I am so excited about our summit today. I've come to think of it in my mind as leave no behind behind. Great. So, our panel is here, and I'm happy to field questions from the audience. I had a couple of questions just to start off with. One is for Molly and for our colleagues from exact sciences in the audience, which would be, would it be practical, and if so, but what would be the unintended consequences if the patient resource you have about getting everything covered were included in a Cologuard kit that get mailed home, or what my wife likes to call poop in a box. Thoughts? Yeah, so I know that our resource is at least on the exact website or making its way to the website. We're certainly open to having the resource be wherever it can be, and I would leave it up to legal, I think, with exact, but. Because I imagine there's probably some unintended consequences that might come from that. I don't know. I think it would be great to, you know, consider all available options. There are some restrictions on what can actually go in the kit, because the kit is FDA reviewed and approved. So, maybe there's creative ways we can accomplish the goal, which is to get that message to people as quickly as possible. While I have the mic, I just wanted to correct one comment. During the last panel session, Jim had asked about Medicaid adherence rates with Cologuard, and they are actually closer to 51 to 55 percent, not 59 percent, if anybody is interested. That's the subset of GI patients who adhere. Anyway, thanks. Great. Thank you. Do I have any questions from the audience? Yeah. Samir, you mentioned a placeholder goal for the follow-up measure of 80 percent. So, for our learning collaborative, we like to set goals, but they kind of have to be realistic goals. And we know that for the initial screening, the goal is 80 percent. So, our baseline rates, I was just sharing with Frank, of follow-up are at 30 percent. Within 90 days. That is true. That's an important point. The reason we set 90 days is it's a short collaborative. We want to be able to see things quickly and see change. But that aside, so we know it's about 50 percent, if it were 180 days. So, 80 percent seems high, maybe as a stretch goal. But we're struggling with what should the goal be. Sometimes we just do a — and there's a big range, as I mentioned, right? So, it could be a 20 percent gap closure, or just — I asked Dorado, he said 100 percent. So, I don't know if you or anyone else has any ideas of what a realistic goal might be for the follow-up measure. So, I might push back and say 80 percent is realistic because you're still talking about — absolute number-wise, in terms of patients who need the follow-up, it is going to be a very small number relative to the total volume of colonoscopy orders or things that are going on. So — and I would come back on that, you know, it's tied to mortality. You know, there's no escaping that. And then the liability, if, you know, it's one in 30 to one in 20 who have a cancer, and your health system or practice doesn't follow up on that, and I get called to the stand about, you know, there was no colonoscopy order, it's open and shut. So I don't think — I think 80 percent is reasonable. I recognize we have a ways to go, and that we have to be patient in our expectation of how quickly we can get there. In my health system, UC Health, we are not there. It's still embarrassing, but I think that we need to push hard, and especially if we're talking about this from the ASGE perspective, I totally would support we have to be very forceful, and back it up with why. Yes, please. Oh, got it. No, I — no, a very interesting session, a couple of thoughts. So there were modeling studies earlier on done on the time to colonoscopy and risk of, you know, the ones that Ms. Ken has done. Of course, those things typically will show a linear trend, right? So plug a number, see a linear trend, and I think the point I was going to make was that I think a nudge around six months may be a little late, and perhaps consider having a nudge occur earlier, and so in the studies we've done, if you put in three months, you see a very strong effect, and if you look at it in the quality study, at about seven to eight months, you see 1.27, if I remember that number correctly. It's not significant because those numbers are smaller. So I think we have to think about is that sort of a trajectory that becomes significant at some point. There's always confounding by indication that makes it harder to show. For lung cancer screening, you see that really profound confounding by indication that makes it hard to show that, but I think from a patient's perspective, the argument that we've made in the past is I think it's unreasonable for anybody to wait that long for something in your view that potentially means you may have cancer, right? So why should you wait six months or even end of the year to get the test done if you may have cancer? So that's one thought. The other thought I have is, you know, from a primary care perspective, no one likes best practice alerts, but you could flag the positive FIT or something, Cologuard, as something that's a care gap. It's a care gap thing that can be flagged. So that's also one implementation that can be done because you have to do something about it for it to go away. It wouldn't stop you from doing the work, but it could go away. I think we have underleveraged AI approaches, and we should consider how AI could be a tool. You'd have to put that in a problem list, flag it, bring it to someone's attention so that it goes away. There's a piece I also would so I would suggest that don't forget ASER as a partner in this process in trying to move this forward. This is so important to me, to all of us, because this is a place where there's a big gap. Samir made a really important point. Who gets the FIT mostly? People who don't have access to colonoscopy, then they don't get access to colonoscopy. So I think that's an important piece. We have to change our language from follow-up or diagnostic colonoscopy to the colonoscopy and screening. Screening colonoscopy. Nuts. to perhaps reflect that. I'm not sure