Reflections on Health Equity from the Leaders of CMS’ Quality Improvement Innovation Group

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Members of the Quality Improvement and Innovation Group team
Sitting: Dr. Paul McGann, Jeneen Iwugo, and Dennis Wagner. Standing: Members of the Quality Improvement and Innovation Group team.

Health equity is a critical focus area for quality improvement, and leadership at the Centers for Medicare & Medicaid Services (CMS) is committed to it. Three individuals who are personally and professionally devoted to addressing health disparities are Chief Medical Officer for Quality Improvement Dr. Paul McGann, Quality Improvement and Innovation Group (QIIG) Director Dennis Wagner, and QIIG Deputy Director Jeneen Iwugo. Below, they share their thoughts on the impact of health disparities in the Medicare community, as well as ways that CMS and the Quality Improvement Organization (QIO) Program are working to achieve health equity.

Dennis Wagner: In all aspects of our work, we have a tendency to document the problem. We are trained to be critical thinkers and data analysts. But we already have so much evidence of significant disparities in health outcomes and health care that are tied to race, gender and income. Our view is that our energy primarily should be put toward action to improve what is critically important — the lives and health care outcomes of our underserved populations.

Jeneen Iwugo: It is true that the data is there. Just look at life expectancy. Overall, the white population will live almost four years longer on average than the black population due to disparities in death rates from heart disease, cancer, diabetes and homicide. And the richest one percent of American men live nearly 15 years longer than the poorest one percent. For women, the average difference is just over 10 years.

Paul McGann: That is exactly why CMS has a renewed focus on erasing these gaps as we move into the next few years of work. We have garnered input and recommendations from senior leaders at federal agencies and other stakeholders, and what we have heard is the recurring notion of addressing health disparities more systematically — that is, not so much in stand-alone projects and programs, but as a key element of our overarching goals.

JI: It is absolutely necessary for us to embed health equity across all our work, but many of our programs are already making strides. One example is our work in diabetes care, where we’re focused on systematically reducing disparities in targeted vulnerable populations via diabetes self-management education (DSME) classes. This work began back in 2007 with Paul, Dennis, Sue Fleck, Cheryl Bodden, Jean Moody-Williams and others, and has grown into what you see today with the Everyone with Diabetes Counts (EDC) program and more. We have also built it into our behavioral health work with initiatives like increasing screening for depression, as well as our immunizations work.

DW: Another example is Partnership for Patients. Under that program, we’ve partnered with approximately 4,000 of the nation’s 5,000 acute care hospitals through Hospital Improvement Innovation Networks (HIINs) to reduce readmissions and harms. Part of the fabric of work is to identify high-performing hospitals. This approach of identifying and spreading high performance stems all the way back to 1998 when I helped lead the 100% Access and 0 Health Disparities” campaign at the Health Resources and Services Administration (HRSA) with Marilyn Gaston, MD, the director of the Bureau of Primary Health Care at the time. Our key methodology was to identify health care organizations and communities that had successfully reduced disparities and to profile their work for further adaptation and replication. Even today, the same idea applies: We’re always on the hunt to find organizations doing the right things to spread innovation and best practices.

PM: The QIO Program has also played an instrumental role in Million Hearts’ first five years. In its next phase, Million Hearts 2022 is adding a specific focus on populations at high risk for and with a high burden of cardiovascular disease, starting with defined priority populations” like black men and women with high blood pressure and adults with mental illness or substance use disorders. Million Hearts is bringing data, effective interventions and strong partnerships to bear to help close the gap on these disparities.

DW: Something I want everyone to take away from this is that real-life experience is a tremendous source of learning and opportunity for spread and improvement. I always say that if there is something for which you want more, the odds are really high that it already exists somewhere in the world. There are examples across the United States and worldwide of organizations and individuals that have found solutions to the systemic issues we face with health disparities. Therefore, it’s important that we all continue to learn what’s working, celebrate it and work to systematically and methodically spread it.

JI: One of the things I’ve heard said is that you’re always in danger of something getting lost if you don’t maintain a clear focus on it. Let me take this time to assure you that this will not happen with our work to reduce health disparities in the Medicare community. CMS is committed to achieving health equity and will keep it front and center in our day-to-day tasks and in our larger strategy for overall health care quality improvement.