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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs (2008)

Chapter: 6 Public- and Private-Sector Policy Support

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Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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]

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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)

 

 

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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)

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Health and behavior assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.


The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments. The focus of the intervention is to improve the patient’s health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.


Codes 96150-96155 describe services offered to patients who present with primary physical illnesses, diagnoses, or symptoms and may benefit from assessments and interventions that focus on the biopsychosocial factors related to the patient’s health status …

96150 health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient, initial assessment

96151 re-assessment

96152 health and behavior intervention, each 15 minutes, face-to-face; individual

96153 group (2 or more patients)

96154 family (with the patient present)

96155 family (without the patient present).

Each of the H/B codes refers to a 15-minute intervention; interventions requiring more time are billed by reporting multiple units of service. For example, a 30-minute assessment would be billed as two units of 96150. Currently, these codes are used most often by clinical psychologists.

The use of these codes and the delivery of the behavioral health services they represent are growing. Table 6-2 shows Medicare trend data for reimbursement of these services during 2003–2005 as reported by the American Psychological Association. All Medicare carriers now reimburse claims for services using these codes (except 96155, which Medicare does not cover). Although the extent to which private insurers and state Medicaid programs reimburse for these codes is not comprehensively tracked, in early 2007 an American Psychological Association list serve contained anecdotal reports of denial of reimbursement for these services by Medicaid, and coverage by private-sector health plans is not yet uniform.8

8

Personal communication, Alan Nessman, American Psychological Association, March 27, 2007.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

TABLE 6-2 Psychologist Claims Paid by Medicare, 2003–2005, by Type of Intervention, and Comparison 2005 Claims Paid for All Provider Types

Code

Description

2003 Psychologist Claims

2004 Psychologist Claims

2005 Psychologist Claims

2005 All Provider Claims

96150

H/B Assessment

50,660

74,371

78,008

90,016

96151

H/B Reassessment

51,888

47,599

18,421

21,913

96152

H/B Intervention—face-to-face, individual

136,904

245,088

291,103

300,463

96153

H/B Intervention—group (two or more patients)

9,252

16,431

17,873

34,052

96154

H/B Intervention—family (with patient present)

6,129

7,003

7,508

7,942

96155

H/B Intervention—family (without patient present)

Medicare does not reimburse for this type of intervention

Total

254,833

390,492

412,913

454,386

SOURCE: American Psychological Association analysis of data from the Centers for Medicare & Medicaid Services’ Physician/Supplier Procedure Summary Master File.

Policies Addressing Care Planning, Linking of Patients to Psychosocial Services, Care Coordination, and Follow-Up

Current Support in Fee-for-Service Reimbursement

Addressing patients’ identified psychosocial needs by planning, linking patients to service providers, coordinating psychosocial with biomedical care, and following up on the receipt and effectiveness of services is provided for to some extent in existing FFS reimbursement policy. Although perhaps not always recognized (Adiga et al., 2006), the CPT codes for E/M services (reimbursed by all public- and private-sector insurers) explicitly (1) provide for physicians’ need to take patients’ “social history” and “relevant social factors” into account in evaluating and managing their symptom(s), condition, or illness; (2) provide for clinicians’ review of mental health status; and (3) include “coordination of care with other providers or agencies … consistent with the nature of the problem(s) and the patient’s and/or family’s needs” as part of their definition. These codes also acknowledge that sometimes coordination of care may be the predominant purpose of an E/M visit: “When counseling and/or coordination

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

of care dominates (more than 50%) of the physician/patient and/or family encounter …, then time [emphasis in original] may be considered the key or controlling factor to qualify for a particular level of E/M services” (Beebe et al., 2006:8). Further, the different levels of E/M services (and concomitant increasing payment levels) incorporate the time physicians spend before and after their face-to-face contact with patients performing such tasks as “arranging for further services, and communicating further with other professionals and the patient through written reports and telephone contact” (Beebe et al., 2006:5). This is one reason why Medicare does not reimburse separately for telephone contacts on a patient’s behalf. Although there are separate CPT codes for telephone calls of varying length, Medicare considers this service to be bundled into the E/M CPT codes (CMS, 2006a).9 Medicare’s 2007 Payment Schedule, which went into effect on January 1, increased payments for some E/M services (e.g., code 99213, office visit for an established patient) (CMS, 2006a,b), but reduced payments for others (e.g., code 99203, office visit for a new patient) (Ginsburg and Berenson, 2007).

Thus, just as Medicare does not reimburse clinicians separately for the individual steps of performing a physical exam, taking a patient’s history, making a diagnosis, and developing a treatment plan, it also does not pay separately for planning for meeting nonmedical service needs, making referrals and otherwise linking patients with other service providers, and coordinating care. In the past, when most health care was dominated by acute conditions, this payment strategy may not have attracted much attention, but as the conditions addressed by health care providers are increasingly those of older adults and those with chronic illnesses, these aspects of providing high-quality health care and the way clinicians are reimbursed for them are undergoing more scrutiny.

Further, although E/M codes typically can be used only by physicians and other practitioners licensed to practice independently (e.g., nurse practitioners and physician assistants), reimbursement for E/M services could also support the costs of nurses, social workers, or other personnel (e.g., patient navigators) employed by medical practices to assist in coordinating the care of their patients (MEDPAC, 2006). This potential exists by virtue of the way in which Medicare determines the rates it pays for E/M services.

