated. Restrictions on which clinicians can be paid can make it difficult to access those with special expertise and present a barrier to the collocation of clinical oncology and mental health services—a situation that is problematic since collocation is an effective approach for increasing access to mental health services and coordination of those services with biomedical care. Moreover, the results of many studies finding that poor-quality health care is widespread show that reimbursement by itself does not ensure the provision of needed health care services. Reimbursement and other incentives need to be aligned with quality measurement and improvement activities, which currently are inadequate in addressing psychosocial health services. To overcome these obstacles, the committee recommends that group purchasers of health care coverage, health plans, and quality oversight
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs organizations take a number of actions to fully support the interventions necessary to deliver effective psychosocial health services. The National Cancer Institute, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services also should spearhead the development and use of performance measures to improve the delivery of these services. SUPPORTS FOR AND CONSTRAINTS ON INTERVENTIONS TO DELIVER PSYCHOSOCIAL SERVICES Chapter 4 delineates the processes that all oncology providers need to have in place to ensure that the psychosocial problems affecting their patients’ health care and outcomes are effectively addressed. These include processes that (1) support effective patient–provider communication; (2) identify individuals with psychosocial health needs; (3) link patients with service providers; (4) coordinate psychosocial and biomedical care; (5) help patients manage their illness; and (6) follow up to ensure the effectiveness of services. The need for these processes is already recognized by many group purchasers, insurers, and other policy makers, as reflected in their policies (see Table 6-1 and the discussion that follows). Other policies, however, do not reflect existing evidence on the need for and methods of delivering psychosocial health care. Medicare policies are of particular interest for several reasons. Because 60 percent of new cancer cases occur among people aged 65 and older, Medicare is the principal payer for cancer care (IOM, 1999). Moreover, Medicare typically pays about 83 percent of what private insurers pay (MEDPAC, 2007); therefore, to the extent that Medicare payment rates allow for reimbursement of practice expenses related to the processes enumerated above, reimbursement by private payers should do so to a greater extent. Medicare also is a leader in technology assessment and coverage determinations; its decisions are often followed by private-sector insurers. Finally, Medicare’s policies on coverage determination and rate setting are more visible to the public than those of the private sector, enabling their study. This section reviews key Medicare reimbursement policies and their effects on the provision of psychosocial health services to individuals with cancer. The discussion encompasses both “traditional” Medicare payments to physicians—payments made to individual health care clinicians on a fee-for-service (FFS) basis after an individual patient has made an outpatient visit or undergone a procedure—and Medicare’s advance (prospective, capitated) payments to managed care and other health plans for the delivery of an array of inpatient and outpatient services that a Medicare beneficiary may need over a specified period of time (the Medicare Advantage [MA]
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs program).1 Policies of private insurers and of Medicaid, the State Children’s Health Insurance Program (SCHIP), and other government programs also are discussed as data are available. Policies Addressing Effective Patient–Provider Communication As indicated in Table 6-1, a few large-scale policy initiatives are under way to promote more effective patient–provider communication in general.2 The Cancer Survival Toolbox (available free of charge) teaches people living with cancer how to obtain information, make decisions, solve problems, and generally communicate more effectively with health care providers (NCCS, 2007). The Questions Are the Answer Campaign (AHRQ, 2007b) and Ask Me 3™ initiative (Partnership for Clear Health Communication, undated) also encourage all patients to ask questions of their providers. Policy support for the provider side of the patient–provider partnership is illustrated by the efforts of the Veterans Health Administration, whose Employee Education System provides mandatory and optional classes on such topics as clinician–patient communication to enhance health outcomes, communication to affect behavior change, and disclosure of unanticipated outcomes and medical errors. Other initiatives to improve patient–provider communication by organizations such as Kaiser Permanente, Geisinger Health System, the American Academy of Orthopedic Surgeons, Affinity Health System, and Washington State University are chronicled by the Institute for Healthcare Communication (2005), which has conducted more than 9,000 workshops for more than 120,000 clinicians and health care workers on improving communications between clinician and patient. Further support is provided by the Agency for Healthcare Research and Quality’s (AHRQ’s) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey Instruments. This ambulatory care survey tool has separate versions for adult specialty care and adult and child primary care, each containing multiple questions specifically asking patients about how their physician communicated and shared decision making with them (AHRQ, 2007a). In addition to these instruments’ potential use as performance measures, the American Board of Medical Specialties (ABMS) is pursuing use of the specialty version to help determine physician competency in effective communication as part of its Maintenance 1 MA plans serve approximately 17 percent of Medicare beneficiaries (MEDPAC, 2007). 