New Directions: The Future of Cancer Screening
In 1990, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established to increase breast and cervical cancer screening among low-income, uninsured, and underinsured women. Twenty years later, the NBCCEDP has a substantial infrastructure across the nation and effective systems to reach underserved communities and assure timely follow-up and treatment.
The NBCCEDP is CDC's core cancer screening program. Since it was started, the NBCCEDP has been designed to serve women in the United States who don't have health insurance. The program's reach has been quite significant over the last two decades, providing more than 10 million screening tests to more than 4 million women. The program reaches many underserved women, and plays an important role in reducing screening disparities across different populations.
The NBCCEDP also has substantial capacity, with a network of more than 22,000 clinical providers in—
- Community health centers and federally qualified health centers (FQHCs).
- Private practices.
- Health plans.
- Cancer centers.
- Tribal health clinics.
- Local health departments.
- Minority health clinics.
- "Safety net" hospitals.
The NBCCEDP funds every state in the U.S. to provide screening services, as well as 11 tribes and five territories. Each health department works with an extensive network of clinical providers to provide these services.
CDC funded the Colorectal Cancer Control Program (CRCCP) in 2009. The CRCCP's real emphasis is on population-based screening promotion. The 25 states and four tribes in the program use evidence-based interventions to increase colorectal cancer screening rates among men and women between 50 and 75 years old.
CDC is also interested in fostering collaborations between state health departments and state Medicaid and Medicare programs. For example, in Minnesota, the state Medicaid program identifies unscreened individuals through its claims database, and the state health department sends them invitations, reminders, and incentives to be screened.
The Impact of Health Care Reform on Breast and Cervical Cancer Screening
Health care reform through the Affordable Care Act (ACA) will increase access to breast and cervical cancer screening services for many low-income, underserved women through expanded insurance coverage and eliminating cost-sharing. Other provisions of the ACA and the American Reinvestment and Recovery Act (ARRA, the stimulus bill) will also improve delivery of these essential services by improving health care quality and driving wider adoption of electronic health records. However, all ACA provisions will not be implemented until 2015 and some effects will take longer. Currently, even with adequate health insurance, many women will still face substantial barriers to obtaining breast and cervical cancer screening like geographic isolation, limited health literacy or self-efficacy, lack of provider recommendation, inconvenient times to access services, and language barriers.
The Role of Public Health in Organized Cancer Screening
CDC and other public health agencies now have an unprecedented opportunity to embrace new roles that build on the NBCCEDP's capacity and extensive clinical network. Much of this work can focus on assuring the delivery of clinical preventive services. Widespread participation in screening and aggressive outreach to underserved communities with a disparate cancer burden can be achieved through the following population-based approaches—
- Public Education and Outreach: Educate women about breast and cervical cancer screening through traditional media and new communication avenues like social media. Increase the use of peer educators and patient navigators to help women in underserved communities adhere to cancer screening recommendations.
- Screening Services and Care Coordination: Provide screening services to women not covered by the ACA's new insurance provisions, particularly in states that do not expand Medicaid eligibility. Help all women who have positive screening results get appropriate follow-up tests and treatment.
- Quality Assurance, Surveillance, and Monitoring: Use state and local health departments' existing infrastructure to monitor the provision of screening services in every community. Develop electronic reporting mechanisms for use in aggressive management of cancer cases found through screening tests. Expand CDC's quality assurance system to other health care settings like federally qualified health centers. Use new resources like health information exchanges to monitor screening and follow-up.
- Organized Systems: Develop more systematic approaches to cancer screening to organize health care providers' efforts. Take a more central role in developing the infrastructure for systematic approaches—such as population-based screening registries—to identify eligible adults who need to be screened, and manage the screening process. Work with state Medicaid programs and state insurance exchanges to promote, coordinate, and monitor cancer screening.
As public health agencies develop aggressive approaches to improve cancer screening through the NBCCEDP's infrastructure, this will provide a foundation for future expansion to other clinical preventive services.
CDC Program Activities Related to Health Care Reform
CDC has implemented several new activities to prepare for the implementation of health care reform and expand the impact and reach of our cancer screening programs. As the ACA and related efforts are implemented, CDC and its state program partners will continue to look for possible gaps that can be filled by their programmatic activities.
- Colorectal Cancer Control Program (CRCCP): Up to one-third of the funds provided through the CRCCP may be used to pay for screening. The remaining funds are used to implement population-based approaches to increase screening among both insured and uninsured populations, such as patient and provider reminder systems, nurse referral protocols, and patient navigation systems.
- Study on the ACA's Impact: CDC funded George Washington University to estimate the ACA's impact on expanded insurance coverage rates and on clinical preventive services provided for NBCCEDP- and CRCCP-eligible populations. The results of these analyses [PDF-149KB] provide data on the size and characteristics of the population that will not have health insurance in 2014 and beyond.
- Medicaid Collaboration Planning Grants: CDC supports the National Association of Chronic Disease Directors to work with Michigan, North Carolina, and Washington to plan collaborative approaches to improve cancer screening rates in their state Medicaid programs. These programs will develop policies that facilitate organized cancer screening programs for Medicaid enrollees, and move NBCCEDP patients into state Medicaid programs as Medicaid eligibility criteria are expanded.
- Collaboration with the Health Resource and Service Administration (HRSA): Many FQHCs are NBCCEDP and CRCCP providers. Grantees are expanding their work by collaborating with state primary care associations and FQHC networks to implement evidence-based approaches to increase cancer screening. At the federal level, CDC and HRSA are working together to address colorectal cancer screening rates as a Uniform Data Set (UDS) quality measure for all FQHCs.
- Innovative Demonstration Projects: CDC supports large-scale demonstration projects in two state health departments to develop data systems and systematic outreach for active screening recruitment and follow-up in a state Medicaid program, and to develop and implement cancer screening registries in a statewide system of FQHCs.
- Care Coordination Funding: Supplemental funding was awarded to 11 grantees in fiscal year 2010 to demonstrate new roles in early breast and cervical cancer detection through targeted outreach, patient navigation, and case management. This two-year demonstration project explored ways to use proven cancer-related patient care coordination programs in new settings and evaluated their cost-effectiveness.
- NBCCEDP Promising Practices Assessment: Non-screening practices that increase quality cancer screening in the NBCCEDP are being documented so they may be used for newly insured populations under the ACA. The three program areas include health education and promotion, quality assurance and quality improvement, and case management and patient navigation.
- NBCCEDP Waiver Demonstration Project: This two-year demonstration project in Washington, Massachusetts, and Utah assesses the feasibility of waiving the mandates to provide screening services so that more federal resources can be used for non-clinical activities like patient navigation, public education, and outreach.
The National Prevention Strategy and Breast Cancer Screening
Moving Forward in an Era of Reform
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