apologize to everyone for slipping out early ahead of time. You have to give us two good ideas in. Yeah. Great. Well, I'm Molly McDonald. I'm the Director of Advocacy with Fight for Our Future. Alpha Banks, Private Practice, Maryland. So much more than that from your presentation. Brian Jacobson. I'm at Mass General Hospital in Watson. Yes, right around the corner. Donald Palmzada, CEO of ASG. Ophelia Bonta. I'm a Policy Consultant for ASG. I'm the General Counsel for Med Chi, the Maryland State Medical Society. And I'm Sonny Anderson. I'm President of the California Cervical Cancer Coalition. Basically, what I do, we're just sort of saying what we do. Perfect. Go ahead. You're up. I'm the Chief Commercial Officer for Braintree Stella. Okay. Heidi Bosling. On my own. Okay, let me read. I like going around the room because otherwise the same people will talk. So identifying rank. One more. They were going to describe, but I don't think we did. I don't know. Do you want to write on the board there for us? And how's your handwriting? Is it okay? You're not a physician. You got it. So here's our task. Identify and rank the top three to five key political policy interventions and the top three ACS actions and key discussion points to share with a full group. Increase the follow-up colonoscopy rate for the uninsured, underinsured patients who have a positive stool test. Okay. And so we'll start once again with Molly. And so which one do you give one, but I everyone's I'm going to have everyone get everyone's idea, please. Well, I would say one potential opportunity is increased funding for this year. Program. Being able to expand that to additional states and be able to support additional direct screening services. One way that essentially does that. So you're going to talk about a policy intervention, which has a good example of intervention. And then we have to go through the ACS actions and key discussion points to implement the policy. And we're, these are policy interventions that we're going to talk about. Increase the follow-up colonoscopy in the under and uninsured. Okay. Okay. I was going to say increase collaboration between community-based partners. Okay. Could you give an example of that? We'll, we'll put that down a little. I would say that an example is probably. For example, the health systems that are there that are in the community. Most of them tend to have a closed network within their network, but there are patients who would benefit from services within each of those different systems. So there has to be one that has to be, but it would be beneficial. Yeah. To have a close network within their network. Okay. So there has to be one that has to be, but it would be beneficial. Yeah. To have a little bit more collaboration of where patients would not be not restricted, but kind of could float across those platforms and get services. Okay. You're up. So. I was thinking about. State level. And if there are advocacy packages where we can standardize like a toolkit. That people in individual states can go to for their own state regulators and legislators to improve or clarify coverage decisions. So that would be more standardized. And in particular, is that what the ICC is working on? The making sure they don't have the cost sharing for the required colonoscopy. By the way, I think we should always say the colonoscopy after a positive non-colonoscopic test is the required colonoscopy, not the follow-up colonoscopy, not the anything else, just the required colonoscopy. Yeah. I think of it as stage two, the two-step process. Yeah. Screening. Yeah. Yeah. So it's that as one of the pieces, but as a toolkit also, like, for example, bringing up the idea of people don't even know, and there's some of the insurers themselves don't know. So how do you just publicize that? Use what you guys have is amazing. And then, but are there other things that we add to that? It's sort of the full picture of colorectal cancer screening, not just. Right. Right. So that there's a single vernacular. Everyone understands what are the regulations actually say. And so that you can, you could go to your insurer, your local insurers, but also if you're looking for discussions with your local Medicaid, whatever it is in your state, if it's not covered, how do you get things covered? What are the things that we can do? All right. I would say that just to piggyback on the increased funding, I would say it's more of a sustainable source of funding through the state legislature. And I think that is really what's lacking because you've already got the data. You've already got a lot of information, the advocacy pieces and everything else. The thing that's been lacking on the policy side, and I think that's what we've been missing is the data. So I would kind of amend yours to sustainable funding piece versus just an increased funding. Just the CDC on this. State funding. You're talking about the state. You're talking about the federal. Right. Yeah. But state funding, that would be, I would love to see that. Let me see if this is what you're