I'll lead with the first question. This is for Dr. Asaka. So what perspectives or approaches do you think are missing from the literature when evaluating barriers to follow-up colonoscopy? That was the question that I had for the group. So I mean, for example, when I looked at the source data, one thing that I realized was missing was family members and the people who support individuals, you know, in getting follow-up colonoscopy. So I thought that it was interesting that there weren't a lot of studies out there from that perspective. And just community, because the community piece comes up a lot as a barrier, like, oh, we don't talk about this, or this is not, you know, we don't think this is an issue, so that those perspectives weren't embedded as well. And you know, really, I think the point, and I know we're all focused on this, is like, how can you then design interventions to address this issue? And so I think if those perspectives inform interventions, then absolutely, let's make sure that they're there. But if not needed, then perhaps they don't matter as much. So just some things to think about. Thank you. Please. I think I got it. So Rachel, actually, I have a question for you and the panel about this, because I think I'm wondering about also if there's information on the payer perspective, like, are they going to care? And you know, if there is a quality metric, are they going to care, and what would make them care? You know, what sort of other decision points that could help us? I can jump in about metrics and quality metrics, and that will absolutely make many, many payers care. There's a lot of value-based healthcare systems that are very much focused on their quality report cards and how things are, and through my contact with the MGA and the work on that collaborative and just looking at the applications that came in, the groups that were interested, I think there's kind of a growing level of interest in this, and definitely at the payer level or the health system level, for sure. And I was just going to say that I think part of the issue is the wrong pocket problem, right? So like, the Kaiser's, we don't have payers that have integrated models of how they look at this problem. So I think having a metric is going to be critical. Without a metric or measure, we're not going to be able to move it very much, that people care about. And if I could just add, too, and I think payers care about this. Payers are absolutely interested in getting their folks screened for colorectal cancer. It's on all of their metrics. Our biggest barriers have been health systems that incorrectly code these follow-ups, and that's another barrier. I mean, you get to walk in after your prep, and you've got the person at the desk who's signing you in says, oh, you got a $1,000 copay today before we get started. I thought this was a screening. So I think the payers are all in on this. And I would recommend from a state level, too, get with your managed Medicaid organizations within your individual state, because they are the drivers for many of these folks in disparate populations. They also want QIPI, and they want to win. And the other thing I'll add to that as well, I think, obviously, the quality metric and, you know, mandating people to actually report it, right, and use it, but then also cost-saving. So if we can demonstrate that by actually achieving follow-up and diagnosing people earlier or preventing people from having surgery, radiation, chemotherapy, I think that would be attractive to them as well, to see kind of the cost-effectiveness of follow-up. We'll hear about the payer perspective later today, so that'll be great. Well, following up on a point that was just raised, so how can we better disseminate the information to both patients and providers that follow-up colonoscopy post a positive stool-based test is now covered without cost-sharing? How do we get that information out there? Yeah, well, I would, you know, I guess you guys heard my story. I think we ought to be talking to them earlier. I mean, getting a mailed FIT test, you have no context around that, really, you know, and I think that lack of context and that lack of recurrent messaging, like how many times should they hear the message that this is a two-step process, that's a complex thing for professionals to have finally arrived at. How long do you think it's going to take individuals to arrive at that if that's not being presented to them on multiple occasions prior to the event itself? So I think it's frequency and lead time, is my answer. So I think the barrier that, since I sent that question in, was that they don't know that they don't have to pay. So we hear that a lot, and, I mean, providers, maybe at the top level, they know, but it's not trickling down to the providers, so they're not able to tell their patients, and we hear from providers that so many patients still say, well, I'm not even going to do a stool-based test because if it's positive, I'll have to pay, and I don't want to do a colonoscopy, so I'm going to do nothing. So, yeah, TR's got to... No, I mean, people had this experience just a few years ago, where they had patients who had those copayments. So to unlearn something, we had a CEO in our medical group who said, you have to tell somebody 17 times before they actually will get, where they can kind of internalize that information, so