[Federal Register Volume 59, Number 169 (Thursday, September 1, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-21488]
[[Page Unknown]]
[Federal Register: September 1, 1994]
_______________________________________________________________________
Part II
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
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42 CFR Part 412, et al.
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and FY 1995 Rates; Final Rule
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, 466, 482, 485 and 489
[BPD-802-FC]
RIN 0938-AG46
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1995 Rates
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final rule with comment period.
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SUMMARY: We are revising the Medicare hospital inpatient prospective
payment systems for operating costs and capital- related costs to
implement necessary changes arising from our continuing experience with
the system. In addition, in the addendum to this final rule, we are
describing changes in the amounts and factors necessary to determine
prospective payment rates for Medicare hospital inpatient services for
operating costs and capital-related costs. These changes are applicable
to discharges occurring on or after October 1, 1994. We are also
setting forth rate-of-increase limits for hospitals and hospital units
excluded from the prospective payment systems. Finally, we are revising
the criteria used by the Medicare Geographic Classification Review
Board (MGCRB) to decide on applications by hospitals for geographic
reclassification for prospective payment purposes.
DATES: Effective Date: This final rule with comment period is effective
on October 1, 1994, except that the changes to Sec. 412.230 (concerning
the geographic reclassification criteria used by the MGCRB) are
effective on September 1, 1994.
Comments: Comments on the revisions to the criteria for geographic
reclassification by the MGCRB will be considered if we receive them at
the appropriate address, as provided below, no later than October 31,
1994. We will not consider comments concerning any other issues.
ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPD-802-FC, P.O. Box 7517,
Baltimore, MD 21207-0517.
If you prefer, you may deliver your written comments (1 original
and 3 copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore,
MD 21207.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-802-FC. Comments received timely will be available for
public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 309-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7890).
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
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FOR FURTHER INFORMATION CONTACT: Lana Price, (410) 966-4529.
SUPPLEMENTARY INFORMATION:
I. Background
A. Summary
Under section 1886(d) of the Social Security Act (the Act), a
system of payment for the operating costs of acute hospital inpatient
stays under Medicare Part A (Hospital Insurance) based on
prospectively-set rates was established effective with hospital cost
reporting periods beginning on or after October 1, 1983. Under this
system, Medicare payment for hospital inpatient operating costs is made
at a predetermined, specific rate for each hospital discharge. All
discharges are classified according to a list of diagnosis-related
groups (DRGs). The regulations governing the hospital inpatient
prospective payment system are located in 42 CFR part 412. On September
1, 1993, we published a final rule with comment period (58 FR 46270) to
implement changes to the prospective payment system for hospital
operating costs beginning with Federal fiscal year (FY) 1994.
For cost reporting periods beginning before October 1, 1991,
hospital inpatient operating costs were the only costs covered under
the prospective payment system. Payment for capital-related costs had
been made on a reasonable cost basis because, under sections 1886(a)(4)
and (d)(1)(A) of the Act, those costs had been specifically excluded
from the definition of inpatient operating costs. However, section
4006(b) of the Omnibus Budget Reconciliation Act of 1987 (Public Law
100-203) revised section 1886(g)(1) of the Act to require that, for
hospitals paid under the prospective payment system for operating
costs, capital-related costs would also be paid under a prospective
payment system effective with cost reporting periods beginning on or
after October 1, 1991. As required by section 1886(g) of the Act, we
replaced the reasonable cost-based payment methodology with a
prospective payment methodology for hospital inpatient capital-related
costs. Under the new methodology, effective for cost reporting periods
beginning on or after October 1, 1991, a predetermined payment amount
per discharge is made for Medicare inpatient capital-related costs.
(See subpart M of 42 CFR part 412, and the August 30, 1991, final rule
(56 FR 43358) for a complete discussion of the prospective payment
system for hospital inpatient capital-related costs.)
B. Summary of the Provisions of the May 27, 1994 Proposed Rule
On May 27, 1994, we published a proposed rule in the Federal
Register (59 FR 27708) to amend the prospective payment systems for
operating costs and capital-related costs as follows:
We proposed changes for FY 1995 DRG classifications and
weighting factors as required by section 1886(d)(4)(C) of the Act. This
section requires that we adjust the DRG classifications and relative
weights at least annually.
We proposed to revise the methodology for computing the
wage index and to update the wage data. Specific issues addressed
included updating the wage index for FY 1995, changes in the reporting
of hospital wage index data, revising the wage index based on hospital
redesignations, the impact of the revised hospital wage index,
occupational mix adjustment, research on refinements to labor market
areas, and State labor market options.
We discussed several provisions of the regulations in 42
CFR parts 412, 413, 485, and 489 concerning the prospective payment
system for inpatient operating costs. The proposed changes concerned
the following:
--Definition of and payment for transfer cases.
--Review of DRG assignments.
--National average standardized amounts for FY 1995.
--Outliers.
--Rural referral centers.
--Determination of number of beds in determining the indirect medical
education adjustment.
--Disproportionate share adjustment.
--Changes affecting essential access community hospitals (EACHs) and
rural primary care hospitals (RPCHs).
--Clarification of payments to rural referral center/EACH hospitals.
--Direct graduate medical education payment.
--Other technical changes.
We discussed several provisions of the regulations in 42
CFR parts 412 and 413 concerning the prospective payment for capital-
related costs. The proposed changes concerned the following:
--Evaluation of provisions relating to obligated capital for hospitals
subject to lengthy certificate-of-need (CON) process.
--Specific adjustment for taxes to the capital prospective payment
system federal rate.
--Revision of provision relating to exceptions payments.
--Extraordinary circumstances exceptions payments.
--Funding of depreciation.
We discussed changes to the regulations at 42 CFR parts
412 and 413 for hospital units excluded from the prospective payment
system. The proposed changes concerned the following:
--New requirements for certain long-term care hospitals excluded from
the prospective payment systems.
--Removal of the 1986 malpractice rule.
--Related technical changes.
In the addendum to the proposed rule, we set forth
proposed changes to the amounts and factors for determining the FY 1995
prospective payment rates for operating costs and capital-related
costs. We also proposed new update factors for determining the rate-of-
increase limits for cost reporting periods beginning in FY 1995 for
hospitals and hospital units excluded from the prospective payment
system.
In Appendix A of the proposed rule, we set forth an
analysis of the impact that the proposed changes described in the
proposed rule would have on affected entities.
In Appendix B of the proposed rule, we set forth the
technical appendix on the proposed FY 1995 capital acquisition model
and budget neutrality adjustment.
In Appendix C of the proposed rule, we set forth our
initial estimate of a recommended update factor for FY 1995 for both
prospective payment hospitals and hospitals excluded from the
prospective payment system, as required by section 1886(e)(3)(B) of the
Act.
In Appendix D of the proposed rule, we provided our
recommendation of the appropriate percentage change for FY 1995, as
required by sections 1886(e)(4) and (e)(5) of the Act, for the
following:
--Large urban, other urban, and rural average standardized amounts (and
hospital-specific rates applicable to sole community hospitals) for
hospital inpatient services paid for under the prospective payment
system for operating costs.
--Target rate-of-increase limits to the allowable operating costs of
hospital inpatient services furnished by hospitals and hospital units
excluded from the prospective payment system.
In Appendix E of the proposed rule, we set forth a
preliminary framework for developing the annual update factor for
inpatient hospital capital-related costs.
In the May 27, 1994 proposed rule, we also discussed in detail the
March 1, 1994 recommendations made by the Prospective Payment
Assessment Commission (ProPAC). ProPAC is directed by section
1886(e)(2)(A) of the Act to make recommendations on the appropriate
percentage change factor to be used in updating the average
standardized amounts. In addition, section 1886(e)(2)(B) of the Act
directs ProPAC to make recommendations regarding changes in each of the
Medicare payment policies under which payments to an institution are
prospectively determined. In particular, the recommendations relating
to the hospital inpatient prospective payment systems are to include
recommendations concerning the number of DRGs used to classify
discharges, adjustments to the DRGs to reflect severity of illness, and
changes in the methods under which hospitals are paid for capital-
related costs. Under section 1886(e)(3)(A) of the Act, the
recommendations required of ProPAC under sections 1886(e)(2)(A) and (B)
of the Act are to be reported to Congress not later than March 1 of
each year.
We printed ProPAC's March 1, 1994 report, which includes its
recommendations, as Appendix F of the proposed rule. The
recommendations, and the actions we proposed to take with regard to
them (when an action is recommended), were discussed in detail in the
appropriate sections of the preamble, the addendum, or the appendices
of the proposed rule.
Set forth below in sections II, III, IV, V, VI, VII, and VIII of
this preamble, the addendum to this final rule, and the appendices, are
detailed discussions of the May 27, 1994 proposed rule, the public
comments received in response to the proposed rule, and the responses
to those comments, as well as any changes we are making.
We note that the proposed rule included an extensive discussion of
our research concerning refinements to the labor market areas that are
used to construct the hospital wage index. Comments on this issue were
due on August 31, 1994, and we intend to discuss the comments and
respond to them in the FY 1996 prospective payment system proposed
rule.
C. Public Comments Received in Response to the May 27, 1994 Proposed
Rule
A total of 1339 items of correspondence containing comments on the
May 27, 1994 proposed rule were received timely. The main areas of
concern addressed by commenters were the following:
Changes in the reporting of hospital wage index data.
Definition of and payment for transfer cases.
New exclusion criteria for long-term care hospitals.
Revisions to the capital exceptions policy.
Requests for changes in DRG classifications and relative
weights.
II. Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on the basis of a rate per discharge that varies by the DRG to
which a beneficiary's stay is assigned. The formula used to calculate
payment for a specific case takes an individual hospital's payment rate
per case and multiplies it by the weight of the DRG to which the case
is assigned. Each DRG weight represents the average resources required
to care for cases in that particular DRG relative to the average
resources used to treat cases in other DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
annually. These adjustments are made to reflect changes in treatment
patterns, technology, and any other factors that may change the
relative use of hospital resources. The changes to the DRG
classification system and the recalibration of the DRG weights for
discharges occurring on or after October 1, 1994 are discussed below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective
payment system based on the principal diagnosis, up to eight additional
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The diagnosis and
procedure information is reported by the hospital using codes from the
International Classification of Diseases, Ninth Edition, Clinical
Modification (ICD-9-CM). The Medicare fiscal intermediary enters the
information into its claims system and subjects it to a series of
automated screens called the Medicare Code Editor (MCE). These screens
are designed to identify cases that require further review before
classification into a DRG can be accomplished.
After screening through the MCE and any further development of the
claims, cases are classified by the GROUPER software program into the
appropriate DRG. The GROUPER program was developed as a means of
classifying each case into a DRG on the basis of the diagnosis and
procedure codes and demographic information (that is, sex, age, and
discharge status). It is used both to classify past cases in order to
measure relative hospital resource consumption to establish the DRG
weights and to classify current cases for purposes of determining
payment. The records for all Medicare hospital inpatient discharges are
maintained in the Medicare Provider Analysis and Review (MedPAR) file.
The data in this file are used to evaluate possible DRG classification
changes and to recalibrate the DRG weights.
Currently, cases are assigned to one of 491 DRGs in 25 major
diagnostic categories (MDCs). Most MDCs are based on a particular organ
system of the body (for example, MDC 6, Diseases and Disorders of the
Digestive System); however, some MDCs are not constructed on this basis
since they involve multiple organ systems (for example, MDC 22, Burns).
In general, principal diagnosis determines MDC assignment. However,
there are four DRGs to which cases are assigned on the basis of
procedure codes rather than first assigning them to an MDC based on the
principal diagnosis. These are the DRGs for liver and bone marrow
transplant (DRGs 480 and 481, respectively) and the two DRGs for
tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs
before classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs (based
on a surgical hierarchy that orders individual procedures or groups of
procedures by resource intensity) and medical DRGs. Medical DRGs
generally are differentiated on the basis of diagnosis and age. Some
surgical and medical DRGs are further differentiated based on the
presence or absence of complications or comorbidities (hereafter CC).
Generally, GROUPER does not consider other procedures; that is,
nonsurgical procedures or minor surgical procedures generally not
performed in an operating room are not listed as operating room (OR)
procedures in the GROUPER decision tables. However, there are a few
non-OR procedures that do affect DRG assignment for certain principal
diagnoses, such as extracorporeal shock wave lithotripsy for patients
with a principal diagnosis of urinary stones.
We proposed to make several changes to the DRG classification
system for FY 1995. These proposed changes and the comments we received
concerning them, as well as our responses to those comments and the
final DRG changes, are set forth below.
2. MDC 2 (Diseases and Disorders of the Eye)
When a case is coded with a principal diagnosis of subcorneal
pustular dermatosis (diagnosis code 694.1), it is classified to MDC 2
(Diseases and Disorders of the Eye), where it is assigned to DRGs 46,
47, and 48 (Other Disorders of the Eye).\1\ As discussed in the
proposed rule, we received a suggestion from the public that we should
review the DRG classification of subcorneal pustular dermatosis because
it is a dermatological condition and is not a disease or disorder of
the eye.
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\1\A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second is for cases without CC. If a third number is included, it
represents cases of patients who are age 0-17. Occasionally, a pair
of DRGs is split on age >17 and age 0-17.
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Since this issue involves a possible medical misclassification of a
diagnosis, we asked our medical consultants to evaluate the condition.
They determined that subcorneal pustular dermatosis is indeed a
dermatological condition and not an eye condition. Based on their
determination and recommendations, we proposed to remove diagnosis code
694.1 from its current classification in MDC 2 and assign it to MDC 9
(Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast).
In order to determine the appropriate DRG assignment in MDC 9, we
first made a clinical evaluation of the medical DRGs. Based on the
current MDC 9 configuration, the only possible DRGs appear to be DRGs
272 and 273 (Major Skin Disorders) or DRGs 283 and 284 (Minor Skin
Disorders). After reviewing the average standardized charges and the
types of costs assigned to DRGs 272 and 273, we believe the best
assignment for 694.1 is DRGs 283 and 284. The proposed FY 1995 relative
weights of DRGs 46, 47, and 48 (0.7573, 0.4330, and 0.4182,
respectively) were approximately equal to those of DRGs 283 and 284
(0.7142 and 0.4358, respectively). Therefore, we proposed to move
diagnosis code 694.1 to DRGs 283 and 284. We received only one comment
on this proposal, which supported our change. Thus, we are
incorporating our proposal in this final rule.
3. MDC 15 (Newborns and Other Neonates With Conditions Originating in
the Perinatal Period)
In the September 1, 1993 final rule (58 FR 46283), we stated that
we would evaluate the newborn and neonate DRG classifications and
relative weights for possible improvements. Because of the low volume
of cases in these DRGs in the MedPAR file, we stated that we intended
to rely on data bases outside the Medicare claims file to supplement
our data. We expect that any major reclassification changes to MDC 15
will be based on an evaluation of actual neonate case data, including
charges and clinical information.
In the proposed rule, we stated that we had not yet completed this
evaluation, so we did not propose MDC 15 revisions for FY 1995.
However, we discussed several suggestions from the public concerning
improvements for the neonate DRG classifications. Some commenters
suggested that we reevaluate the diagnoses that are currently
considered significant problems in determining the assignment of a
neonate case to DRG 390 (Neonate with Other Significant Problems)
rather than DRG 391 (Normal Newborn). These commenters believe that
many of the diagnoses currently assigned to DRG 390 are not truly
significant clinically and in terms of resource use. These commenters
also identified specific diagnoses within this group that are
problematic. Even though we are not ready to proceed with a
comprehensive proposal for revising MDC 15, we did ask our medical
specialists to evaluate the specific conditions that were identified as
problematic in the assignment of newborns to DRG 390.
Currently, cases of otherwise normal newborns with one of the
following diagnoses are assigned to DRG 390 rather than DRG 391:
752.5 Undescended testicle
795.4 Other nonspecific abnormal histological findings
V05.3 Need for prophylactic vaccination against viral hepatitis
V05.4 Need for prophylactic vaccination against Varicella
V20.1 Other healthy infant or child receiving care
All of these diagnoses were identified by the commenters as
nonsignificant conditions that either are not problems or require only
minimal diagnostic work-up, no treatment, and result in the consumption
of minimal or no additional resources. For these reasons, the
commenters believe that these diagnoses should be added to the list of
conditions that may be found as secondary diagnoses for DRG 391.
Specifically, a healthy newborn with undescended testicles requires
only a minimal diagnostic work-up and no treatment at the time of
birth. In addition, the conditions that are assigned to diagnosis code
795.4 (Other nonspecific abnormal histological findings) are
nonsignificant problems and require no additional resources to treat.
Commenters also pointed out that it has become standard practice to
inoculate newborns against viral hepatitis, and that a prophylactic
vaccination against Varicella is normal and routine and does not
indicate a problem with the newborn. Diagnosis code V20.1 is generally
used to identify a healthy infant that remains in the hospital for an
extended period of time because of maternal illness, and should not be
considered a significant problem.
All of the conditions listed above were reevaluated on a clinical
basis by our medical specialists, who determined that these diagnoses
are not significant problems in neonates. Therefore, we proposed to add
them to the list of secondary diagnoses that would assign an otherwise
normal newborn to DRG 391.
We also reevaluated perinatal jaundice (diagnosis codes 774.0
through 774.7) and its DRG assignments in response to suggestions we
received. Currently, all of these diagnosis codes except 774.6
(unspecified fetal and neonatal jaundice) are considered major problems
and are assigned to DRGs 387 (Prematurity with Major Problems) and 389
(Full Term Neonate with Major Problems). Diagnosis code 774.6 is not
considered a significant problem and is assigned to DRG 388
(Prematurity without Major Problems) and DRG 391. Some did not believe
that 774.6 should be assigned to DRG 391 when all the other perinatal
jaundice codes are considered major problems. Others believe that some
of the perinatal jaundice diagnoses that are currently considered major
are really not that resource intensive.
Our medical specialists reevaluated these perinatal jaundice
conditions, and, based on their determinations, we proposed several
revisions to the neonatal DRG assignments. First, the following
diagnosis codes would be removed from the major problems list in DRGs
387 and 389 and would be added to the significant problems list:
774.0 Perinatal jaundice from hereditary hemolytic anemias
774.1 Perinatal jaundice from other excessive hemolysis
774.2 Neonatal jaundice associated with preterm delivery
Thus, a premature newborn with one of these codes would be assigned to
DRG 388 and a full-term newborn with one of these codes would be
assigned to DRG 390.
The following diagnosis codes would be removed from the major
problems list in DRGs 387 and 389 and would not be added to the
significant problems list:
774.30 Neonatal jaundice due to delayed conjugation, cause unspecified
774.31 Neonatal jaundice due to delayed conjugation in diseases
classified elsewhere
774.39 Other neonatal jaundice due to delayed conjugation from other
causes
774.5 Perinatal jaundice from other causes
Therefore, a premature newborn with one of these conditions would be
assigned to DRG 388 and a full-term newborn with one of these
conditions would be assigned to DRG 391.
The following diagnosis codes would remain on the major problems
list and continue to result in assignment to DRGs 387 and 389:
774.4 Perinatal jaundice due to hepatocellular damage
774.7 Kernicterus not due to isoimmunization
Finally, diagnosis codes 774.6 (Unspecified fetal and neonatal
jaundice) would continue to be considered a nonsignificant condition
and result in assignment to DRGs 388 and 391.
We note again that these proposals were based only on clinical
considerations and responded to specific requests made by the public.
We will continue our work on a more comprehensive evaluation of the MDC
15 DRGs and will announce our proposal when that evaluation is
completed.
Comment: We received two comments regarding these proposed changes.
One commenter supported all of the changes; the other commenter
supported the reassignment of diagnosis codes 752.5, 795.4, V05.3,
V05.4, and V20.1 from DRG 390 to DRG 391, but disagreed with the
proposed changes to the classification of the perinatal jaundice codes.
This commenter stated that perinatal jaundice frequently involves
significant testing and prolonged hospitalization and that
classification changes to these diagnoses should be delayed until HCFA
completes the evaluation of the newborn and neonate DRGs.
Response: Under our proposal, two perinatal jaundice diagnoses
remain on the major problems list (codes 774.4 and 774.7) and three
remain on the significant problems list (codes 774.0, 774.1, and
774.2). The diagnoses that have been redesignated from the major and
significant problems list are conditions that are not considered to be
clinically significant. That is, our medical staff do not believe that
these conditions require the expenditure of significant additional
resources by the hospital for treatment.
We note that under the New York All-Patient (AP) DRGs, the only
perinatal jaundice conditions considered to be major problems are 774.4
and 774.7. This is consistent with our proposal. In addition, of the
remaining codes, only 774.2 is considered a significant problem. The
remaining perinatal jaundice codes are not considered problems for
newborns under the AP-DRGs. Since New York uses the AP-DRGs to classify
and pay hospitals for the treatment of an all-patient population, we
believe that their classification of neonate diagnosis codes is a
reliable reflection of the actual resources used.
Since there is agreement with the AP-DRGs on the major problems and
we have included additional codes under the Medicare significant
problem DRGs, we are confident that our proposal is supportable.
Therefore, we are incorporating our proposed changes as final. As a
part of our analysis of the MDC 15 DRGs, we will evaluate our revisions
to verify that we have appropriately classified the perinatal jaundice
diagnoses. We note again that these changes are made in response to
public request and do not have a significant impact on the Medicare
population. In FY 1993, there were 25 cases classified in DRGs 387
through 391.
4. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different DRG within the MDC to which the principal diagnosis is
assigned. It is therefore necessary to have a decision rule by which
these cases are assigned to a single DRG. The surgical hierarchy, an
ordering of surgical classes from most to least resource intensive,
performs that function. Its application ensures that cases involving
multiple surgical procedures are assigned to the DRG associated with
the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of DRG reclassification and recalibration, we
reviewed the surgical hierarchy of each MDC, as we have for previous
reclassifications, to determine if the ordering of classes coincided
with the intensity of resource utilization, as measured by the same
billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example,
in MDC 5, the surgical class ``heart transplant'' consists of a single
DRG (DRG 103) and the class ``coronary bypass'' consists of two DRGs
(DRGs 106 and 107). Consequently, in many cases, the surgical hierarchy
has an impact on more than one DRG. The methodology for determining the
most resource-intensive surgical class, therefore, involves weighting
each DRG for frequency to determine the average resources for each
surgical class. For example, assume surgical class A includes DRGs 1
and 2 and surgical class B includes DRGs 3, 4, and 5, and that the
average charge of DRG 1 is higher than that of DRG 3, but the average
charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To
determine whether surgical class A should be higher or lower than
surgical class B in the surgical hierarchy, we would weight the average
charge of each DRG by frequency (that is, by the number of cases in the
DRG) to determine average resource consumption for the surgical class.
The surgical classes would then be ordered from the class with the
highest average resource utilization to that with the lowest, with the
exception of ``other OR procedures'' as discussed below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, which may sometimes occur in
cases involving multiple procedures, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or DRGs in that surgical class may be higher than that for other
surgical classes in the MDC. The ``other OR procedures'' class is a
group of procedures that are least likely to be related to the
diagnoses in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should only be considered
if no other procedure more closely related to the diagnoses in the MDC
has been performed.
A second example occurs when the difference between the average
weights for two surgical classes is very small. We have found that
small differences generally do not warrant reordering of the hierarchy
since, by virtue of the hierarchy change, the relative weights are
likely to shift such that the higher-ordered surgical class has a lower
average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we proposed to
modify the surgical hierarchy as set forth below. As discussed in
section II.C of this preamble, the final recalibrated weights are
somewhat different from those proposed, since they are based on more
complete data. Consequently, we have further revised the hierarchy in
this final rule using the principles set forth above.
In MDC 2 (Diseases and Disorders of the Eye), we proposed
to reorder Extraocular Procedures Except Orbit (DRGs 40 and 41) above
Intraocular Procedures Except Retina, Iris and Lens (DRG 42).
In MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth
and Throat), we proposed to reorder Rhinoplasty (DRG 56) above Salivary
Gland Procedures Except Sialoadenectomy (DRG 51).
We received no comments concerning the proposed surgical hierarchy.
In addition, based on a test of the proposed changes using the most
recent MedPAR file and the revised GROUPER software, we find that the
changes are still supported by the data and are adopting the proposals
in this final rule. However, based on the final MedPAR file, we need to
make another change in the surgical hierarchy for MDC 3. In MDC 3, in
addition to reordering DRG 56 above DRG 51, we will also reorder DRG 56
above DRG 50 (Sialoadenectomy). Therefore, the final revised hierarchy
for these three DRGs is as follows:
Rhinoplasty (DRG 56)
Sialoadenectomy (DRG 50)
Salivary Gland Procedures Except Sialoadenectomy (DRG 51)
5. Refinement of Complications and Comorbidities List
There is a standard list of diagnoses that are considered
complications or comorbidities (CCs). We developed this list using
physician panels to include those diagnoses that, when present as a
secondary condition, would be considered a substantial complication or
comorbidity. In preparing the original CC list, a substantial CC was
defined as a condition that, because of its presence with a specific
principal diagnosis, would increase the length of stay by at least 1
day for at least 75 percent of the patients.
In previous years, we have made changes to the standard list of
CCs, either by adding new CCs or deleting CCs already on the list. For
FY 1995, we did not propose to make any changes to the current CC list.
In the September 1, 1987 final notice concerning changes to the DRG
classification system (52 FR 33143), we modified the GROUPER logic so
that certain diagnoses included on the standard list of CCs would not
be considered a valid CC in combination with a particular principal
diagnosis. Thus, we created the CC Exclusions List. We made these
changes to preclude coding of CCs for closely related conditions, to
preclude duplicative coding or inconsistent coding from being treated
as CCs, and to ensure that cases are appropriately classified between
the complicated and uncomplicated DRGs in a pair.
In the May 19, 1987 proposed notice concerning changes to the DRG
classification system (52 FR 18877), we explained that the excluded
secondary diagnoses were established using the following five
principles:
Chronic and acute manifestations of the same condition
should not be considered CCs for one another (as subsequently corrected
in the September 1, 1987 final notice (52 FR 33154)).
Specific and nonspecific (that is, not otherwise specified
(NOS)) diagnosis codes for a condition should not be considered CCs for
one another.
Conditions that may not co-exist, such as partial/total,
unilateral/bilateral, obstructed/unobstructed, and benign/malignant,
should not be considered CCs for one another.
The same condition in anatomically proximal sites should
not be considered CCs for one another.
Closely related conditions should not be considered CCs
for one another.
The creation of the CC Exclusions List was a major project
involving hundreds of codes. The FY 1988 revisions were intended to be
only a first step toward refinement of the CC list in that the criteria
used for eliminating certain diagnoses from consideration as CCs were
intended to identify only the most obvious diagnoses that should not be
considered complications or comorbidities of another diagnosis. For
that reason, and in light of comments and questions on the CC list, we
have continued to review the remaining CCs to identify additional
exclusions and to remove diagnoses from the master list that have been
shown not to meet the definition of a CC stated above, as appropriate.
(See the September 30, 1988 final rule for the revision made for the
discharges occurring in FY 1989 (53 FR 38485), the September 1, 1989
final rule for the revision made for discharges occurring in FY 1990
(54 FR 36552), the September 4, 1990 final rule for the revision made
for discharges occurring in FY 1991 (55 FR 36126), the August 30, 1991
final rule for the revision made for discharges occurring in FY 1992
(56 FR 43209), the September 1, 1992 final rule for the revisions made
for discharges occurring in FY 1993 (57 FR 39753), and the September 1,
1993 final rule for the revisions made for discharges occurring in FY
1994 (58 FR 46278).)
We proposed a limited revision of the CC Exclusions List to take
into account the changes that will be made in the ICD-9-CM diagnosis
coding system effective October 1, 1994. (See section II.B.7, below,
for a discussion of these changes.) These proposed changes were made in
accordance with the principles established when we created the CC
Exclusions List in 1987.
In addition, upon review of our current CC Exclusions List, we
found that there are some diagnosis codes that do not exclude
themselves as CCs. In the September 1, 1987 final notice, we noted that
a very few codes were not excluded from themselves because they may
signify the bilateral occurrence of a particular condition (for
example, diagnosis code 730.02 (acute osteomyelitis of upper arm)) (52
FR 33154). However, we found some diagnosis codes that do not meet this
criterion. Therefore, we proposed to add the following diagnosis codes
to the CC Exclusions List as excluding themselves when they are
secondary diagnoses:
710.0 Systemic lupus erythematous
710.1 Systemic sclerosis
710.3 Sicca syndrome
710.4 Dermatomyositis
710.8 Other specified diffuse diseases of connective tissue
Based on a comment we received, we also proposed to exclude
diagnosis code 707.1 (Ulcer of lower limb, except decubitus) as a CC
when the principal diagnosis is 440.23 (Atherosclerosis of the
extremities with ulceration). The commenter believes that this
exclusion is similar to the current exclusion of 785.4 (Gangrene) when
the principal diagnosis is 440.24 (Atherosclerosis of the extremities
with gangrene), and we agree with the commenter's assessment.
Finally, it was brought to our attention by another commenter that
when a patient's principal diagnosis is complication of a transplant
condition (diagnosis codes 996.71 and 996.8x), the diagnosis codes used
to denote transplant status (V42.x) should not be considered CCs. Thus,
for the following principal diagnoses, we proposed to delete the
indicated status code:
For code 996.71 (Complications due to heart valve
prosthesis) delete code V42.2 (Heart valve transplant influencing
health status) as a CC.
For code 996.80 (Complications of unspecified organ
transplant) delete code V42.0 (Kidney transplant influencing health
status), V42.1 (Heart transplant influencing health status), V42.6
(Lung transplant influencing health status), V42.7 (Liver transplant
influencing health status), V42.8 (Other specified organ or tissue
transplant influencing health status) as CCs.
For code 996.81 (Complications of kidney transplant)
delete code V42.0 (Kidney transplant influencing health status) as a
CC.
For code 996.82 (Complications of liver transplant) delete
code V42.7 (Liver transplant influencing health status) as a CC.
For code 996.83 (Complications of heart transplant) delete
code V42.1 (Heart transplant influencing health status) as a CC.
For code 996.84 (Complications of lung transplant) delete
code V42.6 (Lung transplant influencing health status) as a CC.
For code 996.86 (Complications of pancreas transplant)
delete code V42.8 (Other specified organ or tissue transplant
influencing health status) as a CC.
For code 996.89 (Complications of other specified organ
transplant) V42.8 (Other specified organ or tissue transplant
influencing health status) as a CC.
Comment: We received one comment that supported our revision of the
CC Exclusions List. However, another commenter, while agreeing that
transplant status (V42.x) is implied in the organ-specific complication
codes (996.8x), disagreed with one of our revisions. Specifically, the
commenter believes that code V42.8 (Other specified organ or tissue
transplant influencing health status) should not be excluded for cases
in which the principal diagnosis is 996.86 (Complications of pancreas
transplant) or 996.89 (Complications of other specified organ
transplant). The commenter notes that code V42.8 includes transplants
other than pancreas (for example, intestines). Therefore, to exclude as
a CC a code that is not organ specific means that, for example, a
pancreatic transplant patient experiencing a complication with an
intestinal transplant would not have the V42.8 code associated
classified as a CC.
Response: We agree with the commenter that the fact that all the
complication codes (996.8x) and the status codes (V42.x) are not
perfectly matched in organ specificity occasionally leads to the
inability to code certain otherwise allowable CCs. However, we believe
the problem is extremely limited in the Medicare population, who do not
tend to have multiple transplanted organs. The problem with leaving
V42.8 (a ``not elsewhere classified'' code) as a CC for 996.86 and
996.89 is that it opens the door for incorrect coding in order to gain
a higher DRG assignment.
If hospitals followed correct coding guidelines concerning the V
status codes, we would not have had to make the proposed changes to the
CC Exclusions List. That is, it is not correct to code the status code
for an organ transplant when the principal diagnosis is complication of
the same organ transplant. However, based on the information in the
MedPAR file, hospitals were following this incorrect procedure and were
gaining an inappropriate financial advantage. Therefore, we believe
that leaving V42.8 off the exclusion list for 996.86 and 996.89 would
cause more incorrect DRG assignments than including it on the list. We
note that when a transplant complication is coded as the principal
diagnosis, hospitals may code the actual complication and any other
secondary diagnoses documented by the physician.
Tables 6f and 6g in section V of the addendum to this final rule
contain the final revisions to the CC Exclusions List (including the
change for V42.8) that will be effective for discharges occurring on or
after October 1, 1994. Each table shows the principal diagnoses with
the changes to the excluded CCs. Each of these principal diagnoses is
shown with an asterisk and the additions or deletions to the CC
Exclusions List are provided in an indented column immediately
following the affected principal diagnosis.
CCs that are added to the list are in Table 6f--Additions to the CC
Exclusions List. Beginning with discharges on or after October 1, 1994,
the indented diagnoses will not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6g--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 1994, the indented diagnoses will be recognized by the GROUPER as
valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can
be obtained from the National Technical Information Service (NTIS) of
the Department of Commerce. It is available in hard copy for $84.00 and
on microfiche for $20.50, plus $3.00 for shipping and handling. A
request for the FY 1988 CC Exclusions List (which should include the
identification accession number, (PB) 88-133970) should be made to the
following address: National Technical Information Service; United
States Department of Commerce; 5285 Port Royal Road, Springfield,
Virginia 22161; or by calling (703) 487-4650.
Users should be aware of the fact that all revisions to the CC
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, and 1994) and those
in Tables 6f and 6g of this document must be incorporated into the list
purchased from NTIS in order to obtain the CC Exclusions List
applicable for discharges occurring on or after October 1, 1994.
Alternatively, the complete documentation of the GROUPER logic,
including the current CC Exclusions List, is available from 3M/Health
Information Systems (HIS), which, under contract with HCFA, is
responsible for updating and maintaining the GROUPER program. The DRG
Definitions Manual, Version 12.0, which includes the changes set forth
in this final rule, is available for $195.00, which includes $15.00 for
shipping and handling. These manuals may be obtained by writing 3M/HIS
at: 100 Barnes Road; Wallingford, Connecticut 06492; or by calling
(203) 949-0303. Please specify the revision or revisions requested.
6. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive OR
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR
procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive
OR Procedure Unrelated to Principal Diagnosis) in order to determine
whether procedures are properly assigned among these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the OR procedures performed is related to the principal diagnosis.
These DRGs are intended to capture atypical cases, that is, those cases
not occurring with sufficient frequency to represent a distinct,
recognizable clinical group. DRG 476 is assigned to those discharges in
which one or more of the following prostatic procedures are performed
and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic tissue
60.2 Transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostratic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures if performed
with an unrelated principal diagnosis was published in Table 6C in
section IV of the addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990,
August 30, 1991, September 1, 1992, and September 1, 1993, we moved
several other procedures from DRG 468 to 477. (See 55 FR 36135, 56 FR
43212, 57 FR 23625, and 58 FR 46279, respectively.)
a. Adding Procedure Codes to MDCs. We annually conduct a review of
procedures producing DRG 468 or 477 assignments on the basis of volume
of cases in these DRGs with each procedure. Our medical consultants
then identify those procedures occurring in conjunction with certain
principal diagnoses with sufficient frequency to justify adding them to
one of the surgical DRGs for the MDC in which the diagnosis falls. On
the basis of this review, we proposed the following DRG classification
changes in order to reduce unnecessary assignment of cases to DRG 468
or 477.
MDC 1 (Diseases and Disorders of the Nervous System).
We have observed that surgical pacemaker procedures are being
performed with increasing frequency for anatomical nerve problems
associated with heart block. These diagnoses, diagnosis codes 337.0
(Idiopathic peripheral autonomic neuropathy), 742.8 (Other specified
anomalies of nervous system), and 742.9 (Unspecified anomaly of brain,
spinal cord, and nervous system), are assigned to MDC 1, but the
surgical pacemaker procedures are not. Consequently, when a pacemaker
procedure is performed on a patient with one of these diagnoses, the
case is assigned to DRG 468. Therefore, we proposed to add the
following procedure codes to DRGs 7 and 8 (Peripheral and Cranial Nerve
and Other Nervous System Procedures):
37.74 Insertion or replacement of epicardial lead (electrode) into
epicardium
37.75 Revision of lead (electrode)
37.76 Replacement of transvenous atrial and/or ventricular lead(s)
(electrode)
37.77 Removal of lead(s) (electrode) without replacement
37.79 Revision or relocation of pacemaker pocket
37.80 Insertion of permanent pacemaker, initial or replacement, type
of device not specified
37.85 Replacement of any type pacemaker device with single-chamber
device, not specified as rate responsive
37.86 Replacement of any type pacemaker device with single-chamber
device, rate responsive
37.87 Replacement of any type pacemaker device with dual-chamber
device
37.89 Revision or removal of pacemaker device
In addition, during our review of DRG 468 cases, we found that
there are several hundred cases of lower limb amputation procedures
with a principal diagnosis from MDC 1. Patients with diabetes often
develop complications that require the performance of a lower limb
amputation. Although the majority of the diagnosis codes for diabetes
are assigned to MDC 10 (Endocrine, Nutritional and Metabolic Diseases
and Disorders), cases with a principal diagnosis of diabetes with
neurological manifestations (diagnosis codes 250.60, 250.61, 250.62 and
250.63) are assigned to MDC 1. Therefore, we proposed to move the
following procedures to DRGs 7 and 8:
84.11 Amputation of toe
84.12 Amputation through foot
84.13 Disarticulation of ankle
84.14 Amputation of ankle through malleoli of tibia and fibula
84.15 Other amputation below knee
84.16 Disarticulation of knee
84.17 Amputation above knee
Two commenters wrote concerning the proposal to add pacemaker and
amputation procedures to DRGs 7 and 8.
Comment: One commenter noted that pacemaker procedure codes that
are not recognized by the GROUPER unless they are paired with their
related codes were excluded from the list of codes to be moved to DRGs
7 and 8. The commenter recommends that all pacemaker procedures with a
principal diagnosis assigned to MDC 1 be added to DRG 7 and 8.
Response: The pacemaker codes we proposed to move to DRGs 7 and 8
are only those codes considered to be OR procedures. The pacemaker
procedures that are considered to be non-OR procedures were not moved.
Coding the initial implantation of a permanent cardiac pacemaker
requires that one lead and one device code must be used in combination
for DRG assignment. Coding of revision and replacement pacemaker
procedures does not require combined codes to be assigned to DRGs.
The pacemaker procedure codes that are non-OR procedures are not
recognized by the GROUPER unless they are combined with their related
codes. That is, they are considered for DRG assignment only if they
occur in pairs. Otherwise they are treated as other non-OR procedures
and do not affect DRG assignment. These non-OR procedures are as
follows:
37.70 Initial insertion pacemaker lead, not otherwise specified
37.71 Initial insertion of transvenous lead into ventricle
37.72 Initial insertion of transvenous leads into atrium and ventricle
37.73 Initial insertion of transvenous lead into atrium
37.81 Initial insertion of single-chamber device, not specified as
rate responsive
37.82 Initial insertion of single-chamber device, rate responsive
37.83 Initial insertion of dual-chamber device
These non-OR procedures were not included in the list of pacemaker
codes that we proposed to move from DRGs 7 and 8 when they occurred
with an MDC 1 principal diagnosis.
