Background

The American Cancer Society (ACS) and the US Preventive Services Task Force (USPSTF) both have issued recommendations for cervical cancer screening frequency across age groups. As of 2020, the ACS recommends that women begin screening at age 25 (up from 21 in previous recommendations) and that those ages 25–30 be screened every three years. This differs from USPSTF’s 2018 recommendation that screenings start at age 21 and occur every three years until age 30. Both organizations recommend only Papanicolaou (Pap) tests for women ages 21–30. For women ages 31–65, both organizations recommend a Pap test every three years, a human papillomavirus (HPV) test every five years, or HPV/Pap co-testing every five years. In 2021, the American College of Obstetricians and Gynecologists, American Society for Colposcopy and Cervical Pathology, and Society of Gynecologic Oncology endorsed USPSTF’s cervical cancer screening recommendations.  

The Affordable Care Act (ACA) mandates that most commercial health insurers provide coverage of women’s preventive healthcare—such as mammograms and screenings for cervical cancer—with no cost sharing. Screening can detect precancerous changes and cervical cancer before symptoms are present. Early detection of cervical cancer may facilitate earlier interventions to reduce risk of the advancement to more difficult-to-treat stages of cervical cancer, potentially saving lives through effective treatment strategies. HPV infection is associated with nine in ten cervical cancers; therefore, screenings inform the risk of developing cervical cancer in the future.  

The incidence and mortality rate of cervical cancer remains relatively higher among certain populations. According to the Centers for Disease Control and Prevention, every year in the United States, about 11,500 new cases of cervical cancer are diagnosed and approximately 4,000 women die of this cancer. Rates in African American, American Indian/Alaska Native, and Hispanic women are disproportionately higher than those of White women.  

Claims Analysis

Methodology 

Avalere performed a retrospective analysis of women of screening age in a convenience sample of Managed Medicaid and commercial insurance claims to identify the utilization of cervical cytology Pap smears in order to determine how many women received screenings consistent with USPSTF and ACS recommendations.  

We analyzed 2018–2022 claims data to determine the proportion of women between the ages of 21 and 65 who received at least one Pap smear during that time. We used a five-year range for the claims data to account for any care delays or barriers due to the COVID-19 pandemic. To capture women eligible for screening in the five-year timeframe, we capped the upper age to enter the analysis at 61, since women who are older in 2018 would not be eligible for screening  for the full five-year period. The analysis also looked specifically at women continuously enrolled in the insurance type for the entire timeframe. 

Findings 

The analysis showed that about 38% of the approximately 12 million women in this sample received at least one cervical cancer screening. Less than half of women with commercial insurance (41%) and even fewer with Managed Medicaid (33%) insurance received at least one cervical cancer screening during the five-year period (see Figure 1).  

Figure 1. Rates of Cervical Cancer Screening in Women 21–65 Years of Age, by Insurance Type (2018–2022) 

Avalere also analyzed cervical cancer screening rates by age group, since USPSTF and ACS recommendations differ for women less than 30 years of age.   

In the commercial payer population (N= 7,604,391), women in the 26–40 age group had marginally higher screening rates (45%) when compared to the 21–25 age group (39%). We observed a steady decline in percent of women who received at least one cervical cancer screening from ages 41–61 (see Figure 2).  

Figure 2. Rates of Cervical Cancer Screening for Commercially Insured Women 21–65 Years of Age, by Age Group (2018–2022)

In the Managed Medicaid population (N= 4,482,500), women between the ages of 21 and 30 had marginally higher screening rates (38%) than women between the ages of 31 and 65 (30%). We observed a steady decline in screening rates across age groups, from 38% for women aged 21–25 to 22% for women aged 56–61 (see Figure 3). 

Figure 3. Rates of Cervical Cancer Screening for Women Covered by Managed Medicaid, 21–65 Years of Age, by Age Group (2018–2022)

Barriers to Access

In navigating the landscape of cervical cancer screenings, an array of challenges emerges. 

