Our Take

Addressing racial health disparities in cancer screening

20 Minute Read

Cancer screening leaders have focused on increasing screening rates for years. Yet disparities in screening and, subsequently, cancer outcomes continue to persist, particularly among communities of color. Screening leaders must reshape their strategy to reduce the inequities heavily influenced by the social determinants of health. Without doing so, programs cannot meet their mission as providers of preventive care.

 

The conventional wisdom

There is plenty of evidence in the literature about disparities in cancer incidence, care, and outcomes between patients of color and their white counterparts.

Cancer disparities

Data also shows disparities exist across the screening care pathway. While white women on average receive a diagnostic mammogram 20.6 days after their screening mammogram, this number is 25.6 days for Black women and 30.9 for Hispanic women.1,2

There are ethical, moral, and emotional reasons for addressing these disparities. Depending on what payment models an organization partakes in, there are also varying incentives to reduce these disparities through early screening efforts.

Organizations in fee-for-service payment models have increased screening rates with the aim of gaining downstream revenue. While only a small percentage of screened patients require downstream services, the revenue from these services can cover the cost of a screening program. However, this downstream revenue is larger for commercial volumes, which means that these programs are less financially incentivized to reduce disparities for Medicare, Medicaid, and uninsured patients.

Comparatively, organizations in value-based payment models are incentivized to expand cancer screening rates for all patients, especially for publicly insured or uninsured patients. Wider spread and earlier cancer detection can lead to cost savings for programs operating under risk by avoiding downstream clinical escalation. Consequently, as more programs take on risk, they have increased financial incentive to reduce disparities in screening.

Despite financial incentives for screening and a growing public awareness about racial disparities in health care, disparities in screening rates and cancer outcomes persist. While some screening leaders recognize the need to revisit their screening strategies to reduce disparities, they are often relying on traditional fee-for-service growth strategies built to capture commercial volumes. These strategies have limited potential to improve racial equity in screenings.

Common screening strategies

The result is that screening leaders are more likely to attract privately insured populations and existing health care utilizers who already receive screenings. Research shows these patients are also more likely to be white.

Today’s traditional cancer screening strategy overlooks communities of color and, as a result, their barriers to screening are left unaddressed. Relying on these growth strategies ultimately expands rather than reduces existing screening disparities.

 

Our take

To effectively address racial disparities in cancer screening, leaders should apply a social determinants of health framework to understand and respond to the specific barriers faced by people of color in their community. Social determinantsof health (SDOH) are “the conditions in which people are born, grow, live, work, and age that shape health.”1,2 They include the non-clinical factors of economic stability, food security, physical environment, education, and social context as well as the actions and biases of the health care system. One estimate suggests that up to 50% of a patient’s health can be attributed to non-clinical factors.

The three most pressing determinants that impact screening rates are highlighted below.

SDOH affects screening rates

Furthermore, while social determinants of health are important factors in the current health disparities faced by people of color, health care programs also cannot ignore the role of bias. To successfully reduce racial disparities in screening, leaders will also need to address clinician, staff, and data biases.

While the financial benefits of reducing disparities in care are straightforward for programs operating under risk, the monetary benefits to fee-for-service programs may be less readily apparent. But shifting away from a traditional growth strategy of trying to attract cancer patients away from competitors, and toward a strategy of expanding screening to capture patients from the beginning, offers our key advantages.

Four benefits of an equitable screening strategy

  1. New market expansion: The traditional growth strategy aims to attract health care users away from competitors. Targeting patients who lack screening access represents an easier way to increase market share.
  2. Earlier cancer detection: Tapping into under-screened populations increases the chance of catching cancers in earlier, more treatable stages.
  3. Greater long-term revenue: Providing preventive services can lead to not only downstream revenue but also the opportunity to retain patients within the system for unrelated care needs in the future.
  4. Improved quality outcomes: Organizations participating in value-based care models benefit financially when patients are treated in a timely manner and do not require costly, avoidable downstream care.

Please note that the non-financial benefits of equitable screening and care are numerous. We are focusing solely on the financial benefits as these are both less widely published on and necessary to convince health care leaders of the wisdom of investing in expanded screening.

 

Four imperatives to advance screening equity

Launching an equitable cancer screening strategy is a task that screening leaders should feel empowered, and compelled, to pursue. Without doing so, cancer disparities will persist. The following four imperatives outline how to use the broad SDOH framework to design and implement a targeted screening strategy.

 

  • Imperative

    Identify specific barriers faced by local communities

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  • Imperative

    Build trust through community partnerships

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  • Imperative

    Design programs around patient barriers

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  • Imperative

    Address bias throughout screening processes

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Parting thoughts

As organizations take on more downside risk, screening leaders will be held increasingly accountable for population health goals. This makes the work of equitable access to cancer screening not only a moral imperative but part of a growing value-based care strategy. And regardless of your organization’s payment model, expanding an organization’s reach into new market volumes can also increase downstream care utilization.

That said, this work can’t happen within screening alone. While screening is the point of entry for many cancer patients, health disparities also persist throughout the cancer care pathway.

The work of addressing these disparities must go beyond the screening team and include key oncology players such as department leaders, oncologists, surgeons, and frontline staff. If patients are to receive appropriate care across their care pathway, the entire team must work together to reduce inequities.

Sources

1: Data derived from CMS’s Carrier File, which is a 100% sample of claims submitted by non-institutional providers for 5% of traditional, fee-for-service Medicare beneficiaries.

2: Data filtered to patients who received a diagnostic mammogram within 6 months of their screening mammogram.

Pg. 4: “Cancer Disparities,” National Cancer Institute, https://www.cancer.gov/about-cancer/understanding/disparities; CMS’s Carrier File; Advisory Board research.

Pg. 5: Berchick ER, et al., “Health Insurance Coverage in the United States: 2017,” United States Census Bureau, https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf; American College of Physicians, “Racial and Ethnic Disparities in Health Care,” https://www.acponline.org/acp_policy/policies/racial_ethnic_disparities_2010.pdf; Advisory Board research and analysis.

Pg. 6: Artiga S, Hinton E, “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,” KFF, https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/; “Social Determinants of Health”, Physician Executive Council; Advisory Board research.

Pg. 14: Musa D, Schulz R, et al., “Trust in the Health Care System and the Use of Preventive Health Services by Older Black and White Adults,” AM J Public Health, 99, no. 7 (2009), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/.

Pg. 17: Schulman KA, et al., “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” NEJM, 340 (1999), https://www.nejm.org/doi/10.1056/NEJM199902253400806?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov; Badreldin N, et al., “Racial Disparities in Postpartum Pain Management,” Obstetrics & Gynecology, 134, no. 6, https://journals.lww.com/greenjournal/Fulltext/2019/12000/Racial_Disparities_in_Postpartum_Pain_Management.4.aspx; Gordon HS, et al., “Racial differences in doctors’ information-giving and patients’ participation,” Cancer, 107, no. 6, https://pubmed.ncbi.nlm.nih.gov/16909424/; “Disparity in Data”, Health Care IT Forum, Advisory Board; “Breast cancer risk prediction is less accurate for Black patients. Deep learning is changing that”, Care Transformation Center Blog, Advisory Board.

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