Now, it's my pleasure to introduce Dr. Stoney Anderson. In addition to being the president and a member of the board of the California Colorectal Cancer Coalition, he's a volunteer clinical professor of medicine at the University of California San Diego, and he's a gastroenterologist with the Southern California Permanente Medical Group. He served as the chair of the Colorectal Cancer Screening Guideline Development Committee for Southern California Permanente Medical Group, helping to increase the group's colorectal cancer screening rate to more than 80% using a FIT test program. Dr. Anderson also started a project, sorry, started a project, Access San Diego Super Saturdays, which provides surgical procedures and colonoscopies for low-income and uninsured people. Dr. Anderson won the American Cancer Society St. George Award, and he has a medical degree from the University of Arkansas School of Medicine. Welcome, Dr. Anderson. What happened was, we started this C4 in about 2007, and in that same year, Kaiser Permanente gave a big grant to our community clinics consortium, which was a group of federally qualified health centers that were serving about 500,000 people in San Diego County. And I went there to talk to them about colon cancer screening. We had just started what TR started in Northern California, the male outfit, and so we wanted to do that. I even asked them, what are your screening rates, and they said, oh, about 80%. And I said, that's awfully good. How do you measure that? He said, well, we look at the charts, and if they said you should be screened for colon cancer, you're screened. So obviously it wasn't any good. And of course, uniform data said it wasn't going on. But I knew that they had between 20 and 30% of their patients were uninsured. So ethically, we felt we had to have a path for the uninsured if the FIT test was positive. So today, I have no conflicts. No one pays me anything anyway. So we're going to describe this SuperSATI program, and I'm going to give you the nuts and bolts of it, so you could actually set one up, and then talk about how it's morphed a lot through COVID into the integrated method, and that's the method that's been described by other speakers. And then review the steps and results of California's efforts to really reduce our uninsured so it's not as big a problem. So we modeled ours and got the memorandums of understanding and all the paperwork from Operation Access in the Bay Area, and it's 20 years old, very similar to the SuperSaturdays. And it was started by Dr. Gray, who was a UCSF surgeon, and no, he was a Kaiser surgeon and Dr. Slecker. And they said, why volunteer in other countries when you have plenty of people that need medical care here? And it made sense. And they're committed to expanding the model and will help, but they operate in the Bay Area and a little bit central Bay Area in 18 counties now, so they're quite large. So we started San Diego SuperSaturdays, and this was probably taken from our first one, and the, I'll go backwards here, I want to talk about the four components of the program, and this was our first one, and you get publicity, and your access has to be good, as I'll talk about later, because you get on TV providing free colonoscopies at a Kaiser facility, okay? So we, it was one of the programs in the San Diego County Medical Society's foundation, and it was Project Access. They had the structure, the 501c3, which you need, but it really wasn't providing any specialty care, but I knew the people that were actually the president of the society at that time was a Kaiser physician, and so they were able to embrace this SuperSaturday model. And we started on December 2008, we did 19 surgeries, and what, the win for the health hospital, it's Kaiser Hospitals, is donating the facility on a day that it's not being used, usually a Saturday, it's one of our surgery centers that wasn't open, and they get to write off the cost of all the procedures. So the first one, they were able to say it was worth $179,000. So as our hospital administrator said, this is a win-win. We do this, and we get the write-off. So we started doing it. And Project Access' role was first to provide, select the patients, and confirm eligibility. And they were doing a lot of specialty care from all the community clinics in San Diego and the free clinics from the university. And they would provide a physician with a medical record, for me, for the colonoscopy it was me, and then review prior to the pre-procedure visit for the surgery. And we did not, we did a pre-procedure class, there was no visit. And we coordinated communication between the community clinic and the volunteer physician. So when we would do our procedures, we would send it to Project Access, Project Access made sure that the community physician that sent the patient knew about it. The health plan was to sign an MOU, so this is legal, and commit to a pre-surgery and post-surgery visit if needed. Commit to the necessary pre-surgery labs and x-rays, post-surgery, post-colonoscopy, pathology medications, and or treatment. So when we would find inflammatory bowel disease, they would start the treatment from our pharmacy. And the donation was usually about $180,000 per supercenter. The patient's role, now we've not talked about this, but had to be a San Diego County resident, and immigration status was