9

Reimbursement for telephone calls is problematic for other reasons. First, for both provider and payer, the costs of submitting, paying, and collecting on claims for reimbursement of calls would in many cases likely be greater than the reimbursement itself. Second, major difficulties are involved in ensuring financial integrity (i.e., auditing the number and length of calls). Third is the risk of “moral hazard”—an insurance concept denoting the phenomenon that occurs when an event is in the control of the insured, and the insured may wish the event (e.g., telephone calls) to occur. In such cases, the event does not well lend itself to the statistical principles that govern insurance (Berenson and Horvath, 2003).

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

The amount Medicare pays for a specific physician service is based in part on the relative value units (RVUs) Medicare assigns to that service compared with other types of physician services. (There are more than 7,000 Medicare-covered services, each with its own assigned RVUs.) Each service’s RVUs are a composite of three factors: (1) the time and intensity of the direct work performed by physicians (or other practitioners licensed to practice independently) to provide the service (Work RVUs); (2) the practice expenses (PEs) associated with the service, such as costs of office space, supplies, equipment, and other clinical and administrative staff (PE RVUs); and (3) professional liability insurance RVUs.10 To the extent that all physicians’ clinical practices in the aggregate include nurses, medical assistants, social workers, or other support personnel who aid in planning, linking, coordinating, and following up on psychosocial service needs, this is reflected in physician PEs. Thus, to the extent that physicians typically employ such staff in their practices, Medicare indirectly reimburses for the services provided by these support personnel whenever it pays a claim for E/M services. Medicare payments then reflect what is current typical care, rather than what should be. The result is a situation in which clinicians may not want to invest in advanced work systems and personnel to provide better care because Medicare payments do not fully reimburse for them, while at the same time, Medicare payments do not well reimburse for these expenditures in part because physicians are not typically making them.

Limitations of Fee-for-Service Reimbursement

Despite the inclusion of care coordination functions in the definition of E/M codes, the potential to capture the costs of care coordination activities performed by other clinical and administrative personnel as part of physicians’ PEs, the increase in Medicare reimbursement for some E/M services that took place in January 2007, and the adequacy of Medicare payment rates for physician services overall (MEDPAC, 2007), FFS payments may reimburse inadequately for the costs of planning, linking, coordination, and follow-up for several reasons. First, the care coordination work included in the definition of each E/M code refers only to the work performed by the physician or other licensed clinician with independent billing privileges (e.g., nurse practitioner). The time spent on this work by other support personnel may not be used to determine clinicians’ billing for E/M services. Moreover, for Medicare, the practice expense portion of reimbursement

10

Medicare’s actual payment rate for each E/M CPT code is then determined by an equation that assigns a dollar amount to the individual RVU (a monetary “conversion factor”), multiplied by a geographic adjustment factor to account for cost variations in different geographic areas.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

is based on survey data, with the aim of identifying the current typical practice expenses of physicians in general. To the extent that assistance with planning, linking, coordination, and follow-up on needed psychosocial services is currently limited in physician practices in general, estimates of the associated physician practice expenses will be limited as well. This situation financially penalizes practices that have in place mechanisms and personnel to help address patients’ psychosocial needs; these practices will be reimbursed the same amount as those that have not taken such steps or have done so to a lesser degree.11 Perhaps most important, experts have identified some fundamental limitations in the data sources and approaches used to calculate Medicare payment rates that have resulted in erosion of payment rates for E/M services over time (Ginsburg and Berenson, 2007).

Because of the above limitations of indirect reimbursement for planning, linking, coordination, and follow-up activities, some advocate that Medicare and other private insurers reimburse directly for explicit case management or care coordination services. Medicare FFS does not do so at present, and clinical practices participating in The Robert Wood Johnson Foundation’s Depression in Primary Care Initiative found that likewise, “Few, if any explicit care management billing codes are recognized by third party payers, especially private insurers” (Bachman et al., 2006:280). Moreover, it is not clear to what extent insurers that do reimburse for case management services do so for the full array of psychosocial health services, rather than paying for a benefit that includes only coordination of biomedical care from multiple providers or a more limited array of services.

Several fundamental issues would need to be resolved if explicit reimbursement for case management/care coordination were to be implemented. First, the subset of patients for whom such services would be reimbursed would need to be identified. All patients with psychosocial health care needs require some degree of planning, linking, coordination, and follow-up, and this level of service is provided for in the construct of E/M services as described above. Most case management/care coordination initiatives target individuals with higher-than-average needs, sometimes with the expectation that the added services will generate lower costs. How should the subset of individuals for whom additional reimbursement is required be identified? Moreover, the entity that is to assume responsibility for coordinating care would need to be identified. This entity might vary by the characteristics of

11

Conversely, if tomorrow all physicians identified attention to patients’ psychosocial health needs as integral to the provision of medical care and put in place mechanisms to address these needs, the practice expenses associated with doing so could be captured in the data sources Medicare uses to estimate practice expenses, and this could lead to an increase in payment rates. However, since Medicare payments are based on the value of each service “relative” to another, when relative values (and payments) increase for some services, they decrease for others.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

the physician group providing care, such as the size of its patient population and the degree to which information technology is present in the practice to support care coordination. Finally, the extent to which case management payment should be placed at risk would have to be addressed. Otherwise, Medicare would need to define the specific set of care coordination activities to be reimbursed, how they could be delivered, and who would be eligible for payment (MEDPAC, 2006).

