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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6 Public- and Private-Sector Policy Support CHAPTER SUMMARY Policies set by public and priate purchasers, oersight bodies, and other health care leaders shape how health care is accessed, what serices are deliered, and the manner in which they are deliered. Many of these policies already support the proision of some psychosocial health care. The decision by Medicare and leading purchasers in the priate sector to pay for behaioral health assessments and interentions is a strong example of these policies, as is Medicare’s recent decision to increase pay- ment leels for patient ealuation and management serices. Howeer, other reimbursement policies hae not kept pace with the eidence 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 indiiduals 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 clini- cal oncology and mental health serices—a situation that is problematic since collocation is an effectie approach for increasing access to mental health serices and coordination of those serices with biomedical care. Moreoer, the results of many studies finding that poor-quality health care is widespread show that reimbursement by itself does not ensure the proision of needed health care serices. Reimbursement and other incenties need to be aligned with quality measurement and improement actiities, which currently are inadequate in addressing psychosocial health serices. To oercome these obstacles, the committee recommends that group purchasers of health care coerage, health plans, and quality oersight 21

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22 CANCER CARE FOR THE WHOLE PATIENT organizations take a number of actions to fully support the interentions necessary to delier effectie psychosocial health serices. The National Cancer Institute, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Serices also should spearhead the deelopment and use of performance measures to improe the deliery of these serices. 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 in- clude 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 ef- fectiveness 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 poli- cies, 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 enu- merated 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 adance (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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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT 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 ™ 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 In- stitute 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. Fur- ther support is provided by the Agency for Healthcare Research and Qual- ity’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 mak- ing 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 physi- cian 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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2 CANCER CARE FOR THE WHOLE PATIENT 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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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT Other Government Private Insurance Programs Other Private Sector • Some health plans and Support is provided by: Support is provided by: providers make patient– • Agency for Healthcare • Accreditation Council provider communication Research and Quality’s for Graduate Medical a priority throughout (AHRQ) Questions Are Education (ACGME) their organization. the Answer campaign Outcome Project See examples at • AHRQ’s Consumer competencies on residents’ Institute for Healthcare Assessment of interpersonal and Communication: http:// Healthcare Providers communication skills www.healthcarecomm. and Systems (CAHPS) • American Board of Medical org/index.php Clinician and Group Specialties’ Maintenance of Survey questions on Certification initiative effective provider • Cancer Survival Toolbox communication and • Joint Commission Speak shared decision making Up™ initiatives • Veterans Health • Partnership for Clear Health Administration’s Communication’s Ask Me mandatory and optional ™ Initiative 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) continued

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2 CANCER CARE FOR THE WHOLE PATIENT TABLE 6-1 Continued Interventions (from Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP Identification of • Medicare law generally Coverage and reimbursement Psychosocial Needs proscribes fee-for-service vary by state, but generally: (FFS) reimbursement • Some screening covered for “screening,” but for children under age screening still occurs 21 through the Medicaid in FFS and Medicare Early Periodic Screening, Advantage plans in Diagnosis, and Treatment several ways (EPSDT) benefit • Medicare FFS also • Coverage of Health provides full coverage and Behavior Current for health and behavior Procedural Terminology assessment (CPT) codes varies by state Care Planning; Linking of • Some reimbursement • Medicaid payments are Patients with Psychosocial is provided as part generally low, but states’ Services; Coordination of FFS payments for Primary Care Case of Psychosocial and medical Evaluation and Management (PCCM) Biomedical Care; Management (E/M) programs offer some Follow-up services, and payments financial support, as do for some E/M services state Medicaid agency increased in 2007 contracts with managed • Medicare Advantage care plans; as of 2005, plans’ more flexible 25 states offered PCCM reimbursement also services with some limits allows for these services • Most states also • Multiple demonstration offer “targeted case projects are ongoing management” to certain to test models of care beneficiaries to enable coordination access to and coordination of necessary medical, social, and educational care and other service needs (CMS, 2005a)

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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT Other Government Private Insurance Programs Other Private Sector • Coverage of mental Other government Voluntary organizations offer health screening varies programs reimburse or mental health screenings by health plan provide services to identify • Coverage for health and psychosocial needs, e.g., behavior assessment • Department of Veterans CPT codes is provided Affairs Medical Centers by many insurers annually screen all patients for depression and alcohol misuse prompted by patients’ computerized medical records • Older Americans Act programs also perform needs assessments • Some support is Support is provided by Support is provided by provided through nurse Maternal and Child Health American Cancer Society’s support systems for Programs for Children Patient Navigator program patients established by with Special Health Care some private insurers Needs • 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) continued