saying. There was one presentation where they took some of the tobacco funds. Right. And they put it towards colon cancer. Right. And in California, it all went to breast and cervical. Right. And none to colon cancer. So I guess the policy would be to see if, are you thinking something like the, breast and cervical cancer program that rolled out a bunch of states where they covered everyone? And everybody was focused on that tobacco money, right? Each state kind of determined what they were going to do with that tobacco. Yeah. In Georgia, they went a different route than say, California. Right. So this would be a separate line item in the state budget. Virginia. Like they did. So that's what. So if you think about it, we were able to do pilot projects in Georgia, back like 10 years ago. And it was getting that money into the budget. Because it's a big budget, right? If you throw a million dollars in there, a million dollars is like around a million dollars. So it's, that's where I think. And that's what we've kind of talked about. So I'm kind of, this has been discussed internally, but that's what I think one of the big policy issues is. That's the policy intervention. And that would be a ongoing or, and Kentucky, you saw that their money for their free colonoscopies is an annual. Correct. Or they have to pass the law each time or the distribution. So you would, you would want something that set up something like every woman counts where every woman counts. Where it's continually funded. Correct. Yeah. It's just once you get the line item and then do you need more? I'm sure it's still on, but once it's a line item, then it gets easier to deal with. Perfect for colonoscopies. Yeah. Because, because if not, then like I know in Georgia, because I'm originally from Georgia where when you start to go after tobacco money, then everybody has their own piece in the tobacco money. So then you're going to be fighting advocates and everybody else. Right. So. You don't want to have to fight them and then fight all the other people that are opposed to it. Anyone fiscal conservatives, whatever. Right. So, so part of it is to kind of do something a little bit different, but you already have the data. And if you have the data and can show what savings it is to the state with this program, that's the opportunity. Okay. And as you hear these, we're thinking about what ASG can do to help. Implement something like that. And for example, as I hear this, I think ASG could provide, we all talk about how colon cancer screening can save money. There's only one article I know of. It's out of the group from the Netherlands. Iris. Her last name is very long. Anyway, that article showed that 50% of the people who have colon cancer, screening actually put money back in the system, but that's an old article and colonoscopy screening costs a little bit, but for your life saved, it was very low. It was very effective, but the fit testing actually put money back and we use that to get this copay thing. Law passed in California. So it would be one of the strategies for ACS for that one would be, and we'll go around for the strategies after we get through this would be to develop a showing the financial benefit of providing the screen. And we haven't had a good paper in a long time that I know of. Does anyone else know why? Anyway. Okay. And I think the cost effectiveness analysis seemed pretty. Yeah. Of course it always goes into the assumptions, but, you know, pretty consistently they show that they can be cost savings from the population or. Oh, if you just look at a population, not a screening probe, but I would even say we should try to get, or have someone repeat the work that she did. What's her last name? Yeah, that's it. And the show that some of the screening actually puts money back into the healthcare system. So I think that's a good. Anyway. Good. Thank you. All right. You're up. This may be a strategy. I don't know, but just thinking of it from the quality piece, some of the most effective ways I've seen the needle get moved is developing one or more measures and getting it into, I don't know that it would be CMS, but perhaps partnering with CDC or other groups. And I think you can start looking at your cost savings too. You can link it with the quality. It has a stronger message. So I would, that would be a strategy to develop one or more measures and start seminating to test it, get it in the Medicaid court. That's a few other things. Are you, are you talking about the measure that, that Samir talks about the measure of what we're discussing? Yeah. Of how many, yeah. I think that's a great. Priority. Right. Yeah. And be thinking about this. Samir presented two options and be thinking about which option. You would think we should be pushing. Bardo. You can write down what you think. You have to tell us. The quality measure was where I see. That's yeah. Yeah. That's. Okay. Okay. Yes. Yes. So at the top of my list was measures. And. Sort of. A couple of things. Thinking about. The fact that the. There's something. For the FQHCs