Addressing Colorectal Cancer Screening Disparities in Ethnic Populations

R. Reid Kiser, MS National Director, Clinical Excellence UnitedHealthcare Jack Newsom, ScD Vice President, Analytics Silverlink Communications 1 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

The Colorectal Cancer Screening Challenge Colorectal cancer is the

second leading cause

of cancer-related mortality in the U.S.

According to the National Cancer Institute, more than

145,000

new cases are diagnosed and more than

49,000

people die from this disease each year Appropriate colorectal cancer screening often reveals a problem

before symptoms occur,

allowing for early diagnosis and treatment .

Regular screening

is a critical preventive measure that saves lives 2 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

2

Colorectal Cancer Screening Campaign Learning Objectives Understand the impact of

interactive, automated phone

outreach on colorectal cancer screening rates Understand how

ethnic specific messaging

can impact screening rates Examine how

engagement is influenced by the gender of the voice

in communications outreach

HEDIS Impact and Return on Investment

for resource allocation 3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

3

Colorectal Cancer Screening Campaign Approach

1 2 3 4 5 1

Members enrolled in communications received an

interactive automated call

between October 26-November 5, 2009 plus a

follow-up letter

on November 17, 2009.

2 Assignment of race and ethnicity

based on data purchased from reputable third party.

Analysis based on

3 claims data

HEDIS calculations.

4

Members were determined to have had a test if there was

no evidence of: colonoscopy, fecal occult blood test (FOBT), flexible sigmoidoscopy or double contrast barium enema (DCBE)

between November 2, 2009 and December 31, 2009.

5

Overall

77.1%

of those to whom communications were directed were

HEDIS eligible

at the end of the year and included in analyses. 4 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

4

Colorectal Cancer Screening Campaign Example Scripting

Custom Messaging



Caucasian:

And, despite colon cancer affecting so many people, only about 50% are getting screened for it. 

Hispanic/Latino:

And if you happen to be Hispanic or Latino, you’re part of a group that is least likely to have colon cancer screenings, compared with other ethnic groups.



African-American:

And if you happen to be African American, you’re part of a group that only gets colon cancer screenings about 40% of the time. 

Asian:

And if you happen to be Asian American, you’re part of a group that only gets colon cancer screenings about 34% of the time.

5 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

5

Call Engagement Correlates with Higher Screening Rates

Colorectal Cancer Screening Rates for Those Who Listened to Message

10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 5.2% 6.3% Control Group (Not Called) Called Source: UnitedHealthcare, Silverlink Communications 2010 * 6.7% Reached 7.7% 8.1% Authenticated * Listened to B2 *

*Differences are significant at the 95% confidence interval

6 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

6

Colorectal Cancer Screening Campaign Hispanics

Colorectal Cancer Screening Rates for Hispanics Who Listened to Message

15% 10% 5% 6.7% 4.8% 10.4% 11.4% 0% Woman's voice x Ethnic message Woman's voice x Standard message Man's voice x Ethnic Message Man's voice x Standard Message

N = 45, 42, 48, 35

Source: UnitedHealthcare, Silverlink Communications 2010 Note: Excludes anyone taking the call in Spanish 7 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

7

Ethnic-Specific Messaging Impact

Colorectal Cancer Screening Rates by Ethnicity

10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 8.6% 9.3% African American Source: UnitedHealthcare, Silverlink Communications 2010 4.4% 5.1% Asian 8 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

10.2% improvement with ethnic message for Latinos

8.6% 7.8% Ethnic Message Standard Message Latino 8

Female vs. Male Voice Impact

Colorectal Cancer Screening Rates by Ethnicity

14% 12% 10% 8% 6% 4% 2% 0% 10.2% 7.8% 8.0% 8.1% African American Caucasian Source: UnitedHealthcare, Silverlink Communications 2010 9 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

89.4% improvement using the male voice for Latinos

10.8% 5.7% Female Voice Male Voice Latino 9

Colorectal Cancer Screening Barriers

Colorectal Cancer Screening Barriers

45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 38% 42% 40% 36% No Symptoms 31% 25% 23% 33% 19% 30% 30% 22% Cost No Doctor Recommendation Source: UnitedHealthcare, Silverlink Communications 2010 11% 4% 8% 9% Caucasian Asian Hispanic-Latino African American  Cultural diversity can often be the basis of barriers to care.  Survey included ethnic-specific messaging and provided personalized barrier-breaking tips targeted to the member.