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2 CANCER CARE FOR THE WHOLE PATIENT TABLE 6-1 Continued Interventions (from Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP Support for Illness • Full coverage is provided • Patient and family Self-Management for Health and Behavior instruction/education in Intervention CPT codes managing illness is provided • Patient and family for in E/M codes, but instruction/education Medicaid payment rates are in managing illness is lower than those of private provided for in E/M insurance and Medicare, codes which may be a disincentive • Multiple care to provide these services coordination demonstrations are teaching illness management practices 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 commu- nicate 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 com- munication. 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 effec- tive 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 Compe- tence Program. Personal communication, Stephen Miller, MD, President, ABMS, March 23, 2007.

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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT Other Government Private Insurance Programs Other Private Sector • Some coverage is • Administration on Aging • Large number of programs provided for Health and grant program to states offered in the voluntary Behavior Intervention and local communities, sector (see Chapter 3) CPT codes • Employer programs and Empowering Older • Managed care policies such as Employee People to Take More plans’ more flexible Assistance Programs Control of Their Health reimbursement also and leave policies, e.g., through Eidence- facilitates these services availability of extended Based Preention, (see, e.g., AHIP, 2007) requires use of illness leave of absence, flex • Patient and family self-management time work hours, and instruction/education unscheduled leave 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 a barrier to addressing psychosocial issues (Astin et al., 2006). Reimburse- ment 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 pa- tients’ 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 screen- ing 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 substan- tial, although following up on numerous, complex needs thus identified may be, as discussed below. Screening Although FFS Medicare generally does not pay explicitly and sepa- rately for screening services (except when coverage for a specific screening

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20 CANCER CARE FOR THE WHOLE PATIENT procedure is explicitly added to the Medicare statute by congressional ac- tion), 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 sce- narios. These practices provide some evidence of the feasibility of screening under current policies. Second, MA private plans are not restricted to offer- ing 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 depres- sion. 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 reim- bursed 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 explic- itly 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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21 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT 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 psy- chologists—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 psychologi- cal, 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 leuke- mia 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 seda- tion 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 Strat- egies Inventory), which, in view of the child’s age, were administered in a structured format. The medical staff and child’s parents were also inter- viewed. 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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22 CANCER CARE FOR THE WHOLE PATIENT TABLE 6- Continued Number and Description of Adopted/ Number of Endorsed Performance Measures Performance Measures Addressing Psychosocial Health Care in Initiative Adopted/Endorsed Community Settings 2006 National 211 measures, • Cancer-specific measures do not address Health Care Quality including 15 addressing psychosocial health services Report effectiveness of cancer • 8 address effectiveness of mental health care and substance abuse care • 15 address timeliness of care • 24 address patient–provider communication across conditions National Quality • 6 measures for • No psychosocial measures among the Forum breast cancer; 4 for breast and colorectal cancer measures colorectal cancer (NQF, 2007a) • 9 measures • Symptom management and end-of-life of symptom measures predominantly (8 or 9 of 9) management and address hospice, death, and last 30 days end-of-life care for of life patients with cancer (NQF, 2006) • 112 ambulatory • Ambulatory measures for mental health care measures address major depressive disorders, new endorsed as of July episodes of depression, attention-deficit 2007 for treatment hyperactivity disorder, bipolar disorder, of 9 noncancer alcohol and other drug treatment conditions (e.g., • Other ambulatory care measures asthma, diabetes), address tobacco cessation, physical plus emergency care, activity, and cancer screening geriatrics, medication • Patient experience of care measures management, patient include CAHPS survey of adult experience with specialty care and survey for children care, screening, with chronic conditions and preventive care (NQF, 2007b) pilot testing the measures, ensuring calculation and submission of the measures, auditing to ensure their accuracy, analyzing and displaying mea- surement results in a format suitable for the intended audiences, and main- taining 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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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT Leadership Leadership is a critical factor in the success of any major change ini- tiative 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, fi- nancial support, and ability to inform consumers in the marketplace. Such organizations, working together, could constitute a critical mass of leader- ship creating substantial incentives for oncology providers to improve the delivery of psychosocial health care for patients with cancer and their fami- lies 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 psycho- social 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 “char- acterized 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 re- search 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 per- formance 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 calcu- lation 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’ perfor- mance in these areas, and requiring the calculation and reporting of the

