All right. So getting on with our program today, I'd like to now introduce Dr. Josephine Young, who is a medical director for Primera Blue Cross. She works with Primera's national and large accounts with an emphasis on driving innovation, improving patient outcomes, and addressing health equity. She joined Primera in 2020. Dr. Young previously served as a chief operating officer at Allegro Pediatrics, where she was responsible for day-to-day operations and overseeing more than 100 providers and 300 staff at nine clinics. Dr. Young has a medical degree from Boston University. Good morning. So excited to be here, especially a pediatrician in a room of GI docs and adult medicine docs. So I'm here to talk a bit about the payer perspective as it relates to colon cancer screening, which I think has sparked some interest this morning. And for me, this is really interesting because having only been on the payer side for about three years, I have learned a ton. You know, some of the frustrations that I saw before are still there, but there's also I see a lot of opportunities where there's the potential for way more partnership than I ever would have expected could have existed when I was on the doctor side of things. So in terms of thinking about the role of payers, payers are in this very tight, highly regulated industry. And it's really, you know, based on what the NCQA says, National Committee for Quality Assurance, health plans have to support care that keeps members at optimum levels of health while also controlling costs and meeting government and purchaser requirements. And it ends up creating a very narrow space in which to do this work. And there are a whole variety of payers, and I'm actually going to limit my conversation today to mostly the employment-based private plan component of it, but there's obviously multiple other players in the mix. And so this is just a breakdown of looking at health insurance coverage of the non-elderly population, so under 64, across different races and ethnicities, and just looking at what proportion has the employer-sponsored insurance versus state insurance and other types of insurance. And so in 2010, the Affordable Care Act, everybody is aware, I mean, like really changed things. And so it includes that requirement, and I'm going to stop here for just one second to talk about the specifics of what's in here, because I think it's come up a little bit in terms of, you know, what does ACA cover or not. And so, you know, it really talks about the requirement of non-grandfathered plans, and I don't like that term, but it is there. So it includes requirement of non-grandfathered plans for private health insurance to cover program services without cost share by the member. However, it's very specific. It's covered at 100 percent of allowed amounts without deductible, co-insurance, co-payment, but the key thing is that the service has to be provided by an in-network provider for that coverage of no member cost share. So even if you have all of these things covered, but somebody goes in to see a provider that is not in-network, they're not going to get that coverage. And I think that just adds to the confusion for the patient, because they're trying to sort out all of these things. The other thing is that the grandfathered plans are exempt. So the question is, you know, how many people are actually covered by these grandfathered plans? And this actually shows that from the inception of ACA back in 2010, that center line, that orange one, is kind of like if you consider all firms together. So that overall, it's definitely been steadily falling. But still, about 13 percent of those that have commercial insurance are not covered under the ACA. That's a substantial amount, and that's concerning, and hopefully it will continue to drop, but that is part of the reality that's there as well. So why do health plans care about screening? Because health plans are rated based on, so for commercial, Medicare, Medicaid, and exchange health plans, there's a rating that is publicly available out there, and it's frequently represented in STARS and other programs. And so it is a composite weighted average of the HEDIS performance, the Healthcare Effectiveness Data and Information Set, which includes access and clinical quality metrics. And then there's the consumer experience surveys, which I think on the doctor side of it, there are the CAHPS surveys for the docs, but there's also the CAHPS survey for the health plan ratings, the consumer assessment of healthcare providers and systems. And that's a lot of just like, for health plan members, what is their experience overall in their interactions with the health plan? How do they use it? What are those interactions like? And then if you have NCQA accreditation status as of June 30th of the measurement year, because this is done each year, you get bonus points. And so what's in that accreditation? These are the things that are included in the NCQA accreditation standards. And so it's all of the things that you would kind of expect there to be, and I won't read the bullets to you. But it's certainly that quality management and improvement and population health management is a huge piece of it. So when we think about the HEDIS measure that we're specifically talking about as it relates to colon cancer screening, I mean, everyone here is well aware of it, is, you know, all the things that are included there. What I wanted to just mention is that starting in measurement year 2024, there is an increased requirement by NCQA to actually have directly collected race and ethnicity data to address health equity. That is a huge challenge because the proportion of data that's available through different collection mechanisms is relatively low depending on which system you're talking about. And so as health plans are kind of scrambling to work on this, there is a much greater push to be able to reach out to the population and say, okay, we need this information. But there's a lot of trust involved in being able to be clear on what is the data governance around this, how is this data going to be stored, where is it, who's going to be able to use it, who's going to have access to it, what kind of decision making will come out of it. So there's a lot of communication of that that needs to occur. And most critically, there is no measure to evaluate the completion of colonoscopy after a positive stool-based screening test. And therefore, it makes it really hard to really capture anything beyond that first phase or screening getting done or not. And so hence, for payer plans, we don't have information as it relates to who had a positive screen. So we're still focused on the front end of, hey, are people getting screened at all? And so this just looks at, this is from NCQA, looking at, since 2004, from the start of the measure, with the HEDIS measure, what kind of screening rates have existed. And the blue line that's there is the commercial HMO. And the orange line that's there, I guess I can point, whoops, I cannot point, let me go back. Well, I don't need to point. So that the orange line that's there, why is this not being, sorry, the color is looking different from one to the other. So the blue line is the commercial HMO. The orange-ish, reddish line, maybe, is the commercial PPO population. So that's, you know, where people aren't limited in their choices of where to go and where many of the employee-based plans have membership. And then the other two lines that are higher are in the Medicare space, the gray one being Medicare HMO and the kind of golden brown one being the Medicare PPO. And there's a