2 Many more initiatives are in place to improve provider communication with members of cultural and ethnic minorities and other vulnerable populations.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs TABLE 6-1 Examples of Policy Support for Interventions to Deliver Psychosocial Health Care Interventions (from Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP Support for Effective Patient–Provider Communication (excluding initiatives providing information on services only and those focused solely on cross-cultural communication)
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Private Insurance Other Government Programs Other Private Sector Some health plans and providers make patient–provider communication a priority throughout their organization. See examples at Institute for Healthcare Communication: http://www.healthcarecomm.org/index.php Support is provided by: Agency for Healthcare Research and Quality’s (AHRQ) Questions Are the Answer campaign AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey questions on effective provider communication and shared decision making Veterans Health Administration’s mandatory and optional courses on effective communication for all employees and National Symposium on Clinician-Patient Communication National Cancer Institute’s (NCI): Research Symposium on Consumer–Provider Communication in 2002 Synthesis of literature on physicians’ communication behaviors in cancer care and generally State-of-the-science report Patient-Centered Communication in Cancer Care puts forth a comprehensive research agenda addressing patient-provider communication (Epstein and Street, 2007) Support is provided by: Accreditation Council for Graduate Medical Education (ACGME) Outcome Project competencies on residents’ interpersonal and communication skills American Board of Medical Specialties’ Maintenance of Certification initiative Cancer Survival Toolbox Joint Commission Speak Up™ initiatives Partnership for Clear Health Communication’s Ask Me 3™ Initiativ
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Interventions (from Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP Identification of Psychosocial Needs Medicare law generally proscribes fee-for-service (FFS) reimbursement for “screening,” but screening still occurs in FFS and Medicare Advantage plans in several ways Medicare FFS also provides full coverage for health and behavior assessment Coverage and reimbursement vary by state, but generally: Some screening covered for children under age 21 through the Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit Coverage of Health and Behavior Current Procedural Terminology (CPT) codes varies by state Care Planning; Linking of Patients with Psychosocial Services; Coordination of Psychosocial and Biomedical Care; Follow-up Some reimbursement is provided as part of FFS payments for medical Evaluation and Management (E/M) services, and payments for some E/M services increased in 2007 Medicare Advantage plans’ more flexible reimbursement also allows for these services Multiple demonstration projects are ongoing to test models of care coordination Medicaid payments are generally low, but states’ Primary Care Case Management (PCCM) programs offer some financial support, as do state Medicaid agency contracts with managed care plans; as of 2005, 25 states offered PCCM services with some limits Most states also offer “targeted case management” to certain beneficiaries to enable access to and coordination of necessary medical, social, and educational care and other service needs (CMS, 2005a)
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Private Insurance Other Government Programs Other Private Sector Coverage of mental health screening varies by health plan Coverage for health and behavior assessment CPT codes is provided by many insurers Other government programs reimburse or provide services to identify psychosocial needs, e.g., Department of Veterans Affairs Medical Centers annually screen all patients for depression and alcohol misuse prompted by patients’ computerized medical records Older Americans Act programs also perform needs assessments Voluntary organizations offer mental health screenings Some support is provided through nurse support systems for patients established by some private insurers Some support also provided through the E/M billing codes reimbursed by private insurers Managed care plans’ more flexible reimbursement also facilitates these services (see, e.g., AHIP, 2007) Support is provided by Maternal and Child Health Programs for Children with Special Health Care Needs Support is provided by American Cancer Society’s Patient Navigator program
