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Originally published as JCO Early Release 10.1200/JCO.2008.19.7780 on December 29 2008 © 2009 American Society of Clinical Oncology.
Barriers to the Delivery of Psychosocial Care for Cancer Patients: Bridging Mind and BodyThe New York State Psychiatric Institute; Department of Psychiatry, Columbia University, College of Physicians and Surgeons; Irving Institute for Clinical and Translational Research, Columbia University and NewYork-Presbyterian Hospital, New York, NY; and RAND Corp, Pittsburgh, PA
The New York State Psychiatric Institute; Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY The split between the mind and body has been with us for centuries. In contemporary times, this split has been reified in the separate structures for how general health care and mental health care are both provided and financed. In this issue of Journal of Clinical Oncology, Azzone et al1 found that administration and management of behavioral health care, through specialized behavioral health vendors (ie, "carve-out" arrangement) compared with integrated general and mental health care plans, is associated with lower use of behavioral health services among women with breast cancer. This study offers evidence that insurance arrangements may pose a barrier to receiving psychotherapy visits for women with such carve-out plans. Furthermore, once behavioral health services were accessed, women in carve-out arrangements used more behavioral health services than women in integrated plans. The authors suggest that women in carve-out arrangements may have had more visits and used more psychotherapeutic medications because only the individuals with most severe problems were able to access services. The results of this article indicate a system-level barrier to the delivery of behavioral health services for cancer patients and argue for solutions to the challenges faced in integrating psychosocial care for cancer patients. The diagnosis and treatment of cancer can be a time of significant psychological distress, which can have both direct and indirect effects on health; however, few patients who experience this distress receive behavioral health services.2 Efficacious treatment strategies have been developed in the field of psychosocial oncology, yet patients face multiple barriers in accessing these services. Barriers to accessing psychosocial care are encountered at multiple levels: patient, provider, practice/delivery system, health plan, purchaser, and population/policy.3 Individuals may face barriers to receipt of psychosocial services because they lack health insurance altogether or lack coverage that includes mental health services, or because they do not ask for help because of lack of knowledge or misperception of mental health services, as well as linguistic or cultural reasons. An estimated 8% of women with breast cancer lack health insurance coverage, and many more have inadequate health insurance coverage for even basic health care needs.4 Health insurance often provides poor coverage of mental health benefits or imposes restrictions on benefits through high out-of-pocket payments or limits on care. Of key importance are government mandates to cover mental illness on par with other illnesses, such as the parity bill recently approved by the US House of Representatives and Senate, and which is currently in negotiation in a conference committee. Among the barriers imposed at the provider and practice level are patient-provider miscommunication; failure to implement clinical practice guidelines; inexperience with assessment for psychosocial distress and rapid screening tools; poor coordination and fragmentation of complex care; a lack of provider familiarity with community resources; geographic distribution of cancer care facilities; separation of medical from behavior or mental health in different and unrelated contracts; and limited systems of quality assurance and accountability.4 Empirically validated models have been developed to deliver effective psychosocial health services for chronic medical illness.5–9 Evidence from the models all point to the importance of a combination of activities in delivering appropriate psychosocial health care effectively to individuals with complex health conditions. The Institutes of Medicine committee assembled to produce the publication Cancer Care for the Whole Patient10 recommended a unifying model for planning and delivering psychosocial health care for patients with cancer. This model emphasizes identifying patients with psychosocial health needs that are likely to affect their ability to receive health care and manage their illness; linking patients to appropriate psychosocial health services; supporting them in managing their illness; coordinating psychosocial and biomedical health care; and following up on care delivery to monitor the effectiveness of services to determine whether any changes are needed. Central to this model is effective patient-provider communication such that patients are able to receive and understand medical information and able to express freely their needs and preferences during the treatment process. Conversely, the provider is able to exchange information, foster healing relationships, manage uncertainty, and make decisions while garnering support and resources available for the patient within the health care system. Within each component of this model, there are strategies proposed to address the challenges in accessing care. Some of these solutions include training and administration of appropriate screening tools to identify needs of patients11 and then linking patients to psychosocial services, structured referral, or formal arrangements, including coordination of care on referral