Paving the Way to Equity: A Progress Report 2015-2021

Paving the Way to Equity: A Progress Report (2015-2021)

Centers for Medicar e & Medicaid Services

Office of Minority He alth

2015-2020

Table of Contents

Executive Summary .................................................................................................................. 3

Introduction ............................................................................................................................... 6

The CMS Equity Plan for Improving Quality in Medicare ..................................................... 7

CMS Equity Plan for Medicare: Priority Areas ..................................................................... 9

Measuring Progress ................................................................................................................ 10

Evaluation Goal ................................................................................................................ 10

Evaluation Questions ........................................................................................................ 11

Limitations of This Report ................................................................................................. 11

Increasing Understanding and Awareness of Disparities .................................................... 11

CMS Expanded the Collection, Reporting, and Analysis of Standardized Data ................. 12

CMS Developed Resources to Increase the Health Care Workforce’s Understanding of

Disparities ......................................................................................................................... 15

Gaps, Needs, and Next Steps To Increase Understanding and Awareness of Disparities . 17

Developing and Disseminating Solutions to Achieve Health Equity ................................... 18

CMS Evaluated Disparities Impacts and Integrated Equity Solutions across CMS

Programs .......................................................................................................................... 18

CMS Developed and Disseminated Promising Approaches to Support the Health Care

Workforce in Addressing Health Disparities ...................................................................... 20

Gaps, Needs, Next Steps to Achieve Health Equity By Developing and Disseminating

Solutions ........................................................................................................................... 25

Implementing Sustainable Actions to Achieve Health Equity.............................................. 25

CMS Leveraged Qualitative and Quantitative Research Findings to Improve Programs and

Policies to Reduce Disparities ........................................................................................... 26

CMS Convened and Mobilized Partners to Take Action on Disparities .............................. 28

Gaps, Needs, and Next Steps to Implement Sustainable Actions ..................................... 30

Paving the Way to Equity: A Progress Report (2015-2021)

Executive Summary

Disparities in health and health care persist despite decades of research and widespread efforts

to improve health in the United States.

Certain populations – including racial and ethnic

minorities, sexual and gender minorities, people with disabilities, and individuals living in rural

areas – are more likely to experience worse health outcomes, limited access to health care

services, and lower quality of care than the general population.

ii,iii,iv,v

These disparities are

reflected among vulnerable Medicare beneficiaries. These individuals typically have lower

preventive care utilization, limited access to chronic disease management, lower patient

experience scores, and higher rates of hospital readmissions and chronic disease compared to

their non-minority counterparts.

vi,vii,viii

In 2015, in recognizing these disparities and seeking to close gaps in health care access,

quality, and outcomes among those CMS serves, the agency developed the first-ever CMS

Equity Plan for Improving Quality in Medicare (CMS Equity Plan for Medicare). This plan

provides an action-oriented, results-driven path for achieving health equity by focusing on

populations that experience disproportionately high burdens of disease, worse quality of care,

and barriers to accessing care – specifically, racial and ethnic minorities, sexual and gender

minorities, people with disabilities, and individuals living in rural areas. CMS developed this

strategic approach to addressing disparities to support and advance work already underway

within the agency and among partners. This includes CMS’ network of quality improvement

partners, federal, state, local, and tribal organizations, health care providers, health plans,

individuals and families, researchers and policymakers, and other stakeholders invested in

achieving health equity among Medicare beneficiaries. The CMS Equity Plan for Medicare

focuses the agency and external stakeholders on results, unleashing innovation, and

empowering patients, while eliminating disparities among those we serve.

The CMS Equity Plan for Medicare reflects CMS’ Path to Equity, an organizing framework with

three core elements: 1) increasing understanding and awareness of disparities; 2) developing

and disseminating solutions to achieve health equity; and 3) implementing sustainable actions

to achieve health equity. CMS uses this framework to guide health equity work within the

agency and with external partners. This report describes some of the key ways CMS has

demonstrated progress on the Path to Equity between 2015 and 2021, including:

Paving the Way to Equity: A Progress Report (2015-2021)

Increasing Understanding and Awareness of Disparities

► CMS expanded the collection, reporting, and analysis of standardized data through

publication of reports, public data sets, increased access to CMS data for researchers,

and data visualization products. These resources allow users to see variations across

communities. They also empower users to enhance their own data collection and analysis

to deliver results. For example in 2016, CMS began annually releasing data and reports on

the Medicare Advantage (MA) population stratified by race and ethnicity. In 2018, CMS

expanded this effort with the annual publication of its Rural-Urban Disparities in Health

Care in Medicare report. These tools and reports are broadly used – as of October 2020,

the Mapping Medicare Disparities Tool has been used by over 39,800 individuals to learn

more about local health disparities and identify opportunities for improvement.

► CMS produced numerous resources to increase the health care workforce’s understanding

of disparities and of ways to improve patient experience, and disseminated research

findings on the drivers of disparities and best practices on the provision of culturally and

linguistically appropriate services (CLAS).

Developing and Disseminating Solutions to Achieve Health Equity

► CMS focused on results, evaluating disparities impacts and integrating equity solutions

across programs through the development and implementation of the CMS Disparities

Impact Statement. The CMS Health Equity Technical Assistance Program is available to

support quality improvement partners, providers, and all other CMS stakeholders.

Stakeholders can ask questions about how to embed health equity and reduce disparities

among enrollees and beneficiaries they serve. From its inception in 2017 through October

2020, the Health Equity TA team has responded to over 278 technical assistance requests

from stakeholders in 39 states as well as Washington, DC, and Puerto Rico.

► CMS developed and disseminated innovative and promising approaches to support the

health care workforce in addressing health disparities and improving the patient

experience through provider-focused, accredited trainings supported by the Medicare

Learning Network and other platforms. Nearly a dozen provider-focused guides have been

produced to help practices take strategic, step-by-step approaches to improving care for

vulnerable communities.

► CMS responded to the Coronavirus (COVID-19) pandemic and public health emergency

through listening sessions, creation of new resources, developing Medicare COVID-19

data snapshots to indicate impact on minority populations, and helping to accumulate all

existing resources for minority populations, providers serving minority populations, and

anything in additional languages.

Implementing Sustainable Actions to Achieve Health Equity

► CMS embedded a focus on health equity results in programs and policies through

standardized monthly and quarterly reporting on health disparities in the QIN-QIO and

Hospital Innovation and Improvement Network (HIIN) programs in the 11

Statement of

Work. The HIINs were also required to complete and update CMS Disparities Impact

Statements and action plans to monitor and reduce disparities.

Paving the Way to Equity: A Progress Report (2015-2021)

► CMS engaged with stakeholders, focusing attention on vulnerable and rural communities

who have been hardest hit by the public health emergency and COVID-19. CMS is

working with stakeholders and partners to identify barriers, solutions, and opportunities to

improve access to care and the quality of care in health settings including nursing homes

and hospitals.

► CMS convened and mobilized partners to take action to reduce disparities through the

CMS Health Equity Award focused on results and innovation. This recognition has

fostered dedicated communities of national stakeholders working together and

independently to close gaps in health care, access, and outcomes. In the 3 years this

recognition has been shared, nearly 90 organizations have applied for the award and six

have been profiled for their ability to reduce and eliminate disparities.

Each section of this report concludes by considering emerging opportunities to build on our

progress with a focus on CMS’ current strategic initiatives, HHS priorities, and areas in which

CMS quality improvement contractors will be in action moving forward. For example, CMS will

continue to rethink and improve its work in partnership with rural and other vulnerable

communities to ease the burden on local providers and focus on results, innovation, and patient

experience. We will build on successful work embedding evaluation, monitoring, standardized

data, and tools to reduce disparities for minority beneficiaries served by CMS programs, further

inspire our partners to collaborate to achieve health equity, and continue spreading resources

and innovative practices to reduce disparities across organizations and communities.

CMS will also enhance and strengthen existing work supporting providers in underserved and

rural areas as they move toward Merit-Based Incentive Payment, Advanced Alternative

Payment Models, and other value-based payment systems, to ensure that all individuals served

by CMS can reach their highest level of health. CMS will continue to explore opportunities to

advance health equity across all of the Agency’s programs and policies, broadening the reach

and impact of the CMS Equity Plan beyond the Medicare program to benefit the millions of

individuals we serve. COVID-19 has shed new light on the prevalence of disparities in access,

quality, and outcomes among minority and vulnerable communities, and has underscored the

importance of taking action to promote health equity. Although the Path to Equity is long and

challenging, CMS is committed to working with partners and communities to move the needle

on disparities and achieve health equity for all those impacted by CMS programs.

