title: Using knowledge of multiple levels of variation in care to target performance incentives to providers.
abstract: BACKGROUND
  In developing "pay-for-performance" and capitation systems that provide incentives for improving the quality and efficiency of care, policymakers need to determine which healthcare providers to evaluate and reward.
  
  
  OBJECTIVE
  This study demonstrates methods for determining and understanding the relative contributions of facilities and physicians to the quality and cost of care. Specifically, this study distinguishes levels of variation in resource utilization (RU), based on research to support the development of an expanded Medicare dialysis prospective payment system.
  
  
  METHODS
  Mixed models were used to estimate the variation in RU across institutional providers, physicians, patients, and months (within patients), after adjusting for case-mix.
  
  
  METHODS
  The study includes 10,367 Medicare hemodialysis patients treated in a 4.2% stratified random sample of dialysis facilities in 2003.
  
  
  METHODS
  Monthly RU was measured by the average Medicare allowable charge per dialysis session for separately billable dialysis-related services (mainly injectable medications and laboratory tests) from Medicare claims.
  
  
  RESULTS
  There was financially significant variation in RU across institutional providers and to a lesser degree across physicians, after adjusting for differences in case-mix. The remaining variation in RU reflects unexplained differences across patients that persist over time and transitory fluctuations for individual patients.
  
  
  CONCLUSIONS
  The greater variation in RU occurring across dialysis facilities than across physicians is consistent with targeting payments to facilities, but alignment of incentives between facilities and physicians remains an important goal. Similar analytic methods may be useful in designing payment policies that reward providers for improving the quality of care.
authors.affiliation: Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan 48103, USA. turenne@umich.edu
authors.forename: Marc N
authors.initials: MN
authors.lastname: Turenne
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hirth
authors.forename: Qing
authors.initials: Q
authors.lastname: Pan
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wolfe
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Messana
authors.forename: John R C
authors.initials: JR
authors.lastname: Wheeler
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities / Q000191:economics* / Q000592:standards; D003953:Diagnosis-Related Groups; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D016345:Medicare Part B / Q000191:economics / Q000592:standards*; D008875:Middle Aged; D017059:Models, Econometric; D010816:Physician Incentive Plans; D011445:Prospective Payment System; D011785:Quality Assurance, Health Care / Q000191:economics*; D012052:Reimbursement, Incentive; D006435:Renal Dialysis / Q000191:economics* / Q000592:standards; D020379:Risk Adjustment; D014481:United States