By Jessica Ganchrow Senior Director, Operations, ComplexCare Solutions

For health plan quality teams - key points:

• The HEDIS COL measure requires a completed, returned specimen - not just kit delivery
• The dominant failure mode is abandonment, not refusal: members who don't complete FIT kits typically deferred rather than declined
• In a Medicare Advantage Pilot, only 29 percent of patients who received a mailed FIT kit returned a completed specimen - and the authors noted this was on the higher end of what programs typically achieve
• Securing member buy-in before a kit ships, and reinforcing it with a clinician during an in-home visit, removes much of the friction that makes deferral possible
• COL is a required HEDIS measure across all three lines of business, with national completion rates of 64% for Medicare and 39% for Medicaid in measurement year 2023

The kit is somewhere in the house. Probably on the kitchen counter, or in the bathroom cabinet, or tucked into the stack of mail near the door. It arrived on time. The member held it, recognized what it was, and set it down with every intention of completing it. Later. When things settle.

The measurement year ends. The specimen was never returned.

Colorectal cancer is the second leading cause of cancer death in the United States. The evidence for screening is unambiguous. Health plans have invested in COL outreach: kit ordering systems, mailing infrastructure, provider reminders, member follow-up campaigns. And every year, many of those kits arrive at the right address and sit there - not because the member refused, but because there was no moment when completing it became more urgent than deferring it.

That's an abandonment problem. Mailing a kit doesn't fix it.

Members Don't Refuse FIT. They Defer It.

The FIT requires a small stool sample, collected at home, sealed and returned by mail - no fasting, no lab appointment, no clinician involvement. That convenience is precisely what makes the failure mode so persistent. When a test can be done anytime, it can always be done later. The FIT kit is not refused. It is deferred, then forgotten, then discovered at the bottom of a stack of papers in a measurement year that has already closed.

In a Medicare Advantage pilot, only 29 percent of patients who received a mailed FIT kit returned a completed specimen - and the authors noted this was on the higher end of what programs typically achieve. In safety-net and Medicaid settings, return rates are often closer to 12 to 20 percent. Those members weren't declining screening. They received the kit, and they stopped there.

For a health plan running outreach at scale, that's the majority of a mailed-kit population never crossing the finish line, and it shows up directly in Star ratings, state P4P payments, and QRS scores, not just in a count of kits shipped.

The problem isn't the member, and it isn't the kit. It's a model that treats delivery as the intervention when delivery is only the beginning.

The Measure Closes When the Specimen Returns

The HEDIS Colorectal Cancer Screening measure requires a completed and returned specimen documented within the measurement year. A kit ordered does not satisfy it. A kit mailed does not satisfy it. The gap closes when the specimen comes back.

This creates a structural problem for outreach programs that measure their own success by kits shipped. A provider reminder can be sent, a kit can be ordered, and the kit can arrive at the member's home - all of which represents genuine investment - while the COL gap remains open. The behavioral gap between intent and action isn't a problem that a better kit or a cleaner mailing can address. What closes it is a moment of human contact that turns a passive delivery into an active commitment.

What Changes the Outcome: Buy-In Before the Kit Ships, and a Clinician During the Visit

CCS's approach to COL gap closure centers on removing the moment where a kit becomes a "counter kit" - delivered, set down, and never touched again.

In-Home Assessment. The process starts before the kit ever arrives. When a member's visit is scheduled, CCS's scheduling team confirms with the member that they want the kit and explains why it matters - so the member is agreeing to complete a screening, not just accepting a package. That upfront buy-in is what keeps a kit from becoming a counter kit in the first place. The kit itself typically arrives ahead of the visit, and during the in-home assessment, an Advanced Practice Clinician reinforces why the screening matters, walks the member through each step of the collection process in person, and answers questions in real time. The member self-collects the specimen (that's the nature of the test), but the clinician's presence closes the gap between "I have this kit" and "I understand what to do with it and why it matters now."

Health plans have already made substantial investments in in-home programs: scheduling infrastructure, clinician networks, documentation workflows. CCS's approach adds COL gap closure to visits and scheduling conversations that are already happening, without requiring a parallel outreach infrastructure.

