Rutgers Health Researchers on Medicaid Cancer Screening Trends, Best Practices

New Jersey has the tenth-highest rateof cancer incidence rate in the United States. The second leading cause of death in New Jersey, thousands of residents die from preventable cancers each year.

NJ FamilyCare, the state's Medicaid program insuring more than 1.8 million residents, provides coverage for cancer prevention services and screenings to thousands of beneficiaries throughout the state. However, the New Jersey Department of Human Services estimates nearly 1 in 5 Medicaid recipients could lose coverageunder President Donald Trump's tax cut and spending bill.

Ann Nguyen, an associate research professor and implementation scientist at the Rutgers Center for State Health Policy, led the most up-to-date analysis of Medicaid cancer screeningtrends in New Jersey as well as companion studies of best practicesand key factorsfor facilitating cancer screenings.

Overall trends point to an increase in screening rates for certain types of cancer, though disparities owing to geography, cancer type, race and ethnicity remain. New Jersey is making progress, however, partly because of the increased availability of culturally competent care that bridges accessibility gapsbetween certain communities and their health systems.

Anita Kinney, co-author of the two studies and an associate director for Population Science and Community Outreach at Rutgers Cancer Instituteand director of ScreenNJ, a partnership between the Rutgers Cancer Institute, the New Jersey Department of Health and health care and community organizations across the state aimed at increasing cancer screenings.

Nguyen and Kinney discuss how addressing the individual- and system-level barriers to accessing cancer prevention services can save lives and save money for patients and payers alike.

What are some of the barriers to accessing cancer screenings in New Jersey? How do these barriers affect different communities?

Kinney: There are barriers at different levels.

Patient-level barriers include social drivers of health such as care accessibility, health insurance, language and culture, health literacy and medical mistrust.

Clinical-level barriers include ordering screening tests, up-to-date knowledge about recommendations, and time constraints - clinicians are very busy with competing demands.

System and clinical level barriers include diversity and equity concerns. There is a body of evidence that shows that patients may relate better to clinicians who are from the community they serve. At the system level, many health systems don't have infrastructure for streamlined screening. Clinicians often can't ask all the questions they need to, and details aren't well captured in medical records. Imaging is not done at the health system sites, and there's often not good cross-talk between those two entities.

Systematically, certain patients aren't being offered screenings, and that could be related to race and ethnicity or socio-economic status and other social drivers.

Nguyen: There also aren't enough primary care providers. They're overburdened and underpaid. It's so important that we try to catch cancer early on when it's preventable and treatable. So, there's a burden on these providers to do that.

What role does New Jersey's Medicaid program, NJ FamilyCare, play in facilitating access to cancer screenings?

Kinney: Medicaid reimburses for preventive health care and guideline-based screenings. To make screenings affordable for patients, they need some form of health insurance. Medicaid covers all of that. Policies over the years for colorectal screening have expanded to cover the cost of diagnostic testing as well. Medicaid serves the population with the highest needs - low-income families and children, people who are pregnant and people with disabilities.

Dr. Kinney, you lead ScreenNJ. While you recently saw state funding partially restored, how might changes to federal Medicaid funding impact cancer screenings in New Jersey?

Kinney: With the Affordable Care Act and the implementation of targeted cancer control actions, we've made great strides in downstaging cancer. Certain cancers can be detected early and removed, so the stage of diagnosis is such an important measure to reduce mortality. But Screen NJ is already operating under a decreased budget, and if these Medicaid cuts hold, we're going to see more people diagnosed with later-stage cancer. They're going to need more expensive treatments, they're going to have poorer outcomes, and it's going to drive up costs of care to institutions, patients, families, social network members, the state and third-party payers. Later-stage cancer results in more suffering.

How have cancer screening rates in New Jersey changed during the study period? What might have caused the trends you observed?

Nguyen: We looked at Medicaid claims data from older adults aged 50 to 75 between 2017 and 2022. The original thought behind this study was to see the impact of COVID-19 on screenings, knowing primary care settings were brought to a halt. We saw close to 0 screenings in that early period, but how did we rebound? Did we make up for that drop in rates? For breast cancer screenings, we did. The screenings exceeded the previous peaks. With cervical and colorectal screenings, we haven't seen as rapid a rebound.

We've also identified sociodemographic groups rebounding at different rates. We saw higher screening rates in Hispanic enrollees in New Jersey, which was quite different than what other states were seeing. So, what are we getting right in New Jersey?

It's likely due to the culturally competent patient navigation and outreach teams that New Jersey health systems and ScreenNJ have been able to build. It is so important for communities to have connections in the health system who speak the same language. These navigators and coordinators are embedding themselves into the community. We think this is why we're seeing higher rates of cancer screenings in these populations.

We're also seeing higher rates in different regions of the state. There were higher screening rates along the Shore region. We did a close examination of the factors driving variations in screening rates because when you look at a state as a whole, it's very different than when you zoom in. Hopefully, this helps health systems make more targeted approaches.

Kinney: We're also going to look at cultural enclaves more in-depth. We have to be able to apply evidence-based measures that work for different cultural groups.

Based on your recent research, how can health care organizations work to increase cancer screening rates among their patients?

Nguyen: New Jersey is doing well at building culturally competent community navigator teams. Beyond the pandemic, patients are looking for different things. These navigator teams need to be diverse and cohesive. They need to embed themselves in communities like churches and grocery stores. It's a long-term investment in building trust. In terms of being cohesive, these navigators are close to their colleagues and work together well.

Kinney: Through ScreenNJ, we see that our community partners value our central core of community navigators and seek grants to help support patient navigators, knowing they can reduce the burden on primary care providers and increase access to cancer prevention services and screenings. These people can identify patients, educate them and facilitate the process, including follow-up. They can increase awareness, address barriers, and guide people from screening to test results to handoff to cancer treatment. It's complex, and there are many gaps along the way. There is considerable evidence that navigation has a greater impact on historically disadvantaged populations, for example, racial and ethnic minorities, low health literacy and low income.

Nguyen: Our research also found other ways health care organizations can increase screening rates including personalizing outreach to patients and local organizations; using digital tools to connect with existing patients eligible for screening; offering multiple screenings in one visit and a seamless transition to the next service; advertising incentives and opportunities that can address patients' social determinants of health needs; and developing relationships and referral systems with local specialists and residency programs.

This is a multipronged approach that is hard to implement, but it's what Screen NJ and the Rutgers Cancer Institute can help develop further with sustained support from the state and federal governments.

Support from Medicaid, in particular, will be crucial to bridging the screening gaps we observed in certain communities.