However, we agree with the commenter that these non-OR pacemaker
procedure codes, when accompanying an MDC 1 principal diagnosis, should
be assigned to DRGs 7 or 8 rather that DRG 468 when they are paired
with the related procedure code. Therefore, we are adding the following
pacemaker codes, when they occur in combination, to DRGs 7 and 8:
37.70 & 37.81 Initial insertion pacemaker lead and single-chamber
device, non-rate responsive
37.70 & 37.82 Initial insertion pacemaker lead and single-chamber
device, rate responsive
37.71 & 37.81 Initial insertion of transvenous lead into ventricle and
single-chamber device, non-rate responsive
37.71 & 37.82 Initial insertion of transvenous lead into ventricle and
single-chamber device, rate responsive
37.72 & 37.83 Initial insertion of transvenous leads into atrium and
ventricle & dual-chamber device
37.73 & 37.81 Initial insertion of transvenous lead into atrium and
single-chamber device, non-rate responsive
37.73 & 37.82 Initial insertion of transvenous lead into atrium and
single-chamber device, rate responsive
We emphasize that procedure codes 37.70, 37.71, 37.72, 37.73,
37.81, 37.82, and 37.83 are not considered by the GROUPER unless used
in combination with their related codes. If used singularly, these
codes will be ignored for the purpose of DRG assignment. The pacemaker
codes originally proposed may occur alone or in pairs, and will be
assigned to DRG 7 or 8 when they occur with a principal diagnosis in
MDC 1 as proposed.
We are adopting the changes in the proposed rule, with the
revisions discussed above.
Comment: We received a comment that objected to the placement of
pacemaker procedures and lower limb amputation procedures in DRGs 7 and
8. The commenter stated that unless clinical evidence supported the
assignment of these pacemaker cases to DRG 7 or 8, it would be more
reasonable to move these cases to DRG 115 (Permanent Cardiac Pacemaker
Implant with AMI, Heart Failure, or Shock) or DRG 116 (Other Permanent
Pacemaker Implant or AICD Lead or Generator Procedures) in MDC 5
(Diseases and Disorders of the Circulatory System). It was also
suggested that the amputation cases be assigned to DRGs in MDC 10
(Endocrine, Nutritional, and Metabolic Diseases and Disorders), where
diabetic patients with manifestations are classified.
Response: The DRGs were developed as a patient classification
scheme consisting of classes of patients who were similar clinically
and in terms of their consumption of hospital resources. The concept of
clinical coherence requires that the patient characteristics included
in the definition of each DRG relate to a common organ system or
etiology and that a specific medical specialty should typically provide
care to the patients in the DRG. Each case is assigned to a DRG,
usually within an MDC. The MDCs are generally based on a common organ
system that is identified by principal diagnosis.
Thus, the proposed assignment of procedures from DRG 468 was based
on the principal diagnosis that is currently assigned to the DRGs in
question. For example, a patient may have a principal diagnosis of
idiopathic peripheral autonomic neuropathy (diagnosis code 337.0) and a
secondary diagnosis of congestive heart failure (diagnosis code 428.0)
that requires the insertion of a pacemaker lead and a single chamber
device (procedure codes 37.70 and 37.82, respectively). Cases with the
principal diagnosis code 337.0 are assigned to MDC 1; however, the
pacemaker procedures have not been assigned to this MDC. Therefore,
this case would be grouped to DRG 468. We have proposed to place the
pacemaker procedures, when occurring with a principal diagnosis found
in MDC 1, to the most appropriate DRG within that category. It would be
inappropriate to assign the pacemaker procedures, when they occur with
a principal diagnosis classified to MDC 1, to a DRG in MDC 5 or any
other unrelated MDC. In the past, these cases have been assigned to DRG
468 because the procedure performed is unrelated to the principal
diagnosis.
This is true, also, for the amputation procedures. The principal
diagnoses defining diabetes with neurological manifestations are found
in MDC 1, although the procedures were not. Clinical experts concurred
with the classification of the neurological manifestations of diabetes
to MDC 1 as sharing a common body system rather than to MDC 10, which
relates to the endocrine and metabolic manifestations of the condition.
MDC 5 (Diseases and Disorders of the Circulatory System).
Closed endoscopic biopsy of lung (procedure code 33.27) and open
biopsy of lung (procedure code 33.28), diagnostic tools for vascular
tumors, are often performed on patients with a principal diagnosis of
228.00 (Hemangioma of unspecified site) or 228.09 (Hemangioma of other
sites). Although these principal diagnoses are assigned to MDC 5, the
diagnostic procedures are not. Thus, if they are included together on
the same claim, the case will be assigned to DRG 468. Therefore, we
proposed to assign procedure codes 33.27 and 33.28 to DRG 120 (Other
Circulatory System OR Procedures) in MDC 5.
In addition, we identified the following nonextensive OR procedures
(that is, procedures assigned to DRG 477) as appropriate to move to MDC
5:
40.11 Biopsy of lymph structure
40.19 Other diagnostic procedures on lymphatic structures
40.21 Excision of deep cervical lymph node
40.23 Excision of axillary lymph node
40.24 Excision of inguinal lymph node
40.29 Simple excision of other lymphatic structure
40.3 Regional lymph node excision
These procedures are commonly performed with a variety of diagnoses
found in MDC 5 such as disorders of the peripheral vascular system
(diagnosis codes 747.60 and 747.69) and peripheral angiopathy
(diagnosis code 443.81), as well as a number of heart conditions
including malignant neoplasm of the heart (diagnosis code 164.1), and
coxsackie carditis, coxsackie pericarditis, coxsackie endocarditis, and
coxsackie myocarditis (diagnosis codes 074.20, 074.21, 074.22, 074.23,
respectively). We note that these commonly performed diagnostic
procedures are assigned to virtually every other MDC because they are
associated with many diagnoses. Therefore, we proposed to move these
procedures to DRG 120.
We also note that hemangioma and anomalies of the peripheral
vascular system may require open rectal biopsy (procedure code 48.25)
or excision of the rectal lesion (procedure code 48.35) as part of
their treatment. At the present time, neither of these procedure codes
classify to MDC 5. Thus, we proposed to move procedure codes 48.25 and
48.35 to DRG 120.
MDC 6 (Diseases and Disorders of the Digestive System).
A total splenectomy (procedure code 41.5) may be performed on
patients with a principal diagnosis of secondary malignant neoplasm of
other digestive organs and spleen (diagnosis code 197.8). This
diagnosis is included in MDC 6, but the procedure is not, resulting in
the assignment of cases to DRG 468. Thus, we proposed to add procedure
code 41.5 to DRG 170 and 171 (Other Digestive System OR Procedures) in
MDC 6.
Comment: One commenter, while concurring with the proposed
assignment of procedure codes from DRG 468 to relevant MDCs, did not
agree with several of our proposed DRG classifications. This objection
was based on the DRG relative weight differential between the relative
weight of the proposed DRG and the relative weight of other DRGs to
which these procedures are already assigned. This commenter believes
that new DRGs should be created within the MDCs for the procedures we
proposed to move out of DRG 468 with weights similar to the weights
they command in other DRG assignments. If we cannot do this, the
commenter requested that these cases remain in DRG 468.
Specifically, this commenter agreed with the assignment of
pacemaker codes, as well as lower limb amputation associated with
diabetes, to MDC 1 but disagreed with their assignment to DRGs 7 and 8.
Further, this commenter supported the addition of the lung biopsy codes
33.27 and 33.28 to MDC 5, but objected to their assignment to DRG 120
because the weights of DRG 75 (Major Chest Procedures) and DRG 76 and
77 (Other Respiratory System OR Procedures) in MDC 4 (Diseases and
Disorders of the Respiratory System) to which procedure 33.27 and 33.28
are classified, respectively, have a higher relative weight than DRG
120.
Nor did this commenter agree with the assignment of procedure code
41.5 to DRGs 170 and 171 because the weights of these DRGs do not
reflect the resources used in these cases. Again, the commenter
believes that a new DRG should be created within MDC 6 for this
procedure with a relative weight similar to that of DRG 392
(Splenectomy Age > 17) in MDC 16 (Diseases and Disorders of the Blood,
Blood Forming Organs and Immunological Disorders), to which these
procedures are also assigned, or the cases should remain in DRG 468.
Response: We do not believe it is appropriate to compare the DRG
relative weights for the proposed DRG assignments to other DRGs in
which the same procedures may be classified. Each surgical DRG
classification is determined by a combination of principal diagnosis,
secondary diagnoses, surgical procedures, age, and sex. To compare
procedure classifications and relative weights without taking into
consideration the principal diagnosis and other factors is
inappropriate and results in misinterpretation and misleading
comparisons.
Many of the procedures we have proposed to move from DRG 468 are
assigned to multiple DRGs, depending on the principal diagnosis. Thus,
to compare lung biopsies (procedure codes 33.27 and 33.28) to DRG
assignments in MDC 4 fails to take into account the principal diagnosis
responsible for the MDC assignment. Procedure code 33.28 is currently
assigned to 7 DRGs in 4 MDCs, with FY 1995 weights that range from
0.9529 to 3.0551. (The FY 1995 weights for DRGs 7 and 8 are 2.5005 and
0.9185, respectively). Similarly, to compare splenectomy procedures
with a principal diagnosis of secondary malignant neoplasm of other
digestive organs and spleen (diagnosis code 197.6), for example, to a
splenectomy performed in conjunction with a principal diagnosis
assigned to DRG 392 in MDC 16 is specious. To interpolate from a DRG
assignment with one set of related principal diagnoses to one with
another set of related principal diagnoses significantly underestimates
the role of principal diagnosis in determining resource intensity.
As noted above, one of the basic principles of DRG classification
is that cases assigned to each DRG should be similar both clinically
and in resource utilization. As the first step in ensuring clinical
coherence, we subject all DRG modifications under consideration to
careful, thorough medical judgment and evaluation. Total charges,
submitted by hospitals on inpatient claims, serve as a proxy measure of
resource use. Similar resource use does not mean identical resource
use, but, rather, that the resources used to treat a range of patients
within one DRG classification will be relatively consistent and that
this level of variation is known and predictable. Thus, although the
procedures we have proposed moving from DRG 468 to more specific DRGs
may have charges slightly higher or lower than the average for the DRG
to which they are assigned, this variation is well within the expected
range and can be accurately predicted.
In each MDC there is usually a surgical class referred to as
``other surgical procedures.'' The ``other'' classes are not as
precisely defined from a clinical perspective and include diagnoses or
procedures which are infrequently encountered or not well defined
clinically. The ``other'' surgical category contains surgical
procedures which, while infrequent, could still reasonably be expected
to be performed for a patient in the particular MDC. We note that the
procedures we proposed to move from DRG 468 to specific MDCs are all
assigned to the ``other'' surgical class DRG or DRGs. We believe it is
appropriate to assign cases to the DRG that contains clinically similar
cases within the most specific MDC possible. DRG 468 exists for those
patients who receive surgical procedures that are completely unrelated
to the MDC to which the patient was assigned. For the procedures
identified to be assigned to specific MDCs, the principal diagnosis was
appropriate for the proposed MDC assignment, the cases occurred in
sufficient volume and were clinically similar enough to those existing
in the proposed DRG assignment to justify our decision to move them.
The ``other'' category exists within each MDC for this express purpose:
to classify those cases that are sufficiently related to be assigned to
the MDC, but are not clearly defined or occur in low volume. We believe
the procedures we have recommended for MDC assignment meet these
criteria.
We do not believe it would be prudent policy to create new DRGs
within the relevant MDCs to cover the procedures being reassigned from
DRG 468. This would represent a departure from the process of defining
the surgical classes within MDCs by organizing a DRG based on
procedures more appropriately categorized in the ``other'' surgical
class. DRG classification requires physician judgment, statistical
analysis, and historical data. Until we have sufficient data to
determine the performance of these procedures within the relevant DRGs,
we can not justify creating additional DRGs. We will continue to review
and evaluate these procedures to determine the appropriateness of DRG
assignment. Until we have data documenting the need for further
modification, we are adopting the DRG assignment of the procedures as
proposed with revisions as discussed.
b. Reassignment of Procedures Among DRGs 468, 476, and 477. For the
proposed rule, we also reviewed the list of procedures that produce
assignments to each of DRG 468, 476, and 477 to ascertain if any of
those procedures should be moved to one of the other DRGs based on
average charges and length of stay. Generally, we move only those
procedures for which we have an adequate number of discharges to
analyze the data. Based on our review this year, we proposed to move a
limited number of procedures.
In reviewing the list of OR procedures that produce DRG 468
assignments, we analyzed the average charge and length of stay data for
cases assigned to that DRG to identify those procedures that are more
similar to the discharges that currently group to either DRG 476 or
477. We identified three procedures that are significantly less
resource intensive than the other procedures assigned to DRG 468.
Therefore, we proposed to move the following procedures to the list of
procedures that result in assignment to DRG 477:
24.5 Alveoloplasty
53.61 Incisional hernia repair with prosthesis
53.69 Repair of other hernia of anterior abdominal wall with
prosthesis
We conducted a similar analysis of the procedures that assign cases
to DRG 477 to determine if any of those procedures might more
appropriately be classified to DRG 468. Again, we analyzed charge and
length of stay data to identify procedures that were more similar to
discharges assigned to DRG 468 than to those classified in DRG 477. We
did not identify any procedures in DRG 477 that should be assigned to
DRG 468.
We received no comments on the proposed reassignments to DRG 477,
therefore, they are adopted as final and will be effective with
discharges beginning on or after October 1, 1994.
7. Changes to the ICD-9-CM Coding System
As discussed above in section II.B.1 of this preamble, the ICD-9-CM
is a coding system that is used for the reporting of diagnoses and
procedures performed on a patient. In September 1985, the ICD-9-CM
Coordination and Maintenance Committee was formed. This is a Federal
interdepartmental committee charged with the mission of maintaining and
updating the ICD-9-CM. That mission includes approving coding changes,
and developing errata, addenda, and other modifications to the ICD-9-CM
to reflect newly developed procedures and technologies and newly
identified diseases. The Committee is also responsible for promoting
the use of Federal and non-Federal educational programs and other
communication techniques with a view toward standardizing coding
applications and upgrading the quality of the classification system.
The Committee is co-chaired by the National Center for Health
Statistics (NCHS) and HCFA. The NCHS has lead responsibility for the
ICD-9-CM diagnosis codes included in Volume 1--Diseases: Tabular List
and Volume 2--Diseases: Alphabetic Index, while HCFA has lead
responsibility for the ICD-9-CM procedure codes included in Volume 3--
Procedures: Tabular List and Alphabetic Index.
The Committee encourages participation in the above process by
health-related organizations. In this regard, the Committee holds
public meetings for discussion of educational issues and proposed
coding changes. These meetings provide an opportunity for
representatives of recognized organizations in the coding fields, such
as the American Health Information Management Association (AHIMA)
(formerly American Medical Record Association (AMRA)), the American
Hospital Association (AHA), and various physician specialty groups as
well as physicians, medical record administrators, health information
management professionals, and other members of the public to contribute
ideas on coding matters. After considering the opinions expressed at
the public meetings and in writing, the Committee formulates
recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes at public
meetings held on May 6, August 5, and December 2, 1993, and finalized
the coding changes after consideration of comments received at the
meetings and in writing within 30 days following the December 1993
meeting. The initial meeting for consideration of coding issues for
implementation in FY 1996 was held on May 5, 1994. Copies of the
minutes of these meetings may be obtained by writing to one of the co-
chairpersons representing NCHS and HCFA. We encourage commenters to
address suggestions on coding issues involving diagnosis codes to: Sue
Meads, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee;
NCHS; Rm. 9-58; 6525 Belcrest Road; Hyattsville, Maryland 20782.
Questions and comments concerning the procedure codes should be
addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination
and Maintenance Committee; HCFA, Office of Coverage and Eligibility
Policy; Rm. 401 East High Rise Building; 6325 Security Boulevard;
Baltimore, Maryland 21207.
The ICD-9-CM code changes that have been approved will become
effective October 1, 1994. The new ICD-9-CM codes are listed, along
with their DRG classifications, in Tables 6a and 6b (New Diagnosis
Codes and New Procedure Codes, respectively) in section IV of the
addendum to this final rule. As we stated above, the code numbers and
their titles were presented for public comment in the ICD-9-CM
Coordination and Maintenance Committee meetings. Both oral and written
comments were considered before the codes were approved. Therefore,
comments were solicited only on the proposed DRG classification.
Further, the Committee has approved the expansion of certain ICD-9-
CM codes to require an additional digit for valid code assignment.
Diagnosis codes that have been replaced by expanded codes, other codes,
or have been deleted are in Table 6c (Invalid Diagnosis Codes). The
invalid diagnosis codes will not be recognized by the GROUPER beginning
with discharges occurring on or after October 1, 1994. The
corresponding new or expanded codes are included in Tables 6a and 6b.
The committee did not delete any procedure codes effective for October
1, 1994. Revisions to diagnosis and procedure code titles are in Tables
6d (Revised Diagnosis Code Titles) and 6e (Revised Procedure Code
Titles), which also include the proposed DRG assignments for these
revised codes.
The comments we received regarding the ICD-9-CM coding changes fall
into three general categories: Spelling or other technical errors in
our Tables 6a through 6e; disagreement with the assignment of a new
code or revised code; and comments about coding policy.
Based on the comments and our own review, we have corrected
misspellings, added omitted codes, and corrected phrasing in the code
descriptions in Tables 6a, 6c, and 6d. The codes for which changes have
been made are as follows: Table 6a: 709.01, 760.76, 996.04, V12.00, and
V57.22. Table 6c: 305.10, 305.11, 305.12, and 305.13 were added. Table
6d: 440.24.
The remaining comments are addressed below.
Comment: We received one inquiry regarding our assignment of
procedure code 998.81 (Emphysema resulting from a procedure) to DRGs
452 and 453 (Complications of Treatment). The commenter suggested that
the code be assigned to DRGs 101 and 102 (Other Respiratory System
Diagnoses) in MDC 4 (Diseases and Disorders of the Respiratory System).
Response: Procedure code 998.81 is one of three new codes that are
5th-digit expansions of the existing 998.8 category of codes for
specific complications of procedures, not elsewhere classified. The new
code 998.81 is to be used for a systemic condition, subcutaneous
emphysema, that results from a procedure rather than one of the more
specific emphysema conditions assigned to a DRG in MDC 4. Therefore, we
are not changing its designation in this final rule.
We note that the current 4-digit code 998.8 is assigned to DRGs 452
and 453. Our usual practice is to continue to assign 5th-digit
expansions of a code to the same DRGs to which the 4-digit code was
assigned unless there is a compelling or practical reason to make a
different assignment. As noted by the commenter, we did assign code
998.82 (Cataract fragment in eye following cataract surgery) to DRGs
46, 47, and 48 (Other Disorders of the Eye) in MDC 2 because of the
specificity of the coded condition and the similarity of the new code
to the other complication codes currently assigned to DRGs 46 through
48. However, this is a very isolated case of change in DRG assignment.
Comment: We received one comment regarding the DRG assignment of
code 440.24 (Atherosclerosis of native arteries of the extremities with
gangrene). The commenter requested that the code be assigned to DRG 387
(Prematurity with Major Problems) in addition to DRGs 130 and 131
(Peripheral Vascular Disorders) as is indicated in Table 6d.
Response: The DRG assignment of code 440.24, which has a revised
title for FY 1995, has not been changed. It continues to be considered
a ``major problem'' for purposes of assignment to DRG 387 and we have
corrected this oversight in Table 6d.
Comment: A commenter questioned why we assigned new diagnosis code
677 (Late effect of complication of pregnancy, childbirth, the
puerperium) to DRG 469 (Principal Diagnosis Invalid as Discharging
Diagnosis) rather than DRGs 373 (Vaginal Delivery without Complicating
Diagnoses), 376 (Postpartum and Post Abortion Diagnoses without OR
Procedure), and 384 (Other Antepartum Diagnoses without Medical
Complications).
Response: This code was created by the National Center for Health
Statistics, the group responsible for revisions to the ICD-9-CM
diagnosis codes, for use as an epidemiologic tool to trace the
physical, long-term effects of childbearing. It should not be used as a
principal diagnosis. Rather, the specific complication that has
occasioned the inpatient stay should be coded as the principal
diagnosis. Code 677 should be included as a secondary diagnosis.
Therefore, if 677 is coded as principal, the case will group to DRG
469.
Comment: We received two comments requesting that we reconsider our
non-OR designation for new procedure code 41.04 (Autologous
hematopoietic stem cell transplant). The commenters both believe that
this should be considered an OR procedure based on the resource use
associated with it. In addition, one commenter has requested that the
code be assigned to DRG 481 (Bone Marrow Transplant) along with the
other codes in category 41.0 (Bone marrow transplant).
Response: Currently, these stem cell transplant procedures are
included in procedure code 99.73 (Therapeutic erythrocytapheresis), a
non-OR procedure. As noted above, our practice is to assign a new code
to the same category as its predecessor code. One compelling reason for
this practice is our inability to move the cases associated with a new
code to a new DRG assignment as a part of DRG reclassification and
recalibration. Because we cannot separately identify the stem cell
transplant cases from the other cases coded with 99.73 in order to
reclassify them and their charges to a new DRG, we are unable to
predict the new weights of both the DRGs in which this code currently
is classified and the new DRG to which it would be assigned. Therefore,
we are prevented from redesignating code 41.04 as an OR procedure.
Regarding the request that this code be reassigned to DRG 481, we
note that the procedure represented by this code is not a bone marrow
transplant procedure. While it may consume hospital resources similar
to those transplant procedures, we will be unable to verify that
assumption until we can evaluate the newly coded stem cell transplant
cases in the FY 1995 MedPAR file. That file will be available in
calendar year 1996 and we will analyze the cases with procedure code
41.04 as a part of our DRG agenda for FY 1997.
Comment: One commenter requested that we publish revised diagnosis
code category headings when a formerly valid diagnosis code is made
invalid due to a revision of the codes in that group to require a
fourth or fifth digit.
Response: We publish the ICD-9-CM coding system changes in the
proposed and final rules in order to display our CC and DRG assignments
of new and revised codes. We also publish an informational list of
invalid codes that will no longer be recognized by the Medicare
GROUPER. The proposed and final prospective payment rules are not a
replacement for ICD-9-CM coding manuals. We publish only that coding
information that is necessary for public understanding and
implementation of the DRG classification system. Therefore, we do not
believe that we should publish the information requested by the
commenter.
Comment: We received one comment expressing disappointment in the
very minor changes made to Volume 3 of the ICD-9-CM (the procedure
codes) for FY 1995. The commenter recommends that we do much more to
update and revise Volume 3.
Response: There are severe physical space constraints that limit
the number of changes that can be made to the procedure codes in Volume
3. HCFA is aware that this Volume does not contain the most current
codes to match changing technology, but, due to its current
configuration, Volume 3 is limited to 4-digit codes. We have begun the
process to revise this Volume, but that work will require several years
for completion and implementation.
We again encourage commenters to address questions, comments, and
suggestions on issues involving diagnosis codes to Sue Meads and those
concerning procedure codes to Patricia E. Brooks at the addresses set
forth above.
8. DRG Refinements
For several years, we have been analyzing major refinements to the
DRG classification system to compensate hospitals more equitably for
treating severely ill Medicare patients. These refinements, generally
referred to as severity of illness adjustments, would create DRGs
specifically for hospital discharges involving very ill patients who
consume far more resources than do other patients classified to the
same DRGs in the current system. This approach has been taken by
various other groups in refining the DRG system, most notably the
research done for Yale, the changes incorporated by the State of New
York into its all patient (AP) DRG system, and the all-patient refined
(APR) DRGs, which are a joint effort of 3M/HIS and the National
Association of Children's Hospitals and Related Institutions.
In the proposed rule, we announced the availability of a paper we
have prepared that describes our proposed severity DRG classification
system as well as the analysis upon which our proposal was formulated.
Comments are due to HCFA by September 30, 1994.
Our plan is to incorporate comments and suggestions we receive and
to consider proposing the complete revised DRG system as part of the FY
1996 prospective payment system proposed rule, which will be published
in the spring of 1995. However, as the final rule published on
September 1, 1992 (57 FR 39761) indicates, we would not propose to make
significant changes to the DRG classification system unless we are able
either to improve our ability to predict coding changes by validating
in advance the impact that potential DRG changes may have on coding
behavior, or to make methodological changes to prevent building the
inflationary effects of the coding changes into future program
payments.
Besides the mandate of section 1886(d)(4)(C)(iii) of the Act, which
provides that aggregate payments may not be affected by DRG
reclassification and recalibration changes, we do not believe it is
prudent policy to make changes for which we cannot predict the effect
on the case-mix index and, thus, payments. Our goal is to refine our
methodology so that we can fulfill, in the most appropriate manner,
both the statutory requirement to make appropriate DRG classification
changes and to recalibrate DRG relative weights (as mandated by section
1886(d)(4)(C) of the Act) as well as to make DRG changes in a budget
neutral manner.
One approach to this problem would be to maintain the average case
weight at 1.0 after recalibration, thereby eliminating the process of
normalization. In other words, after recalibration, we would not scale
the new relative weights upward to carry forward the cumulative effects
of past case-mix increases. We would, instead, make an adjustment or
include in the annual update factor a specific allowance for any real
case-mix change that occurred during the previous year. This is a
relatively simple and straightforward system for preventing the effects
of year-to-year increase in the case-mix index from accumulating in the
DRG weights. It could be done in a budget neutral fashion.
In addition to the severity changes, we also intend to improve the
classification and relative weights of the DRGs that apply to newborns,
children, and maternity patients. The Medicare population does not
include many of these individuals. The original DRG classification
system was developed from analysis of claims data representative of the
total inpatient population. When we calculated the original Medicare
weights for the DRGs to which newborn, children and maternity patients
are classified, we used non-MedPAR discharge records from Maryland and
Michigan hospitals because there were either no MedPAR cases or too few
cases assigned to these DRGs to provide a reasonably precise estimate
of the average cost of care. (See the September 1, 1983 prospective
payment final rule with comment period (48 FR 39768).) Since that time,
because of the lack of MedPAR data, these low-volume DRGs have not been
analyzed and refined, and the relative weights assigned to them may no
longer be entirely reflective of the resources needed to treat the
patients. We again intend to rely on data bases outside the MedPAR file
to supplement our data.
We received some comments on the proposed revisions to the DRGs to
incorporate a measure of severity. We do not intend to answer any of
the specific comments at this time, but rather answer all the comments
in the document that sets forth our final proposal. There were,
however, two general types of comments that we will respond to in this
document.
Comment: Several commenters requested that HCFA make more
information available to the public so that they can more easily assess
some of the changes in case-mix value that result from implementation
of the revised DRGs. One commenter noted that it appears that 10
percent of the Medicare inpatient payments are shifted from rural to
urban hospitals.
Response: The data we have made available to the public on the
severity DRG proposal are similar to the data we make available during
the annual rulemaking process addressing changes to the prospective
payment system. These include a complete MedPAR file with the current
and revised DRG designations, a revised case-mix index file, a revised
DRG Table 5, and the AOR/BOR File. We believe that these data, coupled
with the description of the changes in the paper, the list of revised
CC designations of all diagnosis codes, and the impact analysis are
sufficient to allow analysis of our proposal. Since the available
MedPAR file lists every case and its revised DRG assignment and the new
weights are listed in Table 5, we believe that those who are interested
can evaluate why the case-mix index value for specific hospitals or
groups of hospitals has changed.
Concerning the commenter's contention that there is a shift of 10
percent of Medicare payments from rural to urban hospitals, we note
that the impact analysis of the refined DRGs shows that rural hospitals
overall lose 0.6 percent of their payments, other urban hospitals lose
0.3 percent, and large urban hospitals gain 0.2 percent.
Comment: We received several comments concerning the proposal to
recalibrate the DRG weights to 1.0. Some commenters believe that this
will eliminate all real case-mix index increase as well as coding
``creep.'' Other commenters stated that HCFA should not pursue this
policy as there currently is no way to measure satisfactorily real
case-mix index change.
Response: We did not include a proposal to recalibrate the DRG
weights to 1.0 in the proposed rule. We presented it as one solution to
our current problem of being unable to make DRG reclassification
changes in a budget neutral fashion. We agree with commenters that it
is important to develop a mechanism to accurately distinguish real
case-mix increase from that attributable merely to changes in coding.
As noted above, we would make an additional adjustment to include real
case-mix change in Medicare payments. We intend to continue to analyze
possible solutions to this problem.
9. Other Issues
a. Lung Transplants.
Comment: We received comments urging that we create a new DRG
solely for lung transplants. The commenters state that, even though
HCFA has not made a national coverage determination for these
procedures, Part A fiscal intermediaries are approving some lung
transplant cases for coverage. Because there is no specific lung
transplant DRG, these cases are classified to DRG 75 (Major Chest
Procedures), which the commenters argue results in a DRG payment that
is woefully inadequate to cover the costs of the procedure. In
addition, one of the commenters understands that HCFA is in the process
of approving a national coverage determination for lung transplants
that will be effective in the very near future. Therefore, the
commenter believes that HCFA should not delay in having a DRG in place
for the procedure. This commenter also recommends that heart/lung
transplants be assigned to the new DRG.
Response: Because we are considering making a Medicare national
coverage determination on lung transplants in the near future, we are
establishing a new DRG for lung transplants as a part of this final
rule. As noted by the commenters, these cases currently are assigned to
DRG 75 in MDC 4 (Diseases and Disorders of the Respiratory System).
Cases will be assigned to the new DRG 495, Lung Transplant, based
on the presence of the procedure code for lung transplants (33.5) and
will not first be assigned to an MDC based on the principal diagnosis.
This is the same procedure we follow for liver and bone marrow
transplants.
As is our current policy for organ acquisition costs for kidney,
heart, and liver transplant cases paid under Medicare, lung acquisition
costs will be paid on a reasonable cost basis and are not included in
the prospective payment amount. We are revising Secs. 412.2(d)(4) and
412.113(d), which describe payment for organ acquisition costs as a
reasonable cost payment, to include lung acquisition costs.
The relative weight assigned to DRG 495 is based on the lung
transplant cases in the FY 1993 MedPAR file. When the weight of DRG 495
was initially calculated, the weight was less than the weight of DRG
483, Tracheostomy Except for Face, Mouth and Neck Diagnoses. Since
several lung transplant cases also received tracheostomies, we removed
these cases from DRG 495 and classified them to DRG 483 to receive the
higher payment assigned to that DRG. We note that each of these cases
had an average standardized charge that was much higher than the
average for all lung transplants. Thus, the final DRG 495 weight of
12.8346 is based on 105 cases of lung transplants in which no
tracheostomy was performed in the FY 1993 MedPAR file. This weight
places DRG 495 after DRGs 480, 483, and 481 (Bone Marrow Transplant) in
the pre-MDC surgical hierarchy. For a detailed discussion of surgical
hierarchy, see section II.B. 4 of this preamble.
Regarding the commenter's request that we include heart/lung
transplants with lung transplants in the new DRG, we note that heart/
lung transplants remain covered on a case-by-case basis as determined
by the fiscal intermediaries. Therefore, we do not believe we should
move them from their current classification in DRG 103, Heart
Transplant. We note that, for FY 1995, the relative weight for DRG 103
(13.5495) is actually higher than the weight for DRG 495.
b. Cochlear Implants (DRG 49).
Comment: We received two comments regarding cochlear implants. Both
commenters expressed concern that the cost incurred by cases receiving
the implant device far exceeds the Medicare payment these cases receive
under DRG 49 (Major Head and Neck Procedures) to which they are
assigned. According to these commenters, the cost of the device itself
represents more than the total DRG payment and, thus, is not subject to
traditional hospital cost control techniques. One commenter noted that
the economic facts regarding the costs of this implant procedure
require a more expeditious and effective adjustment than has been
granted in the past. This commenter suggests that the payment weight
assigned to cochlear implants should be appropriately adjusted, either
by assignment to a different DRG or by creation of a new DRG
specifically for cochlear implants. The other commenter requests that
cochlear implant procedures be assigned to DRG 1 (Craniotomy Age > 17
Except for Trauma) in MDC 1 (Diseases and Disorders of the Nervous
System).
Both commenters noted that, although we agreed in the September 1,
1993 final rule (58 FR 46273) to continue monitoring cochlear implant
cases, we did not discuss them in the proposed rule. One of the
commenters requested that we review the FY 1994 data for DRG 49, as
this would be the first data to reflect the change in DRG 49 weight as
a result of moving a lower cost procedure to another DRG.
In addition to the issue of inadequate payment, one commenter
observes that the number of Medicare cochlear implant cases continue to
decline. The commenter attributes this decrease to hospitals
determining that the financial loss suffered in providing the cochlear
implant to the Medicare population precludes a viable ongoing cochlear
implant program. This commenter is concerned that cochlear implants may
not exist for the Medicare population in the future.
The commenter also observes that the number of extraordinarily low
charges submitted by hospitals for the cochlear implant procedure has
decreased substantially and may be an indication that our instructions
to intermediaries on proper coding for this implant is having an
effect.
Response: Cochlear implants were first covered by Medicare in 1986
and were assigned to DRG 49 (Major Head & Neck Procedures), the highest
weighted surgical DRG in major diagnostic category (MDC) 3 (Diseases
and Disorders of the Ear, Nose, Mouth and Throat). Since that time, the
cochlear industry has contended that the weight of DRG 49 is too low
and does not adequately reflect the resources necessary for the
cochlear implant procedure. In response to these concerns, we have
analyzed Medicare data every year since 1986.
Effective October 1, 1993, in an effort to improve the homogeneity
of resource use in cases within DRG 49, we moved the lowest charge
procedure, partial glossectomy, from DRG 49 to DRGs 168 and 169 (Mouth
Procedures). This resulted in a slight increase in the average charge
for DRG 49. We have evaluated the remaining procedures in DRG 49 to
determine if further reclassification is appropriate. However, there
are no other low charge procedures remaining in DRG 49 that occur in
sufficient volume to justify further DRG shifts. We note that FY 1994
does not end until September 30, 1994, so we will not be able to
evaluate thoroughly the impact of the modification to DRG 49 until
after that date.
We note also that although we do not always publish the results of
our analysis in the Federal Register, this does not mean we have failed
to honor our commitment to continue monitoring the cochlear implant
procedures. On the contrary, we have reviewed and analyzed these data
annually. We did not include our results in the May 1994 proposed rule
because they did not vary from previous findings and we had nothing new
to add to our prior discussions. However, we will present them now.
Using FY 1993 Medicare claims data, we identified a total of 81
cochlear implant cases. These cases represent 3.5 percent of all cases
in DRG 49, and incurred an average charge of $22,386 compared to an
average charge of $15,679 for all cases in DRG 49. While there is a
higher charge for the 81 cochlear cases than for the other cases in DRG
49, we note that the cases are distributed across 54 hospitals, with no
more than 7 cases at any one hospital. The majority of hospitals (70
percent) treated only one case (38 of 54 hospitals).
We have repeatedly addressed the recommendation that we assign
cochlear implants to DRG 1, most recently in the September 1993 final
rule (58 FR 46274). Our objection to this suggestion is that the
diagnosis associated with cochlear cases (diagnosis code 389 (Hearing
loss)) is not clinically coherent with the diagnosis codes assigned to
MDC 1. A basic premise of DRG classification is the assignment of
clinically similar discharges within categories based on a common body
system or organ system. To reassign cochlear implant cases to MDC 1, we
would have to move the principal diagnosis code 389 from MDC 3, which
would move all cases with this diagnosis to a clinically inappropriate
MDC.
We acknowledge that the Medicare payment for cochlear implant
patients has been an issue for several years. However, we find no
justification for creating a special DRG for cochlear implants. We have
consistently classified clinically similar patients in DRGs who use
approximately the same amount of hospital resources. In addition, we
prefer to maintain DRGs with enough cases to ensure a normal
distribution and relative stability over time. We continue to believe
that the low volume of these cases does not justify the establishment
of a new DRG specific to cochlear implants. Nor do we generally create
DRGs that are specific to a single technology, especially those
available through a single source manufacturer.
Although some new technologies may engender a certain amount of
fixed costs, and thus, do not lend themselves readily to cost control
techniques, there are other occasions within the hospital's performance
that are responsive to cost containment. Thus, the incentive is for the
hospital to treat a mix of patients and to manage its operations in
such a way to offset losses on cases where payment is less than cost
with gains on cases where the payment is in excess of cost.
In response to the commenter's concern that cochlear implants may
not be available to Medicare beneficiaries in the future, we note that
a hospital may not refuse to provide a covered service to a Medicare
beneficiary if it provides that service to other patients.
Specifically, the Medicare regulations at 42 CFR 489.53(a)(2) provide
that HCFA may terminate a hospital's Medicare provider agreement if it
finds that the hospital places restrictions on the persons it accepts
for treatment and fails to apply them to Medicare beneficiaries the
same as to all other persons seeking care.
c. Epilepsy (DRGs 24, 25, and 26).
Comment: We received several comments addressing the classification
in DRGs 24, 25, and 26 (Seizure and Headache) of patients with
intractable epilepsy, particularly those admitted for neurodiagnostic
monitoring. The commenters believe that it is critical that a revision
be made to these DRGs for the intractable epilepsy patients to account
for the greater resource use and length of stay compared to all other
patients admitted under the same DRGs. The commenters state that the
financial risk is greatest to the small number of specialized epilepsy
centers that treat the majority of these complex patients.
The commenters refer to an analysis conducted by HCFA that reviewed
the FY 1993 average charges for all cases with a diagnosis of
intractable epilepsy where video/radio-telemetered monitoring
(procedure code 89.19) was performed. The commenters believe that the
results of the HCFA study support the need for a change in the DRG
classification system for certain cases, to be implemented in FY 1995,
using the following criteria:
A diagnosis of intractable epilepsy (diagnosis codes
345.0-345.9 with a 5th digit of 1).
The performance of video/radio-telemetered monitoring
(procedure code 89.19).
Patient age under 60.
Finally, one commenter believes that we need to address the
appropriate diagnosis code to use for patients who receive
neurodiagnostic monitoring whose seizures are not epileptic. These
patients are currently coded under 780.3 (Convulsions). The commenter
would prefer to include these patients under the unspecified
intractable epilepsy code of 345.91 so that they can be included in any
new DRG we create.
Response: The epilepsy treatment community has for some time
expressed concern that the resources used to treat the intractable
epilepsy patients far exceeded those needed for other patients in the
same DRGs, and that Medicare payment is inadequate to meet these costs.
We have previously addressed the issue of Medicare payment for
intractable epilepsy cases, most recently in the September 1, 1993
final rule (58 FR 46287). As a result of our previous analyses, we have
concluded that although intractable epilepsy patients incur higher
average charges than other patients in the same DRGs, there is not a
sufficient differential nor a sufficient volume to warrant a DRG
change.