Paving the Way to Equity: A Progress Report (2015-2021)

Introduction

Health and health care disparities are related but unique concepts: health disparities typically

refer to higher burdens of illness, mortality, injury, or quality of life experienced by one group

relative to another, whereas health care disparities generally refer to differences between

groups in access to, use of, quality of care, or health coverage.

ix,x,xi,xii

These differences cannot

necessarily be explained by variations in health needs, preferences, or treatment

recommendations but are more likely to be related to social, systemic, and environmental

inequities or inequalities that affect individuals.

xiii,xiv,xv

For example, language barriers, how

health care is organized and accessed, provider bias, geography, affordability, transportation,

social isolation, housing, nutrition, access to technology, and other social risk factors that affect

individuals’ health behaviors, work together and independently to create gaps between and

among groups of varied socioeconomic status, age, location, gender, disability status, race and

ethnicity, and sexual identity and orientation. Disparities can affect any and all populations and

subgroups within populations, and may differ for communities across locations and over time.

xvi,

,xvii

Many communities face significant disparities in health care quality, outcomes, and access, but

racial and ethnic minorities, sexual and gender minorities, individuals with disabilities, and

individuals living in rural areas are disproportionately affected.

xviii,xix,xx

For example:

► In 2017, across nearly every state and territory Black, Hispanic, Asian Pacific Islander, and

American Indian and Alaska Native Medicare beneficiaries have a higher prevalence of

chronic conditions including hypertension, diabetes, chronic kidney disease, and heart

failure than Whites.

xxi

► The LGBTQ population has the highest rates of tobacco use, and certain LGBTQ

subgroups have more chronic conditions as well as higher prevalence and earlier onset of

disabilities than heterosexuals.

xxii,xxiii

► Individuals with disabilities experience worse health and poorer access to mental health

care services compared to people without a disability. Women with disabilities are less

likely to receive regular breast and cervical cancer screenings and are more likely to have

cancer and then be diagnosed at a later stage, than women without disabilities.

xxiv,xxv

► The prevalence of diabetes is 8.6 percent higher in rural areas than in urban areas, and

those diagnosed with diabetes in rural areas are at higher risk of amputations and

inpatient death. They are less likely to receive a professional foot exam, and less likely to

be able to access diabetes self-care education than their urban counterparts.

xxvi

Providers, government agencies, and researchers have worked for decades to understand and

reduce health and health care disparities. However, despite improvements in overall population

health, communities including racial and ethnic minorities, sexual and gender minorities,

individuals with disabilities, and those living in rural areas, experience a lower quality of care

and worse health outcomes than their non-minority counterparts.

xxvii,xxviii,xxix

Disparities persist,

and in some cases, continue to worsen, and affect individuals throughout their lifespan from

birth into older adulthood, often leading to complex and compound health conditions at later life

Paving the Way to Equity: A Progress Report (2015-2021)

stages.

xxx,xxxi

It is not necessarily a lack of effort or intention allowing these gaps to grow. Rather,

in many cases CMS has heard that organizations struggle with knowing where to begin to

address the driving forces of these disparities and how they can systematically change

communities’ and individuals’ social determinants of health and their health trajectory. In order

to effectively reduce disparities, government, providers, and health care organizations need to

work deliberately and collaboratively to address the factors driving these gaps, so that each

individual can achieve their highest level of health.

CMS is committed to quality improvement and reducing disparities while meeting the needs of

providers, individuals, and families. Though the Path to Equity is long, CMS and its many

partners will continue to work together to bring about long-term change. This report highlights

some of CMS’ progress from 2015 through 2021 and identifies areas of opportunity to achieve

health equity moving forward.

THE CMS EQUITY PLAN FOR IMPROVING QUALITY IN MEDICARE

CMS developed the CMS Equity Plan for Improving Quality in Medicare (CMS Equity Plan for

Medicare) in 2015, to support its commitment to achieving health equity through a focus on

results, innovation, and improving the patient experience. The CMS Equity Plan for Medicare

lays out an action-oriented, results-driven path for achieving health equity. It focuses on driving

improvement in communities with disproportionately high burdens of disease including chronic

conditions, worse quality of care, and barriers to accessing care. These vulnerable populations

include racial and ethnic minorities, sexual and gender minorities, people with disabilities, and

individuals living in rural areas. This strategic approach to disparity reduction advances work

underway at CMS’ network of quality improvement partners, federal, state, local, and tribal

organizations, providers of all types, health plans, beneficiaries and their families, researchers

and policymakers, and other stakeholders invested in achieving health equity among Medicare

beneficiaries.

To develop the plan, CMS conducted a literature review to identify evidence-based health care

interventions, quality improvement programs, and initiatives with potential to reduce disparities

among our priority populations. CMS also conducted an environmental scan to identify

promising health care interventions, programs, initiatives, and policies. Most importantly, CMS

gathered initial and ongoing input from stakeholders in a series of regional listening sessions

across the U.S. Over the last five years and into the future, CMS OMH has and will continue to

engage in conversations with national, regional, and local thought leaders to carve out a timely,

responsive, and actionable plan for a Path to Equity in Medicare.

Paving the Way to Equity: A Progress Report (2015-2021)

The CMS Equity Plan for Medicare is built around a framework that consists of three core

elements:

1. Increasing understanding and awareness of disparities;

2. Developing and disseminating solutions to achieve health equity; and

3. Implementing sustainable actions to achieve health equity.

CMS has termed this focus on understanding, solutions, and actions the Path to Equity. This

organizing framework is pictured in

Figure 1

, below, showing how these areas feed into each

other on a continuum, each one leading to the next. This report summarizes CMS’ progress

over the last four and a half years (September 2015 to January 2021)

in achieving health equity

through its policies and programs. It is illustrated with examples of how the agency has

increased understanding, solutions, and actions to reduce disparities nationwide. The examples

included in this report are not exhaustive, and CMS’ work is ongoing. We encourage

stakeholders to visit CMS OMH’s webpage to navigate and explore the full suite of resources,

tools, and information that is publicly available.

Figure 1. CMS Path to Equity

Data on utilization of products and resources is reported as of October 2020.

Paving the Way to Equity: A Progress Report (2015-2021)

CMS EQUITY PLAN FOR MEDICARE: PRIORITY AREAS

On this foundation of understanding,

solutions, and actions, CMS has built up a

focus around six high-impact priority areas

identified by Agency stakeholders. These

priorities incorporate both community- and

systems-level approaches to achieving

health equity. They were established based

on stakeholder input and requests for

increased CMS support and direction, a

review of the evidence base, and

consideration of CMS’ role in the work

underway within the U.S. Department of

Health and Human Services (HHS). These

priorities were drafted in alignment with

existing CMS and HHS initiatives and were

designed with particular focus on how CMS

could best support QIN-QIOs and other

quality improvement contractors in the 11

Statement of Work. They are intentionally flexible to allow our work to adapt to our evolving

health care system. Activities related to these priorities cut across the three areas of the Path to

Equity. The six priorities embedded in the CMS Equity Plan for Medicare are listed in

Figure 2

and described in more detail below.

Priority 1: Expand the Collection, Reporting, and Analysis of Standardized Data. The focus of

Priority 1 is to increase the importance placed on collecting and analyzing standardized patient

data, and to develop solutions that enable stakeholders to collect and analyze data in their

communities. Comprehensive patient data, including race, ethnicity, language, sexual

orientation, gender identity, disability status, and geographic location are required to plan for

quality improvements and address changes among the target populations.

Priority 2: Evaluate Disparities Impacts and Integrate Equity Solutions across CMS Programs.

The focus of Priority 2 is two-fold: 1) to measure and understand the effects that CMS programs

and policies have on vulnerable populations and embed evaluation instruments into existing and

new CMS policies, programs, models, and demonstrations; and 2) to build solutions into the

fabric of the agency that will help close gaps in health care quality, access, and outcomes,

moving CMS and partners to take action together to reduce disparities. To achieve Priority 2,

CMS is always engaging partners to identify any gaps among vulnerable populations’ health

care quality, outcomes, and access and working to close those gaps through the agency’s

programs, policies, models, and demonstrations.

Priority 3: Develop and Disseminate Promising Approaches to Reduce Health Disparities. The

focus of Priority 3 is to develop promising solutions to achieve equity in Medicare quality and to

replicate and adapt effective models and strategies. Priority 3 activities identify and share best

Figure 2. CMS Equity Plan for Medicare:

Priority Areas

• Priority 1: Expand the Collection, Reporting,

and Analysis of Standardized Data

• Priority 2: Evaluate Disparities Impacts and

Integrate Equity Solutions across CMS

Programs

• Priority 3: Develop and Disseminate Promising

Approaches to Reduce Health Disparities

• Priority 4: Increase the Ability of the Health

Care Workforce to Meet the Needs of

Vulnerable Populations

• Priority 5: Improve Communication and

Language Access for Individuals with Limited

English Proficiency and Persons with

Disabilities

• Priority 6: Increase Physical Accessibility of

Health Care Facilities

Paving the Way to Equity: A Progress Report (2015-2021)

practices and promising approaches in the reduction of health disparities to complement the

work of other priorities in the CMS Equity Plan for Medicare.

Priority 4: Increase the Ability of the Health Care Workforce to Meet the Needs of Vulnerable

Populations. The focus of Priority 4 spans understanding, solutions, and actions. It aims to

increase the understanding of health care workforce innovations that reduce disparities for

vulnerable populations. Work under this priority also supports developing solutions to equip the

health care workforce to increase the provision of culturally and linguistically appropriate and

effective care for beneficiaries. Finally, this work drives actions to adopt and adapt promising

practices that enhance the workforce’s ability to improve quality of care and outcomes for the

individuals and communities they serve.

Priority 5: Improve Communication and Language Access for Individuals with Limited English

Proficiency and Persons with Disabilities. The focus of Priority 5 is to improve communication

and language access for Medicare and dual eligible beneficiaries. Through the development of

tools and resources, this activity supports organizations as they provide communication and

language assistance services to consumers to ensure they can actively participate in the care

they receive.

