Am J Manag Care. 2026 Jul;32(7):376-379. doi: 10.37765/ajmc.2026.89931.
ABSTRACT
Cancer screening in the US is at a critical juncture, facing an urgent need to shift from a focus on initial test uptake toward a mandate for complete diagnostic resolution. Historically, quality metrics have prioritized the singular event of a recommended test over the necessity of diagnostic resolution. Financial barriers, administrative blind spots in quality metrics, and the “Medicare 5-star paradox” have created a screening purgatory in which patients with abnormal findings are frequently left without a definitive diagnosis. Although the Affordable Care Act successfully increased access to initial screening tests by eliminating cost sharing for insured individuals, it historically left subsequent diagnostic pathways financially unprotected, contributing to late-stage diagnoses despite the availability of effective tools. This commentary explores the systemic failures of current Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star Ratings metrics that continue to reward test volume while neglecting the consequences for health equity, cancer prevention, and patient survival. We review key regulatory shifts, including new 2026 federal mandates for first-dollar coverage of diagnostic follow-up for breast and cervical cancers, while noting that significant gaps remain for lung cancer screening and clinical navigation. Additionally, we highlight the potential of the 2025 HEDIS measure for breast cancer follow-up after abnormal mammogram and the proposed 2027 HEDIS measure for colorectal cancer follow-up to serve as a nascent model for aligning quality with timely resolution. Finally, we emphasize the importance of physician leadership, advocacy, and universal diagnostic closure in ensuring that screening fulfills its lifesaving potential. Aligning quality metrics with the entire screening continuum is essential to moving beyond the “easy screen” toward a system that preserves patient-centered outcomes and reduces avoidable cancer mortality.
PMID:42640205 | DOI:10.37765/ajmc.2026.89931
