So we've heard a lot today already about some of the challenges and some possible opportunities. I guess what stands out to you guys in terms of what health systems can do? I think there's alignment in their interests and the goals of colorectal cancer screening. I mean, it's so aligned because they make money, they drive business, they serve their community. You know, how do we do it more efficiently? That's the only question. It's not whether there's alignment between patient and societal goals and hospital goals. And maybe if you took out the uninsured. But in general, they do procedures, they work on wellness and health care. That's what we're all seeking. So there's alignment in the goals. So then what do we do to kind of increase the rates? To increase the rates? I think if it's important, you measure it. That's how Peter Brekker would say. And so I think measuring and following it and reporting it and getting out in front. And again, we're all facing this new paradigm that's coming. And I don't think that there's anyone out there that's given as good a discussion today at the health system level as we've had today. And I think informing them about that and giving them preparation for what's going to happen in the next five years is critical. And as Samir just said, this has to be a win-win. You know, doctors can continue to be busy. Hospitals continue to be busy. But we deliver better care to more people. That's the win. So measurement is my answer. And save money in the long run. And save money in the long run if possible. Or spend the same money and deliver better care. I think to go upstream a little bit, inform, automate, measure, monitor would be sort of the key elements to me. I think there still is a lack of awareness, maybe at the provider level more than the health system level, but it probably is both. OK, so inform, automate. I think if you add one more thing, even at the systems level, it's just too hard. So automate, how can we help identify the population, how can we create the flow so that it requires minimal, if any, manual intervention. Measure, you know, the measures are what we talked about, and then monitor. You know, I love in the gastroenterology world, once people started, you know, paying attention to their ADRs and communicating their ADRs, guess what? The practice improved. Yeah, yeah, they got better. So who do we need to inform? Patients, providers, administrators. You know, a lot of the stuff about policy change, we still heard that. It takes 17 times and 17 years to inform. So the topic might be policy, and you might inform kind of patients, providers. The data like Jake showed, you know, over a 700-fold increase in risk if you don't follow up on a positive school test. Yeah. Right, so there's the head and the heart and the heat. So there's, right? So if you have, like, the head would be the data. There are a lot of places that don't know what their data are, and how well are they following up. And I think we heard earlier that at the insurer level, that's going to be really challenging to measure performance. But there's a much better position to measure it in the health system. The camera. Yeah. And the heart is obviously the impact you can have on those patients. Okay. And then the heat is, you know, failing to do it and being exposed to the heat. Oh, the consequences. All the consequences. Okay. And one of the big challenges is that, you know, we're talking about health systems. We're talking about the big systems. Yeah. You know, the hospital systems, the series of hospitals. A lot of them don't report their screening data. Yeah. Okay. In fact, I think there's only four or five in Georgia that do it out of 36. The other thing is, in these conferences about equity, you know, a lot of people don't make that equity connection. And that's why I say that these UDS numbers come out every year. You know what they are. So in Georgia, you can map and see who's doing well, who's not. And you can put this together. But, you know, making that connection there also requires some process of engagement. You know, we did this Blank Secure thing where we brought health systems together. But I think, you know, ASGE and American Cancer Act probably could engage states. So we're looking at Georgia to engage our volunteer hospitals to come together and say, you know, here's a project. Satisfies your COC requirements. Satisfies Title H, you know. So, you know, I think that that would be something that would be big GI groups like this one, you know, have some convening power if you link to BACS. And I think, you know, we saw that at national conferences too. The key is how do you get these isolated entities that often compete to look to the same strategy, for example. And I think it can be one that's pretty difficult. I know, you know, public health can't do it, you know. Community health centers can't do it. If you're poor and you've got no money, you know, it's hard to get an audience. But, you know, organizations like this and ACS can do that. And I've seen that