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Interventions (from Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP Support for Illness Self-Management Full coverage is provided for Health and Behavior Intervention CPT codes Patient and family instruction/education in managing illness is provided for in E/M codes Multiple care coordination demonstrations are teaching illness management practices Patient and family instruction/education in managing illness is provided for in E/M codes, but Medicaid payment rates are lower than those of private insurance and Medicare, which may be a disincentive to provide these services of Certification initiative.3 A CAHPS specialty version could be used in oncology practices as a way to systematically measure and help improve patient–provider communication. Despite the above initiatives to help patients and providers communicate more effectively, the limited number and scope of such initiatives constrains improvement in this area. The new CAHPS Clinician and Group Survey instruments can provide a vehicle to help educate both patients and providers and facilitate clinicians’ adoption of new communication behaviors, but mechanisms need to be in place to collect the data from patients and relay them back to providers in ways that will improve communication. These mechanisms (discussed later in this chapter) are not yet in place. In addition, although ineffective patient–provider communication is not typically identified as resulting from a failure to reimburse for effective communication, financial incentives to see greater numbers of patients (and thereby limit providers’ time with each patient) are sometimes cited as 3 The ABMS Member Boards helped develop the three versions of the survey—one for adult primary care, one for proceduralists/surgeons, and one for pediatricians. The impetus for these efforts was the need for instruments to measure patient care experiences and physician–patient communication as an aspect of physician competence in the ABMS Maintenance of Competence Program. Personal communication, Stephen Miller, MD, President, ABMS, March 23, 2007.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Private Insurance Other Government Programs Other Private Sector Some coverage is provided for Health and Behavior Intervention CPT codes Managed care plans’ more flexible reimbursement also facilitates these services (see, e.g., AHIP, 2007) Patient and family instruction/education in managing illness is provided for in E/M codes Some telephonic case management or nurse support systems offered by some private insurers offer support Administration on Aging grant program to states and local communities, Empowering Older People to Take More Control of Their Health through Evidence-Based Prevention, requires use of illness self-management Large number of programs offered in the voluntary sector (see Chapter 3) Employer programs and policies such as Employee Assistance Programs and leave policies, e.g., availability of extended leave of absence, flex time work hours, and unscheduled leave a barrier to addressing psychosocial issues (Astin et al., 2006). Reimbursement policies could be structured in ways that would reward providers with the best performance in communicating with patients. Policies Addressing the Identification of Psychosocial Needs As discussed in Chapter 4, two general means are used to identify patients’ psychosocial needs reliably: screening for problems, followed by an assessment, or bypassing screening and conducting a more comprehensive assessment by itself. Given the brevity of several reliable and valid screening instruments (as discussed in Chapter 4) and the fact that many of these instruments can be self-administered by the patient (often in the waiting room prior to contact with the physician, also as discussed in Chapter 4), the resources required to administer such instruments may not be substantial, although following up on numerous, complex needs thus identified may be, as discussed below. Screening Although FFS Medicare generally does not pay explicitly and separately for screening services (except when coverage for a specific screening
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs procedure is explicitly added to the Medicare statute by congressional action), this may not be a major barrier to the performance of psychosocial screening by itself. First, the exemplar organizations described in Chapter 5 (and others identified by the committee but not discussed in this report) all perform screening and more in-depth assessment under a variety of scenarios. These practices provide some evidence of the feasibility of screening under current policies. Second, MA private plans are not restricted to offering services explicitly allowed under Medicare’s FFS statutory provisions. MA plans (especially health maintenance organization [HMO]–type plans, as opposed to preferred provider organizations [PPOs] and private FFS plans) often offer benefits beyond those in FFS Medicare, such as routine health exams, some care coordination, and eyeglasses. Managed care plans in the private sector also often offer additional services. For example, in 2005 Aetna began an initiative offering financial incentives to primary care physicians to identify and care for certain health plan enrollees with depression. Primary care physicians who serve Aetna enrollees are trained in the use of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool, are supplied with care management resources designed to support patients and primary care providers, and have access to mental health specialists for collaborative consultation (Moran, 2006). For every patient identified though screening as positive for symptoms of depression, Aetna pays the physician $15.00.4 Moreover, brief screening for some conditions takes place and is reimbursed as part of Medicare’s FFS payment for office visits. For example, when a nurse takes a patient’s blood pressure at each routine visit, this is essentially screening for hypertension. Similarly, if a primary care provider incorporates depression screening or screening for alcohol misuse into a visit for evaluation or management of physical symptoms or an already documented medical condition, these screening services are included in Medicare’s payment for Evaluation and Management (E/M) services—one of the most commonly delivered health services. Such screening is explicitly identified as a component of E/M services in the Current Procedural Terminology (CPT) codes5 reimbursed by all payers (public and private) (Beebe et al., 2006). 