During the past 22 years, the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has provided high-quality breast and cervical cancer screening to low-income women who do not have health insurance or who have inadequate insurance. State health departments, tribes and tribal organizations, and territory grantees who receive CDC funding have contracted with local clinical provider systems to provide breast and cervical cancer screening to medically underserved, low-income women. The program is legislatively mandated (Public Law 101-354) to use at least 60% of federal funds to pay for direct clinical services, and up to 40% may be used for nonclinical activities that support screening services. The articles in this supplement provide important documentation about the history of the NBCCEDP and illustrate the components and activities of its public health-based organized screening model. As the health care landscape changes, it is time for CDC to address newly identified needs and opportunities to increase cancer screening and further explore new or expanded roles for the program in the future.
The NBCCEDP is the only nationally organized breast and cervical cancer screening program in the United States—one that has successfully weathered the test of time by effectively serving diverse populations of women through public health and primary health care delivery systems established across the entire country through states, territories, and tribes. This program was designed on the basis of a public health model that spans the cancer screening continuum from raising awareness among women about the importance of getting screened to assuring timely diagnosis and appropriate treatment referral for women diagnosed with cancer. The program's services have integrated patient tracking and surveillance to continually monitor screening and outcomes, as well as to assess and ensure the quality of screening services provided. These data are used in the evaluation of the program's effectiveness, as well as to provide performance feedback to grantees and providers based on nationally established program quality standards.[3, 4]
The US Health Care Environment
This is a critically important and pivotal time for the US health care system. Cost is frequently cited as a barrier to cancer screening among low-income women. The Patient Protection and Affordable Care Act is increasing access to health insurance coverage for millions of people, including coverage of the United States Preventive Services Task Force recommended clinical preventive services with no cost sharing, such as breast and cervical cancer screening (§1302). This will substantially increase access to cancer screening services by removing important financial barriers.
However, it is well documented that financial barriers are not the only barriers to seeking cancer screening or needed medical care; thus, having insurance coverage alone is inadequate. Limited health literacy or self-efficacy, language barriers, lack of knowledge about screening, fear of cancer, and geographic isolation are common patient barriers that will not be addressed by improved health insurance coverage alone.[9-11] In addition, the lack of a provider recommendation for screening, structural barriers such as inconvenient clinic times, and the lack of an organized system for screening are common barriers related to the health care system.[9-11]
A fragmented and opportunistic US health care system presents challenges to systematically bringing women in for screening and ensuring the delivery of high-quality screening and timely follow-up, whether they have health insurance or not. Typically, cancer screening is recommended when a patient visits her health care provider; however, a busy physician's office focused on the primary reason for her medical visit may overlook making recommendations for needed preventive health services. Moreover, low-income, disadvantaged women who are not current participants in the health care system and who do not have a primary care physician or medical home, may not regularly use preventive health services such as cancer screening. These women need to be reached with education in the communities where they live and encouraged to make appointments for cancer screening. For established patients, many physicians' offices may not have systems in place to remind providers or women to make appointments for screening. These factors call for partnerships between public health, communities and the health care system to leverage each other's expertise, connections, and resources to implement more organized and coordinated efforts to increase use of clinical preventive services, which include cancer screening.
Public Health's Role in Cancer Screening
The Institute of Medicine (IOM) has noted that “public health's broad mission of ensuring healthy communities requires interactions among a number of health-influencing actors, such as communities, businesses, the media, governmental public health, and the health care delivery system.” A recent IOM report on the integration of primary care and public health specifically discussed colorectal cancer screening as an area in which primary care and public health could collaborate, which in turn has implications for breast and cervical cancer screening. The report noted the potential role of patient navigators in primary care clinics that could be supported by public health, the importance of health information technology in meeting the needs of both individual- and population-level health, and the emerging concept of a medical home supported by community health teams.
The NBCCEDP is well positioned to build on its experience, established clinical and community partnerships, and successes in serving disadvantaged and diverse populations to address many of these important barriers to cancer screening. In addition, the program can adapt its extensive experience with establishing and managing an organized system of delivering cancer screening for low-income women and apply it to promote a more organized approach to screening through health care systems on a larger population level.
Transitioning to New Roles
In anticipation of the Affordable Care Act, CDC reviewed the current status of cancer burden and screening rates in the United States, the strength and capacity of its screening programs, and the needs and opportunities to increase appropriate screening on a population level.[15, 16] A more organized systems approach to cancer screening may effectively further the goals of increasing cancer screening and ensuring quality screening. This approach would include determining baseline screening rates in health care systems; monitoring changes in screening rates; actively inviting women through screening reminders; raising awareness and facilitating connection to cancer screening through community-based media strategies, education, and partnership strategies; conducting targeted outreach to disadvantaged populations with low screening rates; supporting cancer screening, follow-up, and treatment through patient navigation; and tracking screening and follow-up to ensure quality standards are met. In addition, innovation using electronic health records and screening registries should be explored with priority for use of the effective interventions recommended in the Guide to Community Preventive Services as well as implementing promising practices that incorporate evaluation.
The CDC has invested in several projects during the past 3 years in collaboration with grantees, partners, and stakeholders to estimate the potential impact of health reform on the NBCCEDP, and to help define future roles and needs for the NBCCEDP.
Analysis of “Health Reform and Women's Insurance Coverage for Breast and Cervical Cancer Screening”
This study assessed the number of low-income, program-eligible women who will remain uninsured by using a model based on the implementation of health reform in Massachusetts and current program eligibility criteria. Assuming full implementation of the Affordable Care Act including Medicaid expansion and the health insurance marketplace in all states, it was estimated that 4.5 million women would still be eligible for cervical cancer screening and 1.7 million women would be eligible for breast cancer screening through the NBCCEDP. This population is estimated to include a higher proportion of women with limited English proficiency, those with lack of a high school education, and those who are racial or ethnic minorities. This study indicated there will likely be continued need for the NBCCEDP to screen disadvantaged women; moreover, the public health components of the program will become more critical because the women who will remain program-eligible may likely be more challenging to find and recruit into screening.
