Okay, well, let me start with a question for Dr. Sutton. If someone wanted to replicate what you're doing, what would you suggest? So I think that Stoney gave a really good, you know, description of the details. And after you hang up the phone with that enthusiastic friend, you have to look around and say, what do I have more of next? And in replicating this in a couple of cities, we've come to see the pros and cons of both approaches. We've come to see what it means to have a hospital partner in your pocket first. And so then you can, you have access to the resources that are outlined in MOUs. We will gladly share any of those types of MOUs or documents with you. But then you really do have to get a primary care referral source on board, you know, doctors to scope, surgeons, gastroenterologists to scope the patients. And that can take a little longer, that can be a little slower. But if you have, you know, I think as we really did in Louisville, if you have gastroenterologists, surgeons, those are, you know, who are ready to scope, you have a primary referral service, then you got to get the CMO on board. And so they're going to have a lot of questions, a lot of which I've answered many, many times. And so typically, like if somebody is going to a CMO for the first time, I will either offer to do sort of a practice, you know, meeting with them just to kind of share all of those questions that we get. How do we keep track of how much our donation total is? You know, how did you get to that 179,000? We use a little circular billing approach. You know, how do we insure or cover from a malpractice insurance standpoint the providers for that day or that event? Now we are an FTCA covered entity. We have a policy by the federal government. We've previously also used one that looks more typical to hospitals such as, you know, term limits and tail. So we've done both of those before. But these are the kind of questions that you could ask. Both approaches can work. It's just starting, you know, with what you have got more of. Thanks. Do you think, are you looking to franchise out more sites or should people do their own? No. Happy to help. Like you can borrow the name. You can use all of our paperwork, our documents. We'll come to the meetings with you. We love it. All right. Yes, Amir. This has been super interesting. And I feel this, the challenge of the competing needs and priorities, it seems like, you know, obvious in Medicaid non-expansion states that, you know, we should be doing everything possible to try to get expansion done because then the bulk of, or a large bulk of uninsured might have access to them. And we, you know, will continue to need some pathways for people who remain uninsured to get there. And I'm just curious what the panel thinks about that, these sort of competing risks because so much energy can go into one or both. And then I think on top of this, the issue that I think has been alluded to a little bit today is that you get the Medicaid expansion, but even then, you know, they're treated as underinsured patients and, you know, does it really get them access? So how, what's the strategy for addressing that issue? I've been in both states, so I'll wait. Well, I think one of the strategies, the integrated model where you can continue to get some colonoscopies for the uninsured is important. The Super Saturday model, they're still doing it. Operation Access will also help you set up a program. But it's interesting, when colon cancer is diagnosed in California the way the emergency Medi-Cal statute is written, it has to actually be an emergency. So if you come in and you're obstructed and you're uninsured from a colon cancer, you can be insured. If you come in and are bleeding from the colon cancer enough to be admitted, you can be insured. But otherwise, if it's found on a screening and it's asymptomatic, you have to do through either community care, and many of the hospitals in San Diego County are doing this now, Scripps does it, Sharp has not done it yet, and you can do that. The other thing that Operation Access is doing is PURCOL, P-U-R-C-O-L, Persons Residing Under Color of Law, and that means if you're undocumented, you can still, and you have a cancer, you can apply for Medi-Cal. I have no experience with that, but Operation Access does. That's how they handle their uninsured patients in Northern California. It's a problem. We've got to get rid of the uninsured, and I think Samir's point on helping the non-expansion states, get them all the support we can, I mean, Whitney Jones did it, I mean, most of the non-expansion states, if you read on my slide that had the map, that's the Kaiser Family Foundation, and they'll go through the history of each state that isn't expanded, and they've tried, and they've done everything, but they're still not expanded because usually it's either the Republican legislature or the Republican governor vetoes it or adds work requirements to it, so the federal government won't allow it, so anyway, you can talk about it. Yeah, one of the things I did with the American Cancer Society and Dr. Brooks and others is we did this Links to Care, where we actually had the convening power of the ACS and several of the GI societies, and we, for example, went to Yale and said, you know, you have a community health center over there that can't get screening done, and then you had the ability to bring the C-suite in, and then you were able to kind of do due diligence, you know, it's not an infinite number of scopes you have to do. We did that in Beaufort, South Carolina, and linked those with the Hilton Head GI docs. We did that in Minnesota, so that actually never was published, and it probably should be. We use that Links to Care model, and we found that you can actually, you know, we don't create colon cancer, it's there, the COC hospitals, and they're a key player, the health systems have tremendous power because they give you that backside care and that, you know, most of them have an open emergency room