Priority 6: Increase Physical Accessibility of Health Care Facilities. Priority 6 focuses on building

shared understanding of the physical accessibility of health care facilities, identifying solutions,

and facilitating action to increase the physical accessibility of health care facilities.

Measuring Progress

To evaluate CMS’ progress toward achieving health equity among Medicare beneficiaries, we

established a goal and set of guiding questions. The Path to Equity is influenced by many

factors – some that CMS and our partners can influence directly and some that we cannot. This

makes evaluation and measurement a challenge. This progress report acknowledges that

improvements in health outcomes are slow to surface and difficult to attribute to a discrete

action, policy, or change. It gives the reader a snapshot into some of the key work that has been

done to move the needle since the CMS Equity Plan for Medicare was drafted in 2015. Moving

forward, CMS will continue to focus on results, identifying areas where success can be

measured qualitatively and quantitatively.

EVALUATION GOAL

The overarching goal for evaluating and monitoring CMS’ progress in achieving the aims of the

CMS Equity Plan for Medicare is to determine the extent to which CMS’ activities have

increased understanding and awareness of disparities, increased development and

dissemination of solutions, and accelerated the implementation of sustainable actions to

achieve health equity.

Paving the Way to Equity: A Progress Report (2015-2021)

EVALUATION QUESTIONS

To monitor CMS’ progress toward achieving health equity in Medicare, CMS developed four

evaluation questions. The first three align with the Path to Equity and help CMS determine how

its activities contribute to each of these aims. The fourth question helps inform opportunities for

CMS to improve its activities over time and work more effectively toward achieving health equity

among Medicare beneficiaries.

1. How are the activities in the CMS Equity Plan for Medicare increasing understanding and

awareness of disparities?

2. How are the activities in the CMS Equity Plan for Medicare supporting the development and

dissemination of solutions to increase equity in Medicare?

3. How are the activities in the CMS Equity Plan for Medicare leading to sustainable actions

that increase equity in Medicare?

4. What are the gaps, needs, and next steps to achieve equity in the Medicare program?

LIMITATIONS OF THIS REPORT

This progress report focuses on key results of CMS’ activities to achieve health equity in

Medicare. It does not report every initiative undertaken as part of the CMS Equity Plan for

Medicare or more broadly at CMS and HHS. Given the multi-faceted nature of community- and

systems-change and the potential for confounding factors, it is not possible to directly attribute

changes in health disparities among Medicare beneficiaries to CMS’ activities to achieve health

equity through its policies and programs at this time. However, the current and potential future

impact of these initiatives should not be ignored. The purpose of this progress report is to

describe key results and activities between September 2015 – January 2021 that are paving the

way to health equity and helping CMS and partners begin to move the needle on disparities.

Increasing Understanding and Awareness of

Disparities

The first step on the Path to Equity is increasing

understanding and awareness of disparities. CMS’

activities in this area respond to the research

question: How are the activities in the CMS Equity

Plan for Medicare increasing understanding and

awareness of disparities?

In this section, we explore two major areas of

progress: 1) expanding the collection, reporting, and

analysis of standardized data, and 2) increasing the

health care workforce’s understanding of disparities

by disseminating research findings on disparities,

Paving the Way to Equity through

Understanding involves:

• Identifying knowledge gaps across

CMS and partners about disparities

and their drivers;

• Filling knowledge gaps to better inform

programs, policies, and partners;

• Enhancing understanding of the drivers

of disparities; and

• Improving understanding of why

disparities matter and why it is

important to address them.

Paving the Way to Equity: A Progress Report (2015-2021)

their drivers, and best practices on the provision of culturally and linguistically appropriate

services (CLAS).

CMS EXPANDED THE COLLECTION, REPORTING, AND ANALYSIS OF

STANDARDIZED DATA

CMS has worked to achieve equity by making existing data more accessible as well as

increasing and improving the collection of standardized data. This helps quality improvement

partners and other stakeholders, as well as the providers they serve, identify where there are

gaps in health care quality, outcomes, and access. This can show where and how interventions

can be targeted to ensure all beneficiaries are receiving the highest and most equitable care

under the Medicare program. This approach enables CMS and our partners to focus on results,

and to tailor our work to improving patients’ experiences with the health care system.

CMS made existing data more accessible

The published literature suggests that increasing the collection of standardized patient

demographic and language data across health care systems, including race, ethnicity, language

preference, sexual orientation, gender identity, disability status, and geographic location is an

important first step toward improving population health.

xxxii,xxxiii

Equally important is ensuring that

these data are accessible to key stakeholders. As such, CMS is committed to making existing

data relevant, accessible, and easy to use for providers, researchers, quality improvement

professionals, health care organizations, and other stakeholders in support of their efforts to

access federal data to identify and address health disparities.

For example, in 2016, for the first time in its history, CMS released stratified data and reports on

the Medicare Advantage (MA) population. This is significant because Medicare Part C and D

plans cover nearly one-third of Medicare beneficiaries. These data and reports identify

variations in their clinical care outcomes and patient experiences. Because they provide

contract-level data, CMS’ annual publication of these reports encourages health plans to

respond to disparities within their member populations. CMS has published numerous reports

and products on these data, many of which are updated annually and as new data become

available. This provides the public with streamlined and easily accessible information on

disparities in health care by race and ethnicity, gender, and urban-rural location. Some of the

most recent include:

► Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage (April 2020)

describes the quality of health care received in 2018 by Medicare beneficiaries enrolled in

Medicare Advantage (MA) plans nationwide (31.6 percent of all Medicare beneficiaries).

The report highlights racial and ethnic differences in health care experiences and clinical

care, compares quality of care for women and men, and examines racial and ethnic

differences in quality of care among women and men separately. This 2020 report is the

fifth in a series of reports that are updated annually.

Paving the Way to Equity: A Progress Report (2015-2021)

► Rural-Urban Disparities in Health Care in Medicare (November 2020) describes rural-

urban differences in health care experiences and clinical care received nationally in 2019.

In addition to comparing the quality of care delivered to rural and urban Medicare

beneficiaries overall, the report looks at how these differences vary by race and ethnicity

and by race and ethnicity within rural and urban areas.

Another important way CMS has

improved the accessibility of existing

data is through the development of

the Mapping Medicare Disparities

(MMD) Tool, an interactive data

visualization tool used to identify

areas of disparities between

subgroups of Medicare beneficiaries

(e.g., racial and ethnic groups) in

health outcomes, utilization, and

spending. The MMD Tool includes

both a Population and Hospital View.

The Population View uses Medicare

FFS data to show the prevalence of

60 chronic conditions, health care

utilization, and health care costs by race, ethnicity, sex, urban/rural location, dual-eligibility

status, and age. The Hospital View includes data from the Hospital Compare website and allows

comparisons of hospitals on quality and cost of care measures. The MMD Tool’s interactive web

interface allows users to visualize disparities in chronic diseases and health care utilization in

their communities, which enables them to target specific interventions where they are needed

most (see

Figure 3

CMS released the first

version of the MMD Tool

in 2016. Since then,

CMS has incorporated

multiple enhancements

and data updates based

on user feedback to

provide a broader range

of measures for

identifying and

understanding health

disparities. These

enhancements involved

integrating data on:

additional chronic

Figure 3. Mapping Medicare Disparities (MMD) Tool

Stakeholder Feedback on the

MMD Tool

• “We are going to download the data to understand how the data can

support research in radiology. [The MMD Tool] has great potential to

provide additional insight on disparities in preventive services.” –

Comment from providers, March 2019

• “[We] will be a strong partner in using this tool and would like to

provide bi-directional feedback and expand use of the tool in rural

areas and around screenings and other preventive service disparities.”

– Comment from providers, March 2019

• “[The MMD Tool] map and included data are very interesting. The Tool

will help reduce provider burden.” – Comment from a Medicare

Administrative Contractor (MAC), April 2019

Paving the Way to Equity: A Progress Report (2015-2021)

diseases; the utilization of preventive services; opioid use disorders; certain cancer diagnoses;

emergency department visits; the prevalence of disabilities; and behavioral health. The MMD

Tool also now includes county social-risk profiles based on American Community Survey (ACS)

data regarding the proportion of the county’s population with limited English proficiency, average

household income, unemployment rate, percent of vacant homes, average household size, and

poverty rate. The ACS profile is also available at the state and national level. Additionally, a new

trend analysis feature allows users to view changes over time (2012-2018) and compare

differences by race and ethnicity, gender, age, urban/rural location, or Medicare and Medicaid

eligibility within or by county and/or state. To further increase the accessibility of this data, CMS

created a Spanish-language version of the tool for MMD’s Population View along with

accompanying documentation, including end user guidance. As of October 2020, the MMD Tool

had received more than 39,800 views.

CMS increased and improved the collection of standardized data

While evidence-based guidelines and practices exist for improving the collection of data on

race, ethnicity, and language in health care settings, these guidelines may not be known nor

implemented, resulting in wide variations in data collection that negatively impact the accuracy

and reliability of the data. To improve standardized data collection among stakeholders, CMS

developed the Inventory of Resources for Standardized Demographic and Language Data

Collection (updated March 2020). The inventory combines data collection best practices from

reports, toolkits, webinars, and training tools into a single resource that can be used by health

care organizations of all types. Stakeholders can use these resources to improve the collection

of standardized data, which can help them identify and address health disparities. Each year,

the inventory is updated to ensure it reflects the most up-to-date guidance available. Between

its initial publication in 2016 and October 2020, this inventory was downloaded over 1,200

unique times and it has been used and shared by CMS quality improvement partners among

their members and providers to improve local and regional data collection.