you have to really keep at it, multiple channels. And I also think you have to... Oh, go ahead. I was going to suggest that, clearly, pushing to the choir, we should engage primary care physicians as well, clinicians, and we have to unlearn some things, right? So we knew that this was a painful area, and we got stuck, and a lot of people remember the pain, and so we have to now unlearn this. The other thing I would recommend is that as we offer non-colonoscopy tests, we should offer it as a package. Complex messaging, but when this test is positive, you're going to need a colonoscopy, and it's free, right? Right. So we have to change that messaging, even if it's more complex. I do... Oh. I was going to just say, though, that I think we have to recognize that, in some cases, it is theoretical, and the providers have to be careful, because there are situations in which patients have been in plans where it's grandfathered, and they actually don't get that follow-up colonoscopy covered. I know that's happened in our health system, so you... And I think that might be the challenge for some of the primary care providers, is they've been in that sticky situation where they've said it will be free, and then the patient gets that surprise bill. So I do think that it's better penetration of the policy, better awareness of the policy, but I still think that there are some loopholes that we need to work on so that it's truly factual for all patients. And it's not just the grandfathered. In some health systems, the patients have to pay for the PrEP, or they have to pay for the MAC. So it isn't always completely free, and those surprise bills, I think, make PCPs very hesitant. Okay. We have some questions from the audience. I'm going to start on this side, and then we'll move to that side. Okay? Please. Yes. A question I've got for Dr. Lindbergh about return rates for Medicaid or low-income or uninsured. Do they differ from the general population? They do, and we've reported those numbers. It's about 59 percent for the Medicaid population compared to the numbers that I showed with the Medicare and the general population. So happy to point you to those resources. Okay. Can you hear me? Great talks across the board, absolutely. And I'm going to speak to something. The question relates to something you mentioned, Dr. Dubini, and it's the problem being the health system. You know, I'm just curious, how do you engage the boots-on-the-ground community GIs to do these procedures? I mean, I think you have to be careful with how do we get their buy-in, because it's got to be a fair amount of volume. And I'm just curious, for those successes you've mentioned, how do you do that? Because at the end of the day, you know, medicine is a business, and so whenever you kind of go to them and say, hey, we've got this program, you know, patients who are underinsured or have no insurance, you know, they will ultimately need a colonoscopy. You know, how do you make that a favorable, you know, everyone can say, oh, that sounds like a great idea. But I think in terms of actually acting on it and being engaged with it, thinking of that other element of medicine being a business, how did you get across that barrier? Was it a barrier at all? Because I see that being a problem. So in Columbus, we have a free colonoscopy, and some folks in this room participate in that program, thanks to the company. It's still a Band-Aid, right? There's still going to be that gap. Let's not kid ourselves about this. There are people, when we were doing a project in Louisiana years back, you know, there are deserts, the places where there's no colonoscopies, and they wouldn't accept people with Medicaid, right? So there's an enormous amount of work that we have to do. My idea, silly idea years back, and I'm still trying to pursue it, is that we have a 5-1-C company with some resources to support that post-non-colonoscopy test follow-up for people who can't afford to, don't have the resources, still probably need transportation, navigation, all those things. And because the hospitals can't actually, as best I know, offer that service for free. Unless you're being in trouble, if you do. So I think we really have to have a national approach to this, regional approach, local approach to this, and to recognize that there are people who actually need it the most, who don't have access to it. Either because insurance doesn't cover it in some silly way, or they don't have insurance to cover it. I don't have an answer, but I do think that's the approach we have to consider. And I'll just address that. In retrospect, the easiest thing about the Kentucky experience hasn't been, in fact, having the money to pay for colonoscopies, which doesn't solve any of these more difficult issues. But at least at the end of that rainbow, they can get screened, and that is a possibility. So I think when you look at the return on investment in cancer screening, colorectal cancer is probably the most returning colorectal cancer screening. So I think that fiscal argument is what I would take at the regional, local level. And in terms of business organizations and docs, I think we're all business folks, but we also understand that the reason we're doing screening is to help with prevention. So I think it's education. I think it's education, education, education. And I think physicians and primary