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Health Care Reform and Colon Cancer Prevention: The Future is Bright!
John I Allen, MD, MBA, AGAF
Clinical Chief of Digestive Disease - Yale University School of Medicine
President Elect – American Gastroenterological Association
Allina Health Board of Directors
Past Chief Medical Director – Minnesota Gastroenterology
80% by 2015!
Colorado Colorectal Screening Program
• Colorado Cancer Coalition, Safety Net Providers and
University of Colorado Comprehensive Cancer Center
• Goals:
– Provide Colonoscopy, FS or BE to people with income
level at or below 250% of FPL and who have no insurance
coverage (Patient Management)
– Integrate screening services among safety net clinic
systems statewide (Population Management)
MEDICAL QUALITY ASSURANCE COMMITTEE
• Develop and assess guidelines
• Patient eligibility
• Entry criteria of patients accrued
• Medical Advice
• Review Complications
• Outcome Measurement and Quality
VALUE
Outline and Goal for This Morning
• Health Care Reform – Current Status
• Colon Cancer Prevention as an Allegory for
Health Care Reform
– Achieving Highest Value
– Transformation of Health Professionals to
Accountability and Coordination
Performance Measurement Population Management Aggregation Cost Accountability
P P A C A
Trends That Will Alter Your Practice
“When sorrows come, they come not in single spies but in battalions ” William Shakespeare – Hamlet (Act 4 Scene 5)
$ 1.5 Trillion $4854
Patient Protection and Affordable Care Act March 23, 2010
Access
• Marketplaces • Medicaid Expansion • Mandated Participation
Regulation 5 Pilots - 30 Demos
• Coverage • Benefits • Infrastructure
• ACO • Global Payments
Election Results and Health Care
• PPACA Fully Implemented – unprecedented competition among Health Plans
• Exchanges (Marketplaces) – Opened October 1, 2013
• Regulated Plan Design
– No Life-Time Cap, restricted rating, Medical Loss Ratio etc
• Migration to Value-Based Reimbursement
• 4 Types of Patients by Coverage
– Medicaid – Low income and others – State by State criteria
– Exchanges – with Premium subsidy for some
– Medicare
– Employer-Based Plans – either self insured or with commercial plans
• State Budgets Under Pressure
• New Taxes – 2018 Excise Tax on High Cost Health Plans
President Obama and a Democratic Senate
4 Major Medical Insurance Options
• Medicaid
– States that Expanded Medicaid to 133% FPL
• Up to 133% (actually 138%) Medicaid
• > 133% Exchange
– States that Did Not Expand Medicaid
• Eligibility varies by State (All Children are eligible)
• 100% Exchange
• Exchanges – Premium Rates Vary by State and Your Address within a State
• Open to Individuals and Small Businesses – soon Large Businesses as an option
• Premium Support (Tax Credits) up to 400% of FPL
• Medicare for > 65
• Traditional Employer Based Commercial Insurance
– Self Insured or Indemnity
– New Payment Models – Total Cost of Care, Bundled Payments, ACO
State and Federal Administration of Health Insurance Exchanges.
Aaron HJ, Lucia KW. N Engl J Med 2013;369:1185-1187.
Exchanges - Marketplaces (October 2013)
• Core function of a Marketplace defined in Section 1311(d)
– Certifying, Recertifying, Decertifying Health Plans
• “Metal Tiers” with Different Coverage of Anticipated Medical Costs
– Bronze 60%
– Silver 70%
– Gold 80%
– Platinum 90%
• Educates Consumers about Costs, Deductibles and Co-Pays
– Standardized Information about Benefits and Costs
– Gateway to all Federal and State Coverage Options and Premium Support
• 150 Federal and State Program Eligibility Requirements
– Ensure coverage for 10 categories of Essential Health Benefits (EHB)
• 14 Services covered under Prevention and Wellness (including CRC screening)
• Aid enforcement of mandates (with IRS)
• Facilitates Enrollment in Selected Plan
Colorado
• On May 13, 2013, Governor John Hickenlooper signed into law the health
insurance alignment and Medicaid expansion that will allow more than
160,000 Coloradans to gain access to Medicaid.
• Beginning October 2013, Connect for Health ColoradoTM will offer
individuals, families and small employers an online marketplace for health
insurance and exclusive access to new up-front financial assistance.
10 carriers about 150 health plans for individuals and families through Connect for Health Colorado:
• All Savers Insurance Company (part of UnitedHealthcare) • Anthem Blue Cross and Blue Shield • Cigna • Colorado Choice • Colorado HealthOP • Denver Health • Humana • Kaiser Permanente • New Health Ventures • Rocky Mountain Health Plans
Anthem, Colorado Choice, Colorado HealthOP, Kaiser Permanente, Rocky Mountain Health Plans and See Change – requested approval to provide nearly 100 health plans to small employers.
CONNECT FOR HEALTH COLORADO
5 Predictions 1. Federal and State Governments will Define Health Care Regulations
– If Exchanges Fail there will be a push towards Single Payer (Vermont)
2. Employer Groups will Drive Rapid and Transformative Change
• Narrow Network and Aggressive Referral Management
3. Health Care will be delivered by large Integrated Delivery Networks
4. Reimbursement Directly Tied to the “Triple Aim” (Value-Based)
• High Value Individual Experience
• Improved Population Health
• Reduced Cost
5. Unprecedented Price Pressure and Competition Among Plans
• 2014 – Exchanges – Health Care moves from wholesale to retail
• 2018 – Excise Tax on high cost plans
Fax
This Model May Be Over
Patient needs screening
PCP
Colonoscopy •GI •Path •Anesthesia •Radiology etc
Patient Outcome
10,000 People Need CRC
Screening and Treatment
ACO Hospital - PCP - Specialist Reduced Cost
Total Cost of Care
Patient needs screening
7 Day Pre to 10 Day post Trigger Event (Colonoscopy)
$
Episode of Care
Fee For Service
WHO IS REALLY DRIVING DELIVERY TRANSFORMATION?
Employers
No confidence in delivery system, health plans,
current “patches”
• P4P
• Quality measurement
• Managed care
• Integration/consolidation (?monopolistic) 17
An “Accountable Care Plan”
• A Health Plan Sponsored System that drives market share to High Performing
Provider Organizations
• Competition at care system level based on
• Risk Adjusted Total Cost of Care
• Quality of Care
• Patient Experience: patient centric care; integrated and coordinated team
care; patient/family involvement; proactive; managed transitions
• No negotiation/no side deals—provider systems presented to market based on
objective measurement
• Target 3-4 choices in each region
• Defined Contribution tied to price of highest value system.
