Importance Growing consolidation in the dialysis industry has raised concerns about market power and the potential need for antitrust enforcement, but a lack of data previously prevented a systematic analysis of these issues. Objective To document the consolidation of dialysis facilities through chain ownership and vertical integration between dialysis facilities and physicians, as well as study associations between consolidation and commercial prices for outpatient hemodialysis and medical director compensation. Design, Setting, and Participants This economic evaluation combined data from Freedom of Information Act requests, Medicare claims, cost reports, commercial prices, and physician registries to conduct a retrospective study of market structure, compensation, and prices in the dialysis industry from 2005 to 2019. Those evaluated include dialysis facilities in the US, physicians involved with dialysis for patients enrolled in Medicare, and patients with end-stage renal disease enrolled in Medicare or one of the commercial insurers in claims data provided by the Health Care Cost Institute. Data were analyzed from April 2024 to April 2025. Exposure Chain ownership, physician ownership, and medical directorship of dialysis facilities in the US from 2005 to 2019. Main Outcomes and Measures Chain ownership of dialysis facilities, share of population living in markets with different levels of chain ownership, share of facilities with physician owners, levels of medical director compensation, and commercial prices for outpatient hemodialysis in markets with different numbers of chain- and physician-owned facilities. Results Between 2005 and 2019, the market share of DaVita and Fresenius increased from 59.1% to 77.1%, with 32.5% of the national population living in a hospital service area (HSA) without access to a dialysis facility other than these 2 chains in 2019. The share of facilities with a physician owner increased from 11.4% to 29.1%. Markets with only 1 large chain had $495.08 (95% CI, $371.21-$619.85) higher mean commercial prices for outpatient hemodialysis and $564.56 (95% CI, $429.03-$700.10) higher medical director compensation per patient than markets that did not have large chain facilities. Conclusions and Relevance In this economic evaluation, market concentration in the US dialysis industry increased from 2005 to 2019 and was associated with higher commercial prices for outpatient hemodialysis. Physician ownership of facilities also increased, and medical directors received higher pay in markets where large chains operate.

We study the relative effectiveness of administrative regulations, criminal enforcement, and civil lawsuits for combatting health care fraud. Between 2003 and 2017, Medicare spent $7.7 billion on 37.5 million regularly scheduled, non-emergency ambulance rides for patients traveling to and from dialysis facilities, with dozens of lawsuits alleging that Medicare reimbursed rides for patients who did not meet the requirements for receiving one. Using a novel data set and an identification strategy based on the staggered timing of regulations and lawsuits across the United States, we find that a regulation requiring prior authorization for ambulance reimbursements reduced spending much more than criminal and civil lawsuits did. Despite the sharp drop in both ambulance transports and the companies that provide them following prior authorization, patients’ health outcomes did not change, indicating that most rides were not medically necessary. Our results suggest that administrative actions have a much larger impact than targeted criminal enforcement, providing novel evidence that regulations may be more cost-effective than ex post ligation for preventing health care fraud.

We use a nonlinear reduction in a bank's check-cashing fees and variation in regulated check-clearing times to identify the elasticity of demand for cashing checks rather than depositing them. We find that an extra day of check-clearing time makes account holders 65.5% more likely to cash a check than deposit it, which implies they are willing to pay $11.17 per day for faster access to their funds – an effective annualized discount rate of 11,054% for the average check. We use this elasticity to evaluate recent proposals that mandate faster check-clearing times.

We develop a dynamic model in which firms decide when and where to enter a growing market. We do not pre-specify the order of entry, allowing instead for the roles of leader and follower to be determined endogenously. We characterize the subgame perfect equilibrium of the dynamic game and show that the times and locations of entry are governed by the threat of preemption. Because each rm has the opportunity to preempt its rival, both firms tend to enter too early. This in turn leads to rent dissipation. We show that rent dissipation may be far greater than when it is assumed that firms enter the market in a pre-specified order, the assumption made in the existing literature on spatial competition. In an empirical application, we study the entry of restaurants, gas stations, and hotels at highway intersections, finding results largely consistent with our model's predictions.