happen. Okay. Okay. So I'm hearing a lot of different ideas, right? I'm hearing that there's alignment. I'm hearing that there could be some things about kind of data reporting, measuring. Go ahead, Chase. What were you going to say? So I was going to talk about alignment. I took on a role as chief health equity officer. So good news on two or three fronts. The Joint Commission, right, has health equity as a national efficiency goal. And one of the examples in there is a clear parameters about what hospitals should do to meet that requirement. And coincidentally, if I remember correctly, one of the examples given was evidence-based intervention to improve cognitive discipline. And I think that's because of the work that the body has done to be able to provide a position to do so. The other piece that is happening is around CMS asking for screening for social determinants of health. And at some point, that will become referral for social determinants of health. So I think if you go beyond the CHNAs, that then creates an alignment where one of the ways that ASGE could advocate is to try to, you know, move colon cancer screening higher up so that more systems are looking at that as one of their measures. What I'm trying to do is to avoid this practice where, look at this measure this year. Next year is a different measure. Next year, you'd never make progress in one year. So you won't need to be able to do this many years to be able to make progress. And I think that's one of the places where you can get a position to work with hospitals. It's not the hospitals, per se. It's the ambulatory clinics that are affiliated with hospitals. That's where this one occurs. That's one place that I will see as an opportunity to kind of put in colon cancer screening as one of those initiatives that systems will do, and that should do across multiple systems. Okay, I can see that. If we might want to also get clear on which – what problem are we trying to solve? Which measure, yeah. Are we trying to solve this colon cancer screening globally? We spent a lot of time talking about follow-up. I guess we're focused on follow-up, yeah. Follow-up is fine. I think I'll use that example as a way to – because the biggest issue that I see, well, many times, even in Columbus, screening is very long, right? But then when they get screened, they don't have the follow-up. I'm not sure you can do one without the other. But it might be two metrics. Yeah. I think the focus today is really on the follow-up. The focus today is on the follow-up, yeah. And so, you know, I mean, I keep thinking about what Kaiser has done. You talked about it earlier, TR. You know, the multiple steps. I think you also had, like, financial incentives or penalties for hospital leadership if they weren't meeting certain benchmarks. Am I correct in remembering that? It was – a portion of the operating budget was held back. But that was really all geared around the EVIS metric, just for the screening. So what we did – what we've done on follow-up has been sort of like on the margins. We don't have a regular – we don't have an infrastructure to regularly report it. And we have put a pause on sort of a lot of that payment gathering during COVID. But you did set a target, right? Like 80%. 80%, but then we were targeting 28 days. Yeah, that – But that was also – the way we measured it was based on when people came in, how long it ended up waiting when we got there. So we need to do another metric, which is, like, what proportion are actually – Oh, so that was 80% of the people who got scoped or scoped within 28 days of when they're positive. But it could have only been 20% who actually followed up. Right, but we have other data that shows it was a high number. Then I think we need to look at any exclusions from the denominator. Like if it's a fit for somebody who presents with melanoma and has a variceal bleed and somebody runs a fit, you don't want to do a colonoscopy necessarily on that person. So do you exclude those people from the denominator? There is the fit screening code and the fit diagnostic code, so that's – People are supposed to use the diagnostic one if there's melanoma, if there's – Yeah, I don't know. Supposed to. And then there's the people who had a colonoscopy six months ago or a year that was – that were inappropriately tested, and then you get into the risk of gaming. But policy is a different group. Yeah, yeah. Okay, so I'm hearing a lot about advocating for a measure so that we know at the health system level, maybe at health plan levels, what the rate is, the rate of completion. I'm also hearing the time to completion is probably pretty important as well, although I know that that wasn't really discussed as part of the measures. Anything else that's important to think about? I mean, I think what you're saying, Jason, is something that I experience all the time, which is that when you look at those positive fits, there's a good 10% that actually shouldn't have gotten a fit in the first place, right? And so, you know, to think about a measure, do