To improve federal data collection, in 2016, CMS conducted cognitive testing around modified

Spanish language for a question about sexual orientation for the National Health Interview

Survey (NHIS). The NHIS has been conducted for more than 50 years through household

telephone interviews to assess the health of the nation. This survey collects data on important

health topics, such as health status, health care access, and progress toward achieving national

health objectives. The research showed that the updated language, while not a direct translation

of the English question, is better understood by Spanish speakers, which could lead to lower

rates of non-response. As a direct result of this work, the Bureau of Justice Statistics adopted

the revised sexual orientation question in the Spanish version of the 2016 National Crime

Victimization Survey, and in 2017, the Centers for Disease Control and Prevention (CDC) began

using the modified language for the

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. These changes will

enable surveys to capture a more accurate picture of health disparities among Spanish-

speaking sexual minorities.

CMS has also been instrumental in improving the availability and use of standardized Medicare

data through the Medicare Current Beneficiary Survey (MCBS). The MCBS is a continuous, in-

Paving the Way to Equity: A Progress Report (2015-2021)

person, longitudinal survey of a representative national sample of the Medicare population.

CMS supported the development of the MCBS Public Use File, which allows individuals to

assess and monitor the impact of the Medicare program on beneficiaries’ health. This public

data file lets users sort beneficiaries by age, race, ethnicity, and gender. Users can view

information about health conditions, access to and satisfaction with care, type of insurance

coverage, and information on utilization, including the number of fee-for-service claims per

beneficiary for certain health care event types. The MCBS data is designed to represent the

Medicare population as a whole and CMS has supported oversampling of certain smaller, but

critically important populations. This method ensures that researchers and other users can

examine the health status of elderly beneficiaries (age 85 and over), beneficiaries with

disabilities, beneficiaries in Accountable Care Organizations (ACOs), and Hispanic beneficiaries

to see health changes over time. The release of the public use file, or PUF, of the MCBS data

makes this information more accessible and usable for anyone interested in understanding

outcomes and disparities among Medicare beneficiaries over time, regardless of whether they

are a researcher with a formal data use agreement with the government.

CMS DEVELOPED RESOURCES TO INCREASE THE HEALTH CARE

WORKFORCE’S UNDERSTANDING OF DISPARITIES

CMS has worked to achieve health equity by supporting the health care workforce’s ability to

provide patients with more culturally appropriate and person-centered care. The agency has

focused on giving providers tools to better understand and meet patients’ needs by sharing

research, information, and best practices that providers can easily find and use in their everyday

practice.

CMS disseminated research findings on disparities and their drivers to increase

the health care workforce’s understanding of disparities

CMS analyzes Medicare beneficiary data to identify and better understand the drivers of

disparities among target populations, including racial and ethnic minorities, sexual and gender

minorities, people with disabilities, and individuals living in rural areas. For example, CMS

analyzed data for transgender beneficiaries, which resulted in three published

manuscripts.

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CMS routinely disseminates reports, briefs, maps, and guidance to stakeholders through its

website. Data highlights, infographics, and research reports on topics related to health

disparities

across a number of vulnerable Medicare populations are available on the CMS OMH

website. A small subset of the products published between 2015 – 2021 are noted on the

following page.

The MCBS sample frame includes all aged individuals, but only individuals 18 and over are interviewed and

included in the LDS files.

Paving the Way to Equity: A Progress Report (2015-2021)

In addition, CMS has supported

innovation in telehealth by

exploring trends of the effect and

utility of expanded telehealth

services for vulnerable Medicare

beneficiaries. This analysis

informs the Agency’s

understanding of this mode of

health care delivery. CMS

analyzed claims data from 2014

through 2016 to quantify the

current extent of telehealth

services provided to Medicare

beneficiaries, the demographic

and diagnostic characteristics of

beneficiaries who receive them,

and high-volume services

provided to Medicare

beneficiaries. Results of this work

showed that telehealth services

can increase access to critically

important care for older, rural, and

low-income beneficiaries as well

as those with disabilities.

xxxvii

CMS

shared these results with

Congress, federal colleagues,

public health professionals, health

care providers, and policy

experts.

CMS worked to increase the health care workforce’s understanding of disparities

by disseminating best practices on providing culturally and linguistically

appropriate services

Providing culturally and linguistically appropriate services (CLAS) and consistently monitoring

health care quality among at-risk populations are effective tactics to address persistent

disparities among vulnerable communities.

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However, there is little national data

available to characterize the provision of CLAS services, nor are there relevant quality

measures that can be used to monitor and engage the health care system to drive

improvement. To address this need, CMS examined the current state of health quality measures

related to CLAS and disparities. CMS assessed gaps in existing measures and their

implementation. CMS then identified measurement opportunities to address these gaps among

racial and ethnic minorities, people with limited English proficiency, people with low health

literacy, people with disabilities, and sexual and gender minorities. In 2016, CMS released A

Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic

Selection of CMS Products to Increase

Understanding of Disparities

• Racial and Ethnic Disparities in Diabetes Prevalence, Self-

Management, and Health Outcomes among Medicare

Beneficiaries (March 2017)

• Does Disability Affect Receipt of Preventive Care Services

among Older Medicare Beneficiaries? (July 2017)

• Medicare Fee-For-Service Beneficiaries with Disabilities, by

End Stage Renal Disease Status, 2014 (July 2017)

• Understanding the Health Needs of Diverse Groups of Asian

and Native Hawaiian or Other Pacific Islander Medicare

Beneficiaries (August 2017)

• Toward the Creation of a Patient-Reported Disability Index

(September 2018)

• Understanding the Health Needs of Diverse Groups of

Hispanic Medicare Beneficiaries (November 2018)

• Putting Patients First: Special Issue of Health Services

Research Journal (January 2019)

• Opioid Prescription in Medicare Beneficiaries: Prescription

Opioid Policies and Implications for Beneficiaries with Sickle

Cell Disease (June 2019)

• How Does Disability Affect Access to Health Care for Dual

Eligible Beneficiaries (July 2019)

• Z Codes Utilization among Medicare Fee-for-Service (FFS)

Beneficiaries in 2017 (January 2020)

• Understanding Rural Hospital Bypass Among Medicare Fee-

for-Service (FFS) Beneficiaries in 2018 (September 2020)

• Chronic Kidney Disease Often Undiagnosed in Medicare

Beneficiaries (October 2020)

Paving the Way to Equity: A Progress Report (2015-2021)

Minorities, People with Disabilities and Sexual and Gender Minorities to support hospitals,

health plans, and other health care organizations in improving health equity and implementing

the National CLAS Standards. This toolkit presents best practices for implementing the national

CLAS standards to address disparities in clinical practice, for example: organizational policies

focused on the provision of CLAS; practical tools for use by organizations and providers;

training and educational resources for organizational governance, leadership, and providers;

assessment tools to gauge cultural competence; and examples of programs designed to provide

culturally competent and person-centered care.

CMS also shared knowledge and promising practices to address disparities among Medicare

beneficiaries with limited English proficiency and those with sensory disabilities who need

additional communication services during health care visits. CMS analyzed 2014 American

Community Survey data to improve understanding of the communication and language needs of

Medicare beneficiaries at the national, state, and local levels. Findings indicated that local

beneficiary needs are not always the same as needs at a state or national level. This

emphasizes the need for providers to understand communication and language trends in the

smallest geography relevant to their service areas. This analysis led to Understanding

Communication and Language Needs of Medicare Beneficiaries (April 2017), an issue brief with

recommendations and promising practices for providers, CMS quality improvement partners,

and other health care stakeholders. From its initial publication through October 2020, the issue

brief has been downloaded more than 1,400 times. CMS also conducted interviews with a

variety of health care organizations across the country (i.e., community health centers,

hospitals, health systems, and health plans) about the innovative approaches to provide

language assistance services to persons with limited English proficiency. Key findings from this

work are highlighted in Providing Language Services to Diverse Populations: Lessons from the

Field (February 2018). This resource describes language assistance approaches suited to

different settings, populations served, and resource availability.

GAPS, NEEDS, AND NEXT STEPS TO INCREASE UNDERSTANDING

AND

AWARENESS OF DISPARITIES

Moving forward, CMS will continue working to achieve health equity by increasing

understanding and awareness of disparities in Medicare, and will explore new opportunities

across all of its programs and policies. For example, consistent with the CMS Rural Health

Strategy and Rethinking Rural Health initiative, the agency will continue to increase

understanding around disparities in rural communities’ health care access, outcomes, and

quality. As the number of individuals with chronic conditions continues to grow, CMS will build

on its ongoing work understanding disparities in diabetes and chronic kidney disease. As

increasing numbers of older adults seek long term care, CMS also recognizes that a growing

proportion of these individuals are racial, ethnic, sexual and gender minorities, individuals with

disabilities, and those living in rural areas.

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CMS will also continue to improve understanding

around disparities related to, and emerging from, our experience with COVID-19. This includes

disparities related to access, quality, and outcomes for those in post-acute care and other

settings. In addition, CMS will continue to work with federal and private partners to collect and

leverage data on social determinants of health to improve our understanding of how social risk

Paving the Way to Equity: A Progress Report (2015-2021)

factors can be addressed to reduce disparities. Finally, and of critical importance, CMS will build

on its commitment to the standardization of data and will continue to release public data that are

standardized and stratified to reveal and monitor disparities among the individuals and

communities CMS serves.

