Health Care Management Science

, Volume 7, Issue 4, pp 253–261 | Cite as

Longitudinal Analysis of Efficiency in Multiple Output Dialysis Markets

  • Hacer Ozgen
  • Yasar A. Ozcan


Provider efficiency in the dialysis industry in the U.S.A. has been of great interest for a variety of parties mainly because of the continuing growth in the number of such patients and providers and in the industry’s costs. This study examined technical efficiency longitudinally among the multiple-output producers of freestanding facilities, as the dominant group of providers, using the DEA-based Malmquist index. Nationally representative data were obtained from Independent Renal Facility Cost Report Data Files for the years 1994 through 2000. The resulting sample comprised 140 facilities that had operated throughout the seven study years and jointly produced all dialysis outputs with nonzero inputs. The results show that over the period 1994–2000, on average multi-output, freestanding dialysis facilities did not achieve improvement in productivity. Decomposition of the Malmquist productivity indices showed improvement in technical efficiency but at the same time regress in technologies with potential to improve their quality of care. Negative change in technology was the major source of negative movement in productivity. The study concludes that under the fixed-price payment policy, multiple dialysis outputs are produced efficiently, but it may be that the quality of care is being sacrificed.


longitudinal technical efficiency multiple-output dialysis production 


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  1. [1]
    R.A. Rettig and E.L. Marks, Implementing the End Stage Renal Disease Program of Medicare, prepared for The Health Care Financing Administration, U.S. Department of Health, Education, and Welfare (1980). Google Scholar
  2. [2]
    United States Renal Data System 2002, Annual data report, The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesta, MD (2002). Google Scholar
  3. [3]
    J.H. Maxwell and H.M. Sapolsky, Prospective payment in the ESRD program: Implications for technology and program administration, in: Health Care, Technology, and the Competitive Environment, eds. H.P. Brehm and R.M. Mullner (1989). Google Scholar
  4. [4]
    S. Garella, The costs of dialysis in the USA, Nephrology, Dialysis, and Transplantation 12(Suppl. 1) (1997) 10–21. Google Scholar
  5. [5]
    E.D. Lowrie and C.L. Hampers, The success of Medicare’s End-Stage Renal-Disease Program: The case for profits and the private marketplace, New England Journal of Medicine 305(8) (1981) 434–438. CrossRefGoogle Scholar
  6. [6]
    D.O. Farley, Financing of end-stage renal disease care: Past, present, and future, Advances in Renal Replacement Therapy 1(1) (1994) 24–31. Google Scholar
  7. [7]
    J.K. Iglehart, The American health care system: End stage renal disease program, The New England Journal of Medicine 328(5) (1993) 366–371. Google Scholar
  8. [8]
    N.G. Levinsky, The organization of medical care: Lessons from the Medicare end-stage renal disease program, The New England Journal of Medicine 329(19) (1993) 1395–1399. Google Scholar
  9. [9]
    A.R. Nissenson and R.A. Rettig, Medicare’s end-stage renal disease program: Current status and future prospects, Health Affairs 18(1) (1999) 161–179. Google Scholar
  10. [10]
    R.A. Hirth, P.J. Held, S.M. Orzol and A. Dor, Practice patterns, case mix, Medicare payment policy, and dialysis facility costs, Health Services Research 33(6) (1999) 1567–1592. Google Scholar
  11. [11]
    Health Care Financing Research Report End Stage Renal Disease, 1993–1995, Health Care Financing Administration, HCFA publication No. 03393 (1997). Google Scholar
  12. [12]
    National Listing of Medicare Providers, Furnishing Kidney Dialysis and Transplant Services, Health Care Financing Administration, HCFA publication No. 10137 (1999). Google Scholar
  13. [13]
    J. Burns, Dialysis providers cope with dwindling reimbursement, Modern Healthcare May (11) (1992) 56–57. Google Scholar
  14. [14]
    R.A. Rettig, The social contract and the treatment of permanent kidney failure, Journal of the American Medical Association 275(14) (1996) 1123–1126. Google Scholar
  15. [15]
    G.D. de Lissovoy, N.R. Powe, R.I. Griffiths, A.J. Watson, G.F. Anderson, J.W. Greer, R.J. Herbert, P.W. Eggers, R.A. Milam and P.K. Whelton, The relationship of provider organizational status and erythropoietin in end-stage renal disease patients, Medical Care 32(2) (1994) 130–140. Google Scholar
  16. [16]
    P.J. Held, J.R. Garcia, M.V. Pauly and M.A. Cahn, Price of dialysis, unit staffing, and length of dialysis treatments, American Journal of Kidney Diseases 15(5) (1990) 441–450. Google Scholar
  17. [17]
    H. Ozgen and Y.A. Ozcan, A national study of efficiency for dialysis centers: An examination of market competition and facility characteristics for production of multiple dialysis outputs, Health Services Research 37(3) (2002) 711–732. Google Scholar
  18. [18]
    W.W. Cooper, L.M. Seiford and K. Tone, Data Envelopment Analysis: A Comprehensive Text with Models, Applications, References and DEA-Solver Software (Kluwer Academic Publishers, Boston, 2000). Google Scholar
  19. [19]
    D.W. Caves, L.R. Christensen and W.E. Diewart, The econometric theory of index numbers and the measurement of input, output, and productivity, Econometrica 50(6) (1982) 1393–1414. Google Scholar
  20. [20]
    R. Färe, S. Grosskopf, B. Lindgren and P. Roos, Productivity changes in Swedish pharmacies 1980–1989: A non-parametric Malmquist approach, The Journal of Productivity Analysis 3 (1992) 85–101. Google Scholar
  21. [21]
    P.J. Held and M.V. Pauly, Competition and efficiency in the end stage renal disease program, Journal of Health Economics 2 (1983) 95–118. Google Scholar
  22. [22]
    R.A. Hirth, M.E. Chernew and S.M. Orzol, Ownership, competition, and the adoption of new technologies and cost-saving practices in a fixed-price environment, Inquiry 37(3) (2000) 282–294. Google Scholar
  23. [23]
    P.P. Garg, K.D. Frick, D.W. Marie and N.R. Powe, Effect of the ownership of dialysis facilities on patients’ survival and referral for transplantation, New England Journal of Medicine 341(22) (1999) 1653–1660. Google Scholar
  24. [24]
    S. Grosskopf and V.G. Valdmanis, Measuring hospital performance: A non-parametric approach, Journal of Health Economics 6 (1987) 89–107. Google Scholar
  25. [25]
    P. Kooreman, Data envelopment analysis and parametric frontier estimation: Complementary tools, Journal of Health Economics 13 (1994) 345–346. Google Scholar
  26. [26]
    R.I. Griffiths, N.R. Powe, D.J. Gaskin, G.F. Anderson, G.V. de Lissovoy and P.K. Whelton, The production of dialysis by for-profit versus not-for-profit freestanding renal dialysis facilities, Health Services Research 29(4) (1994) 473–487. Google Scholar
  27. [27]
    R.A. Hirth, R.A. Wolfe, J.R.C. Wheeler, E.C. Roys, P.J. Tedeschi, A.S. Pozniak and G.T. Wright, Is case mix adjustment necessary for an expanded dialysis bundle? Health Care Financing Review 24(4) (2003) 77–88. Google Scholar

Copyright information

© Kluwer Academic Publishers 2004

Authors and Affiliations

  1. 1.School of Health AdministrationHacettepe UniversitySamanpazari, AnkaraTurkey
  2. 2.Department of Health AdministrationVirginia Commonwealth UniversityRichmondUSA

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