In order to respond to the comments, we updated our most recent
study and evaluated the June 1994 update of the FY 1993 MedPAR file. We
identified 2,284 intractable epilepsy cases with an average charge of
$8,820 compared to an average charge of $7,602 for all patients in the
same DRGs. Nonintractable epilepsy cases incurred an average charge of
$7,423, for 13,412 cases. The incidence of inpatient admissions for all
cases of epilepsy has decreased by nearly 30 percent, with intractable
inpatient admissions down 19 percent from the FY 1992 data (2,817 to
2,284 cases). The following table summarizes our most recent epilepsy
analysis findings, comparing the average charges between epilepsy and
other cases assigned to the same DRG (the number of cases is included
in parentheses):
------------------------------------------------------------------------
Intractable Nonintractable All
DRG epilepsy epilepsy epilepsy All cases
------------------------------------------------------------------------
24................... $10,605
(1,152) $8,525
(9,595) $8,748
(10,747) $8,630
(57,041)
25................... $7,003
(1,132) $4,654
(3,811) $5,192
(4,943) $4,738
(20,456)
26................... 0 $4,003
(6) $4,003
(6) $5,912
(43)
All Cases............ $8,820
(2,284) $7,423
(13,412) $7,626
(15,696) $7,602
(77,540)
------------------------------------------------------------------------
Focusing our analysis on intractable epilepsy patients with and
without video-telemetered monitoring (procedure code 89.19) confirms
our earlier findings; that is, intractable epilepsy patients who
receive the neurodiagnostic monitoring do in fact incur charges greater
than those of other intractable epilepsy cases and of all other
patients in the same DRGs. Although, in the past, there has been a
problem with the underreporting of procedure code 89.19 and an
inability to identify the extent of use of this procedure, we note that
there has been a substantial increase in reporting in the FY 1993 data.
The number of cases now appears to more accurately match the volume
predicted in the past by the epilepsy treatment centers. The results of
this analysis are summarized in the following table:
------------------------------------------------------------------------
Intractable Nonintractable
DRG epilepsy epilepsy
------------------------------------------------------------------------
24 with 89.19.............................. $13,493
(104) $9,711
(28)
24 w/o 89.19............................... $10,318
(1,048) $8,521
(9,567)
25 with 89.19.............................. $10,178
(359) $9,544
(77)
25 w/o 89.19............................... $5,529
(773) $4,553
(3,734)
26 with 89.19.............................. 0 0
26 w/o 89.19............................... 0 $4,003
(6)
------------------------------------------------------------------------
The commenters recommend that, in revising the DRGs, we target the
under age 60 patients who are hospitalized with intractable epilepsy
and receive a neurodiagnostic work-up with video-telemetered
monitoring. We used age 65 rather than age 60 in our analysis because
that is a natural age break in the Medicare patient population. That
is, patients under age 65 who receive Medicare benefits qualify on the
basis of disability rather than on the basis of age. We do not believe
the difference in age break is significant.
Our analysis identified 335 cases of intractable epilepsy with
video-telemetered monitoring in DRG 25 that were under age 65. (We
concentrated on DRG 25 as suggested by the commenters because patients
admitted for neurodiagnostic monitoring must be relatively healthy and,
thus, do not usually have any complicating conditions.) The average
charge for all intractable epilepsy patients in DRG 25 with procedure
89.19 was $10,178. When age less than 65 was taken into account, the
average charge was $10,368, compared to an average of $7,527 for the 24
patients age 65 and over. The following table summarizes the DRG 25
average charges for intractable epilepsy patients under age 65 compared
to other patients:
------------------------------------------------------------------------
DRG 25 Age <65 Age >65 All Ages
------------------------------------------------------------------------
All Cases........................... $4,740
($7,422) $4,737
(13,034) $4,738
(20,456)
Intractable Epilepsy Cases.......... $7,323
(952) $5,313
(180) $7,003
(1,132)
Intractable Epilepsy Cases with
89.19.............................. $10,368
(335) $7,527
(24) $10,178
(359)
Intractable Epilepsy Cases w/o 89.19 $5,670
(617) $4,973
(156) $5,529
(773)
Nonintractable Epilepsy Cases with
89.19.............................. $10,078
(58) $7,913
(19) $9,544
(77)
Nonintractable Epilepsy Cases w/o
89.19.............................. $4,180
(1,520) $4,808
(2,214) $4,553
(3,734)
------------------------------------------------------------------------
While we concur with the commenters that the average charges for
intractable epilepsy receiving video-telemetered monitoring are indeed
greater than those who do not, our findings indicate that this is more
a function of the procedure than age of the patient. The highest
charges of any group are those intractable epilepsy cases with
procedure 89.19 in DRG 24 ($13,493 for 104 cases). The average charge
for all intractable epilepsy cases with procedure code 89.19 is
$10,922, while those under 65 in DRG 24 have average charges of $13,452
and those under 65 in DRG 25 average $10,368. Thus, based on the FY
1993 data, the majority of the intractable epilepsy cases under age 65
who receive video-telemetered monitoring classify to DRG 25 (79
percent; 335 cases of 423). However, the highest average charges for
this age group and procedure are found in DRG 24. In addition, the
nonintractable epilepsy patients under age 65 who receive procedure
code 89.19 in DRG 25 averaged charges of $10,078, only slightly lower
than the average charge for the intractable epilepsy cases in the same
DRG and age category.
At the request of one commenter, we reviewed the number of cases
with diagnosis code 780.3 (Convulsions) and found this diagnosis
accounted for 61 percent of the total cases in DRGs 24 through 26
(47,340 of 77,540 cases). Intractable epilepsy was reported as a
secondary diagnosis in only 10 of these cases, with an average charge
of $3,502; nonintractable epilepsy was a secondary diagnosis in 81
instances, with an average charge of $6,351. We note that, in response
to the commenter's suggestion that these cases would be more
appropriately coded to diagnosis 345.91, the coding notes for 345.91
specifically excludes conditions coded to 780.3. We agree with the
commenter this change in coding be pursued through the ICD-9-CM
Coordination and Maintenance Committee.
As a result of our analysis, we note that, as a group, the
intractable epilepsy cases are not the most resource-intensive set of
cases assigned to DRGs 24 through 26. The highest volume of epilepsy
cases are coded 345.3 (Epilepsy, Grand Mal status), with 5,708 cases
reported in the FY 1993 MedPAR and an average charge of $12,324. Of the
epilepsy diagnoses, the average charge for grand mal epilepsy is
exceeded only by intractable epilepsy partialis continua (diagnosis
code 345.71) with an average charge of $13,346 but only 47 cases.
In response to the commenter's contention that epilepsy centers are
at financial risk, we also evaluated the distribution of epilepsy cases
across hospitals. We found 830 hospitals admitted patients with
intractable epilepsy; 3,141 hospitals treated patients with
nonintractable epilepsy. Of those hospitals treating intractable
epilepsy cases, only 5 percent of these hospitals (44) treated 10 or
more cases, while 2.3 percent treated 20 or more cases. The vast
majority (86 percent) treated 3 or fewer cases (711 of 830 hospitals).
As in our prior analyses, we found that among the high volume
hospitals, charges for these cases were normally distributed, with
approximately 50 percent above the average charge and 50 percent below
the average.
Of the 30 recognized epilepsy treatment centers, only 23 reported
any intractable epilepsy discharges in FY 1993. The remaining epilepsy
centers are either children's hospitals and are excluded from the
prospective payment system or did not treat intractable epilepsy
patients in FY 1993. Approximately 70 percent (16 of 23 centers)
treated 10 or more cases; less than 2 percent treated fewer than 4
intractable epilepsy cases. However, of the total 2,284 intractable
epilepsy cases, less than 18 percent (405 cases) were admitted to
epilepsy treatment centers. The average charge per intractable epilepsy
case treated at an epilepsy treatment center was $9,546, only slightly
higher than the $8,820 average charge at all hospitals.
Although the distribution of intractable epilepsy patients across
hospitals tends to minimize the impact of higher charges on any one
hospital, we acknowledge that, even though the volume of hospitals is
small, many hospitals treating high numbers of intractable epilepsy
patients may incur charges above the average. This is particularly true
for the specialized treatment centers. However, we note that these
hospitals are for the most part large urban or teaching hospitals or
both and, as such, receive some of the highest Medicare payment rates.
We are not recommending any DRG modification for epilepsy cases at
this time. Although the intractable epilepsy cases, especially those
using procedure 89.19, result in higher charges than other cases in the
same DRGs, the difference is neither clearly defined by age category or
DRG nor of sufficient volume to justify a separate DRG for these
patients. Therefore, we do not accept the commenters' recommendation
that we create a DRG for intractable epilepsy patients, under age 60,
using video-telemetered monitoring.
Comment: Another commenter expressed concern that the current
Medicare payment policy may be having an adverse effect on patient
access for those intractable epilepsy cases requiring neurodiagnostic
monitoring.
Response: As noted above, in our response to cochlear implant
comments, hospitals may not refuse to offer a covered service to
Medicare patients if they provide this same service to other patients.
d. Heart Assist Devices.
Comment: We received several comments concerning the DRG assignment
of and payment for the implantation of ventricular assist devices. The
commenters believe that the current assignment of this procedure
(procedure code 37.62) to DRGs 110 and 111 (Major Cardiovascular
Procedures) was made based on outdated data and does not reflect
current practice.
The commenters note that only one heart assist device, the BVS 5000
biventricular support system, has received approval from the Food and
Drug Administration (FDA) and is covered by Medicare when used in
patients suffering from postcardiotomy ventricular dysfunction. (See
section 65-15 of the Medicare Coverage Issues Manual (HCFA Pub. 6).)
One of the commenters, the manufacturer of the BVS 5000, submitted the
results of a study it commissioned to analyze the current Medicare
payments for that device.
The study analyzed the hospital bills for 36 cases of implantation
of the heart assist device that were performed at 13 hospitals. Using
the information on the hospital bills, total hospital charges were
calculated for each of the 36 cases and then standardized using
Medicare formulas and adjustment factors. (The 36 cases are a sample of
all patients receiving the BVS 5000 and are not restricted to Medicare
beneficiaries.) The results of the study indicated that the average
standardized charge for the 36 cases was consistently much higher than
the average standardized charge for each of the nine DRGs to which
these cases would have been assigned. Overall, the average standardized
charge for the 36 cases was $155,396, compared to an estimated average
DRG payment of $30,488, exclusive of capital and outlier payments.
Using the average standardized charge of $155,396, the study
imputes a DRG weight of 19.3803 for these cases. Even if the cases that
would group to DRG 103 (Heart Transplant) and DRG 483 (Tracheostomy
Except for Face, Mouth, and Neck Diagnoses) are excluded, the average
standardized charge is still $114,299, implying a weight of 14.2548.
Based on this result, the study recommends that the BVS 5000 cases be
reassigned from DRGs 110 and 111 to DRG 103, which, with an FY 1994
weight of 14.0215, is the most appropriate DRG assignment in MDC 5
(Diseases and Disorders of the Circulatory System). In addition, from a
clinical perspective, both patients assigned to DRG 103 and those who
receive a BVS 5000 are seriously ill, have cardiac dysfunction that
cannot continue to sustain life, and require lengthy and intensive
hospital care.
Finally, one commenter expressed concern that the volume of cases
in the FY 1993 MedPAR file with procedure code 37.62 (406 cases)
indicates that many of the Medicare patients are receiving nonapproved
heart assist devices that should be excluded from Medicare payment. The
commenter suggested that hospitals should be directed to use code 37.62
only for procedures involving FDA-approved and Medicare-covered
devices.
Response: Our analysis of the FY 1993 MedPAR file identified 406
cases with a procedure code of 37.62. Approximately 10 percent of these
cases (38 cases) were assigned to DRGs outside of MDC 5, with the
highest volume (25 cases) classified to DRG 483. Of the remaining 368
cases, 266 were assigned to DRGs other than DRGs 110 and 111.
Therefore, there were only 102 cases (approximately 25 percent of the
total) that were assigned to a DRG based on the presence of a heart
assist device (96 cases to DRG 110 and 6 cases to DRG 111). In DRG 110,
the average standardized charge for cases with procedure code 37.62 was
$39,038 and the average for all cases in that DRG was $32,939. For the
6 cases assigned to DRG 111, the average standardized charge was
$57,375 compared to $18,259 for all cases in that DRG.
Based on the results of our analysis, we do not believe that the
cases of implantation of a heart assist system assigned to DRG 110 are
vastly underpaid. In fact, the average charge for those cases is only
$6,000 higher than the other cases in the DRG and is well within the
normal range of charges for DRG 110. In addition, although the average
charge for the 6 cases assigned to DRG 111 is much higher than the
overall average (almost $40,000 more), the exclusion of one extremely
expensive case (standardized charge of $258,172) results in an average
charge of $17,218 for the remaining 5 cases, which is below the DRG 111
average charge. We note that the expensive case would have received a
large outlier payment in addition to its operating and capital DRG
payments.
Unlike the manufacturer's study, which identified specific cases
using the FDA-approved device, we are not able to distinguish the
approved device from other devices which are still investigational.
Based on the volume of cases in the FY 1993 data, we are certain that
several different devices are being captured by the 37.62 code for
heart assist implants. We note that the cases in this file were all
discharged prior to the date the BVS 5000 was approved for coverage
(October 1, 1993). Therefore, with the exception of those limited cases
in which contractor discretion has been exercised, there are no covered
devices in the FY 1993 MedPAR file, including the BVS 5000 cases. The
manufacturer of the BVS 5000 declined to honor our request for a list
of the hospitals that purchase and implant its device. A list of
identified hospitals could help us to narrow our analysis to cases that
are likely to be covered under Medicare.
Because of our inability to identify specifically the FDA-approved
device, we cannot determine the DRG distribution nor the charges
attributable to the implant of the BVS 5000. Nor is it possible to
identify those cases where the heart assist device is used as a bridge
to heart transplant, for which it is not covered under Medicare policy.
Therefore, at this time, we do not believe that we have enough
information to recommend any change in DRG classification for this
device. Based on the data available, it does not appear that DRGs 110
and 111 are inappropriate designations for procedure code 37.62.
We cannot advise hospitals that they may use procedure code 37.62
only for those devices that are approved and covered under Medicare.
The ICD-9-CM procedure codes are not the exclusive domain of Medicare
payment policy. These codes are used by many other organizations and
agencies for various health-related purposes. We suggest that the
commenters contact Patricia E. Brooks, co-chairperson of the ICD-9-CM
Coordination and Maintenance Committee, concerning the feasibility of
creating a procedure code specific to implant of the FDA-approved
biventricular support system. Ms. Brooks' address is set forth in
section II.B.7 of this preamble.
e. Automatic implantable cardioverter defibrillator (AICD)
procedures (DRG 116). For several years, we have received
correspondence concerning the appropriate DRG assignment of certain
procedures involving automatic implantable cardioverter defibrillators
(AICDs). When a patient whose principal diagnosis is classified to MDC
5 (Diseases and Disorders of the Circulatory System) receives a total
AICD system implant or replacement (procedure code 37.94), the case is
assigned to DRG 104 or 105 (Cardiac Catheterization). However, prior to
October 1, 1992, if a procedure was performed that involved the
implantation or replacement of only part of the AICD system (that is,
replacement or implant of either the leads or pulse generator only),
the case was assigned to DRG 120 (Other Circulatory System OR
Procedures). Effective with discharges occurring on or after October 1,
1992, these procedures were assigned to DRG 116 (Other Permanent
Cardiac Pacemaker Implant or AICD Lead or Generator Procedure).
Although we proposed no further changes to this DRG assignment for FY
1995, we received several comments.
Comment: Commenters requested that we change the DRG assignment for
procedures in which replacement or implantation of only part of the
AICD system (either the leads or pulse generator) is performed from DRG
116 to DRG 115 (Permanent Cardiac Pacemaker Implantation with AMI,
Heart Failure or Shock). The relevant procedure codes are the
following: 37.95 (Implantation of automatic cardioverter/defibrillator
lead(s) only), 37.96 (Implantation of automatic cardioverter/
defibrillator pulse generator only), 37.97 (Replacement of automatic
cardioverter/defibrillator lead(s) only), 37.98 (Replacement of
automatic cardioverter/defibrillator pulse generator only).
The commenters expressed concern that, even with the revised
classification to DRG 116, hospitals are not adequately compensated for
these procedures. Based on the results of an August 1992 study
commissioned by the only AICD manufacturer at that time, the commenters
estimate that these procedures should be assigned to a DRG with a
relative weight of 3.7300. (The FY 1995 relative weights for DRGs 115
and 116 are 3.5936 and 2.4514, respectively.) Therefore, the commenters
assert that assignment of AICD cases to DRG 115 would be more
equitable.
Response: As explained in detail in the September 1, 1992 final
rule (57 FR 39749), the current clinical composition and relative
weights of the surgical DRGs in MDC 5 do not offer a perfect match with
the AICD cases. After reviewing the current DRGs in terms of clinical
coherence and similar resource use, we determined that DRG 116 was the
best fit possible.
Since reassignment of these procedures to DRG 116, we have annually
reanalyzed the cases based on the most recent data. Based on data in
the 1993 MedPAR file, the average standardized charge for AICD cases
was $27,999 for the 1,933 cases assigned to DRG 116. The average
standardized charge for all cases in DRG 116 was $19,456 and, for DRG
115, $29,001. Although the $8,543 difference between the average charge
for AICD cases in DRG 116 and all cases in DRG 116 is within the normal
range of charges for that DRG, the difference in charges has grown over
the last 2 years.
The average length of stay for these AICD cases is 4.6 days
compared to 4.6 for all cases in DRG 116. However, the length of stay
for cases in DRG 115 is 12.8 days. In general, the patients classified
to DRG 115 are seriously ill and the long length of stay supports this
contention. We believe that even though the average charge for an AICD
case is closer to the average charge in DRG 115 than that of DRG 116,
clinically, the AICD patients are much more similar to the patients
classified to DRG 116 than those in DRG 115. Thus, it is the cost of
the AICD device that is responsible for the high average charge for
these cases and not the intensity of hospital services required to
treat the patient.
Although originally there was only one AICD device on the market,
others have become approved and are now available for hospitals. We
believe that with these new devices, increased competition may result
in a decrease in the price and a corresponding drop in the average
charge for a hospital stay for AICD procedures. In any case, as with
the cochlear implants discussed above in this section of the preamble,
we are reluctant to provide higher DRG weights for categories of cases
that are made costly due to the cost of a device. We do, however,
acknowledge that this problem with new technologies is increasing and
we are interested in finding a cost-effective solution to the problem.
In the meantime, we believe continued assignment of AICD implant cases
to DRG 116 is appropriate. We will continue reviewing this issue during
FY 1995.
f. DRG Assignment Issues. Among the comments received on the
proposed rule were three inquiries regarding DRG case assignments.
These comments, although unrelated to any changes in the proposed rule,
are representative of the types of questions that we receive throughout
the year concerning DRG assignment. We are responding to these comments
in this final rule in the interest of public information and
clarification of the DRG classification system.
Comment: One commenter requests an explanation of why a patient
with a principal diagnosis of osteomyelitis (diagnosis code 730.xx) who
has a toe amputation (procedure code 84.11) is assigned to DRG 225
(Foot Procedures) with a proposed FY 1995 weight of 0.9056 when a
patient with the same principal diagnosis who has no surgical
intervention is assigned to higher-weighted DRG 238 (Osteomyelitis),
with a proposed weight of 1.4971. The commenter suggests that a more
appropriate assignment for the toe amputation would be DRGs 233 and 234
(Other Musculoskeletal System and Connective Tissue OR Procedures) with
proposed weights of 1.9004 and .9497, respectively.
Response: The classification of a case to a DRG begins with
assignment to an MDC based on principal diagnosis. A patient with
osteomyelitis is assigned to MDC 8 (Diseases and Disorders of the
Musculoskeletal System and Connective Tissue). The next step is to
group the case into the appropriate DRG within that MDC. If an
operating room procedure is performed, the case will group to one of
the surgical DRGs in MDC 8. A case with the same principal diagnosis
code and no surgical procedure will group to a medical DRG.
The DRG relative weights assigned to a particular DRG are based on
the average amount of resources used in treating the patients in that
DRG, as measured by total charges, relative to the average resources
used to treat all patients. The commenter assumes that a case in which
surgery is performed has higher resource use and, therefore, should
have a weight that is higher than a case in which no surgery is
performed. This assumption is unfounded since many other aspects,
including length of stay and severity of illness, also account for
resource use. In fact, cases in DRG 225 have a much shorter average
length of stay (5.2 days) than cases in DRG 238 (12.8 days). One reason
we have found for lower relative weights in some surgical DRGs as
compared to medical DRGs in the same MDC is the fact that often the
patients in the surgical DRG have received a clear diagnosis and begin
treatment soon after they are admitted to the hospital. On the other
hand, some medical cases involve lengthy medical diagnostic workup and
testing to discover both the reason for the hospital stay and the
treatment that should be given.
The cases that group to DRG 225 receive one of several well-
defined, relatively low-resource use procedures and are discharged
within a few days. However, the cases that group to DRG 238 encompass a
large range of principal diagnoses, many of which can take several days
to diagnose and treat.
Comment: The same commenter is also concerned about a case in which
a patient is admitted with chest pain, has a cardiac catheterization,
and is ultimately diagnosed with a noncardiac diagnosis such as
gastritis. In this scenario, the case is assigned to a DRG consistent
with the principal diagnosis of gastritis, and the cardiac
catheterization does not affect the DRG assignment. The commenter,
therefore, believes that the hospital is not being adequately
compensated for the resources expended. If the same patient had been
determined to have a cardiac condition, the catheterization would have
counted in DRG assignment.
Response: As discussed above, the classification of a case to a DRG
begins with assignment to an MDC based on the principal diagnosis. In
order to maintain the integrity of the system, cases must be assigned
to DRGs to which they are most clinically related. Cardiac
catheterization is a non-OR procedure that is considered for DRG
assignment within MDC 5, but is treated as any other non-OR procedure
in all the other MDCs. This policy recognizes the fact that
catheterization is an important determinant in the resources used in
the cardiac cases in MDC 5. However, it is not generally associated
with treatment or diagnosis in other MDCs.
Under the prospective payment system, Medicare does not pay for the
costs of individual cases. Because it is a system based on an averaging
process, some cases in a particular DRG will incur costs in excess of
payment while others will receive payment in excess of costs. Thus,
although a patient with a principal diagnosis of gastritis who receives
a cardiac catheterization may consume more resources than the average
patient with that diagnosis, there will no doubt be patients with the
same principal diagnosis and DRG assignment who consume fewer than
average resources.
Comment: Another commenter questions the assignment of a patient
with pulmonary edema and heart disease (principal diagnosis code 428.0
(Congestive heart failure)) who requires mechanical ventilation to DRG
127 (Heart Failure and Shock) with a final FY 1995 relative weight of
1.0239. However, a patient with acute pulmonary edema and no heart
condition (principal diagnosis code of 518.4 (Acute edema of lung,
unspecified)) who requires mechanical ventilation is assigned to DRG
475 (Respiratory System Diagnosis with Ventilator Support) with a FY
1995 relative weight of 3.7005. Again, the commenter cannot understand
the different payment amount for the same type of case.
Response: Although these cases exhibit the same symptom (pulmonary
edema), the principal diagnoses are assigned to two different MDCs.
Under our current system, mechanical ventilation is a determining
factor in the assignment of cases in MDC 4. Therefore, the case that
groups to that MDC is classified to a DRG based on the mechanical
ventilation. In all other MDCs, the use of mechanical ventilation is
not considered in the assignment of the case. In the September 1, 1993
final rule, we discussed our intention to analyze cases with mechanical
ventilation in all MDCs and to consider the appropriate placement of
these cases as a part of our larger DRG refinement work (58 FR 46285.)
As we have discussed above in section II.B.8 of this preamble, that
refinement will not be implemented before FY 1996.
C. Recalibration of DRG Weights
We proposed to use the same basic methodology for the FY 1995
recalibration as we did for FY 1994. (See the September 1, 1993 final
rule (58 FR 46290).) That is, we proposed to recalibrate the weights
based on charge data for Medicare discharges. However, we proposed to
use the most current charge information available, the FY 1993 MedPAR
file, rather than the FY 1992 MedPAR file. The MedPAR file is based on
fully-coded diagnostic and surgical procedure data for all Medicare
inpatient hospital bills.
The proposed recalibrated DRG relative weights were constructed
from FY 1993 MedPAR data, received by HCFA through December 1993, from
all hospitals subject to the prospective payment system and short-term
acute care hospitals in waiver States. The FY 1993 MedPAR file at that
time included data for approximately 10.5 million Medicare discharges.
The MedPAR file updated through June 1994 includes data from
approximately 10.7 million discharges and is the file used to calculate
the weights set forth in Table V of the addendum to this final rule.
The methodology used to calculate the DRG relative weights from the
FY 1993 MedPAR file is as follows:
To the extent possible, all the claims were regrouped
using the revised DRG classification revisions discussed above in
section II.B of this preamble. As noted in section II.B.4, due to the
unavailability of revised GROUPER software, we simulate most major
classification changes to approximate the placement of cases under the
proposed reclassification. However, there are some changes that cannot
be modeled.
Charges were standardized to remove the effects of
differences in area wage levels, indirect medical education costs,
disproportionate share payments, and, for hospitals in Alaska and
Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by
summing the standardized charges for all cases in the DRG and dividing
that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers using the same
criterion as was used in computing the current weights. That is, all
cases outside of 3.0 standard deviations from the mean of the log
distribution of charges per case for each DRG were eliminated.
The average charge for each DRG was then recomputed
(excluding the statistical outliers) and divided by the national
average standardized charge per case to determine the relative weight.
We established the relative weight for heart transplants
(DRG 103) and liver transplants (DRG 480) in a manner consistent with
the methodology for all other DRGs except that the transplant cases
that were used to establish the weights were limited to those Medicare-
approved heart and liver transplant centers, respectively, that have
cases in the FY 1993 MedPAR file. Similarly, we limited the lung
transplant cases that were used to establish the weight for DRG 495
(Lung Transplant) to those hospitals that are established lung
transplant centers.
Acquisition costs for kidney, heart, liver, and lung
transplants are paid on a reasonable cost basis. Unlike other excluded
costs, the acquisition costs are concentrated in specific DRGs (DRG 302
(Kidney Transplant); DRG 103 (Heart Transplant); DRG 480 (Liver
Transplant); and DRG 495 (Lung Transplant)). Because these costs are
paid separately from the prospective payment rate, it is necessary to
make an adjustment to prevent the relative weights for these DRGs from
including the effect of the acquisition costs. Therefore, we subtracted
the acquisition charges from the total charges on each transplant bill
that showed acquisition charges before computing the average charge for
the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. We proposed to use that same case
threshold in recalibrating the DRG weights for FY 1995. Using the final
FY 1993 MedPAR data set, there are 35 DRGs that contain fewer than 10
cases. We computed the weight for the 35 low-volume DRGs by adjusting
the original weights of these DRGs by the percentage change in the
average weight of the cases in the remaining DRGs.
The weights developed according to the methodology described above,
using the DRG classification changes, result in an average case weight
that is different from the average case weight before recalibration.
Therefore, the new weights are normalized by an adjustment factor, so
that the average case weight after recalibration is equal to the
average case weight before recalibration. This adjustment is intended
to ensure that recalibration by itself neither increases nor decreases
total payments under the prospective payment system.
Although we received no comments on the recalibration of the DRG
weights, we did receive two comments that relate to that process.
Comment: Two commenters were concerned that the proposed FY 1995
DRG weights for certain transplant cases were lower than the weights
that were in effect for FY 1994. The DRGs in question are those for
liver transplants (DRG 480) and heart transplants (DRG 103). The
commenters believe that these cases are getting more costly, not less,
as the lower weights would lead one to believe. The commenters suggest
that we further investigate the data on these cases.
Response: Every year when the relative weights are recalibrated, we
use charge information from the most recent Medicare data available.
That is, we use the charges reported by hospitals for the cases paid
under each DRG. Therefore, any change in the relative weight of a DRG
is directly related to the average charge of the cases classified to
that DRG compared to the average charge of all the cases.
The average charges used to calculate the weight for DRG 103
actually increased between the FY 1992 data used to calculate the FY
1994 weights and the FY 1993 data used to calculate the FY 1995
weights; however, the average charge for DRG 480 decreased. The average
charge for DRG 103 increased from $105,748 to $107,489 and the average
charge for DRG 480 decreased from $146,824 to $144,843. These changes
reflect an increase of less than 2 percent in the charges for DRG 103
and a decrease of slightly more than 1 percent in the charges for DRG
480. However, the average charge of all cases in the 2 years increased
from $10,483 to $11,108, an increase of 6 percent. Thus, the weights of
DRG 103 and 480 both decrease between FY 1994 and FY 1995 because the
change in the average charges for those DRGs is less than the increase
in the average charge for all cases.
We note that the relative weight of DRG 103 has been slightly
erratic in the last 5 years, with a low of 12.5568 in FY 1993 and a
high of 14.0323 in FY 1992. This is not unusual for a relatively low
volume DRG (under 400 cases) with a large range of reported charges
(approximately $25,000 to $600,000). A few very low or very high charge
cases can make a dramatic difference in the DRG weight. Regarding DRG
480, we note that the weight has been steadily decreasing since FY 1992
(relative weight of 22.8213).
Section 1886(d)(4)(C)(iii) of the Act requires that beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payment to hospitals is affected by factors other than average case
weight. Therefore, as discussed in section II.A.4.b. of the Addendum to
this final rule, we are making a budget neutrality adjustment to
implement the requirement of section 1886(d)(4)(C)(iii) of the Act.
III. Changes to the Hospital Wage Index and Medicare Geographic
Classification Review Board Guidelines
A. Background
Under the Medicare prospective payment system, different payment
rates are calculated for hospitals located in rural, urban, and large
urban areas. For purposes of the standardized payment amount, section
1886(d)(2)(D) of the Social Security Act requires that we use
Metropolitan Statistical Areas (MSAs) as defined by the Office of
Management and Budget (OMB) to determine whether hospitals are located
in rural, urban or large urban areas (areas with a population over 1
million). However, section 1886(d)(3)(A) of the Act provides for the
elimination of separate urban and rural standardized payment amounts
beginning in FY 1995.
Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary shall adjust the standardized amounts ``for area differences
in hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the national average hospital wage level.'' In
accordance with the broad discretion conferred by this provision, we
currently define hospital labor market areas based on the definitions
of MSAs issued by OMB. Additionally, we adjust the wage index to take
into account the geographic reclassification of hospitals in accordance
with sections 1886(d)(8)(B) and 1886(d)(10) of the Act.
Section 1886(d)(3)(E) of the Act also requires that the wage index
be updated annually beginning October 1, 1993. This section further
provides that the Secretary base the update on a survey of wages and
wage-related costs of short- term acute care hospitals. The survey
should measure, to the extent feasible, the earnings and paid hours of
employment by occupational category and must exclude data with respect
to the wages and wage-related costs incurred in furnishing skilled
nursing services.
For determining prospective payments to hospitals in FY 1995, the
wage index is based on the data collected from the Medicare cost
reports submitted by short-term acute care hospitals for cost reporting
periods beginning in FY 1991 (that is, cost reporting periods beginning
on or after October 1, 1990 and before October 1, 1991). The current
wage index includes wages and salaries paid by a hospital, home office
salaries, fringe benefits, and certain contract labor costs and hours.
The current computation of the wage index excludes salaries and wages
associated with non-hospital type services, such as skilled nursing
facility services, home health agency services, or other subprovider
components that are not subject to the prospective payment system.
In the May 27, 1994 proposed rule, we proposed to use updated wage
data to construct the FY 1995 wage index as required by section
1886(d)(3)(E) of the Act. In addition, we proposed changes in the
future reporting of hospital wage index data. The changes we proposed
to the wage index are discussed in detail below.
In the proposed rule, we also presented our research and analysis
concerning several options for alternative labor market areas and
solicited public comment. The deadline for comments concerning any of
the labor market alternatives was August 31, 1994. As stated in the
proposed rule, we will consider all comments received by this date as
we continue to evaluate possible options for revising wage index labor
market areas.
In addition, we are revising the guidelines for reclassification by
the MGCRB by eliminating the adjacency requirement for individual
hospital reclassifications. This change is discussed below in section
III.F. of this preamble. We welcome public comments on the elimination
of this requirement.
B. FY 1995 Wage Index Update
We proposed to base the FY 1995 wage index, effective for hospital
discharges occurring on or after October 1, 1994 and before October 1,
1995, upon the data collected from the Medicare cost report (Worksheet
S-3, Part II) submitted by hospitals for cost reporting periods
beginning in FY 1991.
We proposed to use all of the categories of data collected from
Worksheet S-3, Part II. Therefore, the FY 1995 wage index reflects the
following:
Total short-term acute care hospital salaries and hours.
Home office costs and hours.
Fringe benefits associated with hospital and home office
salaries.
Direct patient care related contract labor cost and hours.
The exclusion of salaries and hours for non-hospital type
services such as skilled nursing facility services, home health
services, or other sub-provider components that are not subject to the
prospective payment system.
1. Midyear Wage Data Corrections
The data for the proposed FY 1995 wage index was obtained from
Worksheet S-3, Part II, of the HCFA-2552 submitted by short-term acute
care hospitals for cost reporting periods beginning during FY 1991. The
wage data are reported electronically to HCFA through the Hospital Cost
Report Information System (HCRIS). Because of substantial deficiencies
in the initial data reported by hospitals on the cost report (including
missing data items such as excluded hours and total paid hours), we
initiated an intensive review of the wage data and made numerous edits
to ensure quality and accuracy. Medicare intermediaries were instructed
to transmit any revisions to HCFA through HCRIS by early January 1994.
In the proposed rule, we discussed in detail the review of the cost
report data (59 FR 27718), as well as the process that hospitals could
use to verify their wage data and to submit corrections if necessary.
The wage file used to construct the proposed wage index included
data obtained in late January 1994 from the HCRIS database and
subsequent changes we received from intermediaries through March 14,
1994. To allow sufficient time to process any changes, we instructed
hospitals to submit requests for corrections to their fiscal
intermediaries by May 15, 1994. To be reflected in the final wage
index, any wage data corrections had to be reviewed by the intermediary
and transmitted to HCFA via HCRIS on or before June 15, 1994. In the
proposed rule, we noted that we would make a diskette available in mid-
August that would contain the finalized raw wage data used to construct
the wage index values in this final rule. We also noted that we were
making the August diskette available for the limited purpose of
identifying any potential errors made by HCFA or the intermediary in
the tabulation of finalized wage data, not for the initiation of new
wage data correction requests (59 FR 27719).
If, after reviewing the diskette made available to hospitals in
August or after reviewing the data published in this rule, a hospital
believes that its wage data is incorrect due to a fiscal intermediary
or HCFA error, it should immediately send a letter to both its fiscal
intermediary and HCFA. The letters to the intermediary and HCFA should
outline why the hospital believes an error exists. These requests must
be received by HCFA no later than September 23, 1994. Requests should
be sent to: Charles R. Booth, Director; Office of Payment Policy; 181
East High Rise; 6325 Security Boulevard; Baltimore, Maryland 21207. The
intermediary will review requests upon receipt and, if it is determined
that an intermediary or HCFA error exists, the fiscal intermediary will
notify HCFA immediately. As we noted in the proposed rule, after mid-
August, we will make changes to the hospital wage data only in those
very limited circumstances involving an error by the intermediary or
HCFA that the hospital could not have known about before review of the
August diskette.
We stated that if hospitals followed the steps outlined in the
proposed rule, errors in the final wage index should be eliminated.
However, we proposed to allow midyear corrections to the wage data
under limited circumstances. Accordingly, we are revising
Sec. 412.63(s)(2) to provide that the Secretary may make midyear
corrections to the wage index only in those limited circumstances where
a hospital can show: (1) that the intermediary or HCFA made a
tabulation error, and (2) that the hospital could not have known about
the error, or did not have an opportunity to correct the error, by
September 23, 1994. Since a hospital will have the opportunity to
verify its data and the intermediary will notify the hospital of any
changes, we foresee few, if any, specific circumstances under which
midyear corrections would be made. However, should a midyear correction
be necessary, the wage index change for the affected area will be made
prospectively from the date the correction is made. If midyear
corrections to the wage index values are made, we will take their
effect into account in establishing the standardized amounts for the
following Federal fiscal year in accordance with Sec. 412.63(s)(4).
Comment: We received numerous comments about our proposed midyear
correction process. One commenter suggested that we allow providers to
change their wage data at any point in the fiscal year. Another agreed
with our plan for allowing midyear corrections only in cases of
intermediary or HCFA error but wanted us to apply any changes
retroactive to October 1, 1994. Another commenter suggested that we
expand the midyear correction process to include cases in which the
intermediary should have known the data was wrong and therefore should
have investigated any obvious discrepancy as well as cases in which the
intermediary should have reviewed a hospital's data because the
hospital's average hourly wage decreased from the prior fiscal year.
Response: We do not believe that it is appropriate to allow
hospitals to change their wage data at any point in the fiscal year or
to expand the midyear correction process as the commenter has
suggested. As we stated in the proposed rule (59 FR 27719), we believe
that midyear corrections should not be made in most cases. The wage
data correction process described above and in the proposed rule has
provided hospitals with sufficient opportunity to bring errors made in
the preparation of Worksheet S-3 to the intermediary's attention.
Moreover, because hospitals have had access to the raw wage data in
mid-August, they will have had the opportunity to detect any
ministerial tabulation errors made by the intermediary or HCFA before
the implementation of the prospective payment rates. We believe that if
hospitals have availed themselves of the opportunity to review their FY
1991 wage data, the wage index implemented on October 1 should be free
of errors.
We believe our policy is consistent with section 1886(d)(3)(E) of
the Act, which requires that the wage index be updated annually
beginning with October 1, 1993. In so providing, Congress has
essentially created an annual wage data review process that ends with
the publication of the payment rates for the fiscal year at issue.
Moreover, as we noted in the September 1, 1992 final rule (57 FR
39765), implementation of midyear corrections in previous years
resulted in several problems related to the reclassification of
hospitals by the Medicare Geographic Classification Review Board.
Allowing hospitals to continue to raise wage data issues beyond the
deadlines described in this rule would also divert resources that would
otherwise be used to ensure that the following year's wage index is as
accurate as possible. Accordingly, we believe that it is incumbent that
HCFA and the hospital community direct their energies to reviewing and
correcting wage data before the prospective payment system rates for a
given year are constructed.
We also disagree with the commenter's suggestion that the failure
of an intermediary to detect an error made by a hospital in reporting
its wage data should be characterized as an intermediary error or
should require a midyear correction. Hospitals are required to complete
the Worksheet S-3, Part II, along with the rest of the cost report and
to attest to its accuracy at the time the cost report is filed. The
cost report is signed by an Officer or Administrator of the hospital
certifying that the cost report is ``a true, correct and complete
statement prepared from the books and records of the provider in
accordance with applicable instructions * * *.'' Thus, the ultimate
responsibility for the accuracy of the wage data reported on the
Medicare cost report rests with the hospital. Moreover, we have
repeatedly stressed in the Federal Register and other communications
with the hospital industry the importance of reporting accurate wage
data to both the development of the wage index and to the geographic
reclassification process.
We have also expended considerable time and effort to review
hospital wage data for potential errors. Because our initial
examination of the FY 1991 wage data detected substantial deficiencies
in the initial data reported by hospitals on the cost report (including
missing data items such as excluded hours and total paid hours), we
initiated an intensive review of the wage data, which we described in
detail in the proposed rule (59 FR 27718). In September 1993, we sent
each fiscal intermediary a listing of its hospitals' wage data. In
November and December of 1993, our fiscal intermediaries performed desk
reviews for each hospital to ensure the reasonableness of the data. As
a result of this effort and our own review of the wage data, edits for
over 1,300 providers were resolved prior to constructing the proposed
hospital wage index published in the proposed rule.
Intermediaries were also responsible for reviewing hospital
requests for data changes submitted by the May 15, 1994 deadline and
for transmitting any corrections to HCFA on or before June 15, 1994.