Developing and Disseminating Solutions to

Achieve Health Equity

The second step along the Path to Equity is developing

and disseminating solutions to achieve health equity. CMS’

activities in this area respond to the research question:

How are the activities in the CMS Equity Plan for Medicare

developing and disseminating solutions to achieve health

equity in Medicare quality?

In this section, we explore two major areas of progress: 1)

evaluating disparities impacts and integrating equity

solutions across CMS programs, and 2) developing and

disseminating promising approaches to support the health

care workforce in addressing health disparities.

CMS EVALUATED DISPARITIES IMPACTS AND

INTEGRATED EQUITY SOLUTIONS ACROSS CMS PROGRAMS

CMS has focused on results and unleashing innovation, creating solutions for evaluating the

impacts of disparities and embedding new resources and tools within CMS programs and

partner organizations to help quantify disparities and close gaps. CMS’ goals are two-fold: 1)

enhancing providers’ and other stakeholders’ ability to easily identify disparities and

opportunities for improvement among those they serve, and 2) relieving the burden on providers

and planning for creating and testing new solutions that can produce measurable results and

improve outcomes among vulnerable populations.

CMS developed and embedded Disparities Impact Statements and other

evaluation mechanisms across CMS programs and partner organizations

CMS has worked to ensure its programs, policies, and stakeholders are equipped to identify

disparities. This allows stakeholders to prioritize efforts where gaps are greatest, take actions to

improve care, and monitor changes over time. To support this effort, CMS developed and

piloted the CMS Disparities Impact Statement. The CMS Disparities Impact Statement is a

quality improvement tool that enables CMS and its stakeholders to systematically evaluate the

impacts of a policy or program on health disparities. CMS has facilitated organizations’ quality

improvement efforts to reduce disparities through targeted interventions. For example, the HIIN

Paving the Way to Equity

through Solutions involves:

• Creating new solutions based on

our understanding of disparities

and the unique health care

needs of individuals and

communities;

• Testing promising strategies and

interventions; and

• Sharing flexible tools that CMS

stakeholders can use to improve

the health care experience and

health outcomes for those they

serve.

Paving the Way to Equity: A Progress Report (2015-2021)

Statement of Work incorporated provisions

around the Disparities Impact Statement to facilitate

ongoing monitoring and reporting on disparities

reduction. At the close of the 11

Statement of Work

in 2019, more than 4,000 hospitals across 16 HIINs

nationwide participated in the Partnership for Patients

(PfP), a program that focuses on reducing inpatient

harms and readmissions. HIINs were charged to

develop strategic plans to identify, address, and

monitor progress on reducing disparities across harm

areas among their aligned hospitals. Additionally,

within the Accountable Health Communities (AHC)

program, CMS used an instrument called a Health

Equity Resource Statement, a variation on the CMS Disparities Impact Statement, as part of the

scored evaluation criteria for grant awards. The CMS Disparities Impact Statement has been

promoted and used by various organizations, including QIOs, Health Care Innovation

Awardees, health plans, hospital systems, and provider networks.

Further, through internal partnerships across Centers and Offices, CMS has strengthened the

evaluation and reporting elements for the QIO program, Medicare, Medicare Advantage, and

other programs. This yields a more informed understanding of how the agency and its partners

are structuring disparities reduction efforts and helps identify gaps, challenges, and future

opportunities. For example, the recent reports and data highlights focused on Sickle Cell

Disease and the use of opioids among Medicare beneficiaries mentioned in the “Understanding”

section of this report pave the way to “Solutions,” helping drive decisions and quality

improvement work related to pain management in the Medicare program. In addition, annual

reporting of stratified HEDIS and CAHPS scores is now part of the agency’s ongoing monitoring

and CMS Medicare Advantage Organizations are leveraging this data to identify areas of

opportunity to enhance patient experience, access, quality, and outcomes among MA and dual

beneficiaries. Moving forward, CMS will continue to strengthen monitoring and reporting of

disparities across QIOs and other quality improvement contractors. This supports CMS and its

partners in tailored interventions and focuses improvement on our most vulnerable Medicare

beneficiaries.

CMS embedded equity solutions across CMS programs and partners

Through our work with partners and stakeholders, we found that many organizations and federal

partners recognize that disparities exist. However, stakeholders expressed that they do not

know how to evaluate the impact of their program on disparities, nor what steps they should

take to achieve health equity among the individuals they serve. To address this need, in 2016,

CMS formed the Health Equity Technical Assistance program. Health Equity Technical

Assistance provides direct, flexible, on-demand technical assistance to internal CMS partners

and external stakeholders, including quality improvement partners, providers, health systems,

federal partners, health plans, state Medicaid agencies, health care organizations, local

agencies, and community associations. As of October 2020, through the Health Equity

Feedback on the

Disparities Impact Statement

“The Disparities Impact Statement is a

really nice tool. I like that it used the

PDSA approach and helps you think

about what you are doing, identify why

this is a need, what the data show, [and]

who you can partner with to impact

change and develop interventions. What

a great way to get health care

professionals to think about disparities in

a QI framework! This is a thoughtful tool.”

- HIIN, February 2019

Paving the Way to Equity: A Progress Report (2015-2021)

Technical Assistance Program, CMS health equity subject matter experts have responded to

over 278 technical assistance requests from stakeholders in 39 states as well as Washington,

DC, and Puerto Rico. Requests for technical assistance have come from internal CMS staff as

well as partner organizations, including health plans, health departments, universities, hospitals

and health systems, associations, quality improvement contractors, individual providers,

community organizations, researchers, and other stakeholders.

Recognizing the growing numbers of individuals enrolled in Medicare Advantage and managed

care, CMS continues to embed equity solutions to support health plans’ actions to reduce

disparities. For example, CMS began a series of strategic conversations to gather input from

Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) focused on

what they are doing to reduce disparities and how CMS could support their progress. This led to

the development of a cross-agency work group focused on learning from plans and generating

program and policy solutions to address disparities among Medicare Advantage enrollees. CMS

continues to engage with MAOs and MMPs to identify and address areas of opportunity where

plans and CMS can work together to improve care for Medicare Advantage and dual-eligible

beneficiaries.

CMS DEVELOPED AND DISSEMINATED PROMISING APPROACHES TO

SUPPORT THE HEALTH CARE WORKFORCE IN ADDRESSING HEALTH

DISPARITIES

CMS has promoted innovative solutions through trainings and resources for health care

professionals and Medicare beneficiaries to reduce disparities and improve the patient

experience among vulnerable populations. Expanding care teams to incorporate a diverse

group of providers and enhancing providers’ skills and cultural competence can help reduce

burden on the workforce as they improve the health of vulnerable communities.

CMS developed and enhanced trainings and resources for health care

professionals to include health equity solutions

Through the Medicare Learning Network (MLN), CMS’s primary mechanism for engaging and

educating Medicare providers on how to work with CMS programs and beneficiaries, the agency

developed and enhanced trainings for the health care workforce. These trainings are quality-

improvement focused. They help organizations and health care providers understand why and

how to improve the care they provide to vulnerable populations, including racial and ethnic

minorities, sexual and gender minorities, individuals with disabilities, and individuals living in

rural areas. CMS quality improvement contractors and providers can use these trainings to

reduce disparities and improve patient experience across multiple settings, while earning

continuing education credits. Recent trainings have focused on improving the quality of care and

data collection for sexual and gender minorities, and developing and strengthening strategic

responses to reducing disparities among beneficiaries. In addition, CMS has embedded content

related to disparities and practical solutions to achieve health equity in practice settings into

existing MLN trainings. This reduces burden on providers and minimizes the number of

individual training courses the workforce would need to take to feel well-equipped to care for all

patients. By incorporating a health equity lens into existing training content, CMS is efficiently

Paving the Way to Equity: A Progress Report (2015-2021)

enhancing providers’ cultural competency and reinforcing the importance of including health

equity approaches among professionals in all health care settings.

To illustrate CMS’ reach, between its release in January 2017 and October 2020, over 3,700

individuals from all 50 U.S. states, the District of Columbia and U.S. territories, and other

countries completed the training on improving the quality of care and data collection for sexual

and gender minorities. Participants included clinical providers, such as physicians, nurses, and

pharmacists; non-clinical support staff, such as medical billers and coders, front office staff, and

office managers; and others, including researchers. Although the Medicare Learning Network is

tailored to providers serving Medicare beneficiaries, individuals who take this training may be

serving populations that include Medicare, Medicare Advantage, Medicaid, Marketplace and

individuals with other private coverage.