we want to take – remove from the denominator those patients who, in fact, shouldn't be eligible or inappropriate for screening? Well, if your target is 80%, then you've kind of built in – Built in cushion, right? Built in some noise, you know, for people who maybe shouldn't. Yeah. The work that Elizabeth and I did with Mary Barg and NCQA on measure development, if there was an ER or a hospital code within 15 days on either side of the vest, those were thrown out because there was a sense that there was something going on with those patients acutely. Oh, okay. Yeah, we see – That would be a complication of that procedure, right? We see about, like in our health system, about 650 abnormal fits per year, but about 100 of them occur in the setting where the patient is not in panel with a primary care provider, and most likely they're getting it in the hospital or the ER. So there's that close to about 15%, 20% where probably follow-up, and in that population, follow-up colonoscopies yield better than 25%. Yeah, we have in the VA, we have a lot of fits that are ordered in the emergency room or on the ward, and the positivity rate for that location is like 15%, 20%, versus 8% in the ones that are ordered in primary care. So, you know, you might do a separate based on what's ordered, although I don't know that everybody can measure that. I mean, ours is a quantitative fit, and I think they should – you know, the ER will not get the result for at least one day, right, because it requires an automated machine and someone has to process the machine, and they only batch it. But I don't think they know that, so it just shouldn't be done. But I think if you're going to do a measure, you've got to put a health equity lens in that measure. You know, what social determinants, the insurance status, poverty. The suit, yeah. Because you've got to – I mean, that's what this thing is all about. You know, you've got to do that. And, you know, if you have an FQHC affiliated with you, know what their UDS measure is because it is an extraordinarily accurate measure in a number of reports. But I think that that is, you know, important. The big challenge we've got is, you know, what levers do we have over? You know, I always say we're trying to do what we build systems, it's a coalition of the willing. How do we entice them to come into that sector? You know, now, you know, they have to do – you know, these not-for-profits are supposed to be doing that, and they're getting hammered on this. And the Commission on Cancer, you know, supposedly has these standards in there, 8.1 and 8.3. If we could get them all to adopt colon cancer screening and, you know, try to reach out, you know, to people that are uninsured as a way of barriers, you know, that is, I think, one of those key ways to get the big guys involved. Because that link to care I showed you, you know, you've got to knock that all down. CLC hospitals have it all. Yeah. So you're kind of talking more about partnerships, so let's – Well, I think we know what we want them to do, but to get into the door, you've got to figure out, you know, the carrot and the stick, right? You know, what is it – what's good for them on this side of the coin, you know? You know, better care, driving cancers into their treatment zone, chemo, revenue, mainly revenue, revenue, revenue, I think, and quality. Being a cynic, a later diagnosis is going to make them more money because of more chemo. Well, I think that's – you know, I'd say – No, I'm being devil's advocate. Well, I mean, that's a whole different story, which is why oncologists should never be in charge of cancer prevention programs. That ought to be a rule. But I do think, you know, you have to start this conversation about, hi, I'm Whitney Jones, and I'm here to measure you. That's going to be a bad meeting. Right, yeah. How are we going to come into these systems? So you're really thinking about, like, how do we kind of make the sale? Right. What's the carrot, right? What are the carrots? What are the carrots and what are the sticks? So we have, like, this idea of a measure. So HEDIS and UDS, any other group that we want to measure? Like, do we want – It's NCQA's thing to use. Right, that's the same thing. Yeah. And the word I heard is that the NCQA is taking it on, the measure, like, you know, I guess, Elizabeth Siemens. So I think you need that to kind of get hospitals to get aligned. But the point you're making, if I'm getting it right, is are you providing the right care for your patients, right? So if they're positive, you're not getting pull-out, you're not getting the correct care. Right, and the reason I pose it as the carrot and the stick, because it's going to be the same. Better care for your patients, more liability. I'm thinking that health care systems employ the vast majority of gastroenterologists right now. So at the end of the day, they are responsible for that system that backs up their physicians. That physician doesn't stand alone as responsible if they're employed by a health care system. I think