Aligning the Stars: Quality Metrics Must Evolve From Screening Rates to Diagnostic Resolution

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.

Am J Manag Care. 2026;32(7):In Press. https://doi.org/10.37765/ajmc.2026.89931

Takeaway Points

• Existing Medicare Star Ratings and Healthcare Effectiveness Data and Information Set (HEDIS) metrics reward initial screening volume but currently ignore essential diagnostic follow-up.
• Failure to complete a follow-up colonoscopy after an initial positive stool-based test result decreases the number of potential colorectal cancer cases prevented and diagnosed at earlier, treatable stages and diminishes the related economic benefits of screening.
• Although colorectal, breast, and cervical follow-up coverage is improving, significant gaps remain for lung cancer and clinical navigation services.
• Payers should adopt new HEDIS measures focused on timely resolution to align financial incentives with population health outcomes.

In the high-stakes landscape of Medicare Star Ratings, the financial viability of an individual Medicare Advantage or Part D plan can hinge on a few percentage points within CMS-designated quality metrics. Although these metrics—ranging from customer service to preventive screenings—are designed to help beneficiaries and purchasers compare plan quality, they currently harbor a dangerous blind spot.

Despite the widely accepted understanding that screening for a specific condition often entails multiple steps to complete the diagnostic process, the standard definition used for most cancer screening quality metrics is based on uptake of the recommended screening test. This designation fails to include the completion of recommended follow-up testing. This restricted emphasis on initial testing had, until recently, also been the sole implementation requirement of the Affordable Care Act (ACA) provision that eliminated cost sharing for initial screenings rated A or B by the US Preventive Services Task Force (USPSTF) (breast, cervical, colorectal [CRC], and lung cancers) and Advisory Committee on Immunization Practices recommendations for enrollees in ACA-compliant health plans, leaving the subsequent diagnostic pathway financially unprotected.¹

Screening is a process, not a single test; it is only complete when all follow-up procedures are performed to definitively confirm or exclude a cancer diagnosis.^2,3 Existing quality metrics reward initial screening uptake but ignore the follow-up care required for a definitive diagnosis. This incentivizes a superficial “check-the-box” culture that fails patients with abnormal findings when the potential for clinical benefit is greatest. Given the clinical and emotional implications of receiving a positive result without a clear path forward—a scenario we call cancer screening purgatory—it is imperative that we implement policies that mandate and incentivize confirmation of diagnostic resolution.

It is a clinical and economic irony that the ACA’s success in removing financial barriers to initial screening was undermined by high out-of-pocket costs for the very diagnostic tests that are needed to confirm a diagnosis. In response to these barriers, a multistakeholder call to action led by the American Cancer Society has advocated for redefining cancer screening as a multistep continuum.

This advocacy effort yielded critical federal policy shifts mandating first-dollar coverage for diagnostic follow-up for those insured individuals. These requirements—implemented for CRC in 2022 via unified tri-agency guidance (HHS, Labor, Treasury)⁴—ensure that the diagnostic continuum is accessible without patient cost sharing. Similarly, cost sharing–free diagnostic follow-up was mandated for breast cancer in 2025⁵ and will be implemented for cervical cancer in 2027⁶ via Health Resources and Services Administration (HSRA) Women’s Preventive Services Guidelines, rather than USPSTF. The effective date for these requirements aligns with the start of the plan year beginning 1 year after the final recommendation; therefore, implementation may lag for those plan years that do not start on January 1. Additionally, as of 2026, HRSA guidelines mandate individualized patient navigation services without cost sharing for breast and cervical cancer screening.⁶ Despite these advancements, significant coverage gaps persist as of March 2026: Cost sharing is still permitted for CRC screening navigation, and cost sharing could still be applied for both follow-up diagnostic procedures and clinical navigation for those needing follow-up after initial lung cancer screening (Figure).

Improved coverage and navigation are poised to elevate follow-up rates, as evidenced by the 41.2% relative increase in follow-up colonoscopy following the removal of cost sharing.⁷ However, clinical resolution remains elusive for many due to a constellation of systemic barriers. Beyond financial toxicity, the screening process is hindered by low health literacy, specialized workforce shortages, and geographic disparities. Critically, the current quality measurement infrastructure lacks the necessary incentives to prioritize the completion of the diagnostic continuum over initial test uptake.