that will get it anyway. That colonoscopy calculator can actually tell you how many you're going to have and what you can save, so I think if you could figure a way to do this convening, you know, like the state of Georgia, you know, we would meet with the community hospital system, the big systems come together, and the other powerful thing you have, we haven't talked enough about, is the power of that UDS system. Nobody else fully and transparently reports like they do. We're getting a lot of attention at community health centers, so we've got the spotlight on it, but with the spotlight comes the searchlight. Somebody's going to say, why are you guys at 43%, you know, and a lot of it has to do with some of the challenges you have there, so I think building systems, you know, using things like Links to Care models, a way to construct these systems, you know, doing the due diligence, there's an argument that can be made, and the other thing that I'm so impressed by is the willingness of, like, the GI guys I see in this group all say, hey, we're willing to give our damn time. You know, we've got plenty of examples, so they're not the difficult one, but you have a lot more clout in the system, the big producers do. I was chairman of the Board of Regional Hospital, you know, cardiologists, gastroenterologists, the cancer docs, they all get a lot of attention because you're revenue generators, and what you say is they generate a lot of revenue. Can't we make certain that we don't create health inequities? So I think that that's a strategy that, you know, this organization has to think about in the two pilot states you're doing. Thanks. We have a question from Dr. Joseph. Yeah, this is more of a comment. So I think it's important to point out that the vast majority of people who have not been screened actually have insurance. The inverse is also true, right? So when you look at the uninsured, which is a different denominator, most of them have not been screened. So it's both at the same time. So I think that's part of the conundrum we've had at CDC is trying to figure out what is it that we're actually trying to accomplish. If you want to maximize impact, you have to go after the insured. If your goal is to reach the uninsured, understand your impact may be smaller depending on what population you're working with, right? So I think the conundrum always for us, if we're trying to go after impact because, you know, people way above us like to know that they, you know, like to have something to show for all the dollars they invested, how do you do that without making bigger disparities by leaving the uninsured behind? I think that's a very good point. And Dr. Joseph and I serve on a task force on trying to increase screening through the president's Moonshot initiative. And, you know, the Moonshot goal is to reduce cancer mortality by 50% over the next 25 years. And you know, NASA is on board NCI, and NASA astronauts are talking about doing public service announcements on colon cancer screening. So I think we need to do more work to get the message out for all Americans. But I think that's a very important point you make. And whenever we negotiate, we say two-thirds of our patients are insured. So it's not like, you know, it's all gimme's. We just need to have a side thing. It means doing fit on those and colonoscopy on those. So I do think there's an argument that you point out there is important to develop those relationships. Yes, Jake. Just plain devil's advocate here. And I think the point about volunteerism is important. People want to volunteer, and I think it gives them that sense of purpose in the system. What we experience, and I'm sure many of you experience, if not all of us, is the post-COVID workforce challenges and even bottom-line challenges. And so we're just curious the potential impact of that in hospitals' willingness or practices' willingness to donate time and resources of their typical schedule of cases to this versus the Saturday events, which people would volunteer for because people like to do stuff like that. Well, I think the slide I showed from Operation Access, which is by far the biggest donated care for the uninsured in California, and maybe the biggest in the country, COVID decreased their numbers and also made them shift their model. They needed, they couldn't do the super Saturdays where people came in. They could integrate into practices, so they went to mainly integrated donated care away from the super Saturday. They're still doing, on that slide, about 20% super Saturdays, but that means 80%. They go to a clinic, as was mentioned, the gastroenterologist say, well, I'll donate one colonoscopy every two weeks. You can book into my regular schedule, and they do that in someone that's uninsured. Something that I noticed in my practice, especially with the ASC portion, I'm sorry, especially with the ASC portion, was that because of the nursing shortage, we had to be flexible with our endoscopy days, so we actually started scheduling on a Saturday, and what we found was interesting, the rate on Saturday was 100% show rate, where the people, the insured population, they have a ride. They have time. They're not worried about this person who's driving them has to go and do something else. The patients loved it, and the staff also, surprisingly, really enjoyed it as well. Kentucky bounced back with more weekend dates, and we also experienced just a massive slowdown during the pandemic, but since coming back and getting more online, our hospital partners there have said, we'd love to have something on the weekend, and a part of it, and I think we produced this data at one point, is that altruism, that feeling of volunteerism, we ask people, you're doing your same job, do you enjoy this day less than, same as, more than, overwhelmingly enjoyed that day more than for the same job. The other piece that you actually, that the hospital lawyers will tell you about is that nurses cannot volunteer during business hours for the same job for