Samir's point was really germane today, in that the liability of not following up on a positive fit for nine months. I got to tell you, I almost had a heart attack. He said nine months today. Nine months? No, I'm done. A clarifying question. So the Multisociety Task Force has already put out a statement a couple of years ago, 80% target. Well, what happened with that? I mean, is there a way that ASG or other societies could help put some teeth in it? I think this absolutely has to happen. But ADRs weren't a thing until the GI society said ADRs are a thing. We're going to measure you. We're going to hold you accountable. Can there be a next step to build up on that work that was already done? Well, I think that's the HEDIS measure. You need to get that measure, because that's what has teeth. That's what gets reported for the health thing. I don't know, the Multisociety Task Force doesn't have any teeth to say that your ADR is bad or your follow-up rate. It's an interesting case study, though, because ADR is not an NCQA or HEDIS metric. It's a professional society thing. It's provincial. It's become sort of a standard through the force of many KOLs giving their talks and demonstrating to the larger GI community that this is an important value. There's been evidence after evidence validating it Well, we've got plenty of evidence that not doing your colonoscopy after an adrenal fit is bad. So we need to drive a communication plan. Could the societies oversimplify, hey, this is a good thing to do, versus you must do this? This is a quality measure. This is part of a successful program. You will be held accountable to this by your peers. Who's responsible for it? Is it primary care? Is it health system? Is it GI? It's going to be primary care. Well, so I think there's one thing that, I think, a concrete thing that ASG can do is outreach to primary care societies, because there's a lot of knowledge gaps in primary care, right? Would you agree with that type of thing? I'm not sure the issue is knowledge gaps. I think the issue is capacity and resources. Well, I don't know. We've looked at a lot of charts. We heard from Elizabeth's presentation when they did that study. Many doctors said, I thought I was at 100% until you started that. But also, what we've done, in that context, yes. But we've done chart reviews. And we look. They're positive. And the doctor said, oh, I'm going to repeat it and see. And it's negative on repeat. Or they say they're too young. They're 45. Or they're too old. They're 76. I'm not making these examples up. Or they say, they had a colostomy nine years ago. They're not due for another one for a year. I'm going to ignore it. And when this is in the last year, if it was a colostomy within the last year, I can say, OK, I'll trust your judgment on that. But if it was five years ago, three years ago, they should be referring to GI. So I will tell you, the channel in my wife because of this conversation, she went to this practice and found many fits that were not followed up. And then the challenge is that when you try to do so, you run into this brick wall. So then you're trying to do these other things with triage. So there's maybe a knowledge gap. But I do think that the linkages are missing between primary care, when the fit is done, to when they actually get the test done. Those linkages are broken. Yeah, I agree with that. They're broken. And so when you fix those linkages, if you look at it as a model, it's not, human beings are not involved in some level because it gets moved to GI. And GI takes care of it. But that doesn't happen in 99% of systems. We heard, I think Maz learned about this also, in FQHCs. A lot of times, there isn't even a gastroenterologist that you can refer to. Yeah, so I was thinking, the other thing that maybe the ASG can do is reach out to, what is it, the GI Alliance? And what are the other big organizations? You've got thousands of gastroenterologists now in this big organization, these, what are they called? Private venture groups. Yeah, private equity, yeah, yeah, private equity, thanks. I don't know if there's any opportunities there for them to promulgate the surgery on Sunday or other models. Well, you know, we have done that. We presented to the Georgia Gastroenterological and Dysfunctional Society. And I had four big groups, about 250 gastroenterologists, giving cards saying, we'd like to do this. You know, we want to do this. The problem was, is that behind them, you know, there's a billing service. There's an owner who is not as generous with their time. And they put all these barriers there. And I think you can, you know, look at those barriers and basically find ways to overcome them by, you know, bringing folks forward and say, you know, do we really need a Medicaid rejection letter that takes a year after a positive fit test? When you already have a UDF, you already have an R system for community health centers. We know that they're indigent, federally vetted. So I think that there's a lot of roadblocks that are stuck in there. But the