Screening Colonoscopy in the Uninsured: A Model with Widespread Applicability

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Purpose: Lack of access to screening colonoscopy in the U.S. contributes to the ˜150,000 new cases of colon cancer yearly and to the estimated 50,000 deaths per year from this disease. Establishing a system for widespread screening of the uninsured and under-insured in the U.S. is needed in order to save thousands of lives yearly and realize millions of dollars in cost savings. Methods: Gastroenterologists employed by one private practice partnered with a freestanding ambulatory endoscopy center, a local anesthesiology group and the surgical pathology department of the local hospital, to offer “one free colonoscopy/doctor/month” or ten free screening colonoscopies/month. An open access model of screening colonoscopy was employed, utilizing two local Federally Qualified Health Centers (FQHC) for referral of patients. Patient navigators at the FQHCs work closely with patients to ensure that barriers to achieving high quality screening colonoscopy are addressed—-bowel preps are provided free of charge, instructions are written and reviewed in patient's native language, transportation barriers are addressed and repeated phone calls are made to patients to ensure patient adherence to the schedule. Results: From May 2010 through May 2011, 104 patients were scheduled for a “No Cost Colonoscopy”. 96 patients completed a high quality exam. Seven patients failed to keep their appointment (“no-show” rate = 6.7%), one patient exam could not be completed secondary to technical problems. Adenoma detection rate was 42.7%, advanced adenoma detection rate = 4.2% Interview of all providers revealed that the small volume of donated procedures had minimal impact on finances. Each gastroenterologist donated <1% of his/her procedure time per year; the endoscopy facility donated 1.6% of its procedure slots to the uninsured. Physician satisfaction with the program correlated directly with patient compliance. Close collaboration with patient navigators was a key element contributing to the success of this program. Conclusion: There is a clear public health imperative for making screening colonoscopy available on a widescale basis. We have shown that with limited infrastructure and with reliance on patient navigation, ambulatory endoscopy centers partnering with local physicians can provide high quality, screening colonoscopies to the uninsured with minimal financial impact on providers. Implementation of this model at endoscopy centers across the country would have a major impact on national colonoscopy screening rates, would result in thousands of lives saved and would realize millions of dollars in health care savings.

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