care doctors get it. Their bandwidth is narrow right now because they're getting pummeled more than ever. But again, I think the harder issues are not how to pay for it. I think you go to your legislatures, you talk to them, show them that savings in treatment. And unless you've got oncologists on the other side saying, no, don't find that stuff early. We like the blah, blah, blah, blah, new therapy that's coming out. I think the fiscal argument's there, and we've done a great job as a society to make that argument. I think you just have to take some of those to the local levels, particularly if you're talking about Medicaid. Medicaid is a state organization. It's not a federal program. You have to deal with who's delivering Medicaid at your state level. So that's my recommendation. I think the fiscal argument should drive physicians and health systems to the right place. And I believe that the fiscal argument can also be, can move forward with metrics, right? We don't have a metric for colon cancer screening in Medicaid populations. If you did, then that changes the conversation around what proportion of those under Medicaid are up to date with screening, and what are we doing beyond screening completion related to follow-up and their outcomes related to treatment? There are some incentive payments around health equity for payer plans. So then you also have an opportunity to say, how are we doing across different demographic strata? But I really do think that this conversation has to move out of the health system in many ways to state regions and to national policy. Okay. Are we, go ahead, please, Dr. May. Well, I just think, I just want to commend you for your question because I think it's actually the crux of the entire challenge. And I'm going to be honest, in a lot of the FQHC settings that I work in, that's the challenge, is convincing the private GI to do the follow-up colonoscopy for a uninsured, of course, but even an insured patient who has a low reimbursement rate. So I think that should be part of the discussion today, is how can we solve this challenge for those two populations? Because there really is no incentive for the physician to help with the follow-up. And I get the metrics and I get the financial argument for the hospital and for the payer, but for the private doc, it doesn't quite close that gap. And I think that's just it. And I'll just sort of in closing say, I think that being in private practice, I think when you look at some of the big private practice groups, you almost have to really make a big argument to the suits. I mean, yeah, the doctors get it. We understand it and we think this is the right thing to do, but we're not the ones that are making the final decision because we're the ones whose RVUs are being looked at and we're being measured by certain things. So it's an interesting conundrum that I think needs to be investigated. And I think because it's a specialty service, you're not seeing the other costs of the cancer treatment. So that's not in your equation for the cost effectiveness. It's a very important problem that we need to address. And I just wanted to put in two other factors. One is the other issue is also making sure the patients show for their colonoscopy, right? Those shows block slots, send them disincentives to be able to put those patients in their schedule. The second is making sure they have a good bowel prep. All of those require this wraparound services, navigation, community health workers, somebody can work them through the prep. So I think that is also a factor that we should not lose sight of in addition to the payer issues or payment issues. Absolutely. And a question here. Yes. I'll try to make it brief. So I agree with Dr. Adams. That is a big concern. On the practical side of everything, when you code, coding is done by many people who have no idea what a polyp is. They've never seen one. They don't know an adenoma from a cancer. So you get this piece of paper that somebody else created and you have to choose. You don't know the one that you just always choose because there may be 50 codes there and you know where to find it. But the biller knows which one is actually, you know, reimbursed. Aside from little things like that, the referrals that are written are often really written by the medical assistant who is the least trained, doesn't know if it's because they're bleeding versus that this is a follow-up to a screening or a family history. So everything comes to the gastroenterologist as an evaluate and treat. And the question is usually, treat what? So what I'm saying is that that patient who is holding that referral, they walk in and you ask them and they say, call my doctor. I think it would be helpful on a national level somehow if the messaging can go, you know, the way that we just don't say a big polyp. You actually define what big is, what large is. You know, things have characteristics. It would be very helpful somewhere if it can be clear so everybody knows when you check the box for screening, these are the factors that makes it screening versus whatever it's going to be. Somewhere with all of that on the insurance end, when the patient calls in, they actually talk to what I call what is the customer service. Those are the happiest people who always think the sun is shining. So when the patient hangs up, they're always told you don't have to