how it gets entered. I don't see that piece of it, so I don't see that. So Samir, I agree with you completely about the metrics. It's around an error when you put it in. But I actually think that it draws attention to it. So maybe that one approach supports it two ways. You still keep it there, because if you have the data, you can still insert it, but still show it, because the numbers are small. You get 100 patients, you're going to get, like, two. You're not going to see anything. That's part of the challenge with this area, because the 5%, 10% positivity rate ends up being very small numbers when you look at overall population. Just wanted to share that, but I think the piece around language, and I want to get your thoughts whether we should also begin to move that to saying, it's a screening colonoscopy. So we're not talking about that. We're doing a screening colonoscopy, whether that changes how people may receive it from an insurer perspective. I think from an insurer perspective, I mean, it is very much treated as a preventive screening, and that's what that modifier 33 indicates. And so it's so dependent on the coding, because otherwise the procedure is the same either way, and the modifier is the one that delineates it as preventive care. And in the absence of not knowing whether it's an abnormal test or not, anything that comes in, there's no way on the payer side to know was this completion of screening, or is it diagnostic or surveillance for other reasons. And I would make one comment about the six months, because it is something that we are trying to figure out, like what is that best time frame for it? And the idea being that for this particular campaign, that as soon as the abnormal comes in, if the patient had denoted that they have a primary care provider, then they get a copy of the result. If they didn't denote one, then, or whether they denote one or not, then the company that provides the testing, one of their nurses reaches out to the patient to talk to them about the positive test and the fact that they need that to complete the screening with that preventive colonoscopy being done. And then it's a matter of getting a schedule and all that. We're looking at it from the claim side, so that if the claim doesn't come in by six months out from that positive test, then we're reaching out. And I mean, part of me is like, gosh, that feels like so far out. But it takes time to get it scheduled. It takes time for the claim to be submitted. And we frequently look at a three-month run out. And so even if it gets done immediately the next day, or within that first three months, it might not take until six months out to actually get the claim to come in. But it's a fine balance. Well, how many times do you reach out before they feel like, OK, I got it. Leave me be. So we're trying to hit that balance, too. But I appreciate your point. I wanted to just make a quick comment about the time to colonoscopy issue, which I think we should talk about in the groups. I don't think we'd ever be talking about, would it be OK to wait nine months after an abnormal mammogram? Or can we finesse it, and is it OK six months? Or is it OK to do five months? And Chaik knows this. Fola and I know this. Doing these studies is super messy. And putting a lot of faith in, oh, yeah, it's OK to wait six months, maybe we're making ourselves feel better. But I think the message should be as soon as possible. And that a reasonable goal, three months, as sort of where we go. But I think we have to be careful about, as we message this, and what it means around time to colonoscopy, that we're not just, first of all, don't put too much faith in the data. Because there are issues around what the reference group is, and the severity of presentation that we just don't always get in those data and can account for. So I think we really have to be careful. Samir, it's interesting how patients react. Some patients say, oh, that's great. I'm busy this summer. I don't want to do it till November. And the others will say, I'm going to another gastroenterologist because I want this to be done next week. So it's polar opposites, the way the patients respond to that. So, yeah. You have not yet, anybody who's not been talked about the move to 45. We've just moved the goalpost back 20%. And now, how's that impact the CDC program? The advocacy, is insurance going to always pay for that? And now, we've got the American College of Physicians, my group, saying, let's go back to 45 and drop Cologuard. It seems to, we're trying to keep messages clear. Yeah, back to 50. How much has that been a challenge for the various people there and solutions you see to deal with this? I'll at least say from the payer side of it. So with the ACA, once the change is existent in the USPSTF, commercial payers have about a year to adopt it. And so some payers say, OK, I've got the year to do it. Others are saying, we're going to change it as soon as it comes in. I think from a program side, it's just been challenging. On pretty much every level you can imagine, it's been problematic for data collection, very much so because we're all set up to collect things from 50 to 75. It's like you almost have to go back to the drawing board to get 45 to 75. A lot of our FQHCs, they just moved to collecting 45 to 75. So we're just starting to get that. It creates a data continuity issue because it was 50 to 75. Now it's 45 to 75. So it's like a hard reset. So now we don't have any trends. I can't tell you what happened. And it's very difficult to actually get them to split it, to try to ask them, well, give us 50 to 75 and 45 to 75 so we can see, so we have that continuity. I think from an outreach standpoint, it's problematic. So they already were having a hard time just trying to get to the people who were 50 to 75. Now you just added all these extra people that they got to try to outreach to who are sort of screening naive, I would guess. So at least usually by the time you got to 50, a lot of people sort of have at least maybe some clue that they should be screened. But these 45-year-olds are like, wait, why are you calling me? They've never had any sense