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2 CANCER CARE FOR THE WHOLE PATIENT 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 per- formance. 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 pos- sible 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 calcula- tion. 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 mea- surement 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 devel- oped 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 reposito- ries 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 psy- chosocial health care, such is not always the case. Available mechanisms to compensate providers for assessments and interventions to help pa- tients manage their illness are not fully utilized by all insurers. While FFS

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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT reimbursement codes take into consideration the basic need to coordinate care, FFS reimbursement does not well support processes for care coordi- nation 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 ex- amples 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 reim- bursement of mechanisms for identifying the psychosocial needs of cancer patients, linking patients with appropriate providers who can meet those needs, and coordinating psychosocial ser- vices 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 cov- erage 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 pur- chasers in the private sector (e.g., employer purchasers). In recommending

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2 CANCER CARE FOR THE WHOLE PATIENT 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 ex- ample, 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 nec- essary, mental health care providers “with expertise in the treatment of mental health conditions in individuals undergoing complex medical regi- mens such as those used to treat cancer” include mental health care provid- ers 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 insuffi- cient number or type of providers to provide a covered benefit with the ap- propriate 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 provid- ers to the business or personal residence of their members” (p. A-31). Further, ensuring access to such providers means more than just allow- ing them to receive reimbursement; a health care provider possessing this expertise must be accessible to the cancer patient. If, for example, an indi- vidual with such expertise is collocated with the patient’s other oncology

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2 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT providers, this individual should be allowed to receive reimbursement pro- vided that (as specified in the recommendation above) he or she meets the plan’s quality and other standards. The provider should also accept reim- bursement 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 Can- cer Network, American Society of Clinical Oncology, American Col- lege 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 psy- chosocial 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 mea- sured 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 cur- rently perform these functions, but that some funding may be needed to support certain other activities, such as the initial development of the mea- sure 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 clini- cal practice requires or uses a validated instrument or approach to identify systematically all cancer patients with psychosocial needs. Patient report

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2 CANCER CARE FOR THE WHOLE PATIENT instruments, such as AHRQ’s CAHPS Clinician and Group Survey ques- tions, could also be used to obtain information from patients about the extent to which they were linked to needed psychosocial services and re- ceived 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 regard- ing 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 surey of health insurance plans: Chart book of findings. Washington, DC: AHIP. AHIP. 2007. Innoations 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 surey AHRQ, /22/200. 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/ (ac- cessed 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 surey. AQA (Ambulatory Care Quality Alliance). 2007. AQA approed quality measures, Janu- ary 200. http://www.aqaalliance.org/files/ApprovedPerformanceMeasures.xls (accessed April 9, 2007). ASCO (American Society of Clinical Oncology). 2007. Summary of QOPI measures, Spring 200. http://www.asco.org/portal/site/ASCO/menuitem.c543a013502b2a89de91231032 0041a0/?vgnextoid=cdb7dd224254c010VgnVCM100000ed730ad1RCRD&cpsextcurr channel=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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21 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT NQF. 2007a. National Quality Forum endorses consensus standards for diagnosis and treat- ment of breast & colorectal cancer. http://www.qualityforum.org/pdf/news/prbreast- colon03-12-07.pdf (accessed April 10, 2007). NQF. 2007b. National oluntary consensus standards for ambulatory care. http://www. qualityforum.org/pdf/ambulatory/tbAMBALLMeasuresendorsed%2007-27-07.pdf (ac- cessed September 4, 2007). Partnership for Clear Health Communication. Undated. Ask me ™. http://www.askme3. org/for_patients.asp (accessed April 4, 2007). President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Quality first: Better health care for all Americans. Final report to the President of the United States. Washington, DC: U.S. Government Printing Office. Raison, C. L., and A. H. Miller. 2003. Depression in cancer: New developments regarding diagnosis and treatment. Biological Psychiatry 54(3):283–294. Shalala, D. 2000. Report to Congress: Safeguards for indiiduals with special health care needs enrolled in Medicaid managed care. Washington, DC: U.S. Department of Health and Human Services. U.S. Census Bureau. 2007. Census Bureau reises 200 and 200 health insurance coerage estimates. Washington, DC: U.S. Department of Commerce.

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