4 Personal communication, Hyong Un, MD, National Medical Director for Behavioral Health, Aetna, March 29, 2007. 5 CPT, maintained by the American Medical Association, is a listing of medical services and procedures (and an accompanying numerical code for each) used by physicians and certain other clinicians (e.g., physician assistants, nurse practitioners, and nurse midwives) to report the services and procedures they perform as part of their claims to insurers for reimbursement. CPT codes are designated by the federal government as the national standard for coding such services.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Assessment of Psychosocial Needs Assessing and following up on psychosocial problems takes more time than screening; as a result, payment becomes more of an issue. In 2002, new Health and Behavior Assessment and Intervention (H/B) codes were incorporated into the CPT coding set generally used by all ambulatory health care providers when submitting a claim for reimbursement.6 At the time, these codes were described as a “paradigm shift” (Foxhall, 2000) because they allowed direct billing—by nonphysicians such as clinical psychologists—for psychosocial services for general medical illnesses such as diabetes or heart disease as opposed to mental illnesses. The new codes were intended to allow behavioral health specialists to address psychological, behavioral, emotional, cognitive, and social problems interfering with patients’ ability to manage their physical illnesses. Prior to the new codes, the only way to deliver such services was to submit a bill for a mental health intervention, which required a diagnosis of mental illness. Of note, when the American Psychological Association put forth its proposal for the adoption of these codes, the following pediatric oncology case study was used as one example of the range of interventions the codes were intended to capture: A 5-year-old boy undergoing treatment for acute lymphoblastic leukemia is referred for assessment of pain and severe behavioral distress and combativeness associated with repeated lumbar punctures and intrathecal chemotherapy administration. Previously unsuccessful approaches had included pharmacologic treatment of anxiety (Ativan), conscious sedation using Versed, and finally, chlorohydrate, which only exacerbated the child’s distress as a result of partial sedation. General anesthesia was ruled out because the child’s asthma increased respiratory risk to unacceptable levels. Intervention: The patient was assessed using standard questionnaires (e.g., the Information-Seeking scale, Pediatric Pain Questionnaire, Coping Strategies Inventory), which, in view of the child’s age, were administered in a structured format. The medical staff and child’s parents were also interviewed. On the day of a scheduled medical procedure, the child completed a self-report distress questionnaire. Behavioral observations were also made during the procedure using the CAMPIS-R, a structured observation scale that quantifies child, parent, and medical staff behavior.7 As defined in the 2007 CPT coding manual (Beebe et al., 2006:410–411), 6 Reimbursement generally does not take place without a code to describe accurately the service delivered. 7 Personal communication, Diane Pedulla, JD, American Psychological Association, January 5, 2007.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Initiative Number of Performance Measures Adopted/Endorsed Number and Description of Adopted/Endorsed Performance Measures Addressing Psychosocial Health Care in Community Settings 2006 National Health Care Quality Report 211 measures, including 15 addressing effectiveness of cancer care Cancer-specific measures do not address psychosocial health services 8 address effectiveness of mental health and substance abuse care 15 address timeliness of care 24 address patient–provider communication across conditions National Quality Forum 6 measures for breast cancer; 4 for colorectal cancer (NQF, 2007a) No psychosocial measures among the breast and colorectal cancer measures 9 measures of symptom management and end-of-life care for patients with cancer (NQF, 2006) Symptom management and end-of-life measures predominantly (8 or 9 of 9) address hospice, death, and last 30 days of life 112 ambulatory care measures endorsed as of July 2007 for treatment of 9 noncancer conditions (e.g., asthma, diabetes), plus emergency care, geriatrics, medication management, patient experience with care, screening, and preventive care (NQF, 2007b) Ambulatory measures for mental health address major depressive disorders, new episodes of depression, attention-deficit hyperactivity disorder, bipolar disorder, alcohol and other drug treatment Other ambulatory care measures address tobacco cessation, physical activity, and cancer screening Patient experience of care measures include CAHPS survey of adult specialty care and survey for children with chronic conditions pilot testing the measures, ensuring calculation and submission of the measures, auditing to ensure their accuracy, analyzing and displaying measurement results in a format suitable for the intended audiences, and maintaining the measures’ accuracy and reliability over time (IOM, 2006a). Structures and processes for performing many of these functions already exist within the health care system. However, marshaling these resources, especially with respect to ensuring the calculation and submission of the measures, will require leadership.