around screening. I mean, obviously it's really challenging to do kind of the revamped measure. Making sure that there's. After a positive test. If, if there are referral issues. To GIs. That being a resource. Issue. One of the other things that. I'm not sure. There's a real. Policy. That stuck out. To me. With the CDC program. Or funding in there. And for the. For the screening component. Is. To take the Medicare. For those full follow-up. And whether or not there's any flexibility there. To. Untie that. That requirement. We're needed. And then the other is. You know, more general. That is. You know, Medicaid expenses. She actually gave us three. I think. Which is fine. But. I think. It's. It's a much broader. Policy issue. She actually gave us. Three. I think. Which is fine. I think. It's a much broader. Policy issue. So if you broke that little extra thing, I hear the expert here, but I wonder if there's also something in terms of, I know that there's measures that are of that nature, but I wonder if it is something that we could use as a model. And I'll apologize, but I have to move this, I'm sorry to ask that over again. I heard, I think she endorsed again, the quality measure of the completed colonoscopy, the required colonoscopy after a positive fecal test. And then she also mentioned the, what was the other? The CDC screening and the inability to find, oh, there, you've got that. Okay, she mentioned one that I'm gonna mention, so I will go ahead, please. The only thing that I would add is also, I guess, a piggyback, and that's on Dr. Banks's suggestion about collaboration in the community and seeing how many states we can get to collaborate between different EMR modes. For example, in Maryland, we have CRISP that almost, I mean, all of the large hospital systems are on, and it's really fabulous because it can tell Dr. Banks, like, hey, there's a positive, it could tell Dr. Banks, it's a positive, or hey, my patient has gone to the hospital, what's going on? And I feel like some other states, and of course I don't have extensive experience, that just having that communication between the providers would be really critical. And ones that aren't in the same healthcare system is really easy when you're all like in the same healthcare system, talking about outside. Okay. Okay, I endorse the new measure of completion, but I'd also like to propose the policy of providing health in the states that haven't expanded Medicaid. If that may be already up there, you got that? So I like those too, okay. I have a question, if I may. Would it be like, this is totally different, like with the abortion issue now, some states don't offer it, so patients can go to other states and get those services. So for patients who are in the non-Medicaid expansion, would they be able to cross the border and go to a state? Is it possible that there could be some type of rescue that those patients could go there and get those colonoscopies? That's an interesting question, and I should know, but I don't. Your Medicaid eligibility, it's the federally qualified poverty level is one of the, and you're residents, so they would have to reside in that state to get the state because the Medicaid systems is a state system. It's not- Right. The expansion state, in theory, we could pass it on saying we provide reciprocity for our neighbor state, but it's not an expansion. I don't know if they would do that, but. Patients do travel. You know, I remember when I was in Miami to be listed on transplant, you needed to be a Dade County resident. So people would come, and you only had to be there for 30 days. So people would come and just couch surf for 30 days and then come to the emergency room. Wow. And so I was just thinking, because if we're talking cancer prevention, eventually they're gonna show us some of this. Okay. So Mayor, it's your turn. Okay. Well, I, you know, Medicaid expansion, definitely the quality metric, just to add something that ASDE could use. I've been trying to think about like this issue of like not taking Medicaid colonoscopies is really, you know, bothering me and Medicare. So I'm wondering if, you know, ASDE will, you know, accredit an endoscopy unit as a center of excellence. And maybe one of the criteria used to be some bar or some engagement. Some, I mean, I understand that most practices can't have, you know, a payer mix where 50% is Medicare or Medicaid, but there's some amount or some absolute number of patients, some engagement that I think we might be able to promote as a best practice and as something that sits. And I think this is where I think this idea of the, I don't know if it's the links to care or the community collaborative is interesting because I feel like at least when I think about San Diego, everyone's kind of doing their own thing and they're not, but I wonder about if they knew that each of their friends or colleagues or competing practices has signed a pledge that, you know, I'm going to do at least 10 a month or I'm going to pick a number. And if we recognize those that met the metric, it might sort of