GI guys are usually not the bad guys. They're the ones who want to do this. Yeah, I agree with that. Not unless they're with private equity GI groups, right? So, I mean, I don't know if they would go for it or not. I have no idea. And are you saying the private equity GI would be interested in the surgery on Sunday? I don't, just the idea of donating their services. Like the small groups, let's say, you know, a few gastroenterologists working together can do that. But if they're with a private equity group. It's like across multiple states. Yeah, there's hundreds. I mean, yeah, there's like 500, 700 physicians in these groups. I would offer that the point that I made is the same thing. Who is the opponent of this? Who owns this? We've got to figure that out because if no one, why ADR works is because you guys own this reputation on the mind, right? And this did not need someone else to, this thing crosses from one interface to the next potentially, and I think that's one of the things. Yeah, maybe, you know, maybe, you know, like this group is meeting about health systems. I mean, maybe we should think about like the sort of more integrated or larger systems and because then, and how can the system take more ownership, whatever that system means, right? Because it's probably some round table of people who are guiding the health system in making the right decisions, including like in Kaiser, like how do you nudge them so that they can have it steer the whole organization in that way? The lines of communication are very clear cut in our organization. Every medical center has a primary care department and has a GI department, and then there's peer groups that meet, so I think that's what health systems do. Maybe it's like demonstration projects of health systems, kind of, you know. Let me, health system is perfect, but we're really talking about a healthcare ecosystem. You're an integrated health system. Yeah. A lot of what we're talking about where it's not working, it's not integrated. And then, you know, how do you connect the dots? Someone's got to do what Jim does or what you've done to kind of build those connections. What about at the health system level, you know, like working with, because like in the VA, we have a reminder, you're fit, positive. Here's a colonoscopy due reminder that pops up, and if you turn it off because the patient's sick or something else, it pops back up again like a month later. So does Epic have that? Yes, you can do it. Yes. Is this a standard? Epic doesn't do it as like a national standard. It's not a national, but it is a national standard. They contract with each vendor, with each customer, and figure out what that customer wants. I mean, I'm just wondering, is this an opportunity for ASG to work with Epic to say, we want to make sure people get referred to GI when they're fit, positive, or Cologuard positive, or what have you? So that's kind of a best practice alert, but what's the other, is there another word for it? There's a reminder. There's a care gap. So there's two things, there's care gap and there's best practice alert. The care gap happens, my understanding, is at the health maintenance level. So that's more of like- You can set it up however you want to set it up. And that's usually on, in our instance, on the left side, and it turns red on, yeah. But the best practice alert, my understanding, is that if you go into the patient's chart, boom, it pops up. It's a different- And the clinicians will kill you. Right, so you have to be very careful about what pops up on that, right? They clear their health maintenance, or the MAs might go through that, but then the best practice see, like the PCP sees that. But you have to be in the patient's chart to see this? You have to be. So you see a patient today, you order a school-based task. They return it a week, a month, six months down the road. You're not seeing them again for 12 months. You're not getting in that patient's chart again until that next visit. You want that alert when the result comes back. But the result does come into your, quote, your inbox. Right, yeah. It goes into your inbox. But if you don't act on that- If you don't have someone who's monitoring and listening, people who are- Yeah. Who are positive. And that's what we do in REACH. Now, first of all, only about 20% of community health centers in four groups have Epic. Okay, we have NextGen, we have ECW, and there's workarounds in there. The problem is not knowing who needs to be screened. If you work your numbers, you can find those people. And the problem is, once you find them, get them out of the test work and approve. And there's not a lot of educational gaps as far as primary care. Most of us now know what to do. And when it's a UDS measure, we get a lot of rewards from that. The problem is the links to care process, like you're saying. If you ask, and you were on that group with me, what is the biggest thing they complain about? Is that if I have an underinsured somebody, where do I send them? Where do I send them, right? And