Federally qualified health centers (FQHCs) provide high-quality, comprehensive preventive and primary care health services (eg, medical, dental, mental health) to nearly 30 million patients in the United States, particularly populations that are uninsured, underinsured, and low income [1]. Despite their crucial role in providing comprehensive care to low-income patients, those who seek care at FQHCs have lower rates of cancer-preventive service utilization. For example, screening rates for breast cancer at FQHCs are 45.5% compared with 78.2% in the general population [2]. Limited on-site radiologic capabilities at some FQHCs can require referrals to outside imaging centers, further complicating screening and patient care continuity. In this opinion piece, we highlight the complex, interconnected challenges at the patient, provider, health system, and community levels that affect cancer screening rates at FQHCs (Table 1). We focus on lung and breast cancer screening as case examples.
PATIENT-LEVEL BARRIERS
Health-related social needs (HRSNs) are common among patients seeking care at FQHCs, with 27.6% reporting financial strain, 16.3% reporting food insecurity, 15.4% reporting housing insecurity, and 14.1% reporting a lack of transportation [1]. HRSNs have been associated with high rates of missed health (including cancer prevention) appointments and delays in timely diagnostic resolution after an abnormal cancer screening result [3]. Factors such as workdays lost for appointments, need for a caregiver, or lack of access to reliable transportation can create logistic challenges for individuals to prioritize their health. Interventions screening for and addressing HRSNs at FQHCs or similar settings have shown to improve breast and lung cancer screening by 12.3 and 20.3 percentage points, respectively, with interventions targeting transportation barriers showing the most improvement in screening rates [4].FQHCs serve a disproportionate share of uninsured and low-income persons compared with other health care systems, and insurance status presents a challenge to receive consistent and timely cancer screenings [4]. Although some screenings, such as mammography, may be covered through charity, grants, and foundations for uninsured, this does not guarantee consistent screenings. Furthermore, when screening mammography necessitates additional testing (ie, diagnostic mammography and/or ultrasound, image-guided biopsy, and surgical and oncologic intervention), there must be a mechanism in place for these patients to undergo the spectrum of treatment with financial coverage. Otherwise, they risk being lost to follow-up. For other screening tests, such as lung cancer screening, no financial assistance is currently available to cover the cost of the examination for uninsured. To overcome cost barriers, staff members must advocate for Medicaid enrollment to complete screening. If screening shows abnormal results, patients will incur more costs, especially if underinsured with high deductibles. Advocacy efforts for policy changes, such as expanding Medicaid and improving reimbursement rates for FQHCs to expand their services, can improve cancer screening rates in populations seeking care in such settings.
Health literacy is a multifaceted barrier that affects patients’ understanding of when to seek screening and their ability to navigate care effectively. Many patients may need help with scheduling, directions, and understanding the process of completing cancer screening. Patient education is important to improve cancer screening [4]. Patient navigators also play a significant role in coordinating patient care. A systematic review of patient navigators at FQHCs showed that navigation improved mammographic screening, helped those who missed follow-up appointments complete diagnostic procedures, and shortened time to breast cancer diagnosis for those with abnormal results [5]. However, the availability of sustainable resources remains a barrier for long-term implementation of patient navigation programs at FQHCs.
FQHCs also serve a disproportionate share of patients with limited language proficiency. Although FQHCs may have a large number of multilingual staff members, language discordance remains still an issue. Limited language proficiency creates greater challenges in navigating the health care system, resulting in lower rates of health care engagement and screening uptake. FQHCs are required to offer interpreter services for individuals with limited English proficiency, but these services do not always effectively improve communication. Patients without patient-provider language concordance are 56% more likely to be behind on breast cancer screening [6], highlighting the importance of language-concordant care at FQHCs.