The dismal reality of our current metrics is best illustrated by CRC screening. Despite the availability of highly effective tools that can prevent or detect CRC at its most treatable stages and considerable progress in reducing CRC incidence and mortality, CRC remains the second most common cause of cancer death in the US among women and men combined, largely because millions of eligible Americans remain unscreened or irregularly screened⁸; among those who do undergo screening, failure to complete the screening process after a positive test result is common.⁹ As of 2023 (the most recent year for which data are available), CRC became the leading cause of cancer death in people younger than 50 years, due not only to the birth cohort effect leading to rising incidence in individuals born since 1950,¹⁰ but also to slow uptake of CRC screening in individuals aged 45 to 49 years.^11,12

Although CRC is largely preventable, our quality measurement infrastructure creates a perverse efficiency to “hit the numbers” of initial screening tests completed instead of achieving desired population health outcomes such as fewer CRC cases or fewer deaths that would result from initial screening and completion or follow-up. It is often deemed more cost-effective for delivery systems or health plans to mail out low-cost fecal immunochemical tests rather than encourage choices between stool tests or direct visual exams. In this environment, the goal shifts from finding cancer to finding the least expensive way to improve a quality score.

However, progress to align the stars is on the horizon. Building on the momentum created by federal coverage policy to increase the rate of those who complete the entire cancer screening process, the National Committee for Quality Assurance (NCQA) recently implemented a new Healthcare Effectiveness Data and Information Set (HEDIS) measure, Follow-Up After Abnormal Mammogram Assessment (FMA-E), and proposed for 2027 another measure, Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test.¹³ By aligning with new coverage policies—assessing the percentages of individuals who received appropriate follow-up within 90 days of an inconclusive or high-risk result on screening mammography and those who received a colonoscopy within 180 days of a positive stool-based CRC test result—NCQA is shifting the quality measure from test volume to volume and timely resolution.

The clinical and financial stakes of this shift cannot be overstated. In the case of CRC screening, for example, the cost of a dropped ball is measured in lives: Individuals with a positive CRC screening test result who fail to complete a follow-up colonoscopy face 2 to 7 times the risk of death as those up to date with screening.^9,14,15 Moreover, modeling studies conclude that 4 times more CRC cases are averted by follow-up colonoscopy than by screening colonoscopies.¹⁶ Beyond the moral imperative, the economic benefits are substantial; every case prevented is a direct reduction in the catastrophic costs of late-stage cancer treatment. Yet, despite these clear advantages, follow-up colonoscopy rates remain unacceptably low—plummeting to less than 25% in our most vulnerable populations.¹⁷ Similarly low follow-up rates are the norm for breast cancer screening, contributing to unnecessarily high rates of morbidity and mortality.

For the vast majority of people, screening is a single step because their results are normal and require no further action. Yet, to truly measure quality, we must look past the easy successes. Current metrics, which are accepted as highly motivating under the principle of “what gets measured gets done,”^18,19 tell us nothing about the very individuals who have the most to gain—those with a positive test result.

This screening-to-diagnostic gap is a systematic failure not unique to any specific clinical condition. To truly realize the full scope of the clinical and economic benefits of screening—regardless of the clinical condition investigated or screening modality used—we must insist that quality measures mandate diagnostic closure. Whether the initial screening test is administered at home (eg, stool-based test for CRC, human papillomavirus test for cervical cancer), in a clinical setting (eg, HIV, prostate-specific antigen, hepatitis C virus, and any of the nascent molecular-based tests), or in an imaging center (eg, screening mammogram, low-dose CT scan for lung cancer), the quality of any screening program must be predicated on the successful navigation to a definitive clinical answer. We can no longer, in good conscience, label a screening program as high quality if it fails to report the rate of successful follow-up interventions.

If we are serious about realizing the clinical, economic, and human promises of cancer screening, our quality measures must stop rewarding the “easy screen” at the expense of the entire screening continuum. The implementation of HEDIS measures, such as the recently implemented FMA-E measure, that include the performance of indicated follow-up testing will finally align our metrics with our medical mission by providing clinically driven incentives. At the earliest opportunity, this modification of the breast cancer and CRC HEDIS measures should be added to all HEDIS cancer screening test metrics, and going forward, new screening HEDIS measures should measure the continuum of screening. This shift will fundamentally improve screening completion rates, increase the number of cancers prevented or detected at their most curable stages, and ensure that fewer families have to face the avoidable diagnosis and financial adversity that is often associated with late-stage disease.

Author Affiliations: Data-driven Strategies for Medicine & Biotechnology (DSMB), Mercer Island, WA; Department of Health Systems and Population Health, University of Washington School of Public Health (DSMB), Seattle, WA; American Cancer Society (RAS), Atlanta, GA; Center for Value-Based Insurance Design (AMF), Ann Arbor, MI; Department of Internal Medicine, University of Michigan (AMF), Ann Arbor, MI.

Source of Funding: None.

Author Disclosures: Dr Buist reports receiving consultant fees from Natera Inc, DELFI, and RadNet. Dr Fendrick reports receiving consulting fees from AbbVie, Better Medicare Alliance, Centivo, Clover Insurance Company, Community Oncology Alliance, Eebu Health, Elektra Health, Employee Benefits Research Institute, Exact Sciences, GRAIL, Hopewell Fund, Johnson & Johnson, Medtronic, MedZed, Merck, Mother Goose Health, Phathom Pharmaceuticals, Proton Intelligence, Sempre Health, Sera Prognostics, Silver Fern Healthcare, UnitedHealth Group, Virginia Center for Health Innovation, Washington Health Benefit Exchange, and Wellth and serving as a partner for VBID Health and co–editor in chief of The American Journal of Managed Care. Dr Smith reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DSMB, RAS, AMF); drafting of the manuscript (DSMB, RAS, AMF); and critical revision of the manuscript for important intellectual content (DSMB, RAS, AMF).