HOW SERIOUS ARE THEY?
19
PBGH Members
20
#2 purchaser of healthcare in California
National Bundled Payment Network
ACO ACO
BCBS of Minnesota Medica
Independent Specialty Groups
INTEGRATED DELIVERY NETWORK
Single Enterprise EMR, Data Analytics, Predictive Modeling, Population Management and Performance Measurement
HOSPITALS INPATIENT TO OUTPATIENT
TRANSITION
ANCILLARIES
PRIMARY CARE CARE COORDINATION WITH ACTIVE CASE
MANAGEMENT
PCMH
AMBLATORY NETWORK TCU - SNF - ALF
ASC’S
SPECIALTY NETWORK EMPLOYED
CONTRACTED
We are Seeing the Emergence of Large Integrated Delivery Networks That Strive for True Clinical Coordination and 6 attributes
of a high performance health system and strive for the Triple Aim
Allina Health
• Patient Care Facilities
– 11 Hospitals
– 59 Allina Medical Clinics
– 23 Hospital Based Clinics
– Multiple Transitional Care Units
– 15 Community Pharmacy Sites
– 3 Ambulatory Care Centers
THE CRITICAL QUESTION
Market Options for Health Care:
Closed or Restricted Network
• Business + Clinical
Integration • Employed Providers • Tightly Controlled HIT
Affiliated Model
• Wider Network • Clinical Integration but
Looser Business Affiliations
• Some Employed
Providers (PCP) • Affiliated Specialists • Controlled HIT within
core but interface with others
Higher cost must be worthwhile because of better (demonstrated)
Quality
Academic Center
• Teaching and Research Mission
• Cumbersome
patient experience
• Safety Net
• Reduced high margin work
• Department silos sometimes reduce clinical integration efforts
CRC Prevention as an Allegory for Health Care Reform
Colon-Rectal Cancer
Polyp that sits up and Conspicuous
Polyp that is Flat and Inconspicuous
History of CRC Screening
• Minnesota Colorectal Cancer Control Study – 1993
– Decrease Mortality 33%
• Multi-Disciplinary Guidelines and Insurance Coverage – 1997
• National Polyp Study and Medicare Coverage for colonoscopy – 1993 and 1999
• 2000 – Present: Increase in Screening and Migration to Colonoscopy as the Dominant Screen
– Colonoscopy
• ASC’s
• Use of Anesthesia Professionals
• Incorporation of Pathology and Anesthesia Services within Practices
• Shift in the Value Proposition for Colonoscopy
• Key Articles and Concepts of Importance
– Nishihara et al. NEJM 2013 – Colonoscopy (Proximal versus Distal Protection, 5/10 Year Protection, Biology of Interval Cancers)
– Shaukat et al. NEJM 2013 – Long term Follow up of the Minnesota FOBT Trial
– Zauber et al. - Long Term Protection from Colonoscopy with Polypectomy (20 year Follow up of the National Polyp Study)
– Rex et al. AJM 2002 – Quality Indicators for Colonoscopy
– Guidelines – Various
– Recognition of Molecular and Biological Differences in the Proximal Colon – Sessile Serrated Adenomas
Screening Options
• Stool Testing – Fecal Immunochemical Test
• Flexible Sigmoidoscopy (plus FIT)
• Colonoscopy
• CT Colography
• Stool DNA
Inadomi et al. Archives of Internal Medicine 2012
Adherence to Colorectal Cancer Screening: A Randomized Trial of Competing Strategies
Patient Preference and CRC Screening
An important implication of this research is that the notion of “preferred” CRC screening test should include both the physician’s and the patient’s perspective. From a gastroenterologists perspective, it may seem that colonoscopy is the preferred CRC screening strategy. As shown in the study by Inadomi et al a recommendation for colonoscopy only would result in substantially fewer overall patients being screened and fewer cancers and advanced adenomas being detected
ARCH INTERN MED/VOL 172 (NO. 7), APR 9, 2012
CRC Screening Rates for Kaiser California 2004 - 2011
Optimizing Colorectal Cancer Screening by Getting FIT Right. Theodore R. Levin . Gastroenterology 2011; 141:1551-1555.
MN Community Measurement Colon Cancer Screening Top 10 Performers
Medical Group 2012 2011
Lakeview Clinic 94% 76%
Mayo Clinic 92% 76%
Alexandria Clinic 91% 73%
North Clinic 90% 67%
Stillwater Medical Group 89% 59%
Centra Care Health System 88% 91%
St. Luke’s Clinics 86% 81%
Health East Clinics 84% 57%
Silver Lake Clinic 83% N/A
Family Health Services 81% 67%
IF WE INCREASE CRC SCREENING
RATES TO 80%, BUT PHYSICIANS
PERFORMING COLONOSCOPY MISS
LESIONS, WE DO OUR PATIENTS NO
SERVICE AND WE WILL SPEND A LOT
OF MONEY
History of Colonoscopy
1970 2020 1980 1990 2000 2010
ASC NPS 4/93
Medicare CRC
Right Colon
45378 Revalued
Bundled Payment
Wolff & Shinya June 1969
Population Metrics
COLONOSCOPY IS THE MOST INVASIVE, DANGEROUS
AND COSTLY PROCEDURE THAT IS ENDORSED BY THE
USPSTF AS A SCREENING MEASURE FOR THE
GENERAL POPULATION
YET THERE IS NO ACCOUNTABILITY FOR OUTCOMES
OR COST
COLONOSCOPY ACCOUNTS FOR 70% OF A
GASTROENTEROLOGY PRACTICE INCOME AND IS A
SIGNIFICANT REVENUE SOURCE FOR HOSPITALS
GASTROENTEROLOGY 2010;138:27–43
Colonoscopy - The Problem
1997
2002 Multi-Society Statement on
Colonoscopy Quality
Singh, H et al. Reduction in CRC mortality after
negative colonoscopy varies by site of the cancer.
