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