Putting patients first: Today's disparities research leading to health equity tomorrow

The Centers for Medicare & Medicaid Services (CMS) has collaborated with a wide variety of stakeholders to support work in all three areas of its path to equity: increasing the understanding and awareness of disparities and their causes, developing and disseminating solutions, and implementing sustainable actions. To increase understanding and awareness of disparities, CMS sponsored this issue, with a goal of contributing to the conversation on health disparities and emphasizing the value of continuing research in this area. The studies included in this issue underscore the importance of identifying groups of people who do not benefit equally from our health system and identifying root causes of these differences. We value the information and analysis they provide on this important topic and hope that they will create further discussion on how to reduce health disparities. Sponsoring this issue is only the latest in a series of things CMS has done to improve health equity nationwide. To improve our understanding of disparities and their causes, we have fostered demographic data collection through the implementation of data standards; analyzed and reported on health disparities through annual reports on health care quality in Medicare Advantage and other analytic reports; and launched the Mapping Medicare Disparities Tool, which is an interactive webbased tool that allows the user to quickly calculate a range of health outcome measures by population of interest at the county, state, and national levels. The agency also launched the CMS Equity Plan for Improving Quality in Medicare, which focuses on six priority areas, such as increasing the ability of the health care workforce to meet the needs of vulnerable populations, improving physical accessibility of health care facilities, and improving communication and language access for individuals with limited English proficiency and persons with disabilities. We have also implemented From Coverage to Care (C2C), an initiative to help individuals understand their coverage and how to use it to connect to the primary care and preventive services that are right for them; released the first ever CMS Rural Health Strategy; developed a number of resources to help stakeholders build an organizational response to health disparities; and provided Health Equity Technical Assistance to organizations seeking help to identify and address health disparities. Finally, we worked across the agency to ensure that all of our programs are looking for ways to incorporate a focus on health equity, such as the Quality Improvement Organization Program, which seeks in part to improve health quality at the community level for all Medicare beneficiaries; the Partnership for Patients initiative, a publicprivate partnership that aims to improve quality, safety, and affordability of health care; and models such as the Accountable Health Communities Model, a 5year model that tests whether systematically identifying and addressing the healthrelated social needs of Medicare and Medicaid beneficiaries, such as food insecurity and inadequate or unstable housing, through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. We also finalized a payment code for providers who spend additional time during a visit with patients who need it, including persons with a disability or a cognitive impairment. Our efforts are a great start, but we know there are more to do and more to learn, which is why CMS’ Office of Minority Health (OMH) is pleased to support this Special Issue of Health Services Research. This issue further evaluates several areas of interest to CMS, such as chronic disease, quality of care, patient experience and satisfaction, and health coverage. The authors conducted innovative research to examine the multitude of influences that impact health disparities and promote innovation in quality improvement programs, and the targeted interventions to support the most vulnerable populations. Taken together, they move us a little closer toward our goals of achieving health equity. This Special Issue begins with three manuscripts that examine chronic disease through a health equity lens. The first manuscript by Durfey et al (2019) uses Area Deprivation Index (ADI) measures to explore chronic disease management among Medicare Advantage enrollees. While the authors suggest that ADI has limitations as a measure of a social determinant of health, they also suggest that it may help Medicare assess individual risk and target interventions where MA enrollees live. They found that area deprivation is a predictor of chronic disease management and that the relationship did not differ by race or ethnicity. This association remained statistically significant after controlling for individuallevel risk factors. Only the top 10 percent most disadvantaged neighborhoods had a significant association with blood pressure control after adjustment. The


Putting patients first: Today's disparities research leading to health equity tomorrow
The Centers for Medicare & Medicaid Services (CMS) has collaborated with a wide variety of stakeholders to support work in all three areas of its path to equity: increasing the understanding and awareness of disparities and their causes, developing and disseminating solutions, and implementing sustainable actions. To increase understanding and awareness of disparities, CMS sponsored this issue, with a goal of contributing to the conversation on health disparities and emphasizing the value of continuing research in this area. The studies included in this issue underscore the importance of identifying groups of people who do not benefit equally from our health system and identifying root causes of these differences. We value the information and analysis they provide on this important topic and hope that they will create further discussion on how to reduce health disparities.
Sponsoring this issue is only the latest in a series of things CMS has done to improve health equity nationwide. To improve our understanding of disparities and their causes, we have fostered demographic data collection through the implementation of data standards; analyzed and reported on health disparities through annual reports on health care quality in Medicare Advantage and other analytic reports; and launched the Mapping Medicare Disparities Tool, which is an interactive web-based tool that allows the user to quickly calculate a range of health outcome measures by population of interest at the county, state, and national levels.
The agency also launched the CMS Equity Plan for Improving Quality in Medicare, which focuses on six priority areas, such as increasing the ability of the health care workforce to meet the needs of vulnerable populations, improving physical accessibility of health care facilities, and improving communication and language access for individuals with limited English proficiency and persons with disabilities.
We have also implemented From Coverage to Care (C2C), an initiative to help individuals understand their coverage and how to use it to connect to the primary care and preventive services that are right for them; released the first ever CMS Rural Health Strategy; developed a number of resources to help stakeholders build an organizational response to health disparities; and provided Health Equity Technical Assistance to organizations seeking help to identify and address health disparities.
Finally, we worked across the agency to ensure that all of our programs are looking for ways to incorporate a focus on health equity, such as the Quality Improvement Organization Program, which seeks in part to improve health quality at the community level for all Medicare beneficiaries; the Partnership for Patients initiative, a public-private partnership that aims to improve quality, safety, and affordability of health care; and models such as the Accountable Health Communities Model, a 5-year model that tests whether systematically identifying and addressing the healthrelated social needs of Medicare and Medicaid beneficiaries, such as food insecurity and inadequate or unstable housing, through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. We also finalized a payment code for providers who spend additional time during a visit with patients who need it, including persons with a disability or a cognitive impairment.
Our efforts are a great start, but we know there are more to do and more to learn, which is why CMS' Office of Minority Health Another aspect of place, living in a "food swamp," is the focus of the next manuscript. Phillips and Rodriguez (2019) note that while this term is relatively new to the public health literature, food swamps are places in which large numbers of unhealthy energydense food offerings inundate, or "swamp out," the relatively few existing healthy food offerings. They note the contrast with a "food desert," which is defined more by a paucity of healthy options. The authors combine multiple data sources to complete a cross-sectional analysis of 784 counties across 15 states. The study found a positive association between food swamp score and all-cause hospitalizations with a stronger association in rural counties than urban counties.
Karliner et al (2019) combined data from the San Francisco

