But we do want to take some time to do a bit of a recap of what was presented or the ideas that came up in each of the breakout groups. And then we want to talk a little bit at the end about next steps and where we go from here. So, again, my name is Fola May. I'm a gastroenterologist and health services researcher at UCLA Health. And I'll just help push us through this last section. What we'll do is we'll have one volunteer from each group come up and just give us at a very high level a summary of what you discussed, so no more than two minutes summarizing what you discussed. So, I think from Dr. Asaka's group, I don't know if you or someone else is going to be presenting. Okay. And if you want to come up here to the mic. Okay. Okay. So, our group, we were to come together with three to five patient interventions and three to five ASGE actions to increase the follow-up colonoscopy rate for uninsured and underinsured patients. So, we talked about how community health care workers and their relatability can certainly help in getting patients to follow up when they have a positive stool test. We also discussed specifically the distinction between a navigator and a community health care worker and their roles within the process. We also talked about patient interventions for PrEP, having better discussions around what PrEP looks like, what kind of options patients have around PrEP, to kind of overcome this idea of PrEP hesitancy. That was a very big discussion point for us. And then, does the patient truly feel prepared? Do they have the information that they need? What kind of myths need to be dispelled around what a colonoscopy is, what a PrEP process is? So, what could that look like? Could it be a book about what's to come? Could it be an interesting website where people can go and watch videos? Is it engaging influencers? Is it something that's broader, where materials need to be created and engage more groups around it, so kind of a broader messaging around colonoscopies? What else am I missing? I think I've got that covered. Yes? Using navigators. Yes. The use of navigators. Any questions? Very good. Okay. Thank you. Would you like to keep this? Sure. Okay. Okay. Very good. And I'm sorry. I have a question. Yes. So, using navigators, was there anything specific about using navigators? Yes. Okay. So we were talking about the distinction between the community health workers and the navigators. And our group felt that the community health workers typically tended to have cultural concordance with the groups that they were working with. Might not necessarily have a medical background at all, but there are opportunities for specialty training, like the community health education specialist. So some states are using that. The navigators needed to have more of a health systems medical background understanding, although they may not need to be physicians per se. They could be medical assistants, patient care coordinators, but people who work within health systems who understand how that works. Having somebody who's bilingual. And then really their purpose is to navigate folks specifically through that screening care continuum. Thank you. Great, I think I captured that. Okay. So the next group that we have is going to provide some ideas around provider interventions. And I think Patrice, are you gonna? Okay, perfect. We had a lot of notes, but we came up with three primary points to share with the group. First of all, most importantly, we had it as three, but then we moved it up to one, was better provider education to manage the abnormal fit. Establish, working with some type of a checklist. A managed to-do list. Whether it's insurance, a couple of things that should be on the checklist, like check your insurance, have the patient check their insurance. Make sure that they are comfortable with the prep. They know how to take the prep. And then make sure that they have transportation and they're all set to go. So you try to minimize any reason for them not to show up. So again, it was really having the education in hand to share with the patients once they have the abnormal fit. The second one was better communication for provider to the patient when they have an abnormal fit. And they must have a colonoscopy. So, like, I'm not a provider, but the question was, it's like, oh, by the way, you have a positive fit, so you're gonna have a colonoscopy and the patient gets freaked out. So there should be more of a conversation with the patient as to why they're having a colonoscopy and what can happen if they have an abnormal result come back. Just, we were really mindful of time that these physicians have, so we thought an intervention prior to having them come in, like somebody talk to them, whether it's a navigator or somebody in the office, a bilingual, would be helpful prior to even seeing the primary care come in and go through a list of things that they would have a checklist and one of them would be, oh, by the way, you're gonna have a fit, take this. And you could, if they have, if these are the results, this is what are the consequences of it. If everything comes back great, you're all set, you're clear until your next test, or somebody will contact you with information about a follow-up screening. And then the third one was offloading, offloading provider to, you know, offloading from the provider to the navigator, making sure that that navigator picks up the patient, because you have a, we were saying, making sure that the office has a list of abnormal fits, so whoever's responsible for that in the office, having a party responsible in the office to really contact these patients and make sure that they're aware that they had an abnormal fit and they need to have a colonoscopy within a 90-day window, because that seems to be the timeframe, right? I know, we're crazy, right? Ideal world, that's what we would like. But those are three things that we felt would be useful for the provider. But the biggest thing was a checklist and having