After receiving any new wage data from fiscal intermediaries by June
15, 1994, we once again completed our own review of the wage data in
early July. Finally, on July 26, 1994, we sent each intermediary a
listing of the wage data for all their hospitals and requested one
final review to ensure that our database reflected the latest wage data
for each hospital.
In short, we are confident that we have created as accurate a
database as possible under existing time and resource constraints.
Moreover, as we described in detail in the proposed rule, we have
provided ample opportunities to hospitals to review for accuracy the
wage data used to construct the wage index. We note that the diskette
made available to the public in mid-March 1994 contained the raw
hospital wage data for all prospective payment system hospitals. This
not only enabled individual hospitals to detect errors concerning their
own data, but also allowed all hospitals in an MSA or rural area to
check for any obvious discrepancies in the wage index data of other
hospitals in their area, as well as any reduction in the average hourly
wage from previous years. In light of the above, we do not believe that
it is appropriate to make midyear changes to the wage index to correct
substantive wage data reporting errors.
We have also taken steps to ensure that the wage index that will go
into effect October 1, 1994 is free from any ministerial tabulation
errors. As noted above, in mid-August we made available a diskette with
all the wage data used to construct the wage index set forth in this
final rule. We believe hospitals will have ample opportunity to verify
their data prior to the September 23 deadline. Therefore, we foresee
few, if any, circumstances under which midyear corrections would be
made to correct a tabulation error. In those limited cases where a
midyear correction is warranted, the wage index change for the affected
area will be made prospectively from the date the correction is made.
This is consistent with our longstanding policy to allow wage index
corrections on a prospective basis only. This policy was originally set
forth in the preambles to the September 1, 1983 interim final rule (48
FR 39765) and the January 3, 1984 final rule (49 FR 258) implementing
the prospective payment system and was later codified at Sec. 412.63 as
part of the September 4, 1990 final rule (55 FR 36042).
Comment: One commenter suggested that we establish an appeals
process for disputes over corrections submitted by hospitals to
intermediaries. The commenter was concerned over the inability of
hospitals to make final corrections to wage index data before it is
submitted to HCFA. The commenter noted that, even with hospitals having
time to verify their data, any decisions on the changes submitted by
hospitals are left to the discretion of the intermediary without an
appeal process for the hospital.
Response: We do not believe a formal appeals process is necessary.
Moreover, we do not believe that a formal appeals process would be
feasible, since the process could not be completed before the
development of the final wage index. In the few cases where the
hospital and the intermediary have disagreed on specific cost items
reported on Worksheet S-3, the issue has been resolved by contacts
between the hospital or intermediary and HCFA. We continue to believe
that this informal method is sufficient to resolve disputes between
hospitals and intermediaries.
In the proposed rule (59 FR 27718), we detailed the steps that a
hospital must follow to ensure that any corrections to its wage data
are included in the final wage index. We stated that to be reflected in
the final wage index, any wage data corrections had to be reviewed by
the intermediary and transmitted to HCFA via HCRIS on or before June
15, 1994. This deadline was necessary to allow sufficient time to
download and edit the data so that the final wage index calculation
could be completed for development of the final prospective payment
rates to be published in this final rule. After reviewing requested
changes submitted by hospitals, intermediaries transmitted any revised
cost reports to HCRIS and forwarded to the hospitals a copy of the
revised Worksheet S-3, Part II. If requested changes were not accepted,
fiscal intermediaries notified hospitals in writing of reasons why the
changes were not accepted. This procedure ensured that hospitals had an
opportunity to verify the data that will be used to construct their
wage index values.
We continue to believe that fiscal intermediaries are in the best
position to make evaluations regarding the appropriateness of a
particular cost and whether it should be included in the wage index
data. However, in the event that a hospital disagrees with the
intermediary's resolution of a requested change, hospitals may request
that intermediaries re-review the issue and receive HCFA's concurrence.
The intermediary was to submit a written request to HCFA for
concurrence describing its handling of the issue raised by the
hospital. After evaluating the facts, HCFA contacted the intermediary
with the decision, and the intermediary notified the hospital.
This process was designed to resolve all substantive wage data
correction disputes before we finalized the raw wage data for the FY
1995 payment rates. However, we note that this process must be
completed at least 3 months before the publication of the final rule,
to allow the intermediary sufficient time to submit wage data changes.
Therefore, to initiate a change to the FY 1991 data, a hospital had to
submit such requests to its intermediary by May 15, 1994. The hospital
can evaluate the data HCFA is using either by requesting from the
intermediary a copy of the Worksheet S-3, Part II that has been
transmitted to HCRIS or, as indicated in the proposed rule, by
requesting a copy of the public use wage file.
Comment: Several commenters raised concerns about inconsistent
auditing of wage data by the fiscal intermediaries. They indicated that
while certain fiscal intermediaries acted stringently in applying HCFA
guidelines, other fiscal intermediaries were not as restrictive in
their auditing processes. Specifically, commenters cited instances in
which providers have been allowed to include questionable fringe
benefit costs, such as parking expenses, and salaries for Part B
physicians' services. One commenter recommended that our desk review
program include a specific check for Line 1B of the Worksheet S-3, Part
II, to ensure that Part B physicians' services are removed.
Response: We are concerned about all instances of inconsistent
auditing by the fiscal intermediaries and have taken several steps that
we believe should have eliminated most inconsistencies. Specifically,
in November and December of 1993, the fiscal intermediaries performed
desk reviews on the wage data reported by each hospital. These reviews
were conducted based on reasonableness parameters established by HCFA.
Additionally, all fiscal intermediaries have been given a fringe
benefit guideline to assist them in determining if certain reported
fringe benefits are allowable for purposes of the wage index. We have
also instructed fiscal intermediaries to contact a HCFA staff member in
cases where questions arise. In addition, intermediary performances on
the desk reviews are evaluated by HCFA regional office personnel.
Regarding the commenter's concern about Part B physician services,
we agree that there should be a more thorough review of the Line 1B of
the Worksheet S-3, Part II, where that data are reported. Therefore, we
are adopting the commenter's suggestion and will incorporate additional
instructions in the next version of the desk review program to ensure
consistent Part B physician reporting.
In addition, if a hospital has knowledge that an intermediary may
be incorrectly handling a particular issue, the hospital is encouraged
to bring it to our attention. We will continue our efforts to ensure
uniform reporting of wage data. We believe that the changes we are
making to the reporting of wage data for future cost reporting periods
will greatly enhance the uniformity and equity of the hospital wage
index.
Comment: We received two comments from Richmond, Virginia hospitals
requesting relief for an error in the data used to calculate the FY
1994 wage index. They requested that the wage index for the Richmond,
Virginia MSA for FY 1995 be increased to compensate for the
``deflation'' in its FY 1994 wage index.
Response: The issue of whether an error was made in calculating the
FY 1994 Richmond, Virginia wage index is not related to the contents of
this regulation. Accordingly, we intend to respond to the Richmond,
Virginia hospitals concerning this matter in separate correspondence.
We note, however, that section 1886(d)(3)(E) of the Act provides that
we revise the wage index each year based on updated wage data. Given
this provision, we do not believe it would be appropriate in any
circumstance to adjust an MSA's FY 1995 wage index, which is based on
FY 1991 data, to account for additional wages paid in FY 1990.
Comment: We received one comment addressing various aspects of the
availability of wage index data for review by providers. Generally, the
comment centered on the data included in the file and the creation of a
wage data bulletin board that could be updated regularly.
Response: HCFA has continued to work to improve the availability
and distribution of wage index data for provider information.
First, the commenter requested that MSA classifications and MGCRB
redesignations be added to the wage data file that is released before
publication of the proposed rule. It was also suggested that we compile
separate wage data files by State so that hospitals do not have to
purchase the entire file. The purpose of the preliminary diskette is to
allow hospitals to review the database from which the wage index will
be derived, prior to publication of the wage index. It is not intended
to provide data that would allow hospitals to construct the wage index.
Data on MSA classifications and reclassified hospitals can be purchased
on separate diskettes once the wage index is published (59 FR 27756).
With respect to maintaining the wage file on a computer bulletin board,
we do not have resources to maintain and update such a bulletin board
on an ongoing basis as revised wage data is transmitted to HCRIS. Also,
given the modest price of the diskette ($145.00) and the fact that
provider numbers are in State order on the current file, we do not see
the need to provide separate files for each State.
The commenter also asked that we include prior year's data on the
current file, so that hospitals can readily tell what changes have
occurred. The wage data from previous years are made available on
diskette after publication of each year's final wage index. Therefore,
we do not see the need to replicate this information on the subsequent
year's wage file. We advise hospitals to retain this year's diskette
for comparison with next year's wage data information. We see this as
an efficient and inexpensive alternative to repeating information.
With respect to the format of the data included on the diskette, we
plan to evaluate this issue to determine if a more ``user friendly''
format can be developed that would be easily adaptable to most computer
systems.
Comment: We received several comments expressing confusion about
the responsibility of the providers and the fiscal intermediaries in
the submission of the corrections to the final wage index data by the
June 15th deadline.
Response: As we previously indicated, we believe that each provider
has the ultimate responsibility to ensure the accuracy of its data, and
we allow providers ample opportunity to make needed corrections. If,
after reviewing the data used in calculating the proposed rule wage
index (either from the published proposed rule or the diskette that was
made available to all hospitals), a hospital believed that its FY 1991
wage data were incorrectly reported, the hospital should have submitted
corrections along with complete supporting documentation to its
intermediary in time to allow for proper review, verification, and
transmission of the data before the development of the final wage
index. We established a May 15 deadline for submission of revised data
by hospitals in order to allow fiscal intermediaries ample time to
review the submission. We also noted there was no guarantee that
submissions of revised data after that date would be processed in time
for the final wage index. That is, handling of data correction requests
received after May 15 was dependent on the fiscal intermediaries'
workload. The fiscal intermediary was then responsible for sending any
corrected information to HCRIS before the established deadline of June
15, 1994.
This deadline was necessary to allow sufficient time to download
and edit the data, so that the final wage index calculation could be
completed in time for the development of the final prospective payment
rates. We could not guarantee that corrections transmitted to HCFA
after June 15 would be reflected in the final wage index. Therefore, we
suggested that hospitals wishing to submit corrected data do so as soon
as possible and follow up with their intermediaries to ensure inclusion
of the corrected data in the final wage index. Intermediaries were also
instructed to inform providers about the disposition of any data
correction requests and, where changes were made, to supply a copy of
any revised Worksheet S-3, Part II, to providers to alert them that a
correction had been made.
2. Computation of the Wage Index
As noted above, we are basing the FY 1995 wage index on wage data
reported on the FY 1991 cost report. The wage index is based on data
from 5,290 hospitals paid under the prospective payment system and
short-term acute care hospitals in waiver States. The method used to
compute the FY 1995 wage index is as follows:
Step 1--We gathered data from each of the non-Federal short-term
acute care hospitals for which data were reported on the Worksheet S-3,
Part II of the Medicare cost report for the hospital's cost reporting
periods beginning on or after October 1, 1990, and before October 1,
1991. Each hospital was assigned to its appropriate urban or rural area
prior to any reclassifications under sections 1886(d)(8) or 1886(d)(10)
of the Act. In addition, we included data from a few hospitals that had
cost reporting periods beginning in September 1990 and had reported a
cost reporting period exceeding 52 weeks. The data were included
because no other data from these hospitals would be available for the
cost reporting period described above, and particular labor market
areas might be affected due to the omission of these hospitals.
However, we generally describe this wage data as FY 1991 data.
Step 2--For each hospital, we subtracted the excluded salaries
(that is, direct salaries attributable to skilled nursing facility
services, home health services, and other sub-provider components not
subject to the prospective payment system) from gross hospital salaries
to determine net hospital salaries. To the net hospital salaries, we
added hospital contract labor costs, hospital fringe benefits, and any
home office salaries and fringe benefits reported by the hospital to
determine total salaries plus fringe benefits.
Step 3--For each hospital, we inflated or deflated, as appropriate,
the total salaries plus fringe benefits resulting from Step 2 to a
common period to determine total adjusted salaries. To make the wage
inflation adjustment, we used the percentage change in average hourly
earnings for each 30-day increment from October 14, 1990 through
September 15, 1992, for hospital industry workers from S.I.C. 806,
Bureau of Labor Statistics Employment and Earnings Bulletin. The annual
inflation rates used were 5.6 percent for FY 1990 and FY 1991 and 4.8
percent for FY 1992. The inflation factors used to inflate the
hospital's data were based on the midpoint of the cost reporting period
as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
Adjustment
After Before factor
------------------------------------------------------------------------
10/14/90........................................ 11/15/90 1.071953
11/14/90........................................ 12/15/90 1.067097
12/14/90........................................ 01/15/91 1.062262
01/14/91........................................ 02/15/91 1.057450
02/14/91........................................ 03/15/91 1.052659
03/14/91........................................ 04/15/91 1.047890
04/14/91........................................ 05/15/91 1.043143
05/14/91........................................ 06/15/91 1.038417
06/14/91........................................ 07/15/91 1.033713
07/14/91........................................ 08/15/91 1.029030
08/14/91........................................ 09/15/91 1.024368
09/14/91........................................ 10/15/91 1.019727
10/14/91........................................ 11/15/91 1.015751
11/14/91........................................ 12/15/91 1.011790
12/14/91........................................ 01/15/92 1.007845
01/14/92........................................ 02/15/92 1.003915
02/14/92........................................ 03/15/92 1.000000
03/14/92........................................ 04/15/92 0.996101
04/14/92........................................ 05/15/92 0.992217
05/14/92........................................ 06/15/92 0.988348
06/14/92........................................ 07/15/92 0.984494
07/14/92........................................ 08/15/92 0.980655
08/14/92........................................ 09/15/92 0.976831
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1991 and ending December 31, 1991 is June 30, 1991. An
inflation adjustment factor of 1.033713 would be applied to the wages
of a hospital with such a cost reporting period. In addition, for the
data for any cost reporting period that began in FY 1991 and covers a
period of less than 360 days or greater than 370 days, we annualized
the data to reflect a 1-year cost report. Annualization is accomplished
by dividing the data by the number of days in the cost report and then
multiplying the results by 365.
Step 4--For each hospital, we subtracted the reported excluded
hours from the gross hospital hours to determine net hospital hours. We
increased the net hours by the addition of any reported contract labor
hours and home office hours to determine total hours.
Step 5--As part of our editing process, we deleted data for 76
hospitals that are no longer participating in the Medicare program or
that are in bankruptcy status, and for which we lacked sufficient
documentation to verify data that failed edits. We retained the data
for other hospitals that are no longer participating in the Medicare
program because these hospitals contributed to the relative wage levels
in their labor market areas during their FY 1991 cost reporting period.
Step 6--Within each urban or rural labor market area we added the
total adjusted salaries plus fringe benefits obtained in Step 3 for all
hospitals in that area to determine the total adjusted salaries plus
fringe benefits for the labor market area.
Step 7--We divided the total adjusted salaries plus fringe benefits
obtained in Step 6 by the sum of the total hours (from Step 4) for all
hospitals in each labor market area to determine an average hourly wage
for the area.
Step 8--We added the total adjusted salaries plus fringe benefits
obtained in Step 3 for all hospitals in the nation and then divided the
sum by the national sum of total hours from Step 4 to arrive at a
national average hourly wage. Using the data as described above, the
national average hourly wage is $18.2626.
Step 9--For each urban or rural labor market area, we calculated
the hospital wage index value by dividing the area average hourly wage
obtained in Step 7 by the national average hourly wage computed in Step
8.
Comment: A few commenters suggested that we eliminate from the wage
index computation, hospitals that have terminated their participation
in the Medicare program. The commenters believe that wage data from
terminated hospitals do not reflect the wages paid in a labor market
area, since the terminated hospital may have no incentive to ensure
accurate reporting of wage data in the final cost reporting period.
Response: We have always maintained that any hospital that is in
operation during the data collection period should be included in the
database, since the hospital's data reflects conditions occurring in
that labor market area during the period surveyed. Moreover, we believe
that, in general, this is the most practical and equitable way to
administer the data collection process, because it would be difficult
to determine which terminated hospitals should be excluded. For
example, if a hospital's participation in the Medicare program is
terminated just before the publication of the prospective payment
system proposed rule in May, or between the proposed rule and the
publication of the final rule, it would be very difficult to ensure
that such a hospital was identified as terminated, since our analysis
of the database is accomplished well before the final rule is
published.
However, we agree that it is appropriate to eliminate data for
terminated hospitals when there is reason to believe that the data are
incorrect, and the data cannot be verified due to the facility's
closure. We believe this is appropriate since in most cases any
aberrant data reported by terminated hospitals cannot be evaluated for
reasonableness because hospital records may not be available to the
intermediaries.
Each hospital is responsible for accurately completing the cost
report and must attest to the accuracy of the data at the time the cost
report is filed. If the wage data for a terminated hospital did not
fail any of our edits for reasonableness, the hospital remains in the
database and its data are used in developing the wage index for the
labor market area. In preparing the data for the final wage index, we
identified 76 terminated hospitals that reported questionable data and
therefore were eliminated from the wage index database.
Comment: Two commenters suggested that for wage index purposes we
require hospitals to report Full Time Equivalent employees on a
standardized basis of 2,080 hours worked. Commenters are concerned that
inconsistent reporting of total hours results in inequities in the
calculation of the average hourly rate. One commenter indicated that a
hospital could manipulate this policy to increase its average hourly
wage by recomputing the average hourly wage for an employee based on a
7.5 hour day, thereby reporting 37.5 hours per week per employee.
Response: We have always used total paid hours as opposed to total
hours worked for calculating the average hourly rate. Total paid hours
more accurately reflect all elements of total salary. We clarified the
definition of total hours in the cost reporting instructions to specify
that total hours mean total paid hours. Paid hours include regular
hours, overtime hours (counted as a regular hour), and paid holiday,
vacation, and sick leave hours or any other hours associated with paid
time off such as jury duty or bereavement pay. These are included to
achieve comparability among hospitals and to recognize all work hours
for which the hospital paid wages. Salaries are based on a standard
work period (such as 40 hours or 37.5 hours per week) that is specified
by the hospital employer. This work period includes any time covered by
paid leave, as well as any non-productive time for which the employee
receives a salary (such as a paid lunch period or a 15-minute break).
Hospitals are not asked to account for and/or subtract this non-
productive time, because the employee is being paid for the time. If a
hospital elects to pay its employees based on a 7.5 hour day because
employees are not paid for lunch and are free to leave the work site,
and the overtime rate and other fringe benefits are based on the hourly
rate computed based on the 7.5 work day, the hospital's labor
distribution report would appropriately report hours based on 37.5
hours per week.
Additionally, we emphasize that hours reported must correspond to
the salaries reported. If a salary is paid there should be
corresponding hours. We anticipate that this clarification will result
in more consistent reporting of total paid hours for wage index
purposes.
C. Changes In the Reporting of Hospital Wage Index Data
Currently, the data used to develop the wage index are submitted by
hospitals on the Worksheet S-3, Part II, of the Medicare cost report.
We developed this worksheet as part of the FY 1990 cost reports, and we
used the worksheet to calculate the wage index for FY 1994. The
worksheet has been evaluated by HCFA and industry representatives to
ensure that this data collection mechanism captures relative wage costs
as accurately as possible and to determine whether any refinements are
appropriate. The Medicare Technical Advisory Group (MTAG) established a
task force to study and recommend changes to the cost reporting form
used to collect wage index data. The task force comprised hospital,
intermediary, and HCFA representatives. The MTAG task force
recommended, and we are implementing, three major changes to the
Worksheet S-3, Part II; the provider cost report questionnaire (HCFA
339); and accompanying instructions as discussed below. We note that
the changes in the reporting of hospital wage index data, outlined
below, are effective for cost reporting periods beginning on or after
October 1, 1994. Therefore the changes will not affect the FY 1995 wage
index, which is based on FY 1991 wage data.
1. The Elimination of Part A Physicians' and CRNA Salaries
Currently, a hospital that directly employs and pays the salary of
a physician can include the Part A portion of the physician's salary in
total salaries reported on Worksheet S-3, Part II. (The Part B portion
of physician salaries has always been excluded from the wage index.)
However, if a hospital contracts for physician services, it is not
permitted to include the Part A physician services as contract labor
because we consider Part A physician services to be administrative, not
direct patient-care related (currently, to be included in the
computation of the wage index, contract labor must be directly related
to patient care).
Not all hospitals directly employ physicians. There are currently
five States in which State laws specifically prevent hospitals from
directly hiring physicians. Hospitals in these States are forced to
contract out for physicians. The inability of these hospitals to
include the Part A portion of the services as contract labor has been
perceived as inequitable. In States where hospitals may directly employ
physicians, the hospitals may include some of these characteristically
high wages in the wage data, while in States where hospitals must
contract for their physician services, these contract wages cannot be
included in their wage data.
As outlined in the proposed rule, we are providing on the Worksheet
S-3, Part II, for the exclusion of all Part A physician costs
regardless of whether the physician is a hospital employee or
contractor. For purposes of this exclusion, physicians' salaries are
defined as salaries applicable to positions for which a licensed
physician is normally a prerequisite, such as a medical director of a
department. Salaries for physicians employed in other positions that do
not necessarily require a physician, such as hospital administrator,
are not excluded.
All hospitals must separately report any physicians' salaries (both
Part A and Part B related) as part of the wage data reported on the
Medicare cost report. This action should not require any additional
reporting burden since these Part A physician salaries already are
reported on the cost report (Worksheet A-8-2). Regarding Part A CRNA
(certified registered nurse anesthetist) costs, we are requiring
hospitals to exclude these salaries from the wage data reported on the
cost report. In addition, salaries for interns and residents will be
separately reported (see comments below).
We note that these changes are effective for cost reporting periods
beginning on or after October 1, 1994 and will not affect the current
reporting of physicians and CRNA salaries.
Comment: We received over 50 comments concerning our proposal to
exclude from the computation of the wage index all physician salaries
(including those associated with teaching physicians) and CRNA Part A
services. Many commenters supported this proposal; some suggested that
we also eliminate other salaries related to services paid outside the
prospective payment system, such as the salaries of interns and
residents. Other commenters suggested that rather than eliminate all
physicians' salaries, we add contracted Part A physicians' services to
the wage index computation. Some of these commenters argued that the
administrative portion of physicians' salaries are included under the
prospective payment system and should therefore continue to be included
in the wage index. A number of commenters indicated concern about the
redistributional effect of this change and suggested we collect all the
necessary data components before implementing the new policy. In
particular, several teaching hospitals stated that they would be
affected adversely by the elimination of physician salaries from the
computation of the wage index. Finally, several commenters asked that
we clarify that only those salaries for positions that require a
licensed physician be excluded from the wage data.
Response: Consistent with past refinements of the hospital wage
index to exclude those costs related to services not covered under the
prospective payment system, we believe it is appropriate to exclude all
salary costs associated with graduate medical education programs.
Therefore, in addition to the exclusion of teaching physicians' salary
costs, we are adopting the commenters' suggestion and will provide for
the separate reporting (and possible exclusion from the wage index) of
salary costs for interns and residents, since none of the costs
associated with these services are paid under the prospective payment
system. We believe that any redistributional effect on Medicare
payments resulting from this change would be appropriate since teaching
hospitals may be unfairly advantaged relative to other hospitals by the
inclusion of graduate medical education costs in the prospective
payment system wage index. Although this change may significantly
affect teaching hospitals, we believe the timing of the change, which
would not take effect for wage index purposes until FY 1999, will
enable hospitals to anticipate a possible reduction in their wage index
values. With respect to the exclusion of other Part A physicians's
salary costs, we do not believe the redistributional effects would be
significant given that these costs would be excluded for all hospitals
nationwide. Since this change would apply equally to hospitals that are
permitted to employ physicians and to those that must contract for
physician services, we believe this revision would promote payment
equity and provide more uniformity in the wage data across areas.
With regard to the suggestion that we include all Part A physician
costs (whether salaried or under contract) in computing the wage index,
we continue to believe that eliminating all physicians' salaries is
more appropriate than that alternative. As discussed in the proposed
rule (59 FR 27721), we do not believe that physician costs are driven
by normal labor market conditions and, in many cases, hospitals must
hire physicians from outside of their recruiting areas. Second, many
hospitals have indicated that they have difficulty accurately
determining the hours for the physicians attributable to Part A
services, especially for those under contract. Third, we have found
that some hospitals that employ physicians are not appropriately
eliminating Part B physician salaries from the total salaries reported
for the wage index as required in the cost reporting instructions.
Thus, we believe that inclusion of all Part A physician costs would not
accurately reflect relative wages across areas.
We believe that the exclusion of all Part A physician costs (even
though a portion of these costs not related to teaching activities is
recognized under the prospective payment system) is the approach that
would provide the greatest uniformity across areas. Since most
hospitals incur costs associated with Part A physicians contracts, we
do not believe the relative wage index values would vary greatly across
areas under either approach. However, as suggested by commenters, we
will revise the cost reporting form, effective for cost reporting
periods beginning on or after October 1, 1994, to collect separately
additional data elements needed to evaluate the appropriateness of this
change as part of the FY 1999 wage index update.
With respect to the elimination of CRNA Part A services, we note
first that these Part A services are currently paid on a ``pass-
through'' basis, outside the prospective payment system. Therefore, we
believe it is appropriate to exclude these costs from the wage index.
Moreover, this Part A pass-through provision is applicable to a limited
number of hospitals (small rural hospitals). All other hospitals are
paid for CRNA services under Part B of the Medicare program. Therefore,
in order to ensure consistency across areas, we believe that no CRNA
costs should be reflected in the wage index computation. CRNA services
are generally excluded from the wage index as Part B services. Since
the Part A portion was granted as a pass-through for certain rural
hospitals, it is currently included in the wage index. In addition, we
have seen several examples during our editing process where the hours
associated with these services are difficult to determine. CRNAs bill
on 15-minute intervals during surgery; however, time before or after
the billing time (that is, actual surgery time) is difficult to
determine from time records yet is part of the time CRNAs devote to a
particular patient.
Finally, as specified in the proposed rule, salaries for physicians
employed in positions (such as hospital administrator) for which a
licensed physician is not normally a prerequisite, would not be
reported as physician's salaries. The hospital is responsible, however,
for providing its fiscal intermediary with the necessary documentation
to allow an appropriate determination with respect to these salaries.
Therefore, effective with cost reporting periods beginning on or
after October 1, 1994, we are revising the Medicare cost report to
provide for the separate reporting of all salary costs for physicians
(including teaching physicians), interns and residents, and CRNAs.
After evaluating these data, we will propose appropriate changes to the
FY 1999 wage index update.
Comment: One commenter suggested that we exclude the salaries
associated with several other services that could be billed under Part
B, such as the services of nurse midwives, nurse practitioners,
clinical psychologists, and clinical social workers. The commenter
believes these services should be eliminated since they are similar to
Part B physician services, which are currently excluded from the wage
index data.
Response: While we believe it is appropriate to remove from the
wage index data salaries not included in the prospective payment
system, we think that it would be difficult to accurately distinguish
between Part A and Part B services for the services mentioned by the
commenter. It is also unclear to us if the hospitals and intermediaries
will have the documentation to distinguish between the time spent on
Part A services performed by these employees and time spent on Part B
billable services. In addition we believe that these costs are
relatively small, and therefore would have an insignificant effect on
the wage index. However, we will continue to examine this issue, and,
if we find these costs are substantial and can be documented, we will
propose future changes to the reporting of hospital wage data.
2. Management Contracts
The second major change concerns the inclusion of certain
management contracts in the hospital wage index data. Before FY 1994,
the wage index did not include any costs associated with contract
services. However, many hospitals indicated that they were
inappropriately disadvantaged because they were forced to contract out
for nurses and technicians due to shortages of these services in their
areas. To alleviate this problem, we revised the cost report to collect
the data associated with any direct patient care service contract (that
is, nursing, therapeutic, etc.). We specifically excluded any Part B
services, Part A physician services, management contracts, or any
contract for services not directly involved with patient care.
The hospital industry has expressed concern that we do not
currently recognize the cost of certain contract management services.
In particular, many rural hospitals that are either unable to recruit
or cannot afford top managers such as hospital administrators must
contract for the services of these individuals. Therefore, we believe
it is appropriate to include the costs of certain management contracts
in the wage index. We are expanding the definition of contract services
reported on the Worksheet S- 3 to include the personnel cost associated
with contracts for any personnel hired in the top four positions within
the hospital. Allowable contract management services would be limited
to the personnel costs for those individuals who are working at the
hospital facility in the capacity of the Chief Executive Officer (CEO)/
Hospital Administrator, Chief Operating Officer (COO), Chief Financial
Officer (CFO), or Nursing Administrator. The exact titles assigned to
individuals may vary but the individuals should be performing
essentially the same duties as customarily assigned these management
positions.
Hospitals (via HCFA-339 form) will be required to provide fiscal
intermediaries with complete details on all direct patient care related
contracts and the description and aggregate totals for all management
contracts. Because of the difficulty in accurately determining hours
and isolating wage related costs for the other types of contract
services, the wage data will continue to exclude all non-patient care
contract services except those limited management contracts discussed
above.
Since the current cost report does not provide for the collection
of management contract data, this revised definition will not be
effective until cost reporting periods beginning on or after October 1,
1994. To provide consistent reporting of data, hospitals must continue
to exclude all management contracts until the FY 1995 data is reported.
Comment: One commenter suggested that contract labor be included in
the wage index calculation if it is for services for which many
hospitals in the country routinely employ contract personnel.
Response: The services for which hospitals employ contract
personnel vary considerably across the country. Furthermore, the cost
of contract labor is generally higher than the cost of non-contract
labor for the same service. Many times, the cost of contract labor will
include costs for other non-wage related items such as supplies or
equipment, and thus may not accurately reflect relative hospital wage
rates across labor market areas.
Before FY 1994, the wage index did not include any costs associated
with contract services. However, in response to the concerns of
hospitals in areas experiencing nursing shortages that must rely on
contract labor sources, we included in the computation of the wage
index contract labor costs for services directly related to patient
care. Because of the difficulty in accurately determining hours and
isolating wage-related costs for contract services not directly related
to patient care, the wage data will continue to exclude all non-patient
care contract services except certain top management contracts, which
will be reported separately on the Worksheet S-3, Part II.
Comment: A few commenters asked why we did not include the position
of Medical Director in the definition of the top management contract
personnel at the hospital that may be included on Worksheet S-3 of the
cost report.
Response: The position of Medical Director must be filled by a
licensed physician. Thus, the duties performed by the Medical Director
would be described as a Part A physician's salary. Therefore, excluding
these types of management contracts is consistent with our revised
reporting policy and potential exclusion of physician salaries from the
wage index data.
Comment: We received one comment requesting that HCFA clarify the
status of direct patient care service contracts. The commenter was
confused about whether one hospital may report the cost and hours
related to contract services furnished at another prospective payment
system hospital.
Response: We believe there are two situations for which
clarification is needed. In each case, hospitals must take care to
avoid duplicate reporting of the costs and hours of the contract
services.
In the first case, Hospital A may contract out the services of its
nurses to Hospital B. In this case, Hospital A may not claim the
salaries paid to those nurses on the Worksheet S-3, Part II, while they
are working at Hospital B. Instead, Hospital A must deduct the salaries
and corresponding hours associated with the time the nurses worked at
the other facility. Hospital B, however, can include the payment and
corresponding hours for the nurses as direct patient care related
contract labor.
In the second case, Hospital A sends a patient to Hospital B for
tests and procedures that Hospital A cannot provide. Hospital A cannot
claim the labor portion of the amounts paid to Hospital B for contract
labor. We consider this type of arrangement as a purchased service
rather than contract labor. In this situation, the scope of the
contracted service involves more than the services of nurses or
technicians. The associated ancillary services provided also include
costs for supplies, equipment, etc. In many cases hospitals are unable
to accurately provide a breakdown of their charges to show how much is
attributable to direct patient care services as opposed to the supplies
and equipment used to provide those services. Because of the difficulty
of accurately determining the labor portion of such contracted
services, and given the fact that the employees do not work on the
hospital's premises, Hospital A cannot claim this as contract labor for
purposes of the wage index. We believe that this is consistent with our
goal of establishing a uniform method for collecting wage data.
3. Reporting of Wage-Related Costs
Since we began including fringe benefits in the wage index, we have
been concerned with the inconsistent reporting of fringe benefits,
whether because of a lack of provider proficiency in identifying fringe
benefit costs or varying interpretations across fiscal intermediaries
of the definition for fringe benefits in PRM-I, Sec. 2144.1. Although
we have attempted to promote consistent reporting of fringe benefits by
providing fiscal intermediaries with general guidelines to be used in
determining allowable fringe benefit costs, the intermediaries must
necessarily make judgments as to whether certain costs qualify as a
fringe benefit, and inconsistencies persist.
Last summer, HCFA conducted a survey to determine what costs the
health care industry thought should be recognized as fringe benefit
costs. The survey consisted of a questionnaire with a yes/no response
column and a column for comments. We received 238 responses from
hospitals, fiscal intermediaries, state hospital associations, national
hospital associations, state agencies, and bureaus and offices within
HCFA. The results of those surveys were examined closely by the MTAG
task force.
Based on the recommendations of the task force, we are making
several changes that we believe will promote more equitable and
consistent reporting of wage-related costs for all hospitals. Where the
term ``fringe benefit'' has been used in the past, we will now refer to
these costs as ``wage-related costs'' for wage index purposes. We
believe that this change in terminology will eliminate the confusion
regarding those wage-related costs that we will allow to be
incorporated in the wage index versus the definition of fringe benefits
required by Medicare principles for cost reimbursement purposes.
Accordingly, we are revising the Worksheet S-3, Part II, to capture
wage-related costs in three parts.
a. Wage-Related Costs (Core). For most hospitals, the wage-related
costs used to develop the wage index would be limited to ``core'' wage-
related costs. The list of ``core'' wage-related costs includes all
commonly recognized costs that contribute significantly to the wage
costs of a hospital and that are readily identifiable on the hospital
records. These costs will also be listed on the revised HCFA-339 form,
and hospitals will be required to provide the intermediary with a
detailed description of the wage-related costs in Exhibit 7. This
description will allow the intermediary to review the appropriateness
of each wage-related cost. We believe that this core list includes
virtually all significant wage- related costs, including those costs
that are required by statute.
To develop the list of core wage-related costs, the MTAG task force
established a number of specific criteria. To be considered a core
wage-related cost, one or more of the following criteria must be met:
The wage-related cost is provided at a significant
financial cost to the employer.
The wage-related cost is of a type and nature that would
generally be offered as a fringe benefit by most employers.
The perceived value of this wage-related cost is of such
importance that it would influence an individual's employment
decisions.
The wage-related cost is a mandatory requirement under
Federal or State law (for example FICA, Federal and State unemployment,
etc.).
Fees paid to external organizations that are directly
associated with the core wage-related costs may be included as part of
the wage-related cost (for example, actuarial fees, claim
administration fees, IRS form preparation fees, etc.).
The following is the list of core wage-related costs:
(1) Retirement Costs:
401(k) employer contributions
Tax sheltered annuity (TSA) employer contributions
Qualified and non-qualified pension plan cost
Prior year pension service cost
(2) Plan Administration Costs (Paid to external organization):
401(k)/TSA plan administration fees
Legal/accounting/management fees--pension plan
Employee managed care program administration fees
(3) Health and Insurance Costs:
Health insurance (purchased or self-funded)
Prescription drug plan
Dental, hearing, vision plans
Life insurance (if employee is owner or beneficiary)
Accident insurance (if employee is owner or beneficiary)
Disability insurance (if employee is owner or beneficiary)
Long-term care insurance (if employee is owner or beneficiary)
Worker's compensation insurance
Retiree health care cost (only current year, not the extraordinary
accrual required by FASB 106 (that is, the non-cumulative portion))
(4) Taxes:
FICA--employer's portion only
Medicare taxes--employer's portion only
Unemployment insurance
State or Federal unemployment taxes
(5) Other:
Executive deferred compensation
Day care cost and allowances
Tuition reimbursement
b. Other Wage-Related Costs. A hospital may be able to report a
wage-related cost that does not appear on the core list if it meets all
of the following criteria:
The wage-related cost is provided at a significant
financial cost to the employer. To meet this test the individual wage-
related cost must be greater than 1 percent of total salaries after the
direct excluded salaries are removed (Column 3, line 3 on Worksheet S-
3, Part II).
The wage-related cost would be a fringe benefit if
reported to the IRS as a fringe benefit in accordance with IRS
requirements.
The wage-related cost has not been furnished for the
convenience of the provider.
We note that those wage-related costs that are required to be
reported to the IRS as salary (for example, loan forgiveness and sick
pay accruals) would not be included as other wage-related costs, since
the costs associated with these items are considered salaries and would
already be included in the total salaries reported on line 1.01 of the
Worksheet S-3, Part II.
c. Wage-Related Costs (Excluded Area). Wage-related costs
associated with employees in areas of the hospital that are excluded
from the data used to calculate the wage index (such as a hospital-
based SNF) should be removed from the total wage-related costs. This is
not a new policy; however, to ensure that hospitals are removing these
costs, we have added a new line on the Worksheet S-3, Part II.
In addition to the above changes, beginning on or after October 1,
1994, hospitals are required to follow Generally Accepted Accounting
Principles (GAAP) in developing the wage-related costs contained in the
Worksheet S-3, Part II, for purposes of the hospital wage index.
Medicare principles, however, will continue to apply in determining the
allowability of fringe benefit costs. The MTAG task force recommended
application of GAAP for purposes of developing wage-related costs used
to construct the hospital wage index. We believe it is appropriate to
apply GAAP for these purposes because the function of the wage index is
to measure relative hospital labor costs across areas. This function is
distinct from that of cost reimbursement, in which applicable Medicare
principles (which may differ from GAAP) measure the actual costs
incurred by individual hospitals. We believe the application of GAAP
for purposes of compiling data on wage-related costs used to construct
the wage index will more accurately reflect relative labor costs,
because certain wage-related costs (such as pension costs) as recorded
under GAAP tend to be more static from year to year. Application of
Medicare principles, on the other hand, could create large swings in
these costs from year to year, particularly in years when there are
large over- or under-funded pension estimates; such application might
lead to a wage index that does not accurately reflect relative labor
costs. Again, we emphasize that GAAP applies only for purposes of
developing wage-related costs on Worksheet S-3 Part II. Our policy
requiring the use of applicable Medicare principles for determining
fringe benefits for all other purposes remains unchanged.
The revised cost report and the HCFA-339 forms are currently being
evaluated by the Office of Management and Budget. Once these forms are
approved, we propose to implement the form to collect wage data for any
cost report beginning on or after October 1, 1994.
Comment: One commenter believes that the internal administration
costs of many types of core wage-related costs, such as health and
insurance costs, dental, prescription drug plans, etc., should be
included as part of the wage-related cost. The commenter states that
some organizations administer these wage-related costs internally as a
cost-saving measure and that these administration costs should be
included, just as fees paid to external organizations are included in
the calculation of the core wage-related cost. To do otherwise, the
commenter suggested, would encourage a more costly method of
administration and penalize a more efficient one.
Response: In the proposed rule we listed core wage-related costs
including health and insurance costs. We did not intend to exclude
internal administration costs from this list. For example, the proposed
rule included a parenthetical reference that specified that health
insurance costs could be purchased or self-funded (59 FR 27722). We
encourage hospitals to be cost-conscious and efficient in their
administration of health and insurance costs. However, amounts paid to
employees within the hospital are already accounted for in the total
wages paid, and therefore should not be included as part of this wage-
related cost.