that stops the process. So, what do you guys think about the advocating for the patient navigation framework? That's a- That's a topic, right? Well, so there is a, Medicare is reviewing this. I think I shared that with you a few days ago, a few weeks ago. Medicare is reviewing a policy that, there's something in the law, I guess, that says that navigation is covered for things like cancer. For cancer care. Serious illness. So, if a patient's diagnosed with cancer, Medicare will now pay for navigation. And they're writing the fine, they're fine tuning what that means. It doesn't say anywhere in there, if somebody has a FIT or COVID-19 positive result, that they should get navigation. I think we need to lobby for that to be included. I think that's a great element. Okay, so this is a- Positive cancer screening. This is advocating for- No, no, that may be the goal, but if that goes through that, I think in this scenario, it would have to be owned by the health system, no more. Sure. Yeah, and if it's reimbursed, then it gets more- I mean, you're doing it, and you see the value in it, and the health system- You're doing it for people to complete the screening. The screening, the reason why- But also the colonoscopy function. The reason why Xact doesn't navigate to follow up colonoscopy is more illegal anti-kickback. So, we can't refer to a gastroenterology practice X, because there could be inducement for that practice to then order more Coligard. So, we can go so far. We can provide the positives. We can work with a third party and say, these people need to have a colonoscopy appointment, but we can't schedule that through our navigator. But the health system could have a navigator. Correct. Yeah, that's the best- Can you notify their insurer that they're positive? Yeah. Under the right conditions, yeah. Part of an infrastructure mistake could be a navigation system. Yes. They did it in New Hampshire, they do that in South Carolina, of all places, and we do it for the southern part of the state, and you guys do it there. So, one of the things I think this pilot could do is just, if you're gonna go to Georgia, can we convince the state to develop an infrastructure? We already have a piece of it in Georgia, for the thing we're doing, but infrastructure and navigation. Because you can telephonically, efficiently navigate an entire state. That's the key. If it's reimbursable, or somebody can pay for it, then you just have to have somebody set it up. And those core companies are doing this, you can do it telephonically, we get a 90% show rate with good file prep. I would think if I was in private practice, and I'm in the VA frame, who doesn't know that, if I were in private practice, GI, I would say to my primary care colleagues, if you refer patients to me, I will navigate them to their colonoscopy. It will cost me something, but I'll make money off those colonoscopies. Yeah. And that's what people come to us for. It's something that you own right now, right? We navigate insured people, and their GI goes lower, because we reduce the 20% no-show port of opera. We're just making it more efficient. Yeah. Okay, let me try to wrap up, because I know that I'm sold. Yes, I, yeah. In order to create the ROI, but we need to know the economics of that patient navigation, I think. So, maybe we need to build around what is the time to spend on that navigation, and build the economics of that navigation, so we can actually scale up that navigation program across different health systems. I think that's the economics of the navigation. Maybe testing it as a demonstration project would be great, because I like this idea, like figuring out, does it need to be in GI? Should it be in primary care, or what, you know? Okay, let me try to wrap up, because I know they're gonna want us to come back. So, we talked about a measure. We all think that's important. We think it's in progress. So, it's not... We thought it was gonna be 25, but they told Elizabeth it's gonna be 26, that it'll be ineffective. Oh, okay. 2026, yeah. So, in 2026, we can expect that. So, there could be an opportunity to partner, and I know you talked about the community hospitals. There's also this idea of outreaching to primary care societies. I actually agree with you, Jason, that I see a lot of positive fits that shouldn't be there, and I think primary care could actually do a better job of making sure the right people are getting in. There's also talk about surgery on Sundays, and working with private equity GIs. There's this idea of demonstration projects to really improve the electronic health record systems to do a better job of flagging or notifying providers when a patient has a care gap related to the follow-up, and there's the idea about infrastructure for patient navigation, perhaps testing out different scenarios, and advocating for legislation that would reimburse patient navigation. So, I think there's a lot of positive fits that could be there. I think there's a lot of positive fits

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