A Q&A With Josh Sclar, MD, MPH, Chief Medical Officer of BioIQ
GEN: A recent study in the Journal of the National Cancer Institute (2017;109:8) found an increase in the risk for colorectal cancer among members of the millennial generation—and suggests that screening guidelines might need revisiting. However, guidelines take time to change. What should clinicians do in the interim with this new information?
Dr. Sclar: The short answer is, nothing new. Clinicians should continue to evaluate and treat their patients according to their assessment of individual risk, as opposed to population risk, described in this study, and personal preference. Which is to say there are good reasons why screening guidelines, like clinical best practices, don’t change on the basis of a single study—especially one that is cross-sectional or observational in nature like this one.
With respect to assessing individual risk, it would be unsound to extrapolate this study’s findings to a single individual. Clinicians should also be prepared to discuss the way media coverage of epidemiological studies highlights an increase in relative risk, without discussing the associated increase in absolute risk, because the latter is often small and harder to conceptualize. Clinicians should familiarize themselves with the absolute risk increases described in this study, which are quite small; the potential for error/bias/confounding in this type of research (hence the need for further research); and prepare to discuss these aspects of care with patients who may be concerned by media reports picking up on the study’s findings on relative risk.
GEN: What effect, if any, have efforts like the National Colorectal Cancer Roundtable’s (NCCRT) 80% by 2018 initiative and National Colorectal Cancer Awareness Month had on raising CRC awareness and improving screening rates?
Dr. Sclar: According to the CDC, about 23 million U.S. adults are unscreened for colorectal cancer. In a recent blog post, Richard Wender, MD, chair of the NCCRT, discussed early survey results indicating that since the initiation of the 80% by 2018 campaign, nearly 4 million of those adults had been screened.
The American Cancer Society estimates this will translate into some 37,000 preventable deaths, if it can be sustained. How much of this progress can be attributed to individual advocacy efforts is difficult to pinpoint, as their effect can’t be separated from those of increasing insurance coverage, changing measurement and reporting methods, or other contemporaneous factors. But we can safely say stigma and apprehension remain significant obstacles to screening, which is where advocacy campaigns such as 80% by 2018 or National Colorectal Cancer Awareness Month can have an effect.
Ultimately reaching unscreened populations will require more than advocacy, as this alone will not address people’s fundamental desire to have options—particularly those that don’t involve bowel prep or an invasive procedure—when choosing the clinical preventive services that are right for them.
GEN: What role do insurance carriers play in CRC screening?
Dr. Sclar: Clinical preventive services, like stool testing for CRC screening, occupy a unique space on the continuum between treatment services delivered exclusively through the doctor–patient relationship and public health services that are directed toward entire populations or subpopulations, often outside of a doctor–patient relationship. Clinical preventive services, like public health services, are indicated for large populations, including many individuals who are presumed healthy, do not have a doctor and may have limited contact with the health care delivery system.
But increasingly, public health institutions do not provide these services. At the same time, it is impossible to imagine today’s medical system reaching 23 million unscreened individuals through traditional delivery models. Insurance carriers have begun to fill the gap, as institutions that bear financial risk for the health outcomes of their membership, and are subject to quality ratings tied in part to delivery of these services. This means they play a key role in addressing the tens of millions of Americans who remain unscreened, particularly those who have limited or no engagement with the health care system beyond holding an insurance policy.
In addition to deploying tactics intended to increase delivery of clinical preventive services through traditional delivery models, managed care insurance carriers have pioneered the use of alternative screening models—models that extend delivery of clinical preventive services beyond traditional health care settings.
GEN: What differentiates a good alternative screening model from a bad one?
Dr. Sclar: The value of an alternative screening model lies in its ability to reach large numbers of people who have screening gaps with a high-quality screening solution. A good alternative screening model has three basic characteristics:
- Evidence-based screening: Good alternative screening models adhere to published screening guidelines, and deliver best-in-class clinical interventions at scale. In the case of CRC screening, this often means stool testing with fecal immunochemical testing (FIT). In general, these models should deliver testing that is comparable with what’s available through the traditional delivery system. The best alternative screening models have been formally studied, and their outcomes reported in peer-reviewed medical literature, as is the case with at-home stool testing for CRC screening.
- Consumer-friendly delivery: Good alternative screening models meet people where they are both figuratively and literally—often in alternative settings of care, such as their home or retail outlets. They take advantage of expertise in consumer behavior and effective engagement techniques. After all, they are often directed at individuals who have “slipped through the cracks” of the health care delivery system.
- Continuity of care: Good alternative screening models include communication to a number of stakeholders across the care continuum, not just communication to individuals who need to be screened. This includes ensuring primary care and specialty providers understand the program, assisting individuals who test positive to understand their result and to navigate the health care system, and coordinating appropriate follow-up care as needed. Properly performed, these programs can reinforce or even create a doctor–patient relationship. For many people, a positive test result is the motivation they need to designate and visit a primary care provider, and often existing patients go from refusing colonoscopy to demanding colonoscopy in light of a positive test result.
GEN: What should gastroenterologists expect and request when working with insurers that cover colon and rectal screenings? What are a few strategies clinicians can use to make working with health plans a more positive, beneficial experience—for themselves and their patients?
Dr. Sclar: A few tips for GIs when working with alternative screening models offered by an insurer:
- Request that as part of the program, the insurer takes an active role in addressing adherence, including appointment reminders and reinforcing the importance of compliance with bowel prep.
- Request that the insurer communicates information about cost sharing, or lack thereof, to members before any procedure to avoid confusion, and tell the insurer about the effect of cost sharing on your patients and your practice.
- Expect the insurer to use best-in-class screening methods, such as high-quality FIT rather than older tests, such as stool guaiac.
- Champion screening as a clinical expert: Insurers and GIs have a shared goal—screen as many eligible individuals as possible. Being a vocal champion as an in-network specialist can have an effect on screening rates.
- Identify high-risk patients: Deploy tools within your practice to systematically identify and assess patients at elevated risk—first-degree relatives of patients identified through your endoscopy suite.
- Ensure that your practice understands each plan’s coding requirements to reduce patient copays.
Read the original article in Gastroenterology & Endoscopy News.
Dr. Sclar is board certified in preventive medicine and public health and is the chief medical officer for BioIQ, a technology company that creates health improvement programs for employers and insurers.