Comment: Several commenters addressed the proposed changes to the
reporting of wage-related costs on the Worksheet S-3, Part II.
Virtually all commenters supported the establishment of a core list of
wage-related costs, although many suggested variations in the items
included on the core list. Specifically, commenters suggested we add
items such as: moving expenses, health related costs (that is,
physicals, discounted inpatient and outpatient services), parking
expenses, malpractice expenses, employee assistance programs, hospital
sponsored continuing medical education, professional organization dues,
cafeteria discounts, outpatient services, and any fringe benefit that
is reported to the IRS.
We also received a number of comments with respect to our proposed
criteria for including additional wage-related costs that were not
reflected in the core list. Some stated that the 1 percent criterion
for qualifying as an ``Other'' wage-related cost was too high. A few
commenters suggested that we apply the 1 percent test on total salaries
and wage-related costs prior to the elimination of wages and related
costs for the excluded areas. Other comments stated that the second and
third criteria for qualifying as other wage-related costs are
repetitive, and that we should eliminate the IRS reporting requirement.
Response: We developed the list of core wage-related costs in
conjunction with the MTAG Task Force. Our goal was to establish a list
of commonly recognized costs that contribute significantly to the wage
costs of a hospital and are readily identifiable on the hospital
records. We believe the final core list includes virtually all
significant wage-related costs, including those costs that are required
by statute. As part of the process of developing the core list, members
of the MTAG Task Force conducted a limited analysis to determine what
percentage of total fringe benefits or wage-related costs would be
captured using the core list. On average, this percentage exceeded 90
percent for hospitals that were included in the analysis. However, we
were concerned that individual hospitals might incur unusually large
wage-related costs that are not reflected on the core list but that may
represent a significant wage-related cost. Therefore, the task force
recommended that hospitals be allowed to include other wage-related
costs if they meet each of the three criteria listed above.
The provision to include wage-related costs other than those
reflected on the core list is intended to recognize only those limited
circumstances where a hospital incurs any additional wage-related cost
items that truly represent a significant financial burden to the
hospital, but that also meet the current definition of a fringe benefit
cost. We believe the 1 percent threshold is an appropriate measure of
significance, and that the exclusion of any cost representing less than
1 percent of total salaries would not significantly affect the
hospital's overall average hourly wage. We consider the 1 percent test
critical in ensuring that providers only include other wage-related
costs that contribute significantly to their wage costs and that are
not accounted for in the core list. In addition, we believe the 1
percent test should be calculated using total salaries net of all
direct excluded salaries since the excluded salaries and wage-related
costs are removed from the wage index calculations.
Finally, we believe it is appropriate to retain the IRS reporting
requirement, where applicable. Since there are many cost items that may
or may not qualify as a fringe benefit depending on the individual
hospital's circumstances, we believe this requirement delineates
certain of those costs (such as employee meal costs) as a recognized
fringe benefit cost. Therefore, we believe that the second and third
criteria play important parts in determining the allowability of the
other wage-related costs.
Comment: We also received specific comments concerning retiree
health care costs and professional liability insurance costs. With
respect to retiree health care costs, some commenters requested we
allow not only the current year cost, but also any extraordinary
accruals. One commenter stated that these costs should be eliminated
from the core list because they are unrelated to the current employee
workforce. With respect to professional liability insurance costs,
commenters requested that we clarify those situations where these costs
would be recognized as an ``other'' wage-related cost for purposes of
the wage index.
Response: With respect to retiree health insurance costs, we
believe that the extraordinary accruals should be excluded because such
accruals are not representative of the current wage costs to the
hospital. Although costs associated with retired employees also do not
reflect the current workforce, we believe that the availability of
retiree health insurance benefits is a significant factor affecting the
employment decisions of the current workforce and therefore should be
included as a core wage-related cost.
To clarify the allowability of malpractice insurance costs for
purposes of the wage index, only those policies that list actual names
or specific titles (for example, President of the hospital) of covered
employees may be included in the wage index. General malpractice
liability coverage maintained by hospitals is not recognized as a wage-
related cost for purposes of the wage index. We note that effective
with cost reporting periods beginning on or after October 1, 1994,
malpractice insurance costs related to salaried physicians should be
separately reported since physicians' salary costs may be excluded from
the wage index in FY 1999.
Comment: One commenter requested that HCFA release a summary of the
results of the fringe benefit survey conducted last summer to determine
what costs the health care industry thought should be recognized as
fringe benefits.
Response: We will make the results of the survey available to
anyone requesting the data in writing. Requests may be sent to the
following address: Division of Hospital Payment Policy; Attn: Lana
Price; 1-H-1 East Low Rise; 6325 Security Boulevard; Baltimore,
Maryland 21207.
Comment: A few commenters addressed the exclusion of wage-related
costs associated with excluded areas within the hospital. Commenters
requested detailed guidelines to follow when determining the wage-
related costs for excluded areas.
Response: As indicated in the proposed rule, we are revising the
Worksheet S-3, Part II, to incorporate an additional line to ensure
that wage-related costs for any areas excluded from the wage index
calculation are removed from the total wage-related costs reported by
the hospital. Our policy on the removal of fringe benefits associated
with excluded salaries is not new. Since not all hospitals are able to
specifically identify wage-related costs attributable to individuals
who work in the excluded areas, we believe it is appropriate to exclude
a percentage of wage-related costs based on the relationship between
the salaries paid in the excluded areas of the hospital to total
salaries paid. The hospital must make available to its intermediary
calculations used to determine these excluded wage-related costs.
Comment: Many commenters supported the utilization of Generally
Accepted Accounting Principles (GAAP) in reporting wage-related costs
beginning October 1, 1994. However, a few commenters raised concerns
over its implementation, citing differences between the requirements of
GAAP and the IRS. Since GAAP is not always consistent with IRS rules,
they suggested that IRS rules should not be applied with respect to
items such as tuition reimbursement, automobile/transportation
allowances, or the unrecovered costs of employee meals.
Response: We continue to believe the application of GAAP for
purposes of compiling data on wage-related costs used to construct the
wage index will more accurately reflect relative labor costs, because
certain wage-related costs (such as pension costs) as recorded under
GAAP tend to be more static from year to year.
We have added to the form HCFA-339, Exhibit 7, Part 3, a
reconciliation worksheet to aid hospitals and fiscal intermediaries in
moving between GAAP when developing wage-related costs and Medicare
principles when determining reimbursable costs. All providers must
complete this reconciliation form.
The differences between GAAP and IRS requirements, relate to the
reporting of expenses on an entity's tax return and do not relate to
whether a specific item is a fringe benefit that must be reported to
the IRS as income to the employee receiving the benefit. We believe
that following IRS requirements with respect to the reporting of fringe
benefits as employee income is appropriate. Thus, items such as the
unrecovered cost of employee meals, tuition reimbursement, and auto
allowances will only be allowed as a wage-related cost for purposes of
the wage index if properly reported to the IRS on an employee's W-2
form as a fringe benefit.
Comment: Five commenters suggested that, in addition to excluding
the direct salaries and hours for sub-provider components of the
hospital, HCFA should also exclude the general service, or overhead,
wages and hours that are associated with these areas. Most of the
commenters believe that exclusion of only the direct salaries is unfair
to hospitals with sub-providers since the average hourly wages of the
general service cost centers, such as Dietary/Food Service, and
Housekeeping and Laundry Services, are usually lower than a particular
facility's nursing unit costs. Further, the commenters state that these
hospitals do incur additional general service costs relative to the
exempt area, and these costs should be accounted for in the excluded
wage data. They believe that, by removing the higher nursing costs and
leaving in the lower general service costs, the hospital's average wage
per hour is artificially weighted downward.
Response: In 1993, we considered making an allocation of overhead
salaries and hours for the excluded components of the hospital. In
response to requests from the hospital industry for exclusion of
additional costs, we initiated a special data collection to obtain the
hours associated with workers in the general service areas of those
hospitals that reported excluded salaries and hours. We received
general service hour data for 3,811 of the 5,436 hospitals for which we
had wage data. We analyzed this special survey data in conjunction with
the wage data from the cost report to determine whether we could
reasonably allocate the overhead wages and hours to the excluded areas
of the hospital. For several reasons, we concluded that it was not
feasible to allocate overhead wages and hours to the excluded areas of
the hospital.
Our analysis revealed that the average hourly wage for a large
proportion of hospitals would decrease rather than increase as a result
of performing the allocation. This unexpected result contributed to our
conclusion that the data collected regarding overhead hours were
inaccurate. Because of the large number of hospitals removed through
the edit process, which was discussed in detail in the May 26, 1993
proposed rule (58 FR 30237), the large number of hospitals with large
swings in their average hourly wages, and the large proportion of
hospitals whose average hourly wage would decrease rather than
increase, we continue to believe it would be inappropriate to employ
the allocation of general service salaries and hours to the excluded
areas of hospitals in constructing the FY 1995 wage index.
We agree with these commenters that it would be reasonable to
exclude some portion of the general service costs associated with those
areas of the hospital that are excluded from the wage index calculation
once an accurate and uniform allocation method is devised. Although
many hospitals have attempted to make this calculation independently,
we have instructed the fiscal intermediaries that independently
determined allocation methods are unacceptable. We do not believe it is
appropriate to allow some hospitals to allocate certain overhead
salaries to the excluded areas, while other hospitals do not. We plan
to re-examine this issue based on the data reported on the FY 1992 cost
report, which include the general service hours reported on line 16 of
the Worksheet S-3, Part II, and hope to propose an allocation method
all hospitals can use. In addition, we have proposed a change to the
Worksheet S-3, Part III, to collect overhead cost data for excluded
areas effective with cost reporting periods beginning October 1, 1994.
Therefore, we will continue to collect data and attempt to produce a
more accurate and uniform allocation method that can be used by all
hospitals with excluded areas and that will provide data the
intermediary can verify. We will discuss our analysis of the FY 1992
overhead data in the FY 1996 proposed rule.
Comment: Several of the commenters who supported the proposed
revisions to the reporting of wage data with respect to Part A
physician costs, management contracts, and wage-related costs advocated
the immediate implementation of such changes. They suggested that we
reopen previous cost reports and collect the necessary data to effect a
revised wage index based on these changes as early as FY 1995. They
stated that making these changes effective with cost reports beginning
on or after October 1, 1994 will extend inequities until FY 1999.
Response: Making immediate changes in the wage index based on the
revised reporting requirements would be inappropriate for several
reasons. First, the data necessary to institute these changes
immediately are not available. Currently, relevant detailed data have
not been collected for Part A physician salaries, CRNA services, fringe
benefits or management contracts that would enable us to immediately
implement these changes. Moreover, the collection of additional data
applicable to prior periods would create a significant reporting burden
for hospitals. As indicated earlier, we are revising the Worksheet S-3,
Part II, to identify separately Part A and Part B physician services
for potential exclusion from the wage data.
In addition, it has always been our policy not to apply policy
changes retroactively. The revisions to our policies regarding the
reporting of wage-related costs represent a change in policy. The
current policies are still in effect for the FY 1992 cost reports that
will be used in computing the FY 1996 wage index. Since the prior cost
reporting periods have already ended or are about to close for many
providers, we do not believe it is appropriate to change the reporting
rules retroactively. Further, it would not be fair to hospitals to
require that they retroactively revise their recordkeeping systems to
accommodate these changes.
Finally, while it is true that adjustments to the wage index will
not be reflected until FY 1999, this allows time for hospitals that may
be adversely affected to adjust their fiscal plan. The changes we are
implementing on the reporting of wage data are extensive and will
likely result in some payment shifts. We believe that it is incumbent
upon us to allow hospitals sufficient time to adjust their operations
so they can continue to provide efficient and quality services to all
beneficiaries. Therefore, to ensure that hospitals have ample time to
adjust for the changes in the reporting of wage data, all changes will
be effective for cost reporting periods beginning on or after October
1, 1994, and thus are scheduled to be reflected in the wage index for
FY 1999.
D. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more Metropolitan Statistical Areas (MSAs)
are considered to be located in one of the adjacent MSAs if certain
standards are met. Under section 1886(d)(10) of the Act, the Medicare
Geographic Classification Review Board (MGCRB) considers applications
by hospitals for geographic reclassification for purposes of payment
under the prospective payment system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to which they have been redesignated. Therefore,
pursuant to section 1886(d)(8)(C) of the Act, the wage index values
were determined by considering the following:
If including the wage data for the redesignated hospitals
reduces the MSA wage index value by 1 percentage point or less, the MSA
wage index value determined exclusive of the wage data for the
redesignated hospitals applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals
reduces the wage index value for the area to which the hospitals are
redesignated by more than 1 percentage point, the hospitals that are
redesignated are subject to the wage index value of the area that
results from including the wage data of the redesignated hospitals (the
``combined'' wage index value). However, the wage index value for the
redesignated hospitals cannot be reduced below the wage index value for
the rural areas of the State in which the hospitals are located.
Rural areas whose wage index values would be reduced by
excluding the data for hospitals that have been redesignated to another
area continue to have their wage index calculated as if no
redesignation had occurred. Those rural areas whose wage index value
increases as a result of excluding the wage data for the hospitals that
have been redesignated to another area have their wage index calculated
exclusive of the redesignated hospitals.
The wage index value for an urban area is calculated
exclusive of the wage data for hospitals that have been reclassified to
another area. However, geographic reclassification may not reduce the
wage index for an urban area below the Statewide rural average,
provided the wage index prior to reclassification was greater than the
Statewide rural wage index value.
Section 13501(b) of Public Law 103-66 amended section
1886(d)(8)(C) of the Act to provide that a change in classification of
hospitals from one area to another may not result in the reduction in
the wage index for any urban area whose wage index is below the rural
wage index for the State. This provision also applies to any urban area
that encompasses an entire State.
We note that, except for those rural areas where redesignation
would reduce the rural wage index value, and in the situation described
above that was addressed by section 13501(b) of Public Law 103-66, the
wage index value for each area is computed exclusive of the data for
hospitals that have been redesignated from the area for purposes of
their wage index. As a result, several MSAs listed in Table 4a have no
hospitals remaining in the MSA. This is because all the hospitals
originally in these MSAs have been reclassified to another area by the
MGCRB. For those areas, we have listed the Statewide rural wage index
value.
The revised wage index values effective for discharges occurring on
or after October 1, 1994 are shown in Tables 4a, 4b, and 4c of the
addendum to this final rule. Hospitals that are redesignated should use
the wage index values shown in Table 4c. For some areas, more than one
wage index value will be shown in Table 4c. This occurs when hospitals
from more than one State are included in the group of redesignated
hospitals, and one State has a higher Statewide rural wage index value
than the wage index value otherwise applicable to the redesignated
hospitals. Tables 4d and 4e list the average hourly wage for each labor
market area based on the FY 1991 wage data. In addition, we have
expanded Table 3c (Hospital Case-Mix Indexes for Discharges) to include
the average hourly wage for each hospital based on the FY 1991 data.
Hospitals may use the average hourly wage published in the final rule
for purposes of applying to the MGCRB for wage index reclassifications
in FY 1996. We note that in adjudicating these wage reclassification
requests during FY 1995, the MGCRB will use the average hourly wages
for each hospital and labor market area that are reflected in the final
FY 1995 wage index.
The FY 1995 wage index values incorporate all reclassification
decisions made by the MGCRB for FY 1995. At the time the final wage
index was constructed, the MGCRB had completed its review. Any changes
to the wage index that result from withdrawals of requests for
reclassification, wage index corrections, appeals, and the
Administrator's review process have also been incorporated into the
wage index values published in this final rule. There were 425
hospitals redesignated for purposes of the wage index (including
hospitals redesignated under both sections 1886(d)(8)(B) and
1886(d)(10) of the Act).
Comment: One commenter suggested that we incorporate the MSA code
for each area in table 4A.
Response: Since many users may have a need for the MSA code, we
have revised Table 4A by including the 4-digit MSA code to the left of
the name of each area.
E. Impact of the Revised Hospital Wage Index
Section 1886(d)(3)(E) of the Act requires that the wage index be
updated annually beginning October 1, 1993. In addition, this section
requires that updates to the hospital wage index be budget neutral. The
FY 1995 wage index represents the second annual update to the wage
data. We used the wage data from the FY 1991 Medicare cost report to
calculate the updated wage index. For FY 1995, the wage index will
continue to include salaries, fringe benefits, home office salaries,
and certain contract labor salaries. In the past, updates to the wage
data have resulted in significant payment shifts among hospitals. Since
the wage index is now updated annually and there are no changes to the
types of costs included in the wage index data, we expect these payment
fluctuations will be minimized. Based on the wage index calculation
(after reclassifications under sections 1886(d)(8)(B) and 1886(d)(10)
of the Act), there is a significant drop, compared with previous years,
in the number of labor markets that experience major increases or
decreases in wage index values. We reviewed the data for any area that
experienced a wage index change of 10 percent or more to determine the
reason for the fluctuation. When necessary, we contacted the
intermediaries to determine the validity of the data, or to obtain an
explanation for the change. Our review indicated that most of the
significant changes were attributable to improved reporting by
hospitals.
The following chart compares the shifts in wage index values (after
reclassifications) for labor markets for FY 1995 with those experienced
as a result of last year's wage index update.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values -----------------
FY 1995 FY 1994
------------------------------------------------------------------------
Increase more than 10 percent......................... 2 13
Increase between 5 and 10 percent..................... 4 24
Decrease between 5 and 10 percent..................... 13 58
Decrease more than 10 percent......................... 10 14
------------------------------------------------------------------------
Under the FY 1995 wage index, 90.6 percent of all prospective
payment hospitals (5,325 hospitals) would experience a change in their
wage index value of less than 5.0 percent. Approximately 4.7 percent
(248 hospitals) would experience a change of between 5 and 10 percent,
and 4.8 percent (255 hospitals) would experience a change of more than
10 percent. The following chart shows the projected impact for urban
and rural hospitals. (The totals in this chart exceed the number of
hospitals in our database because our projection includes new hospitals
and hospitals that for other reasons are not included in our wage
file.)
------------------------------------------------------------------------
Number of
hospitals
Percentage change in area wage index values -----------------
Rural Urban
------------------------------------------------------------------------
Decrease more than 10 percent......................... 98 70
Decrease between 5 and 10 percent..................... 24 61
Change between -5 and +5 percent...................... 2,116 2,706
Increase between 5 and 10 percent..................... 41 122
Increase more than 10 percent......................... 68 19
------------------------------------------------------------------------
F. Medicare Geographic Classification Review Board--Elimination of the
Adjacency Requirement for Individual Hospital Reclassifications
1. Background
Section 1886(d)(10) of the Social Security Act (the Act) provides
for the establishment of the Medicare Geographic Classification Review
Board (MGCRB). The MGCRB is responsible for issuing decisions on
applications submitted by hospitals seeking reclassification to another
geographic area for purposes of payment under the prospective payment
system. The MGCRB is required by statute to issue decisions on hospital
applications no later than 180 days after October 1, the first day of
the Federal fiscal year (FY) preceding the Federal fiscal year for
which the hospital is seeking reclassification. Hospitals may be
reclassified individually for purposes of their wage index,
standardized amount, or both. Hospitals may also be reclassified as a
group for purposes of both the wage index and the standardized amount,
but not solely for one of these measures.
Guidelines concerning the criteria and conditions for hospital
reclassification are located at 42 CFR Secs. 412.230 through 412.236.
Currently, Sec. 412.230(a)(2) specifies that to qualify for
reclassification, an individual hospital must be located in a county or
MSA that is adjacent to the area to which it seeks reclassification
(``the adjacency requirement''). In addition, under Sec. 412.230(a)(3),
a hospital must meet one of the geographic proximity criteria set forth
at Sec. 412.230(b) (``the proximity requirement''). Specifically, to
meet the proximity requirement, either the distance from a hospital to
the adjacent area to which it seeks reclassification must be no more
than 15 miles for an urban hospital and no more than 35 miles for a
rural hospital, or at least 50 percent of the hospital's employees must
reside in the adjacent area. (Under Sec. 412.230(a)(4), rural referral
centers and sole community hospitals are not subject to the adjacency
or proximity requirements.)
On May 6, 1994, in Athens Community Hospital, Inc. v. Shalala, 21
F.3d 1176 (D.C. Cir. 1994) (``Athens''), the United States Court of
Appeals for the District of Columbia Circuit ruled on the validity of
the adjacency requirement as applied to individual rural hospitals. The
Court of Appeals noted that the Secretary had already demonstrated in
previous litigation that geographic proximity is relevant to
determining whether a hospital competes in a particular area for labor.
Athens at 1175. In Universal Health Services of McAllen v. Sullivan,
770 F. Supp. 704 (D.D.C. 1991), aff'd mem., 978 F.2d 745 (D.C. Cir.
1992), the court had upheld the proximity criterion that requires a
rural hospital seeking reclassification to an urban area to demonstrate
that it is no more than 35 miles from the area to which it seeks
redesignation.
In the Athens decision, the Court of Appeals found that the
proximity requirement's mileage criteria ensure that a hospital is
geographically proximate to the county to which it seeks
reclassification. Athens at 1176. The court further concluded that, as
a supplement to the proximity requirement, the adjacency requirement
has no additional role to play in determining the labor markets in
which a hospital competes. The court invalidated the adjacency
requirement for individual rural hospital reclassifications. Athens at
1176.
2. Elimination of the Adjacency Requirement
We have decided to acquiesce in the Athens decision by eliminating
the adjacency requirement for individual hospitals seeking geographic
reclassification for purposes of the prospective payment system.
(Although the court's ruling specifically pertains only to the
adjacency requirement as it is applied to individual rural hospitals,
we are eliminating the requirement for individual urban hospitals as
well.) As a result of our acquiescence in the Athens decision, an
individual hospital will no longer be required to demonstrate that the
county or MSA in which it is located is adjacent to the area to which
it seeks reclassification. However, individual hospitals seeking
reclassification to another area still must meet the proximity criteria
at Sec. 412.230(b) (except for sole community hospitals and rural
referral centers, as specified in current Sec. 412.230(a)(4)).
This change, which eliminates the adjacency requirement for
individual hospitals, is effective for applications submitted by
October 3, 1994, for hospitals seeking reclassification for FY 1996. We
also are removing the provision in Sec. 412.230(a)(4)(i) that excepted
sole community hospitals and rural referral centers from the adjacency
requirement. Since the adjacency requirement will no longer apply to
any individual hospital applying for reclassification, this provision
is unnecessary.
Although we are eliminating the adjacency criteria for individual
hospital reclassifications, our policies regarding hospitals seeking
group reclassifications under Sec. 412.232 and Sec. 412.234 remain
unchanged. As discussed above, the Athens decision applies only to
individual hospital reclassifications. The court found that the
proximity requirement alone is sufficient to determine whether an
individual hospital is geographically proximate to the area to which it
seeks reclassification. Thus, the court found that for an individual
hospital, the adjacency requirement is an unnecessary supplement to the
proximity requirement. However, urban and rural hospitals applying for
reclassification as a group are not required to meet proximity
requirements similar to those set forth at Sec. 412.230(b). Thus, we
have determined that the adjacency requirement is necessary to
guarantee geographic proximity for hospitals applying for
reclassification as a group.
Accordingly, the elimination of the adjacency requirement only
applies to individual hospitals that are required to meet the proximity
requirements set forth at Sec. 412.230(b). Finally, we note that the
alternative reclassification criteria for hospitals located in a New
England County Metropolitan Area (NECMA), as set forth under
Sec. 412.236 (b) and (c), are also unaffected by this final rule.
3. Provisions of This Final Rule Concerning Geographic Reclassification
Criteria
To implement the policies discussed above, we are amending
Sec. 412.230 as follows:
We are eliminating the adjacency requirement for
individual hospital reclassifications by deleting paragraph (a)(2);
We are redesignating paragraphs (a)(3) through (a)(5) of
Sec. 412.230 as (a)(2) through (a)(4);
We are removing the exception to the adjacency provision
for sole community hospitals and rural referral centers, which is now
unnecessary, by deleting redesignated paragraph (a)(3)(i). (Paragraphs
(a)(3)(ii) through (a)(3)(v) are redesignated as (a)(3)(i) through
(a)(3)(iv)); and
We are making a series of technical changes to
Sec. 412.230 to eliminate references to ``adjacent area'' and to
correct internal cross references.
G. Application for Geographic Reclassification in FY 1996
Hospitals that intend to apply for geographic reclassification for
FY 1996 should make note of the following information regarding the
submission of applications to the MGCRB. First, the statutory deadline
for filing applications with the MGCRB for FY 1996 reclassifications is
October 1, 1994. However, since this date falls on a Saturday, the
MGCRB will accept applications through October 3, 1994, the first
Federal working day following the usual deadline. This extension is
consistent with the provisions in section 216(j) of the Act, which
apply to the Medicare program by virtue of section 1872 of the Act.
Applications must be received by the MGCRB by close of business on
October 3, 1994, in order to be considered timely. Untimely
applications will not be accepted. Hospitals are expected to undertake
the appropriate measures to ensure that their applications are received
by the MGCRB in a timely manner.
In addition, we note that the MGCRB has moved to a new address. All
MGCRB applications should be sent to the following address: Medicare
Geographic Classification Review Board, Professional Building, 6660
Security Boulevard, Suite 13, Baltimore, Maryland 21207-5187. The MGCRB
is not responsible for applications that are not received timely due to
an incorrect address. We received one comment on the MGCRB application
process.
Comment: One commenter noted that hospitals have 45 days from
publication of the proposed rule to withdraw their applications for
geographic reclassification. The commenter asserted that since changes
may occur in the wage index values between the publication of the
proposed rule and the final rule due to editing and the correction of
errors in the FY 1991 data, hospitals should be permitted to withdraw
their applications up to 15 days after the publication of the final
rule.
Response: We continue to believe that the proposed rule constitutes
the latest feasible resource for providing hospitals with the necessary
information to decide whether to withdraw requests for
reclassification. We recognize that the proposed wage index values may
change somewhat as a result of withdrawal requests, the effect of any
decisions by the MGCRB or the Administrator that were not issued in
time to be taken into account in the proposed rule, and the effect of
any further corrections to the wage data.
It is important to note, however, that withdrawals that occur after
the 45-day deadline have a direct impact on the area wage index values
both for the area in which the hospital is located and the area to
which it had previously been reclassified. Therefore, we cannot extend
the 45-day deadline, because doing so would not provide sufficient time
to take withdrawals into account in the development of the final wage
index and prospective payment system rates. We note that although
hospitals are permitted to withdraw their applications for
reclassification at any time during the 45-day period, if an MGCRB
decision has already been made, a hospital that requests that its
application be withdrawn may not request that the MGCRB decision be
reinstated after publication of the prospective payment system final
rule.
IV. Other Changes to the Prospective Payment System for Inpatient
Operating Costs
A. Definition of and Payment for Transfer Cases (Sec. 412.4)
The prospective payment system distinguishes between
``discharges,'' situations in which a patient leaves an acute-care
hospital after receiving complete treatment, and ``transfers,''
situations in which the patient is transferred to another acute-care
hospital for related care. If a full DRG payment were made to each
hospital involved in a transfer situation irrespective of the length of
time the patient spent in the ``sending'' hospital prior to transfer,
this would create a strong incentive to increase transfers, thereby
unnecessarily endangering patients' health. Therefore, the regulations
at Sec. 412.4(d) provide that, in a transfer situation, full payment is
made to the final discharging hospital and each transferring hospital
is paid a per diem rate for each day of the stay, not to exceed the
full DRG payment that would have been made if the patient had been
discharged without being transferred.
Currently, the per diem rate paid to a transferring hospital is
determined by dividing the full DRG payment that would have been paid
in a nontransfer situation by the geometric mean length-of-stay for the
DRG into which the case falls. Transferring hospitals are also eligible
for outlier payments for cases that meet the cost outlier criteria
established for all other cases (nontransfer and transfer cases alike)
classified to the DRG. They are not, however, eligible for day outlier
payments. Two exceptions to the transfer payment policy are transfer
cases classified into DRG 385 (Neonates, Died or Transferred to Another
Acute Care Facility) or DRG 456 (Burns, Transferred to Another Acute
Care Facility), which are not paid on a per diem basis but instead
receive the full DRG payment.
1. Definition of a Transfer Case
Under current policy, cases that are transferred from an acute care
area paid under the prospective payment system to a hospital or unit
excluded from the prospective payment system are considered to be
discharges (as opposed to transfers) from the acute care hospital. As a
discharge, payment for the case is the full DRG amount.
For the most part, inpatient hospital services furnished by
hospitals and units excluded from the prospective payment system are
paid on a reasonable cost basis, subject to a cost per discharge limit.
This payment does not vary by source of admission or discharge
destination. Under Secs. 412.22 through 412.29, the following types of
facilities are identified as being excluded from the prospective
payment system: psychiatric hospitals and distinct part units;
rehabilitation hospitals and distinct part units; long-term care
hospitals; cancer hospitals; children's hospitals; hospitals outside
the 50 States, the District of Columbia, or Puerto Rico; Veterans
Administration and other Federal hospitals; and nonparticipating
hospitals furnishing emergency services to Medicare beneficiaries. Also
listed in Sec. 412.22(c) (2) and (3) are hospitals paid under approved
State cost control systems and hospitals paid in accordance with
authorized demonstration projects. Under Sec. 412.4(b)(3)(i), patients
moving from an acute care hospital paid under the prospective payment
system to hospitals within either of these categories are currently
considered transfers, and therefore they are not referred to in the
following discussion.
Since implementation of the prospective payment system over 10
years ago the distinctions between the types of services provided in
acute care hospitals and excluded hospitals and hospital units have
become less clear. Acute care hospitals may have an incentive to reduce
patient lengths of stay, and thus patient costs, in order to maximize
profits since payment is no longer linked to actual costs. This has led
to a steady increase in the numbers of excluded hospitals and units, as
well as postacute-care facilities, as acute-care hospitals look to
discharge patients whom heretofore they were treating until the
patients were ready to be discharged to their homes. (See Langenbruner
et al., Health Care Financing Review, Spring 1989.)
As part of a study of Medicare transfer cases funded by HCFA
(``Transfers of Medicare Hospital Patients under the Prospective
Payment System'', PM-191-HCFA, January 1994), RAND examined trends in
transfer episodes from FY 1987 to FY 1991. RAND's analysis found that,
from 1987 to 1991, while transfers from one prospective payment system
setting to another increased 4.1 percent, transfers from a prospective
payment system setting to excluded rehabilitation units and excluded
psychiatric units increased 18.9 percent and 7.0 percent, respectively.
We believe that this growth in transfers to excluded hospital units is
an indication that the distinction in the types of services provided in
short-term, acute care settings and excluded settings is not as
significant as it was in 1983.
We strongly believe that patients should be treated in settings
that are best suited to provide the levels of care the patients need.
Decisions regarding the most appropriate setting should be based on
clinical criteria. To help ensure that this occurs, to the greatest
extent practicable, financial incentives should be neutral regarding
the setting wherein a patient is treated. This means matching payments
as nearly as possible to the resources required to treat the patient.
We believe our current definition of transfer cases may provide
financial incentives on the acute-care side to transfer patients to
excluded hospitals and units in order to reduce lengths of stay and at
the same time receive payment at the full DRG amount. These incentives
may exist whether the acute-care hospital is transferring patients to
its hospital-based excluded units or to other excluded hospitals.
For these reasons, we proposed to change our definition of a
transfer case by adding new Sec. 412.4(b)(4) to include cases
transferred from an acute-care setting paid under the prospective
payment system to an excluded hospital or unit. We believed that this
policy would more appropriately pay those prospective payment hospitals
that are transferring patients to an excluded hospital or unit before
completion of a course of treatment. The proposed policy would have
applied to cases transferred to all excluded hospitals and units,
Veterans Administration hospitals, other Federal hospitals, and
hospitals not participating in Medicare. However, discharges to
nonhospital settings, such as skilled nursing facilities and
intermediate care facilities, would still be paid as discharges.
2. Payment for Transfer Cases
Since the inception of the prospective payment system, there has
been concern that a flat per diem payment rate for transfer cases fails
to account for the likelihood that the beginning of a patient's
hospitalization is the most resource intensive portion of the stay.
Comments received in response to the September 1, 1983 interim final
rule, which first implemented the prospective payment system,
recommended that the transferring hospital should either receive the
full DRG amount or be paid on a sliding scale to reflect the higher
costs of the first few days of a patient's stay. Our response at that
time was that little or no data were provided in support of this
position (49 FR 245; January 3, 1984).
In 1993, as a part of a study of transfer case payment, RAND found
that among cases transferred prior to reaching the mean length-of-stay,
1-day stays cost 2.096 times the per diem payment amount for cases in
nonsurgical DRGs (based on the geometric mean length of stay) and 2.576
times the per diem for surgical DRGs. Among nonsurgical transfer cases,
the costs of the second day are about 1.215 times the per diem payment
amount, and the costs after the second day are about 10 percent more
than the applicable per diem amount. Among surgical cases, the costs
per day beyond 2 or more days are actually about 7 percent below the
applicable per diem amount.
To evaluate the impact of replacing the flat per diem methodology
with one designed to reflect the observed relationship between costs
and the first few days of hospitalization, RAND simulated a transfer
payment methodology that multiplies the per diem amounts by the
coefficients referred to above. The improvement in payment-to-cost
ratios for per diem transfer cases was significant, from 0.7224 under
current policy to 0.9722 using the scaled per diem.
We did not propose a change to the transfer payment policy last
year, however, due to concerns over the specification of the transfer
payment formula. First, the coefficients used to graduate the per diem
amount are dependent on the specification of the model and the data
employed. Ensuring the continued validity of the per diem weighting
factors would require frequent reestimation as other payment parameters
change and more recent data become available.
Second, we were concerned that weighting the per diem amounts by
the coefficients directly from the regression may overstate the
precision of the estimates of costs per day prior to transfer. Because
available data do not attribute charges or costs to a particular day,
the estimated costs for each additional day reflect the incrementally
higher costs per case compared to transfers occurring 1 day earlier.
If, in transfers occurring after 3 or more days, for example, costs per
day were more evenly distributed than the graduated per diem payments,
the coefficients in the regression might not reflect the costs of
additional days.
This leads to a third concern, that the graduation of the scaled
per diem amounts may generate inappropriate incentives to transfer
patients as soon as possible, that is, before the point at which costs
equal payments. This incentive could arise, for example, for cases in
which payments early in a patient's stay are greater than costs (that
is, cases with more even costs throughout the stay rather than high
costs in the first day or two). In such cases, the longer the patient
stays in the hospital, the more likely that total costs will approach
total payments. Under this scenario, a hospital seeking to maximize its
profit could do so by transferring the patient as soon as possible.
Despite these concerns, we proposed at Sec. 412.4(d)(1) to pay
transfers twice the per diem amount for the first day of any transfer
stay plus the per diem amount for each of the remaining days prior to
transfer, up to the full DRG amount. We believed that the potential
improvement in payment equity outweighed the concerns of the proposal.
We proposed that this change be applied uniformly for both medical and
surgical transfer cases; although surgical transfer cases appear to be
more costly, on average, the first day, they are relatively less costly
for the second day and beyond.
Using the graduated per diem methodology we proposed, RAND
estimated the payment-to-cost ratio of transfer cases that were
transferred prior to reaching the geometric mean length of stay would
be 0.9321. While this is somewhat less than the payment-to-cost ratio
for nontransfer cases (0.9645), it represents a significant improvement
over the current ratio for these cases (0.7224).
Since publication of the September 1, 1993 final rule, RAND has
completed the second and final phase of its study. This phase of the
study focused on the receiving hospitals and how they fare under our
current transfer payment policy. Their findings in this regard were
more ambiguous than in the case of sending hospitals. RAND performed
regressions on transfer cases in receiving hospitals to determine
whether these cases were more expensive than nontransfer cases within
the same DRGs. They found no consistent relationship.
Over 60 percent of all transfer cases were assigned DRGs from MDC 5
(Diseases and Disorders of the Circulatory System). According to RAND,
``. . . for the surgical DRGs in MDC 5 (DRGs 104 through 116), the
costs of transfer cases relative to nontransfer cases at the same
hospital range from almost the same (in DRG 106, coefficient = 0.007)
to about 11 percent greater (DRG 105, coefficient = 0.105). In the
medical DRGs in MDC 5, the range is even wider, with transfers received
into DRG 121 and 122 actually costing less than other cases in the same
DRG at the same hospital and transfers received in DRG 127 costing 37
percent more.'' (See RAND page 40.)
Based on these results, RAND did not recommend and we did not
propose any change in the payments for the receiving hospital in a
transfer episode. That is, if the receiving hospital is also the final
discharging hospital, they will be paid the full DRG amount plus any
outlier payments they are eligible to receive (under either the day or
cost outlier thresholds). If the patient is transferred again prior to
discharge, then, under the change we proposed, the sending hospital in
this second transfer episode would be paid using the graduated per diem
methodology, rather than the flat per diem rate they currently receive.
We received over 1000 comments on the transfer policy proposals,
the majority of which disagreed with our proposed revision in the
transfer definition. Based on these comments and further analysis we
are not making the proposed changes to our transfer policies in this
final rule. However, we intend to continue to analyze our policies.
Comment: The most frequent comments were objections to our
rationale for proposing the change. Many stated that this proposal was
an overreaching attempt to address a small number of inappropriate
transfers by penalizing all transfers to excluded hospitals and units.
Many of the commenters stated that the problem should be addressed
through Peer Review Organizations rather than through our proposal.
Other commenters questioned our analytic basis for the change,
pointing out that they believe we misinterpreted the studies referenced
in the proposed rule, and that the real reason for the increase in the
number of excluded hospitals and units and the corresponding increase
in the number of transfers is the clinical needs of the Medicare
patients. Similarly, many commenters asserted that, contrary to the
assertions in the proposed rule, the distinctions between the types of
services provided in short-term acute care settings and excluded
hospital settings is more significant now than it was in 1983.
Response: We believe that the majority of the commenters
misunderstood our rationale for this proposed change. A primary
objective in proposing this change was to improve the extent to which
payments match the cost of the services provided in each of the various
settings involved in the course of treatment of a particular patient.
Our proposal to pay the transferring acute care hospital a per diem
amount is based upon the premise that an increasing number of patients
are being transferred to excluded hospitals or units and that these
patients are still in the acute care phase of treatment when they are
transferred (we note that many commenters agreed with this premise). As
these excluded settings are treating more severely ill patients and
receiving correspondingly higher payment amounts from Medicare
(particularly through adjustments to the limits on the rate-of-increase
in their operating costs per case), we believe it is more appropriate
to define these cases as transfers under the same logic applied to
cases transferred from one acute care hospital to another; that is, the
transferring hospital generally is not providing the entire course of
treatment associated with the DRG.
As noted in the proposed rule (59 FR 27735), when the prospective
payment system was implemented in 1983, we believed that the transfer
of patients to excluded hospitals or units indicated that the acute
phase of their treatment was completed and that payment in full to the
transferring hospitals for that treatment was warranted. We believe
this has changed. Patients who 10 years ago would have stayed in an
acute care hospital throughout their course of treatment are now being
transferred to excluded settings, and these transfers are occurring
earlier during the acute hospital stay. Consistent with the data we
cite in the proposed rule indicating increased utilization of excluded
facilities, many of the commenters noted that there is an increasing
emphasis on beginning rehabilitative therapy as soon as possible.
