Transcript Colorectal Cancer Screening 101

Colorectal Cancer
Screening 101
Provider Education
December 2014
Comprehensive Approach
to Colorectal Cancer (CRC)
Screening
The Best Test is the Test that Gets Done
CRC Screening – Why?
• Colorectal cancer (CRC) is common
o 2nd leading cancer cause of death in the US
o 3rd most common cancer diagnosed in men and women
• CRC screening is effective
o CRC is preventable through timely colonoscopy screening
o CRC is detectable through endoscopic screening and
stool based screening
• CRC screening is cost effective
o Less costly for the individual and the health
care system if detected early
CRC Screening – Why?
• Biggest risk factor is being 50 years or older
• Often there are no symptoms
• If everyone aged 50 and older received regular
screenings, almost two-thirds (60%) of colorectal
cancer deaths could be prevented
Colorectal Cancer in CO
• Screening behaviors
o Estimated 1,720 new cases of colorectal cancer and 670
deaths from CRC in Colorado in 2014
(American Cancer Society, Cancer Facts & Figures 2014)
o In 2012, 66.8% of eligible Coloradans reported having ever
had CRC screening via sigmoidoscopy and colonoscopy
(Behavioral Risk Factor Surveillance System Prevalence and Trends 2012)
 National initiative is to have 80% of all eligible people
screened by 2018
o Colorado CRC Rates (age adjusted)
 Incidence rate per 100,000
 Male: 43.6
 Female: 33.6
 Mortality rate per 100,000
 Male: 16.7
 Female: 12.4
(American Cancer Society, Cancer Facts & Figures, 2014)
CRC Screening Methods
• Detect Adenomatous Polyps and Cancer
o Flexible Sigmoidoscopy
o Colonoscopy
o Computed Tomographic (CT) Colonography
(virtual colonoscopy)
• Detect Polyps/Abnormalities
o Video capsule
• Detect Cancer
o High Sensitivity Fecal Occult Blood Test
o Fecal Immunochemical Test
o Stool/Fecal DNA Test
Systems Change
• Involves a change in the rules/policy of an
organization
• Enables all clinic staff to understand and participate
in CRC screening activities
• Ensures every eligible patient receives a screening
recommendation
• Guarantees screening methods are properly
executed
Reaching All Clinic Patients
• Uninsured
o In 2011, the number of uninsured Coloradans ages 50-64 years
was 138,619
 Income at or below 138% poverty level, 46,126
 Income between 138% and 400% poverty level, 68,931
o There are still uninsured individuals after the implementation of
health care reform
• Medicaid/Newly Eligible Medicaid
o In 2011, 33.6% of Coloradans, aged 50-64 years, who were at or
below the poverty level had Medicaid
o Newly eligible Medicaid as a result of health care reform
• Adults without dependent children
• Income at or below 133% poverty level
Quick Health Facts 2012: Selected State Data on Older Americans. Multack M and Miller, CN. AARP Public Policy Institute. December 2012.
http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/quick-health-facts-2012-state-data-AARP-ppi-health.pdf
Reaching All Clinic Patients
• Medicare
o In 2011, 13.2% of Coloradans were Medicare beneficiaries
o Part B covers preventive services to include CRC screening
• Insured/Newly Insured
o In 2010, 78.4% of Coloradans, aged 50-64 years, were
covered by employer or other private insurance
o Colorado Health Benefit Exchange since implementation
of health care reform
 Connect for Health Colorado
www.connectforhealthco.com
 Essential Health Benefits covers preventive services to
include CRC screening
Quick Health Facts 2012: Selected State Data on Older Americans. Multack M and Miller, CN. AARP Public Policy Institute. December 2012.
http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/quick-health-facts-2012-state-data-AARP-ppi-health.pdf
Colorectal Cancer
Screening Guidelines
http://www.oregonclinic.com/about-us/blog/colon-cancer-preventable-treatable-beatable
CRC Screening Guidelines
• Guidelines vary slightly between organizations
• All guidelines look at level of risk
o Average
o Increased
o High
• Be sure that everyone in your facility understands
the guidelines and follows the guidelines chosen by
your organization
Risk Assessment
• Average Risk
o 50 years and older with no symptoms
o No personal or family history of polyps or CRC
o Screening Modalities
 Flexible sigmoidoscopy every 5 years
 Colonoscopy every 10 years
 FIT/FOBT every year
• Increased/High Risk
o Prior to age 50 begin CRC screening via colonoscopy
 Screening interval will be more frequent
o Increased risk
 A personal history of CRC, adenomas, IBD
 A strong family history of CRC or adenomas
o High risk
 A family history of a hereditary CRC syndrome
CRC Screening Guidelines
Resources
• American Cancer Society
http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-detection-recommendations
• Health Team Works: Building Systems. Empowering Excellence
http://www.healthteamworks.org/guidelines/guidelines.html
• United States Preventive Services Task Force
http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
• American College of Gastroenterology
http://gi.org/guideline/screening-and-surveillance-of-the-early-detection-of-colorectal-cancer-and-adenomatous-polyps/
• American Society for Gastrointestinal Endoscopy
http://www.asge.org/press/press.aspx?id=552&terms=colorectal%20cancer%20screening%20guidelines
• Centers for Disease Control and Prevention
http://www.cdc.gov/cancer/colorectal/basic_info/screening/guidelines.htm
• Consensus Guidelines: American Cancer Society, US MultiSociety Task Force on Colorectal Cancer and American
College of Radiology
Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline
from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of
Radiology. Levin B, Lieberman D, McFarland B, et al. CA Cancer J Clin, May 2008, 58:130-160.