Gastroenterology 139:1128, 2010
• Manitoba database – 1987-2007
– 24,342 men / 30,461 women who had colonoscopy
• CRC mortality compared to no colonoscopy
• Reduction in CRC Mortality
– 29% Overall
• Distal 47%
• Proximal ZERO %
• Gastroenterologists
• Distal 56% 47% -14% GS, PCP, IM
• Proximal 39% 0% GS, PCP, IM
Minnesota Gastroenterology Established 1972
ASC # 4
Corporate
ASC # 1
ASC #2
ASC # 5 Specialty Clinics
82 Providers (61 MD’s)
180,000 patient visits/year
80,000 procedures/year
Infusion centers, Pathology
Fully integrated EMR (2004)
Centers of Subspecialty Care
Consolidated, Protocol-Driven Business
ASC # 3
2005: Endorsed Performance Measurement as a Practice
• Completion Rate
• Adenoma Detection Rate
– First screening exam
– Gender Specific
– Includes all pre-cancerous polyps
• Surveillance interval recommendation
Percent Adenomas –Female > 50
10.0%
20.0%
30.0%
40.0%
296 ± 111 per MD
Benchmark >15%
Minnesota Gastroenterology
Physician Report Card
Is adenoma detection rate modifiable?
Shaukat A, Allen J et al. unpublished data
0
500
1000
1500
2000
2500
3000
2007 2008 2009 2010
Number of SSA’s Normalized to 2007 Colonoscopy Numbers
Right sided ADRs
Shaukat A, Allen J et al. unpublished data
Minnesota Gastroenterology Data 2004-2010
2004 2005 2006 2007 2008 2009 2010
Number 27,253 33,995 35,099 37,817 36,972 36,031 37,050
Complete 97% 98% 98% 97% 97% 97% 97%
Path Sent 39% 43% 35% 41% 52% 54% 57%
AFR Male 28% 32% 26% 30% 32% 40% 44%
AFR Female 18% 21% 17% 19% 22% 28% 30%
> 6 Min WT NM NM NM 76% 95% 99% 99%
0%
10%
20%
30%
40%
50%
60%
70%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
0%
10%
20%
30%
40%
50%
60%
70%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
2004 Male ADR 2010 Male ADR
Adenoma Detection Rates From Screening Exams in Men Age 50 and Older Minnesota Gastroenterology
Each bar represents one Endoscopist’s Results: % of Screening Colonoscopies where a precancerous polyp was found. Data from 2004 (left) and 2010 (right – after multiple
interventions to increase rates. Average number of Exams per partner = 267 (range 76-467)
25% = Accepted Threshold for Quality
Results of Quality Measurement
Special Report: The cost of healing How America puts the wrong price on healthcare.
How a secretive panel
uses data that distorts
doctors’ pay
Cost Drivers – 27,310 exams
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
Base 63% Path
85% Cecum Cons Propofol Hops 1 Hosp 2
$1.3
$2.5 $3.4
Annual USA = 14 million
$8.2 $6.1 $12.6
Added Costs (millions)
Overuse of Surveillance Colonoscopy is Documented Goodwin et al. ARCH INTERN MED/VOL 171 (NO. 15), AUG 8/22, 2011
Percentage of all Medicare colonoscopies with a screening code was only 4.6% in 2001 and 14.6% in 2007 through 2008, while an estimated two-thirds of all
colonoscopies are performed for CRC screening
Is expensive anesthesia for colonoscopy worth it? Megan Brooks, Reuters 6:56 am, July 25, 2013
Liu et al. JAMA 2012
Use of Anesthesia Professionals During Colonoscopy
Endoscopy Codes are to be Surveyed
Quality/Price Transparency will Drive Business
Safeway: applying the concept to lower cost services
Colonoscopy Cost Per Procedure – Greater SF Bay Area
Reference Pricing: $1500.00
65
AGA Task Force on Colonoscopy Bundle
• Definition of Population
• Pre-Operative Services
• Colonoscopy – all aspects
• Post Procedure 10 Day Interval
• Reporting Services
• ICD, CPT and Exclusions
Allows a sophisticated, integrated practice to negotiate favorable rates with self insured companies, ACO’s and IDN’s
1 Year
Colonoscopy
Consult
Prep
Professional Fee
Facility Fee
Sedation – Anesthesia
Pathology
Performance Measures Uploaded
Surveillance Recommendation
Complications – 10 days Post Procedure
Bundled Payment for 21 Day Episode of Care
• HEDIS and CMS Star Scores based on % Screened • FIT + Colonoscopy
• Coordinated Program with Performance Metrics
Colonoscopy “Episode” Prevention of CRC for a Population
Colon Cancer Prevention Today and Tomorrow
Health Care Reform and Colon Cancer Prevention: The Future is Bright!
1. Health Care Delivery is being transformed – build your programs with
this in mind
2. Attack CRC Prevention at both an individual and population level
always striving to meet the Triple Aim
3. Measure performance and outcomes at critical steps and funnel
patients to providers with the highest health care value
Take Home Points
Thank You
Questions?
S C R E E N I N G , I N C I D E N C E A N D M O R T A L I T Y
Colorado Colorectal Cancer
Randi Rycroft, MSPH, CTR
Unit Manager, Colorado Central Cancer Registry
October 2013
Overview
General CRC data
Health Statistics Regions characteristics
Screening compliance and late stage CRC diagnosis by Health Statistics Regions
Incidence and mortality rates by race and gender
Colorectal Cancer in Colorado
Third most commonly diagnosed cancer among men and women
About 1750 malignant CRC cases diagnosed each year in Colorado residents
About 630 deaths due to CRC each year
Women have lower incidence and mortality rates
6
1
5
8
9
11
10
12
2
7
4
18
13
19 173
21
1415
16
20
WELD
MOFFAT
MESA
BACA
PARK
YUMA
LAS ANIMAS
ROUTT
GUNNISON
LINCOLN
LARIMER
GARFIELD
PUEBLO
BENT
SAGUACHE
KIOWA
LOGAN
RIO BLANCO
GRAND
EL PASO
EAGLE
ELBERT
MONTROSE
LA PLATA
DELTA
WASHINGTON
OTERO
KIT CARSON
JACKSON
ADAMS
CHEYENNE
PROWERS
MONTEZUMA
FREMONT
PITKIN
MORGAN
HUERFANO
CONEJOSCOSTILLA
HINSDALE
ARCHULETA
DOLORES
CHAFFEE
SAN MIGUEL
MINERAL
CUSTER
DOUGLAS
CROWLEY
PHILLIPS
OURAY
LAKE
ALAMOSA
TELLER
ARAPAHOE
RIO GRANDE
SEDGWICK
SUMMIT
BOULDER
JEFFERSON
SAN JUAN
CLEAR CREEK
GILPINDENVER
BROOMFIELD
Colorado Health Statistics Regions
Population 50 and older by Health
Statistics Region 2010
Data Source: Colorado Health Information Dataset (COHID)
Screening Data
Data source: Colorado BRFSS, 2012
Question: Have you ever had sigmoidoscopy/colonoscopy? (50+)
Data source: Colorado BRFSS, 2012
Question: Have you ever had sigmoidoscopy/colonoscopy? (50+)
Overall Screening Compliance
82% FOBT in the past year OR sigmoidoscopy past
5 years OR colonoscopy past 10 years
Source: CO BRFSS 2012
Incidence and Mortality
Questions?