• Locality Differences: Published studies has shown that women living in rural areas have worse cancer survival outcomes due to lack of screening services and long distances to access care.  
• Increased Risk Due to HIV: According to the World Health Organization, approximately 5% of cervical cancer diagnoses are traceable to HIV. The immunosuppressive nature of HIV makes women with HIV more susceptible to high-risk HPV, which is the underlying cause of almost all cervical cancer cases.  
• Increased Risk Due to HPV: Nearly all (99.7%) of cervical cancer cases are caused by persistent HPV infection. Published cohort and case-controlled studies have shown that sexual activity at a younger age and with a greater number of partners increases the risk of obtaining HPV. 
• Costs of Follow-on Testing: Although the ACA may enable cervical cancer screening with no cost sharing, follow-on tests may not be covered by every insurer, leading to further affordability challenges and impeding early detection. Published studies have shown that women were paying anywhere from $100 to $1,000 out-of-pocket for additional tests after initial screening. 
• Confusion on Screening Recommendations: Inconsistency around screening recommendations and poor provider and patient education around cervical cancer can exacerbate the problem.  
• Cultural and Religious Factors: Some women may face barriers to gynecological care due to cultural practices and belief systems, impacting individuals’ ability or willingness to undergo screenings.  
• Emotional and Mental Factors: Emotional barriers, such as embarrassment or fear of results, may impede screening. 
• Mistrust in the Healthcare System: Due to historic and ongoing medical mistreatment of minorities, individuals may be deterred from seeking timely screenings.  

Addressing these diverse obstacles is essential for promoting equitable healthcare and fostering proactive preventative measures. 

Conclusion

The data shows that compounding factors of women’s identities impede access to cervical cancer screenings. Women covered by Medicaid and private insurance showed were less likely to be screened for cervical cancer as they got older, with women aged 56–61 having the lowest screening rates. Women covered by Managed Medicaid had lower screening rates than women covered by commercial insurance. Although the ACA mandates coverage of women’s preventive health care with no cost sharing, we are still observing more than 50% of women in the commercial space not receiving any cervical cancer screening in a five-year study period. 

Stakeholder Call to Action

Stakeholders should monitor any legislative or regulatory changes aimed at improving cancer screening rates in the United States to improve patient outcomes. As the claims analysis shows, removing cost sharing for preventative services does not guarantee that women will receive cervical cancer screenings. Manufacturers with pipeline products in cervical cancer detection and/or treatment should consider the various types of barriers (e.g., educational, financial, cultural, and emotional) and seek patient support solutions to increase screening rates and subsequently, diagnoses and treatment. Providers can work with other interested stakeholders to better educate patients on the importance of screening for cervical cancer at an early age. Payers can explore improving screening rates through coverage of follow-on testing and through any value-based incentives to providers for properly counseling patients. 

How Avalere Can Help

Avalere is committed to addressing barriers that patients face when accessing cervical cancer screenings. Avalere can support clients evaluate the current landscape for diverse groups of women, analyze the potential pathways for patient access and provide strategic insights informed by patient perspectives. Specifically, Avalere can assist stakeholders to evaluate the state and federal legislative developments to observe cervical cancer diagnosis screening and disparities to inform implications to access and inform portfolio decisions. 

Avalere is also able to conduct qualitative and quantitative analyses. Avalere can analyze coverage, coding and reimbursement of women’s preventive health services to provide perspectives on coverage, healthcare utilization and financial barriers to women for screenings. Avalere can also parlay those findings with primary research from patients, payers and/or providers of access barriers and challenges.  

To speak with a women’s health subject matter experts, connect with us. 

Data Source

For this analysis, Avalere used commercial and Managed Medicaid claims data from Inovalon’s proprietary “Medical Outcomes Research for Effectiveness and Economics” (MORE2) Registry®, accessed by Avalere via an Agreement with Inovalon, Inc.