Direct-to-Member Mail Kit. Not every member is eligible for or reached through an in-home assessment, and a direct-to-member mail kit has real value for that population, including as a year-end effort to close remaining gaps. The same scheduling-time buy-in applies here too: members agree to receive and complete the kit before it ships, rather than a kit arriving unrequested. From there, CCS works with a testing partner whose program is built around kit return: reminder outreach across calls, text, and mail, with CCS monitoring outreach activity and confirmed returns through partner reporting. This model won't outperform a clinician standing in the room, and it isn't meant to; it's the right tool for members the in-home model doesn't reach.

The Case for Closing COL Runs Through What Happens When You Don't

COL is a required performance measure in NCQA Health Plan Ratings across all three lines of business: Commercial, Medicare, and Medicaid. HEDIS national average completion rates in measurement year 2023 were 64 percent for Medicare, 56 percent for commercial, and 39 percent for Medicaid - and those figures represent any qualifying colorectal screening, not FIT alone. The share who received a mailed kit and returned it is lower. That gap, between "any qualifying screening" and "mailed FIT kit returned," is where most plans are losing performance points.

The clinical stakes are straightforward: colorectal cancer detected at Stage I carries a five-year survival rate above 90 percent. At Stage IV, that figure falls below 20 percent. Treatment costs follow the same curve - incremental per-person costs for advanced-stage disease exceeded $47,000 in a study across two state Medicaid programs. For a plan carrying even a few hundred open COL gaps, that's not an abstract quality metric. It's a direct line to avoidable medical cost, on top of the outcomes at stake. Every open COL gap is a member whose cancer, if present, goes undetected. Each measurement year a kit goes unreturned is another year the clinical window narrows.

For Medicare Advantage plans navigating the threshold between 3.5 and 4 Stars, every measure trailing the cut point matters. For Medicaid plans, the 39 percent national rate reflects an enormous gap in a population for whom mailed outreach alone has repeatedly proven insufficient - members who aren't unwilling, but who face the accumulated friction of managing competing health priorities without the structure that makes follow-through more likely. For commercial and ACA plans, COL performance is consumer-visible through QRS ratings, and below-average performance on a well-established preventive screening is a reputational liability.

Raise the Standard from Kit Mailed to Specimen Returned

Health plans have invested in colorectal screening outreach, and those investments have closed gaps for members who follow through on their own. For the members whose kits arrived and never came back, they didn't reach the finish line.

CCS's standard for COL gap closure is the returned specimen, not the mailed kit. A member who completed the test during an in-home visit, or whose mailed kit return has been confirmed, has had their gap closed. A member who received a kit in the mail and hasn't been heard from since hasn't. That's the standard your quality program should hold.

Frequently Asked Questions

What is the HEDIS Colorectal Cancer Screening (COL) measure?

The Colorectal Cancer Screening measure - designated COL-E in recent NCQA measurement years - tracks whether health plan members aged 45 to 75 completed appropriate colorectal cancer screening during the measurement year. Qualifying methods include a fecal immunochemical test (FIT), colonoscopy, CT colonography, and other methods specified in the NCQA measure definition. The measure applies across all three lines of business: Commercial, Medicare, and Medicaid. A completed, returned specimen is required to satisfy the measure - kit delivery alone does not close the gap.

How does CCS measure success for mail-based FIT outreach?

CCS tracks confirmed specimen return, not kits shipped. Our testing partner manages outreach attempts and return reminders, and CCS monitors that activity - including live contact and confirmed returns - through partner reporting, so success is measured by actioned gap closure rather than mailing volume.

Why do so many members receive FIT kits but not return them?

The failure mode for FIT is abandonment, not refusal. FIT's simplicity - a screening the member can complete at any time, at home, at their convenience - is also the source of its completion problem. Because it can be done anytime, it is easy to defer to a future moment that never arrives. Members who don't return a FIT kit typically intended to complete it. The behavioral gap between intent and action is the problem that standard mailed outreach was not designed to close.

How does CCS support FIT completion during an in-home visit?

The FIT kit typically arrives ahead of the in-home assessment, and an Advanced Practice Clinician reinforces why the screening matters and walks the member through each step of the collection process in person. The member self-collects the specimen - FIT requires member collection and cannot be completed by the clinician - but the clinician is present to explain the steps, answer questions, and make sure the member understands what's needed to complete and return it. For members who aren't eligible for an in-home visit, CCS supports a direct-to-member mail kit option, with member buy-in secured at scheduling and a testing partner managing return reminders.

Does the HEDIS COL measure apply to Medicare Advantage, Medicaid, and commercial health plans?