Contact Information:
Randi Rycroft
Colorado Central Cancer Registry
303-692-2542
Program Update
2013
Holly J. Wolf, PhD, MSPH
IN THE BEGINNING….
• In 2004,only about half Coloradans ages
50+ ever screened for CRC
• About three quarters ages 65 + (Medicare)
• A little more than half ages 50-64 with health
insurance
• About a quarter ages 50-64 without health
insurance
• About a quarter of minorities insured and
uninusred
COLORADO COLORECTAL
SCREENING PROGRAM
• Goal: Increase colorectal screening rates among Coloradans ages 50 and older to 80% by 2015.
• 2004 - Awareness Campaign funded by CDC Comp Cancer Program
• 2006 -Screening for the Medically Underserved -funded by tobacco tax revenues via the CCPD grant program
• Began in January 2006, expanded statewide in November 2006
• Partnership between community clinics and coordinating center and Colorado Cancer Coalition
APPROACH
• Provide endoscopic colorectal screening to
Coloradans without health insurance or
uninsured for screening who are under 250%
Federal Poverty Level and who need
screening
• Encourage all Coloradans ages 50 and older
to get screened.
• Partner with others.
• Catalyze system change.
PROGRAM COMPONENTS
• Endoscopic screening in
clinics or by referral
• Follow-up and Rx
• Patient navigation support
• Capacity development
• Public outreach & marketing
• Evaluation
• Organized CRC screening
RESULTS FROM COLONOSCOPIES-
14,990 PEOPLE
• 62% female • 32% Hispanic and 3% African American • 9% <50 (high risk)
• Very high show rates (>95%) • 95% adequate exam • 27% had adenomas (6% advanced)
• About 400 cancers prevented
• 1% had cancer (n =129)
SUCCESSES
• Primary care/specialty partnerships
• Patient navigation in primary care
• Colorectal screening capacity
• CDC CRC Control Program established
• Establishing the case for prevention
• Achieved in spite of highly variable funding • ($5.5 – 0.8 million – $3.8 Million)
CURRENT PROGRAM
ACTIVITIES
• Sustain statewide screening • Reestablish primary care/ specialty care partnerships
• Support patient navigation
• Maintain flexibility for screening approaches
• Include promotion of screening to the insured
• Leverage treatment funds
• Provide 2500 colonoscopies per year
INVEST IN ACTIVITIES TO ASSURE SMOOTH
TRANSITION WITH HEALTH CARE CHANGES
• Health system change
Organized comprehensive screening program at the clinic level
• Partnership with RCCOs (Medicaid care coordination)
• Public health reform to increase collaboration/ integration in chronic disease integration /cooperation
CCPD grantee partners
• Navigation/ community health workers
TRENDS IN COLORECTAL ENDOSCOPIC SCREENING
IN COLORADO, BY ETHNICITY
25
30
35
40
45
50
55
60
65
70
1999 2002 2004 2006 2008
NHW
Hisp
BRFSS question regarding ever having been examined by sig or colo
%
LESSONS LEARNED THUS FAR
• Partnership are key • Embed screening within existing healthcare system
• Partner for treatment too!
• Partner for awareness and shift of the norm
• Incorporate existing infrastructure/groundwork
• Establish an organized statewide program
• Include Navigators
• Include evaluation for Quality Improvement
• Plan Carefully but don’t wait for everything to be in place
Commit! Success will breed success
Program information : http://colonscreen.coloradocancercenter.org
Holly Wolf
Sheryl Ogden
Carol Brown
Shannon Pray
Keavy McAbee
Ashley Abeyta
Andrea Dwyer
Lori Workman
Dennis Ahnen, MD
Dana Kennedy
Latashia Warren
Many thanks to many others!
Program Components
CCSP PROGRAM COMPONENTS
• Endoscopic Screening
• Sheryl L. Ogden, RN, BSN, CCSP Program Manager
• Comprehensive Screening Approach
• Keavy McAbee, MPH, CCSP Clinical Services Coordinator
• Integration
• Andrea Dwyer, BS, CCSP Integration Manager
Endoscopic Screening
• Provide endoscopic screens either as a follow-up to
a positive FOBT or as a preventive screening
through partnering clinics
• FY 13 (Oct 1, 2012-June 30, 2013)
• Completed 1712 of planned 1859 endoscopic screens (92%)
FY 13 SCREENS PER MONTH
FY 13 DEMOGRAPHICS
• N=1517
• 40% male, 60% female
• 13% reported family history of CRC
• 10% reported family history of adenomatous polyps
• 17% were symptomatic
RACE/ETHNICITY
Race/Ethnicity Number %
Non Hispanic White 987 65.1
Hispanic 459 30.3
Black 21 1.4
Other 14 0.9
Unknown/Not Reported 36 2.3
Total 1517 100
PRELIMINARY SCREENING RESULTS
• 52 % had a biopsy at screening colonoscopy
Pathology
Results
Number % of screens
(N=1517)
Adenoma 502 33
Benign/ Normal 242 16
Other/Unknown 40 3
Cancer 9 0.6
FY 13 QUALITY MEASURES
Cecum Reached Number %
Yes 1457 96
No 31 2
Unknown/Not Reported 29 2
Total 1517 100
FY 13 QUALITY MEASURES
Prep Quality Number %
Excellent/Good 1368 90
Adequate 57 4
Poor 92 6
Total 1517 100
FY 13 QUALITY MEASURES
Results Given Number %
Yes 1187 78
No 6 <1
Unknown/not Reported 317 21
Total 1510 100
ADENOMA DETECTION RATES
Program Year ADR
FY 12-13 33.5%
FY 11 31.1%
FY 10 29.6%
FY 09 28.3%
PATIENT NAVIGATION
• Patient Navigators at partnering clinics navigate
clients through the screening process
• Clinic In-reach and Outreach
• Eligibility determination
• Bowel Prep with instruction
• Reminder calls and addressing barriers (language, transportation, etc.)