pay anything. And on the practice side of things, you just simply take their card, put their number in on the insurance company's portal and it comes back with a deductible of $2,000 not yet met in September. So somewhere there has to be a meeting of the mind that doctors cannot solve. Patients have a trust issue. They don't know what the cards mean in their, I mean, wallets. They really don't. It's nothing against them. I don't know what mine means most of the time either. But when you go in and hand it in, you don't know it's like, you know, it's like a credit card. You don't know if you have a balance. You don't know if it's really going to cover it. They don't know either. So when they get there and they have drank a breath and they find out that they have to pay $500 out of pocket and they have a neighbor who says, listen, how long are you going to be there? That's the question at the door. They oftentimes leave for a lot of reasons. And it's embarrassing to say I don't really have money, you know. So I think this is a bigger picture. I mean, we all see the need, obviously. But I think there needs to be a conversation because most people don't know who the ASGE is. And so, you know, what I hear all the time a lot, I'm very close to a lot of primaries because they make me look good. You know, they call me with a problem, I try to solve it. Whether I scope the patient or not, I can find the appropriate place for them. So I'm like an air traffic controller on certain days and all kinds of things. But when you talk to them, they say, listen, we're tired of you all giving us something else to do. We're busy. Everything that you specialists don't want to do, you say send it to primary care. So when you discharge people from the hospital with the GI bleeds, see your doctor in two days. That is not going to happen. And so it's just that for everything. So I think that when we tell them something else to do, we have to tell them how to do it. So the mechanism has to kind of be in place. And sorry to be so wordy about that. Great points. Can I just make one? What I would say is, you know, since January, you know, we've had the federal legislation around this. You know, even in Kentucky where we passed this in 15, we still have hospital systems and individuals coding incorrectly. So I think a take home action item for ASGE is a consistent educational process around this coding piece, not only to physicians, but practice management components as well. And you can't send one letter and solve this. This is going to have to be a reminder. It's going to have to be an ongoing piece. And one question. How many people require an office visit before doing a colonoscopy on a positive fit test or a Cologuard? How many of you guys? I heard that in the talks like multiple times that where people were having to go to see their doctor for a positive fit. You do? We don't. I don't either. That's what private practices do because they've never seen the patient. And the other thing is they are not risk stratified. So the idea of them showing up in the unit prepped is terrifying, right? Because they have no information about their heart disease, their lung disease. So they often require a follow-up office visit. Yeah, but you have a whole team of people who are doing that pre-visit. The anesthesiologist are prepping them. The primary care knows who they are. You know, most of these people who are asymptomatic and normal risk, they don't have any of those. It's the minority that have that. I just think that's another huge barrier is to require that for risk stratification. Health records that don't talk to each other. If you're integrated, if you have an integrated health system, you can look it up. But if you're a private practice sitting out with no connection, you know nothing about that patient. Yeah. We have something called Fast Track where it's, you know, a patient has to go, they go online, they fill out a health history survey. And it will point you to the direction of you need a visit if, you know, the patient has a symptom like blood in the stool or something along those lines. But if it's anything other than a symptom and it's just a positive test, they go through an MA who then schedules the patient right away. Because we were losing a lot of patients that way, actually, by requiring everyone to have an office visit. Because then you don't have enough slots for everyone to be seen. And then they fall off. Right? So the Fast Track actually, and it's not perfect. I mean, there's a lot of holes in it. But it actually has helped a lot. So helping practices set up things like that, I think it would be a huge gain. Yes. Because they don't know how to re-stratify. Agree. We're out of time. But I'm a primary care doctor. They're trying to shut us off. I know. They're trying to shut us off. No, I think it's great. It's a wonderful dynamic. I know. Please. I think I'm a primary care doctor. There are ways to do this. It doesn't, the patient doesn't need to get in the middle of this. This is a problem to solve, not the patients. I don't relate to some of, I mean, I see them happen. But these are easily fixable. They are systems issues, not the patients. Absolutely. Okay. Thank you, everybody. We're out of time.

barriers to follow-up colonoscopy

missing perspectives

family members

community perspectives

payer perspective

quality metrics