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Leadership Leadership is a critical factor in the success of any major change initiative or quality improvement effort (Burns, 1978; Bodenheimer et al., 2004; National Institute of Standards and Technology, 2007). Fortunately, a number of organizations that already play a leadership role in oncology have the ability to influence quality through their certifying activities, financial support, and ability to inform consumers in the marketplace. Such organizations, working together, could constitute a critical mass of leadership creating substantial incentives for oncology providers to improve the delivery of psychosocial health care for patients with cancer and their families by supporting the development of a small, strategic set of performance measures addressing psychosocial health care and then incorporating these measures into their organizational policies and practices. As the nation’s leader in cancer care, NCI has a number of venues through which performance measures could be used to improve psychosocial health care. NCI’s 61 designated cancer centers and comprehensive cancer centers together constitute the “centerpiece of the nation’s effort to reduce morbidity and mortality from cancer” (NCI, 2004:2) and are “characterized by strong organizational capabilities, institutional commitment, and trans-disciplinary, cancer-focused science; experienced scientific and administrative leadership, and state-of-the-art cancer research and patient care facilities [emphasis added]” (NCI, undated-a). NCI could encourage these facilities to set the benchmark for performance in meeting standards for psychosocial health care incorporated in the performance measures, and to measure and report their performance in providing such care. NCI’s Outcomes Research Branch also coordinates and sponsors research aimed at improving cancer outcomes; reducing health disparities; and reducing the cancer burden on patients, families, and society. In doing so, it coordinates and funds research and applications designed to assess, monitor, and improve the quality of cancer care, and translates research findings into products and strategies for use by public and private policy makers who provide, pay for, regulate, and set standards for cancer care (NCI, undated-b). Incorporating the development and application of performance measures of psychosocial health care into this agenda also could help advance the use of such measures. Leading private-sector funders of cancer research and demonstrations, such as the American Cancer Society, Lance Armstrong Foundation, and Susan G. Komen for the Cure Foundation, also could incentivize the calculation and public reporting of performance measures of psychosocial health care by including questions about how organizations deliver such care in their requests for proposals, making awards based on applicants’ performance in these areas, and requiring the calculation and reporting of the
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs measures as a condition of their financial support. For example, the Lance Armstrong Foundation could require participants in its LIVESTRONG Survivorship Center of Excellence Network (Lance Armstrong Foundation, 2007) to calculate and submit the measures to a performance measures repository as part of membership in the network. Organizations supporting patients with cancer and their families as consumers in the marketplace could also use performance measures to create strong incentives for improved performance in psychosocial health care. Approved performance measures constitute de facto standards of performance. Publicizing the measures (even before there are any measurement results) can help educate consumers about what services to expect and ask about when they begin their cancer care. Publicizing the measures can also filter up to employers (and other group purchasers), who want the best possible care for their employees facing treatment, and thereby to the insurers with whom they contract to provide coverage for health care. An Infrastructure to Support Performance Measurement As discussed above, successful performance measurement requires more than the creation of measures and an entity that will require their calculation. Structures and processes are needed to transform the concepts to be measured into sets of technical specifications, pilot test the measures, audit a sample of measures to ensure their accuracy, analyze and display measurement results, and maintain the accuracy of measurement specifications over time. Structures and processes for performing many of these functions already exist within the health care system. The National Quality Forum, for example, working in collaboration with many of its members, has developed or endorsed technical specifications for many measures across a wide variety of conditions. Accrediting bodies such as the Joint Commission and the National Committee for Quality Assurance (NCQA) serve as repositories of submitted data and convert the data to formats useful to consumers and others. Consolidating a combination of organizations and resources to carry out the various performance measurement–related activities will require planning, collaboration, and perhaps financial support. This, too, will require leadership across many sectors of cancer care. CONCLUSIONS AND RECOMMENDATIONS The committee concludes that, although the policies and practices of many organizations support the delivery of several components of psychosocial health care, such is not always the case. Available mechanisms to compensate providers for assessments and interventions to help patients manage their illness are not fully utilized by all insurers. While FFS