Background All patients starting dialysis should be informed of kidney transplant as a renal replacement therapy option. Prior research has shown disparities in provision of this information. In this study, we aimed to identify patient sociodemographic and dialysis facility characteristics associated with not receiving transplant information at the time of dialysis initiation. We additionally sought to determine the association of receiving transplant information with waitlist and transplant outcomes. Methods We retrospectively analyzed CMS-2728 forms filed from 2007 to 2019. The primary outcome was report of provision of information about transplant on the Centers for Medicare and Medicaid Services Form CMS-2728. For patients not informed at the time of dialysis, we collected the reported reason for not being informed (medically unfit, declined information, unsuitable due to age, psychologically unfit, not assessed, or other). Cox proportional-hazards model estimates were used to study determinants of addition to the waitlist and transplant (secondary outcomes). Results Fifteen percent of patients did not receive information about transplant (N=133,414). Non-informed patients were more likely to be older, female, white, and on Medicare. Patients informed about transplant had a shorter time between end-stage renal disease onset and addition to the waitlist; they also spent a shorter time on the waitlist before receiving a transplant. Patients at chain dialysis facilities were more likely to receive information, but this did not translate into higher waitlist or transplant rates. Patients at independent facilities acquired by chains were more likely to be informed but less likely to be added to the waitlist post acquisition. Conclusions Disparities continue to persist in providing information about transplant at initiation of dialysis. Patients who are not informed have reduced access to the transplant waitlist and transplant. Maximizing the number of patients informed could increase the number of patients referred to transplant centers, and ultimately transplanted. However, policy actions should account for differences in protocols stemming from facility ownership.

Health insurers often tie payments to providers' quality of care.Although payers do this to elicit more effort from providers, some providers may game the system by avoiding patients who would cause their quality scores to fall.We use annual variation in the criteria for Medicare's Quality Incentive Program in dialysis to distinguish strategic patient dropping from higher-quality care.Patients who would reduce their facilities' scores are 14.3-71.5% more likely to switch facilities, often to ones that suggest the move was involuntary, while under certain conditions facilities exert more effort to improve their scores by providing better care.

Editor— Everett Rogers' diffusion theory of innovations has been widely applied to examine the timeline for the adoption of new ideas in several domains ranging from agriculture to healthcare, but has not been used to better understand the adoption of new medications, technologies, and procedures in anaesthesia practice. 1 Stol I.S. Ehrenfeld J.M. Epstein R.H. Technology diffusion of anesthesia information management systems into academic anesthesia departments in the United States. Anesth Analg. 2014; 118: 644-650 Crossref PubMed Scopus (47) Google Scholar ,2 Valente T.W. Diffusion of innovations. Genet Med. 2003; 5: 69 Abstract Full Text Full Text PDF PubMed Google Scholar Rogers' curve, with time on the x-axis and the proportions of a population adopting a new practice on the y-axis (see Fig. 1), is bell-shaped with adopters predictably falling into five categories with the following proportions: innovators (2.5% of the cohort), early adopters (13.5%), early majority (34%), late majority (34%), and laggards (16%). 2 Valente T.W. Diffusion of innovations. Genet Med. 2003; 5: 69 Abstract Full Text Full Text PDF PubMed Google Scholar Slow adoption, long delays between the generation of evidence and its routine application in anaesthesia practice, remains common. Rogers' curve has utility in identifying barriers to uptake and in guiding comparative effectiveness research using large-scale real-world data. We explored the uptake of sugammadex within a large nationwide sample of US hospitals between January 2016 and June 2018, the 30-month period after approval by the US Food & Drug Administration (FDA). Large studies have characterised the uptake of sugammadex in the USA but are marked by heterogeneity in the mix of procedures and a focus on patient-level predictors of use. 3 Bash L.D. Black W. Turzhitsky V. Urman R.D. Neuromuscular blockade and reversal practice variability in the outpatient setting: insights from US utilization patterns. Anesth Analg. 2021; 133: 1437-1450 Crossref PubMed Scopus (7) Google Scholar ,4 Dubovoy T.Z. Saager L. Shah N.J. et al. Utilization patterns of perioperative neuromuscular blockade reversal in the United States: a retrospective observational study from the Multicenter Perioperative Outcomes Group. Anesth Analg. 2020; 131: 1510-1519 Crossref PubMed Scopus (13) Google Scholar We address this by focusing on a single common procedure where neuromuscular block and reversal is common, and we examine use at the hospital level (measured as proportions of patients receiving a drug, each month, at each hospital).

IMPORTANCE Despite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic. OBJECTIVE To examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care. DESIGN, SETTING, AND PARTICIPANTS A cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics. EXPOSURES A claim for dialysis care. MAIN OUTCOMES AND MEASURES Out-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection. RESULTS The sample included 309 800 enrollee-months, whichwas a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $ 4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months. CONCLUSIONS AND RELEVANCE In this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.

Context: On March 19, 2020, President Donald Trump endorsed using hydroxychloroquine for COVID-19 treatment despite inconclusive evidence of the drug's effectiveness. This study sought to understand the influence of political preferences on prescription uptake by quantifying the rela-tionship between a geographic area's partisan leaning and hydroxychloroquine prescription rates following Trump's endorsement. Methods: We analyzed hydroxychloroquine prescriptions filled in 205 continental US designated market areas (DMAs) between March 1, 2018, and July 31, 2020, and the percentage of votes for Donald Trump in the 2016 presidential election in each DMA. We estimated associations by using an empirical strategy resembling a difference-in-differences estimation. Findings: Before President Trump's endorsement, mean weekly hydroxychloroquine prescription rates were similar across DMAs with the highest and lowest Trump vote percentages (0.56 and 0.49 scripts per 100,000). After Trump's endorsement, although both high-and low-Trump-supportive DMAs experienced sharp increases in weekly hydroxychloroquine prescription rates, results indicated a 1-percentage-point increase in share of Trump votes was associated with 0.013, or 2%, more weekly hydroxychloroquine prescriptions per 100,000 people (b=0.013, t= 2.20, p=.028). Conclusion: President Trump's endorsement of an untested therapy influenced prescribing behavior, especially when that endorsement aligned with communities' political leanings.