just encourage that willing behavior because again, the numbers that were asked before may not really be that high, you know. No, it's not anymore, but I don't think they, so how do we get ASDE members to realize that what they're doing to make incremental extra profit, it's really damaging to their communities. And just by doing something that they can do in their sleep, a couple of extra times a month, right, a lower rate, they could really help a lot. So it's sort of like an organizational policy thing. How can we work on that? So let me make sure I remember. You're saying that an incentive for gastro GI practices, procedure practices, surgeons, I guess, the GI should be incentivized to treat Medicaid patients, to have a certain number of Medicaid patients. In a way, so I guess what I think about as from a policy, from an ASG policy standpoint, what could be the opportunities for them to, if we see one of the issues as not enough people are willing to accept Medicaid rate colonoscopies, what could be some ASG policy solutions? So could it be going to, you know, again, giving when they give out the badge of an excellent endoscopy center that this is part of it, could it be recognizing or encouraging these collaboratives where people would talk about what the issue is, what the need is in their local area and what each of the GI practices is willing to do to help address it? It's mushy. I mean, we have to sort of think about what the strategies would be, but I feel like there's, I was struck by the presentation where they're talking about, they were, I think in South Carolina, was it in South Carolina or Georgia where they were able to get all of these GIs to, you know, commit to being willing to do that. So, you know, just thinking about how did that happen and how ASG could promote some things like that. Okay. You're up. Now I'll preface my comments with a statement and that is that the work that you do often shapes your view of the world. And I'm one of the few people that just work and think about battle preps all day long. So take that with a grain of salt, but by way of a policy issue, I think it's very interesting if you look from the patient perspective and that is that they report multiple surveys that the biggest current to a colonoscopy and also the worst part of the colonoscopy that they report on isn't the procedure, it's the prep. Right? And I think everybody accepts that. And what's interesting, there's a policy issue that already exists. It was part of the Affordable Care Act and CMS clarified it as well, that a prep should be provided at zero cost to the patient. If you had to guess what percent of patients actually pay zero, what do you think it would be? You can just guess in your head. Zero. It's around 20% that pay zero, right? And then what we also see being driven is that the preps that are offered, the biggest prep that you use is an unapproved prep that is least effective, but it's part of this whole policy issue and what's being covered. The second biggest is the one that is the biggest current preps and has really the lowest patient satisfaction. So there's one policy issue around the preps and I think if we could clarify to offer patient choice, it could change that dynamic around what is the biggest barrier. Okay. What I'd like to do now, I think we have, let's talk about the ones we wanna prioritize. And Eric, I'm gonna go around and go ahead. I'm sorry to interrupt, Sonya. I forgot something that I think is important from a policy standpoint, which is the issue of who pays for the care coordination or navigation. And I know that right now there's a public comment about a Medicare policy that would cover patient navigation for chronic care or for people with diagnosed cancer, but it doesn't include the process of if a person has an abnormal test. So this issue from a policy standpoint could be relevant because there's a gap in who we've shown that navigation can help, but there's a gap in who pays for it and how we get it paid for. Okay. So I think we have, I'm gonna go around. We'll start with Molly and you give your highest priority of the ones you've heard can be yours, obviously. And once we get five or six or seven and we seem to hit the big ones, then we'll sort of figure out how to sort them. We have to come up with about five. So what's yours? I really like your suggestion around potentially including in an accreditation or in a gold star, some sort of, you need to accept a certain amount of Medicaid patients. I think like something like that to get at the sort of backlog and access issue is something that obviously doesn't take legislative action, which is- And it's not under the control of ASG, which is always want to keep that in mind. Right, exactly. So in terms of something that could be done quickly and I think would have an impact, I really like that. Okay. Let me clarify, I actually started with strategies and we're on the second page, first page, but I just need one- Right. Policy. But we're gonna hit the policies and get to our five top ones, then we'll have to