Making the Business Case for Patient Navigation. Lina Jandorf, MA Icahn School of Medicine at Mount Sinai Dialogue for Action April 8, 2016

Transcription

1 Making the Business Case for Patient Navigation Lina Jandorf, MA Icahn School of Medicine at Mount Sinai Dialogue for Action April 8, 2016

2 Objectives 1. Patient Navigation for Screening Colonoscopy a. Currently there is no reimbursement for navigation 2. Focus on African American and Latino Primary Care Patients 3. Return on Investment for the Institution 4. Return on Investment for Society

3 Mount Sinai Patient Navigation Program

4 Standard of Care Direct Referral System Navigation process Grant funded 2, 3 4

5 Direct Referral System Patients medically cleared by their Primary Care Physician at the time of referral Schedule for colonoscopy directly No need for a pre-procedure office visit with Gastroenterologist 5

6 Navigator Who were the navigators? Trained health educators Training lay volunteers previous personal screening experience From the same communities Manualized training materials Formalized curriculum Scripted navigation calls Ethnically and linguistically similar 6

7 Navigation Process 2,3 Series of 3 Phone Calls (following medical clearance) by a navigator Scripted to avoid drift Call 1 schedule the procedure 1-2 weeks following PCP visit Briefly review prep and need for escort Mail prep instructions Call 2 2-week Reminder call Review of prep ensure that they have a plan to purchase it How to use the prep reviewed Need for (and plan) for an escort Answer any questions/concerns Ability to reschedule and back fill the slot Call 3 3-day Reminder call Location Dietary changes Plan for starting the prep Escort plan 7

8 Return on Investment to Institution

9 Calculation of Costs Navigation 1 Patients who completed colonoscopy (78.5%) and those who didn t Navigator time for each of the calls, as well as call attempts 38 minutes for completers; 29 for non-completers Number of times a patient rescheduled Particularly if too late to reschedule that time slot Type of colonoscopy completed Screening; with biopsy; with snare polypectomy Supply and other costs Mailing and printing of materials Prep cost if we purchased for the participant Car service 9

10 Calculation of Costs Institution Contribution margin of each procedure Revenue generated subtracting out direct medical costs Direct medical costs Staffing in endoscopy Endoscopy costs Supplies; room time Program costs Administrative Support services Housekeeping, laundry, record keeping Did not include professional fees All endoscopists salaried 10

11 Results Cost of Navigation Sample of ~500 people $14, 027 Includes navigation for completer and non-completers Add on costs Did not include oversight Colonoscopy Revenue Screening Colonoscopy (53.4%) Colonoscopy with biopsy (30.1%) Colonoscopy with snare polypoctomy (16.5%) Total Revenue = $95,266 (395 completers) Net Income: $81,238 Modeling conducted on Theoretical Cohorts 11

12 Return on Investment from a societal perspective

13 CRC screening via Colonoscopy 4 Examined the cost-effectiveness of navigation for screening colonoscopy Payor view Minority population Minority screening rates generally lower than for whites Mortality also high for some groups (e.g. African Americans) Analyzed based on Mount Sinai sample and 10,000 case-cohorts Cost of navigation included No reimbursement for navigation so need to prove its worthiness Goal of improving Population Health Potential to also reduce health disparities 13

14 Model 1-time screening; real-world based on our population Then modeled on larger cohorts Mixed population both on race/ethnicity and age Screening reproduces the natural history if adenomas and CRC without screening Normal -> small polyp ->-> CRC ->-> Death 14

15 Comparisons Colonoscopy every 10 years Adherence at 40% without navigation; 65% with navigation Annual FOBT or FIT If positive colonoscopy offered Ages 50 to 80 Based costs using Medicare reimbursement and CRC care costs Measurement of QALY quality adjusted life year measure of disease burden Assess the value for money of a medical intervention 15

16 Results Colonoscopy without navigation more effective and less costly than no screening Colonoscopy with navigation dominant over colonoscopy without navigation Cost-effectiveness shown due to increase in screening achieved when navigation was available QALY Patient navigation for screening colonoscopy may increase life expectancy while decreasing costs 16

17 Final Thoughts Patient Navigation for colonoscopy appears to be cost effective in several models May help to reduce health dispariites in cancer screening and mortality Still non-reimburseable Caveats Samples gathered in a research setting Didn t include overhead costs such as the training and supervision of the navigators Open access referral system Closed system for procedures Did not account for PCP visit or Endoscopist 17

18 References 1. Jandorf, L., Stossel, L.M., Cooperman, J.L., Graff Zivin, J., Ladabaum, U., Hall, D., Thélémaque, L.D., Redd, W., Itzkowitz, S.H. Cost analysis of a patient navigation system to enhance screening colonoscopy adherence among urban minorities, Cancer, Jandorf, L, Stossel, L, Itzkowitz, S, Cooperman, J, Thompson, HS, Villagra, C, Thelemaque, L, McGinn, T, Winkel, G, Valdimarsdottir, H, Shelton, R, Redd, W. Implementation of Culturally Targeted Patient Navigation System for Screening Colonoscopy in a Direct Referral System. Health Education Research, Jandorf, L., Braschi, C., Ernstoff, E., Wong, C.R., Thelemaque, L.D., Winkel, G., Thompson, H.S., Redd, W., Itzkowitz, S.H. Culturally targeted patient navigation for increasing African American s adherence to screening colonoscopy, Cancer Epidemiology, Biomarkers and Prevention, 2013 September. 4. Ladabaum, U., Mannalithara, A., Jandorf, L., Itzkowitz, S. Cost-Effectiveness of Patient Navigation to Increase Adherence with Screening Colonoscopy among Minority Individual. Cancer,

19 Acknowledgements Co-Investigators Steven Itzkowitz William Redd Uri Ladabaum Joshua Graff Zivin Hayley Thompson Our Staff Cristina Villagra Medical Students Lauren Stossel Julia Cooperman Peer Navigators Study Participants 19