• Follow-up to assure results given/understood
• Navigation for those requiring treatment
CCSP RESOURCES FOR NAVIGATORS
• Assistance with clinic in-reach/outreach
• CRC materials
• Support for developing clinic-specific materials
• Support for local mailings/media
• Navigator Training
• PN calls, webinars, training at clinic site and on-site trainings
at Anschutz Medical Campus
• Website
• http://colonscreen.coloradocancercenter.org
TREATMENT
• The Program covers costs (at Medicare-Allowable
rates for:
• Adverse events
• Large polyps requiring removal
• Cancer treatment for patients who were asymptomatic at
the initiation of the screening process (FIT/FOBT or
endoscopic screen)to ‘cap’ of $25,000
FY 13 ADVERSE EVENTS
• 2 AE’s reported from screening colonoscopy
• Both were ER visits for symptoms requiring no further
treatment
• One AE reported from EMR requiring additional
procedure for coagulation
FY 13 LARGE POLYPS
• 7 large polyps required additional procedures for removal
• 3/7 (43%) had successful Endoscopic Mucosal Resection
(EMR)
• 1/7 (14%) attempted EMR, patient scheduled for another procedure
• 2/7 (29%) had surgical removal of large polyp
• 1/7 (14%) never scheduled follow-up procedure, LTF
FY 13 COLON CANCER
• Eleven (11) cancers detected
• 7/11 symptomatic
Site Number (%)
Rectum 7 (64%)
Sigmoid 1 (9%)
Transverse 1 (9%)
Ascending 1 (9%)
Ileocecal 1 (9%)
PROGRAM EVALUATION
• eCAST data system replaced eCRC in September
• Data entered by patient navigators or clinic staff
• Training and Support for eCAST users provided by CCSP
Evaluation Coordinator: Shannon Pray
• Contact information
• Shannon Pray, CCSP Evaluation Coordinator
• Phone: 303-724-3540
• E-mail: [email protected]
MQAC
• The Medical Quality Assurance Committee (MQAC)
provides oversight for the Program
• MQAC has advisory role
• Assess screening/surveillance guidelines
• Provide guidance to staff re: patients eligibility
• Resource for staff regarding medical decisions
• Review medical complications and clinical outcome data
2014 MQAC MEMBERS
Dennis Ahnen, MD-MQAC Chair Tim Byers, MD, MPH
University of Colorado/VAMC Colorado School of Public Health Mark Earnest, MD Hans Elzinga, MD CO Coalition for the Medically Salud Family Health Center Underserved
R. Hill Harris, MD, MSPH Martin McCarter, MD U of CO/Denver Health Surgery, University of Colorado Rosy Probst Lynn Strange, MD, FAAFP CRC Survivor Southern CO Family Med Residency
Neil Toribara, MD, PHD National Jewish Health
CCSP GOALS FOR FY 14
• Provide 2450 endoscopic screens
• Support patient navigation for the
Program
• Provide coordination of treatment and
payment for treatment services for
eligible patients
• Assure standard of care and adherence to consensus guidelines
THANK YOU
Sheryl L. Ogden, RN, BSN
CCSP Program Manager
Phone: 303-724-1281
K E A V Y M C A B E E , M P H
Comprehensive Approach to
Screening
Overview
• Importance of screening for colorectal cancer
• Guidelines & Types of tests
• Why Comprehensive Screening?
• Reaching All Clinic Clients
Why is screening for colorectal cancer
important?
• PREVENTABLE through timely colonoscopy
screening
• DETECTABLE through timely colonoscopy or FOBT/FIT
testing
• 2nd leading cancer cause of death in the US
• Less costly for individual and system if detected
early
Why is screening for colorectal cancer important?
• Biggest risk factor is being 50 or older
• Often has no symptoms
• If everyone age 50 or older received regular
screenings, almost two-thirds (60%) of colorectal
cancer deaths could be prevented
Screening Guidelines
• Average Risk FOBT/FIT or Colonoscopy or Flex Sig
• 50+
• No personal or family history of polyps or CRC
• No symptoms
• Increased Risk Colonoscopy
• Personal or family (1st degree) history of adenomatous polyps or CRC
• Initial screening age depends on family history
• High Risk Colonoscopy
• Genetic reasons – Lynch Syndrome, Familial Adenomatous Polyposis
• State screening rate is 64.8% • From 2010 BRFSS data
Screening Tests
• Beginning at age 50, both men and women at average risk for developing colorectal cancer should use ONE of the screening tests below:
• Tests that can detect cancer • Fecal immunochemical test (FIT) every year
• High-sensitive fecal occult blood test (FOBT) every year
• Stool DNA test (sDNA), interval uncertain
• Tests that find polyps and cancer • Flexible sigmoidoscopy every 5 years
• Colonoscopy every 10 years
• Soluble-contrast barium enema every 5 years
• CT colonography (virtual colonoscopy) every 5 years
Fecal Occult Blood Testing
• Fecal Occult Blood Test (FOBT) is a
colorectal cancer screening test for patients
50 and over • Must be done annually to be effective
• Two types of FOBT tests currently used for screening:
• High Sensitivity Guaiac-based FOBT
• Immunochemical FOBT, or FIT
• The Program will refer to both tests more broadly as FOBT
• Patient completes the FOBT test in the privacy of their home
• If test is positive, colonoscopy is required to determine the source of bleeding
Fecal Occult Blood Testing
• Challenges • Limited resources
• Staff, funding, time
• Successes • Increased staff awareness
• Selection of evidence-based testing
Comprehensive Approach to Screening
• “The Best Test is the One that Gets Done”
• Systems Approach
• ensure screening methods are properly executed
• Involves change made to rules within an
organization
• Systems and policy change often work hand-in-
hand
How can Systems Change impact screening rates?
• Can enable all clinic staff to understand and
participate in CRC screening activities • Who does what, how, and why
• Comprehensive approach to ensure every eligible
client is screened
• Uninsured
• Medicare
• Newly Eligible for Medicaid / Medicaid
• Newly Insured / Insured
Reaching All Clinic Clients
• Uninsured1
• Current estimates project there will still be uninsured clients after 2014 ACA Implementation
• Medicare2
• Part B coverage
• Newly Eligible for Medicaid / Medicaid3
• 133% FPL / Adults without dependents • Resources in your area – Regional Care Collaborative Organizations
(RCCOs)
• Newly Insured / Insured4
• Health Benefit Exchange • October 2013 options available for January 2014 coverage • CRC included in essential benefits package
Examples of Systems Change Strategies
• Identification of Payer Source
• Infrastructure Review and Policy Creation
• Effective Communication System
What the Program Can Offer
• Guidance on systems change strategies
• Provide training on comprehensive
screening
• Client In-Reach support and strategies
Special thanks to Erin Martinez for creating many of
these slides.