Afraid 10 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

10

The Impact of Barrier-Breaking Messaging on Colorectal Cancer Screening

Influencing the Resistant

Some people who

said they would not

get a colon cancer screening

actually did

after hearing the outreach.

Response to Barrier Tips

In general,

African American

members were most likely to be

screened after hearing the barrier breaking tips.

Some Barriers Easier to Break

Messaging tips for those who said they were

afraid were most successful

and tips for those who said they had

no symptoms were least successful

.

11 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

11

What’s Next for 2011 Programs and Beyond?

1 2 3 4 5 Run campaign earlier in the year to increase HEDIS impact Determine ROI and prioritize budgets to where significant gaps may exist and there is a market specific need Next stage of custom messaging Apply to other HEDIS cancer screening measures Evaluate multiple contact points throughout each year 12 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

12

APPENDIX

Do not distribute or reproduce without express

HEDIS Colorectal Cancer Screening Outreach Communications History at UnitedHealthcare

2006

Added to annual

HEDIS Interim Reminder Mailings

if member qualified for other HEDIS measure

2007

Partnership with

American Cancer Society

mailer

2008 Increased messaging

for African Americans, Hispanics and Latinos in select markets

2009

Pilot testing with

variable messaging based on race and ethnicity

data 14 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

14

Differences in Colorectal Cancer by Ethnic Population

All Races 55.8

per 100,000 men

41.7

per 100,000 women

White 55.4

per 100,000 men

40.9

per 100,000 women

African American 68.1

per 100,000 men

52.6

per 100,000 women

Asian/Pacific Islander 45.5

per 100,000 men

34.2

per 100,000 women

American Indian /Alaska Native 43.4

per 100,000 men

40.4

per 100,000 women

Hispanic 44.5

per 100,000 men

31.6

per 100,000 women

Hispanic

/

Latino

populations are

least likely to be screened.

Data from National Cancer Institute-2009

15 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

15

Colorectal Cancer Screening Campaign Overview In Fall 2009, Silverlink launched calls to

59,423

commercial members who required colorectal cancer screening Members were

grouped by race/ ethnicity

to test the impact of ethnic-specific messaging compared with standard messaging Impact of

male vs. female voices

was tested where sample size allowed UHC

provided claims information

for its members to assess the ability of the call to promote colorectal cancer screenings

51+ $

Members had to be enrolled in

fully insured commercial HMO/POS plans

, be

older than 51 years old

, and have

no evidence of colorectal screening

in the previous two years. Members from

two regions

(Southeast, “National”) were identified for interventions. 16 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Due to

budgetary constraints

, not all eligible “National” members were loaded. 16

Colorectal Cancer Screening Campaign Testing

Race/Ethnicity

Caucasian

Test

Communication No Communication

Cell Size

31,511 12,209

Region

National, Southeast National, Southeast

Race/Ethnicity

Latino

Test Cell Size

Woman Voice x Ethnic-specific Message Woman Voice x Standard Message Man Voice x Ethnic specific Message Man Voice x Standard Message 267 232 235 251 17 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Region

National National National National 17

The Highest Percentage Of Screenings Came 5-6 Weeks After The Reminder Call

Colorectal Cancer Screening Rates by Ethnicity

20% 15%

Thanksgiving for most participants

17.2% 17.8% 12.4% 12.3% 12.3% 10.4% 10% 5% 0% 1 2 Source: UnitedHealthcare, Silverlink Communications 2010 3 4 5 6

# of Weeks between Last Call and Screening Christmas and New Year

10.2% 7 7.5% 8 18 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

18