somebody dedicated to, you know, following up on these abnormal fits to ensure that the patient does get screened. I didn't miss anything? I think that's great. Thank you so much, Patrice, for doing that. Can I ask a quick question? Could you talk at all about when that conversation for number two could happen? I would propose maybe we would consider before the non-invasive test is even started. Yeah, and I'll- If your result is positive, you'll need to do that. Could I also just make a request? I think we're talking about abnormal non-colonoscopy screening, not just fit. Yes, I'm going to say stool-based tests. And you're correct, this is in the context of at the time the test is given. So setting up that expectation. Okay, sorry, I yelled into the mic. The expectation, but I think we also said in our group it was pre and post, like having the conversation, like you said, at the initial visit, but also when they, if there is an abnormal coming back, that you refresh that conversation and you have that checklist so the patient is more comfortable. Multiple. Right, multiple conversations so they're aware of what could possibly, what their expectations are. I think that's part of the patient fear. And the bowel prep, of course. Yeah. I see you're doing some funny stuff. You're doing great. You know what? I'm going to hold you for one moment. We didn't get a chance to introduce you earlier. So can I do that? Yeah. Okay. Oh my god. So Dr. Coronado's been in the audience and has been an integral part of planning this and coming together with us, but we didn't get a chance to do her formal introduction earlier. So I'm going to do that briefly and then I'll let you present your ideas, okay? So Dr. Gloria Coronado is a distinguished investigator at the Mitch Greenlick Endowed, and the Mitch Greenlick Endowed Scientist for Health Disparities for the Kaiser Permanente Center for Health Research. She has developed several innovative, cost-effective interventions to improve cancer screening rates for patients who are served by community health centers. In addition, Dr. Coronado directs three, or corrects three programs that employ system-based approaches to increase colorectal cancer screening rates and follow-up in health plans and clinics in Washington, Oregon, and California. The communications resources her team has developed have been disseminated to hundreds of health systems, including all the work we did in the VA, very helpful, and community organizations across the United States. Dr. Coronado has a PhD in epidemiology from the University of Washington. I just wanted to make sure we got that in. Great, thank you. So now that you are up here. A little on the spot, right? Yeah, well now that we've introduced you. Yes, I have to say something brilliant. We'd love to hear what your team thought about health system interventions. Great, well thank you. And we had a very interactive and lively discussion. We could have talked for another hour, and I think that our, but we have some great ideas, or at least starting places for great ideas. So I'm gonna do my best to try to capture our conversation. So there was really broad support for making this a reportable measure, yet we do know that, you know, with HEDIS and UDS, we do know that that plan is in process, and I think that it's set to come out in 2026, is what? Yes? Well, yeah, that's the way it's saying. Okay, so. The earliest. The earliest. Okay, okay, so we're happy about that. In terms of informing, or educating, informing, we really wanted to educate, inform primary care providers about screening and the appropriateness of referrals. And so I think both Jason and I see a lot of records of patients that have positive fits that actually aren't appropriate for screening. And so making sure that those primary care providers are very well aware of the factors that can make a patient not an appropriate candidate for screening, we think is really important. And if there's a new measure that's coming out, it might be a nice opportunity to also inform the providers of the importance of the measure and why it's critical. We also talked about advocating for reimbursement for patient navigation, which I see is kind of a theme that it's come up in all the other groups as well. And we think that there's kind of an immediate opportunity to do that, given that there's discussions about reimbursing for cancer care, navigation for cancer care, and really expanding that to make sure it covers follow-up for abnormal cancer test results. We also talked about a couple of demonstration projects, one that would improve electronic health records to make sure that those care gaps were noticeable in the electronic health records. So we didn't want to do a best practice alert, but maybe a care gap, making sure that those electronic health records had that ability to notify providers. And then there was an interest in a demonstration project that would focus on really how you roll out patient navigation either in a statewide way or really figuring out, does this belong in primary care, or does it belong in GI, or does it belong in both? And so really kind of doing some demonstration projects to improve how patient navigation is rolled out and made efficient and effective across different regions. And then we talked a little bit about partnerships. One was with private equity GI groups to really help lift up some of the surgery on Sunday programs. Jim talked about community hospitals. I think T.R. mentioned that AMGA is already doing some work with 20 different sites, really kind of partnering with them and making sure that we're aware of their work. Chai talked about partnerships with ACOs as well as NCI and cancer centers, given that they have community outreach and education programs and perhaps other levers that we could utilize. Anything that I missed? I got the thumbs up. Okay. Anything that I missed? No? GI groups involved? GI groups with the private equity? Yeah. She got it. Yeah. She said it. Josephine distracted