Support from Capitated Payment

Capitated payment is a more flexible mode of reimbursement than FFS that may better promote planning, linking, coordination, and follow-up activities (Berenson and Horvath, 2003; Bodenheimer et al., 2004; MEDPAC, 2006). This is because payment is made not for an isolated visit or procedure, but for the care of each health plan member for the entire period in which he or she is enrolled in the plan. Although payment is made for the provision of a defined benefit package, capitated health plans frequently offer extra services and benefits (often tailored to members’ level of risk) to better manage the care of their enrollees and improve health outcomes, which also may result in cost savings. Although there is no database that comprehensively documents the prevalence of these practices, America’s Health Insurance Plans (AHIP) reports that health plans are increasingly using administrative data and predictive modeling to identify individuals most in need of additional support services, and then planning, linking to, coordinating, and following up on services through such mechanisms as health advocacy, social work, case management, and disease management services. Some of these services specifically target individuals with cancer (AHIP, 2007).

Other Policy Support

Public- and private-sector group purchasers and insurers are continuing to implement and test better ways to plan, link, coordinate, and follow up on needed care (although attention to psychosocial care is not always as evident in these initiatives as is the coordination of biomedical care delivered by different clinicians) (see, e.g., MEDPAC, 2006; AHIP, 2007). In 2006, for example, 26 percent of U.S. employers with three or more employees who offered health benefits to their workers included one or more disease management programs in their health plan with the largest enrollment (Claxton et al., 2006). A 2002 survey of the nation’s managed care plans found that nearly all health plans offered some type of disease management program for some members (AHIP, 2004). The voluntary sector is also implementing programs to help fill this gap, such as the patient

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

navigator program described in Chapter 4. Medicare in particular is implementing several care coordination demonstration projects to inform efforts to develop better support for planning, linking, coordinating, and following up on the delivery of necessary psychosocial health services (see Box 6-1). However, many of these initiatives assume that better care coordination will result in lower costs, and it is not clear whether better health care and health outcomes will do so. Many of these programs also target conditions other than cancer.

Policies Addressing Support for Illness Self-Management

Some support for illness self-management is provided for in the H/B codes discussed earlier in this chapter. Some support also is found in the E/M codes, which define “counseling” as part of an E/M visit. “Counseling” is defined as “discussion with a patient and/or family concerning one or more of the following areas: … instructions for management (treatment) and/or follow up, importance of compliance with chosen management (treatment options), risk factor reduction, patient and family education” (Beebe et al., 2006:1). Other separate CPT codes (98960, 98961, and 98962) are established for more focused “Education and Training for Patient Self-Management” on a one-to-one basis and for group programs. These codes are intended to report “educational and training services prescribed by a physician and provided by a qualified nonphysician health care professional using a standardized curriculum…. The qualifications of the nonphysician healthcare professionals and the content of the educational training programs must be consistent with guidelines or standards established or recognized by a physician society, nonphysician health care professional society/association, or other appropriate source” (Beebe et al., 2006:418). It is not known how many private insurers reimburse for this code, although, as with the provision of planning, linking, coordination, and follow-up on services, many health plans offer other forms of support to their enrollees in managing some aspects of some illnesses (AHIP, 2004, 2007). Medicare pays for separate illness self-management programs for diabetes only.

As discussed in Chapters 3 and 4, illness self-management programs that have been tested empirically generally have not focused on cancer. Instead, they have addressed other illnesses more traditionally viewed as chronic and involving uniform patient interventions that must be performed on a regular basis, such as monitoring blood glucose levels (diabetes) or measuring peak flow volume (asthma). Many programs designed to help cancer patients adopt healthful behaviors, manage the side effects of their illness and treatment, and improve their health also are offered in the voluntary sector (see Chapter 3).

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

BOX 6-1

Medicare Care Coordination Demonstration Projects

Medicare Health Support Demonstration. In this ongoing demonstration (authorized in 2003), the Centers for Medicare & Medicaid Services (CMS) entered into agreements with eight organizations to test disease management and other approaches to care coordination to see whether they could improve the quality of care and life for people who have heart failure and/or complex diabetes among their chronic conditions. This demonstration represents the first time a large-scale initiative of this type has been tried in fee-for-service (FFS) Medicare. Its design randomizes participants into intervention and control groups. Each participating organization offers self-care guidance and support to beneficiaries to help them manage their health, adhere to their physicians’ plans of care, and ensure they know when to seek medical care. Organizations also are required to assist participants in managing their health holistically, including all comorbidities and relevant health care services, in a manner that is responsive to any unique individual needs (CMS, undated). Each organization is paid a prospective fee for the care coordination that is at partial risk if targeted savings are not achieved (MEDPAC, 2006).


Physician Group Practice Demonstration. This first pay-for-performance initiative for physicians under the Medicare program is testing whether performance-based payments would result in better care. During the 3-year project, CMS will reward physician groups that improve patient outcomes by coordinating care for chronically ill and high-cost beneficiaries. Because they will share in any financial savings that result, the groups have incentives to use care management strategies that, based on clinical evidence and patient data, can improve patient outcomes and lower total medical costs. Performance payments will be derived from savings expected through improvements in care coordination for an assigned beneficiary population; by law the demonstration is required to be budget neutral. Approaches to be used for better care coordination include disease management and case management services, improved access to care and providers, and use of electronic medical records and disease registries (CMS, 2007).


Care Management for High-Cost Beneficiaries. This 3-year demonstration, begun in 2005, is designed to test approaches to helping Medicare beneficiaries with complex medical needs achieve better health outcomes through improved care coordination. In addition to providing traditional FFS Medicare benefits, participating health care organizations offer a variety of additional services to coordinate care, including home visits, in-home monitoring devices, electronic medical records, self-care and caregiver support, education and outreach, tracking and reminders of individuals’ preventive care needs, 24-hour nurse telephone lines, behavioral health care management, and transportation services. Organizations receive a monthly fee for each beneficiary to cover their administrative and care management costs; however, they are at financial risk if they do not meet established performance standards for achieving cost savings. Participating organizations also have the flexibility to stratify targeted beneficiaries according to risk and need and to customize interventions to meet individuals’ personal needs (CMS, 2005b).