not a factor, but the patient had to have a home. I heard that, you know, these wouldn't be migrant workers, these would be, and it's not the unhoused, it was people that had a home. They had no health insurance, and income was below 250% of the federal poverty level, which I've given you the amounts there, $25,000 single, and about $52,000 for a family. And they had to have a medical home and a primary care provider, so there would be somewhere to send the results. So the services provided, colonoscopies obviously, and the indications would be the removal of a polyp if one was found on flexible sigmoidoscopy, if it was bigger than five millimeters. This is, remember we're doing this in 2008, we didn't take out every little ditzel. And an evaluation of unexplained iron deficient anemia, we would add an EGD. An evaluation of a positive FOB test, an evaluation of rectal bleeding in a patient over 50. If the patient was under 50, we would schedule a flex sig, but they got the full colon prep, they went to the colonoscopy class, they signed the consent for a colonoscopy, and we did the flex sig with a colonoscopy scope, and I used water exchange method. And if I found something and they needed sedation, I'd give it to them. If I didn't find anything, and they were comfortable with the water exchange, we would do the whole colonoscopy. And we would do screening of a patient over 40 with a first degree relative who developed colorectal cancer under age 61 or 10 years prior. We would do 12 to 18 colonoscopies in two to three rooms, and a flexible sigmoidoscopy in one room. That's usually doing the flex sigs with a colonoscope. Pre-colonoscopy class was given Tuesday, and this was important. Everyone that came to the pre-colonoscopy class, if they had problems with transportation, by then we'd worked out we had drivers volunteer from limousine companies, so our patients would show up in limousines. But anyway, we gave it on the Tuesday prior to the super Saturday, and we really emphasized the prep. And this was in 2008, 9, 10. We started doing the split prep back then when Kaiser wasn't even doing the split prep, and all the volunteers from our division said, why are these preps so good? But anyway, so we did that on Tuesday, so they all came. They got their Colite. They knew how to do it. They knew what the color of the stool should be when they're finished, and so on. We gave that class in English and Spanish at first, but by the end, we only had to give it in Spanish. And if there was an only English speaker, which we didn't have the last few ones, I would just instruct them on the prep, and our one bad prep was someone I instructed. So, flexible sigmoidoscopies were routine screening. Someone just wanted screening in a bright red rectal bleeding in a patient under 50 and constipation. But remember, these flexigs, we were ready to do a colonoscopy. The volunteers roll. They worked on the planning committee. They recruited other volunteers. They helped select the appropriate patients. I can't believe it. Just a second. Anyway, select the appropriate patients and have a good time. So that was our volunteer roles. And here's probably one of the first or second ones. I'm there halfway up. Surgeons, of course, are in the front. And here's our medical director, and this, Nate Obrey, was the hospital administrator that thought that was such a good idea. Yeah, here's Nate, and there's Art Flippin, who was a medical director at the time. And these are just pictures. The Project Access hired a professional photographer who had been Miss Chula Vista, oddly enough, and she was actually a good-looking woman. But anyway, she took all these pictures. This is Rich Brower. We called him Magnum G.I. And so they would go around to all the things, and this is Bob Oakley. Both of them were my fellows in the Navy when I ran that program, but I hired them at Kaiser when I got over there, of course. And this one I put on there because I worked until I was 77, active, because of the nurses and the food. But these Super Saturdays, we had a great breakfast and a great lunch. So we fed all the volunteers well. So that was what that picture's for. And then at the end of every Super Saturday, I would take all the pictures from the professional photographer and make a collage and put them up in our clinics, all three of our clinics, one up in North County, South County, and the one at the main hospital. So we have, over the years, all these Super Saturdays. So we had an excellent or good prep. The one patient didn't prep, as I mentioned, was the one I instructed. All patients did the four-liter preparation split, and everyone attended the class. If you didn't attend the class, we would reschedule you for the next time we were going to do it. And the no-show rate was 0% because we provided transportation. They knew what was going on. We did 215 colonoscopies, about 100 of these we published earlier. I'll show you the article. And we did them from 2009 and 17 sessions. We quit in 2017, and I'll tell you why. 72% were women. And apparently, this is not unusual in these free colonoscopies, that more women come in for them than men. Average age was fairly young, as you can see, 58. And the indications, most were for a positive fecal occult blood test, but we had some rectal bleeding, we had iron deficiency anemia, we had findings on a flexible