1. Colorectal Cancer Screening 101
Provider Education
December 2014

2. Comprehensive Approach to Colorectal Cancer (CRC) Screening
The Best Test is the Test that Gets Done

3. CRC Screening – Why? Colorectal cancer (CRC) is common
2nd leading cancer cause of death in the US
3rd most common cancer diagnosed in men and women
CRC screening is effective
CRC is preventable through timely colonoscopy screening
CRC is detectable through endoscopic screening and stool based screening
CRC screening is cost effective
Less costly for the individual and the health
care system if detected early
“Colorectal cancer is the 2nd leading cause of cancer death in the US and the 3rd most common cancer diagnosed in both men and women in the US. However, CRC screening is effective. It detects CRC through endoscopic screening and stool based testing. It can also prevent CRC through timely colonoscopy screening. CRC screening is also cost effective in that it’s less costly to the individual and the health care system when CRC is detected early.”

4. 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
“The biggest risk factor for developing CRC or having colon polyps is being 50 years and older. Because there are generally no symptoms of CRC in the early stages of the disease, it is important for everyone aged 50 years and older to participate in CRC screening at the recommended guidelines. If everyone aged 50 years and older received regular screening, about two-thirds of CRC deaths could be prevented.”

5. Colorectal Cancer in CO
Screening behaviors
Estimated 1,720 new cases of colorectal cancer and 670 deaths from CRC in Colorado in 2014
(American Cancer Society, Cancer Facts & Figures 2014)
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
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)
“Specifically to Colorado it is estimated that there will over 1700 new cases of CRC and nearly 700 deaths from CRC in In 2012, about 67% of eligible Coloradans reported having ever had CRC screening by sigmoidoscopy and colonoscopy. About 44 men and 34 women per 100,000 will get CRC in Colorado and about 17 men and 12 women per 100,000 will die from CRC in Colorado.”

6. CRC Screening Methods Detect Adenomatous Polyps and Cancer
Flexible Sigmoidoscopy
Colonoscopy
Computed Tomographic (CT) Colonography
(virtual colonoscopy)
Detect Polyps/Abnormalities
Video capsule
Detect Cancer
High Sensitivity Fecal Occult Blood Test
Fecal Immunochemical Test
Stool/Fecal DNA Test
“There are various methods to screen for colorectal cancer. The best test is the one that gets done as no test has been proven better over any other test. However, the colonoscopy has been deemed the “gold standard” because colon polyps, the precursor to colon cancer, can be detected and removed during the procedure. Some or all of these screening methods listed here are recommended by major health care organizations such as the American Cancer Society, U.S. Preventive Services Task Force, American College of Gastroenterology, to name a few. The CRC screening methods include, those procedures that detect adenomatous polyps and cancer, those that detect polyps or abnormalities and those that specifically detect cancer.”

7. 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
“When considering a comprehensive approach to colorectal cancer screening, meaning an approach that seeks to reach and make a recommendation to all eligible individuals in your community and clinic population as well as an approach that encompasses as many evidence-based strategies to screen for colorectal cancer, it is important to understand the systems change that is necessary. These changes involve a modification in the rules/policy of your organization. It requires buy in from the administration and medical staff. It enables all medical staff to understand and participate in CRC screening activities. Systems change also guarantees screening methods chosen by your facility are executed properly.”

8. Reaching All Clinic Patients
Uninsured
In 2011, the number of uninsured Coloradans ages years was 138,619
Income at or below 138% poverty level, 46,126
Income between 138% and 400% poverty level, 68,931
There are still uninsured individuals after the implementation of health care reform
Medicaid/Newly Eligible Medicaid
In 2011, 33.6% of Coloradans, aged years, who were at or below the poverty level had Medicaid
Newly eligible Medicaid as a result of health care reform
Adults without dependent children
Income at or below 133% poverty level
“When we speak of making a recommendation for colorectal cancer screening to every eligible individual, making sure we reach every eligible patient, we must take into account their health insurance resources. The numbers presented here are pre-Affordable Care Act implementation and I’m not going to reach them but it is just for your information. The key point here are to understand that our facilities must consider patients who are uninsured, those with Medicaid coverage, Medicare coverage and private insurance; basically reaching all clinic patients regardless of payer source. The patient populations, in many of our clinics, have changed since the implementation of the Affordable Care Act. There are more people covered by Medicaid and the health care exchanges but there still remain a number of individuals that are uninsured. We have to be sure that every eligible individual receives a recommendation for colorectal cancer screening and a comprehensive approach to CRC screening will help reach that goal.”
Quick Health Facts 2012: Selected State Data on Older Americans. Multack M and Miller, CN. AARP Public Policy Institute. December 2012.