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

SUPPORTS FOR AND CONSTRAINTS ON SERVICE AVAILABILITY

In addition to the policy support for interventions aimed at delivering psychosocial services described above, policies need to support the availability and accessibility of the various services patients require. Multiple health and human services sectors of the U.S. economy are involved in either directly delivering or providing for these services. They include government purchasing and insuring programs, such as Medicare and Medicaid; private-sector purchasers and insurers; the large voluntary sector, including voluntary services provided by health care organizations, such as hospitals, that otherwise require reimbursement for their services; programs offered by federal and state government agencies, such as the National Cancer Institute (NCI), the Centers for Disease Control and Prevention (CDC), and state health departments; and the informal support system of family, friends, and other social networks that provide supportive services. Additionally, many services are available for purchase in the marketplace.

Policies Supporting Service Availability

Table 6-3 lists some of the psychosocial services available from the various sectors cited above, which together form a comprehensive array of such services. Several features of this array are particularly noteworthy. First is the complexity of the providers and the services they offer, which underscores the need for policy support for care coordination and care navigator services, as discussed in Chapter 4 and above. The large role of the voluntary sector also is clear, highlighting the invaluable role played by this sector in cancer care (see also Tables 3-2 and 3-3 in Chapter 3). This partial listing of available services also counters the potential concern that “there is no point in identifying individuals who need psychosocial services because there is nothing to offer them.” The voluntary sector has striven to ensure the availability of substantial psychosocial services for patients with cancer and their families, and the committee concurs with an earlier IOM report that found a “wealth of cancer-related community support services” (IOM and NRC, 2006:229).

The important role of family and other informal supports in providing critically needed services such as transportation and assistance with activities of daily living also is visible, especially in light of the limited availability of these services from other sources. Policies need to support these informal supports for several reasons. First, informal caregivers often know the patient best, and can tailor their support to the patient’s unique needs and preferences. Their service to the patient often comes from their personal love or affection, which a business or regulatory model of care

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

cannot match. Further, informal supports are a major source of emotional and other support. A nationally representative study of individuals aged 70 or older found that those treated for cancer received an average of 10 hours of help in activities of daily living from informal caregivers per week, at an estimated annual cost (in 1998 dollars) of $1,200 per patient and just over one $1 billion nationally. The economic worth of caregiving is actually likely higher, as these estimates do not include costs of caring for patients younger than 70, those residing in a nursing home, and those not being treated for their cancer. Estimates also do not include a number of other costs, including those of addressing limitations not experienced by individuals “most of the time” (Hayman et al., 2001). If informal supports were unable to continue providing these services, the costs to patients and to the health care system would be sizable. Yet despite the widely accepted importance of supporting caregivers in carrying out this role, as discussed in Chapter 3, how best to accomplish this is a question not yet well answered by research.

Policies Constraining Service Accessibility

A final observation on the availability of services as illustrated in Table 6-3 is the extent to which “with limits” or “coverage depends on policy” describes the availability of mental health care. The lack of health insurance generally, greater limits placed on mental health benefits, and restrictions on access to some mental health providers can be a serious impediment to receipt of mental health services.

Absent or Inadequate Insurance Coverage

An estimated 44.8 million Americans (15.3 percent of the population) were without health insurance in 2005 (U.S. Census Bureau, 2007), and many more have only modest insurance coverage, coupled with an income level that limits their ability to pay health care costs out of pocket. The adverse effects of no or inadequate insurance are well documented and include poorer health, delayed treatment, and worse outcomes of medical treatment for people with cancer as well as other diseases (IOM, 2002). Even for those who are fully insured, coverage for mental health services is frequently more limited than that for other medical conditions. In 2002, 2 percent of workers with employer-sponsored health insurance did not have a mental health benefit. Of the 98 percent that had coverage, 74 percent had limits on the number of outpatient visits they could make in a year, and 22 percent had to pay a higher copayment for a mental health visit than for a general medical visit (Barry et al., 2003). Medicare similarly requires higher

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

TABLE 6-3 Some Availability of Psychosocial Services in Health and Human Services Sectors and from Informal Supports

Service

Medicare

Medicaid/SCHIP

Private Insurance

Provision of Information (e.g., on cancer-related treatments, health, and psychosocial services)

 

 

 

Peer Support for People with a Cancer Diagnosis

 

 

 

Counseling/Psychotherapy

Covered benefit with limits

Covered benefit with limits

Coverage depends on policy

Pharmacological Management of Mental Symptoms

Covered benefit with limits

Covered benefit with limits

Coverage depends on policy

Health Behavior Interventions

Included as part of Evaluation and Management (E/M) services, Health and Behavior (H/B) Interventions, and additional services from managed care plans

Medical Supplies

Some coverage

Some coverage

Coverage depends on policy

Transportation

 

Some coverage in almost all states

 

Family and Caregiver Support

Family education included as part of E/M services, services from managed care plans

Assistance with Activities of Daily Living (ADLs)

Part-time or intermittent assistance reimbursed under certain circumstances

Some reimbursement under Medicaid’s “personal care” benefit and state-specific waivers of federal law

Not typically covered unless insured has long-term care insurance

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Voluntary Sector

Health Care Providers (nonreimbursed)

Out-of-Pocket Purchase

Other Government Programs

Informal Supports

Widely available from many voluntary organizations (see Table 3-2 in Chapter 3)

Varies by provider

 