me. I own that. It was the dress. All right. That's fantastic. Thank you so much. So a lot of chatter, and I think what we'll do is just a few minutes for people to look at this list. I don't know if I can get it all on the same page. Oh, maybe I can. Oh, no, we have one more group. I'm so sorry. Stoney, we have one more group. Are you going to present for your group? We forgot policy intervention. I'm sorry. Policy, that's what this whole conference is. And then in the meanwhile, think about what we want to talk about after. Do you want this, Stoney? No, I think you should hear me, right? Okay. Oh, they're recording. If you stand here facing this way, then it actually will catch your voice. Perfect. We endorse the other one first, to develop the quality measure for the required colonoscopy after the positive non-colonoscopic test. And ASG's action on that would be to develop a policy brief, for NCQA probably, on the risk of not completing the screening process so it's laid out well for them, okay? Number two is increased funding of CRCPT program. And number three, work with the fight colorectal cancer to develop materials to ensure that cost sharing does not occur in a colorectal cancer screening process. And ASG would collaborate with fight colorectal cancer to make sure that material gets out to both patients and insurers, okay? And we had a great group, by the way. We have six things, but... I think I already missed one. And then we want to develop a packet to increase ongoing funding, similar to what Kentucky is doing, but more like what the Every Woman Counts or the Breast and Cervical Cancer programs are doing in all the states, where you have ongoing line-item budgets so that you do colorectal cancer screening and treatment in the uninsured and have programs in their federally-qualified health centers to not only be the uninsured, but also the insured, decrease the screening rate. So that's developed a packet to increase that. And then... And just so I understand, so the packet is to help increase funding for the underserved communities? It's... We would probably have to go to the breast lobby and find out what they did to get those statewide efforts to cover breast and cervical cancer screening. We're so far behind them, but I'm sure we can learn from them. But the idea was to make sure there's ongoing funding from your state legislator to do colorectal cancer screening. Similar to the Every Woman Counts project in California, it's got different names in different states. Okay. Okay. And then in the ASG, in their rewarding endoscopy centers, make sure that there's a criteria for doing colonoscopies in the required colonoscopy in Medicaid patients. So you have to do so many Medicaid patients to get this certain reward. I'm not sure how you would do that. But that's number six or so, I don't know. Okay, I think I missed your second. Oh. Oh, it increased funding for CRCPT program for the national program, yeah. CRCPT, yeah. What I was thinking about is, ASG designates centers of excellence. So like a health equity criteria, if you will, would be to make sure that there's some way of measuring or reporting that they're keeping access open to Medicaid colonoscopies. I don't think we can say it has to be 30% or whatever, but something that helps open that conversation and awareness that that's part of serving the community. Well, it's just to track it, but not to require them. I hope. Well, you get the reward, yeah. We didn't have time to get into. Okay, so the idea, but the idea is to establish some sort of health equity criteria for the centers of excellence. That could be one way, or the other was to leverage what we learned about in terms of making all the GI practices within a state aware of the need and make it so that everyone is ready to contribute some, to make some of their endoscopy slots available for underinsured people. Okay, anyone else that was in the room that has a comment? I wasn't in the room, but I wonder about number two, like it says a policy brief on the risk of not completing the screening process. Is that like a, what do you mean about? No, that's a strategy for number one. That's a strategy for number one. Got it, correct, the NCQA. That's what ACA, ASG can do. Yeah, that's, we didn't get to many strategies, you know. Got it, okay, thank you. One of the things we talked about in this quality metric, at least have some social determinants in there so you can see if, you know, if you're uninsured, if you're poor, you know, if there's a difference in your outcomes. That's the plan for the measure, at least race ethnicity. So that's gonna be required in most measures. So I know, maybe. Goes beyond race and ethnicity. I agree, I agree with you, but I know at least that's as much as I know that they're planning to have a requirement of stratification by race and ethnicity. I think it should be more. Maybe it will be. It's good reading to read the CMS pro-eclocancer screening guidelines. It's fairly bare bones about how you develop the measure, what's in the denominator, what's in the numerator, and which tests, and they don't get into that sort of thing in developing the measure. That would be more what we would do with it once it's measured. Any other, anyone else? Yeah, TR. Back on this idea of the endoscopy unit recognition program that the ASGE runs, that provides a potential lever for a lot of these things. In our meeting, we were talking about how did ADR become so well accepted as a quality measure? And that's actually a big part of the EURP is everyone has to report their ADR and be above whatever threshold. So whether it's health equity angle on that, having some or commitment of resources to follow up abnormal stool-based testing, or there may be, obviously we need more time to kind of probably work that, and I'm sure that's just because we say it in this room doesn't mean that's gonna happen exactly that way. But just put this, try and figure out a way to fold this into that to make that part of running