gap a little bit in there just because reporting requirements for those years were changed for Medicare during the pandemic. And so you can kind of see where it sort of peaked right before the pandemic, and we've seen it drop, and now it's making this slow climb back. And one of the worries that was there was, well, with all of the screening dropped off, do we have, like, these huge numbers of cancers that have yet to be diagnosed? We kind of took a look at it internally at the plan that I'm at in terms of how much screening has been done, you know, what was missed, and what's been the result of it. And when we look at all the cancers that we would have expected to have been diagnosed during the time period of 2020, 2021, and 2022, we haven't seen it catch up yet. Each of those years we're still lower, so we know that we need to put an increased emphasis on screening and doing the follow-up because there's a number of people out there that we would have expected to see in those three years that we haven't seen yet. So this is just, you know, a quick look at what's the cost of treating colon cancer in the U.S. It's the second highest total cost treatment of any cancer, and it's an estimated $24.3 billion, and it's only second to breast cancer, and this estimate was from 2020. So it represents about 12.6 percent of all cancer treatment costs, and I know there was an earlier slide about, you know, what that initial costs were in the first year after diagnosis and then the continuing per year and then the end-of-life piece. So certainly a lot of money that could be saved along with saving lives. And so certainly screening aligns with commercial payer priorities, so in addressing all the elements of the quintuple aim, and then also for health plan quality, reputation, all of that from the rating perspective, and then also within value-based agreements, being able to incorporate that into the conversations with our provider organizations that we work with. And then in addition to that, because most of the large employers are self-funded, and so especially with the large nationals, we also have specific performance guarantees with them of what we as a health plan will do to help maintain or achieve optimal health for their membership. And from that perspective, frequently cancer screening is in there, colorectal cancer screening being one of the key ones. So what are the challenges? Commercial payers, we are the least, absolute least trusted influencer of anything related to member patient clinical decision-making. As a doctor, that makes me very sad because that's where I'm working in, but I also see it as potential opportunities. And so it's hard with the messaging that goes out, because anything that a health plan outreaches and said, this is a great thing to do, people are immediately suspect, why? And what do I as a patient lose if you gain something? Am I going to get the screening test? So we frequently have to help channel our messages through other avenues. We don't have that longitudinal member data for care gaps. We don't know as people come into employment with one company, we have no previous history. So they just got their colonoscopy done last year and it was perfectly fine. We end up chasing after people who don't need screening done. They're going to ignore us. And that's just not time worth spent. And then there's a frequent lack of access to other opportunities to reach out to members, because if we don't do it quite right, then they're going to say, nope, shut off. All communication, don't want to hear from you about anything. So we have to be really strategic in how we're going about it. These are just some of the challenges. So what are opportunities? There's a lot of different things that we're really kind of after in terms of, you know, for patients, members coming into health insurance, depending on what their previous experience has been, they may or may not be familiar with what's there. So we consider that as part of the overall health literacy about just knowing that these services are available. I think, you know, something everyone's spoken to. But it's also recognizing this is not a one-way education. It is very much a two-way, because from a health plan perspective, there is so much that we need to learn about what patients are experiencing and why they can't pursue their own best health in the way that they want to. And what are obstacles that health plans are putting in the way that we can potentially help with? We are really focusing on trying to, I mean, health plans in general are trying to really promote more of that primary care provider relationship, knowing that that's where those trusted conversations can occur. And how do we more facilitate that? We also do try that whenever we are encountering members, whether they're calling customer service for something or whatever else, to try to have things in place to say, hey, while you're here, are you aware that you haven't had these things done? Those conversations sometimes are a little iffy. It's kind of like, why do you know so much about me? This is not what I've called you for. But others are like, oh, this is very helpful. Or those customer service reps are able to then refer those patients over to case management. So the case managers can do an outreach and say, hey, how can I help you? What's getting in your way? And that's part of that advocacy navigation case management. But also sometimes we can have vendor partners that do that. And when I'm saying we, whether it's my plan or just kind of commercial health plans in general, these are some of the approaches that are being used. Certainly a lot of employer group partnership to coordinate communications, maybe on-site screening events, maybe distributing things on-site, all of that are always conversations that we have. Pharmacy collaboration with pharmacists being able to hand out FitKits with conversations. Healthcare system partnership. To say the least, we can't do this alone. And health plans are not the driving force for this. We can kind of keep facilitating things in the background. But so much of that is really those conversations with primary care providers, with their own local doctors. And then also with the at-home fit testing vendor solutions, that is one avenue that we're pursuing where we're going to be able to send out FitKits, work with a vendor that will do the initial outreach and follow-up for positives that come back. And those positive results will also come back to the health plan. So like for the first time, we can actually get access to that information. And what we're planning to do, and this campaign will start shortly, is that if we don't see a follow-up claim for colonoscopy done within six months of a positive result, then we as a health plan will also reach out. And part of it too is that when the vendor reaches out with the positive test and helps people get scheduled for their colonoscopy, if they don't have a doctor, then they will refer back to the health plan. And then our case managers will help find a doctor for them and potentially even help make appointments if need be. Oh, and then the last thing is there are a lot of other virtual primary care solutions out there that are also employing health coaches and navigation around different aspects of care to close care gaps across a number of things. And because they're in direct contact with the patients, it definitely increases our potential for being able to reach folks. So I think that's my last slide. Yes, it is.

Dr. Josephine Young

payer perspective

colon cancer screening

Affordable Care Act

preventive services