National Cancer Institute and other federal programs, e.g., Administration on Aging, Veterans Health Administration

 

Widely available

Some availability

 

 

Some availability

Some counseling available

 

Can be purchased

Veterans Health Administration

 

 

 

Can be purchased

Veterans Health Administration

 

Much support

Varies by provider

Can be purchased

Centers for Disease Control and Prevention initiatives

 

Some supplies provided at no charge

 

Can be purchased

 

A source of financial resources for purchase

Some support

 

Can be purchased

Area Agencies on Aging

Available

Much support

 

Can be purchased

 

 

 

 

Can be purchased

Area Agencies on Aging

A substantial resource for these services

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Service

Medicare

Medicaid/SCHIP

Private Insurance

Legal Services (e.g., regarding the Americans with Disabilities Act, the Family and Medical Leave Act, wills, power of attorney, disposition of assets)

 

 

 

Cognitive and Educational Assistance

Covered as needed for persons under age 21 under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit

Reports of inconsistent coverage of pediatric neurocognitive evaluations

Financial Planning, Counseling, and Management of Day-to-Day Activities (e.g., bill paying)

 

 

 

Insurance Counseling (e.g., health, disability)

 

 

 

Eligibility Assessment/Counseling for Other Benefits (e.g., Supplemental Security Income [SSI]/Social Security Disability Insurance [SSDI])

 

 

 

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Voluntary Sector

Health Care Providers (nonreimbursed)

Out-of-Pocket Purchase

Other Government Programs

Informal Supports

Some availability (e.g., Cancer Legal Resource Center); some in defined geographic areas (e.g., Legal Information Network for Cancer in Virginia)

 

Can be purchased

Some Area Agencies on Aging

 

 

 

 

An Individual Education Program (IEP) and services available to children with disabilities under the Individuals with Disabilities Education Act (IDEA)

 

Limited availability

 

Can be purchased

Some Area Agencies on Aging

Day-to-day financial management assistance available, depending on individual’s informal supports

Limited availability

 

 

 

 

 

 

 

Eligibility assessment as part of the specific government programs

 

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Service

Medicare

Medicaid/SCHIP

Private Insurance

Financial Assistance

Pays for some health care for those over age 65 or with disabilities who have made social security payments

Pays for some health care for certain categories of persons with low income

Approximately 85% of Americans have some health insurance to help pay certain acute health care costs; far fewer have short- and long-term disability insurance

cost sharing for outpatient mental health care (50 percent)12 compared with general medical visits (20 percent).

This situation has substantial implications for the receipt of psychosocial services. When people without insurance need treatment for cancer, they must begin a search to locate health care providers in their community who will treat them at no or reduced cost, are willing to work out a payment plan, or some combination of these.13 Once they are successful in locating such a provider, they may be unlikely to have the energy, time, or other resources to repeat the search to locate another provider who will provide mental health services on a similar basis—services they may not even anticipate needing at the outset of their illness. Grateful to the provider of their biomedical treatment, they may be unwilling to ask the facilitator of those services to subsidize as well the cost of any mental health services. Heavy out-of-pocket costs for the biomedical treatment of their cancer may also make them less willing to seek out mental health services, which they may view as of lower priority than the treatment of their life-threatening cancer. As a consequence, they are at risk of foregoing those services. Members of the American Psychosocial Oncology Society (APOS) report the frequent failure of patients with cancer to pursue or continue mental health care because of limited insurance coverage (APOS, 2007).

12

However, visits for medication management require only a 20 percent copayment.

13

See, for example, http://www.natlbcc.org/nbccf/access/affordable.html or http://www.breastcancer.org/faq_insurance.html.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Voluntary Sector

Health Care Providers (nonreimbursed)

Out-of-Pocket Purchase

Other Government Programs

Informal Supports

Very limited availability from voluntary organizations (e.g., American Cancer Society, CancerCare, The Leukemia and Lymphoma Society, Patient Advocate Foundation)

Limited free and reduced-cost health care at some hospitals under Hill-Burton Act

 

Federal SSI and SSDI programs provide limited funds to certain disabled persons

Some provided by informal supports

The committee notes that in the first half of 2007 (when this report was being written) there was renewed interest in Congress in expanding health insurance to all Americans, and legislation had been introduced in both houses of Congress to achieve comparable coverage of mental and general health care by health insurance (S 558, Mental Health Parity Act of 2007, and HR 1424, Paul Wellstone Mental Health and Addiction Equity Act of 2007). The committee strongly endorses action on this issue.

Restricted Access to Mental Health Clinicians with Special Expertise or Those Located at the Site of Cancer Care

Even when insurance covers mental health services, the ability of a patient to access appropriate mental health care conveniently can sometimes be hindered. Insurance for mental health services is often provided by a health plan that limits the clinicians included as part of the network of providers available to those it insures. When this happens, individual mental health care clinicians, such as psychiatrists and psychologists, who do not belong to and cannot gain admission to that network may not be able to be reimbursed for services to patients insured by the plan (APOS, 2007). This can thwart appropriate mental health care in two ways.

First, individuals with complex comorbid mental health and general medical conditions (such as cancer) sometimes require mental health clinicians with expertise in the management of these complex conditions. In the case of cancer care, for example, a high level of knowledge of cancer-

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

induced cytokine production and its relationship to depression (Raison and Miller, 2003), as well as the pharmacological treatment of such depression in the presence of a complex drug regimen for the treatment of cancer and other comorbid conditions, is required. For such situations, in 2003 ABMS approved a new subspecialty in psychosomatic medicine to address “the high prevalence of psychiatric disorders in patients with medical, surgical, obstetrical and neurological conditions, particularly for patients with complex and/or chronic conditions (‘the complex medically ill’)” (Lyketsos et al., 2001:5). Although there were only 583 psychiatrists in the United States with certification in this subspecialty as of 2007,14 to the extent that these specialists are available in the community and the oncologist believes this expertise is needed to address the patient’s depression, failure of the patient’s health plan to allow these clinicians admittance to its network or otherwise provide reimbursement for their services can effectively deny the patient access to this care.