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs reimbursement codes take into consideration the basic need to coordinate care, FFS reimbursement does not well support processes for care coordination that require additional resources. Although capitated payments to managed care plans allow better for the provision of linking services, care coordination, follow-up, and illness self-management support, these examples are still considered noteworthy, rather than “usual and customary” practice. Lack of health insurance, high cost sharing for patients, and health plan policies that hinder collocated services and access to certain providers also can keep patients from receiving needed services. Solutions exist that are feasible for group purchasers of health care coverage and health plans to implement. Recommendation: Support from payers. Group purchasers of health care coverage and health plans should fully support the evidence-based interventions necessary to deliver effective psychosocial health services: Group purchasers should include provisions in their contracts and agreements with health plans that ensure coverage and reimbursement of mechanisms for identifying the psychosocial needs of cancer patients, linking patients with appropriate providers who can meet those needs, and coordinating psychosocial services with patients’ biomedical care. Group purchasers should review cost-sharing provisions that affect mental health services and revise those that impede cancer patients’ access to such services. Group purchasers and health plans should ensure that their coverage policies do not impede cancer patients’ access to providers with expertise in the treatment of mental health conditions in individuals undergoing complex medical regimens such as those used to treat cancer. Health plans whose networks lack this expertise should reimburse for mental health services provided by out-of-network practitioners with this expertise who meet the plan’s quality and other standards (at rates paid to similar providers within the plan’s network). Group purchasers and health plans should include incentives for the effective delivery of psychosocial care in payment reform programs—such as pay-for-performance and pay-for-reporting initiatives—in which they participate. In the above recommendation, “group purchasers” include purchasers in the public sector (e.g., Medicare and Medicaid), as well as group purchasers in the private sector (e.g., employer purchasers). In recommending
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs that group purchasers include in their contracts and agreements with health plans provisions to ensure the coverage and reimbursement of mechanisms to identify psychosocial needs, link patients to psychosocial health services, and coordinate these services with biomedical care, the committee is not necessarily calling for these interventions to be reimbursed separately by group purchasers and health plans. Rather, these parties should assess the extent to which these processes are explicitly addressed in their agreements with each other and with health care providers, make these expectations explicit if they are not already so, and assess the adequacy of their payment rates for these processes. Purchasers and health plans may find, for example, that these interventions are currently provided for in their capitated payments or included to some extent in FFS reimbursements. In contrast, mechanisms may need to be developed for reimbursing higher-than-average levels of care coordination. The predictive modeling techniques now being used by some health plans can help identify when special reimbursement of or arrangements for care coordination may be called for. With respect to reimbursement of out-of-network providers when necessary, mental health care providers “with expertise in the treatment of mental health conditions in individuals undergoing complex medical regimens such as those used to treat cancer” include mental health care providers who possess this expertise through formal education (such as specialists in psychosomatic medicine), as well as mental health care providers who have gained expertise though their clinical experiences, such as mental health clinicians collocated with and part of an interdisciplinary oncology practice. The recommended approach of guaranteeing access to such expertise through the use of out-of-network providers is consistent with similar recommendations of other health care quality initiatives (Shalala, 2000), including the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998), whose patient Bill of Rights states: “All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay…. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers. Plans also should establish and maintain adequate arrangements to ensure reasonable proximity of providers to the business or personal residence of their members” (p. A-31). Further, ensuring access to such providers means more than just allowing them to receive reimbursement; a health care provider possessing this expertise must be accessible to the cancer patient. If, for example, an individual with such expertise is collocated with the patient’s other oncology
