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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations The FY 2017 IPPS/LTCH PPS final rule 81 FR 57248 through 57249;
The FY 2018 IPPS/LTCH PPS final rule 82 FR 38471 through 38474;
The FY 2019 IPF PPS final rule 83
FR 38606 through 38608; and The FY 2020 IPF PPS final rule 84
FR 38467 through 38468.

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D. Closing the Health Equity Gap in CMS Quality ProgramsRequest for Information RFI
Persistent inequities in health care outcomes exist in the U.S., including among Medicare patients. In recognition of persistent health disparities and the importance of closing the health equity gap, we requested information on revising several CMS programs to make reporting of health disparities based on social risk factors and race and ethnicity more comprehensive and actionable for facilities, providers, and patients. The RFI that was included in the proposed rule is part of an ongoing effort across CMS to evaluate appropriate initiatives to reduce health disparities. Feedback will be used to inform the creation of a future, comprehensive, RFI focused on closing the health equity gap in CMS
programs and policies.
The RFI contained four parts:
Background: This section provided information describing our commitment to health equity, and existing initiatives with an emphasis on reducing health disparities.
Current CMS Disparity Methods:
This section described the methods, measures, and indicators of social risk currently used with the CMS Disparity Methods.
Future potential stratification of quality measure results: This section described four potential future expansions of the CMS Disparity Methods, including 1 Stratification of Quality Measure ResultsDual Eligibility; 2 Stratification of Quality Measure ResultsRace and Ethnicity;
3 Improving Demographic Data Collection; and 4 Potential Creation of a Facility Equity Score to Synthesize Results Across Multiple Social Risk Factors.
Solicitation of public comment:
This section specified 12 requests for feedback on these topics. We reviewed feedback on these topics and note our intention for an additional RFI or rulemaking on this topic in the future.
1. Background Significant and persistent inequities in health care outcomes exist in the U.S.
Belonging to a racial or ethnic minority group; living with a disability; being a member of the lesbian, gay, bisexual, transgender, and queer LGBTQ+

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community; living in a rural area; or being near or below the poverty level, is often associated with worse health outcomes.2 3 4 5 6 7 8 9 Such disparities in health outcomes are the result of number of factors, but importantly for CMS programs, although not the sole determinant, poor access and provision of lower quality health care contribute to health disparities. For instance, numerous studies have shown that among Medicare beneficiaries, racial and ethnic minority individuals often receive lower quality of care, report lower experiences of care, and experience more frequent hospital readmissions and operative complications.10 11 12 13 14 15 Readmission rates for common conditions in the Hospital Readmissions Reduction Program are higher for Black Medicare 2 Joynt KE, Orav E, Jha AK. Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care. JAMA. 2011;3057:675681.
3 Lindenauer PK, Lagu T, Rothberg MB, et al.
Income Inequality and 30 Day Outcomes After Acute Myocardial Infarction, Heart Failure, and Pneumonia: Retrospective Cohort Study. British Medical Journal. 2013;346.
4 Trivedi AN, Nsa W, Hausmann LRM, et al.
Quality and Equity of Care in U.S. Hospitals. New England Journal of Medicine. 2014;37124:2298
2308.
5 Polyakova, M., et al. Racial Disparities In Excess All-Cause Mortality During The Early COVID19
Pandemic Varied Substantially Across States.
Health Affairs. 2021; 402: 307316.
6 Rural Health Research Gateway. Rural Communities: Age, Income, and Health Status.
Rural Health Research Recap. November 2018.
7 https www.minorityhealth.hhs.gov/assets/
PDF/Update_HHS_Disparities_Dept-FY2020.pdf.
8 www.cdc.gov/mmwr/volumes/70/wr/
mm7005a1.htm.
9 Poteat TC, Reisner SL, Miller M, Wirtz AL.
COVID19 Vulnerability of Transgender Women With and Without HIV Infection in the Eastern and Southern U.S. Preprint. medRxiv.
2020;2020.07.21.20159327. Published 2020 Jul 24.
doi:10.1101/2020.07.21.20159327.
10 Martino, SC, Elliott, MN, Dembosky, JW, Hambarsoomian, K, Burkhart, Q, Klein, DJ, Gildner, J, and Haviland, AM. Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage.
Baltimore, MD: CMS Office of Minority Health.
2020.
11 Guide to Reducing Disparities in Readmissions.
CMS Office of Minority Health. Revised August 2018. Available at: https www.cms.gov/AboutCMS/Agency-Information/OMH/Downloads/OMH_
Readmissions_Guide.pdf.
12 Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014
Dec;7312:210715.
13 Rivera-Hernandez M, Rahman M, Mor V, Trivedi AN. Racial Disparities in Readmission Rates among Patients Discharged to Skilled Nursing Facilities. J Am Geriatr Soc. 2019 Aug;678:1672
1679.
14 Joynt KE, Orav E, Jha AK. Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care. JAMA. 2011;3057:675681.
15 Tsai TC, Orav EJ, Joynt KE. Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care. Ann Surg. Jun 2014;2596:10861090.

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beneficiaries and higher for Hispanic Medicare beneficiaries with Congestive Heart Failure and Acute Myocardial Infarction.16 17 18 19 20 Studies have also shown that African Americans are significantly more likely than white Americans to die prematurely from heart disease, and stroke.21 The COVID
19 pandemic has further illustrated many of these longstanding health inequities with higher rates of infection, hospitalization, and mortality among Black, Latino, and Indigenous and Native American persons relative to White persons.22 23 As noted by the Centers for Disease Control longstanding systemic health and social inequities have put many people from racial and ethnic minority groups at increased risk of getting sick and dying from COVID19. 24 One important strategy for addressing these important inequities is improving data collection to allow for better measurement and reporting on equity across our programs and policies.
We are committed to achieving equity in health care outcomes for our beneficiaries by supporting providers in quality improvement activities to reduce health inequities, enabling them to make more informed decisions, and promoting provider accountability for health care disparities.25 For the purposes of this final rule, we are using a definition of equity established in 16 Rodriguez F, Joynt KE, Lopez L, Saldana F, Jha AK. Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction. Am Heart J. Aug 2011;1622:254261 e253.
17 Centers for Medicare and Medicaid Services.
Medicare Hospital Quality Chartbook: Performance Report on Outcome Measures; 2014.
18 Guide to Reducing Disparities in Readmissions.
CMS Office of Minority Health. Revised August 2018. Available at: https www.cms.gov/AboutCMS/Agency-Information/OMH/Downloads/OMH_
Readmissions_Guide.pdf.
19 Prieto-Centurion V, Gussin HA, Rolle AJ, Krishnan JA. Chronic obstructive pulmonary disease readmissions at minority-serving institutions. Ann Am Thorac Soc. Dec 2013;106:680684.
20 Joynt KE, Orav E, Jha AK. Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care. JAMA. 2011;3057:675681.
21 HHS. Heart disease and African Americans.
March 29, 2021. https www.minorityhealth.hhs.
gov/omh/browse.aspx?lvl=4&lvlid=19.
22 https www.cms.gov/files/document/medicarecovid-19-data-snapshot-fact-sheet.pdf.
23 Ochieng N, Cubanski J, Neuman T, Artiga S, and Damico A. Racial and Ethnic Health Inequities and Medicare. Kaiser Family Foundation. February 2021. Available at: https www.kff.org/medicare/
report/racial-and-ethnic-health-inequities-andmedicare/.
24 https www.cdc.gov/coronavirus/2019-ncov/
community/health-equity/race-ethnicity.html.
25 https www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/
QualityInitiativesGenInfo/Downloads/CMS-QualityStrategy.pdf.

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