from general health to behavioral health and tracking of follow-up and receipt of referral. Other approaches include case management and care/system navigators for helping low-income patients participate in cancer screening.12 Linking patients to care for depression in primary care has been effectively achieved through on-site or colocated care.13,14 Integration of care facilitates patient follow-through on referrals and allows for face-to-face verbal communication, informal sharing, and exchange of expertise across medical disciplines.15 Illness self-management can be supported through the wide range of psychosocial interventions (ie, from education and emotional support to legal services) that have been developed to assist patients and their families manage the psychological and behavioral aspects of illness. Care-coordination of psychosocial and biomedical health care often includes multidisciplinary teams of oncologists, nurses and social workers, as well as high-tech approaches for sharing information and coordinating care using electronic health records. A psychosocial health assessment can be incorporated into an electronic health record as a best-practice alert or laboratory value that assists members of a team in ensuring access to care and tracking follow-up of care over time. Currently, reimbursement for many of these strategies is not possible. Moreover, to address provider- and patient-level barriers, incentives must be shifted. As Azzone et al have found, organizational structures under which care is paid for and managed introduce barriers that affect the delivery of care and reinforce the separation of general medical and behavioral care. Economic and organizational strategies such as clear contractual expectations, innovative payment methods, and performance measurement can help to mitigate these systems-level barriers.16 Purchasers, both private and public, should consider incorporating such strategies into their contracts with health plans. The National Business Group on Health has noted that "the lack of coordination and integration among managed care vendors of employers...has created significant quality and accountability problems" and has developed a set of recommendations for employers.17 Many barriers need to be overcome to meet the psychosocial needs of women with breast cancer. Azzone et al have provided us with critical evidence of the impact health insurance and insurance arrangements have on access to behavioral health services. As the political dialogue in this country begins to approach health care reform, we need to make sure that proposals incorporate strategies to bridge the mind and the body. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. AUTHOR CONTRIBUTIONS Conception and design: Harold Alan Pincus, Sapana R. Patel Financial support: Harold Alan Pincus Administrative support: Harold Alan Pincus Data analysis and interpretation: Harold Alan Pincus, Sapana R. Patel Manuscript writing: Harold Alan Pincus, Sapana R. Patel Final approval of manuscript: Harold Alan Pincus, Sapana R. Patel REFERENCES
1. Azzone V, Frank RG, Pakes JR, et al: Behavioral health services for women who have breast cancer. J Clin Oncol 27:706–712, 2009. 2. Ganz PA. Psychosocial Services for Women with Breast Cancer: Needs Assessment in Clinical Practice. Washington, DC: National Academies Press, 2002. 3. Pincus HA, Hough L, Houstinger JK, et al: Emerging models of depression care: Multi-level (6P) strategies. Int J Methods Psychiatr Res 12:54–63, 2003.[CrossRef][Medline] 4. Hewitt M, Herdman R, Holland J, et al. Meeting the Psychosocial Needs of Women With Breast Cancer. Washington, DC: National Academies Press, 2004. 5. Improving Chronic Illness Care: Improving chronic illness care. http://www.improvingchroniccare.org/index.html. 6. National Comprehensive Cancer Network. National comprehensive cancer network. http://www.nccn.org/default.asp. 7. Katon WJ: The Institute of Medicine "Chasm" report: Implications for depression collaborative care models. Gen Hosp Psychiatry 25:222–229, 2003.[CrossRef][Medline] 8. National Institute for Clinical Evidence. Guidance on cancer services: Improving supportive and palliative care for adults with cancer—The manual. http://www.nice.org.uk/page.aspx?0+csgspfullguideline. 9. National Breast Cancer Centre and National Cancer Control Initiative. Clinical Practice Guidelines for the Psychosocial Care for Adults With Cancer. Camperdown, Australia: National Health and Medical Research Council, 2003. 10. Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: National Academies Press, 2007. 11. Jacobsen PB, Ransom S: Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Canc Netw 5:99–103, 2007.[Medline] 12. Dohan D, Schrag D: Using navigators to improve care of underserved patients: Current practices and approaches. Cancer 104:848–855, 2005.[CrossRef][Medline] 13. Druss BG, Rohrbaugh RM, Levinson CM, et al: Integrated care for patients with serious mental disorders: A randomized trial. Arch Gen Psychiatry 58:861–868, 2001. 14. Samet JH, Friedmann P, Saitz R: Benefits of linking primary medical care and substance use services: Patient, provider and societal perspectives. Arch Intern Med 161:85–91, 2001. 15. Pincus HA: The future of behavioral health and primary care: Drowning in the mainstream or left on the bank? Psychosomatics 44:1–11, 2003.[CrossRef][Medline] 16. Frank R, Huskanmp HA, Pincus HA: Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatr Serv 54:682–687, 2003. 17. Center for Prevention and Health Services. An Employer's Guide to Behavioral Health Services. http://www.businessgrouphealth.org/pdfs/fullreport_behavioralhealthservices.pdf.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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