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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations among those social risk factors that ASPE examined and tested.
In the FY 2018 IPPS/LTCH PPS final rule we also solicited feedback on two potential methods for illuminating differences in outcomes rates among patient groups within a providers patient population that would also allow for a comparison of those differences, or disparities, across providers for the Hospital IQR Program 82 FR 38403 through 38409. The first method the Within-Hospital disparity method promotes quality improvement by calculating differences in outcome rates among patient groups within a hospital while accounting for their clinical risk factors. This method also allows for a comparison of the magnitude of disparity across hospitals, permitting hospitals to assess how well they are closing disparity gaps compared to other hospitals. The second methodological approach the AcrossHospital method is complementary and assesses hospitals outcome rates for dual-eligible patients only, across hospitals, allowing for a comparison among hospitals on their performance caring for their patients with social risk factors. In the FY 2018 IPPS/LTCH PPS
proposed rule under the IPFQR Program 82 FR 20121, we also specifically solicited feedback on which social risk factors provide the most valuable information to stakeholders. Overall, comments supported the use of dual eligibility as a proxy for social risk, although commenters also suggested investigation of additional social risk factors, and we continue to consider which risk factors provide the most valuable information to stakeholders.
Concurrent with our comment solicitation on stratification in the IPFQR Program, we have considered methods for stratifying measure results for other quality reporting programs. For example, in the FY 2019 IPPS/LTCH
PPS final rule 82 FR 41597 through 41601, we finalized plans to provide confidential hospital-specific reports HSRs containing stratified results of the Pneumonia Readmission NQF
0506 and Pneumonia Mortality NQF
0468 measures including both the Across-Hospital Disparity Method and the Within-Hospital Disparity Method disparity methods, stratified by dual eligibility. In the FY 2019 IPPS/LTCH
PPS final rule 83 FR 41554 through 41556, we also removed six condition/
procedure specific readmissions measures, including the Pneumonia Readmission measure NQF 0506 and five mortality measures, including the Pneumonia Mortality measure NQF
0468 83 FR 41556 through 41558
from the Hospital IQR Program.

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However, the Pneumonia Readmission NQF 0506 and the other condition/
procedure readmissions measures remained in the Hospital Readmissions Reduction Program. In 2019, we provided hospitals with results of the Pneumonia Readmission measure NQF0506 stratified using dual eligibility. We provided this information in annual confidential HSRs for claimsbased measures.
We then, in the FY 2020 IPPS/LTCH
PPS Final Rule 84 FR 42388 through 42390, finalized the proposal to provide confidential hospital specific reports HSRs containing data stratified by dual-eligible status for all six readmission measures included in the Hospital Readmission Reduction Program.
3. Potential Expansion of the CMS
Disparity Methods We are committed to advancing health equity by improving data collection to better measure and analyze disparities across programs and policies.38 As we previously noted, we have been considering, among other things, expanding our efforts to provide stratified data for additional social risk factors and measures, optimizing the ease-of-use of the results, enhancing public transparency of equity results, and building towards provider accountability for health equity. We sought public comment on the potential stratification of quality measures in the IPFQR Program across two social risk factors: Dual eligibility and race/
ethnicity.
a. Stratification of Quality Measure ResultsDual Eligibility As described previously in this section, landmark reports by the National Academies of Science, Engineering and Medicine NASEM 39
and the Office of the Assistant Secretary for Planning and Evaluation ASPE,40
which have examined the influence of social risk factors on several of our quality programs, have shown that in the context of value-based purchasing VBP programs, dual eligibility, as an indicator of social risk, is a powerful 38 Centers for Medicare Services. CMS Quality Strategy. 2016. https www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/
QualityInitiativesGenInfo/Downloads/CMS-QualityStrategy.pdf.
39 National Academies of Sciences, Engineering, and Medicine. 2016. Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors. Washington, DC: The National Academies Press. https doi.org/10.17226/21858.
40 https aspe.hhs.gov/pdf-report/reportcongress-social-risk-factors-and-performanceunder-medicares-value-based-purchasingprograms.

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predictor of poor health outcomes. We noted that the patient population of IPFs has a higher percentage of dually eligible patients than the general Medicare population. Specifically, over half 56 percent of Medicare patients in IPFs are dually eligible 41 while approximately 20 percent of all Medicare patients are dually eligible.42
We are considering stratification of quality measure results in the IPFQR
Program and are considering which measures would be most appropriate for stratification and if dual eligibility would be a meaningful social risk factor for stratification.
For the IPFQR Program, we would consider disparity reporting using two disparity methods derived from the Within-Hospital and Across-Hospital methods, described in section IV.D.2 of this final rule. The first method based on the Within-Facility disparity method would aim to promote quality improvement by calculating differences in outcome rates between dual and nondual eligible patient groups within a facility while accounting for their clinical risk factors. This method would allow for a comparison of those differences, or disparities, across facilities, so facilities could assess how well they are closing disparity gaps compared to other facilities. The second approach based on the Across-Facility method would be complementary and assesses facilities outcome rates for subgroups of patients, such as dual eligible patients, across facilities, allowing for a comparison among facilities on their performance caring for their patients with social risk factors.
b. Stratification of Quality Measure ResultsRace and Ethnicity The Administrations Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government directs agencies to assess potential barriers that underserved communities and individuals may face to enrollment in and access to benefits and services in Federal Programs. As summarized in section IV.D of this final rule, studies have shown that among Medicare beneficiaries, racial and ethnic minority persons often experience worse health outcomes, including more frequent hospital readmissions and operative 41 https aspe.hhs.gov/basic-report/transitionscare-and-service-use-among-medicare-beneficiariesinpatient-psychiatric-facilities-issue-brief.
42 https www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/DataStatisticalResources/Downloads/
MedicareMedicaidDualEnrollmentEverEnrolled TrendsDataBrief2006-2018.pdf.

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