We did not mean to imply (as some commenters inferred) that we view
this trend as inappropriate. On the contrary, we developed the proposal
under the assumption that increasing transfers to excluded settings
would continue in the future. The important point is simply that we
believe that there is now substantial overlap in the care being
provided by acute care and excluded facilities, particularly with
regard to inpatient rehabilitation settings. As one rehabilitation
professional commented, ``Inpatient rehabilitation units are equipped
medically and staffed to handle many continuing medical problems.''
Our second objective in proposing this change was to ensure that
the payment methodology, as much as practicable, is neutral in terms of
any incentives affecting where and how patients are treated. To the
extent that the transfer payment methodology is representative of the
average per diem costs hospitals incur for these cases, we disagree
with the argument that our proposal would penalize acute care hospitals
for transferring patients to excluded facilities. To the contrary,
paying the full DRG amount for these cases rewards hospitals for
transferring patients as soon as possible, particularly as excluded
facilities have equipped themselves to treat more acutely ill patients.
Again, we wish to emphasize that we are not under the assumption that
the general trend toward earlier discharges is in itself inappropriate.
We agree with the commenters that we do not have evidence that patient
care has suffered overall as a result of this trend. Rather, we
proposed the change in definition of a transfer because we believed
that a per diem payment, based on average costs per day within specific
DRGs, would more appropriately compensate the acute care hospital.
Comment: Numerous commenters questioned whether our objective was
to create an incentive to send patients to skilled nursing facilities
(SNFs) or other postacute or subacute settings. They noted that,
although SNFs are increasingly providing rehabilitative services and,
in some cases, competing with inpatient rehabilitation facilities, few,
if any, SNFs are accredited by the Commission on Accreditation of
Rehabilitation Facilities. Many commenters opined that, rather than
neutralizing the incentives affecting where patients are treated, the
proposed change would create a financial incentive for acute care
hospitals to transfer patients to SNFs instead of rehabilitation
facilities, since they would receive a full DRG payment for these
cases. Most of the commenters expressed a belief that the proposal
would have a detrimental impact on patient care.
Response: Our proposal was not intended to create an incentive for
hospitals to transfer patients to SNFs for rehabilitation services in
order to save money. Rather, we remain committed to ensuring that the
payment system not unduly influence the choice of setting in which
patients are treated. We did not propose to consider discharges to SNFs
as transfers because we do not consider SNFs to be hospital settings;
thus, there is generally little overlap with acute care hospitals in
the services provided. In fact, the unanimous opinion expressed by the
commenters was that SNFs and other post-hospital care providers do not
generally provide the same intensity of services as rehabilitation
hospitals and units.
Nevertheless, we are concerned that the criteria used to indicate
the most appropriate rehabilitation setting may not be well understood.
Although we believe that decisions regarding appropriate settings will
predominantly be made based on the clinical needs of the patient, we
intend to study this issue further. In particular, we will explore the
implications associated with use of the Uniform Needs Assessment
Instrument for determining appropriate post-acute hospital settings.
Comment: We received some comments stating that we failed to
document the impacts our proposal would have on hospital payment.
Response: In Appendix A (Regulatory Impact Analysis) to the
proposed rule (59 FR 27847), we analyzed the impacts on hospital
payment of all of the proposed FY 1995 changes, including the transfer
changes. That analysis found that the combined impacts of the proposed
changes to the transfer policy (that is, to the payment methodology and
the definition of transfers) was budget neutral across all hospitals.
The higher payments for transfer cases due to the proposed graduated
per diem methodology were offset by the reduction in payments for
transfers to excluded settings. Among specific categories, the changes
generally affected urban hospitals negatively (0.1 percent) and rural
hospitals positively (0.5 percent). The impact on small hospitals was
also positive.
In response to the commenters, we have also evaluated the impact of
the proposed transfer definitional change by itself. Transfers to
rehabilitation settings account for nearly 78 percent of the total
transfers from acute care to excluded settings (rehabilitation units
account for over one-half of these transfers). Because rehabilitation
settings receive such a large percentage of transfers, and because the
vast majority of comments we received pertained to the impact on
rehabilitation facilities of the change, we focused our analysis on
cases going to rehabilitation settings. Of these transfers, three DRGs
stood out because of the large number of such transfer cases: DRG 14,
Specific Cerebrovascular Disorders Except TIA; DRG 209, Major Joint and
Limb Reattachment Procedures--Lower Extremity; and DRG 210, Hip and
Femur Procedures Except Major Joint Age >17 With CC. We also examined
DRG 483, Tracheostomy Except For Face, Mouth and Neck Diagnoses.
Although it presently constitutes a much smaller percentage of transfer
cases, it is of special concern because of its high DRG weight (and
payment) and long average length of stay.
We analyzed how well our payment methodology would compensate
hospitals for the costs of cases in these DRGs when patients are
transferred to excluded settings prior to reaching the geometric mean
length of stay for the DRG, minus one. (Based on the proposed change in
payment methodology, a full DRG payment is received at that point). The
results of our analysis are as follows. First, for each of these DRGs,
over 90 percent of the cases are transferred to excluded settings after
the geometric mean length of stay minus one, and, thus, would be
unaffected by the change in definition of a transfer (except for cases
that may qualify as a day outlier, since transfers are ineligible for
this adjustment). Second, for DRGs 14 and 483, the costs of these cases
progress evenly with length of stay, indicating that a per diem payment
methodology would adequately compensate for the costs incurred prior to
transfer.
A problem arises, however, with DRGs 209 and 210. Consistent with
RAND's analysis of the per diem costs of transfers of surgical DRGs
between two acute care settings, the bulk of the costs appear to occur
during the first day of the acute care stay. In fact, costs in DRGs 209
and 210 appear to be even more heavily skewed toward the first day than
RAND found. This is of significant concern, given that these DRGs
account for such a high proportion of transfers to excluded facilities.
(RAND found, consistent with prior analyses, that surgical DRGs
comprise only a fraction of transfers between acute care hospitals).
Even with the proposed change in the per diem payment methodology,
hospitals would be systematically underpaid for short-stay cases on
DRGs 209 and 210 if we were to adopt the proposed change in transfer
definition.
Therefore, we have decided to withdraw this proposal at this time.
Thus, transfers from acute care hospitals to hospitals and units
excluded from the prospective payment system will continue to be
considered discharges. We wish to emphasize that we remain concerned
about the appropriateness of this policy and intend to continue our
research in this area.
Comment: The comments we received regarding the change to the per
diem payment methodology were generally favorable. One commenter
recommended that we provide for different gradations to the per diem
for medical and surgical cases. Another, while supporting the change in
principle, felt that we should pay more than twice the per diem for the
first day of a transfer stay. Several commenters indicated their belief
that the standardized amounts for all hospitals would have to be
recalculated to reflect our proposed changes to transfer policy.
Response: We are also withdrawing the proposed change to the
payment methodology for transfer cases. In assessing the
appropriateness of the proposed change, we must balance the merits
against the problems. As discussed above and in the proposed rule (59
FR 27736), we have several concerns with a graduated payment
methodology, such as problems in specifying the gradation and possible
incentives to transfer. (See also the discussion in the September 1,
1993 final rule (58 FR 46307).) Nevertheless, we proposed to change the
payment methodology because we believed the benefits outweighed the
problems.
In the proposed rule, we estimated that the proposed change to the
transfer payment methodology in conjunction with the proposed change to
the definition of transfer would result in zero net impact on overall
spending (59 FR 27854). However, as explained above, we are withdrawing
the proposal to change the definition of transfers. Accordingly, the
financial impact of the proposed payment methodology must be
reevaluated. We estimate that the costs of the proposed change in
payment methodology, standing alone, would be just over $150 million.
This cost must be considered together with the other factors
arguing for and against a change to the payment methodology. Given
those other factors, and given current Federal budgetary constraints,
we do not feel it would be appropriate to change the transfer payment
methodology absent an offsetting savings provision. We note that, in
its March 1, 1993 report to Congress, ProPAC recommended that Congress
provide authority to HCFA to implement a graduated payment methodology
in a budget neutral manner; as yet, no such legislative change has been
enacted.
Comment: We received several other more general comments with
respect to our proposed transfer changes. Some commenters believe that
the prospective payment system is a self-correcting system; thus, it is
inappropriate to reduce payments for discharges made before the mean
length of stay without similarly adjusting payments upward for
discharges made beyond the mean length of stay. Reducing payment alone
penalizes efficient hospitals, which is contrary to the objectives of
the prospective payment system. Other commenters, including ProPAC,
noted the health reform movements toward a continuum of care, although
ProPAC did not express the view of some commenters that the proposed
change to transfer definitions was contrary to this movement. In its
comments, ProPAC also discussed its findings with regard to hospitals
that receive high percentages of transfer cases, primarily that these
incoming transfers frequently become outlier cases. The Commission
referred to its comments on outlier policy in this regard.
Response: During the next year, we intend to continue our
evaluation of all aspects of transfer payment policy. Our analysis has
indicated several areas for potential improvements that we believe
should be addressed in a comprehensive manner. We disagree with the
comment that it is inappropriate to reduce payments for transfers
without increasing payments beyond the mean length of stay, since we do
increase payments at the high cost end through our outlier policy, but
we do intend to carefully examine the overall symmetry of the
prospective payment system in terms of payment equity at both the low
and high ends of inpatient stays. As part of that examination, we will
approach this analysis from a perspective that recognizes the
increasing movement of patients in and out of various treatment
settings.
B. Review of DRG Assignments (Sec. 412.60, 466.71, and 466.78)
Under the provisions of Sec. 412.60(d), a hospital has 60 days from
the date of the notice of the initial DRG assignment of a claim to
request review of that assignment. The hospital may submit additional
information as part of its request. The intermediary reviews the
request and any additional information and decides if a change in the
assignment is appropriate. Any change by the intermediary to a higher-
weighted DRG must be reviewed by the hospital's Peer Review
Organization (PRO) to determine if the request and the change are
appropriate.
Under the first PRO contract cycle, this review was conducted on a
postpayment basis. However, the second PRO contract, effective July 1,
1986, required that this review be conducted on a prepayment basis.
Therefore, Sec. 412.60(d)(2) currently provides that the intermediary
must request that the PRO review any change in assignment to a higher-
weighted DRG.
Under the fourth contract cycle, the PROs are no longer required to
review these cases on a prepayment basis. Rather, the cases are flagged
and the PRO conducts a 100 percent review after payment. Therefore, we
proposed to revise Sec. 412.60(d)(2) to conform the regulations to
current practice. At the same time, we proposed to revise an incorrect
cross-reference to the regulations that govern the PROs' review of
these DRG reassignments. The correct cross-reference is
Sec. 466.71(c)(2).
We received one comment on this proposal, which was in favor of the
change. Thus, we are incorporating the proposed change concerning the
PRO review of DRG assignments in this final rule. In addition, we are
making technical changes Secs. 466.71(c)(2) and 466.78(a) to conform
the text of those sections to this revised policy.
C. National Average Standardized Amounts for FY 1995 (Sec. 412.63)
Section 1886(d)(3)(A) of the Act directs the Secretary to compute
national average standardized amounts for use in determining payments
for inpatient operating services, updated annually by the applicable
percentage increase set forth under section 1886(b)(3)(B) of the Act.
Under section 1886(d)(3)(A)(ii) of the Act, for FYs 1988 through 1994,
the Secretary has computed separate national average standardized
amounts for large urban, other urban and rural areas. However, section
1886(d)(3)(A)(iii) of the Act requires that, for discharges occurring
after October 1, 1994, the average standardized amounts for hospitals
located in a rural area shall be equal to the average standardized
amount for hospitals located in an other urban area. We note that
hospitals located in a rural area will continue to be considered rural
for all other payment purposes, such as the disproportionate share
adjustment.
The Secretary has been applying updates to the average standardized
amounts for each fiscal year as provided under section 1886(b)(3)(B) of
the Act. For FY 1995, section 1886(b)(3)(B)(i)(X) of the Act directs
the Secretary to update the rural national average standardized amount
by the amount necessary to make it equal to the other urban national
average standardized amount.
Current Sec. 412.63(m) already reflects the requirement that, for
discharges occurring after October 1, 1994, we will pay for inpatient
hospital services based on national average standardized amounts for
large urban and other areas. Thus, there will no longer be separate
national average standardized amounts for other urban and rural areas.
However, we proposed to make several technical changes to
Sec. 412.63(m) and (r), concerning computation of Federal rates, to
eliminate now obsolete references to the rural and other urban
standardized amounts and replace them with references to the
standardized amounts for other areas. In the addendum to this final
rule, we provide a description of the updates for FY 1995 under the
requirements of sections 1886(b)(3)(B)(i)(X) and 1886(d)(3)(A)(iv) of
the Act.
D. Outliers (Secs. 412.80, 412.82 and 412.84)
Section 1886(d)(5)(A) of the Act provides that, in addition to the
basic prospective payment rates, payments must be made for discharges
involving day outliers and may be made for cost outliers. Under section
1886(d)(3)(B) of the Act, the Secretary has been required to separately
reduce the urban and rural national standardized amount by the
proportion of estimated total DRG payments attributable to outliers in
each respective area. Beginning with FY 1995, section 1886(d)(3)(B) of
the Act, as amended by section 4002(c)(2)(B)(iii) of Public Law 101-
508, requires the Secretary to reduce the large urban and other
national standardized amounts by the same factor to account for the
proportion of total DRG payments made to outlier cases. (As explained
in section IV.C. of this preamble, section 1886(d)(3)(A)(iii) of the
Act specifies that beginning in FY 1995, the standardized amount for
other urban and rural areas will be equal, with the result that there
will be only two standardized amounts, one for large urban areas and
one for all other areas.) Section 1886(d)(9)(B)(iv) of the Act requires
that the urban and other standardized amounts applicable to hospitals
in Puerto Rico be reduced by the proportion of estimated total DRG
payments attributable to estimated outlier payments. Furthermore,
section 1886(d)(5)(A)(iv) of the Act directs that outlier payments in
any year ``may not be less than 5 percent nor more than 6 percent of
total payments projected or estimated to be made based'' on the
prospective payment rates.
Section 13501(c) of the Omnibus Budget Reconciliation Act of 1993
(Public Law 103-66) amended section 1886(d)(5)(A) of the Act with
respect to outliers beginning in FY 1995. With regard to cost outliers,
section 13501(c) of Public Law 103-66 modifies the methodology for
determining the cost outlier threshold. Formerly, section
1886(d)(5)(A)(ii) of the Act specified that a hospital can receive
payment for a cost outlier if the adjusted costs for a discharge exceed
the greater of a fixed dollar amount or a fixed multiple of the DRG
payment for the case. As amended by section 13501(c)(2) of Public Law
103-66, section 1886(d)(5)(A)(ii) of the Act now specifies that, for
discharges on or after October 1, 1994, a hospital may receive payment
for a cost outlier if adjusted costs exceed the DRG prospective payment
rate plus a fixed dollar amount determined by the Secretary. We will
refer to this revised cost outlier threshold as ``fixed loss.'' A
further discussion of the methodology for determining the fixed loss is
provided below.
Section 13501(c) of Public Law 103-66 also amended section
1886(d)(5)(A) of the Act with respect to day outliers. Beginning with
FY 1995, section 1886(d)(5)(A) of the Act requires the Secretary to
reduce the proportion of total outlier payments paid under the day
outlier methodology. Under the requirements of section 1886(d)(5)(A)(v)
of the Act, the proportion of outlier payments paid under the day
outlier methodology, relative to the proportion of outlier payments in
FY 1994, shall be 75 percent in FY 1995, 50 percent in FY 1996 and 25
percent in FY 1997. Under the provisions of section 1886(d)(5)(A)(i) of
the Act, the Secretary will no longer pay for day outliers for
discharges occurring after September 30, 1997. As indicated in the
table published in our September 1, 1993 final rule (58 FR 46348), we
estimated that 18 percent of FY 1994 outlier payments would be for
outliers meeting the day outlier threshold only, while 13 percent would
meet the day and cost outlier thresholds and be paid under the day
outlier methodology. Thus, a total of 31.3 percent of total outlier
payments in FY 1994 would be paid as day outlier cases. Pursuant to
section 1886(d)(5)(A) of the Act, we proposed to set the day outlier
thresholds for FY 1995 through FY 1998 so that day outlier payments
approximate the following proportion of total outlier payments:
FY 1995--24 percent (75 percent of 31.3 percent).
FY 1996--16 percent (50 percent of 31.3 percent).
FY 1997--8 percent (25 percent of 31.3 percent).
As payments to day outliers are reduced, there will be a
corresponding increase in payments to cost outliers.
1. FY 1995 Outlier Thresholds
For FY 1994, the day outlier threshold is the geometric mean length
of stay for each DRG plus the lesser of 23 days or 3.0 standard
deviations. The marginal cost factor (or the percent of Medicare's
average per diem payment paid for each outlier day) for day outliers is
equal to 55 percent in FY 1994. The cost outlier threshold is the
greater of 2.0 times the prospective payment rate for the DRG or
$36,000 ($33,000 for hospitals that have not yet entered the
prospective payment system for inpatient capital-related costs). The
marginal cost factor (or the percent of costs paid after costs for the
case exceed the threshold) for cost outliers is 75 percent.
For FY 1995, we are establishing the day outlier threshold at the
geometric mean length of stay for each DRG plus the lesser of 22 days
or 3.0 standard deviations (for a detailed discussion of the
methodology, see section II.A.4.c of the addendum to this final rule).
Section 13501(c)(3) of Public Law 103-66 provides that the additional
payments for outlier cases may be different than the hospital's
marginal cost of care during the transition period phasing out payments
to day outliers. As proposed, we are revising Sec. 412.80 to reflect
this provision. We are also revising Sec. 412.82(c), so that it does
not specify a marginal cost factor of 55 percent. HCFA will specify the
level of the marginal cost factor for each fiscal year during the day
outlier phase-out in the annual prospective payment system rulemaking
process.
We stated that our proposed policy would reduce the proportion of
outlier payments paid to day outliers as required by section
1886(d)(5)(A) of the Act. We proposed to accomplish the required
reduction in payments to day outliers for FY 1995 solely through a
reduction in the marginal cost factor rather than through an increase
in the threshold. To determine the marginal cost factor necessary to
achieve the mandated reduction in outlier payments, we simulated both
the FY 1994 and FY 1995 outlier policies. Based on these simulations,
in the proposed rule we determined that a reduction in the marginal
cost factor to 49 percent is necessary to achieve the required 25
percent reduction in the proportion of payments paid under the day
outlier methodology. In this final rule, based on updated simulations,
we are establishing a marginal cost factor of 47 percent in FY 1995, a
reduction from the 55 percent in FY 1994.
We are also establishing a fixed loss cost outlier threshold in FY
1995 equal to the prospective payment rate for the DRG plus $20,500
($18,800 for hospitals that have not yet entered the prospective
payment system for capital-related costs). The fixed loss threshold
would replace the current threshold, which is equal to the greater of
2.0 multiplied by the DRG payment for the case or $36,000.
We are using the fixed loss threshold pursuant to section
1886(d)(5)(A) of the Act. We believe the fixed loss threshold is an
improvement over current policy because it focuses Medicare's outlier
payments on the most costly cases. Under current policy, it is possible
that cases in certain high-weight DRGs can incur losses significantly
greater than $36,000 before Medicare will make an outlier payment. (We
note that the fixed loss threshold is adjusted by the wage index,
similar to the current cost outlier threshold.)
To further focus Medicare's cost outlier payments on the costliest
cases, we are increasing the marginal cost factor from 75 percent to 80
percent, as proposed. We note that raising the marginal cost factor to
80 percent is consistent with a recommendation made by ProPAC in its
March 1, 1994 annual report. While we are raising the marginal cost
factor for cost outlier cases to 80 percent, we are continuing to set
the cost and day outlier thresholds in order to maintain the estimated
5.1 percent proportion of total DRG payments paid as outliers.
The thresholds we would have used if we were not implementing the
change in the day and cost outlier payment methodology required by
section 1886(d)(5)(A)(v) of the Act and discussed above are:
Day outliers--The geometric mean length of stay for each
DRG plus the lesser of 21 days or 3 standard deviations.
Cost outliers--The greater of 2.0 times the prospective
payment rate for the DRG or $27,000.
We estimate that the final FY 1995 outlier thresholds that we are
establishing would result in 55 percent of outlier cases paid using the
cost outlier methodology and 45 percent paid using the day outlier
methodology. Cases that meet the day outlier threshold but that would
be paid using the cost outlier methodology, because it yields the
higher payment, would represent 22 percent of all outlier cases. Our
simulation of FY 1995 outlier payments based on FY 1993 MedPAR data
indicates that the percentage of outlier cases that would qualify as
day outliers is approximately 67 percent. The cases paid as day
outliers would receive approximately 24 percent of operating outlier
payments in FY 1995.
The following table illustrates these findings in greater detail:
----------------------------------------------------------------------------------------------------------------
Percentage of Percentage of
Percentage of operating capital Percentage of
Type of outlier outlier cases outlier outlier total outlier
payments payments payments
----------------------------------------------------------------------------------------------------------------
Meets day threshold only........................ 36.0 12.0 10.0 12.0
Meets day and cost thresholds, paid using day
methodology.................................... 9.0 12.0 10.0 12.0
Meets day and cost thresholds, paid using cost
methodology.................................... 22.0 49.0 47.0 49.0
Subtotal--All cases meeting day threshold....... 67.0 73.0 67.0 73.0
Meets cost threshold only....................... 33.0 27.0 33.0 27.0
Total..................................... 100.0 100.0 100.0 100.0
----------------------------------------------------------------------------------------------------------------
When we modeled the combined operating and capital outlier
payments, we find that using a common set of thresholds resulted in a
slightly higher percentage of outlier payments for capital-related
costs than for operating costs. We estimated that the final thresholds
for FY 1995 will result in outlier payments equal to 5.1 percent of
operating DRG payments and 5.9 percent of capital payments based on the
Federal rate.
The following is an example of how additional payment to a hospital
paid using the fully prospective payment methodology will be determined
for an outlier case in FY 95.
Example: Hospital X is a 150 bed hospital located in the San
Francisco, California MSA, which is a large urban area. Hospital X
has a ratio of interns and residents to beds of .1, a ratio of
interns and residents to average daily census of .085, and a
disproportionate patient percentage of 30.2%. Mr. Jones is admitted
to Hospital X on October 1, 1994 and is discharged on November 30,
1994. The billed charges for Mr. Jones' stay are $100,000. Mr. Jones
is classified in DRG 286. Because Mr. Jones' 61 day stay exceeds the
30 day length of stay outlier threshold for DRG 286, Hospital X is
eligible for payment for 31 outlier days in addition to the
otherwise applicable prospective payment. The amount of Hospital X's
outlier payment (excluding the usual Federal payments for operating
and capital costs that apply for both outlier and non-outlier cases,
and the hospital-specific portion of the capital payment) is
calculated as follows:
Day Outlier:
Step 1: Computation of the Federal Rate
(excludes capital, indirect medical
education (IME) and disproportionate share
hospital (DSH) payments):
National Large Urban Standardized Amounts:
Labor-Related......................... $2,709.42
Nonlabor-Related...................... 1,085.29
San Francisco MSA Wage Index.............. 1.4120
DRG 286 Relative Weight................... 2.2621
DRG Relative Weight x [(Labor-Related
National Large Urban Standardized Amount x
San Francisco MSA Wage Index) + Nonlabor-
Related National Large Urban Standardized
Amount] = Federal Rate for Operating Costs:
2.2621 x [($2,709.42 x 1.4120) + 11,109.15
$1,085.29] =.
Step 2: Computation of Federal Capital
Payments:
Federal Capital Rate...................... 376.83
DRG 286 Relative Weight................... 2.2621
Federal Portion of Capital Rate........... 40%\1\
Geographic Adjustment Factor.............. 1.2665
DRG Relative Weight x Federal Capital Rate
x Federal Portion of Capital Rate x
Geographic Adjustment Factor x Large Urban
Add-On = Federal Rate for Capital Costs:
2.2621 x $376.83 x 0.40 x 1.2665 x 444.79
1.03 =.
Step 3: Computation of Day Outlier Payments:
Arithmetic Mean Length of Stay for DRG 286 9.3 days
Outlier Days.............................. = (61 - 30) = 31 days
Marginal Cost Factor...................... 47%
A. Operating Outlier Payment (excludes IME
and DSH) = Number of outlier days x
(Operating Federal Payment .
Arithmetic Mean Length of Stay for DRG 17,404.34
286) x Marginal Cost Factor = 31 x
($11,109.15 9.3) x .47 =.
B. Capital Outlier Payment (excludes DSH)
= Number of outlier days x (Capital
Federal Payment Arithmetic.
Mean Length of Stay for DRG 286) x 696.84
Marginal Cost Factor = 31 x ($444.79
9.3) x .47 =.
Step 5: Computation of IME Adjustment For
Day Outliers:
i. IME Operating Factor................... .0744
Operating Outlier Payment x IME Operating
Factor = IME Operating Outlier Adjustment:
$17,404.34 x .0744 =.................... 1,294.88
ii. IME Capital Factor.................... .0243
Capital Outlier Payment x IME Capital
Factor = IME Capital Outlier
Adjustment:
$696.84 x .0243 =................... 16.93
Step 6: Computation of DSH Adjustment for
Day Outliers:
i. Operating DSH Adjustment Factor........ .1413
Operating DSH Adjustment Factor x
Operating Outlier Payment = DSH Operating
Outlier Adjustment:.
.1413 x $17,404.34 =................ 2,459.23
ii. Capital DSH Adjustment Factor......... .0631
Capital DSH Adjustment Factor x
Capital Payment = DSH Capital Outlier
Adjustment:
.0631 x $696.84 =................... 43.97
Step 7: Total Day Outlier Payments:
Regular Operating Outlier Payment......... 17,404.34
Regular Capital Outlier Payment........... 696.84
IME Operating............................. 1,294.88
IME Capital............................... 16.93
DSH Operating............................. 2,459.23
DSH Capital............................... 43.97
-------------------------
Total................................... 21,916.19
Cost Outlier:
Step 1: Computation of Hospital X's
Standardized Costs:
Billed Charges............................ 100,000
Hospital X's Operating Cost-to-Charge .72\2\
Ratio.
Hospital X's Capital Cost-to-Charge Ratio. .06
IME Operating Adjustment Factor........... .0744
IME Capital Adjustment Factor............. .0243
DSH Operating Adjustment Factor........... .1413
DSH Capital Adjustment Factor............. .0631
(Billed charges x Operating Cost-to-Charge
Ratio) (1 + IME Operating Adjustment
Factor + Operating DSH Adjustment Factor) =
Standardized Operating Costs:
($100,000 x .72) (1 + .0744 + 59,225.14
.1413) =.
(Billed Charges x Capital Cost-to-Charge
Ratio) (1 + IME Capital Factor +
Capital DSH Factor) = Standardized Capital
Costs:
($100,000 x .06 (1 + .0243 + 5,517.75
.0631) =.
Step 2: Determination of Cost Thresholds:
A. Computing the Operating Threshold
Amount:
Operating Federal Rate for DRG 286.... 11,109.15
Fixed Loss Threshold.................. 20,500
Labor-Related Share, Operating........ .7140
Nonlabor Share, Operating............. .2860
i. Operating standard cost a share
of total costs Operating Cost-to-
Charge Ratio (Operating
Cost-to-Charge Ratio + Capital Cost-
to-Charge Ratio) = Operating Cost
as a Share of Total Costs: .72
(.72 + .06) = [.9231]
Wage Index Adjusted Operating Cost Outlier
Threshold = {[Fixed Loss Threshold x
((Labor-Related Share x San Francisco MSA
Wage Index) + Nonlabor-Related Share) x
Operating Standard cost as a share of total
costs] + (Operating Federal Rate for DRG
286]}
{[20,500 x ((.7140 x 1.4120) + .2860) 35,599.40
x .9231] + 11,109.15{time} =.
B. Computing the Capital Threshold Amount:
Federal Capital Rate.................. 376.83
Fixed Loss Threshold.................. 20,500
DRG 286 Relative Weight............... 2.2621
San Francisco Geographic Adjustment 1.2665
Factor.
i. Capital Standard Cost as a Share .0769
of Total Costs Capital Cost-to-
Charge Ratio (Operating Cost-to-
Charge Ratio + Capital Cost-to-
Charge Ratio) = Capital Cost as a
Share of Total Costs: .06
(.72 + .06) =
Geographic Adjustment Factor Adjusted Capital 3,168.46
Cost Outlier Threshold = [(Fixed Loss
Threshold x Geographic Adjustment Factor x
Large Urban Add-On Factor x Capital
standard cost as a share of total costs) +
(Federal Rate x DRG 286 Relative Weight x
San Francisco MSA Geographic Adjustment
Factor x Large Urban Add-On Factor)]
[(20,500 x 1.2665 x 1.03 x .0769) +
(376.83 x 2.2621 x 1.2665 x 1.03)] =
Computation A Result, Operating........... 35,599.40
Computation B Result, Capital............. 3,168.46
Threshold = $35,599.40 + $3,168.46 =...... 38,767.86
Step 3: Determination of Cost Outlier
Payment:
Marginal Cost Factor...................... .80
A. Operating Outlier Payment:
Operating Outlier Cost = Standard
Operating Costs - Operating Threshold:
$59,225.14 - $35,599.40 =............. 23,625.74
Operating Outlier Payment = Operating
Outlier Cost x Marginal Cost Factor:
$23,625.74 x .80 =.................. 18,900.59
B. Federal Portion of Capital Outlier
Payment:
Capital Outlier Cost = Standard Capital
Costs - Capital Threshold:
$5,517.75 - $3,168.46 =............... 2,349.29
Capital Outlier Payment = Capital
Outlier Cost x Marginal Cost Factor:
$2,349.29 x .80 =................... 1,879.43
Federal Portion of Capital Outlier
Payment = Federal Portion of Capital
Rate x Capital Outlier Payment:
$1,879.43 x .40 =................... 751.77
Step 4: Cost Outlier Payment for IME:
i. Operating Outlier Payment x IME
Operating Adjustment Factor = Cost
Outlier Payment for IME Operating:
$18,900.59 x .0744 =................ 1,406.20
ii. Capital Outlier Payment x IME
Capital Adjustment Factor = Cost Outlier
Payment for IME Capital:
$751.77 x .0243 =................... 18.27
Step 5: Cost Outlier Payment for DSH:
i. Operating Outlier Payment x Operating
DSH Adjustment Factor = Cost Outlier
Payment for DSH Operating:
$18,900.59 x .1413 =................ 2,670.65
ii. Capital Outlier Payment x Capital DSH
Adjustment Factor = Cost Outlier Payment
for DSH Capital:
$751.77 x .0631 =................... 47.44
Step 6: Total Cost Outlier Payments:
Operating................................. 18,900.59
Federal Portion of Capital................ 751.77
IME Operating............................. 1,406.20
IME Capital............................... 18.27
DSH Operating............................. 2,670.65
DSH Capital............................... 47.44
-------------------------
Total................................... 23,794.92
Determination of Outlier Payment:
Total Day Outlier Payment................. 21,916.19
Total Cost Outlier Payment................ 23,794.92
Hospital X receives the greater of the two
payments, which is $23,794.92, the cost
outlier payment.
\1\a. If Hospital X were a hold harmless hospital, it would use the
lesser of:
The hospital-specific ratio of new to total capital, or
The national average ratio of new to total capital.
b. If Hospital X were a 100% Federal hospital, the Federal portion would
1.0.
\2\This is the same cost-to-charge ratio currently used to determine
outlier payments using operating costs only. The capital cost-to-
charge ratio, when added to the operating cost-to-charge ratio, will
yield a total cost-to-charge ratio. (This occurs because the
denominator in both cases is total charges. The charges are not
divided into operating and capital charges.)
Comment: Several commenters disagree with the change in the cost
outlier methodology, from the higher of 2.0 times the DRG rate or a
fixed dollar amount to the DRG amount plus a fixed dollar amount (the
``fixed loss'' method), asserting that although the statute permits us
to make this change, it does not require it. These commenters believe
the revised formula adversely affects various hospital groups with low
payment-to-cost ratios for outlier cases. The commenters stated that we
should continue to calculate the cost outlier threshold using the
current method, since the provisions of Public Law 103-66 allows us the
option of using either method.
Response: We believe that the change to the fixed loss method of
calculating the cost outlier threshold is appropriate because it
addresses concerns regarding outlier payments. Under the current method
of calculating the thresholds, cases with losses of up to $100,000
might not qualify for outlier payments. Under the fixed loss method,
all cases at a given hospital, regardless of the DRG to which they are
assigned, will face no more than a fixed loss amount at which time they
would begin receiving outlier payments. While the language of section
13501(c)(2) of Public Law 103-66 may be somewhat ambiguous, we note
that the conference report accompanying Public Law 103-66 states that
the conference agreement includes the House provision regarding the
phase-out of day outlier payments ``with an amendment to require that
the payment threshold for cost outlier cases be set at the applicable
DRG payment plus a fixed dollar amount'' (emphasis added) (H.R. Conf.
Rep. No. 213, 103d Cong., 1st Sess. 749 (1993)). We believe that it
would be inappropriate to use any other method of calculating the cost
outlier threshold, given this indication of Congressional intent.
Nevertheless, as a result of the comments we received on this
issue, we performed additional analysis of the impact on payment-to-
cost ratios for outlier cases and for all cases using the data
available for this final rule. Our analysis indicated that under this
change in cost outlier payment methodology, overall payment-to-cost
ratios change only slightly, with the majority of hospital groups
facing changes in their payment-to-cost ratios of less than 0.2
percentage points. The payment-to-cost ratios for all rural hospitals
decrease by 0.1 percentage points while those for sole community
hospitals increase by 0.3 percentage points. The payment-to-cost ratios
for teaching hospitals with 100 or more residents increase 0.3
percentage points, while those for urban disproportionate share
hospitals with at least 100 beds are unchanged. Payment-to-cost ratios
for outlier cases increase 1.2 percentage points for all hospitals.
Outlier case payment-to-cost ratios decrease 0.1 percentage points for
rural hospitals and increase for urban hospitals (as they do for the
majority of hospital groups). We believe that the results of our
analysis, which show outlier payment-to-cost ratios increasing overall,
indicate that we are more appropriately targeting outlier payments to
those cases that face the greatest losses. As a result, we continue to
believe that the change to the fixed loss cost outlier methodology is
appropriate, as well as consistent with Congressional intent.
Comment: The Prospective Payment Assessment Commission (ProPAC)
believes that, in the calculation of the cost of an outlier case, we
should no longer standardize to remove the effects of indirect medical
education (IME) and disproportionate share hospital (DSH) adjustments.
In addition, they believe that once this change is implemented, we
should no longer make IME and DSH payments on the outlier portion of a
hospital's payment.
Response: Currently the operating and capital costs of an outlier
case are calculated as follows:
Cost = (Charges x CCR) (1 + IME + DSH), where:
CCR = the operating or capital cost-to-charge ratio, as appropriate;
IME = the indirect teaching adjustment for operating or capital PPS
payments; and,
DSH = the disproportionate share adjustment for operating or capital
PPS payments.
By dividing the charges, adjusted to cost, by (1 + IME + DSH) we are
removing from the costs of the case the effects of teaching and serving
a disproportionate share of low income patients. We remove these costs
because sections 1886(d)(5) (B) and (F) of the Act require that we make
additional payments for IME and DSH on outlier payments. If we did not
remove the effect of IME and DSH from the estimated costs of outlier
payments, we would be paying IME and DSH twice: once through the
estimate of the marginal cost of treating these patients, which would
include the effects on cost of IME and DSH, and again through the
additional payments made on outlier payments. Thus, it would be
inappropriate to eliminate the standardization since we are required by
statute to make additional IME and DSH payments on outlier payments.
2. Outlier Changes Planned for FY 1996 Through FY 1998
As stated above, section 1886(d)(5)(A) of the Act requires us to
phase out payments for day outliers over the FY 1995 through FY 1997
period. We currently expect to meet the statutory reductions in day
outlier payments for FY 1996 and FY 1997 solely through a reduction in
the marginal cost factor without having to raise the day outlier
threshold. If necessary, we will propose achieving the reduction in day
outlier payments between FYs 1996 and 1997 through a combination of
reducing the marginal cost factor and raising the threshold. There will
be corresponding increases in payments to cost outliers as we phase-out
payment to day outliers.
E. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act,
Sec. 412.96 sets forth the criteria a hospital must meet in order to
receive special treatment under the prospective payment system as a
rural referral center. For discharges occurring before October 1, 1994,
rural referral centers receive the benefit of payment based on the
other urban payment rate rather than the rural payment rate. As of that
date, the other urban and rural payment rates will be the same.
However, rural referral centers will continue to receive special
treatment under both the disproportionate share hospital payment
adjustment and the criteria for geographic reclassification.
One of the criteria under which a rural hospital may qualify as a
referral center is to have 275 or more beds available for use. A rural
hospital that does not meet the bed size criterion can qualify as a
rural referral center if the hospital meets two mandatory criteria
(number of discharges and case-mix index) and at least one of three
optional criteria (medical staff, source of inpatients, or volume of
referrals). With respect to the two mandatory criteria, a hospital is
classified as a rural referral center if its--
Case-mix index is at least equal to the lower of the
median case-mix index for urban hospitals in its census region,
excluding hospitals with approved teaching programs, or the median
case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 discharges per year
or, if fewer, the median number of discharges for urban hospitals in
the census region in which the hospital is located. (The number of
discharges criterion for an osteopathic hospital is at least 3,000
discharges per year.)
1. Case-Mix Index
Section 412.96(c)(1) provides that HCFA will establish updated
national and regional case-mix index values in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. In determining the proposed national and
regional case-mix index values, we followed the same methodology we
used in the November 24, 1986 final rule, as set forth in regulations
at Sec. 412.96(c)(1)(ii). Therefore, the proposed national case-mix
index value included all urban hospitals nationwide, and the proposed
regional values were the median values of urban hospitals within each
census region, excluding those with approved teaching programs (that
is, those hospitals receiving indirect medical education payments as
provided in Sec. 412.105).
The values in the proposed rule were based on discharges occurring
during FY 1993 (October 1, 1992 through September 30, 1993) and
included bills posted to HCFA's records through December 1993.
Therefore, in addition to meeting other criteria, we proposed that to
qualify for initial rural referral center status for cost reporting
periods beginning on or after October 1, 1994, a hospital's case-mix
index value for FY 1993 would have to be at least--
1.3028; or
Equal to the median case-mix index value for urban
hospitals (excluding hospitals with approved teaching programs as
identified in Sec. 412.105) calculated by HCFA for the census region in
which the hospital is located. (See table set forth in the May 27,
1994, proposed rule at 59 FR 27739.)
Based on the latest data available (through June 1994), the final
national case-mix value is 1.3040 and the median case-mix values for
each region are set forth in the table below:
------------------------------------------------------------------------
Case-mix
Region index
value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)..................... 1.1986
2. Middle Atlantic (PA, NJ, NY)............................. 1.2040
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 1.3091
4. East North Central (IL, IN, MI, OH, WI).................. 1.2185
5. East South Central (AL, KY, MS, TN)...................... 1.2492
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 1.2047
7. West South Central (AR, LA, OK, TX)...................... 1.2835
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 1.3488
9. Pacific (AK, CA, HI, OR, WA)............................. 1.3090
------------------------------------------------------------------------
For the benefit of hospitals seeking to qualify as referral centers
or those wishing to know how their case-mix index value compares to the
criteria, we are publishing each hospital's FY 1993 case-mix index
value in Table 3C in section V of the addendum to this final rule. In
keeping with our policy on discharges, these case-mix index values are
computed based on all Medicare patient discharges subject to DRG-based
payment.