a high-quality endoscopy unit is kind of being part, either are you partnering with your primary care doctors to assist your positive stool-based test patients to come in to get their colonoscopy? Are you handling, what are you doing about equity? You know, those sorts of things. Yeah, so for example, they have the 2012 and 2015 document on colonoscopy quality indicators. So could this be, could there be a quality indicator about equity? Document's actually being written right now. Yeah, so that would be a perfect opportunity to include in these. It may be, the book, the ink may be dry on that, I'm not sure. Thanks so much. Thank you, Drew. So I, you know, I thank you so much everyone who provided the summaries. What do we think of these? I mean, we started this conversation. Any other thoughts? Are there some we wanna highlight as top priorities? I mean, the measure came up a few times. I think that's one we wanna highlight. Actually, I don't, I can't highlight on here, but if someone wants to keep a list. Are we recording this? Are there others? Yeah. No, just a quick, from our group, we also talked about partnership with the primary care societies, because an important discussion point is that there's not a clear owner of this part of how it moves from one place to the other, right? Because it could be primary care, it could be GI. This is for the health, your health systems? Health system-based one, yes. I think. You can add it to number six. Yeah, at number six, yes. I think that should be where it says GI groups, ACOs. I think primary care societies should be there as well. Yeah, I think Gloria said it, but it didn't make it into your notes, but the AMGA work that's also happening. We're getting 20 demonstration projects to kind of think about how to evaluate this. Trying to say type slow, Tiara? AM, well, no. I would never say that. You're doing better than most people. There's a lot happening. There's a lot going on. There's a lot. No, I literally cannot type. What am I saying about AMGA? She's another partner. You can incorporate me into six. Oh, okay. Yeah, yeah. Yeah, you're typing pretty slow. And I think the other piece around this is also, is it a scorecard that we're talking about? It's a health equity CRC scorecard that we developed around, because we're looking at multiple measures around this process. All right, I keep my piece. Oh my gosh. Okay, what else should we add to the list? What's missing? Because this is gonna help us determine our next steps. And Ed. Oh, sorry. Sorry, yes, please. No, it's okay. Maybe this is two soapbox issues, but one is I think in the provider education piece, I really think we have to emphasize the issue of mortality and the expected one in three, one in four people with an advanced polyp, like the opportunity for prevention and the liability issue, which it was my intent before the meeting to try and collate some of this information that's out there about abnormal cancer screening tests and how much liability, how much that accounts for malpractice and liability for primary care docs. But I couldn't find something on that. But I think that's something that they're not aware of what they're exposing themselves to. And the second is, and this is definitely a soapboxing, is related to in our documents around terminology. Like I strongly feel we should be talking about abnormal tests, not positive tests. You know, I'm positive about the test. I think another thing that came up in our group is I think we're really struggling with the clunkiness of how in a succinct way do you talk about the follow-up colonoscopy? You know, don't call it diagnostic, don't call it follow-up. How do you still call it screening? And so, you know, do we call it screening secondary to abnormal fit or, you know, but we need some kind of solution there. I would use the term required. Just use. I would say abnormal fit follow-up, but then you're using fit. So abnormal. Wouldn't use follow-up. But this, we have to solve this terminology issue. Colonoscopies are used. The U.S. Preventive Services Task Force uses the term required, and that's what swayed all these departments. Would you call it required follow-on screening colonoscopy? Or just the required colonoscopy. It's required. It's required. Completion, yeah. It's a completion. Screening completion colonoscopy. Yes. Required. But, you know, there's so many different ways, but I think we have to. Not use follow-up. It'll help if there's an expectation that the average colonoscopist knows, in the same way they know how to distinguish between average risk screening colonoscopy and a surveillance colonoscopy for polyps, that they understand what we need to do to help address this issue of cost sharing and clarity around why the scope is being done. So the way I do it when I make the request is I say screening colonoscopy for a follow-up of abnormal blank. So having sort of advocated for that language, I think the required piece did help CMS to do it, but I'm not sure how we'll personalize it. So I do think that one thing we need to think about is how do we map out that process? You know, so we talked about a lot of these, but these studies were mapped out into a process that can get implemented, because that's what is gonna show up where the gaps are. I think there's a lot of great fodder from this meeting for the various ASG committees. You know, we have committees for education, we have health policy committees, and so I think the report from this meeting today can go to those committees, and they can sink their teeth into it with patient education materials, provider education materials. I don't know what it would take to partner with, you know, American College of Physicians, family physicians, other primary care groups to talk to them about, you know, this is an area we're concerned about. In a couple of years, there's gonna be a quality metric coming out that's gonna impact your people, you know, and so we need to work together on getting messaging out. I think