11/11/2015. Colon Cancer Screening in Underserved Communities The Road to 80% by Colonoscopic Findings. Eighty by Cancer Screening Rates

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1 Colonoscopic Findings Polyps Polyp encircled with wire loop and cut from wall using electrical current Post Polypectomy Colon Cancer Screening in Underserved Communities The Road to 80% by 2018 Suzanne Lagarde, MD MBA FACP CT Cancer Partnership November 5, 2015 Cancer Cancer Screening Rates Eighty by 2018 Percentage of adults up-to-date with screening for breast, cervical, and colorectal cancers by test, sex, and year U.S Percentage up-to-date Pap test Mammogram Any CRC test (men) Any CRC test (women) 277,000 cases 203,000 deaths

2 How do we increase the # of patients screened? Many Adults Are Not Being Tested The principal determinant of screening is whether or not a primary care clinician recommends screening. Testing status of adults aged years 65% 7% 28% 76 % 24 % Insurance status of never tested adults aged years Up-to-date CRC testing Insured Tested but not up-to-date Uninsured Never tested SOURCE: Behavioral Risk Factor Surveillance System, 2012 Not surprisingly Colon cancer screening rates are higher among Insured Better educated Non-Hispanic Those with regular source of medical care Role of Income Level in CRC screening rates 100% 80% 60% Percentage of adults aged years who received colorectal cancer screening by family income level Healthy People 2020 Target: 70.5% 40% 20% 0% Below federal poverty level 100%-199% federal poverty level 200%-399% federal poverty level 400%-599% federal poverty level 600% federal poverty level SOURCE: National Health Interview Survey, U.S.,

3 Conclusion Colonoscopy vs FIT? If we want to increase Colon Cancer Screening Rates, we need to figure out how to screen minority, low income, poorly insured patients FIT = Fecal Immunochemical Test Not all equivalent Must be done annually to have similar impact as colonoscopy Best screening test is the test that gets done..but, Colonoscopy superior in that it can PREVENT future CRC by eliminating cancer precursor, ie polyp Conclusion: FIT is option when colonoscopy is not available, BUT must be done yearly. THE CoNNECticut Experience: 2008 through present Open Access Endoscopy Three programs State funded Private practice No Cost Colonoscopy program American Cancer Society and Fair Haven Community Health Center What have we learned from these programs and are best practices scalable to other sites within the state? FQHC Hosp Clinic MD Office Does pt meet screening guidelines? Yes Provider recommends screening colonoscopy to patient Pt agrees Provider fills out one page referral form listing H&P, meds, prior colonoscopy history, FH Patient Navigator (PN) PN (Bilingual) 1. Reviews prep & provides written instructions in pt s native language 2. Makes appointment 3. Ensures transportation needs are met 4. Calls patient prior to and day before procedure to ensure problems addressed 5. Sends History & Physical, demographics to endoscopist CT Dept of Public Health, RFP # , grant to Community Health Center Association of CT (CHCACT). 3

4 Outcomes: State Program 262 patients cancers, 69 patients with at least 1 adenoma (26%) No show rate 8.1% Provider and Patient satisfaction rates HIGH Economic argument for Patient Navigation #1 Can navigate 8 to 10 patients/day With open access, for ASA I and II patients, visit to GI is not needed. Hence insurer is spared the cost and SHOULD apply it to reimbursing navigation Predecessor to No Cost Colonoscopy program highlighted key role of patient navigation with open access Cost of $66 (Medicaid) # Patients seen by PN/day 8-10 Savings/week $2640 $3300 Savings/year $121,000 $152,000 Average PN salary + fringe $45,000 $50,000 Economic argument for Patient Navigation #2 With quality navigation, no show rate plummets Busy GI does AT LEAST 1000 colonoscopies yearly No Show Rate Without PN 10 30% No Show Rate with PN 3 6% # additional colonoscopies performed yearly 40 to 270 Outcomes: No Cost Colonoscopy 232 patients Run out of private practice, in privately owned ambulatory endoscopy suite GOAL: minimize financial impact, maximize patient compliance One free colonoscopy/doctor/month (with capacity of 1000/year) Ten free colonoscopies at center (with capacity of 600/month) 232 screening colonoscopy over 3 years 6.4% no show rate Open access/patient navigation 4

5 Percentage of Cases Donated by Each Provider Group Over a 13 Month Period 7,000 6,000 5,000 4,000 3,000 Number of Cases May 2010 June % 1.6% 1.5% 1.3% Outcomes: American Cancer Society Links to Care Three sites in the country, all Community Health Centers St. Paul Minnesota Port Royal South Carolina New Haven CT; Fair Haven Community Health Center partnership with Yale New Haven Hospital starting to develop relationships with private GI Practices 18 months, $75,000 primarily used to cover PN salary/fringe 2,000 1,000 0 Endoscopy Center Gastroenterologists Anesthesiologists Pathologists Referrals June 2014 August 2015 Payer Profile Colonoscopy Referrals 671 Pending 160 Performed 326 Not Performed % 56% Medicaid Medicare Normal 128 (39%) Polyps 192 (59%) Cancer 1 (0.3%) Poor Prep 5 (1.5%) 9% 6% Both Uninsured Private Hyperplastic 75 (39%) Advanced Lesions 6 (3%) Tubular Adenoma 109 (57%) Not retrieved 2 (1%) 6% 5

6 Race / Ethnicity Best Practices 116 (17%) 61 (9%) 15 (2%) Hispanic Patient Navigator Checklists Guidelines AA White 484 (72%) Other Patient Navigator Bilingual, from community Training Oversight Checklists Document!! Demographics Does patient meet criteria for screening Confirm H&P up to date Med lists, allergies 6

7 Guidelines or Rules of engagement Face to face encounter with PN Patient education importance of procedure, dispel urban myths Procedure scheduled with 4 weeks Confirm transportation, including contact info for transporter Review bowel prep in native language, verbal & written, appropriate literacy level PN provides bowel prep. In CT, Golytely fully covered by Medicaid. Uninsured get free samples Addresses key meds: anti-platelet agents, anti-coagulants, insulin, DM meds, BP meds **Patient told must make contact within 7-10 days before scheduled appointment or canceled All patients called day before to encourage prep, push fluids, etc What Will Kill a Program? No-shows What is the message to take back to your communities? Gastroenterologists, Endoscopy Centers, Anesthesiologists, Pathologists We can prevent colon Cancer and lower the incidence of morbidity and mortality from this disease in CT We have a moral imperative to do so Economic model is clear. If everyone contributes 2-3% of their colonoscopy time & effort, we will achieve our goal of 80% by 18 What is the message to take to payers, including Medicaid & Medicare Need our payers to recognize the key role of patient navigation and reimburse according ROI is obvious Eliminate pre-procedural visit with GI Markedly lower no-show rate If we reach 80% by 2018, over the next 12 years, we will prevent 277,000 cases of colon cancer. If each case costs a minimum of $100,000 to treat, save $27BN!!! 7