Additionally, some oncology providers wish to locate mental health care clinicians within their practices. Doing so facilitates collocated, integrated care—one of the recommended approaches for coordination of health care described in Chapters 4 and 5. However, if these practices’ mental health clinicians cannot receive reimbursement because they are not admitted to the insuring health plan’s network, this prevents integrated care and decreases access to mental health services for the patient. The Moffitt Cancer Center in Florida, for example, reports that some managed behavioral health plans will not reimburse staff mental health clinicians because they are not part of the plan’s network, but also will not allow them to become part of the network.15,16

Such problems with health plan networks are not explicitly addressed in leading accreditation standards for behavioral health plans.17 However, health plans need to consider expertise in the mental health treatment of patients with complex chronic diseases as an important competency of their provider panels. This is consistent with the findings and recommendations of other health care quality improvement initiatives (President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998; Shalala, 2000).

14

Personal communication, Jennifer Vollmer, American Board of Psychiatry and Neurology, September 4, 2007.

15

Personal communication, Paul B. Jacobsen, PhD, Clinical Program Leader, Psychosocial and Palliative Care Program, Moffitt Cancer Center, April 6, 2007.

16

The Rebecca and John Moores Cancer Center, University of California, San Diego, reports similar experiences, as described in Chapter 5.

17

Personal communication, Kathleen C. Mudd, MBA, RN, Vice President, National Committee for Quality Assurance, April 4, 2007.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

USE OF PERFORMANCE MEASUREMENT TO IMPROVE THE QUALITY OF PSYCHOSOCIAL HEALTH CARE

Even if reimbursement policies were to fully support the provision of all the psychosocial services described above, individuals being treated for cancer might still be unlikely to receive the psychosocial health services they need to manage their illness effectively. The many studies of health care quality conducted in the United States in recent years that have found widespread deficiencies in care, including underprovision of needed services (Fisher et al., 2003; McGlynn et al., 2003; Hussey et al., 2004; AHRQ, 2006), clearly show that the availability of reimbursement by itself does not ensure the provision of needed health care. Accordingly, many professional associations, payers, regulators, accrediting bodies, consumer groups, and other organizations have undertaken initiatives to report publicly on the performance of health care providers in delivering quality health care, use payments to create incentives for higher-quality care, and/or directly implement quality improvement programs at the provider level. Two mechanisms are common to all three of these pathways to better health care: (1) measuring the attainment of certain aims of quality health care by health care providers and the health care system overall (performance measurement), and (2) using the results of performance measurement to leverage changes in the way health care is delivered (IOM, 2006b).

Use of these two mechanisms to improve the delivery of psychosocial services to cancer patients and their families is hindered in part by the same overall problem that afflicts all of U.S. health care: the nation’s lack of “a coherent, goal oriented, consistent, and efficient system for assessing and reporting on the performance of the health care system” (IOM, 2006b:2). Certain health care organizations, group purchasers, communities, and others have nonetheless used performance measurement to achieve improvements in the segment of the health care system they can influence. However, there are two additional obstacles to similar efforts to improve the psychosocial health care provided to patients with cancer: less well-developed measures of the delivery of psychosocial health services, and a less well-developed network of organizations and partnerships to ensure the application of such measures.

Measurement of Psychosocial Health Care

As experts have noted, some areas of health care have better-developed performance measures than others (IOM, 2006b). Mental health care, for example, historically has been less well addressed in national performance measurement and quality improvement initiatives (IOM, 2006a), although this gap is narrowing. Performance measures for the delivery of a more

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

comprehensive array of psychosocial health services in general and for patients with cancer in particular also are not very visible in major national performance measurement initiatives (see Table 6-4).

Table 6-4 reveals that psychosocial health services are not typically addressed in the limited number of measures of the quality of cancer care. Although components of the model for delivering psychosocial health care described in Chapter 4 (e.g., effective patient–provider communication) and specific psychosocial health services (e.g., treatment for depression) are addressed for health care overall, a well-thought-out, efficient, and strategic set of performance measures addressing psychosocial health care in general or for patients with cancer in particular is not evident. For example, there is no performance measure of the extent to which patients with cancer (or those with other chronic illnesses) have undergone screening or assessment to identify psychosocial problems. Neither are there measures of the extent to which these patients have been linked to needed services.

Measurement of the quality of care does not take place only in the context of performance measurement initiatives; programs that accredit certain types of health care providers are another venue for ensuring that organizations have in place the structures and processes necessary to deliver good-quality health care. The American College of Surgeons’ multidisciplinary Commission on Cancer, for example, sets standards for cancer care delivered primarily in hospital settings, surveys hospitals to assess compliance with those standards, and uses the resulting data to evaluate hospital performance and develop effective educational interventions to improve cancer care at the national and local levels (American College of Surgeons, 2007). However, no organization targets the accreditation of organizations providing ambulatory cancer care. This is problematic as most patients with cancer receive treatment on an ambulatory rather than an inpatient basis.