2. Discharges
Section 412.96(c)(2)(i) provides that HCFA will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, we
proposed to update the regional standards. The proposed regional
standards were based on discharges for urban hospitals' cost reporting
periods that began during FY 1992 (that is, October 1, 1991 through
September 30, 1992). That is the latest year for which we have complete
discharge data available.
Therefore, in addition to meeting other criteria, we proposed that
to qualify for initial rural referral center status for cost reporting
periods beginning on or after October 1, 1994, the number of discharges
a hospital must have for its cost reporting period that began during FY
1993 would have to be at least--
5,000; or
Equal to the median number of discharges for urban
hospitals in the census region in which the hospital is located. (See
table set forth in the May 27, 1994, proposed rule 59 FR 27739.)
Based on the latest discharge data available, the final median
numbers of discharges for urban hospitals by census region are as
follows:
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)..................... 6,814
2. Middle Atlantic (PA, NJ, NY)............................. 8,878
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 7,157
4. East North Central (IL, IN, MI, OH, WI).................. 7,024
5. East South Central (AL, KY, MS, TN)...................... 5,659
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 5,180
7. West South Central (AR, LA, OK, TX)...................... 4,517
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 8,409
9. Pacific (AK, CA, HI, OR, WA)............................. 5,788
------------------------------------------------------------------------
We reiterate that, to qualify for rural referral center status for
cost reporting periods beginning on or after October 1, 1994, an
osteopathic hospital's number of discharges for its cost reporting
period that began during FY 1993 would have to be at least 3,000.
3. Retention of Referral Center Status
Section 412.96(f) states that each hospital receiving the referral
center adjustment is reviewed every 3 years to determine if the
hospital continues to meet the criteria for referral center status. To
retain status as a referral center, a hospital must meet the criteria
for classification as a referral center specified in Sec. 412.96(b)(1)
or (b)(2) or (c) for 2 of the last 3 years, or for the current year. A
hospital may meet any one of the three sets of criteria for individual
years during the 3-year period or the current year. For example, a
hospital may meet the two mandatory requirements in Sec. 412.96(c)(1)
(case-mix index) and (c)(2) (number of discharges) and the optional
criterion in paragraph (c)(3) (medical staff) during the first year.
During the second or third year, the hospital may meet the criteria
under Sec. 412.96(b)(1) (rural location and appropriate bed size).
A hospital must meet all of the criteria within any one of these
three sections of the regulations in order to meet the retention
requirement for a given year. That is, it will have to meet all of the
criteria of Sec. 412.96(b)(1) or Sec. 412.96(b)(2) or Sec. 412.96(c).
For example, if a hospital meets the case-mix index standards in
Sec. 412.96(c)(1) in years 1 and 3 and the number of discharge
standards in Sec. 412.96(c)(2) in years 2 and 3, it will not meet the
retention criteria. All of the standards would have to be met in the
same year.
The requirement for triennial review was originally added to the
regulations in 1984, to be effective for cost reporting periods
beginning on or after October 1, 1987 (the end of the first 3 years of
the referral center adjustment). However, three statutory moratoriums
on the performance of the triennial reviews were enacted by Congress.
The third of these moratoriums expires at the end of cost reporting
periods that began during FY 1994. (See the September 1, 1993 final
rule (58 FR 46310) for a detailed explanation of the moratorium and the
implementation of the triennial reviews.)
With the expiration of the current moratorium, we will begin
reviewing each rural referral center's compliance with the triennial
review criteria effective with cost reporting periods beginning on or
after October 1, 1994. As noted above, although rural referral centers
will no longer be paid a higher standardized amount than other rural
hospitals, hospitals approved as rural referral centers continue to be
entitled to higher disproportionate share payments and continue to
receive preferential consideration before the Medicare Geographic
Classification Review Board. Therefore, we believe it is important that
only those hospitals that meet the rural referral center triennial
review criteria continue to be so classified. Thus, effective with cost
reporting periods beginning on and after October 1, 1994, a hospital
that has been classified as a referral center for at least 3 years will
be subject to the triennial review criteria as discussed below.
In accordance with Sec. 412.96(f)(2), the review process is limited
to the hospital's compliance during the last 3 years. Thus, if a
hospital meets the criteria in effect for at least 2 of the last 3
years or if it meets the criteria in effect for the current year (that
is, the criteria for FY 1995 outlined above in this section of the
preamble), it will retain its status for another 3 years. No hospital
is subject to a review until the end of its third full cost reporting
period as a referral center. We have constructed the following chart
and example to aid hospitals that qualify as referral centers under the
criteria in Sec. 412.96(c) in projecting whether they will retain their
status as a referral center.
Under Sec. 412.96(f), to qualify for a 3-year extension effective
with cost reporting periods beginning in FY 1995, a hospital must meet
the criteria in Sec. 412.96(c) for FY 1995 or it must meet the criteria
for 2 of the last 3 years as follows:
------------------------------------------------------------------------
Use the
discharges
Use for the
For the cost hospital's hospital's Use numerical standards as
reporting period case-mix cost published in the Federal
beginning during FY index for reporting Register on
FY period
beginning
during FY
------------------------------------------------------------------------
1994................ 1992 1992 September 1, 1993.
1993................ 1991 1991 September 1, 1992.
1992................ 1990 1990 August 30, 1991.
------------------------------------------------------------------------
Example: A hospital with a cost reporting period beginning July
1 qualified as a referral center effective July 1, 1992. The
hospital has fewer than 275 beds. Its 3-year status as a referral
center is protected through June 30, 1995 (the end of its cost
reporting period beginning July 1, 1994). To determine if the
hospital should retain its status as a referral center for an
additional 3-year period, we will review its compliance with the
applicable criteria for its cost reporting periods beginning July 1,
1992, July 1, 1993, and July 1, 1994. The hospital must meet the
criteria in effect either for its cost reporting period beginning
July 1, 1995, or for two out of the three past periods. For example,
to be found to have met the criteria at Sec. 412.96(c) for its cost
reporting period beginning July 1, 1993, the hospital's case-mix
index value during FY 1991 must have equaled or exceeded the lower
of the national or the appropriate regional standard as published in
the September 1, 1992 final rule. The hospital's total number of
discharges during its cost reporting year beginning July 1, 1991,
must have equaled or exceeded 5,000 or the regional standard as
published in the September 1, 1992 final rule.
For those hospitals that seek to retain referral center status
by meeting the criteria of Sec. 412.96(b)(1)(i) and (ii) (that is,
rural location and at least 275 beds), we will look at the number of
beds shown for indirect medical education purposes (as defined at
Sec. 412.105(b)) on the hospital's cost report for the appropriate
year. We will consider only full cost reporting periods when
determining a hospital's status under Sec. 412.96(b)(1)(ii). This
definition varies from the number of beds criterion used to
determine a hospital's initial status as a referral center because
we believe it is important for a hospital to demonstrate that it has
maintained at least 275 beds throughout its entire cost reporting
period, not just for a particular portion of the year.
We received no comments on the rural referral center policies;
therefore, they are adopted as proposed.
F. Determination of Number of Beds in Determining the Indirect Medical
Education Adjustment (Sec. 412.105)
Section 1886(d)(5)(B) of the Act provides that prospective payment
hospitals that have residents in an approved graduate medical education
program receive an additional payment to reflect the higher indirect
operating costs associated with graduate medical education. The
regulations regarding the calculation of this additional payment, known
as the indirect medical education (IME) adjustment, are at
Sec. 412.105. The additional payment is calculated by multiplying a
hospital's DRG revenue (including outlier payments) by the applicable
IME adjustment factor. The adjustment factor is calculated by using a
hospital's ratio of residents-to-beds in the formula set forth at
section 1886(d)(5)(B)(ii) of the Act.
Section 412.105(b) states that the number of beds used in the
resident-to-bed ratio is calculated by dividing the number of days
during the cost reporting period into ``the number of available bed
days during the cost reporting period, not including beds assigned to
newborns, custodial care, and excluded distinct part hospital units. .
. .'' Since we added this language to the regulations in the September
3, 1985 final rule (50 FR 35679 and 35690), there has been some
confusion over whether this definition includes or excludes bed days
attributable to neonatal intensive care units. This confusion has
resulted in some hospitals contesting their fiscal intermediaries'
inclusion of neonatal intensive care beds in the hospitals' count of
available beds.
Prior to the adoption of Sec. 412.105(b), the definition of
available beds was at section 2510.5A of the Provider Reimbursement
Manual--Part 1, which was originally used to establish bed-size
categories for purposes of applying the cost limits under section
1861(v)(1)(A) of the Act. That definition excluded newborn beds but
specifically included beds in intensive care units, coronary care
units, and other special care inpatient hospital units. The exclusion
of newborn beds was consistent with the exclusion of newborn days and
costs from the determination of Medicare's share of allowable routine
service costs (see section 2202.11B of the Manual). If a neonatal unit
qualifies as an intensive care unit, however, the costs of that unit
are included in determining Medicare's costs (see section 2202.7.II.B
of the Manual). Correspondingly, the days in a neonatal unit that
qualifies as an intensive care unit are counted as intensive care type
days rather than nursery days (see section 2202.7.II.A of the Manual).
Finally, section 2510.5A of the Manual clearly indicates that intensive
care unit beds and special care unit beds are included in a hospital's
bed complement.
In the September 3, 1985 final rule, we added the definition of
available beds to the regulations governing the IME adjustment (then
Sec. 412.118(b)). The expressed purpose for the change was to stop
counting beds ``based upon the total number of beds available on the
first day of the pertinent cost reporting period'' and to begin
counting based on ``the number of available bed days (excluding beds
assigned to newborns, custodial beds, and beds in excluded units)
during the current cost reporting period divided by the number of days
in the cost reporting period'' (50 FR 35679). We did not change the
definition of available beds. Our current position regarding the
treatment of these beds is unchanged from the time when the cost limits
established under section 1861(v)(1)(A) of the Act were in effect and
is consistent with the way we treat beds in other hospital areas. That
is, if the bed days and costs are allowable in the calculation of
Medicare's share of inpatient costs, the beds within that unit are
included as well.
Some hospitals have asserted that when we excluded beds assigned to
newborns, we changed our treatment of neonatal intensive care unit
beds. However, we note that the term ``newborn'' has historically been
used synonymously with nursery. Perhaps the clearest illustration of
this is the definition of a ``newborn inpatient day'' as a day that
``an infant occupies a newborn bed in the nursery'' (see section 2815
of the Provider Reimbursement Manual--Part 2). This definition dates
back to at least 1975. If Sec. 412.105(b) was indeed meant to change
our established policy, we would have referenced that intent at the
time. This would have been necessary since neonatal intensive care
costs and days were still included in the calculation of Medicare's
costs.
Finally, in August 1988, we issued Provider Reimbursement Manual
Transmittal No. 345, revising section 2405.3G of the Manual, which
provides implementing instructions for the IME adjustment. As part of
this revision, the definition of the number of beds was clarified to
specifically exclude beds ``. . . assigned to newborns which are not in
intensive care areas. . . .'' Those who argue that Sec. 412.105(b)
excludes neonatal intensive care unit beds from the hospital bed count
also argue that this Manual issuance is contradictory to the
regulations.
In order to clarify our policy, we proposed to revise the
regulations at Sec. 412.105(b) to exclude specifically only beds
assigned to newborns in the nursery. Thus, neonatal intensive care beds
would not be excluded from the bed count. We stressed that this does
not represent a policy change in our bed counting rules, but rather a
reaffirmation of our longstanding position. Revising the wording of the
regulations should alleviate any future misunderstandings, as well as
clarify our position regarding previous application of this policy,
both before and since the original publication of our bed counting
regulations now specified at Sec. 412.105(b).
We also proposed to make a technical change to Sec. 412.105(d)(1)
to correct a reference.
Comment: We received several comments in opposition to our proposed
clarification. One commenter stated that this was a policy change
requiring public comment that cannot be applied retroactively. Other
commenters claimed that since Medicare has little or no utilization in
these areas, all of the beds should be excluded from the available bed
count. One commenter stated that including these beds in the hospital
bed size determination was incongruous with the determination of
Medicare allowable costs.
Response: As explained in the proposed rule and repeated above, we
are only clarifying our longstanding policy position regarding neonatal
intensive care beds and are not making a change in policy. We note that
the United States Court of Appeals for the Eighth Circuit recently
upheld this long-standing policy Sioux Valley Hospital v. Shalala, No.
93-3741SD (8th Cir. July 20, 1994).
We disagree with the position that neonatal intensive care beds
should be excluded based on the degree of Medicare utilization. Rather,
we believe it is appropriate to include these beds because the costs
and days of these beds are recognized in the determination of Medicare
costs (nursery costs and days, on the other hand, are excluded from
this determination). We also note that time spent by residents working
in these areas is included in the resident-to-bed ratio calculation,
irrespective of Medicare utilization.
Comment: Another commenter elaborated on the definition of a
newborn, pointing out that Dorand's Illustrated Medical Dictionary,
27th Ed., makes no distinction with regard to the physical status of
newborn infants, describing them only as ``a recently born infant.''
This commenter then contends that the term ``newborn'' in
Sec. 412.105(b) includes infants regardless of whether they are in an
intensive care unit. The commenter goes on to state that by including
neonatal intensive care unit beds, we are placing an undue burden on
these facilities.
Response: Our policy to include the costs, days, and beds of
neonatal intensive care units has been in place since prior to the
prospective payment system and has been the subject of considerable
attention. We believe we have a responsibility to apply this policy
consistently over time and across providers. Excluding these beds from
the determination of bed size would have an adverse impact on some
hospitals. Several other prospective payment system special adjustments
are based on bed size; for example, thresholds and adjustments for the
disproportionate share (DSH) adjustment for urban hospitals with 100 or
more beds. If we no longer considered neonatal intensive care beds in
determining bed size, DSH adjustments to some hospitals would be
sharply reduced. To prevent any future confusion about the term
``newborn'' in Sec. 412.105(b), we are revising the proposed language
to reference ``nursery beds.''
We reiterate that our policy is unchanged and that we are merely
clarifying the regulations at Sec. 412.105(b). We are adopting the
proposed change with technical revisions.
G. Disproportionate Share Adjustment (Sec. 412.106)
Section 1886(d)(5)(F) of the Act provides for additional Medicare
payments for hospitals that serve a disproportionate share of low
income patients. Section 1886(d)(5)(F)(vii) of the Act, as added by
section 6003(c)(1)(B) of Public Law 101-239 and amended by section
4002(b)(1) of Public Law 101-508, specifies the formula for determining
the disproportionate share adjustment percentage for hospitals that are
located in an urban area and have 100 or more beds, or are located in a
rural area and have 500 or more beds. The statute establishes different
payment formulas for different years, including a change in the formula
for discharges occurring on or after October 1, 1994.
Regulations concerning the Medicare disproportionate share
adjustment are set forth at Sec. 412.106. Under Sec. 412.106(c)(1)(i),
a hospital that is located in an urban area and has 100 or more beds,
or is located in a rural area and has 500 or more beds, must have a
``disproportionate patient percentage'' of at least 15 percent to
qualify for a disproportionate share payment adjustment. Section
412.106(d)(2) sets forth the formulas for determining the
disproportionate payment adjustment factors applicable to these two
groups of hospitals.
In the proposed rule, we did not propose changes to any part of
Sec. 412.106. However, we wish to ensure that hospitals are aware of
the revised payment formulas that will take effect in FY 1995 pursuant
to the statute. Specifically, for discharges occurring on or after
October 1, 1994, any such hospital with a disproportionate share
patient percentage greater than 20.2 percent will receive a
disproportionate share adjustment equal to 5.88 percent plus 82.5
percent of the difference between 20.2 percent and the hospital's
disproportionate share patient percentage.
H. Changes Affecting Essential Access Community Hospitals (EACHs) and
Rural Primary Care Hospitals (RPCHs) (Secs. 412.109, 485.602, 485.635,
and 489.102)
On May 26, 1993, we published a final rule to implement the EACH
program (58 FR 30630). The rule set forth the requirements for
designating certain hospitals as EACHs or RPCHs, the conditions that an
RPCH must meet to participate in Medicare, and the rules for Medicare
payment for services furnished by EACHs and RPCHs. The final rule
implemented section 1820 of the Act, as added by sections 6003(g) and
6116(b)(2) of Public Law 101-239 and revised by section 4008(d) of
Public Law 101-508. The amendments were intended to promote
regionalization of rural health services in grant States, improve
access to hospital and other health services for rural residents, and
enhance the provision of emergency and other transportation services
related to health care.
Since the publication of that rule, we have identified several
necessary additions to the EACH/RPCH provisions. First, to provide for
orderly review and adjudication of disagreements about whether a
facility's designation has been terminated properly, we proposed to
specify under new Sec. 412.109(e) that a determination by HCFA that a
hospital does not meet the criteria for EACH designation, or that a
hospital's EACH designation should be terminated, is subject to review
under 42 CFR part 405, subpart R.
We also proposed several clarifying changes to the definition of
``direct services'' at Sec. 485.602, as well as clarifying references
in Sec. 485.635, the condition of participation on provision of
services. These revisions merely would restate more clearly our
existing policies under which the services listed in Sec. 485.635(b)
(``direct services'') must be furnished by employed staff, not under
agreements or arrangements.
In addition, we proposed to revise the range of laboratory services
that an RPCH must furnish as direct services. In a final rule with
comment period published on December 2, 1993 (58 FR 63533), we revised
the RHC regulations at Sec. 491.9 to eliminate, as required direct
services, tests not classified as waived under the Clinical
Laboratories Improvement Act of 1988 (CLIA). (See 42 CFR 493.15.) We
made these changes in the RHC regulations because the CLIA program
introduced participation requirements that may cause some RHCs to
withdraw from the program, creating a shortage of available medical
care in some areas.
Because RPCHs typically are located in rural areas similar to those
served by RHCs and serve similar patient populations, and because the
RPCH designation criteria in section 1820(f)(1)(H) of the Act state
that RPCHs must meet the requirement for direct provision of routine
diagnostic services in the statutory definition of ``rural health
clinic,'' we believe it is appropriate to impose the same requirements
in both settings. Therefore, we proposed to revise the RPCH regulations
at Sec. 485.635 to require the RHCs to provide directly the following
laboratory services:
(1) Chemical examination of urine by stick or tablet method or both
(including urine ketones);
(2) Hemoglobin or hematocrit;
(3) Blood glucose;
(4) Examination of stool specimens for occult blood;
(5) Pregnancy tests; and
(6) Primary culturing for transmittal to a certified laboratory.
We noted that this change would not prevent any RPCH from providing
tests that are not listed in Sec. 485.635(b)(2). An RPCH is free to
choose a higher level CLIA certification than the certificate of waiver
if it wishes to provide tests of a higher complexity and to comply with
all CLIA requirements.
The current regulations do not set out a clear and consistent
position on the applicability of the advance directives requirement.
Under the regulations in Sec. 485.645(b)(1), swing-bed RPCHs are
required to meet a number of skilled nursing facility (SNF)
requirements, including Sec. 483.10(b)(4). That regulation requires
that the patient be given the right to make an advance directive. (An
advance directive is a written instruction, such as a living will or a
durable power of attorney for health care, that deals with the
provision of health care when the individual is incapacitated. See
Subpart I of 42 CFR Part 489.) Thus, the regulations apply the advance
directives requirement to RPCH inpatients receiving a SNF level of care
in swing beds, but not to inpatients receiving RPCH care.
We believe the RPCH benefit could be administered more simply and
equitably if both hospitals and RPCHs were required to comply with the
same advance directives requirement. As explained in the preamble to
the May 26, 1993 final rule on EACHs (58 FR 30635-30636), as authorized
by section 1861(e) of the Act, we have read the word ``hospital'' to
include RPCHs where the context appears to support such a reading. We
believe the context of section 1866(a)(1)(Q) of the Act would support
this reading, since many patients are likely to seek RPCH care as an
alternative to treatment in a hospital or SNF, and many RPCHs will
accept patients who are at risk of the kind of incapacitating condition
addressed by an advance directive. Thus, we proposed to revise the
regulations at Sec. 489.102 to provide for more consistent application
of the advance directive requirement, by specifying that it will apply
to RPCHs on the same basis as to hospitals.
We believe this approach is simpler to administer and expands
beneficiary rights. Moreover, since all prospective RPCHs must be (or
have been) hospitals and have been required to meet the advance
directive requirement, there should not be any added burden.
In response to our proposal to provide for appeals of EACH
designation decisions under 42 CFR Part 405, Subpart R, we received one
comment.
Comment: A commenter indicated that the proposed regulations are
not clear with respect to when the 180-day time period for filing
appeals of a HCFA determination on a hospital's EACH status begins. The
commenter recommended that the regulations be revised to state whether
the time period begins on the date of notice to the hospital of the
determination, or on the date of the Notice of Program Reimbursement
(NPR) that reflects the determination.
Response: The regulations at Sec. 405.1801, concerning provider
reimbursement determinations and appeals, define an ``intermediary
determination'' as ``a determination of the amount of total
reimbursement due the provider pursuant to Sec. 405.1803 following the
close of the provider's cost reporting period * * *.'' Section
405.1811(a) states that a provider that has received a NPR may request
an intermediary hearing if the amount in controversy exceeds a
specified level and the request is in writing and is filed with the
intermediary within 180 calendar days after the date of the notice. In
addition, the regulations at Sec. 405.1841(a)(1) allowing Provider
Reimbursement Review Board (PRRB) hearings provide a similar time frame
for filing appeals for Board hearings.
We believe it is appropriate to make appeals of determinations
affecting EACH status subject to the same time limitations as other
determinations affecting the amount of payment due providers. Thus, a
determination that a hospital does not qualify (or no longer qualifies)
as an EACH will be considered to be made on the date of the NPR that
reflects the non-EACH status of the hospital.
To clarify this point, we have revised Sec. 412.109(e) to state
that a determination by HCFA on the EACH status of a hospital for a
cost reporting period is considered to be an intermediary determination
subject to review under 42 CFR Part 405, subpart R, including the time
limits for filing requests for hearings as specified in
Secs. 405.1811(a) and 405.1841(a)(1) and (b).
We received no comments on the other changes described above.
Therefore, we are adopting those changes as proposed.
I. Clarification of Payment to RRC/EACH Hospitals
In the preamble to the proposed rule, we stated that we wish to
clarify a response in the EACH final rule of May 26, 1993 (58 FR 30639-
30640), regarding the effect on a rural referral center's (RRC) payment
rate should it elect to become an EACH. An RRC that elects to become an
EACH is considered to have dual classification; that is, it is
classified as an RRC/EACH. Since section 1886(d)(5)(D)(iii)(III) of the
Act specifies that an EACH is to be treated as an sole community
hospital (SCH), in determining which of the three payment rates will
yield the highest aggregate payment, we will use the ``other''
standardized amount in determining the Federal payment rate for
discharges occurring on or after October 1, 1994. (As discussed above,
as of that date, the other urban and rural payment rates will be the
same.) For discharges occurring before October 1, 1994, the Federal
payment rate is based on the ``other urban'' payment rate.
Thus, an RRC that elects to become an EACH is paid based on
whichever of the following rates yields the greatest aggregate payment
for the cost reporting period:
The national Federal rate applicable to the hospital (that
is, other urban before October 1, 1994 and ``other'' on or after that
date);
The updated hospital-specific rate using FY 1982 cost per
discharge; or
The updated hospital-specific rate using the FY 1987 cost
per discharge.
We did not propose to revise any regulations in connection with
this clarification, and no comments on the clarification were received.
J. Direct Graduate Medical Education Payment (Sec. 413.86)
1. Definition of Initial Residency Period
Section 1886(h)(4) of the Act bases payment for direct graduate
medical education (GME) costs on the hospital's number of full-time
equivalent (FTE) residents multiplied by a hospital-specific adjusted
base year per resident amount. The number of FTE residents is
determined by applying a weighting factor to each FTE resident. A
resident in an initial residency period is weighted as 1.0 FTE.
Residents in approved training programs that are beyond their initial
residency period are required by law to be counted as .50 FTE. The
initial residency period is defined at Sec. 413.86(g)(1), as the
minimum number of years of formal training necessary to satisfy the
requirements for initial board eligibility in the particular specialty
plus 1 year, not to exceed 5 years.
Section 13563(b) of Public Law 103-66 amended section 1886(h)(5)(F)
of the Act by deleting ``plus one year'' from the statutory definition
of initial residency period, effective July 1, 1995. To conform the
regulations to the statute, we proposed to revise Sec. 413.86(g)(1) by
specifying that, effective July 1, 1995, an initial residency period is
defined as the minimum number of years required for board eligibility.
For example, if a resident completed a 3-year internal medicine
program and then started a cardiology program that requires an
additional 2 years of training, the resident would be counted as 1.0
FTE for the 3 years spent in internal medicine and as a .50 for 2 years
in the cardiology program. (Prior to Public Law 103-66, the resident
would have been counted as 1.0 FTE during the first year of the
cardiology residency program.)
2. Part-time Resident
Currently, the last sentence of Sec. 413.86(f)(1)(ii) specifies
that, for purposes of GME, ``[a] part-time resident counts as a partial
FTE based on the proportion of time worked as compared to the average
time spent by other residents working in the same specialty program.''
The definition of part-time resident for purposes of GME is
consistent with the definition of part-time resident for purposes of
IME. However, the language in the regulations text differs and this
difference has led to some confusion. Therefore, we proposed to revise
the language at Sec. 413.86(f)(1)(ii) to be consistent with the IME
definition specified at Sec. 412.105(g).
Comment: A commenter noted that in making the language for
determining the part-time status of a resident for purposes of GME
payments consistent with the IME language at Sec. 412.105(g), we
limited the determination to time spent by the intern or resident
working ``in the hospital.'' Limiting the determination to time spent
in the hospital is inconsistent with the regulation at
Sec. 413.86(f)(iii).
Response: It was not our intent to limit the determination only to
time spent by the intern or resident in the hospital. Our intent was
solely to make the language regarding the comparison to the total time
necessary to fill a full time internship or residency slot, consistent
for both GME and IME. The reference to time worked in the hospital was
inadvertent. The reference should have been to the allowable time the
resident worked in the program, as specified at Sec. 413.86(f).
Accordingly, we have revised the language at Sec. 413.86(f)(1)(ii) as
follows:
A part-time resident counts as a partial FTE based on the
proportion of allowable time worked compared to the total time
necessary to fill a full-time internship or residency slot.
We also proposed to make a technical change to Sec. 412.113(b)(3)
to correct a reference to Sec. 413.86 and we are adopting the proposal
in this final rule.
K. Other Technical Changes (Sec. 412.232)
We are republishing provisions in Sec. 412.232(c) that were
inadvertently deleted from the regulations text published in the Code
of Federal Regulations (CFR) due to an error in amendatory language in
our September 1, 1992 final rule. In order to provide the public with
the complete text of the provisions of Sec. 412.232(c), pending
publication of the next edition of the CFR, we are publishing
Sec. 412.232(c) in its entirety.
V. Changes and Clarifications to the Prospective Payment System for
Capital-Related Costs
A. Evaluation of Provisions Relating to Obligated Capital for Hospitals
Subject to Lengthy Certificate-of-Need (CON) Process
(Sec. 412.302(c)(2))
Section 412.302(c)(2) of the regulations specifies the conditions
under which capital projects may be treated as obligated capital for
hospitals subject to a lengthy CON process. Under this provision, a
capital project that is subject to a CON process may qualify as
obligated capital if several conditions are met. These conditions are:
The hospital is required under State law to obtain prior
approval of the capital project by a designated State or local planning
authority in the State in which the hospital is located;
The hospital filed by December 31, 1989, an initial
application meeting the requirements of the State that includes, at a
minimum, a detailed description of the project and its estimated cost,
and had not received approval or disapproval by September 30, 1990;
The hospital expended the lesser of $750,000 or 10 percent
of the estimated project cost by December 31, 1990; and
The project is completed and the asset put into use for
patient care on or before the earlier of September 30, 1996 or 4 years
from the date CON approval is received.
The purpose of allowing hospitals in CON states to qualify projects
for recognition as obligated capital under these special conditions was
to recognize that in situations where there is a lengthy CON process,
hospitals may have deferred making the legal commitments required under
the general rule for recognizing obligated capital until the CON
approval was received. We believe that such hospitals should not be
disadvantaged if they reasonably anticipated the CON approval process
in their capital planning but were unable to meet the December 31, 1990
cut-off date for obligated capital because timely approval had not been
received. Our intent was not to afford more favorable treatment for
these hospitals relative to other hospitals, but rather to make a
reasonable and equitable allowance for the impact a lengthy CON process
may have on the ability of hospitals that have already made a
substantial financial commitment to meet the criteria for recognition
of obligated capital costs. Thus, the intent was to put these hospitals
on an even footing with other hospitals.
In the interests of maintaining an equitable policy for those
hospitals, we proposed to change the deadline for putting assets into
use for patient care to the later of September 30, 1996 or 4 years from
the date of CON approval. We received two comments on the proposal to
extend the deadline for putting assets into use for patient care under
the obligated capital provision to the later of September 30, 1996 or 4
years from the date of CON approval. Both commenters supported the
proposal. Therefore, we are adopting as final the proposed change in
the deadline, under the special obligated capital provision for CON
states, for putting assets into use for patient care.
B. Specific Adjustment for Taxes to the Capital Prospective Payment
System Federal Rate (Sec. 412.312)
In our May 27, 1994 proposed rule, we discussed an adjustment to
the capital prospective payment system for capital-related taxes (59 FR
27744-27746). We described the background of this issue, our data
collection efforts and preliminary results, approaches to making a
hospital-specific tax adjustment, and the costs and concerns we could
initially identify with making such a change. We noted that it was
premature to make a regulations proposal at that time due to the
problematic nature of the data currently available on taxes and on
payments in lieu of taxes. We stated that we would seek clarifying
information on the 23 percent of proprietary hospitals not reporting
tax costs and the 13 percent of non-proprietary hospitals reporting
taxes or payments in lieu of taxes. We requested comments from the
entire hospital community on the appropriateness of and preferred
methodology for any capital prospective payment system adjustment for
tax costs.
Based on the comments we received and our analysis of the property
tax component of capital-related costs, we agree that specific
adjustments for tax costs should be made, along with a corresponding
adjustment to the capital prospective payment system Federal rate, at
such time that we have substantially completed and verified data
necessary to implement both adjustments. We intend to complete this
process in time for the FY 1996 proposed rule.
We concur with commenters that maintain that capital-related taxes,
as defined by Medicare regulations, may be a unique cost imposed on
certain hospitals that are readily defined and distinct from other
capital-related costs. Therefore, it may be inequitable to continue to
include those costs in the Federal rate payment made to all hospitals,
as hospitals move to capital payments based on 100 percent of the
Federal rate. We also agree that a payment adjustment for tax costs
should not be limited to proprietary hospitals. Non-proprietary
hospitals that can document costs that meet the criteria for taxes as
specified at Sec. 413.130(a)(2) and (i)(5) should also be eligible for
such an adjustment. An assessment in lieu of property taxes may also
qualify as a capital related payment if the assessment is based
specifically on the assessed value of the hospital's land or
depreciable assets which are used for patient care. An assessment that
is made on a hospital that is not based on the value of those assets
would not qualify as a capital related payment in lieu of taxes and
would therefore not be subject to this adjustment. We intend to
institute a change in cost reporting instructions which will restrict
entries of tax information on Worksheet A-7 to capital-related taxes
that meet the criteria for taxes as specified at Sec. 413.130(a)(2) and
(i)(5).
Although we are committed to implementing specific adjustments for
capital-related tax costs, we find that we are not in a position to
make an appropriate adjustment in the FY 1995 Federal rate to account
for the tax adjustment. After two additional updates to the FY 1992
cost report data on the Hospital Cost Report Information System (HCRIS)
since the May 27, 1994 proposed rule discussion, we still lack tax data
for nearly 22 percent of proprietary hospitals. Also, we have no data
on the amount of payments in lieu of taxes that could meet the criteria
specified above for non-proprietary hospitals. Based on the information
provided by our regional offices, it appears that in many instances
hospitals have included other costs (for example, sales taxes) as
payments in lieu of taxes that do not qualify as capital-related tax
costs.
In order to avoid making duplicate payments to hospitals that would
receive a payment adjustment for taxes, the Federal capital prospective
payment system rate must be adjusted to adequately offset the total of
hospital-specific tax adjustment payments that will be made with
implementation of this initiative. These missing or questionable
amounts are potentially too significant to make an accurate Federal
rate adjustment. In addition, we believe that since nearly 5 out of 6
hospitals will face a Federal rate reduction without any increase in
payments, and that the level of the Federal rate adjustment may be even
more substantial than our earlier data indicated (2 to 3 times the 0.77
percent reduction to the base capital rate reported at 59 FR 27745),
every effort must be made to make an accurate adjustment to the rate.
We believe that we need to develop the methodology and complete any
data analysis prior to publishing the proposed rule for the FY 1996
capital prospective payment system in order to ensure that we will be
in a position to finalize an appropriate tax adjustment for FY 1996.
Thus, solicitation of data and comments on the methodology must be
essentially completed no later than December 15, 1994.
In order to meet these objectives, we are initiating (through
Medicare intermediaries) data collection and verification of Medicare
capital-related tax costs incurred during a hospital's cost reporting
period(s), totalling 12 months, beginning on or after October 1, 1991,
but before October 1, 1992. In order for a hospital to be eligible for
a hospital-specific tax payment adjustment for discharges occurring on
and after October 1, 1995, all tax costs that meet the definition of
capital-related tax costs (including payments in lieu of taxes) cited
above along with supporting documentation must be submitted to the
intermediaries no later than December 15, 1994. Furthermore, payment
eligibility for this adjustment to the capital prospective payment
system rates may be dependent on accurate data being provided by the
hospital on Worksheet A-7 of the hospital's cost report in all future
fiscal periods. Medicare intermediaries will contact each hospital in
writing requesting verification of the amount of and exact source and
basis for taxes or payment in lieu of taxes reflected in the hospital's
FY 1992 Form 2552-92, Worksheet A-7, Part III, column 6, line 5, or for
submittal of that information if it was not reflected on Worksheet A-7.
Using this verified data and other pertinent FY 1992 cost report
information for each hospital, an adjustment to the Federal capital
prospective payment system rate for FY 1996 removing taxes and payments
in lieu of taxes, would be developed along the following lines: We
would propose an adjustment to the Federal capital prospective payment
system rate to remove amounts for taxes and payments in lieu of taxes.
The adjustment will be based on data from cost reports beginning in FY
1992. The adjustment would reflect the allowable capital-related taxes
from Worksheet A-7, supplemented by Medicare fiscal intermediary data
as described in the previous paragraph, and may be allocated through
step-down to Medicare cost amounts. The total capital-related taxes
allocated to Medicare would be subtracted from total Medicare capital-
related costs for all hospitals, yielding Medicare capital-related
costs without taxes. An adjustment reflecting the ratio of Medicare
capital costs without taxes to total Medicare capital-related costs
(including capital-related taxes) would then be applied to the Federal
capital prospective payment system rate. This adjustment is necessary
in order to remove tax costs currently reflected in the Federal capital
prospective payment system rate.
With respect to a hospital-specific tax payment methodology, two
approaches were presented in general outline in the proposed rule (59
FR 27745). In any method ultimately selected, we would use only a
hospital's verified FY 1992 tax cost data based on the intermediary
initiative described above. Hospitals (other than new hospitals) that
have no taxes or payments in lieu of taxes verified by the intermediary
for FY 1992 would not receive an adjustment for taxes in the future.
Based on the FY 1992 tax data and other pertinent information from the
hospital's FY 1992 cost report, a Medicare tax cost per discharge in
the FY 1992 base year would be established for each eligible hospital.
In our May 27, 1994 proposed rule (59 FR 27745) we discussed a
method whereby the tax cost per discharge amount would be calculated as
part of the property tax factor (PTF) approach. Under that methodology
we would determine a ratio of the FY 1992 base year tax cost per
discharge to the base year FY 1992 Federal capital prospective payment
system rate. This percentage would then be applied to the Federal rate
for each eligible hospital for cost reporting periods beginning on or
after October 1, 1995. This percentage (or property tax factor (PTF))
adjustment would be applied on a discharge basis to the Federal capital
prospective payment system rate for FY 1996 and future years.
However, we no longer believe that this approach is desirable.
Since the payments would increase or decrease as a function of changes
to the Federal capital prospective payment system rate, the total
amount paid to hospitals eligible for this adjustment in FY 1996 could
differ substantially from FY 1992 total Medicare tax costs trended
forward to FY 1996. This is because some factors affecting changes in
the Federal rate may not be correlated with a change in capital-related
taxes.
The second option discussed in the proposed rule was to apply a
hospital-specific Medicare tax cost per discharge amount from the FY
1992 base year as a direct add-on amount to each discharge for eligible
hospitals, beginning October 1, 1995. Again any hospital for which the
intermediary has not documented FY 1992 taxes or payments in lieu of
taxes (except for new hospitals) will not receive a tax add-on in
future years. The direct add-on approach has the advantages of
separating the tax adjustment from changes in the Federal rate, thereby
limiting the potential for a divergence in payments for taxes as
compared to the hospital's original tax experience. In addition, it
would improve comparability of the Federal rate adjustment to the total
amount of hospital-specific tax adjustment payments.
Under this approach each hospital's FY 1992 Medicare tax cost per
discharge would be calculated and then subsequently updated by an
appropriate factor for periods after FY 1996. We are using each
hospital's FY 1992 tax cost per discharge as the base year because it
is the hospital's first cost reporting period under capital prospective
payment system and is the most recent data available. Changes in tax
policies after the base period will not be recognized. In establishing
the update factor we would evaluate the appropriateness of applying an
index consistent with the update index used for the Federal capital
rate.
In the event that a unique tax update factor is necessary, we
believe that one possibility is to use 2 or 3 years of reliable cost
report tax data from which we can calculate either a national or
regional rate of change in tax costs. However, any update methodology
would necessarily need to be insulated from the effects of arbitrary
actions by taxing jurisdictions. Under this methodology we would
anticipate utilizing the applicable Federal rate update factor until an
alternative tax cost specific or other appropriate factor is developed.
Finally, we would assure that new hospitals would have the benefit
of a similar adjustment in the future. The hospital's first full cost
reporting year's tax amount could be used to establish its tax
adjustment factor. Timely comments on this option are sought.
Again, we reiterate the importance of hospitals cooperating with
their servicing intermediary in providing capital-related tax
information and documentation, and in submitting specific comments on
the issues and options discussed in this section on hospital tax
adjustments to the Federal rate and capital prospective payment system
payments. Submissions of tax data must be made to the intermediary no
later than December 15, 1994. Comments must be received by the same
date. Mail all comments to the following address: Health Care Financing
Administration, Department of Health and Human Services, Bureau of
Policy Development, Attention: Tzvi Hefter, Room 1-H-1 ELR, 6325
Security Blvd., Baltimore, MD 21207-5187.
Comment: Comments were received that objected to any consideration
of a specific property tax adjustment. One basis for the objection was
that many hospitals are currently required to provide certain levels of
charity care or other specified services in order to maintain their
tax-exempt status. The commenters stated that such requirements were in
effect the equivalent of paying real estate and personal property taxes
which are then used by these same tax jurisdictions to pay for the
provision of medical and other services. Since we do not provide an
adjustment to any Medicare payments in such instances, the commenters
believe that none should be considered for taxes paid by proprietary
hospitals or any others.
