title: Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments.
abstract: To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.
  
  
  
  Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD).
  
  
  
  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.
  
  
  
  We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Wilk
authors.affiliation: Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hirth
authors.affiliation: Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI.
authors.forename: Wei
authors.initials: W
authors.lastname: Zhang
authors.affiliation: Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI.
authors.forename: John R C
authors.initials: JRC
authors.lastname: Wheeler
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, MI.
authors.forename: Marc N
authors.initials: MN
authors.lastname: Turenne
authors.affiliation: Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI.
authors.forename: Tammie A
authors.initials: TA
authors.lastname: Nahra
authors.affiliation: Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI.
authors.forename: Kathryn K
authors.initials: KK
authors.lastname: Sleeman
authors.affiliation: Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Messana
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005102:Health Expenditures; D006436:Hemodialysis Units, Hospital / Q000191:economics / Q000706:statistics & numerical data*; D006437:Hemodialysis, Home / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics / Q000706:statistics & numerical data*; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D006278:Medicare / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D012044:Regression Analysis; D014481:United States
keywords: Medicare; Variation; dialysis