which they're paid for the hospital, because if you're negotiating contracts that say that you get the best rate, the best rate is zero, then that's what Medicare wants, and so that's a little bit, I think, why the hospitals bounced back to being interested in our weekend model. The comment you made about the financial status of hospitals, I'm on the board of a large regional hospital, and we took it on the chin in COVID, lost about $30 million, and I think it was throughout the hospital industry, so everybody was sitting on their wallets. At least next year, it looks like we'll have an operating margin of about 2%. A lot of hospitals are looking at doing that, and of course, your bond rating is attached to your, and so there's a complex finance behind it, and that's why I say the CF know is the guy you have to, because they're the ones who present to the board what's going on, and having a very well-thought-out argument to bring them on board. They are somewhat breaking out of the COVID impact right now. Dr. Sutton, did you say the, I know you said that the nurses can't volunteer, is that on the weekends, too? Can they volunteer? They can volunteer on the weekend, but they cannot volunteer during their working, so when we integrate the model, and we have some places that say, can we do surgery on Thursdays? Can we do the same program, but we don't have to come in on the weekend? At that time, the nursing staff, environmental services, SPD, they cannot be volunteers in the integrated model. They have to be paid, so let's say that you add this case on to Thursday, and everybody stays 45 minutes later, they're paid for that time. You're saying, even though they couldn't be paid on Saturday, they still, like all the people you just mentioned, they actually came? Oh, yeah. I love it. I would say that being in an, when I'm in an expansion state, when we're doing activities in Louisville, Kentucky, we actually have a little bit more protection for the hospital, so some of our most expensive cases were like an umbilical hernia repair that had asthma. It ended up in the ICU for, you know, overnight, and then had like a day over, and now imagine me talking to the CF know about this, right? We've done, we've done diaphragmatic hernia repairs, and we had a rectal cancer, a low rectal cancer, a prostate cancer, a chemo, I mean, the care went boom. Fortunately, we were in the state of Kentucky, and so when we got those diagnosed, when we got the diagnoses, or when we get this bill, they can apply for emergent coverage. In Georgia, we'd have to rely upon the hospital's community care benefit. It's interesting. The Kaiser Nursing Union in Southern California for the Super Saturdays made us set up a system where they got paid on the Saturday, and then they donated everything except the indirect benefits back to Project Access San Diego, so it really made, helped Project Access San Diego, but the union was scared. They were reassured by all our lawyers that they were completely covered for malpractice, but they decided it wasn't worth the battle having with the union, so they set up this system, which was very interesting. I've got a question for Ms. Bosley. You may have heard Dr. Gupta talk earlier about the measure of the proportion of people who complete the colonoscopy over the proportion with an abnormal screening test, and I understand that there's some movement to make that adopted by the NQF. Also, I hear challenges of where are you going to get the data, like the lab results, how are those rolled up, so do you foresee any barriers or any advice on dealing with such barriers? Sure, so there are going to be barriers. There always is. I think the key is, like I said before, if I was approaching this, I'd want to understand what data might be available, what's feasible, and from there, that may help me tailor my measure to be something. It may not be as perfect as I want, and have a path forward to get the additional data you need. There are different approaches you can take. The more you can do this electronically, the better, but it's, as we've heard, incredibly hard to do. Everyone assumes an EHR pulls out this data. It doesn't. And so there is work underway to be a little more novel on this. So radiology, for example, is a specialty that has spent a lot of time on natural language processing and looking at artificial intelligence and machine learning and pulling this information out. I would encourage you to start thinking about those types of approaches, because I think that is the future. Not everything will be documented in a discrete field. Not everything will be shared across settings. So the more you can start thinking about where that data comes from, how you could manipulate it and get a little fancy with how you pull that data, I would encourage you to. And we heard from Dr. Siemens earlier that the proportion from Optum was about 10 percent lower than the reality because of out-of-network care that occurred. And so, you know, unless we can get all the health plans, all providers, to share data in one common registry, we're not going to be able to solve that problem, I fear. I think, Frank, you had a question or comment? Yeah, I've just, you know, we talked about that when we were developing the measure, the FIT positive versus FIT negative. I mean, we have to report CPT-2 codes for blood pressure control values, for A1C control values. I'm sure there's going to be a code that will be attached to the FIT CPT code to let the ALDAP plan know if it was a positive or negative test, and then to watch the follow-up claim. That's probably going to be the easiest way for it to happen. It'll be one way. Some people don't like working with CPT Category 2 codes, but yes, it is. And there are other ways you can do it, so I would say be as novel as you can and think outside the box. Well, I want to thank the panel for a great series of presentations today.

colon cancer screening

uninsured individuals

hospital partners

primary care referral source

COVID-19