develop strategies for them. Okay, well, it's okay. I view ASG promoting this best practice as a strategy as opposed to policy. So are we voting on both or should I move it to the policy page? The way I heard it was a policy to make it where to achieve a certain reward, you have to do so many Medicaid patients. So she liked that one. Carol? I got rid of the policy of really coupling and tracking knowing how many of those patients who tested positive go on to completion. And I like you're saying to not call it a follow-up because it's a reasonable follow-up, but to change the language. I think that policy is exactly what you need. So an NCQA measure of colonoscopies after a positive not to stop the test. Just real quick, I'm sorry to interrupt. Jennifer, Dr. Christie wants to take a picture downstairs and when people kind of taken off, she asked if we could wrap this up in about like four minutes. Four minutes? Four minutes. So I'm confident you can knock out of yours in five minutes. We've got two. So if you're looking for the top, like the quality measure, there's like so many heads nodding. Yeah, I made that. That's like the given. Part of what colors my thoughts is also, I also am familiar with how ASGE works and things about advocacy. So the CCR, what is the CCR? CRCCP. Thank you. CRCCP. I think now it's just Soviet Union. That's increased funding. That's increased funding. Or just continuing to fund it. That is something that from an advocacy standpoint, we have brought to Congress for you that you have advocated for. Something we should continue to do and highlight because it's- Give me the letters. It's the funding of the- CRCCP. Yeah. Okay. And then develop quality measure. You know, the screening colonoscopy issue could just be addressed through definitions. Like we define screening colonoscopy, average of screening is someone who is asymptomatic, age eligible, no family history. And we allow for that to include people who've had an abnormal screening test, who meet those criteria and have an abnormal screening test. So that's just the definition. And we just start to call it a screening colonoscopy and encourage everyone to call it back. Yeah, I feel like it was like a formalized, not overly formalized, but some sort of formalized process around that. Like, I don't know if that's maybe a role for NTCRT or for the GI societies together or something, but to come out with like a document that can be referenced to say like, we are on the agreements that this is what screening means. This is the process and this is what it's inclusive of, I think could be helpful to just have the- We haven't actually started saying that. Well, so one of the ways we've started to do this, but it's just, you're right, it should be just set in stone is there's one stage and there's two stage screenings. One stage, you get a colonoscopy. Two stage screening is you do something first and if it's positive, it's a colonoscopy. And either one, it's that screening, it just is a one stage screening test or a two stage screening test. And there's a lot of, if you look at U.S. Preventative Services Task Force, there's other screenings that are one stage or two stage. I forget, like syphilis, I think it's still like a, do the RPR and then do this as positive. That's considered the screening. We're just changing the vernacular. Yeah, but no question, the U.S. Preventative Services Task Force on their latest thing made it absolutely clear that colorectal cancer screening is a combination, they actually use that word, combination of screening tests, not just one. So they said, so that's actually what got all this, what made the departments change their guidance and so on. The one thing I would add- One on the, go ahead. Oh, I'm sorry, just to follow up on Fig's point about perhaps that there was a report that just came out from the consumers to the National Association of Insurance Commissioners. So it's all the insurance commissioners in the States come together under NAIC. They put out model legislation and all this. They identified three or four areas, smoking cessation, HIV, drugs, a couple of things. One of them was the PrEP. And they said that there's inconsistency in the know that patients will shy away from getting colonoscopies because of the PrEP. So some insurance companies cover all PrEPs. Some just do one, United and stuff like that. So I think that, and it has an impact on all that. So as you look at that report that just came out, and if we, that's just something to kind of keep in the back of your mind as well, that the PrEP portion is a big issue, as well as this is a program. You want to make sure that everything is in place. One last thing. What funding stream, I'll put that down. It's number six. Use your policy. State funding. A little bit different than the feds. But the AFG could develop a packet. Packet to increase. Yeah. State funding. Correct. A ongoing. Yep.

follow-up colonoscopy rate

uninsured patients

positive stool tests

increased funding

patient navigation

screening colonoscopies

state funding stream