9. Reaching All Clinic Patients
Medicare
In 2011, 13.2% of Coloradans were Medicare beneficiaries
Part B covers preventive services to include CRC screening
Insured/Newly Insured
In 2010, 78.4% of Coloradans, aged years, were covered by employer or other private insurance
Colorado Health Benefit Exchange since implementation of health care reform
Connect for Health Colorado
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.

10. Colorectal Cancer Screening Guidelines

11. CRC Screening Guidelines
Guidelines vary slightly between organizations
All guidelines look at level of risk
Average
Increased
High
Be sure that everyone in your facility understands the guidelines and follows the guidelines chosen by your organization
“There are numerous organizations and resources with CRC screening guidelines and they vary slightly from organization to organization but all guidelines consider the patients risk of getting CRC. We will discuss this further in one moment. When considering CRC screening guidelines, it’s important that as an organization you pick a set of guidelines, make sure everyone in the organization understands the guidelines and follows them.”

12. Risk Assessment Average Risk Increased/High Risk
50 years and older with no symptoms
No personal or family history of polyps or CRC
Screening Modalities
Flexible sigmoidoscopy every 5 years
Colonoscopy every 10 years
FIT/FOBT every year
Increased/High Risk
Prior to age 50 begin CRC screening via colonoscopy
Screening interval will be more frequent
Increased risk
A personal history of CRC, adenomas, IBD
A strong family history of CRC or adenomas
High risk
A family history of a hereditary CRC syndrome
“The risk assessment informs what procedures and at what interval screening is recommended. Generally, a patient is considered average risk if they are 50 years or older, have no symptoms, personal history or family history of polyps or CRC. Their screening options are flex sig every 5 yrs, colonoscopy every 10 years or FIT/high sensitivity FOBT every year. For increased and high risk individuals, it’s recommended that they are screened with the colonoscopy prior to 50 years because they either have a personal or family history of CRC, adenoma or IBD (increased risk) or a family history of a hereditary CRC symdrome (high risk). They will also be screened more frequently based on their individual circumstances.”

13. CRC Screening Guidelines Resources
American Cancer Society
Health Team Works: Building Systems. Empowering Excellence
United States Preventive Services Task Force
American College of Gastroenterology
American Society for Gastrointestinal Endoscopy
Centers for Disease Control and Prevention
Consensus Guidelines: American Cancer Society, US Multi-Society 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:
“These are other reputable resources for CRC screening guidelines and there are many more. Again the important thing to note here is that your organization decide on and adhere to a guideline to ensure effective screening of all eligible individuals in your clinic population and community.”

14. Coverage for CRC Screening: Payer Source & Co-Insurance

15. 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
“Under the ACA, preventive services are now covered by private health insurance without cost sharing. This includes screening colonoscopy. “
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.

16. Findings
People continue to be charged co-payments or co-insurance for colorectal cancer screening
If a polyp is identified and removed during a screening colonoscopy
If a biopsy is taken
Following a positive stool-based screening
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.
“However, even though colorectal cancer screening is covered by insurance, this has not come without several challenges. A major challenge is patients being charged co-payments or co-insurance for components of the screening exam as listed here.”
***read the slide***
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.

17. Findings Why is cost sharing applied?
Health care providers vary in how procedures are coded
Insurers vary in how cost sharing rules apply as well as interpretation of health care provider coding
States appear to be taking different regulatory positions on the issue
Medicare and Medicaid vary from private insurance
“It has been found that some of the reasons for this cost sharing include the following:
***read the slide***
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.