A N D R E A ( A N D I ) D W Y E R
Integration Activities
Care Coordination and Patient Centered
Medical Home Initiatives
In Partnership With Networks and Clinic Sites:
• Colorado Rural Health Center • Colorado Community Health Network (CCHN)
• Clinic Net
Examination of:
• Determination of Best Practices (Assessment Tool Developed) • Products to Be Delivered for other clinics use such as webinar
and quality improvement tools
Focus on Achieving Standards Such as:
• NCQA • Joint Commission • AAHC (Hospital Ambulatory Care)
• Triple Aim
• CO State Based PCMH Criteria
Women’s Wellness Connection
Colorado Heart Healthy Solutions
Tri County Health Department
• Cross Training Program Information
• ‘Warm Referral’ Process
• Tracking of Referrals and Screening
CCPD PARTNERS-COMMUNITY HEALTH
WORKERS, COMMUNITY COORDINATORS
AND PATIENT NAVIGATION
Partnerships with Regional Care
Collaborative Organizations (RCCOs)
Initial Partnership with Rocky Mountain Health Plans-Examining Linkages with Care Coordination Efforts and Link with Prevention and Early Detection Programs
Patient Navigation and Community Health Work a Cornerstone-Focusing on North Front Range
Helping Influence Prevention as a Priority
Explore Linkages with Additional RCCO partners
Community Health Worker and Patient
Navigation Collaborative
Convened by The Colorado Trust with initiation at CDPHE, with multiple community and academic partners-CSPH.
Over 100 people/organizations joined to date.
WE NEED YOU!
Statewide Survey completed to assess baselines of efforts in Colorado and Resource Directory.
CPHA Conference in Breckenridge, CO. Focus on PN and CHW. Thanks to those who submitted abstracts and the CRC Prevention Panel and Posters.
Comments-Ideas
Andrea (Andi) Dwyer
303.724.1018
WORKING WITH COMMUNITY AND
CLINICAL PARTNERS FOR PREVENTIVE
SCREENING
To serve our community we first have to understand our community.
To serve our community we have to understand our community.
ECONOMY
· 57% of the population is over 50
· The Median income is $29,737
· The unemployment rate is 11.3% vs 7.2% Statewide
· 38% of our children live in poverty
· 43% of our children live in a single parent home
HEALTH 22% of our adults and 36% of our children are obese
Dental care is prohibitive for most adults and children
Health care is regularly received in the emergency room
Huerfano County is ranked 59 of 59 in the RWJ Foundation
Colorado County Health Rankings
In 2011 CIGNA performed bio-screens for 186 employees of SPRHC - the results were concerning;
77% registered pre-hypertension or hypertension levels, 43% with pre-diabetes fasting glucose
38% overweight, 34% obese and 4% extremely obese. This is a mirror of the face of Huerfano County.
Julio is a 76 old local gentleman
that comes to the clinic for weekly
monitoring of his health. He has
glaucoma, high blood pressure
and is a cancer survivor. On a
typical visit he will get his vitals
checked, visit with the nutrition
counselor, check on when his next
prescription assistance
application is due, visit with our
chronic disease case manager,
and occasionally visit with our
mental health worker when he
feels the need. Julio leaves the
Clinic feeling re-assured, through
EMR his providers know his status
and he tells his friends about the
one stop shop.
BARRIERS
Transportation
Poor time management
Money
No Insurance
Confusion
Fear of “what if they find
something???”
ASSETS
Pride
Strong Family Ties
Patriarchs and Matriarchs Willingness to Learn
Compassion
Staff understands the community and how all programs work
together.
Communication is the key to addressing the needs of our clients and patients.
We recognize that our time and opportunity to engage our clients is limited
and we need to make the most of their visit.
Staff meets monthly to review how our referrals are working and if we need
to adjust any parts of our process.
We are able to discuss our common clients to make sure we are all on the
same page and the client is aware of all of our prevention programs and has
the opportunity to participate.
Staff is aware of the demographics of the community and
respects where they are coming from.
Communication with each other is the key to addressing the
needs of our clients and patients.
We recognize that our time and opportunity to engage our
clients is limited and we need to make the most of their visit.
Staff meets monthly to review how our referrals are working
and if we need to adjust any parts of our process.
We are able to discuss our common clients to make sure we are
all on the same page and the client is aware of all of our
prevention programs and has the opportunity to participate.
All patients receive this referral form as well as all of our
referring agencies. The statement in the release is very simple and
easy to understand.
STATEMENT OF RELEASE OF INFORMATION REFERRAL FORM
The Spanish Peaks Outreach Clinic would like to tell you about programs that are available to you at low or no cost. Please indicate whether you are interested in any of the programs below. By signing this form, you agree to have your information sent to the Outreach and Women’s Clinic. You will be contacted by a staff member to set up an appointmen.
Yes No _____ _____ Women's Wellness Connection – Free or low cost exams for women 40 to 64 to identify breast and cervical cancer. _____ _____ Heart Healthy Solutions – Free screenings that include a lipid panel (cholesterol, triglycerides and glucose levels) and heart risk assessment. The information is sent to your Primary Care Provider.
_____ _____ CCSP – Free Colonoscopies to qualifying adults 50 years or older or younger if there is a family history. Early detection and treatment prevent up to 80% of cancer relate deaths.
_____ _____ Mental Health – Free mental health care for qualifying residents of Huerfano County.
_____ _____ Chronic Disease Management – A licensed RN will come to your home for free to assess your Chronic Disease and will identify and refer programs that will support an increase in quality of Life. She will also talk your Primary Care Provider to ensure you are receiving the services that you need.
_____ _____ Nutrition Education -Learn how to cook healthy meals on a budget to improve your health.
_____ _____ Family Planning - Programs for women and men of child bearing age. Staff can counsel with you to determine what's right for you! Most services are free including vasectomies. _____ _____ CHP+ and Medicaid - We are a presumptive eligibility site and can help you with your paperwork to apply for public assistance.
_____ _____ Bright Beginnings - A free program for parents of children 0-3 that focuses on early literacy and brain development. Receive books, CD’s and more!
_____ _____ Nurturing Parent - A more intensive free 12 week class that helps you become the best parent you can be! You will receive class incentives (gift cards) and meals at each class.
_____ _____ Nurse Family Partnership – A free program for first time parents that starts during your pregnancy and helps you until your child turns two. Where else can you get a private nurse?