NBCCEDP Care Coordination Project
Case management and patient navigation have been an integral part of approaches used by NBCCEDP grantees to assist women in receiving high-quality breast and cervical cancer screening and follow-up services. To demonstrate how public health may collaborate with health care system partners to implement care coordination models, CDC provided additional funds to 11 grantees to: 1) create and implement changes in health care organizations' systems and policies to improve the coordination of cancer prevention and early detection activities, and 2) extend existing patient navigation and case management services into larger health care settings to reach women not currently served by the NBCCEDP.
This demonstration project showed that NBCCEDP grantees are well positioned to integrate the program's nonscreening components such as patient navigation into existing health care provider systems to alleviate barriers to care and improve population-based screening. Three recommendations for public health to extend the application of their expertise based on this project are: 1) become familiar with the infrastructure for serving persons through population-based approaches, 2) develop a set of quality standards for patient navigation service delivery; and 3) develop appropriate performance provider incentives for data collection and use of data for quality improvement.
Medicaid Collaboration Demonstration Grants
State Medicaid programs and Federally Qualified Health Centers (FQHCs) are critically important partners to reach disadvantaged populations. Eight states received small CDC-funded planning grants through the National Association of Chronic Disease Directors to collaborate with their state Medicaid programs to conduct strategic planning for increasing cancer screening among their enrollees. The purposes of these grants are to explore and plan: 1) policies that facilitate organized cancer screening for Medicaid enrollees, 2) processes needed to transition NBCCEDP clients into state Medicaid programs as eligibility criteria are expanded, and 3) data systems to monitor screening, diagnostic follow-up, and outcomes. These projects are in progress to identify opportunities and challenges that will guide and support successful collaborations with Medicaid to increase cancer screening in the future.
Collaboration With Federally Qualified Health Centers (FQHs)
Many FQHCs and community health centers participate in the clinical provider networks of the NBCCEDP. NBCCEDP grantees are expanding their work with FQHCs by collaborating with a larger number of clinics to increase cancer screening and by partnering with state Primary Care Associations. The performance of FQHCs in the Health Resources Services Administration's Uniform Data System measures provides baseline measurements of screening rates and allows for identification of gaps and the setting of targets to increase cancer screening.
New CDC-Funded Innovation Projects
The Minnesota Department of Health (MDOH) is testing the effectiveness of direct mail coupled with patient navigation and a financial reward to increase breast, cervical, and colorectal cancer screening rates in its state Medicaid population. This is a partnership of the MDOH with the Minnesota Department of Human Services' Medicaid program. Medicaid enrollees who have not been screened are identified by using claims data and sent a mailing and an invitation to get screened; a financial reward ($15) is paid once the screening is completed and verified with claims data.
The New York State Department of Health is partnering with the Community Health Care Association of New York State, which represents more than 60 FQHCs and 500 clinic sites, to improve the capacity of FQHCs to deliver quality preventive care for breast, colorectal, and cervical cancers. A cancer screening registry is being developed and implemented in participating FQHCs that includes automated provider assessment and feedback on screening and screening results. The data will be used to support improvements in quality and in patient and population health outcomes; also, deliver screening services as well as to target practices and communities with low cancer screening rates for evidence-based interventions.
Colorectal Cancer Control Program
In 2009-2010, CDC funded 25 states and 4 tribes/tribal organizations to implement the Colorectal Cancer Control Program. This program is built on the infrastructure and experiences of the NBCCEDP; however, the program places greater emphasis on broader public health activities to increase population-level screening rates and to provide limited direct screening services to the underserved. The primary focus of the program is to implement evidence-based, population-level interventions to increase colorectal cancer screening. Up to one-third of grantee funds may be used to provide colorectal cancer screening services to low-income, underinsured and uninsured men and women. Programs are expected to implement the evidence-based strategies recommended by the Guide to Community Preventive Services, such as client reminders, provider reminders, small media, reduction of structural barriers to screening (eg, lack of transportation or lack of translation services), and provider assessment and feedback. Programs implement these strategies at organizational, community, and policy levels, where greater impact is expected through a broader population reach. Partnerships with health care systems, insurers, state Medicaid offices, FQHCs, large employers, professional organizations, and others are used to implement these interventions and maximize their reach into communities.
Although the NBCCEDP will continue to provide high-quality breast and cervical cancer screening services to low-income uninsured women, there is a new emphasis on increasing high-quality screening services to a broader population, especially in light of opportunities provided through the Affordable Care Act. To take greater advantage of these opportunities, the 60/40 funding requirement for the NBCCEDP may need to be changed to allow for more flexibility in how the program will be focused and managed. CDC's grantees are encouraged to implement activities that facilitate and support the increased adoption of a more organized approach to cancer screening, working collaboratively with health care systems (eg, FQHCs, health plans), payers (eg, Medicaid, Medicare, insurers), purchasers (eg, employers), and others. Emphasis is placed on the implementation of evidenced-based interventions proven to be effective in increasing cancer screening rates, promising practices, and other organizational policy and health systems interventions previously described in this article.
With 22 years of experience in effectively leading and managing a national organized breast and cervical cancer screening program, the NBCCEDP is ideally suited to collaborate with health care systems, payers, and purchasers to support the use of appropriate and high-quality breast and cervical cancer screening through expansion of organized approaches to screening.