there's great opportunities for the committees to further develop this. I just wanna add a thought in the mix. This is being a bit more of an outsider around this, is, you know, for ASGE as a whole, essentially, what is your brand in this conversation? I think about the equivalent in pediatrics, where it's like, oh, well, the American Academy of Pediatrics says this, and that level of credibility is like, okay, we've heard the definitive, so what is ASGE's position in that? And I think one way to potentially amplify the brand in that is, I was recently part of a cancer work group through Blue Cross Blue Shield Association or consortium, rather, and one of the things we were looking at is, because all the Blue's plans operate independently, but sort of work together in some ways, that we were thinking about what if we did a much broader cancer screening initiative of some sort, but part of it was like, you know, there's so many other things to deal with, and it was gonna take a lot of resources to pull that together, but then I was sort of thinking about what if it's a partnership, potentially, with ASGE, let's say, to really bring the messaging forward? Okay. Yeah, well, I think we're gonna bring this home, and so I think we have a lot of great ideas here, and I'm gonna invite Dr. Christie up in a minute to just kind of talk about where we go from here, but I think what we have demonstrated today is that this is a very complicated problem. This isn't an easy one intervention solution that's gonna solve this problem of follow-up after abnormal stool-based screening, and I think we've also emphasized today that the problem is multi-level, where we have challenges at the patient level, at the provider level. The health systems aren't set up in a way that is best positioned to have these patients follow up in a timely manner, and there are policy challenges, so whatever interventions we come up with are really gonna have to tackle this problem at all of those levels as well, requiring us to be thoughtful in how we address this and how we roll out those interventions. So I'm gonna ask Dr. Christie to come up now just to wrap things up and tell us where we go from here. Thank you very much. Thank you. Thank you, Paula. That was excellent. Thanks, everybody. And this actually, you did a great job typing, by the way. It makes everybody's job easier, and Deb McBride back here thanks you as well. She's our writer, but yeah, this has been an incredible day. At least I can say for me personally, it far exceeded our expectations. Just the level of expertise and engagement and compassion and passion for this work is just, you can feel it, and I'm just happy to be a part of it and be able to, like I said at the beginning of the day, use my platform in this organization to move this work forward along with you. As far as next steps, so we're gonna take all of this back, including the recording of, good luck, Deb, it's what, nine hours? To pull it all together. Our goal is to create a, I guess it could be a white paper, it could be a summit outcomes paper, but publish that in one of the journals, and then Deb and I were talking earlier, just something we could send out to our members that may be a little shorter, but something they can kinda know what we did today and what we're doing going forward. And then we're also gonna, the advisory council's gonna regroup, synthesize and analyze some of this information to help inform our processes and workflows going forward. We are going to finalize the sites with which we're going to work with to execute much of what we talked about today. And we'll be reaching out to many of you as well in follow-up to see how we can continue to partner to execute on this project. But we also want to have you reach out to us if there's anything we can do. I love the EURP suggestions, anything we can do to help support our patients, support our members, and then perhaps they can help support you in your work to get colon cancer screening rates and completion rates up. So again, we want this to be interactive and collaborative, and so we really wanna help move this work along with you. And then we were talking about perhaps doing like a summit update or a regroup, maybe it's virtual, we'll see if we have time and money to bring everybody together again. But this is, and then the timing of that, but we'll certainly keep everyone updated. But we wanna keep this conversation going because obviously if it was easy, we would've figured it out 50 years ago or even earlier. So any last questions? I don't know if LaKeisha or Tom or Donald had anything or any of the advisory council. But yeah, again, I wanna thank everybody for your time today. Thank ASGE staff for all of the work to host us and make this happen. And then Tom, I mean, you guys have all heard from Tom at least 10 times, so I don't know how he does it, but just that communication. Right? But yeah, so he's a really good, great resource for us. So if there's anything you wanna share, any other questions, please reach out to any of us. And then I don't think if you met, Donald's our CEO for ASGE. And LaKeisha's our chief policy officer and member engagement officer that many of you all have met. So again, thank you. Again, I'm grateful that, oh, and then, sorry, Josephine, to your stance, I don't know if we have a firm stance on where we are in this. And as I've talked with TR and some other folks today, it's evolving, right? So if you had said this, asked that question 10 years ago, said colonoscopy, colonoscopy, we still believe colonoscopy is a great test and probably the best test, right? But as we've all said, the best test is the one that gets done, right? So we just have to make sure people get screened and along that follow-up. So that's, so it's evolving, okay? That's where we are. But thank you, everybody, and appreciate you. All right. Thank you.

Fola May

breakout groups

patient education

colonoscopy

provider interventions

policy interventions

collaboration