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Objective: To examine which factors are driving improvement in the Dialysis Facility Compare (DFC) star ratings and to test whether nonclinical facility characteristics are associated with observed longitudinal changes in the star ratings. Data Sources: Data were collected from eligible patients in over 6,000 Medicare-certified dialysis facilities from three annual star rating and individual measure updates, publicly released on DFC in October 2015, October 2016, and April 2018. Study Design: Changes in the star rating and individual quality measures were investigated across three public data releases. Year-to-year changes in the star ratings were linked to facility characteristics, adjusting for baseline differences in quality measure performance. Data Collection: Data from publicly reported quality measures, including standardized mortality, hospitalization, and transfusion ratios, dialysis adequacy, type of vascular access for dialysis, and management of mineral and bone disease, were extracted from annual DFC data releases. Principal Findings: The proportion of four- and five-star facilities increased from 30.0% to 53.4% between October 2015 and April 2018. Quality improvement was driven by the domain of care containing the dialysis adequacy and hypercalcemia measures. Additionally, independently owned facilities and facilities belonging to smaller dialysis organizations had significantly lower odds of year-to-year improvement than facilities belonging to either of the two large dialysis organizations (Odds Ratio [OR]: 0.736,95% Confidence Interval [CI]: 0.631-0.856 and OR: 0.797, 95% CI: 0.723-0.879, respectively). Conclusions: The percentage of four- and five-star facilities has increased markedly over a three-year time period. These changes were driven by improvement in the specific quality measures that may be most directly under the control of the dialysis facility. KEYWORDS public reporting, quality measures, star ratings, dialysis, medicare, 1 | INTRODUCTION In 2000, Dialysis Facility Compare (DFC) emerged as one of the earliest public reporting programs implemented by the Centers for Medicare & Medicaid Services (CMS) and has [...]

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. Key Words. Variation, Medicare, dialysis, It is a basic assumption of much of the geographic variation literature that Medicare beneficiaries have coverage for the same set of services if they receive care in Alaska or [...]

Objective. To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative [...]

Objective. To determine the predictors of chain acquisition among independent dialysis providers. Data Sources. Retrospective facility-level data combined from CMS Cost Reports, Medical Evidence Forms, Annual Facility Surveys, and claims for 1996-2003. Study Design. Independent dialysis facilities' probability of acquisition by a dialysis chain (overall and by chain size) was estimated using a discrete time hazard rate model, controlling for financial and clinical performance, practice patterns, market factors, and other facility characteristics. Data Collection. The sample includes all U.S. freestanding dialysis facilities that report not being chain affiliated for at least 1 year between 1997 and 2003. Principal Findings. Above-average costs and better quality outcomes are significant determinants of dialysis chain acquisition. Facilities in larger markets were more likely to be acquired by a chain. Furthermore, small dialysis chains have different acquisition strategies than large chains. Conclusions. Dialysis chains appear to employ a mix of turn-around and cream-skimming strategies. Poor financial health is a predictor of chain acquisition as in other health care sectors, but the increased likelihood of chain acquisition among higher quality facilities is unique to the dialysis industry. Significant differences among predictors of acquisition by small and large chains reinforce the importance of using a richer classification for chain status. Key Words. Chain acquisition, end-stage renal disease, dialysis, Medicare, The last two decades have seen dramatic growth in the size and number of chain organizations in several health care sectors, including hospitals, nursing homes, and outpatient kidney dialysis facilities [...]

There is considerable interest in examining how Medicaid payment affects nursing home care. This study examines the effect of Medicaid payment methods and reimbursement rates on the delivery of rehabilitation therapy to Medicaid nursing home residents in six States from 1992-1995. In States that changed payment from prospective facility-specific to prospective case-mix adjusted payment methods, Medicaid residents received more rehabilitation therapy after the change. While residents in States using case-mix adjusted payment rates for Medicaid payment were more likely to receive rehabilitation than residents in States using prospective facility-specific Medicaid payment, the differences were general and not specific to Medicaid residents. Retrospective payment for Medicaid resident care was associated with greater use of therapy for Medicaid residents., INTRODUCTION Through payment and regulation, governments play an important role in the nursing home market. Public payers have substantial influence, accounting for the majority of nursing home revenues, with State-funded [...]

Congress has required CMS to expand the Medicare outpatient prospective payment system (PPS) for dialysis services to include as many drugs and diagnostic procedures provided to end stage renal disease (ESRD) patients as possible. One important implementation question is whether dialysis facility case mix should be reflected in payment. We use fiscal year (FY) 2000 cost report and patient billing and clinical data to determine the relationship between costs and case mix, as represented by several patient demographic, diagnostic, and clinical characteristics. Results indicate considerable variability in costs and case mix across facilities and a significant and substantial relationship between case mix and facility cost, suggesting case mix payment adjustment may be important., INTRODUCTION Currently, the Medicare outpatient PPS pays a fixed amount for a limited bundle of routine, dialysis-related services, known as the composite rate (CR). Dialysis facilities are allowed to bill [...]

Health Services Research has a reputation for providing high quality and detailed feedback to authors, which is largely due to the individuals who volunteer to serve as our external peer [...]

Health Services Research has a reputation for providing high quality and detailed feedback to authors, which is largely due to the individuals who volunteer to serve as our external peer [...]

Health Services Research has a reputation for providing high quality and detailed feedback to authors, which is largely due to the individuals who volunteer to serve as our external peer [...]

This article empirically examines how various elements of market structure affect the pricing behavior and profitability of individual nursing homes in California. Market structure elements include seller concentration, the concentration [...]

NEIL R. POWE [*] This paper develops a multiple-period theoretical model of health maintenance organization (HMO) coverage of medical procedures as a function of HMO competition and a market's predisposition [...]