Coverage for CRC Screening:
Payer Source & Co-Insurance
Cost Sharing
• Under the Patient Protection and Adorable Care
Act (ACA), preventive services are covered by
private health insurance without cost sharing
• Colorectal cancer screening is a preventive service
Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit. Pollitz K, Lucia K, Keith K, Smith R, Doroshenk M,
Wolf H and Weber T. September 2012.
http://kaiserfamilyfoundation.files.wordpress.com/2012/08/8351-coverage-of-colonoscopies-under-the-affordable-care-act.pdf
Findings
• People continue to be charged co-payments or
co-insurance for colorectal cancer screening
o If a polyp is identified and removed during a screening
colonoscopy
o If a biopsy is taken
o Following a positive stool-based screening
o If a patient undergoes a routine screening colonoscopy at
an earlier age than typically recommended (e.g.
increased risk due to family history)
• The USPSTF recommendations indicate that the
above circumstances are integral to the screening
process.
Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit. Pollitz K, Lucia K, Keith K, Smith R, Doroshenk M,
Wolf H and Weber T. September 2012.
http://kaiserfamilyfoundation.files.wordpress.com/2012/08/8351-coverage-of-colonoscopies-under-the-affordable-care-act.pdf
Findings
• Why is cost sharing applied?
o Health care providers vary in how procedures are
coded
o Insurers vary in how cost sharing rules apply as well as
interpretation of health care provider coding
o States appear to be taking different regulatory
positions on the issue
o Medicare and Medicaid vary from private insurance
Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit. Pollitz K, Lucia K, Keith K, Smith R, Doroshenk M,
Wolf H and Weber T. September 2012.
http://kaiserfamilyfoundation.files.wordpress.com/2012/08/8351-coverage-of-colonoscopies-under-the-affordable-care-act.pdf
Medicare: Part B
• Coverage for proven CRC screening tests
o FOBT/FIT covered annually
• No co-insurance or deductible
 Colonoscopy following a positive FOBT/FIT will result in
deductible and co-insurance payments
o Colonoscopy covered depending on risk level
• High risk: every 2 years
• Average risk: every 10 years
• No co-insurance, co-payment or deductible
o If test results in biopsy or removal of a polyp patient will be
charged co-insurance or co-pay but not a deductible
o Other modalities covered as well
Your Medicare Coverage: Colorectal cancer screening.
http://www.medicare.gov/coverage/colorectal-cancer-screenings.html
Medicaid
• Expansion under the Patient Protection and
Affordable Care Act
o Coverage now includes childless adults who earn up to
133% of Federal Poverty Level in 2014
• Provides coverage for FOBT, sigmoidoscopy and
colonoscopy for adults 50-64 years
o No deductible charged
o A co-payment for a diagnostic or treatment colonoscopy
may be charged if a polyp is found or if a follow up to a
positive FOBT/FIT test
Colorado Department of Health Care Policy & Financing. Colorado Medicaid: Benefits & Services Overview. 2013.
https://www.colorado.gov/pacific/hcpf/colorado-medicaid-benefits-services-overview
Helpful Tips
• How screening procedures are coded makes a
difference
• Encourage patients to call their insurers to know
what their coverage includes
o Is there a charge if a polyp is removed?
o Is there a charge for pathology and anesthesiology?
o Is there a copay if the colonoscopy is a follow up to a
positive FOBT/FIT?
• Work with insurers to assure that colonoscopy is
viewed as a screening procedure, not diagnostic
Importance of
Patient Navigation
Why Patient Navigation (PN)?
By reducing or eliminating barriers to care,
individuals can receive the screening and
diagnostic services needed. With early
detection and treatment of cancer, morbidity
and mortality can be reduced.
~C-Change: Collaborating to Conquer Cancer
Importance of
Patient Navigation
• Patient encounter is critical
• PN improves a patients bowel preparation through
education and ensuring understanding
• PN increases the likelihood that patients will follow
through with their screening appointments
• PN increases patient satisfaction with the colorectal
cancer screening process
Purpose of
Patient Navigation
• Eliminate barriers to cancer care
• Individual assistance across the cancer continuum
of care
• Promote continuity of care
• Improve the quality of care patients receive
Increasing CRC Screening
Rates
Steps to Increasing Colorectal Cancer Screening Rates: A
Manual for Community Health Centers
Maria Syl D. de la Cruz, MD and Mona Sarfaty, MD, MPH
http://nccrt.org/about/provider-education/manual-for-community-health-centers-2/
Four Important Steps
• Step One: Develop your screening plan
• Step Two: Assemble your team
• Step Three: Get eligible patients screened
• Step Four: Coordinate patient care across the
continuum
• CCSP is available for further training on this process
of increasing your CRC screening rates.
Questions