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs providers, this individual should be allowed to receive reimbursement provided that (as specified in the recommendation above) he or she meets the plan’s quality and other standards. The provider should also accept reimbursement at rates paid to similar providers within the plan’s network. In recognition that full implementation of the above recommendation will not by itself ensure the provision of appropriate psychosocial health services, the committee also makes the following recommendation. Recommendation: Quality oversight. The National Cancer Institute, CMS, and AHRQ should fund research focused on the development of performance measures for psychosocial cancer care. Organizations setting standards for cancer care (e.g., National Comprehensive Cancer Network, American Society of Clinical Oncology, American College of Surgeons’ Commission on Cancer, Oncology Nursing Society, American Psychosocial Oncology Society) and other standards-setting organizations (e.g., National Quality Forum, National Committee for Quality Assurance, URAC, Joint Commission) should Create oversight mechanisms that can be used to measure and report on the quality of ambulatory oncology care (including psychosocial health care). Incorporate requirements for identifying and responding to psychosocial health care needs into their protocols, policies, and standards. Develop and use performance measures for psychosocial health care in their quality oversight activities. The research to be funded will need to transform concepts to be measured into technical specifications, pilot test the measures, audit a sample of measures to ensure their accuracy, analyze and display measurement results, and address how the accuracy and reliability of the measures will be maintained over time. The committee expects that these activities will make use of already established mechanisms and organizations that currently perform these functions, but that some funding may be needed to support certain other activities, such as the initial development of the measure specifications. The committee also believes that a small number of measures (five or fewer) should be targeted for development, and that these could consist of structural as well as process and outcome-of-care measures. Structural measures are typically addressed in accreditation processes and could be used to deal with such areas of concern as whether a health plan or clinical practice requires or uses a validated instrument or approach to identify systematically all cancer patients with psychosocial needs. Patient report
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs instruments, such as AHRQ’s CAHPS Clinician and Group Survey questions, could also be used to obtain information from patients about the extent to which they were linked to needed psychosocial services and received education and training in managing their illness. Thus, the expert organizations to be encompassed by and consulted in this planning process would be diverse, including government agencies such as AHRQ; private-sector accreditation bodies such as the Commission on Cancer, NCQA, and the Joint Commission; and performance measurement bodies such as the National Quality Forum. REFERENCES Adiga, K., M. Buss, and B. W. Beasley. 2006. Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement: A national needs assessment survey of internal medicine residents. Journal of General Internal Medicine 21(5):466–470. AHIP (America’s Health Insurance Plans). 2004. 2002 AHIP survey of health insurance plans: Chart book of findings. Washington, DC: AHIP. AHIP. 2007. Innovations in chronic care. Washington, DC: AHIP. AHRQ (Agency for Healthcare Research and Quality). 2006. National health care quality report. Rockville, MD: U.S. Department of Health and Human Services, and AHRQ. AHRQ. 2007a. CAHPS clinician and group survey AHRQ, 3/22/2007. https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 (accessed March 23, 2007). AHRQ. 2007b. Questions are the answer. http://www.ahrq.gov/questionsaretheanswer/ (accessed April 4 2007). American College of Surgeons. 2007. What is the Commission on Cancer? http://www.facs.org/cancer/coc/cocar.html (accessed April 11, 2007). APOS (American Psychosocial Oncology Society). 2007 (unpublished). APOS reimbursement survey. AQA (Ambulatory Care Quality Alliance). 2007. AQA approved quality measures, January 2007. http://www.aqaalliance.org/files/ApprovedPerformanceMeasures.xls (accessed April 9, 2007). ASCO (American Society of Clinical Oncology). 2007. Summary of QOPI measures, Spring 2007. http://www.asco.org/portal/site/ASCO/menuitem.c543a013502b2a89de912310320041a0/?vgnextoid=cdb7dd224254c010VgnVCM100000ed730ad1RCRD&cpsextcurrchannel=1/ (accessed August 20, 2007). Astin, J. A., K. Soeken, V. Sierpina, and B. Clarridge. 2006. Barriers to the integration of psychosocial factors in medicine: Results of a national survey of physicians. Journal of the American Board of Family Medicine 19(6):557–565. Bachman, J., H. A. Pincus, J. K. Houtsinger, and J. Unutzer. 2006. Funding mechanisms for depression care management: Opportunities and challenges. General Hospital Psychiatry 28(4):278–288. Barry, C. L., J. R. Gabel, R. G. Frank, S. Hawkins, H. H. Whitmore, and J. Pickreign. 2003. Design of mental health benefits: Still unequal after all these years. Health Affairs 22(5):127–137.
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