As a complement to accredited training modules, CMS has created a number of provider-

focused resources to help drive solutions to reducing disparities. For example, to address

disparities in diabetes, a key focus area for CMS quality improvement contractors and partners,

CMS created a Culturally and Linguistically Tailored for Type 2 Diabetes Prevention Resources

Inventory for CDC-managed Diabetes Prevention Program (DPP) suppliers. This inventory

includes fully translated curricula and supplemental materials tailored to various minority

populations. The inventory meets the need for culturally and linguistically tailored resources to

support organizations delivering lifestyle-change programs to minority populations. As of

October 2020, it includes links to 11 sets of culturally and linguistically tailored materials

developed for organizations that may work with minorities seeking to prevent type 2 diabetes

and improve overall health and wellness. The materials presented in this inventory can support

organizations offering the National DPP lifestyle-change program and lifestyle-change program

curricula recognized by the CDC’s DPP, including the Medicare Diabetes Prevention Program

(DPP) Expanded Model. The inventory is available to all Diabetes Prevention Program providers

and other aligned stakeholders to help enhance DPP programming and will be updated

regularly to reflect improved and new training resources as they become available.

CMS also created a

Directory of Provider Resources for Diabetes Management, which compiles

existing guidelines and clinical recommendations; toolkits and clinical reference tools; continuing

education courses; and diabetes care, e-prescribing, and formulary management apps. The

directory is designed to facilitate the effective management of type 2 diabetes by primary care

teams. It is tailored to meet the needs of providers working with Medicare beneficiaries and

vulnerable populations who experience a higher prevalence of type 2 diabetes and its

complications. As with the DPP Resource Inventory, this directory will be routinely updated to

equip providers with timely tools to help patients manage their health. These two resources

were both released at the end of 2019. As of October 2020, together they have been

downloaded from the CMS website more than 2,700 times.

To support hospital-based practices and hospital networks, CMS has spread solutions for

reducing disparities among vulnerable populations through the Guide to Reducing Disparities in

Readmissions (revised August 2018). Hospital admissions and readmissions for chronic

illnesses generate significant costs for Medicare, and research has shown that minority and

Paving the Way to Equity: A Progress Report (2015-2021)

other vulnerable populations are more likely to be readmitted to the hospital within 30 days of

discharge for chronic conditions.

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CMS developed this guide as a tool for hospital leaders

to reduce avoidable readmissions for their diverse Medicare beneficiary populations. It provides

leaders of all types of hospitals (e.g., rural, urban, private, and nonprofit), and quality

improvement organizations that provide support to hospitals, with: 1) an overview of key issues

related to disparities in readmissions; 2) a set of activities that can help hospital leaders address

readmissions in these populations; and 3) strategies aimed at reducing readmissions in diverse

populations. From its initial release in August 2016 through October 2020, the guide was

downloaded from the CMS website more than 5,300 times and was shared widely by CMS

quality improvement contractors to address key drivers of readmission rates at hospitals

nationwide.

CMS developed Modernizing Health Care to Improve Physical Accessibility, to educate health

care providers across all practice settings on strategies to increase physical accessibility of

health care facilities and services. This resource was downloaded more than 1,900 times

between its release in July 2019 and October 2020. In addition, CMS collaborated with the

Department of Justice (DOJ), the HHS Office of Civil Rights (OCR), and the Administration for

Community Living (ACL) on Increasing the Physical Accessibility of Health Care Facilities (May

2017). This issue brief provides an overview of the importance of physical accessibility of health

care facilities, laws to promote accessibility, and examples of federal and state-level efforts to

better understand patient needs and support improvements in accessibility. The brief has been

downloaded more than 1,400 times since its publication through October 2020. These

resources educate stakeholders about the complexity of issues related to Medicare beneficiary

access and highlight opportunities for CMS and other federal agencies to work together in

addressing the need for more accessible facilities. They also close a gap in research and

practice by focusing explicitly on improving care for members of the Medicare population with

mobility-related disabilities. Each provides examples of mechanisms that have increased the

accessibility of facilities and real-world strategies and tools providers can access to make

improvements in their practice for individuals they serve.

Further, because effective communication is critical to ensuring mutual provider-patient

understanding, empowering patients, and providing high-quality care across all patient care

settings and provider types, CMS developed a practical tool to improve how providers and plans

communicate with individuals and communities. The Guide to Developing a Language Access

Plan (February 2018) helps organizations go through the steps they can take to provide high-

quality, appropriate language assistance services to all individuals they serve. Following a

Language Access Plan helps ensure that staff members are aware of what to do when an

individual with limited English proficiency needs assistance. CMS also developed two resources

(November 2020) to support providers serving those with sensory disabilities. When serving a

patient who is blind or has low vision or who is deaf or hard of hearing, it is important for an

organization to plan how they will provide effective, accessible communication. These resources

describe how to assess practices, develop communication plans, and be prepared to implement

accessible services.

Paving the Way to Equity: A Progress Report (2015-2021)

During the public health emergency, CMS is working to support providers and partners in our

most vulnerable communities. To assist administrators and providers in rural communities

during COVID-19, CMS OMH developed a Rural Crosswalk: CMS Flexibilities to Fight COVID-

19. The crosswalk is intended to assist rural providers in accessing information on key

provisions CMS has issued during the public health emergency. Rural providers including those

in Rural Health Clinics, Federally Qualified Health Centers, Critical Access Hospitals, rural

hospitals, and long term care facilities face numerous challenges while trying to serve their

patients. This document brings together key information that CMS has released to date in one

location to improve provider access to this crucial information and allowing them time to better

serve their patients. In addition, the CMS OMH website now includes a site with COVID-19-

related federal resources for vulnerable populations to help consumers, health care

professionals, community organizations, and other CMS stakeholders find trusted resources in

one place, including resources in languages other than English.

CMS designed, pilot-tested, and continuously enhances these provider tools and other

resources through engagement with health care professionals and disparities experts. This

ensures organizations have relevant, applicable tools and solutions to improve the quality of

care provided to vulnerable populations and create inclusive clinical practice environments.

CMS developed beneficiary-facing resources to improve care in vulnerable

communities

In addition to developing trainings and resources for health care professionals, CMS has also

developed individual and family-facing resources for Medicare beneficiaries. For example, CMS

developed the consumer-facing Getting the Care You Need: A Guide for People with Disabilities

to help raise awareness among individuals with disabilities about working with their providers to

ask for needed accommodations. An accompanying checklist highlights steps individuals and

family members can take before, during, and after appointments with health care providers to

ensure individuals with access challenges can get the care they need. From their publication in

July 2019 through October 2020, the handout and accompanying checklist have been

downloaded from the CMS website over 2,900 times. CMS’ release of these resources included

a Braille translation, and based on user feedback they are translated into multiple languages.

CMS also produced a suite of videos featuring the personal experiences of individuals with

disabilities navigating care, called Navigating Health Care with a Disability: Our Stories. One

video is aimed at a provider audience while the other is intended for individuals with disabilities.

As of October 2020, together these videos had been viewed on YouTube 5,000 times.

Further, to address the growing number of Medicare beneficiaries managing chronic conditions,

CMS partnered with HRSA’s Federal Office of Rural Health Policy to launch the Connected

Care campaign. This campaign was designed to raise beneficiary and provider awareness for

the services now available for chronic care management (CCM).

Medicare beneficiaries with

two or more chronic conditions may be eligible for CCM services. CCM services can be

The CCM campaign was specifically mandated by Congress to focus on racial and ethnic minorities, and rural

populations, and a Report to Congress was prepared and delivered to address the Connected Care campaign.

Paving the Way to Equity: A Progress Report (2015-2021)

delivered by several provider types and bring significant benefits to individuals in rural areas and

other vulnerable communities. CMS has released a number of beneficiary- and provider-facing

Connected Care resources to ensure that all eligible Medicare-covered individuals can get

services to help them manage their multiple chronic conditions. The campaign focused on

ensuring that individuals and providers in underserved communities were aware of these

reimbursable services. Connected Care resources include patient education resources such as

a poster, postcard, and video that can be used in clinical and community settings, and a toolkit

for healthcare professionals and community partners. CMS recognizes that CCM services take

providers’ time and effort. These resources help individuals with asking the right questions so

they can get help managing their care. These support tools also help providers account for the

additional time and resources they spend to provide help between appointments. Since the

campaign’s launch at the end of 2016, the Connected Care website has more than 108,000

unique pageviews, and resources have been downloaded by tens of thousands of users. Many

Medicare and dual eligible patients, including those in underserved communities, depend on this

extra effort to help them stay on track with their treatments and plan for health.

To address the public health emergency, CMS looked for ways to assist local communities and

our partners who work with those most vulnerable—such as older adults, those with underlying

medical conditions, racial and ethnic minorities, rural communities, and people with disabilities.

CMS sought feedback through a series of calls and listening sessions to find out what partners

needed to better serve vulnerable populations, specifically racial and ethnic minority

populations. Based off of this feedback, the From Coverage to Care (C2C) initiative created two

new consumer-facing resources to encourage people to stay healthy during COVID-19, receive

needed care, and understand how their health coverage would work during the public health

emergency. The first resource Coronavirus and Your Health Coverage: Get the Basics

helps

consumers learn how to protect themselves and their family during COVID-19 with tips for

staying healthy. This resource also has information about what health services are typically

covered under Medicare and Marketplace plans and additional resources. Second, C2C

released Stay Safe: Getting the Care You Need, at Home which offers tips for how to stay

healthy during COVID-19 with information about scheduling health appointments from home

and planning ahead for prescriptions. Both resources were originally posted in English and

Spanish with additional languages in development. To further assist partners in their work with

local communities, social tiles and graphics with key messages were also created.