_____ ____ Dental Care - Dr. Dennis Driscoll sees children 18 and under twice a month on Wednesday! He accepts CHP+, Medicaid and other insurance. Free dental care is available for uninsured children. _____ _____ Children's Physicals – Children 18 and under receive a comprehensive physical that includes vaccinations and follow up care for identified problems. _____ _____ Prescription Assistance - If you are unable to afford your medicine, we can help you apply to receive your meds for low or no cost. _____ _____ Voice Care/Med Timer – This is the answer to piece of mind for the elderly. If they fall and cannot get up they push the button. Struggling with medication compliance? The Med Timer will distribute your medications on time Name: Address: Phone: email: Signature: Date: Referred By
Educating our partners as well as our clients and patients is critical to successful screening and prevention. Participating in community events
and agency meetings provides the opportunity to promote programs. We use a PEACE philosophy.
Partnerships – Service agencies:
• Pueblo Community Health (Midwife, Nurse
Family Partnership) • Catholic Charities • CICP • Department of Social Services • Home Health Care • Local Providers • Advocates Against Domestic Assault • Local School Districts • Family Resource Center • Council of Governments • Las Animas/Huerfano Health Department
Events
Heart Healthy Solutions Screenings: Hospital Employees, Businesses, County Employees, Senior Citizen lunches, School Districts Health Fairs: Communitywide, mini health fairs; women’s health fair, children’s health fair, men’s health, etc. Outreach CDOT Safety Meetings, College Orientation, Community Celebrations Art in the Park, Oktoberfest, Ft. Francisco Days, Parade of Lights, Sports physicals
Attitude
Operate under a common philosophy of “Caring for the Community”.
Quality staff; Patient, Compassionate, Knowledgeable, Confidential, Friendly, Non-judgmental and Respectful. Community inclusiveness; Zumba, Karate, Fencing, Dance, Birthdays, Graduation.
Always advocating for health.
Committees/Community –
All staff participate on numerous committees and boards. Community based: CASE Conference, Child Protections, Adult Protection, Communication Coalition, Nurse Family Partnership Advisory Board, Children First Advisory Board, Community Events. Hospital: Quality Improvement, Customer Services, Wellness Committee, Compliance, Body-Mind-Spirit, Provider Journaling, SPEAC, Tobacco, IT Steering Committee.
Education – Community and Staff.
Community: In addition to education in the exam room we also go into the community to offer education - Healthy Adolescents at John Mall High School, Sangre de Cristo Center for Youth. Exam room: appointments are scheduled long to allow time for education creating the ability to integrate multiple prevention programs. Staff are encouraged to and do attend as many trainings as possible.
Now for the real work! Successful integration of services requires a lot of communication and follow through. As we screen patients for CCSP, Heart Healthy Solutions or Women’s Wellness for early detection, we also take the time to educate them about the benefits of early detection and prevention. Successful referrals depend on all participants and partners being educated and able to talk about the client about how the programs work. Communication is the key and follow up keeps your patients in the loop and feeling valued. Thank you!
CRC Screening in High Risk
Groups
Dennis J. Ahnen MD
Staff Physician, Denver VA Medical Center
Professor of Medicine, University of Colorado
School of Medicine
Objectives
• Background
• Define high risk groups
• Describe CRC risk factors
• Discuss the rationale for differences in
screening based upon risk
• Review CCSP screening for high risk
groups
Lung
CRC
51,690
Breast Prostate
Lung
CRC
143,450
Other Other
Prostate
Breast
Pancreas
New Cases- 1,638,910 Deaths- 577,190
Magnitude of CRC Risk
CRC Incidence and Mortality- U.S. 2012
Cancer Mortality Time Trends
Men Women
Scre
en
ing
Rate
(%)
Incidence
Mortality
Overall
Screening
Lower
Endoscopy
0
50
100
150
200
250
Adapted from Patel SG, Ahnen DJ. Epi Stud Cancer Prev & Screening. 2013
CRC Time Trends- US
Who is left behind?
Those at high risk
Those who don’t get screened
17
75-
60-
45-
30-
-
15-
0-
CR
C p
er
100,0
00
*
*
*
What does high risk mean?
• Identifiable Risk Factors
• Demographic
• Lifestyle
• Diet
• Those who don’t get screened
• Demographic
Risk/Protective Factors
Risk Factors Demographic
• Age
• Country of origin
• Family History
• Sex
• Race/Ethnicity
• SES
Lifestyle
• Obesity
• Low Physical Activity
• Smoking
• Alcohol
Diet
• Low Fiber
• Low Fruit and
Vegetable
• High Fat
• High Caloric/Energy
• High Red Meat
Protective Factors
• Screened
• NSAIDs
• HRT
CRC Incidence-Age and Sex
Colorectal Cancer
Incidence and Mortality
1930 1940 1950 1960 1970 1980 1990
Year
70
60
50
40
30
20
10
0
Ra
te p
er
10
0,0
00
Incidence
Mortality
Males
Females
CRC Mortality
globocan.iarc.fr/factsheets/cancers/colorectal.asp
Colorectal Cancer Incidence and Mortality
Men Women
Men > Women
Risk/Protective Factors
Risk Factors Demographic
• Age
• Country of origin
• Family History
• Sex
• Race/Ethnicity
• SES
Lifestyle
• Obesity
• Low Physical Activity
• Smoking
• Alcohol
Diet
• Low Fiber
• Low Fruit and
Vegetable
• High Fat
• High Caloric/Energy
• High Red Meat
Protective Factors
• Screened
• NSAIDs
• HRT
CRC Incidence/Mortality-Race/Ethnicity
Black
Black
White
White
Hispanic
Hispanic
Incidence
Mortality
Cumulative CRC Mortality by Race
CRC Screening Rates Impact of Race,Education and Insurance
CRC Screening Time Trends by Race/Ethnicity
FOBT Time Trends by Race/Ethnicity
Colonoscopy Time Trends by Race
CRC Screening- Risk Groups
• Average risk
• No personal or FH of colonic neoplasia or IBD
• Start at age 50
• Increased risk- FDRs of patients with colonic
cancer
• Start at age 40 or earlier depending on # and age of
CRCs in family, colonoscopy may be preferred
• Very high risk- Hereditary Syndromes
• Start much earlier (12-25), annual colonoscopy
Hereditary Colon Cancer Syndromes
Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996
Sporadic
(65%–
85%) Familial
(10%–30%)
Lynch Syndrome (2-3%)
(HNPCC)
Familial Adenomatous
Polyposis (<1%)
Rare CRC
Syndromes
MYH Polyposis
PJS, Cowden’s,
JPC
0
1
2
3
4
5
6
7
8
9
10
1 FDR/Ca 1 FDR < 50 2 FDR/Ca >2 FDR/Ca
Family History and CRC Risk