PROVIDER-LEVEL AND HEALTH SYSTEM–LEVEL BARRIERS
Cancer screening requires verifying eligibility, which can be challenging for preventive services such as lung cancer screening because of complex criteria. In a survey of medical directors of FQHCs, only 13% indicated that their data systems could identify patients eligible for lung cancer screening [7]. Despite requirements to collect tobacco use data, only 54% of providers documented pack-year history, and only 29% felt comfortable using this information for clinical decisions [7]. Unlike breast or colorectal cancer screening, there are no current requirements for reporting screening rates for lung cancer at FQHCs, and limited time and staffing may add additional difficulties. Although the issue of identification of patients for lung cancer screening may not be limited to FQHCs, low adoption of screening by FQHCs that care for low–socioeconomic status individuals, including large numbers of smokers, may result in emerging disparities in access to screening.
Many FQHCs may lack infrastructure, staffing, and capacity to monitor abnormal findings and remind patients to follow up. Only 21% of FQHC directors reported tracking abnormal findings on initial lung cancer screening [7]. Lower tracking may result from a limited number of medical assistants or health coaches available for patient follow-up. A study of five public health systems affiliated with FQHCs and community health centers revealed that only 64% of women with abnormal mammograms received a timely biopsy within 21 days [8]. In addition to patient-level factors, variations in health system factors, including personnel, test follow-up processes, the presence of a robust cancer screening program as part of the imaging center, and data infrastructure, were found to substantially influence the follow-up of abnormal mammographic results [8].
Providers must also navigate how to provide optimal care despite financial barriers to patients. Although the initial screening may be covered through the Patient Protection and Affordable Care Act, subsequent follow-up tests and procedures, and treatment may not be covered. Underinsured patients may face denial of claims and high out-of-pocket costs for such follow-up medical services. Therefore, providers may worry about ordering screening tests for fear of the financial burden patients may incur because of follow-up tests. Additionally, if an FQHC is not qualified for a state-based program that may help these patients along the continuum of care of their treatment, this also lessens the chance the patient will receive the comprehensive care they need. Having knowledge of the resources available to patients at all levels and striving for collaboration with entities that can assist are imperative in ensuring these patients have access to the critical preventive services and care they deserve.
COMMUNITY-LEVEL BARRIERS
Individuals in disadvantaged neighborhoods who seek care at FQHCs report lower cancer screening rates [2]. FQHC patients may have limited access to imaging centers and subspecialty care, requiring them to travel to multiple locations to complete screening, resulting in fragmented health records that pose significant challenges. Only 40.9% of FQHCs reported lung cancer screening imaging centers within 30 miles of their main clinics [7]. Furthermore, in states with high uninsured rates because of a lack of Medicaid expansion, FQHCs must secure alternative fundings to support screening services for uninsured patients.
Mobile cancer screening at FQHCs brings services directly to individuals without access or transportation, reaching patients who may otherwise not get screened, and thus presents a complementary approach to facility-based cancer screening. Furthermore, imaging centers and hospital-based radiologists who receive referrals from the FQHC population can contribute by offering same-day interpretation and biopsies, reducing delays in cancer diagnosis and follow-up. After-hours imaging can further improve accessibility. The radiology community must support FQHCs to ensure that individuals can receive timely screenings and continuous care. These initiatives address barriers to cancer screening at FQHCs and foster a culture of proactive, preventive care in underserved communities by targeting upstream barriers, bringing cancer screening directly to the community.
CONCLUSIONS
In summary, factors at the patient, provider, health system, and community levels affect the receipt of guideline-concordant screening tests among patients seeking care at FQHCs. To address the structural inequities driving screening disparities, we need more health care providers, including radiologists, who are structurally competent and able to recognize how patients’ attitudes toward screening are consequences of upstream social, economic, and political decisions that affect health outcomes at the individual and community levels. Working toward a more equitable system will ensure that individuals receive timely screenings and the necessary support for the next steps in their care.
AP
Dr. Amy Patel
Radiology · Breast ImagingThe University of Kansas Health SystemamypLiberty, MO, USA