Recognizing the interaction between chronic conditions and COVID-19 outcomes, and the

disproportionate number of racial and ethnic minorities with diagnosed Type 2 diabetes, CMS

created Managing Diabetes: Medicare Coverage and Resources. This two-page resource is

available in English and Spanish and pools CDC and CMS resources from over 20 websites into

a single, easy-to-navigate document. With one click on Medicare.gov, Medicare beneficiaries

can find links to help live with diabetes, how to find diabetes self-management education and a

provider to help them manage their care, how to get coverage for diabetes services, and how to

get help with costs. CMS and CDC’s collaboration on this product aims to help individuals,

particularly members of vulnerable communities who bear a high burden of Type 2 diabetes,

improve their management of diabetes and their overall health to decrease the risk of the severe

and adverse effects of COVID-19.

Paving the Way to Equity: A Progress Report (2015-2021)

GAPS, NEEDS, NEXT STEPS TO ACHIEVE HEALTH EQUITY BY DEVELOPING

AND DISSEMINATING SOLUTIONS

Moving forward, CMS will continue working to achieve health equity by developing and sharing

solutions and tools to eliminate disparities in Medicare, and will explore new opportunities

across all of its programs and policies. CMS will remain focused on developing resources for

beneficiaries and providers to improve vulnerable communities’ understanding and

management of their chronic conditions. This includes paying deliberate attention to conditions

that heavily impact minority and rural communities, such as diabetes, cancer, and heart

disease. Each of these conditions, among many others, place beneficiaries at increased risk for

severe illness from the virus that causes COVID-19. If current data trends hold, COVID-19

related disparities will continue to deepen across CMS OMH’s priority populations.

xlvii

Based on ongoing stakeholder feedback, the agency will also prioritize resources that help

providers and partners reduce avoidable readmissions, address social determinants of health in

various care settings, and manage patient safety concerns across settings from hospitals to

primary and post-acute care and as individuals transition between settings. Consistent with the

agency’s overarching priorities, CMS will continue to focus efforts on ensuring rural communities

have resources and tools to improve access, quality, and outcomes, and will work to develop

and share innovative solutions to address the opioid epidemic for vulnerable communities

nationwide. Finally, CMS will continue to build on its ongoing commitment to results through the

evaluation and monitoring of disparities among those we serve by embedding tools including the

CMS Disparities Impact Statement and monitoring and reporting on disparities across our

programs.

Implementing Sustainable Actions to Achieve

Health Equity

The third step along the Path to Equity is

implementing sustainable actions to achieve health

equity. CMS’ activities under this area inform the

following research question: How are the activities in

the CMS Equity Plan for Medicare leading to

sustainable actions that achieve equity in Medicare

quality?

In this section, we explore two major areas of

progress: 1) taking action to improve CMS programs

and policies to reduce disparities, and 2) mobilizing

partners to take action to reduce disparities.

Paving the Way to Equity through

Actions involves:

• Bringing stakeholders together and

spurring collective and individual

action among partners;

• Supporting stakeholders in their efforts

to achieve health equity;

• Making adjustments for continuous

quality improvement; and

• Ensuring actions are sustained over

time.

Paving the Way to Equity: A Progress Report (2015-2021)

CMS LEVERAGED QUALITATIVE AND QUANTITATIVE RESEARCH FINDINGS TO

IMPROVE PROGRAMS AND POLICIES TO REDUCE DISPARITIES

CMS has driven results across the nation and the agency, promoting action among CMS

components and external stakeholders through new partnerships and focused efforts to

measure, monitor, and eliminate disparities.

CMS programs are measuring and monitoring progress to eliminate disparities

The QIO program is one of the largest federal programs dedicated to improving health and

health care quality at the local level for Medicare beneficiaries. The program’s 11

Statement of

Work focused on five primary functions: 1) excellence in operations; 2) better health; 3) better

care; 4) lower costs; and 5) technical assistance. Under this program, CMS specifically aimed to

reduce disparities in diabetes and cardiac health. QIOs routinely updated CMS on their activities

related to vulnerable communities across all tasks, for example those targeting racial and ethnic

minorities, sexual and gender minorities, individuals with disabilities, and individuals living in

rural areas. CMS tracked QIO progress, as well as progress made by HIINs, CMS’ hospital-

focused quality improvement contractors. This helped ensure that the agency was aware of, and

able to encourage, our partners and stakeholders to continue to move the needle on health

disparities. As CMS and partners support the 12

Statement of Work, the agency will continue

to support the network of quality improvement and innovation contractors’ strong focus on

health equity so that together we can demonstrate results. In particular, CMS will work with

quality improvement contractors and individual providers to drive improvements in nursing

homes and hospitals as they navigate the current public health emergency. The Agency and our

partners will seek opportunities for improvement in health care quality, outcomes, and access

for vulnerable and rural communities – particularly those hardest hit by COVID-19.

CMS has also focused on testing approaches to reducing disparities through our models and

demonstrations. For example, health equity monitoring and measurement was embedded into

the scored grant selection criteria for the Accountable Health Communities (AHC) model. As

mentioned above, the AHC model required a Health Resource Equity Statement, a form of the

CMS disparities impact statement, to be included with each application and monitored over

time. CMS’ grant application with embedded equity statement ensured that selected awardees

were demonstrating a commitment and awareness of local health disparities and the

communities they serve. This was the first time a scored element related to health equity was

included in CMS’ grant application process and represents a significant step along the Path to

Equity for the agency.

CMS has increased internal collaboration to reduce disparities

Over the last several years, CMS has worked to increase collaboration and communication

across teams to ensure that beneficiaries and providers benefit from the most streamlined and

intelligently designed programs and policies. For example, CMS collaborated across Centers

and Offices to gather feedback from Medicare beneficiaries, providers, advocates, and health

care suppliers that would inform changes to Medicare payment policy to improve access to care

of people with disabilities. As a result of this work, CMS implemented a change to the Medicare

Paving the Way to Equity: A Progress Report (2015-2021)

Physician Fee Schedule (PFS) to support providers in spending additional time providing

preventive care to their patients. Beginning January 1, 2018, using a new provider billing code,

providers can bill for services that extend beyond the typical time assumed for eligible

preventive services. This change recognizes the increased resource costs associated with

providing care to some patients, including the medically necessary use of specialized mobility-

assistive technology during an office visit, such as adjustable height chairs or tables, patient

lifts, and adjustable padded leg supports.

CMS also recommended that beneficiaries with sickle cell disease be excluded from the opioid

safety edits starting in 2020. Previously, the CDC Guideline for Prescribing Opioids for Chronic

Pain stated that “given the challenges of managing the painful complications of sickle cell

disease, readers are referred to the NIH National Heart, Lung, and Blood Institute’s Evidence

Based Management of Sickle Cell Disease Expert Panel Report for management of sickle cell

disease.”

xlviii

In 2018, CMS released a report on the challenges of pain management for

beneficiaries with sickle cell disease titled “The Invisible Crisis: Understanding Pain

Management in Medicare Beneficiaries with Sickle Cell Disease” (September 2018), which

provided supporting evidence for this change. CMS encouraged its partners to work with their

pharmacy and therapeutics (P&T) committees to identify other vulnerable patient populations for

exclusion from the opioid safety edits. To further support these efforts, CMS released

comprehensive guidance for sponsors and educational materials for providers, beneficiaries,

and other partners, such as pharmacies, professional organizations, and advocacy groups,

which are available on the Improving Drug Utilization Review Controls in Part D webpage.

In addition, in 2019, CMS identified and developed standardized patient assessment data

elements (SPADEs) to assess social determinants of health and embedded these data

elements into the Post-Acute Care Quality Reporting Programs, to be collected starting in 2020.

Although data collection is delayed due to the public health emergency, this policy change in

Medicare’s prospective payment system makes collection of social determinants of health data

part of the required standardized patient assessments administered in post-acute care settings.

This extends to long-term care hospitals, skilled nursing facilities, intermediate rehabilitation

facilities, and home health agencies. The additional SPADEs include race, ethnicity, preferred

language/interpreter services, health literacy, transportation, and social isolation. Collecting

these data elements will allow CMS to inform provider understanding, facilitate coordinated care

and care planning, reduce readmissions, and improve quality of care and outcomes for

beneficiaries. While CMS acknowledges that there are other important social determinants

worth measuring, CMS also aims to balance the value of capturing data with the burden of

reporting for post-acute care providers. CMS strategically identified these specific demographics

and determinants of health because of their relevance to patients and residents receiving post-

acute care. Post-acute care settings have an opportunity to address SDOH. For example, they

may connect patients and residents to transportation programs, certified interpreters, or social

support programs. Collecting these data elements will provide the basis for CMS’ periodic

analyses of the relationship between an individual’s health status and demographic and social

risk factors that can inform efforts to promote health equity. To support post-acute care

providers in meeting this new requirement, CMS continues to refine our guidance on how to

collect these additional data with minimal burden.

Paving the Way to Equity: A Progress Report (2015-2021)

CMS leveraged internal partnerships to identify and mitigate challenges beneficiaries face in

identifying providers with accessible office locations and equipment. To help prospective

enrollees identify providers with accessible offices, CMS worked with states and plans

participating in the Financial Alignment Initiative (FAI) to improve Medicare-Medicaid Plan

(MMP) provider and pharmacy directories. CMS is seeing improvements in these directories,

which now indicate if a provider location is on a public transportation route. Some MMPs have

made progress in indicating which providers have completed cultural competency training. CMS

continues to work with plans about indicating the specific accommodations available at provider

locations for individuals with physical disabilities.

