Webinar Highlights Recommendations to Improve Disparities in CRC Screening

A new report published by the Network for Excellence in Health Innovations (NEHI) holds clues on how to improve the disparities in colorectal cancer (CRC) screening in racially and ethnically diverse populations, according to speakers during a webinar held on October 17, 2023. The report, which was primarily written by Clare B. Cruse, MPH, senior director at NEHI, drove the discussion on how disparities in screening can continue to close in an area that is still known for inequality in preventive care.

Cruse was the moderator for the webinar that included panelist experts from throughout the colorectal health sphere, some of whom also contributed to the report itself.

Cruse started the webinar by describing the contents of the report, which aimed to describe ways in which disparities between racial and ethnic groups could be diminished in the space of CRC screenings, as CRC remains the second leading cause of cancer deaths in the United States. Although the gaps are closing, there are still some persistent issues found throughout the data. The report was put together after a literature scan, talking to experts in the field to fill in gaps in the current literature, and then summarizing all of the research.

Gastroenterologist doctor, intestine specialist. Aesthetic handdrawn highlighted illustration of human intestine | Image credit: mi_viri - stock.adobe.com

“We divided our recommendations into 2 different parts. The first set are a set of recommendations that, with the right resources, we think could be accomplished in the short term,” said Cruse. “And then the second set of recommendations are ones that we recognize might need significant resources and sometimes even political will and alignment to see to fruition.”

The report recommends aggregating data across different sources about CRC screenings. Data need to be shared and stratified by different patient characteristics so that experts can understand who faces the most hurdles. Quality measurement was also a short-term goal, with a recommendation that the National Committee for Quality Assurance (NCQA) require plans to report how many patients have received follow-up colonoscopies after a positive stool test.

Long-term recommendations included requiring all state Medicaid programs to adopt the adult core set of quality measures that includes the CRC screening measure, which would create consistency across all states. States can also ensure that their statutes are current based on the latest US Preventive Services Task Force (USPSTF) recommendations for CRC screening. This is especially important given that only 34 states have CRC statutes and variability is found in each statute. The last recommendation involved bolstering efforts to identify and address needs in communities that are served by the health systems.

The first panel featured a short discussion on data aggregation and how collecting data on the community can help to close disparities in CRC screening. This includes collecting information on who makes up each community and how the ethnic and racial backgrounds of the community can play into decisions on which areas to target in closing those disparity gaps.

Lindsey Roth, MPP, who works with NCQA, described the results shown by data aggregation through the Healthcare Effectiveness Data and Information Set (HEDIS), a set of performance measures for health plans. This measure can be used to track the performance of health plans and to hold those health plans accountable for care, she said. The current version of HEDIS measures the percentage of health plan members aged 45 to 75 years who had appropriate screening for CRC, reported by all 3 of commercial, Medicare, and Medicaid plans.

“As of 2022, health plan performance on this measure shows that, on average, about 30% to 40% of health plan members are not up to date with screening,” said Roth. HEDIS measured a decline in CRC screening after the pandemic as well, which has led to health plans working to make up missed screenings and rebound to levels from pre–COVID-19. NCQA plans to hold health plans accountable for equity and disparities in screening, including having HEDIS performance rates stratified by race and ethnicity.

A major barrier to boosting CRC screening rates is the existential threat of the outcome of the Braidwood v Becerra case. As Richard Hughes IV, JD, MPH, of the law firm Epstein Becker Green, explained, the Affordable Care Act required that all commercial insurance plans cover preventive interventions, such as CRC screening, and also required those same preventive measures be covered through Medicaid expansion. In short, the plaintiffs in the Braidwood v Becerra case argued that they do not need to cover some preventive health measures due to their religious beliefs, and the district judge’s decision overturned the required coverage of preventive screenings recommended by the USPSTF. Insurers creating new contracts can roll back coverage of preventive screenings to what it was in March 2010, when the Affordable Care Act was first enacted.

“So the recommendation that was in effect back in 2010…there was a 2008 recommendation in effect, and it was basically a Grade A recommendation for individuals aged 50 to 75. What we are missing is that very important 45- to 49-year-old segment that was added in 2021,” said Hughes. “So we would see basically for that age group the requirement to cover would be rolled back.”

Hughes said that if the Biden administration wants this area of the Affordable Care Act to continue, it could potentially remove the political insulation of the USPSTF so that they would have some accountability. “I think there’s an opportunity all around to think about ways to improve the work of the [USPSTF]. And in the process make sure that we’re saving coverage and access throughout the framework,” he said.

A. Mark Fendrick, MD, co–editor in chief of The American Journal of Managed Care^® and director of the Center for Value-Based Insurance Design at the University of Michigan, said that he was not hopeful that the decision in the case would be overturned, which would potentially affect 150 million Americans as the 46 services that have a Grade A or B rating would no longer have guaranteed coverage.

Making sure that patients have access to those screenings is therefore important. Bev Green, MD, PhD, senior investigator at the Kaiser Permanente Washington Health Research Institute, described how screening rates improved 30% when patients in the Kaiser system were mailed stool kits. However, 2 studies that focused on communities in Oregon and Washington found that follow-up colonoscopies after a positive test were low at 55% and 32%, respectively.

“So as we think about the people that have never had any screening, we have to address priorities and we have to address the needs of the community,” she said.

Fendrick focused on CRC screenings in particular and how to improve the rate of CRC screenings in the general population. According to him, celebrity endorsements have helped in getting people to get their initial screening, but the follow-up screening is equally as important. Recently, the follow-up CRC screening has become free for Americans with insurance.

“The good news is the financial barrier is gone. The bad news is, having received 2 colonoscopies, 1 diagnostic, there’s a lot of reasons why people don’t want to get a colonoscopy besides money,” said Fendrick.

According to a news release from the University of Michigan, recent work published by Fendrick and colleagues found that if the policy that removes cost sharing for follow-up colonoscopy remains, it will ultimately save the Medicare system money as a whole and can improve the number of people who get the initial screening, as they will know going in that the process is free.

Green also said that transportation was a big issue when surveying 50,000 patients in the Kaiser region, as among those who had any social needs relating to transportation, social isolation, financial insecurity, food insecurity, or financial strain, the screening rates were cut in half compared with people without those barriers. “I think race is 1 issue, neighborhood is a really important issue in the community you live in and your own social determinants of health and what you prioritize,” she noted.

Improving screening rates, Cruse concluded, would require different mechanisms, policies, and programs to work together to improve disparities, not only in CRC screening but all other preventive services.