Two Models for Improving Colorectal Cancer Screening Rates in Health Plan Populations

Background: Screening decreases colorectal cancer (CRC) incidence and mortality by 30%–60%; however, CRC screening rates remain low among minorities and low-income individuals. No available data shows the effectiveness of a direct-mail program initiated by health insurance plans that serve these populations. The BeneFIT study supports two health plans implementing a program that mails fecal immunochemical tests (FIT) to patients’ homes. Methods: We present the implementation models and decision factors about participating in BeneFIT. BeneFIT involves two health plans: one in a single state with ~250,000 enrollees, another in multiple states with several million enrollees. These health plans are using two distinct models to implement BeneFIT. Results: One health plan is using a collaborative model. A vendor centrally mails the FIT kits and reminder letters; completed FITs are returned to the clinic, where labs are ordered. This model reduces staff burden while still enabling clinics to use their standard lab, follow-up and referral processes. Early implementation challenges have been logistical issues for smaller clinics, the need for lab vendors to provide free kits (claims pay for processing of completed FITs), and data issues with patient-clinic assignment lists. The other health plan is using a centralized model. A vendor orders and mails the FITs and conducts reminder calls; a central lab receives completed FITs and sends results to the vendor, which notifies the patient-assigned clinic. The plan uses its care coordinators to follow-up positive FITs. The model has economics of scale for administration and plan-based follow-up of FIT results. Challenges to implementation have been incomplete prior CRC screening data and possible redundancy of screening. Baseline qualitative interviews with the health plans identified motivations to participate including increasing patient education, the possibility to improve screening rates and health outcomes, and the opportunity to translate a promising approach to an underserved population and formally evaluate the results. Factors that could affect future health plan decisions to maintain the direct mail approach include return rates, staff and resource requirements, and provider/patient satisfaction with the BeneFIT program. Conclusion: Weighing the successes and challenges in these two plans will help decision makers choose between outreach strategies for CRC screening