Mammography Registry and Facility Survey and California Cancer
Registry to explore follow-up times, population vulnerability (defined by race/ethnicity, educational attainment, and English proficiency), system-based processes, and association with cancer stage at diagnosis in mammography facilities. They found that where population vulnerability was highest, facilities had longer follow-up times and these facilities also had fewer radiologists, longer biopsy appointment wait times, and less direct patient communication. However, even within these facilities, whites had better outcomes than their non white counterparts. Longer follow-up time at a facility was also associated with a higher adjusted odds ratio of advanced-stage cancer at diagnosis. This body of work in chronic disease raises many questions for health equity researchers and policy makers about health equity methodology and interventions. First, if we begin to use Area Deprivation Index as a factor to assess risk, what do we do to capture the variation within ADI segments-and how much variation is there? In their study, Durfey and colleagues found that the relationship remained significant for both whites and blacks; however, more work is necessary to determine whether this finding is generalizable to health outcomes beyond chronic disease management. Second, The next set of manuscripts examine quality of care as it relates to health equity and provide a springboard from which to begin new discussions on population health. In the first one, the authors examine and underexplored aspect of quality of care-one that occurs before patients even step into clinic doors. Leech, Irby-Shasanmi, and Mitchell (2019) conducted a pilot field experiment to explore the influence of linguistic and name cues on pediatric provider offices' reports of availability for well-child visits. Their findings included that auditors giving linguistic and name cues of black patients were less likely to be told that an office was accepting new patients and were more likely to experience both withholding behaviors and misattributions about public insurance, when compared to the control group.
In their work, Lloren and colleagues (2019)   Four composite measures were the focus of this manuscript: getting needed care, getting care quickly, doctor communication, and customer service. The authors found that when compared to whites, American Indians and Alaska Natives (AIAN) and Asians or Pacific Islanders (API) beneficiaries reported worse experiences but blacks reported better experiences. Additionally, they found that beneficiaries in large, urban areas reported worse experiences than others, particularly with regard to access to care.
A considerable segment of the health equity literature focuses on between-group variation-but here we learn that when we also consider within-group variation, our understanding of distinctions of health equity issues and approach solutions is enhanced. Elliott's studies reinforce the need for training in cultural competency, linguistically appropriate services, linguistic support, and health literacy, as well as an eye toward geographic variation in patient experience. But health equity issues extend far beyond the walls of health care facilities-we also need to look outside of the health care system in order to better understand our patient populations and barriers to care that may be relevant to health equity. Access to quality care is often thought of as a rural vs. in total health care costs and a significant decrease in out-of-pocket costs. They also saw evidence of an increase in prescription drug use and reports of a usual source of care, a decrease in foregone care, and significant improvements in severe psychological distress. Lastly, when they examined the data with a health equity lens, comparing outcomes by race and ethnicity revealed significant differences by race and ethnicity in prescription drug costs and total prescription drug fills.
Marton and colleagues (2019), using data from the American Community Survey (ACS), examined coverage disparities across income, race and ethnicity, marital status, age, gender, and with enough precision to consider local and state geographic variation. Their results showed that the predicted impact of full ACA implementation, including Medicaid expansion, on the probability of having any coverage is as high as 22.6 percentage points. The predicted impact of having any coverage when the ACA is implemented without the Medicaid expansion is as high as 9.5 percentage points. Overall, the impact was greater for those with the lowest income, minority populations, younger populations, women, and rural communities.
We at CMS OMH know that we cannot achieve health equity alone-but together, we can learn from all of these studies to gain a better understanding of health disparities so that all of us can move forward in our work to eliminate disparities.