In support of Medicare’s evolving payment systems in 2019, CMS strengthened the validation

criteria for Quality Payment Program Merit-Based Incentive Payment System (QPP MIPS)

Improvement Activities to align with our goal of achieving health equity. Providers participating

in the Merit-Based Incentive Payment System, or MIPS, may participate in Improvement

Activities to improve their score, and therefore their reimbursement, under this new Medicare

payment system. Improvement Activities are structured to improve care for beneficiaries, and

CMS’ cross-component collaboration helps reduce burden on providers as they engage in – and

are recognized for – meaningful, impactful disparities reduction efforts as a part of their

participation in the Medicare program.

This progress report has highlighted a number of examples of internal CMS collaboration to

reduce disparities among priority populations. However, there are many more partnerships that

help inform and advance health equity work across the agency each day. CMS has

strengthened its internal operations to improve our work across components, paving the way for

the agency to address new and emerging equity issues and continually improve CMS programs

and policies.

CMS CONVENED AND MOBILIZED PARTNERS TO TAKE ACTION ON

DISPARITIES

CMS mobilized communities, partners, and providers to take action on reducing disparities and

implementing innovative, self-directed health equity activities.

CMS inspired action and sharing among providers and external partners

In an effort to spur ongoing, sustainable health equity actions among health care providers and

others, CMS announced the CMS Health Equity Award in 2018. From 2018-2020, this

recognition highlighted organizations demonstrating an exceptional commitment to health equity

by reducing disparities among the CMS beneficiaries they serve, particularly among racial and

ethnic minorities, individuals with disabilities, sexual and gender minorities, and those living in

rural areas. CMS used a rigorous, peer-reviewed selection process to select and recognize

organizations who can demonstrate results in reducing disparities in health care quality, access,

or outcomes for a priority population. This award helped mobilize CMS stakeholders, spurring

CMS’ partners to share and spread innovative best practices that measurably reduce

Paving the Way to Equity: A Progress Report (2015-2021)

disparities, and lifting up organizations who are successfully closing gaps among those they

serve.

For example, in 2018, CMS recognized Kaiser Permanente for reducing disparities in

hypertension control, closing the Black/White gap to dramatically improve hypertension control

for African Americans through a targeted intervention. CMS also recognized Novant Health for

identifying and reducing a disparity in pneumonia readmission rates, improving pneumonia-

related readmissions for African Americans over less than one year to close the gap between

this population and other patients served. In 2019, CMS recognized HealthPartners for their

organization-wide approach which helped them reduce health disparities and close or eliminate

gaps between racial and ethnic minority enrollees and white enrollees for multiple health

outcomes across the clinic, health plan, and hospital settings. CMS also recognized Centene

Corporation for their national initiative to increase the accessibility of provider offices and

services for people with disabilities by providing grant funding directly to providers to make

improvements. In 2020, CMS presented the award to UnitedHealthcare, which used home

visits, local primary care and obstetric nurse partnerships, and care coordination to improve the

delivery of timely, comprehensive postpartum care among Black women in Michigan and Ohio

as well as rural women in Hawaii. CMS also presented the award to Atrium Health, which

improved their collection of demographic data, created an analytic tool that stratifies health-

related data by key demographic variables, and used the results to design and implement

culturally appropriate interventions in communities and primary care practices. This effectively

closed the gap in colorectal cancer screenings for Hispanic males.

Further, in 2018, inspired by CMS’ work to reduce disparities, the HIIN community initiated a

self-driven effort to develop, test, and implement a Health Equity Organizational Assessment.

This assessment was completed by enrolled hospitals and helped HIINs, hospitals, and CMS to

refine our understanding of where hospitals are on their journeys to eliminating disparities and

how to meet their members’ needs. The elements that HIINs identified and measured in their

hospital assessment bring health equity to the forefront of the program. Coupled with CMS

Disparities Impact Statements and the robust self-governed HIIN Health Equity Affinity Group,

CMS and HIINs gained insight on a broad swath of hospitals and could track health equity

progress nationwide.

Another example of how CMS has generated self-directed health equity activities is through

engagement with federal stakeholders to identify actions to improve accessibility in health care

and other facilities for people with disabilities. CMS has engaged more than 40 federal

stakeholders representing 11 federal agencies on a regular basis to identify solutions that will

The receipt of a CMS Health Equity Award should not be interpreted as a release of or a statement made on a recipient’s

compliance with its specific legal or regulatory obligations, or the merit, existence or lack of existence of any investigation, lawsuit, or

other matter relating to compliance or law enforcement. The CMS Health Equity Award solely represents recognition for specific

efforts to improve health equity, as evaluated based on the information reviewed by CMS’s selection committee.

Paving the Way to Equity: A Progress Report (2015-2021)

ensure health care and other facilities are physically accessible

to individuals with mobility impairment. This work created a

robust network of disability experts who are now pursuing and

generating opportunities to eliminate disparities for beneficiaries

with disabilities. For example, this group collaborated to inform

CMS’ most recently released provider accessibility resources,

ensuring providers and beneficiaries get the most well-rounded

and well-informed perspective. Throughout the public health

emergency, this group has engaged in regular discussions to

assess the unique challenges and barriers that individuals with

disabilities face related to COVID-19. Each agency has shared

their perspectives, assets, and the challenges they face to

collectively identify solutions and improve quality, access, and

outcomes for individuals with disabilities in the public health

emergency.

Understanding that many of the office’s populations were being hit the hardest by the COVID-19

public health emergency, CMS hosted three listening sessions focusing on racial and ethnic

minority populations and COVID-19. The feedback received in these sessions was shared

within the Agency to inform next steps to continue addressing the unique needs minority

communities face during the public health emergency.

Lastly, CMS administers the Minority Research Grant Program (MRGP) to support researchers

at minority-serving institutions who are exploring how CMS can better meet the health care

needs of racial and ethnic minorities, people with disabilities, sexual gender minorities, and

individuals living in rural areas. Minority-serving institutions include Historically Black Colleges

and Universities, Hispanic-Serving Institutions, Tribal Colleges and Universities, and Asian

American and Native American Pacific Islander-Serving Institutions. CMS supports recipients of

the MRGP by providing research funding for 24 months along with technical assistance, one-on-

one support, and progress reports. Between 2005 – 2020, the MRGP has funded 48 grantees

resulting in expanded health-related knowledge, attitudes, behaviors, and outcomes as evident

by more than 40 published manuscripts, 55+ abstracts and presentations, book publications,

and over 190 citations in subsequent research. This work has increased the agency’s and

external partners’ knowledge of new and emerging research to support health equity through

the expertise and technical mastery of research faculty at minority-serving institutions.

GAPS, NEEDS, AND NEXT STEPS TO IMPLEMENT SUSTAINABLE ACTIONS

In the future, CMS will continue to implement sustainable actions across its programs and

policies to achieve health equity among Medicare beneficiaries, and will explore new

opportunities across all of its programs and policies. CMS will promote and expand upon its

current efforts to support providers in small practices, and those in rural and underserved areas,

through the Quality Payment Program as they transition to Advanced Alternative Payment

Methodologies and the Merit-Based Incentive Payment System, as well as through other CMS

payment systems and models. In addition, CMS, in collaboration with the Office of the Assistant

Feedback from Listening

Session Participant:

“Thanks very much for

providing an opportunity for

those of us who have been

working for many years on

health equity for people with

disabilities to participate in

today's listening session on

increasing physical

accessibility of health care

facilities. We appreciate the

leadership of [CMS] OMH on

this issue and look forward to

continued discussions.”

Paving the Way to Equity: A Progress Report (2015-2021)

Secretary for Planning and Evaluation (ASPE) and other HHS partners, will continue to consider

ways to standardize data collection of social determinants of health and demographic

information. CMS and HHS partners will continue to collaborate on ways to leverage this data

collection to add value to federal agencies, providers, and local communities.

CMS will continue convening partners and consumers to understand where action is needed,

and what actions will be most impactful. The Agency will maintain their focus on continuous,

system-wide, sustainable quality improvement. CMS will continue to engage on ways to

encourage providers to address the needs of the whole person and link individuals with the

services they need to achieve their highest level of health. CMS will also continue to explore

how best to encourage providers to eliminate disparities through Medicare and other value

based payment systems and model tests. The agency will maintain a focus on vulnerable

communities hit hardest by the public health emergency, considering barriers and solutions

specific populations face during the COVID-19 crises and other emerging diseases. Finally,

CMS will build on its current work embedding health equity and standardized data into its rules,

regulations, and guidance across health care settings. This work, and all of the work of the CMS

Equity Plan, will maintain a focus on ensuring that CMS programs and policies are designed to

help organizations across the health care continuum work together to reduce disparities and

achieve health equity for CMS beneficiaries nationwide.

Paving the Way to Equity: A Progress Report (2015-2021)

SUGGESTED CITATION

Centers for Medicare & Medicaid Services, “Paving the Way to Equity: A Progress Report

(2015-2021),” (2021).

CMS OFFICE OF MINORITY HEALTH

7500 Security Blvd.

MS S2-12-17

Baltimore, MD 21244

HealthEquityTA@cms.hhs.gov

go.cms.gov/omh

Paid for by the US Department of Health & Human Services.

January 2021

Paving the Way to Equity: A Progress Report (2015-2021)

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