Lifetime Risk 5%
Fold
Ris
k
Family History of CRC Increases Risk
Fuchs et al NEJM 1994
CRC Screening- Risk Groups
• High risk- FDRs of patients with CRC
• 1 FDR > 60 years old- 10% population
• Start screening at age 40
• Use any standard screening approach
• 1 FDR <60 years or >1 FDR- 3% population
• Start screening at age 40 or 10 yrs
younger than earliest CRC in family
• Use colonoscopy
CCSP follows these guidelines
Screening Rates in High Risk Groups
0
10
20
30
40
50
60
1 FDR >60 1FDR<60 or >1FDR
Fobt
Flex Sig
Colonoscopy
Per
cen
t
Ait Ouakrim et Fam Cancer Epub ahead of print
CRC Screening- Risk Groups
• Average risk
• No personal or FH of colonic neoplasia or IBD
• Start at age 50
• High risk- FDRs of patients with colonic cancer
• Start at age 40 or earlier depending on # and age of
CRCs in family, colonoscopy may be preferred
• Very high risk- Hereditary Syndromes
• Start much earlier (12-25), annual colonoscopy
Hereditary Colon Cancer Syndromes
Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996
Sporadic
(65%–
85%) Familial
(10%–30%)
Lynch Syndrome (2-3%)
(HNPCC)
Familial Adenomatous
Polyposis (<1%)
Rare CRC
Syndromes
MYH Polyposis
PJS, Cowden’s,
JPC
Familial Adenomatous Polyposis
Autosomal Dominant
High CRC risk ≈100%
Early Onset
Easily recognized
Genetic testing or
screening at around
age 12
Surveillance annually
Lynch Syndrome
• Autosomal Dominant
• High CRC risk- up to 50%
• Early onset- 44 yrs
• Proximal location- 65%
• Other cancers
• Under-recognized
• Screening works
• Annual colonoscopy
• Start at age 25 or 10 years younger than earliest Lynch cancer in the family
Cancer Risk in Hereditary Syndromes
CCSP covers FAP and HNPCC
nd follows guidelines
CCSP Screening Protocol Risk Category Age to Begin Reimbursable Screening Recommendation
Average Risk 50 years Colonoscopy every 10 years or
Flexible Sigmoidoscopy or DCBE every 5 years
Increased Risk
1 FDR with CRC > 6 40 years Colonoscopy every 10 years or
Flexible Sigmoidoscopy or DCBE every 5 years
1 FDR or 1 <60 40 or 10 yrs younger than Colonoscopy every 5 years
earliest cancer in family
High Risk
Family history of
FAP 18 Genetic testing/Colonoscopy annually
HNPCC 25 or 10 yrs younger than Genetic testing/Colonoscopy annually
earliest cancer in family
Conclusions
• Background- CRC common, lethal, preventable
• Define high risk groups
• Identifiable risk factors- age, family history
• Unscreened- low income, uninsured, fam hist
• Differences in screening based upon risk
• 1 FDR >60- start any screening strategy at age 40
• 1 FDR <60 or >1 FDR – colonoscopy q5 at 40 or earlier
• High risk- younger/colonoscopy
• Screening rates are low in high risk groups
• CCSP screening addresses high risk groups
H O L L Y J . W O L F
Colorectal Cancer Screening &
Health Care Reform
Affordable Care Act
Creates an “ essential health benefits package” for new insurance plans
• Includes USPSTF A and B recommendations without cost sharing
Increases the health insurance coverage of most US Citizens and legal residents
• Expands coverage to low income persons by
establishment of health exchanges
increased Medicaid coverage
Colonoscopy Copay:
• Collaboration with Georgetown Health Policy Institute and Kaiser Family Foundation to better understand colonoscopy copay issue in the private sector setting
• Met with key HHS officials to share preliminary data
• Produced fact sheet on preliminary findings
• Report published on Kaiser Family Foundation website
Preliminary Findings
:
• ACA requires that private plans provide USPSTF-recommended preventative services with no cost sharing, but this protection is not being experienced equally by all consumers.
• Protection depends on the provider a patient uses, the insurer that administers the plan, or the state in which they live.
• In some states, this issue has generated the largest number of consumer complaints out of all the early market reforms.
Preliminary Findings
• We see this in three circumstances: • If a polyp is identified and removed or a biopsy is taken,
during a screening colonoscopy
• Following a positive stool-based test done for screening.
• If a patient undergoes routine screening colonoscopy at an earlier age than is typically recommended because they are at increased risk for colon cancer (for example, due to a family history.)
• The USPSTF recommendations indicate that the above circumstances are integral to the screening process.
Preliminary Findings:
• Why is cost sharing applied?
• Health care providers vary in how they code
• Insurers vary in how they apply the no cost sharing
rule and how they interpret health care provider
coding
• States appear to be taking different regulatory
positions on this issue, but are reluctant to get
ahead of HHS
Health & Human Services Guidance for
private insurance
• No cost sharing for screening colonoscopy for
provider & facility services including if a polyp is
found, removed and biopsied
• Copays still may be charged for pathology and
anesthesiology costs with polypectomy
• No copays for colonoscopy screening of moderate
or high risk people ( family history of CRC or colon
cancer) even if interval is more frequent
• Currently working to clarify if copays can be
charged for screening colonoscopy after positive
FOBT or FIT test
Medicare
Coverage for proven CRC screening tests
• No deductible charges
• No copay for colonoscopy if no polyps found
• Copay may be charged if polyp found and
removed
• Copay on colonoscopy if following positive FOBT
test
• Decisions controlled by CMS & legislative action
Medicaid Expansion
Medicaid coverage expanded to childless adults
who earn up 138% of FPL starting in 2014
• Estimates - about 55 % of uninsured Coloradans 50-
64 under 250 % FPL may be eligible
Medicaid to provide coverage for FOBT,
sigmoidoscopy or colonoscopy in adults ages 50-64
• No deductible will be charged
• Currently, copay may charged for colonoscopy if
polyp is found or if carried out as follow up to
positive FOBT/FIT test similar to Medicare
What can we do?
• Those getting CRC screening need to be informed
on what is covered and what isn’t so there are no
surprises – insurers and providers play a role • Pathology and anesthesiology charges may apply
• Colonoscopy to follow up on positive FOBT/FIT may have
copays
• Coding practices for billing should be used to assure
colonoscopy is viewed as a screening procedure
• Insurer can make policy decisions on
reimbursement practices