CIG, and then some family history. These are all the indications. We had eight colon cancers. And the second patient there, I did him, and he had familial adenomalous polyposis. And his son has it. So not only did we save him, all of these, oops, let me go backwards. All of these, except this distant node, were treated at Kaiser. Kaiser not only provided the supersaturated, but these were community benefit patients. And the medical director, Nate Obrey, when I said, you know, emergency Medi-Cal doesn't really work when you find a cancer from screening. They have to be in the emergency room. They have to be having some emergency for them to get emergency Medi-Cal. And I said, I'm not sure we've got really good treatment options for this cancer we found. I said, we'll just handle it. So Kaiser took care of all these patients. And seven of the eight, when the program ended, were still alive. And some of them were over five years, so. As you can mention there, we found, and that's 4% of the screen population. That's about what you should get in a positive fit or a high risk group. So 4% is what we expected. Our advanced neoplastic numbers were good, a little low. And the adenoma detection rate was decent, but I remember this was before 2017. So we weren't that interested in small polyps at that point. So we published the first hundred of these in an article done by the, in the National Cancer Institute from the World Endoscopy Association Society. And as you can see, half the people here are on this, are on this, are on this. Samir was running the screening group for the WEO. And so we published this. Now the alternate program. So what's happened in 2017, colonoscopy need at Kaiser and San Diego increased and we had a backlog and the hospital and the medical group wouldn't let us continue because we would get publicity at each one of these super Saturdays. And so we had to go to the alternate method and Project Access went to the alternate method almost completely. And that is, and it's also used by Operation Access and, and you add on uninsured in the regular schedule. So let me ask you a question. What is the disadvantage, there are a lot of advantages to that program because you can schedule more frequently, but the disadvantage is what? Do the nurses volunteer in an integrated program? Like they were so happy volunteering. In general, they don't. And the physician donates their services, but a lot of the staff doesn't get to volunteer. So that was a disadvantage. And sometimes the physicians in Kaiser, when we do the alternate method in our regular schedule, we don't volunteer, they pay us the same, they don't care. And so it can, as I mentioned, ongoing services at more frequent intervals. And this is used by UCSD, UC Davis, and now Operation Access, I'm going to show you some of that. This is what's happened with Operation Access. It's a massive program in the Bay Area, as I mentioned, 18 counties are served, and they, each one does about 20 colons a year for the county to serve the uninsured. And as you can see, the percent Super Saturdays here dropped during, guess what, COVID, and it's coming back, but they don't think it's ever going to come back to where it was. More people are using the alternate method, and from what I've heard at this conference, that's what people are using for the uninsured. So what's another approach to this besides the alternate method? We just want to reduce the number of uninsured, so we won't have as many colons that need to be done. And we did Medi-Cal expansion in 2014. We did Medi-Cal expansion to the undocumented. Almost all of our uninsured are undocumented in San Diego, below age 27 in 2020. And then we did it for people 50 years and older last year, and that's going to get 185,000 more individuals covered and really helped us in the colon cancer screening. So all these people that we were doing would have been eligible now for Medi-Cal, which is our Medicaid. And then the final budget of 2022 approved the expansion of Medi-Cal from undocumented to cover that donut hole from 26 to 49, and provide insurance for another 700,000 Californians. Medi-Cal covers about a third of our population in California. And we were worried that some of the undocumented, but we've looked back and I've talked to the Department of Health Care Services, the undocumented have no problem signing up for Medi-Cal, and it doesn't affect the final rule. In other words, it's not considered taking government assistance. So here's what's happened in 2010 when we started the program. This was the Federal Qualified Health Center's uninsured rate, and it's dropped to 15%. And here's some San Diego Federal Qualified Health Centers, and they, when we were doing this procedure, had a high problem with uninsured, and now it's dropped off. And once they get the rest of the group, it'll be 5%. So the biggest part of this was the Medi-Cal expansion, and I'm hoping we can talk about how we can help these states expand Medi-Cal. And this is what I really do now. This was, we had a 5K, and this is the colon that Fight Colon Cancer helped us buy, and these are my grandkids. That's Steele and Peyton, and the twins, and Daniel, who was named after me, the grandson. So thank you very much.

Dr. Stoney Anderson

Super Saturday program

colonoscopies

uninsured individuals

Medi-Cal expansion

colorectal cancer screening