Performance measurement is well recognized as essential to performance improvement. Measuring specific aspects of the quality of care and reporting the results back to providers is linked both conceptually and empirically to reductions in variations in care and increases in the delivery of effective care (Berwick et al., 2003; Jha et al., 2003). A number of organizations could help develop and test measures of psychosocial health care (e.g., the National Quality Forum, the AHRQ CAHPS team), but the existence of measures alone will not be sufficient to achieve change. Structures and processes to enable use of the measures and leadership with influence over how cancer care is delivered are needed to spearhead the development and use of such measures.

Means of Ensuring the Use of Performance Measures

Effective performance measurement requires mechanisms for conceptualizing the measures, translating these concepts into technical specifications,

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

TABLE 6-4 Performance Measures of Psychosocial Health Care Adopted/Endorsed by Leading Performance Measurement Initiatives as of July 2007

Initiative

Number of Performance Measures Adopted/Endorsed

Number and Description of Adopted/Endorsed Performance Measures Addressing Psychosocial Health Care in Community Settings

AQA Alliance (formerly Ambulatory Care Quality Alliance)

100 as of January 2007; 4 addressing cancer care (AQA, 2007)

  • None among the 4 cancer care measures

  • Primary care measures include 4: advising smokers to quit and asking about tobacco use, and two addressing depression medication management

  • Dermatology measures include 1: counseling those with new or a history of melanoma to perform a skin self-exam

ASCO Quality Oncology Practice Initiative (QOPI)

52 measures as of Spring 2007 (ASCO, 2007)

  • 2 address discussion of chemotherapy with patient

  • 6 address assessment of pain

  • 2 address smoking cessation

  • 4 address enrollment in hospice

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Adult Specialty Care Questionnaire

37 basic items and additional supplemental questions

  • 6 supplemental questions address how well the physician communicated with the patient

  • 3 address shared decision making

Healthplan Employer Data and Information Set (HEDIS)

73 for 2007, 3 of which are survey instruments asking about satisfaction with the experience of care (NCQA, 2007)

  • Follow-up after hospitalization for mental illness

  • Antidepressant medication management

  • Medical assistance with smoking cessation

  • Initiation and engagement of treatment for alcohol and other drug dependence

  • Mental health utilization: inpatient discharges and average length of stay (ALOS), percentage of health plan members receiving inpatient and intermediate care and ambulatory services

  • Chemical dependency utilization: inpatient discharges and ALOS

  • Identification of alcohol and other drug services

  • Medicare Health Outcomes Survey

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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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.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Beebe, M., J. A. Dalton, M. Espronceda, D. D. Evans, R. L. Glenn, G. Green, D. Hayden, A. Majerowicz, J. Meggs, M. L. Mindeman, K. E. O’Hara, M. R. O’Heron, D. Pavlovski, D. Rozell, L. Stancik, P. Thompson, S. Tracy, J. Trajkovski, and A. Walker. 2006. Current Procedural Terminology. CPT 2007 Professional Edition. Chicago, IL: American Medical Association.

Berenson, R. A., and J. Horvath. 2003. Confronting the barriers to chronic care management in Medicare. Health Affairs (Suppl. web exclusive):W3-37–W3-53.

Berwick, D. M., B. James, and M. J. Coye. 2003. Connections between quality measurement and improvement. Medical Care 41(1):Supplement I-30–I-38.

Bodenheimer, T., M. C. Wang, T. G. Rundall, S. M. Shortell, R. R. Gillies, N. Oswald, L. Casalino, and J. C. Robinson. 2004. What are the facilitators and barriers in physician organizations’ use of care management processes? Joint Commission Journal on Quality and Safety 30(9):505–514.

Burns, J. 1978. Leadership. New York: Harper and Row.

Claxton, G., I. Gil, B. Finder, B. DiJulio, S. Hawkins, J. Pickreign, H. Whitmore, and J. Gabel. 2006. Employer health benefits: 2006 annual survey. Menlo Park, CA, and Chicago, IL: Henry J. Kaiser Foundation and Health Research and Educational Trust.

CMS (Centers for Medicare and Medicaid Services). Undated. Medicare Health Support. Highlights of the program. http://www.cms.hhs.gov/CCIP/02_Highlights.asp#TopOfPage (accessed November 18, 2007).

CMS. 2005a. Medicaid at-a-glance. CMS-11024-05. Washington, DC: Department of Health and Human Services.

CMS. 2005b. Medicare to award contracts for demonstration projects to improve care for beneficiaries with high medical costs. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/CMHCB_Press_Release.pdf (accessed April 4, 2007).

CMS. 2006a. Medicare program; revisions to payment policies, five-year review of work relative value units, changes to the practice expense methodology under the physician fee schedule, and other changes to payment under part B; revisions to the payment policies of ambulance services under the fee schedule for ambulance services; and ambulance inflation factor update for CY 2007. Federal Register 71(231):69623–70251.

CMS. 2006b. CMS announces proposed changes to physician fee schedule methodology. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1887 (accessed March 19, 2007).

CMS. 2007. Medicare physician group practice demonstration. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Fact_Sheet.pdf (accessed April 4, 2007).

Epstein, R. M., and R. L. Street. 2007. Patient-centered communication in cancer care: Promoting healing and reducing suffering. NIH Publication No. 07-6225. Bethesda, MD: National Cancer Institute.

Fisher, E., D. Wennberg, T. Stukel, D. Gottlieb, F. Lucas, and E. Pinder. 2003. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Annals of Internal Medicine 138(4):273–287.

Foxhall, K. 2000. New CPT codes will recognize psychologists’ work with physical health problems. Monitor on Psychology 31(10):46–47.

Ginsburg, P. B., and R. A. Berenson. 2007. Revising Medicare’s physician fee schedule: Much activity, little change. New England Journal of Medicine 356(12):1201–1203.

