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Colorectal Cancer Screening 101
Provider EducationDecember 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 USo 3rd most common cancer diagnosed in men and women
• CRC screening is effectiveo CRC is preventable through timely colonoscopy
screening o CRC is detectable through endoscopic screening and
stool based screening
• CRC screening is cost effectiveo 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 Sigmoidoscopyo Colonoscopyo Computed Tomographic (CT) Colonography (virtual colonoscopy)
• Detect Polyps/Abnormalitieso Video capsule
• Detect Cancero High Sensitivity Fecal Occult Blood Testo Fecal Immunochemical Testo 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
• Uninsuredo 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 Medicaido In 2011, 33.6% of Coloradans, aged 50-64 years, who were at
or below the poverty level had Medicaido 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
• Medicareo In 2011, 13.2% of Coloradans were Medicare beneficiarieso Part B covers preventive services to include CRC screening
• Insured/Newly Insuredo In 2010, 78.4% of Coloradans, aged 50-64 years, were
covered by employer or other private insuranceo 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 Averageo Increasedo 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 symptomso No personal or family history of polyps or CRCo Screening Modalities
Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years FIT/FOBT every year
• Increased/High Risko Prior to age 50 begin CRC screening via colonoscopy
Screening interval will be more frequento 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 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, 58:130-160.
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 screeningo If a polyp is identified and removed during a screening
colonoscopyo If a biopsy is takeno Following a positive stool-based screeningo 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 Acto 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 yearso No deductible chargedo 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 includeso 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, MPHhttp://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