Address Correspondence to: Diana S. M. Buist, PhD, MPH, Data-driven Strategies for Medicine & Biotechnology, 6228 83rd Pl SE, Mercer Island, WA 98040. Email: DianaBuist@DSMBStrategy.com.

REFERENCES

1. Forsberg VC. The ACA preventive services coverage requirement. Library of Congress. May 23, 2025. Accessed March 17, 2026. https://www.congress.gov/crs-product/IF13010

2. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281. doi:10.3322/caac.21457

3. American Cancer Society position statement on the elimination of patient cost-sharing associated with cancer screening and follow-up testing. American Cancer Society. February 26, 2023. Accessed March 17, 2026. https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/overview/acs-position-on-cost-sharing-for-screening-and-follow-up.html

4. FAQS about Affordable Care Act implementation part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act implementation. US Department of Labor. January 10, 2022. Accessed March 17, 2026. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-51

5. Update to the Health Resources and Services Administration-supported women’s preventive services guidelines. Fed Regist. 2024;89(249):106522-106525. Accessed March 17, 2026. https://www.govinfo.gov/content/pkg/FR-2024-12-30/pdf/2024-31228.pdf

6. Update to the women’s preventive services guidelines. Fed Regist. 2026;91(2):283-287. Accessed March 17, 2026. https://www.govinfo.gov/content/pkg/FR-2026-01-05/pdf/2025-24235.pdf

7. Greene M, Le QA, Ozbay AB, Karlitz JJ, Fendrick AM. Completing the colorectal cancer screening process: impact of eliminating cost-sharing for follow-up colonoscopy. Curr Med Res Opin. 2025;41(9):1697-1703.
doi:10.1080/03007995.2025.2577763

8. Siegel RL, Wagle NS, Star J, Kratzer TB, Smith RA, Jemal A. Colorectal cancer statistics, 2026. CA Cancer J Clin. 2026;76(2):e70067. doi:10.3322/caac.70067

9. Doubeni CA, Fedewa SA, Levin TR, et al. Modifiable failures in the colorectal cancer screening process and their association with risk of death. Gastroenterology. 2019;156(1):63-74.e6. doi:10.1053/j.gastro.2018.09.040

10. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst. 2017;109(8):djw322. doi:10.1093/jnci/djw322

11. Siegel RL, Wagle NS, Jemal A. Leading cancer deaths in people younger than 50 years. JAMA. 2026;335(7):632-634. doi:10.1001/jama.2025.25467

12. Star J, Siegel RL, Smith RA, Schafer EJ, Jemal A, Bandi P. Trends in colorectal cancer screening in US adults aged 45 to 49 years. JAMA. 2025;334(9):827-829. doi:10.1001/jama.2025.10618

13. NCQA advances development of a new HEDIS measure for colorectal cancer screening follow-up. National Committee for Quality Assurance blog. March 4, 2026. Accessed March 16, 2026. https://www.ncqa.org/blog/new-hedis-measure-for-colorectal-cancer-screening-follow-up/

14. Lee YC, Chen SLS, Ming-Fang Yen A, et al. Association between colorectal cancer mortality and gradient fecal hemoglobin concentration in colonoscopy noncompliers. J Natl Cancer Inst. 2017;109(5):djw269. doi:10.1093/jnci/djw269

15. Zorzi M, Battagello J, Selby K, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut. 2022;71(3):561-567. doi:10.1136/gutjnl-2020-322192

16. Fendrick AM, Borah BJ, Burak Ozbay A, Saoud L, Limburg PJ. Life-years gained resulting from screening colonoscopy compared with follow-up colonoscopy after a positive stool-based colorectal screening test. Prev Med Rep. 2022;26:101701. doi:10.1016/j.pmedr.2022.101701

17. Wang CP, Shah AM, Zhao MY, et al. Rates and timing of follow-up colonoscopy after a positive stool-based test in an integrated health system. J Gen Intern Med. Published online February 26, 2026. doi:10.1007/s11606-026-10226-8

18. Sarfaty M, Myers RE. The effect of HEDIS measurement of colorectal cancer screening on insurance plans in Pennsylvania. Am J Manag Care. 2008;14(5):277-282.

19. Stathakos K, Hon J, Palazzo L, et al. System-wide implementation of colorectal cancer screening in a value-based care setting. J Gen Intern Med. 2026;41(3):780-787. doi:10.1007/s11606-025-09706-0