that they should be screened. So then it diverts. It's like we got the same amount of people and the same amount of money. So it diverts attention away from the group you were working on, and now you got to get these other people up to speed. So it's problematic. Is it doable? Yes. I'm sure we'll figure it out. But yeah, I mean, it's hard to split your attention or to roll in this whole new group of people that previously you have not had to deal with. From a public health standpoint, my biggest concern about moving to 45, which I support, is that we would actually save more lives if we did better with abnormal test follow-up in the 50 to 75-year-old group than by screening. And so as I think about it as an endoscopist, we now have the privilege of access to another 20 million people that we can help and make money off of. And I think that should go with a commitment to making sure that everyone gets to benefit and that this abnormal test issue is not left behind. Because if we just let what has been going on go on, the worried well are the ones who are going to show up for the 45 to 49 scopes. And they're pretty low-risk people. But I think the 45 issue has made abnormal test follow-up harder. I would also just add from the patient perspective with what came out from ACP, it just creates a lot of confusion. So the first time I saw the announcement was a Today Show spot that I watched, and I was like, what are we doing here? And I'm in this world and understand the guidelines. And so I think that's really challenging. And I understand the challenge even that from moving from 50 to 45 that puts on the system. But I'll say from our community that is increasingly younger than 45, we routinely have to field calls for why do we not eliminate the screening age? Why is the screening age not 30? I was diagnosed at 35, so even 45 doesn't help me. So I'm not advocating in any way for removing the screening age, but there's obviously a growing population of people that it doesn't help and that are angry about that. So that's just another part of, I think, that dynamic. And with social media, we now have kind of colorectal cancer patient influencers who are being seen by a broader population and sharing their story. And so the way, to Whitney's earlier point, the way that information is getting out there is very different than it was 10, 15 years ago. So when you have these conflicting guidelines, that only further creates challenges. And actually, just a plug. So in your folders, I think we sent a letter to ACP and a number of folks in your organization signed on. We had a pretty disappointing response. I think it's also in there. So we're kind of continuing to think about next steps. I don't know that we'll be able to make them change course. Messaging, but to make sure that everybody's talking to everyone. Because there are certain things that insurance companies need to hear. Maybe another group needs to hear something totally different. So it's important to make sure that at least everybody can hear everyone who's at the table. I had a question and a comment for Josephine. So I was very intrigued in hearing the role of the insurer, to some extent, as really providing care services on a population level. That was intriguing to hear about the virtual vendor, to provide support for the primary care provider. More specific to this summit, what is the model for health insurers to collect laboratory data? You talked about claims data, but to collect laboratory results, whether it's in the diabetes space. And what are the regulatory issues for an insurer to be able to collect that data and to act on it? Yeah, I mean, those end up being part of quality metrics where provider organizations agree to as part of value-based agreements or other aspects. And then so it comes in as hybrid measures if there is no way to get it off of claims. And so that just sort of goes on as part of the challenge in terms of how do we get at that data and how do we get it in a way that doesn't add more burden to the provider side of things. That value-based measure, is it something that between the insurer and the network or group that you come to an agreement on, like these are the ones that we're going to pay for that performance? Right, yeah. It might be part of a quality scorecard or something like that. Now, as it relates to the vendor reporting those results, that's part of our agreement with the particular vendor that does the mail-fit testing. And then we do the follow-up on there because those members don't necessarily have maybe a doctor or a usual place of care that they're going to. This is just sort of another way to get that outreach for people who aren't getting care at all. And it's interesting because there's all these ideas about, well, virtual care should help solve a lot of these issues. And so if people aren't getting care in brick and mortar, they must be getting it there. And so we've been more actively looking at some of that. And some preliminary information that's kind of interesting is that about half of the people who are accessing virtual care services have a regular brick and mortar usual place of care. So it's like, well, that's interesting too. So then we're trying to figure out, how do we leverage all of that? And there's more and more virtual companies that are consolidating, and they're doing kind of like, we're going to do the whole continuum of care, and we're going to provide this. So I look at this and say, OK, that's great. You can do all these things. But how do you then connect with brick and mortar providers when you fundamentally still can't do everything you need to do without being in person at some point? And how do you complement that versus actually fragmenting the system even more and just duplicating services all over? I'm curious about whether there's any precedent for test and insurers paying for requiring that they get a report on whether the result is abnormal or not. We're all used to having to talk to insurers about to get approval for something to be able to explain what was abnormal that justifies the next thing. But is there any precedent for something like that? Not that