Becker's ASC Review

46 Gastroenterology W ith accountable care organizations and population health on the rise, a premium is placed on preventative care. Colorectal cancer screening has been a central focus in healthcare and gastroen- terology for years, with a significant pay-off, but more remains to be done. Four gastroenterologists offer insight into the successful history of colorectal cancer screening and what the field looks like in 2015. Question: Do you expect colorectal cancer screening rates to increase in 2015? David A. Lieberman, MD, AGAF, AGA Institute Clinical Re- search Councillor, Professor of Medicine; Chief, Division of Gastroenterology and Hepatology, Oregon Health and Science University (Portland): Colorectal cancer screening rates have been increasing steadily over the past two decades. Over the past 10 years, there has been a 30 percent reduction in CRC mortality — an incredible success story. Currently, about 65 percent of individuals over age 50 years have had some form of CRC screening. I expect these rates to continue to increase. The American Cancer Society and the National Colorectal Cancer Round- table, which includes the American Gastroenterological Association, have strongly endorsed the "80 percent by 2018" campaign. This will be a multi- pronged effort to reach the public and primary care providers. In addition, as accountable care organizations mature their products, I would anticipate a strong emphasis on preventive health measures, and chief among them will be CRC screening. Harry E. Sarles Jr., MD, FACG, President of the American College of Gastroenterology: Screening rates will increase as the population ages. Family practice practitioners are very gung-ho about referring people. There continue to be attempts, such as the effort to eliminate co-pays, to lower barriers. The ACG is now signed on with HHS and the American Cancer Society to get to the "80 percent by 2018" goal. The push for screening is really related to the fact we have such a tremendous success rate with decreasing mortality. If we continue to boost screening, we will be able to decrease the rate even further. This could be one of the most unbelievable healthcare stories in the last decade. Colleen M. Schmitt, MD, MHS, FASGE, President of the American Society for Gastrointestinal Endoscopy: I think screening rates will continue to increase. We are driving our efforts along with our sister GI societies. We are having con- versations on the Hill, with the Department of Health and Hu- man Services and we are working with the National Colorectal Cancer Roundtable to improve CRC screening efforts. Q: If CMS were to cut colonoscopy reimbursement, how could this affect CRC screening goals? Xavier Llor, MD, PhD, chair, American Gastroenterological Institute In- ternational Committee, AGA representative, National Colorectal Cancer Roundtable: This would affect screening. Colonoscopy is one of the most effective ways to detect and prevent cancer. Cuts in GI have already been hap- pening and our margins are becoming tighter and tighter. DL: Colonoscopy is at the center of all CRC screening programs, either as an initial screening test, follow-up of another screening test or surveillance in higher-risk individuals. We have emphasized the need to perform and docu- ment high-quality exams. The impact of reduced reimbursement is difficult to predict. Some healthcare systems and providers may offer alternatives to colonoscopy as a primary screening strategy for CMS patients if there is a large reduction in reimbursement. CS: Frankly, I think that would be a tragic move. We are really seeing decreas- ing colorectal cancer rates and mortality. I think reimbursement cuts could potentially reduce access to screening colonoscopies for Medicare patients. HS: This might turn the success story into a great American tragedy. Every- thing is related to access. Access for Medicare and Medicaid recipients would be adversely affected. There are physicians that ration exposure to those pay- ers. Some physicians don't even work these payers. I think others would jump on this band wagon if these cuts were to take place. Q: What do you think are some of the largest barriers to CRC screening in 2015? DL: There are several important barriers. First, and foremost, is access to care. If patients do not have a medical home and a primary care provider, they are unlikely to receive or accept CRC screening. There are still concerns and reservations about undergoing testing, which involves collection of stool samples or colonoscopy. Research suggests that these barriers can be over- come, but requires the active participation of primary care providers. There are cultural barriers that can apply to any form of screening and prevention in healthy individuals. There is poor recognition of high-risk individuals with a family history of CRC. These individuals should have more intensive screening, which often begins at a younger age. XL: Coverage is the number one barrier. Number two, we have to do a better job of spreading the word. It is important that we are reaching out to un- derserved populations and ensuring they have the proper information and access. CS: Education and awareness are obviously important. Patients are asking smart questions about physicians and procedures. I think these two issues are less of a barrier than they were before. The other barrier we are seeing is financial. ASGE has worked to eliminate co-pays for Medicare beneficiaries when a polyp is removed during a screening colonoscopy. It is also important that we educate patients about their financial responsibility. More and more offices are creating ways to work with patients to educate them on cost. Pa- tients are bringing it up more than they used to, as well. HS: There has been a bit of negative press surrounding colonoscopy. We need to be constantly aware of articles that show up in major publications. Our organization continues to work to convey the importance and value of screening colonoscopy. We are also working on eliminating co-pays and de- ductibles. Q: What can individual GI physicians do to help reach the "80 percent by 2018" goal? HS: I honestly think to achieve this goal all GI physicians have to open their doors and improve access. We need to offer complimentary screenings for the underinsured and uninsured. HHS is working on clinics to improve access. There are a lot of people involved in this. Hopefully payers will see that access is a driving factor as well. DL: I believe that GI physicians need to engage with primary care providers who are on the front lines of the screening effort to emphasize the remark- able benefits of screening. From 2000 to 2010, there has been a 30 percent reduction in CRC deaths, and some of this benefit is due to CRC screening. There is evidence that primary care providers play a crucial role in improving adherence to screening. Colorectal Cancer Screening in 2015: Achievements to Date & Hurdles Ahead By Carrie Pallardy

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