BeneFIT: A Mailed FIT Program to Increase Colorectal Cancer Screening in Two Medicaid/Medicare Health Insurance Plans Qualitative Learnings from BeneFIT’s First-Year Implementation Laura-Mae Baldwin Jen Schneider Malaika Schwartz Jen Rivelli Bev Green Amanda Petrik Gloria Coronado 11 th Annual Conference on the Science of Dissemination and Implementation in Health December 5, 2018
Ac Acknowled edgem emen ents § The authors thank the health insurance plans that have worked with the study team as they implemented mailed FIT programs to improve colorectal cancer screening in their enrollee populations. § This presentation is a product of a Health Promotion and Disease Prevention Research Center grant supported by Cooperative Agreement Number U48DP005013 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Wha What t is is Be BeneFIT? § A colorectal cancer screening program, § administered by Medicaid/Medicare health insurance plans, § that mails fecal test kits to eligible enrollees, § aiming to increase colorectal cancer screening
Wh Why Be BeneFIT? § Timely colorectal cancer screening saves lives, but screening rates remain well below the Healthy People 2020 target of 70.5% 70% 62.2% 60% 47.4% 50% 40% 24.8% 30% 20% 10% 0% Privately insured Medicaid-insured Uninsured
Wh Why Be BeneFIT? § US Preventive Services Task Force recommends CRC screening with any of a number of approaches -- Annual fecal testing (gFOBT, FIT, FIT- DNA) -- Sigmoidoscopy -- Colonoscopy -- CT colonography
Po Population-Ba Based M Mailed F FIT P T Progr ograms ar are Effectiv tive § Clinics and health care systems have increased CRC screening rates by using population-based mailed fecal immunochemical testing (FIT) programs Screen to Prevent (STOP) Colorectal Cancer Smart Options for Screening (SOS) Trial Proportion Current for Screening Over 2 Years 80% 60% 40% 20% 0% Usual Care (1,166) Mailed FIT Only (1,169) Mailed FIT + Phone Assistance (1,159) Mailed FIT + Phone Assistance + Navigation (1,170)
Ov Overcom omin ing im imple lementation tion ch challe allenges s by mo moving ng ma mailed d FIT T pr programs ms to the he level of f the he he health h insur nsuranc nce pl plan n § Health plans have: § QI departments that regularly conduct population management programs § Relationships with vendors § Access to claims data for identifying enrollees eligible for CRC screening § Motivation to improve care quality § Published performance on quality measures § Incentives (e.g., Medicare five-star program)
BeneFI Be FIT study team worked with two health insuran in ance ce plan lans in in WA A an and OR OR to o develop lop an and im imple lement t maile ailed FIT prog ogram ams § Study team provided expertise to the quality teams at the health plans § Quality teams designed their own programs to fit their contexts § The health plans developed two very different models § Studied the implementation process to provide guidance to health plans interested in developing their own mailed FIT programs
Be BeneFIT Or Oregon: A Collaborative model Medicaid Health Print Vendor Plan Health Health Health Center 1 Center 2 Center 3 FIT kit returned Claim received
BeneFIT Wa Be Washington: A Centralized Model Kit Ordering/ Medicaid Health Print/Mail/ Plan Follow-up Vendor Clinics/PCPs Centralized Lab Positive results received FIT kit returned Claims received Results received
Me Methods § Consolidated Framework for Implementation Research (CFIR) used as the guiding framework. § In-depth interviews with all health plan leaders/staff (5 in each plan) instrumental in designing and executing the mailed FIT programs 6-9 months after implementation. § The interviews explored: -- implementation activities -- challenges and successes related to implementation -- enrollee and provider reaction/feedback -- strengths and weaknesses of the program model -- reaction to initial program results -- reflections on improvements. § Interviews were audio-recorded and transcribed
Me Methods § Transcripts from interviews were -- formally coded in Atlas.ti -- content analyzed for themes -- stratified by state, since the programs had such different models § Triangulated results using other data sources: -- field notes during planning meetings between health plans and study team -- internal research team debrief meetings
Ch Challenges i in k key a y areas Program design § time consuming to set up § some health centers or providers didn’t want to participate “At the very beginning we did have a few provider groups that opted out because they were already providing kits to their members.” Vendor Experience “The largest barrier we encountered was § complex/time around patients receiving the FIT kits from the vendor…it took longer than we consuming to work anticipated for the pre-letter mailing to go with vendors out [from vendor]… and unfortunately the kits were not mailed out [by vendor] until § vendor delays a month after the pre-letter went out.”
Challenges in Ch in key ar areas as Engagement and Communication § lack of communication across the health plans about the program “The customer service people at [health plan] didn’t really know about the program and should have because they would get [member] phone calls – so we should have written something up for them beforehand.” Reaction/Satisfaction of Stakeholders § patient and provider resistance to FIT and CRC screening “There is still that resistance to using FIT out there in some areas…we had one health center group that had very little penetration of patients touched by the BeneFIT program, and [in those] we have a high percentage of clinics where provider groups are still pushing colonoscopy.”
Ch Challenges sp s specific t to t the Co Collaborative M Model Program design -- kits were sent to patients who hadn’t yet established care in the clinics Processing/Returning of Mailed Kits -- unestablished patients completed kits, but they could not be processed
Ch Challenges sp s specific t to t the Ce Centralized M Model Vendor experience -- difficult to oversee vendor adequately to make sure all program processes being followed as expected Engagement and Communication -- lack of health plan staffing to conduct follow-up that was planned for positive FITs Reaction/Satisfaction of Stakeholders -- providers/health centers wanted to know results before data available
Mo More e succes esses es than challen enges es Program design -- flexibility to design to context Reaction/Satisfaction of Stakeholders -- health plan enrollees appreciative and engaged Processing/Returning Mailed Kit -- established workflows -- early results showed more enrollees screened
Mo More e succes esses es than challen enges es Compatibility with Health Plan § fit health plans’ mission and goals “From a program perspective I think it gets to what is needed and necessary for improving access to the tests and for more testing to be completed – so as a program it runs well.” “This whole approach of collaboration…is another big driving factor for this… [Health plan] has a really strong ethos of working with clinics to help their patients get healthier and to push out preventive care.”
More Mo e succes esses es than challen enges es Broader Impacts § provided roadmap for other population health efforts § increased engagement with enrollees “Members were very appreciative…We often don’t get a sense of member [satisfaction] but through this we were able to do a lot of member outreach.” § increased awareness of providers and patients of health plan quality efforts “Providers are very grateful that this is just another way that we can tap into getting them in for screening…and the resources required at clinic level were so low… …and another success is that we are getting more provider engagement around the intervention and understanding around what we are doing here in the quality department .”
Con Conclusion ons § Supporting the health plans with resources and expertise allowed their development of mailed FIT programs highly adapted to their culture and resources. § Program implementation challenges were focused largely in two domains of the Consolidated Framework for Implementation Research § Characteristics of the intervention -- time consuming § Outer setting – vendor challenges
Con Conclusion ons § Program implementation successes were focused in CFIR domains of: § Inner Setting § leveraged existing health plan QI staff and processes for the program and to identify eligible enrollees for program § Outer Setting § strengthened relationships between health plan and health systems and patients § built on existing vendor relationships
Con Conclusion ons § Documenting shared as well as individual successes and challenges from health plans using two very different implementation models can guide health plans in adapting these programs to their own culture and resources, and prepare them for potential obstacles.
Fo For more information, contact: Laura-Mae Baldwin, MD MPH University of Washington lmb@uw.edu
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