I'm aware of. Yeah, not that I'm aware of. And I was thinking about your statements about the different measurements. I mean, in a way, I think we need two distinct measurements. One is the percentage of people that are screened, and then the follow-up on the abnormals. Because otherwise, it would be much easier to say, OK, well, I'm just going to make sure I follow up on all the abnormals. And that might just end up being a very small number, but I'm not going to worry about how many people I'm actually getting screened. And so I think if we have both, then we have the potential to really get at the goal we're after. We've had experience working with our Medicaid health plans to do mailed fit programs. And I think there's a couple of different models. One is where the Medicaid health plan will work directly with a vendor that does provide all that information and can provide the positive results. And in some cases, the health plan does have somebody that is credentialed to be able to contact the patient and notify them. I think the biggest challenge there is that often the clinic, you talk about needing to provide that support, and so often the clinic is getting scanned results, reports, and sometimes those don't interface that well with their systems. We also have used a model where the kits get sent out by a vendor that's paid for by the health plan, and that kit comes back. The completed test comes back to the clinic, and then they send it to their referent lab so that that information gets into their chart. I think in that model, the health plan doesn't always get the results, but you could imagine that maybe you could work with a vendor that could still provide those results. But I think that's, I mean, you're onto exactly the right challenge. How do you make sure that the clinic can optimize the care that they're providing while the health plan has enough information to really provide that additional support that the patients might need? Right, yeah, definitely. And I think if there was a way somehow for the health plan to just get the result either way, then at least we can capture that group and say, OK, now we can go chase after it. And I think it could even help potentially on the coding when that colonoscopy comes in, because then there's the potential to say, hey, we're actually waiting for a preventive one to get done. So if the coding isn't coming in right, it could get captured. Great question, first for Josephine. Great panel discussion, you guys, too. Can you confirm that a diagnostic colonoscopy is reimbursed the same as a screening colonoscopy for a physician and a facility? No, I can't. I mean, you know, if I could. Anybody else here have input on that? Yeah, I mean. That's a huge incentive when we're talking about coding issues. If folks are perceiving that if they code a positive fit as a screen, I'm just saying, I've always thought the exact same reimbursement, as long as you take away any modifiers for biopsies or polyps or anything like that, just strictly the diagnosis. That's a really important piece that we ought to know the answer to. And so I don't know that. I always presume they were. And then my second question is to you, Molly. When you're looking at your coding issues, because our biggest issues have been coders, not administration of hospitals. But there's two brands of coders. There's those that work for health systems, and then there are those that work for endoscopy practices, right, in different parts of the country, and have different complete models. How are you tackling that? That's a huge piece, the coding piece. You talked a little bit about it. You want to talk about maybe those different models? Yeah, it's been a challenge. And actually, a phone call from Jason was part of what started some of this, because he'd been talking to coders in Kentucky, and they were saying, I am scared to use this modifier. And there's also different coding guidance. So CMS has coding guidance that currently, as my understanding, doesn't include the modifier. So if people just follow the CMS guidance, then they might be hesitant to do something else. So like I said, we've been trying to get in with some of these coding bodies to have a conversation with them, offer them the resource, have a conversation about how they disseminate this out to their membership. We're also hoping to work with the American Hospital Association, AMA, and others. I've found that it is a bit of a challenge to break through with some of these groups. They often think that we're selling something, or that we have to pay $10,000 to be in their journal, and that's just not feasible for us. So that's been a little bit of a tricky part there. But yeah, I think getting to that population, that community, is I'm all ears if folks have other ideas. Because payers like to pay for colonoscopies. If it's coded as a screening, they're not usually going back. They're accepting that. The biggest area is how it's coded. So that's physician education, but it's also that linkage between the physicians and the coders and the new paradigm that we're promoting and pushing. Super important. I don't know about you all, but as the day's gone on, I've been thinking about, at the end of today, we should have some actionable items. There's going to be key output from this summit. And one of the things I'm hearing, I think, is that the coding piece needs to be thought through. We probably have to have some things around that. Another one, I think Samir's point, I think one of the other outcomes from today's summit will be a quality metric we can all get behind. So I think, whether it's during lunch, people may want to think about it, talk about it. But we'll probably, in the wrap up at the very end, when people are really tired and looking to get out of here, that's the time that we're going to say, what are the take-homes? I'd love people to think about this. We are at time. It's time for lunch. The conversation should 100% continue, but over some vittles. It'll be out where you had your breakfast. Thank you.

colon cancer screening

patient resources

follow-up measures

screening age

insurance coverage

coding