Hayman, J. A., K. M. Langa, M. U. Kabeto, S. J. Katz, S. M. DeMonner, M. E. Chernew, M. B. Slavin, and A. M. Fendrick. 2001. Estimating the cost of informal caregiving for elderly patients with cancer. Journal of Clinical Oncology 19(13):3219–3225.

Hussey, P., G. Anderson, R. Osborn, C. Feek, V. McLaughlin, J. Millar, and A. Epstein. 2004. How does the quality of care compare in five countries? Health Affairs 23(3):89–99.

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

Institute for Healthcare Communication. 2005. Case studies. http://www.healthcarecomm.org/index.php?sec=case (accessed April 13, 2007).

IOM (Institute of Medicine). 1999. Ensuring quality cancer care. M. Hewitt and J. V. Simone, eds. Washington, DC: National Academy Press.

IOM. 2002. Care without coverage: Too little, too late. Washington, DC: National Academy Press.

IOM. 2006a. Improving the quality of health care for mental and substance-use conditions. Washington, DC: The National Academies Press.

IOM. 2006b. Performance measurement: Accelerating improvement. Washington, DC: The National Academies Press.

IOM and NRC (National Research Council). 2006. From cancer patient to cancer survivor: Lost in transition. M. Hewitt, S. Greenfield, and E. Stovall, eds. Washington, DC: The National Academies Press.

Jha, A. K., J. B. Perlin, K. W. Kizer, and R. A. Dudley. 2003. Effect of the transformation of the Veterans Affairs health care system on the quality of care. The New England Journal of Medicine 348(22):2218–2227.

Lance Armstrong Foundation. 2007. How network members are selected and funded. http://www.livestrong.org/site/c.jvKZLbMRIsG/b.1537979/k.739/How_Network_Members_are_Selected_and_Funded.htm (accessed April 11, 2007).

Lyketsos, C., J. Levenson, and Academy of Psychosomatic Medicine Task Force for Subspecialization. 2001. Proposal for recognition of “psychosomatic medicine” as a psychiatric subspecialty. Academy of Psychosomatic Medicine. http://www.apm.org/subspecialty/ABPNsubspecialtyproposal.pdf (accessed April 6, 2007).

McGlynn, E., S. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. Kerr. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348(26):2635–2645.

MEDPAC (Medicare Payment Advisory Commission). 2006. Care coordination in fee-for-service Medicare. In Report to the Congress: Medicare payment policy. Washington, DC: MEDPAC.

MEDPAC. 2007. Report to the Congress: Medicare payment policy, March 2007. Washington, DC: MEDPAC.

Moran, M. 2006. Aetna to pay for depression screening by primary care physicians. Psychiatric News 41(2):5.

National Institute of Standards and Technology. 2007. Baldrige National Quality Program: Health care criteria for performance excellence. Gaithersburg, MD: United States Department of Commerce.

NCCS (National Coalition for Cancer Survivorship). 2007. Cancer survival toolbox®. http://www.cancersurvivaltoolbox.org (accessed March 23, 2007).

NCI (National Cancer Institute). Undated-a. Cancer centers program. DHHS. http://cancercenters.cancer.gov/about/index.html (accessed April 11, 2007).

NCI. Undated-b. Outcomes research: Mission of the outcomes research branch. http://outcomes.cancer.gov/about/ (accessed April 11, 2007).

NCI. 2004. Policies and guidelines relating to the cancer center support grant. http://cancercenters.cancer.gov/documents/CCSG_Guide12_04.pdf (accessed April 11, 2007).

NCQA (National Committee for Quality Assurance). 2007. HEDIS®2007 summary table of measures and product lines. http://web.ncqa.org/Portals/0/HEDISQM/HEDIS2007/MeasuresList.pdf (accessed April 9, 2007).

NQF (National Quality Forum). 2006. National quality forum endorses consensus standards for symptom management and end-of-life care for patients with cancer. http://216.122.138.39/pdf/news/prCancerSxEOL10-12-06.pdf (accessed April 10, 2007).

Suggested Citation:"6 Public- and Private-Sector Policy Support." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

NQF. 2007a. National Quality Forum endorses consensus standards for diagnosis and treatment of breast & colorectal cancer. http://www.qualityforum.org/pdf/news/prbreastcolon03-12-07.pdf (accessed April 10, 2007).

NQF. 2007b. National voluntary consensus standards for ambulatory care. http://www.qualityforum.org/pdf/ambulatory/tbAMBALLMeasuresendorsed%2007-27-07.pdf (accessed September 4, 2007).

Partnership for Clear Health Communication. Undated. Ask me 3™ 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 individuals 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 revises 2004 and 2005 health insurance coverage estimates. Washington, DC: U.S. Department of Commerce.

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Cancer care today often provides state-of-the-science biomedical treatment, but fails to address the psychological and social (psychosocial) problems associated with the illness. This failure can compromise the effectiveness of health care and thereby adversely affect the health of cancer patients. Psychological and social problems created or exacerbated by cancer--including depression and other emotional problems; lack of information or skills needed to manage the illness; lack of transportation or other resources; and disruptions in work, school, and family life--cause additional suffering, weaken adherence to prescribed treatments, and threaten patients' return to health.

Today, it is not possible to deliver high-quality cancer care without using existing approaches, tools, and resources to address patients' psychosocial health needs. All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services.

Cancer Care for the Whole Patient recommends actions that oncology providers, health policy makers, educators, health insurers, health planners, researchers and research sponsors, and consumer advocates should undertake to ensure that this standard is met.

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