Key Points Question What is the association between private equity (PE) acquisition of short-term acute care hospitals and measures of comorbidity, mortality, readmission, length of stay, and spending among Medicare beneficiaries admitted to the hospital with 1 of 5 acute medical conditions? Findings In this cross-sectional study of more than 21 million Medicare beneficiaries with 5 different acute medical conditions who were hospitalized at short-term acute care hospitals, PE acquisition was associated with significantly lower inpatient mortality (−1.1 percentage points) and lower 30-day mortality (−1.4 percentage points) among patients admitted with acute myocardial infarction. However, PE acquisition was not associated with significant differences in other dimensions of quality and spending or with differences across other medical conditions. Meaning The study’s findings suggest that PE acquisition has mixed consequences for patient-level outcomes overall but is associated with moderate and consistent improvement in mortality among Medicare beneficiaries hospitalized with acute myocardial infarction.

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This cross-sectional study compares the prices that private insurers vs Medicare paid for hemodialysis in the US from 2012 to 2019.

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We study the relative effectiveness of administrative regulations, criminal enforcement, and civil whistleblower lawsuits for combatting health care fraud. Between 2003 and 2017, Medicare spent $7.7 billion on regularly scheduled, non-emergency ambulance rides for patients traveling to and from dialysis facilities, with dozens of lawsuits alleging that Medicare reimbursed rides for patients who did not meet the requirements for receiving one. Using a novel data set and an identification strategy based on the staggered timing of regulations and lawsuits across the US, we find that a regulation requiring prior authorization for ambulance reimbursements reduced spending much more than criminal and civil lawsuits did. Despite the sharp drop in both ambulance transports and the companies that provide them following prior authorization, patients’ health outcomes did not change, indicating that most rides were not medically necessary. Our results suggest that administrative actions have a much larger impact than targeted criminal enforcement, providing novel evidence that regulations may be more cost-effective than ex post ligation for preventing health care fraud.

We consider how health care providers respond to bundled payments. Using claims data from dialysis patients, we show that facilities halved their use of injectable anemia drugs following Medicare’s transition from fee-for-service reimbursements to a bundle. We identify the causal effects of the payment reform using a novel instrumental variable — patients at higher elevations naturally require lower doses of anemia drugs — and find that lower doses caused a decrease in mortality but an increase in blood transfusions. Allocative efficiency increased from this change as providers reduced doses more for patients who benefit little from the drug.

Many industries have become increasingly concentrated through mergers and acquisitions, which in health care may have important consequences for spending and outcomes. Using a rich panel of Medicare claims data for nearly one million dialysis patients, we advance the literature on the effects of mergers and acquisitions by studying the precise ways providers change their behavior following an acquisition. We base our empirical analysis on more than 1,200 acquisitions of independent dialysis facilities by large chains over a 12-year period and find that chains transfer several prominent strategies to the facilities they acquire. Most notably, acquired facilities converge to the behavior of their new parent companies by increasing patients’ doses of highly reimbursed drugs, replacing high-skill nurses with less-skilled technicians, and waitlisting fewer patients for kidney transplants. We then show that patients fare worse as a result of these changes: outcomes such as hospitalizations and mortality deteriorate, with our long panel allowing us to identify these effects from within-facility or within-patient variation around the acquisitions. Because overall Medicare spending increases at acquired facilities, mostly as a result of higher drug reimbursements, this decline in quality corresponds to a decline in value for payers. We conclude the article by considering the channels through which acquisitions produce such large changes in provider behavior and outcomes, finding that increased market power cannot explain the decline in quality. Rather, the adoption of the acquiring firm’s strategies and practices drives our main results, with greater economies of scale for drug purchasing responsible for more than half of the change in profits following an acquisition.

Medicare's prospective payment system for long-term acute-care hospitals (LTCHs) provides modest reimbursements at the beginning of a patient's stay before jumping discontinuously to a large lump-sum payment after a prespecified number of days. We show that LTCHs respond to the financial incentives of this system by disproportionately discharging patients after they cross the large-payment threshold. We find this occurs more often at for-profit facilities, facilities acquired by leading LTCH chains, and facilities colocated with other hospitals. Using a dynamic structural model, we evaluate counterfactual payment policies that would provide substantial savings for Medicare.