18. Medicare: Part B Coverage for proven CRC screening tests
FOBT/FIT covered annually
No co-insurance or deductible
Colonoscopy following a positive FOBT/FIT will result in deductible and co-insurance payments
Colonoscopy covered depending on risk level
High risk: every 2 years
Average risk: every 10 years
No co-insurance, co-payment or deductible
If test results in biopsy or removal of a polyp patient will be charged co-insurance or co-pay but not a deductible
Other modalities covered as well
“For patients with Medicare Part B, many CRC screening methods are covered. For stool-based screening (FOBT/FIT or the Stool DNA Test) there is no co-insurance or deductible. However, the colonoscopy following a positive stool-based test will result in cost sharing. The FOBT/FIT is covered yearly and the Stool DNA test is covered every 3 years for average risk, asymptomatic patients 50 to 85 years old.
Flexible sigmoidoscopy is covered, requiring no co-insurance, co-payment or deductible, every 4 years for those 50 years and older, but not within 10 years of a previous colonoscopy.
Virtual Colonoscopy is not covered by Medicare.”
Your Medicare Coverage: Colorectal cancer screening.

19. Medicaid
Expansion under the Patient Protection and Affordable Care Act
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 years
No deductible charged
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
“There is also coverage for CRC screening for individuals with Medicaid coverage. Through the expansion of Medicaid under the ACA adults without dependent children who earn up to 133% of the FPL are covered under Medicaid. There is no deductible charged for FOBT, sigmoidoscopy or colonoscopy for adults years. But, there is a co-payment for diagnostic/treatment colonoscopies if a polyp is found or a follow up is required as follow up to a positive FOBT/FIT. “
Colorado Department of Health Care Policy & Financing. Colorado Medicaid: Benefits & Services Overview

20. Helpful Tips How screening procedures are coded makes a difference
Encourage patients to call their insurers to know what their coverage includes
Is there a charge if a polyp is removed?
Is there a charge for pathology and anesthesiology?
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
“These differences between insurers results because of the way screening procedures are coded. We encourage patients to call their insurers to find out exactly what their health insurance plans cover. They must be informed on what is and what is not covered so there are no surprises. It’s also important that insurers view colonoscopy as a screening procedure and not a diagnostic procedure. Both insurers and providers play a role.”

21. Importance of Patient Navigation

22. 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
“While patient navigation does not solve all the challenges experienced by patients when dealing with the health care system, it can and does help. Navigating patients through cancer screening, diagnosis and treatment, can save lives. C-Change, an organization comprised of cancer leaders from gov’t, corporate and nonprofit sectors, expressed that **read slide**

23. 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
“Research shows that patient navigation is an effective tool to assists patients along the cancer care continuum. This all begins with the patient encounter. At this point the navigator develops a rapport with the patient and the navigator becomes the point of contact for the patient as they embark on the screening journey. PN has been shown to improve bowel preps through education and ensuring understanding. It increases the likelihood that the patient will follow through with their screening appointment and that they will be satisfied with their encounter with the health care system.”

24. 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
“There are numerous barriers faced by individuals trying to navigate the health care system…specifically with the populations we serve in the community health centers and clinics because often times these individuals have been medically underserved and feel intimidated by the prospects of having to find there way through such a complex system of care. So this again reinforces the importance of the relationship between the navigator and patient. Patient navigation helps to eliminate barriers to cancer care; it provides individual assistance and promotes continuity of care; and it improves the quality of the care the patient receives.”

25. 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
“Lastly, we will briefly summarize a new resource available to community health centers on increasing CRC screening rates in your clinics produced by the National Colorectal Cancer Roundtable. There are other tools related to this resource available for download at the website listed here. If you have further questions please refer to the NCCRT website.”

26. 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.
There are four steps recommended to developing a screening process to increase CRC screening process.
The first step is to develop your screening plan. If you have not already, determining your baseline screening rates is very important in order to measure practice improvement. Also, designing your screening strategy by choosing what screening methods you will utilize is important.
The second step involves assembling the team. Leadership and partnering are essential when taking on the task of increasing CRC screening rates.
The third step is getting eligible patients screened, which involves increased education efforts at the clinic level and the patient level as well as quality assurance efforts to include tracking, follow up and evaluation.
The fourth step is coordinating patient care across the cancer continuum which begins with communication between the colonoscopists and primary care providers so information about the patient’s screening and recommendation are understood. This becomes especially important if a patient has a cancer diagnosis and follow up care.
If you’d like further training on this process please contact CCSP.

27. Questions