Table 3.
Illustrative Quotations Regarding Determinants of SDM for LCS Implementation
| Determinants of SDM for LCS Implementation | Quotation No. | Illustrative Quotation (Study Respondent Letter) |
|---|---|---|
| Health system characteristics | 1 | “Our program is a decentralized program. Our university, hospital, and clinic are part of a larger health system in the metropolitan area, which, uh, has several, I think four or five hospitals over a probably 100-mile range and many, many clinics. . . . So because our system is decentralized we never really felt like it was feasible to have a screening clinic and that was never really considered an option.” (19A) |
| 2 | “Our program was developed of using mid-level providers, and we have a very large organization so training all the physicians of all the requirements of the SDMs did not seem to be a feasible task.” (1B) | |
| 3 | “The [name of state] grant opportunity which has been going on for two previous years and now we just got funding, to help integrate the smoking cessation and the lung cancer screening. And that has allowed us to have a programmer, uh myself, another MPH person, to really track the data feedback information to, the lung cancer screening clinic.” (1A) | |
| Available resources and budgetary considerations | 4 | “We looked at the cost of our staffing. We looked at the cost of IT stuff, you know, they would need laptops, and how to present the PowerPoint. We looked at the cost of the brochures and everything we need to hand out to the patients. We looked at the cost of how much we’re gonna get reimbursed per CT, how much you’re gonna be reimbursed per SDM, and then, we looked at the benefits to the patients and we looked at the downstream that could come from all this, and we decided as a health system hiring nurse practitioners that do shared decision-making visits wasn’t cost effective. Instead what would be the best use of everyone to the highest level they’re licensed.” (2A) |
| 5 | “The other sites literally don’t have the manpower or they didn’t have the financial buy-in from administration to do the shared decision making visit . . . . I’m in a position where I can see the difference between how we as an academic center try to do it vs how the community hospitals who are affiliated with our health system do it.” (12A) | |
| 6 | “We do have some grant funding from a local grant fund[er]. I think we would love to increase our federal funding for lung cancer screening. Just to make sure we could increase our capacity. We also need funding that could help us partner with other clinics and hospitals to increase capacity to at-risk populations, a lot of whom don’t interact with health care systems with a regular basis, so really if we really want to impact health disparities, funding that helps us extend our community outreach to reach people.” (16A) | |
| 7 | “We did allocate our thoracic oncology navigators to be part of the lung cancer screening program and they are the ones who kind of keep track. We did also allocate some time for our cancer registrar to maintain the registry.” (6B) | |
| 8 | “We hired a nurse practitioner, who’s excellent, and also expensive. The challenge is keeping her employed because, while she generates a lot of revenue for the health system through surgeries and scans etcetera, she’s actually housed in the Department of Pulmonology, which in the cancer center that doesn’t really directly see that revenue. So, we have to keep advocating and reminding people that she is making money for the health system in general, and she may not be putting money in the cancer center specifically, but she’s generating and causing, several life-saving cancer surgeries.” (7A) | |
| 9 | “I’ve spent a lot of time with nurses from various, outlying clinics to teach them that. The problem is there’s enough turnover in that position that every few years I have to go out and teach it all over again.” (13A) | |
| External policy incentives | 10 | “We work with compliance to make sure that we’re meeting the Medicare, um, like our internal compliance officer to make sure we were meeting Medicare’s rules, and were covered of um, you know, reimbursements and uh, violating all of those CMS policies, um, by having all those attestations statements on the statements that the ordering provider has to sign.” (2A) |
| 11 | “Um, so we were moving towards a closed program, uh, with visits before CMS’s mandate but, CMS’s mandate helped to accelerate that and, uh, allowed us to justify it with our, you know, with our health system and the primary care community.” (21A) | |
| 12 | “While the Medicare patients have to have it done in order to reimburse[], we feel that it is important that all patients to have one, and we sort of consider that our standard of care.” (5A) | |
| 13 | “CMS doesn’t pay for patients who are in the upper USPSTS-recommended age range so we’re gonna put a note on it, just, you know, make sure folks are aware that if they order it for those older patients CMS won’t cover the payment for the, for the test.” (8B) | |
| 14 | “I think just in the general sense that CMS criteria and USPSTS criteria are different. That just adds confusion for people as well.” (17A) |