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Under the Comprehensive End-stage Renal Disease (ESRD) Care (CEC) Model, dialysis facilities and nephrologists form ESRD Seamless Care Organizations (ESCOs) to deliver high value care. This study compared the characteristics of patients and markets served and unserved by CEC and assessed its generalizability. ESCOs operated in 65 of 384 markets. ESCO markets were larger than non-ESCO markets, had fewer White patients, higher household income, and higher Medicare spending per patient. Patients in ESCOs were similar to eligible nonaligned patients in age and sex but differed in race/ethnicity and were more often treated in an urban area; comorbidity prevalence differed modestly. CEC is available to a meaningful share of the dialysis population and relatively few dialysis patients resided in a market where no provider could meet the participation threshold, so market size may not be the primary barrier for potential new participants in CEC or future kidney care models. [ABSTRACT FROM AUTHOR]

Background: To assure and improve the quality and safety of care provided by dialysis facilities, federal oversight has been conducted through periodic survey assessment. However, with the growing number of individuals living with ESRD and dialysis facilities, state survey agencies have faced challenges in time and resources to complete survey activities. Therefore, the survey process (‘Basic Survey’ used prior to 2013) was redesigned in order to develop a more efficient process (‘Core Survey’ newly implemented since 2013). The purpose of this analysis was to evaluate and compare dialysis facility survey outcomes between the Core and Basic Survey processes, using a causal inference technique. The survey outcomes included condition-level citations, total citations (condition- and standard-level), and citation rate per survey-hour. Methods: For comparisons of non-randomly assigned survey types, propensity score matching was used. Data were drawn from CMS’ Quality Improvement Evaluation System (QIES) database from January 1, 2013 through July 31, 2014. Covariates available included survey type, facility characteristics (state, urban, practices catheter reuse, dialysis modalities offered, number of patients, mortality, hospitalization, infection) and survey-related characteristics (number of surveyors, time since last survey). Results: Compared to the Basic Survey, the Core Survey identified 10% more total citations (P = 0.001) and identified condition-level citations more frequently, although the latter finding did not reach statistical significance. These findings suggest an increase of 10% in citation rate (i.e. ratio between citations and survey time) with the Core survey process (P = 0.002). Conclusions: Greater efficiency has implications for attenuating the time-intensive burden of the state survey process, and improving the safety and quality of care provided by dialysis facilities. [ABSTRACT FROM AUTHOR]

Objective: To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.Data Sources/study Setting: Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD).Study Design: We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities.Data Collection: We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims.Principal Findings: MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts.Conclusions: Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity. [ABSTRACT FROM AUTHOR]