Response: While we recognize that charity care and other payments
in the way of services or other charges are being imposed on hospitals
by communities and this trend may be increasing, we believe that these
costs are of a different nature than taxes paid on the value of land
and depreciable assets which form the definition of taxes for Medicare
program purposes. Such costs are, in large part, operating costs rather
than capital-related costs. It is conceivable that these costs were
recognized in the base year amounts used to establish the operating
prospective payment systems rates and, to some degree, are represented
in the adjustments (for example, disproportionate share adjustment) to
those rates. These considerations (that is, charity care, bad debts,
etc.) apply to all hospitals to a greater or lesser extent whether they
are proprietary or non-proprietary facilities.
We believe that due to the special and identifiable nature of
capital-related tax costs used in setting the Federal capital
prospective payment system rate, we should discontinue general
distribution of those specific costs to all hospitals when only about 1
in 6 hospitals are subject to this unique cost. We also believe that
the relationship of capital-related tax costs to other factors that
affect the number or intensity of patient care services that
communities are imposing on a hospital is tenuous at best and,
therefore, only the former should be treated separately in developing
Medicare payment policies.
Comment: We received several comments supporting adjustment of
capital prospective payment system for tax costs originally included in
the Federal rate determinations. A commenter expressed concern that
HCFA was underestimating the impact of the payment inequity arising
from failure to establish an immediate property tax adjustment. The
commenters recommended that HCFA exclude the cost of taxes from the
Federal capital prospective payment system rate and report on, or make
an immediate adjustment for, taxes and payments in lieu of taxes
through a hospital-specific adjustment to capital prospective payment
system payments. Two comments recommended using the actual amount in
each hospital's most recently settled cost report to make the payment
adjustments, in a manner similar to wage index adjustments to
prospective payment system payments. Only one commenter suggested using
the Property Tax Factor (PTF) method discussed in the proposed rule (59
FR 27745).
Response: For the reasons cited in the previous response, we agree
that adjustments for capital-related tax costs should be implemented
for both proprietary and non-proprietary hospitals at the earliest
feasible time. As explained in the foregoing discussion, it would not
be appropriate to attempt payment adjustments on the basis of the
preliminary and unaudited information available at this time. This
adjustment could have a significant redistributional effect on capital
payments to hospitals.
Equally important is the fact that we have not resolved issues
regarding the appropriate methodology to use in providing for capital-
related tax cost adjustments. We received differing suggestions in the
comments regarding which periods to use to make the adjustment and only
one comment recommended a specific methodology. We, therefore, believe
it is necessary to seek additional guidance from interested and
affected parties in the hospital industry and the public before
implementing an adjustment.
We appreciate that in a few instances the burden on a hospital with
high capital-related tax costs may be exacerbated by any delay in
changing the payment policy on the treatment of these tax costs.
However, we maintain that there is no significant and general adverse
impact on proprietary or other hospitals. The capital prospective
payment system transition methodology for payments is based, in large
measure, on the actual historical capital cost components and levels
experienced by hospitals before capital prospective payment system
implementation in FY 1992. Therefore, we believe the rationale
discussed in the proposed rule (59 FR 27745) for delaying the
implementation of any adjustment continues to be appropriate in spite
of the commenter's assertions that tax costs are assumed to have
increased an average of 10 percent since FY 1991 or the commenter's use
of one extreme hypothetical case.
More than 75 percent of affected hospitals are receiving capital
prospective payment system payments on the basis of either the hold-
harmless or the fully prospective methodology less than half-way
through the transition period. Accordingly, the payments they are
receiving are still substantially based on their hospital-specific pre-
transitional cost experience, which includes taxes.
Comment: A commenter objected to the discussion in the proposed
rule (59 FR 27744-27746) where we stated that we believed it was
premature to develop a proposal for a property tax adjustment due to
current data limitations including non-reporting by hospitals, the
status of payments in lieu of taxes and the preliminary nature of the
data contained in the Hospital Cost Report System (HCRIS).
Response: The importance ascribed to adequate data is addressed in
the preceding response. We would also like to point out that regardless
of the reasons that hospitals do not report properly on matters that
directly impact on their payment status, fiscal intermediaries must
perform a substantial amount of work to obtain and verify the necessary
tax data to implement a property tax adjustment. We do not believe that
reliable changes can be made when 20 to 25 percent of the basic
information is missing.
With respect to alleged problems in reporting of tax information
due to problems with the instructions for completing Worksheet A-7 of
the cost report (Form HCFA 2552-92), we believe that the assertion that
it is impossible to report taxes properly is not supported by the fact
that over 77 percent of proprietary hospitals and over 13 percent of
non-proprietary hospitals were able to complete the information and
pass the comprehensive cost report submission editing program required
for submission and entry into HCRIS. We will, however, examine the
specific technical comments provided on the cost report procedures to
determine whether further refinement of the form or instructions for
its completion are needed.
Comment: A commenter addressed our concern with the potential
divergence of the payments that would be made under a percentage
adjustment methodology from the actual ratio of tax costs to Medicare
inpatient costs originally used to establish the property tax factor
adjustment. The commenter suggested that the PTF approach should be
implemented regardless of our concern. The commenter suggested that
when and if data becomes available that conclusively showed that taxes
do not vary consistent with other capital-related costs, another
methodology could be developed.
Response: We concur with the commenter's assumption that several
years of cost report tax data will be needed to analyze and determine
whether changes in taxes and other capital costs are sufficiently
consistent for updating purposes. However, we do not believe that a
parallel function between the cost of taxes and other capital-related
costs, which would only address the need for a separate update factor,
should impact on our decision as to which payment methodology should be
adopted. Our specific concerns with the PTF methodology were discussed
previously. Arbitrarily selecting the PTF method does not
satisfactorily address our concerns.
C. Revision of Provision Relating to Exceptions Payment (Sec. 412.348)
Section 412.348 provides that, during the transition period, a
hospital may receive additional payment under an exceptions process
when its regular payments are less than a minimum percentage,
established by class of hospital, of the hospital's reasonable capital-
related costs. The amount of the exceptions payment is the difference
between the hospital's minimum payment level and the payments the
hospital would receive under the capital prospective payment system in
the absence of an exceptions payment. The comparison is made on a
cumulative basis for all cost reporting periods during which the
hospital is subject to the capital prospective payment transition
rules.
Under current Sec. 412.348(b)(1), the minimum payment percentages
by class of hospitals for FY 1995 are:
For sole community hospitals, 90 percent;
For urban hospitals with at least 100 beds that have a
disproportionate share patient percentage of at least 20.2 percent or
that received more than 30 percent of its net inpatient care revenues
from State or local governments for indigent care, 80 percent;
For all other hospitals, 70 percent of the hospital's
reasonable inpatient capital-related costs.
The current regulations also provide that total estimated payments
under the exceptions process in a year may not exceed 10 percent of
total estimated capital prospective payments (exclusive of hold-
harmless payments for old capital) for the same fiscal year. Therefore,
as we stated in the August 30, 1991 final rule, we will revise the
minimum payment percentages during any subsequent transition year, if
necessary, to ensure that exceptions payments do not exceed the 10
percent limit. It has not yet been necessary to reduce the original
minimum payment percentages to meet the 10 percent limit.
In the final rule for the prospective payment system for capital-
related costs, we stated that we would carefully monitor the impact of
the capital prospective payment system in order to determine whether
``some type of permanent exceptions process is necessary and the
circumstances under which additional payments would be made (56 FR
43409).'' Since the publication of the final rule for the capital
prospective payment system, several commenters have urged us to provide
special protection for hospitals that are undertaking major renovation
or replacement of aging facilities during the decade of the transition.
These commenters have pointed out that, unlike hospitals that undertook
major renovation or replacement during the 1980s, many hospitals that
undertake capital replacement or renovation projects during the
transition do not qualify for the protection for old capital or
obligated capital during the transition. In addition, unlike hospitals
that will undertake major capital replacement or renovation in the
decade after the transition period, such hospitals have not had an
opportunity to accrue capital prospective payments to fund the
projects.
We are aware of a number of major projects, scheduled for
completion later in the transition, that could therefore not be
included as old or obligated capital, and that involve major
replacement or renovation of aging facilities. In the design of the
capital prospective payment system, we have made every effort to
consider the circumstances of hospitals for whom the transition to
prospective payment poses special difficulties. We agree with the
commenters that hospitals that need to undertake major renovation or
replacement projects during the transition face special difficulties
merely because of the timing of their projects. We do not believe that
the Medicare program should guarantee to underwrite every major program
of replacement or renovation of capital assets. However, under certain
circumstances we believe that it is fair to provide special protection,
through the exceptions process, for hospitals that find themselves in
the circumstances cited.
In addition to the exceptions categories identified above, we
therefore proposed at Sec. 412.348 to provide special protection for
some hospitals that are undertaking major projects to renovate or
replace aging plant during the transition period. We proposed that this
special protection would provide a 70 percent minimum payment level for
up to ten years beyond the transition period, and would be available
only to the following classes of hospitals:
Sole community hospitals that have a current ratio less
than or equal to 1.75 in the exception year;
Urban hospitals with at least 100 beds that either have
disproportionate share percentages of at least 20.2 percent or receive
at least 30 percent of their revenue from State or local funds for
indigent care, and that have a current ratio less than or equal to 1.75
in the exception year; and
Hospitals with a combined inpatient Medicare and Medicaid
utilization of at least 70 percent.
In addition, we proposed that the hospital must meet an age of
asset test and, if applicable, receive approval for the project from a
State or local planning authority. If planning approval is not
required, an urban hospital must demonstrate either that it is in a
metropolitan statistical area (MSA) that does not have an overall
average occupancy rate less than 80 percent or that its capacity is no
more than 80 percent of its prior capacity (in terms of bed size).
We proposed a two-part age of asset test to identify aging
hospitals that undertake needed major capital replacement or renovation
projects during the transition. The test would only consider changes in
the average age of building and fixed equipment (determined by the
ratio of accumulated depreciation for building and fixed equipment to
current depreciation for building and fixed equipment) in order to
focus on major capital replacement and renovation projects. The average
age of buildings and fixed equipment can be determined on the basis of
information on the current Medicare cost report (HCFA 2552-92,
Worksheet G, Lines 14, 14.01, 16, 16.01, 18, 18.01, 20, and 20.01, and
Worksheet A-7, Part III, Column 9, Lines 1 and 3). The first part of
the age-of-asset test was designed to determine whether a hospital had
an urgent need for replacement or renovation of facilities because of
relatively aged fixed assets at the beginning of the capital transition
period (that is, the hospital's first cost reporting period beginning
on or after October 1, 1991). We proposed that the threshold for
qualifying under this part of the test would be the 75th percentile.
Under the proposed rule, we would determine whether a hospital is at or
above the 75th percentile nationally on the basis of Medicare cost
report data for FY 1992.
We proposed that the second part of the test would compare the
average age of buildings and fixed equipment in the cost reporting
period beginning in FY 1992 with the average age of fixed assets in the
year the hospital reports the completion of a major capital replacement
or renovation. A major renovation or replacement of hospital capital
during the transition period should result in a dramatically reduced
average age of buildings and fixed equipment compared to the first year
of the transition. We therefore proposed that the test would be whether
a hospital's average age of buildings and fixed equipment has declined
by at least 50 percent since the first year of payment under the
capital prospective payment system. Thus, a hospital whose average age
of buildings and fixed equipment is at or above the 75th percentile
nationally in the first year of capital prospective payment, and whose
average age of buildings and fixed equipment has declined by at least
50 percent in a designated year later in the transition, meets the age-
of-assets test.
We do not believe that this special exception for replacement and
renovation of old facilities should apply to hospitals whose capital
projects preserve the overcapacity that is currently evident in much of
the hospital industry. Therefore, we proposed that a hospital cannot
qualify for an exception unless it has received any required approval
from a State or local planning authority. We also proposed that, if
such approval is not required, an urban hospital must demonstrate
either that (1) overall average occupancy in its MSA is at least 80
percent, or (2) its capacity is no more than 80 percent of its prior
capacity (in terms of bed size). We are exempting rural hospitals from
this requirement because of concern about maintaining access to needed
services in rural areas.
We proposed that hospitals qualifying for exceptions under this
special provision could continue to receive exceptions payments for up
to 10 years beyond the transition. Exceptions payments would be
available under the proposal to hospitals that meet the special
criteria above for 10 years after the date when the hospital meets the
age of asset test, provided that the hospital meets the age of asset
test no later than the end of the capital prospective payment system
transition period for the hospital (that is, the last day of the
hospital's last cost reporting period beginning before October 1,
2001).
We proposed to continue to determine the amount of the exceptions
payments under this special provision on a cumulative basis. That is,
we proposed to determine the hospital's exception payment under the
special provision by comparing the cumulative payments made to the
hospital under the capital prospective payments system to the
cumulative minimum payment levels applicable to the hospital for each
cost reporting period subject to the prospective payment system. Any
amount by which the hospital's cumulative payments exceed its
cumulative minimum payment levels would be deducted from the additional
payment that would otherwise be payable for the cost reporting period.
In addition, we proposed to apply another test designed to limit the
amount of exceptions payments under this special provision. We proposed
to reduce the amount of an exception payment that would otherwise be
made for any cost reporting period under this special provision by the
amount of any Medicare hospital inpatient prospective payment system
payments for the cost reporting period (less 75 percent of operating
prospective payment system disproportionate share payments if
applicable) that are in excess of Medicare inpatient operating and
capital costs. The calculation would include payments under both the
capital and operating prospective payment systems but, not graduate
medical education payments, outpatient service payments, or payments
for any other services covered under Medicare Part B. We proposed to
exclude 75 percent of operating prospective payment system
disproportionate share payments from the determination of the Medicare
operating prospective payments system payments in order to account for
the financial pressure that disproportionate share hospitals experience
in other parts of their operations.
We received 14 comments from individual hospitals and hospital
associations on our proposal to extend capital prospective payment
system exceptions payments for some hospitals for up to 10 years beyond
the current transition period. The commenters focused on the use of the
current ratio, the proposed age of asset test, the proposed minimum
payment level, and the proposed exception payment offsets.
Comment: A number of commenters objected to the proposal that sole
community hospitals and urban DSH hospitals demonstrate financial need
in the exception year by maintaining a current ratio less than or equal
to 1.75. Some commenters objected to the use of a single indicator, and
of that particular indicator, to measure financial need. These
commenters contended that liquidity is not the sole indicator of
financial need, and that the current ratio is often not the best
measure of liquidity. These commenters variously recommended
consideration of measures such as the debt service coverage ratio,
operating or total margin, liability to fund balance, and days in
accounts receivable. A commenter recommended that a high
disproportionate share percentage serve as an indicator of financial
need. Other commenters objected to including any financial need test in
the proposed exceptions provision. One of those commenters noted that
the remaining criteria (that is, those related to community service and
capital burden) and the payment restrictions are very restrictive even
without the financial need test. A commenter recommended adoption of a
project size test as a financial need indicator, on the grounds that
major capital projects necessarily create financial stress. That
commenter recommended that hospitals qualify if total project costs
exceed between 75 percent and 100 percent of allowable operating costs
in the year the construction began. Another commenter stated that the
1.75 threshold for the proposed current ratio test was too high, and
recommended a threshold of 1.5 instead.
Response: We agree with the commenters that a separate financial
need test is unnecessary, provided that the other criteria remain
relatively stringent. As we discuss below, we are strengthening the
qualifying requirements so that all hospitals must meet a project size
test, hospitals in CON states must demonstrate CON approval, and
hospitals in non-CON states must meet the age of asset test to
demonstrate the need for capital renovation or replacement. Projects of
sufficient magnitude to pass the project size and/or age of asset tests
would necessarily place a financial strain on hospitals. Furthermore,
the 70 percent minimum payment level and the offsets would prevent
financially robust hospitals from benefiting very much under the
provision. Therefore, we are not adopting the proposed current ratio
test.
Comment: Several commenters objected to the use of the average age
of assets test as the only measure to establish a hospital's need for
major replacement or renovation of capital assets. Some of these
commenters contended that the age of assets measure contains a
distortion. Under the formula which determines age as the ratio of
accumulated depreciation to current depreciation, the true age of
hospitals can be masked by a vintage effect: the inclusion of some
assets acquired more recently at higher relative price levels would
have a disproportionate effect on the ratio, thus making some hospitals
appear to be younger than they really are. A commenter recommended
determining the average age of assets on a price-level adjusted basis
rather than a historical cost basis in order to correct for this
distortion. Other commenters contended that such a test is unnecessary
in states with CON requirements. Some of these commenters recommended
that hospitals be given the alternative of meeting the average age of
asset test or a test of capital project size, for example, undertaking
a capital project that expends a minimum of the lower of $100 million
or 25 percent of average annual operating costs on a CON-approved
project over a specified period. Another commenter simply recommended
that we reconsider the age of asset test and develop an alternative
qualification criterion based upon hospital-specific expenditures for
capital projects over a period of time. A commenter recommended that
the 75th percentile for average age of assets should be determined on a
statewide basis rather than nationally.
Response: Analysis and consultation with industry experts confirms
the possibility of the distortion cited by commenters in the age of
asset measure. However, there is a countervailing distortion in the
measure: the effect of any fully depreciated assets that are still in
use for patient care is to make a hospital appear older than it really
is. We cannot determine the degree to which the two distortions tend to
cancel each other out. However, we cannot accept the recommendation to
determine age of assets on a price-level adjusted basis for two
reasons: (1) a price-level adjusted determination would eliminate only
the distortion identified by the commenters, leaving nothing in the
measure to counteract the effect of the other distortion, and (2) as
the commenter conceded, price-level adjusted depreciation is contrary
to generally accepted accounting principles and thus cannot be applied
to most hospitals. We believe that the measure has sufficient validity
to retain it within the proposed policy.
We do not agree with the commenter who suggested determining the
75th percentile in age of assets on a state-by-state basis. Adopting
the commenter's recommendation would provide an advantage to hospitals
in states with facilities that are generally newer than the national
average, and a disadvantage to hospitals in states with facilities that
are generally older than the national average. Our intention in
developing this special exception provision is to protect hospitals
with the greatest need for replacement or renovation of their
facilities. It would therefore be inappropriate to adopt the
commenter's recommendation.
We agree with those commenters who contended that an age of asset
test is unnecessary for hospitals in CON states. We proposed the age of
asset test as a method for determining whether there was a need for a
major renovation or replacement of capital projects and whether a
hospital had indeed undertaken and completed such a project during the
transition period. The CON process is specifically designed to require
that hospitals demonstrate the need for capital projects that they
undertake. We are therefore requiring that only hospitals in states
that do not require CON approval satisfy the age of asset test in order
to qualify for extended exceptions. However, for reasons that we will
discuss below, we are modifying the age of assets test so that those
hospitals must meet only the first part of the test as we proposed it,
i.e., a hospital that is not required to obtain CON approval must
demonstrate only that its average age of buildings and fixed equipment
was at or above the 75th percentile nationally in the first year of the
capital prospective payment system transition.
We agree with various commenters that a project size test should be
incorporated into the qualifying criteria. A project size test could be
based on a relative scale (that is, a percentage of one year's
operating cost), an absolute dollar threshold (for example, $200
million), or both, over a designated period of time (for example, FY
1986 through FY 2001). A relative scale test accommodates the needs of
smaller hospitals. An absolute dollar threshold favors larger
hospitals. In order to accommodate both smaller and larger hospitals,
we have decided that a project size test should allow hospitals to meet
either an absolute threshold or a relative scale threshold. Available
information about the major projects planned for this decade indicates
that most exceed 75 percent of annual operating expenses, and many
exceed 100 percent. Since we have always intended this special
exceptions provision to apply to circumstances in which hospitals must
undertake significant replacement or renovation of their facilities, we
believe that a relative scale threshold at the level of 100 percent of
annual operating costs is reasonable. (As we noted previously, one
commenter recommended a project size test at the level of 75 to 100
percent of operating cost as a replacement for the current ratio test.)
Similarly, available information concerning the cost estimates for
large hospitals undertaking capital projects in this decade indicates
that a dollar threshold of $200 million is reasonable.
Commenters variously recommended adoption of a project size test as
a replacement for the age of asset test, or as an option to the age of
asset test for demonstrating the need for major renovation or
replacement of capital assets. We have decided to require that all
hospitals must meet the project size test. One reason is a concern that
the qualifying criteria be comparable for hospitals in CON states and
non-CON states. Applying a project size test to all hospitals provides
a set of equivalent criteria: all hospitals must meet both a project
need test (either CON approval or the age of asset test) and a project
size test. In addition, we are persuaded by the argument of the
commenter cited above that a project size test is a reasonable
replacement for our proposed financial need test. Therefore, in
addition to meeting an appropriate project need test (that is, either
receiving CON approval or meeting the age of asset test), hospitals
will be required to show that they have expended, during their capital
prospective payment system transition period, either 100 percent of
average annual operating expenses for that period or $200 million on a
project to renovate or replace capital assets.
Adopting the project size test for all hospitals does, however,
render the second part of the age of assets test redundant. The
requirement that a hospital's average age of buildings and fixed
equipment must decline by at least 50 percent during the transition
period was designed to assure that the hospital had undertaken a major
project of capital renovation or replacement. The project size test
obviously fills that role. We are therefore requiring that a hospital
in a non-CON state demonstrate only that its average age of buildings
and fixed equipment is at or above the 75th percentile nationally in
the first year of the capital prospective payment system transition.
Comment: A commenter suggested that a project need criterion could
be based simply on the chronological age of the hospital. The commenter
pointed out that there comes a point when hospital buildings need to be
replaced because they can no longer be renovated to accommodate new
technologies and patterns of patient care. The commenter suggested that
major renovation and replacement programs to replace patient care
buildings with core original plants older than 50 years old.
Response: It may well be true, as the commenter contends, that a
hospital building of a certain age necessarily has an antiquated
structural design. However, we simply know of no objective criteria
that could be used to establish ``how old is too old.'' In the place of
such criteria, we believe that our tests should effectively screen
hospitals that genuinely require renovation or replacement of capital
assets.
Comment: Several commenters recommended that the exceptions
provision be designed to protect hospitals undertaking major
modernization programs during the period from 5 years before the
beginning of the capital prospective payment system transition period
to the end of the transition. A commenter stated specifically that the
exclusion of hospitals who completed their major modernization projects
in the years just before the beginning of the capital prospective
payment system transition was inappropriate. Other commenters
recommended proposed expenditure tests based on capital expenditures
over the 15-year period from 1987 through 2001.
Response: We believe that it is entirely appropriate to exclude
hospitals who completed their major modernization programs during the
years immediately before the implementation of the capital prospective
payment system. Hospitals who completed major modernization programs
during those years have gained from the protections offered under the
old capital and obligated capital provisions in the capital prospective
payment system regulations. The proposed exceptions policy was
specifically designed to address the situation of hospitals that were
not in the position to benefit from those provisions because of the
timing of their capital projects. Therefore, it would be inappropriate
to expand the proposed exceptions policy to provide additional
protection for those hospitals. The average age of asset and project
size tests adopted under this final rule will therefore apply only to
projects completed during the period of the capital prospective payment
system transition.
Comment: A commenter contended that the selection of 1992 as a base
for the age of asset test is arbitrary. The commenter recommended
calculating the base at a time just before the capital acquisition is
undertaken.
Response: We proposed 1992 as the base year for the age of asset
test because it is the first year of the capital prospective payment
system transition period, and the test was designed to accommodate the
situation of hospitals that, as previous commenters had informed us,
entered the transition period with a need for major replacement or
renovation of their facilities. We are therefore maintaining this
feature of the age of asset test.
Comment: A commenter recommended that the base for calculating the
age of assets should be separated into components instead of being
grouped together since there are often multiple generations of plants
among a hospital's assets.
Response: We do not believe that a component test is feasible or
desirable. Since the exceptions provision will include a minimum level
of payment relative to the Medicare inpatient capital costs of the
entire facility, we do not believe that the qualifying test should
measure only the ages of discrete assets within the hospital.
Comment: A number of commenters objected to adoption of a 70
percent payment floor for all providers under the proposed exceptions
policy. The commenters recommended maintaining the payment floors
established under the current exceptions policy (90 percent for sole
community hospitals, 80 percent for large urban DSH hospitals, and 70
percent for all other hospitals) during the post-transition period.
Several commenters stated that the 70 percent level is inappropriate
for providers with a high volume of Medicare beneficiaries and for
providers in states in which cost-shifting is legally precluded. Two
commenters acknowledged that we would want to reduce support for
hospitals receiving exceptions payments at the higher minimum payment
levels over time. These two commenters contended, however, that reduced
support for these hospitals would occur naturally over time even if we
maintained the higher minimum payment levels because the eligible
hospitals' need for exceptions payments will have waned.
Response: We agree with those commenters who acknowledged that it
is understandable to expect hospitals to reduce their dependence on
cost-based payments from Medicare over time. We will retain the
proposed 70 percent minimum payment level precisely to give effect to
that reasonable expectation. If, as the commenters contend, hospitals'
need for exceptions payments will naturally wane over time, the
difficulty posed by a 70 percent minimum payment level should also
wane. Furthermore, most hospitals are already at the 70 percent minimum
payment level during the transition period. We believe that it is
entirely reasonable that those hospitals for whom we are providing this
special exceptions provision for the period 10 to 20 years after the
beginning of prospective payment for capital receive the same minimum
payment level which most hospitals have been receiving from the
beginning of the transition.
Comment: A number of commenters objected to the proposed cumulative
payment level of 70 percent. The commenters pointed out that the theory
of capital prospective payment system is to allow hospitals to accrue
equity during low capital cost years to reduce the need for borrowing
during high cost capital years. Thus, the commenters contended that it
is inappropriate to deny exceptions payments for hospitals because they
had lower levels of losses in some years. The commenters recommended
that only payments in excess of a hospital's capital costs in prior
years should be offset against the exceptions payment that the hospital
would otherwise receive.
Response: The cumulative minimum payment level limitation is an
existing feature of the transition period exceptions provision. We
continue to believe, as we did when we established the final rule on
exceptions payments during the transition period (see 56 FR 43409),
that it is a reasonable measure to limit the amount of exceptions
payments. We see no reason to exempt the hospitals who qualify under
this exception provision from a requirement imposed on hospitals under
the current exceptions policy.
Comment: A commenter expressed concern about requiring a rebate of
excess capital payment in prior years. The commenter emphasized that
his hospital had used all the capital it has accumulated to replace
needed equipment and to provide the equity required to obtain funding.
Response: We did not propose a requirement that hospitals
``rebate'' excess payments received in previous years, but rather to
offset payments above a certain level in prior years against the amount
of the exception payment that a hospital would otherwise receive. Thus
hospitals will not be required, as the commenter seems to believe, to
return any previous excess payments to HCFA. Rather, we will simply
reduce the exception payment amount in any year when prior year
payments have exceeded the minimum payment level.
Comment: Two commenters contended that the proposed eligibility
criteria ignore hospitals that provide significant community benefits
through their outpatient services. The commenters proposed adding
criteria that reflect a significant amount of outpatient services to
the poor and underserved.
Response: Since the capital prospective payment system is intended
for inpatient capital-related costs, we feel it would be inappropriate
to consider any outpatient services when determining eligibility. Any
outpatient capital-related costs would be reimbursed under Medicare
Part B payments to hospitals.
Comment: Several commenters objected to the proposal to offset any
positive Medicare hospital inpatient margin (including both capital and
operating prospective payment system payments, but excluding 75 percent
of operating disproportionate share payments). A commenter stated that
it would be inappropriate to apply a means test based on a prospective
payment system margin, since a hospital's total margin is a better
measure of its ability to retain earnings for capital formation.
Another commenter opposed means testing as contrary to the philosophy
of Medicare prospective payment to encourage efficient hospital
operations. That commenter stated that the limitation would penalize
efficient, low-cost hospitals that would otherwise benefit under the
proposed exceptions policy. Another commenter contended that this
proposed policy, together with the cumulative payment limitation, leads
to a cyclical underfunding of hospital Medicare operations.
Response: The offset of any positive margin of Medicare inpatient
prospective payment system over costs is new to this exceptions
provision. We believe it is reasonable to provide an additional limit
on exceptions payments for the period 10 to 20 years after the
beginning of capital prospective payments. We believe that such an
offset promotes the goals of a prospective payment system by further
restricting the amount of cost-based exceptions payments which
hospitals may receive. We believe that the Medicare prospective payment
system margin, rather than total margin, is the proper standard for
determining this additional offset, since total margin reflects the
effects of costs and payments attributable to other payers. We do not
believe that this measure penalizes efficient hospitals or contributes
to cyclical underfunding.
Comment: A commenter expressed concern that the proposed offset of
positive prospective payment system margins, in conjunction with the
cumulative minimum payment offset, would result in a ``double dip''
against providers. The same commenter asked for clarification on
several technical points concerning the offsets. The commenter asked us
to:
(1) Clarify whether the comparison of prospective payment system
operating and capital payments to costs is made solely on a year-to-
year basis or cumulatively;
(2) State explicitly in the regulations text that only 25 percent
of prospective payment system inpatient operating DSH payments are
included in that comparison; and
(3) State that GME and other services that are not paid for as part
of the prospective payment system are also excluded from the
comparison.
Response: We do not agree that the proposed offsets contain a
``double dip'' against providers. While both comparisons consider
capital payments, they do not consider the same capital payments, but
rather capital payments from different years (that is, capital payments
from prior years in the case of the cumulative minimum payment offset,
and capital payments during the current year in the case of the
positive prospective payment system margin offset). There is thus no
double counting. We are revising Sec. 412.348 to clarify each of the
other issues raised by the commenter:
The positive prospective payment system margin offset will
be made on a year-to-year basis, rather than cumulatively.
75 percent of operating prospective payment system
disproportionate share payments, if applicable, are excluded from the
comparison of prospective payment system operating and capital payments
to prospective payment system operating and capital costs; and
The comparison of prospective payment system operating and
capital payments to prospective payment system operating and capital
costs considers only services paid for under the prospective payment
system.
Comment: A commenter pointed out the difficulties that some
hospitals will have in maintaining a high disproportionate share
percentage in emerging managed care environments. Medicaid managed care
tends to decrease the average length of stay for Medicaid patients,
render identification of Medicaid patients by hospitals more difficult,
and limit the ability of hospitals to control or predict Medicaid
utilization. The commenter recommended that we allow hospitals to meet
the 20.2 percent DSH threshold under the proposed exceptions policy in
FY 1992. Alternatively, the commenter suggested the adoption of a
graduated minimum payment level based on DSH percentage or changing the
basis of determining disproportionate share utilization to the higher
of utilization determined on the basis of patient days or admissions.
Response: The intention of the 20.2 percent threshold was to
provide additional financial relief to those hospitals serving a
significant disproportionate share population. When a hospital falls
below this threshold, whether or not it is beyond their control, it
fails to fit the intended criteria for special payment protection.
Emerging managed care environments will increase hospitals'
incentive to keep costs competitive with other neighboring hospitals.
This should provide additional incentive for hospitals to make
judicious capital expenditures. In a managed care environment,
hospitals that fail to have competitive costs will lose Medicaid
managed care patients to more cost-efficient providers. When that
occurs, we do not believe that the Medicare program should continue to
pay those hospitals as if they were still treating larger numbers of
Medicaid patients.
For hospitals that continue to serve a large disproportionate share
population, properly identifying Medicaid patients by hospitals will
have to become a priority. We feel that it is not unreasonable to
expect that hospitals adopt reasonable measures to obtain the
information needed to compute the disproportionate share percentage as
a condition of receiving additional financial protection for serving
these patients. We will, however, examine whether the special
difficulties of identifying Medicaid patients in states with Medicaid
managed care programs warrants additional measures to assist hospitals
in obtaining the required information.
Comment: A commenter supported the inclusion of hospitals with
combined Medicare/Medicaid utilization of 70 percent among the
hospitals eligible for exceptions under the proposal. The commenter
contended that providers with high Medicare utilization should be given
the same benefits as currently enjoyed by sole community and
disproportionate share providers. Another commenter disagreed with the
special protection afforded under the Medicare prospective payment
system for hospitals with high Medicaid utilization. The commenter
contended that, since Medicare and Medicaid are financed from separate
trust funds, it is inappropriate to employ criteria that allocate
Medicare funds on the basis of Medicaid utilization. The commenter
recommended adoption of a threshold based only on Medicare utilization
at the 60 percent level.
Response: During the transition period, we have made special
protection available to urban as well as rural sole community
hospitals, and to urban hospitals with at least 100 beds that either
have disproportionate share patient percentages of at least 20.2
percent or receive at least 30 percent of revenue from state or local
funds. We believe that concerns about access to care are most properly
focused on hospitals that serve vulnerable populations, and we have
made special payment protection available to them as a result.
In addition to the exceptions categories above, we proposed to
provide exceptions for up to 10 years after the end of the current
capital prospective payment system transition period for certain
hospitals with major renovation or reconstruction projects during the
transition period. We have extended this exception to hospitals with
heavy utilization by beneficiaries of the Federal health programs. We
believe this additional special protection should continue to focus on
hospitals that serve vulnerable populations. We believe that a combined
Medicare and Medicaid utilization rate is a reasonable qualifying
condition for this type of protection. The average hospital utilization
by Medicaid beneficiaries is approximately 10 percent. As one commenter
mentioned, a 60 percent Medicare utilization rate can be considered
high. We believe that a combined Medicare/Medicaid utilization
threshold of 70 percent is thus reasonable.
Comment: Two commenters objected to the eligibility period under
the proposed exceptions policy. The commenters maintained that, if
there is a continued need for exceptions payments, they should be
allowed to continue through September 30, 2011.
Response: The proposed exceptions policy was designed to address
the situations of hospitals who were unable to qualify for the
protection offered under the old capital and obligated capital
provisions. The special protections for old capital and obligated
capital were limited to the duration of the transition period and were
thus, in effect, limited to no more than 10 years. Old capital assets,
which by definition were in use for patient care by December 31, 1991,
could receive 10 years of payment based on reasonable cost. Obligated
capital assets in most cases have come into use for patient care since
the beginning of the transition period and therefore will receive less
than 10 years of reasonable cost payment. We therefore believe that it
is fair and reasonable to extend exceptions payments for hospitals who
must undertake major renovation or replacement of facilities during the
transition period only for 10 years after the date they meet the
qualifying criteria.
Comment: A commenter stated that implementing such strict
requirements on hospitals so soon after the transition period, which
already affected so many hospitals negatively, will be devastating to
many hospitals.
Response: We do not believe that it is unreasonable to impose
strict requirements as a condition for receiving cost-based exceptions
payments a full 10 years and more after the beginning of prospective
payment for capital costs.
Comment: A commenter objected that the proposed exceptions
provision is too narrowly defined to benefit most hospitals.
Response: The proposed exceptions provision was intended to be
narrowly defined, focusing on a small group of hospitals who found
themselves in a disadvantaged position. The target hospitals were those
who had an immediate and imperative need to begin major renovations or
replacements just after the beginning of capital prospective payment
system. These hospitals would not be eligible for protection under the
old capital and obligated capital provisions, and would not have been
allowed any time to accrue excess capital prospective payments to fund
the projects.
In the design of the capital prospective payment system, we made
every effort to consider the circumstances of hospitals for whom the
transition to prospective payment poses special difficulties. We
believe this exceptions policy provides appropriate protection for
these disadvantaged hospitals.
Comment: A commenter stated the expectation that extended
exceptions payments would be funded through a budget neutrality
discount applied to either the capital prospective payment system rate
or the combined operating and capital rate.
Response: We are revising Sec. 412.308(c)(3) to provide that an
exceptions payment adjustment factor will continue to be applied to the
Federal rate through any period for which an exceptions policy will be
in effect. This revision assures that estimated payments under the new
policy will be funded through a reduction in the Federal rate, as is
the case under the current exceptions policy.
We received no comments on our proposal to require that urban
hospitals in states without CON provisions demonstrate either that they
are located in MSAs with overall occupancy levels at 80 percent or
above, or that they have replaced no more than 80 percent of their
previous capacity (in terms of bed size). We are therefore adopting
that provision as proposed.
In this final rule, we are therefore providing at Sec. 412.348 a
special exception provision for some hospitals that are undertaking
major projects to renovate or replace aging plant during the transition
period. This special exception provision will provide a minimum payment
level to eligible hospitals for ten years after they meet the
qualifying criteria. The eligible classes of hospitals are:
Sole community hospitals;
Urban hospitals with at least 100 beds that either have
disproportionate share percentages of at least 20.2 percent or receive
at least 30 percent of their revenue from State or local funds for
indigent care; and
Hospitals with a combined inpatient Medicare and Medicaid
utilization of at least 70 percent.
To qualify, an eligible hospital must meet both project need and
project size requirements. For hospitals in states with CON
requirements, the project need test is satisfied by obtaining CON
approval. For other hospitals, the project need requirement is
satisfied by meeting an age of asset test. To meet the age of asset
test, a hospital must have an average age of buildings and fixed
equipment (determined on the basis of information on the current
Medicare cost report, HCFA 2552-92, specifically Worksheet G, Lines 14,
14.01, 16, 16.01, 18, 18.01, 20, and 20.01, and Worksheet A-7, Part
III, Column 9, Lines 1 and 3) at or above the 75th percentile
nationally in the first year of capital prospective payment. In the
June 1994 update of the cost report file, the 75th percentile for
buildings and fixed equipment is 16.4. We will make a final
determination of the 75th percentile at a later date on the basis of
more complete cost report information for FY 1992.
In addition, all hospitals must meet a project size requirement. A
hospital must complete, by the end of the capital prospective payment
system transition period, a project whose costs for replacement and/or
renovation of fixed assets related to patient care equal or exceed
either 100 percent of annual operating expenses for FY 1992 or $200
million. Annual operating expenses are the sum of net expenses for all
reimbursable cost centers, before cost allocation. This information is
found on the Medicare cost report, Form HCFA-2552-92, Worksheet B, Part
I, Column 0. It includes the following cost centers (and corresponding
Worksheet B line numbers): general service (lines 1-24), hospital
inpatient service (lines 25-30), other hospital inpatient (line 31 and
lines 33-36), ancillary service (lines 37-59), outpatient service
(lines 60-63), other reimbursable centers (lines 64-68 and lines 70-
82), and special purpose centers (lines 83-94).
For hospitals in states without CON requirements, an urban hospital
must demonstrate either that it is in a metropolitan statistical area
(MSA) that does not have an overall average occupancy rate less than 80
percent or that its capacity is no more than 80 percent of its prior
capacity (in terms of bed size).
A hospital will be eligible for exceptions payments for 10 years
after completion of the project that meets the project need and project
size requirements. We will determine the hospital's exception payment
under the special provision by comparing the cumulative payments made
to the hospital under the capital prospective payments system to the
cumulative minimum payment levels applicable to the hospital for each
cost reporting period subject to the prospective payment system. Any
amount by which the hospital's cumulative payments exceed its
cumulative minimum payment levels will be deducted from the additional
payment that would otherwise be payable for the cost reporting period.
In addition, we will reduce the amount of an exception payment that
would otherwise be made for any cost reporting period under this
special provision by the amount of any Medicare hospital inpatient
prospective payment system payments for the cost reporting period (less
75 percent of operating prospective payment system disproportionate
share payments if applicable) that are in excess of Medicare inpatient
operating and capital costs. This comparison will consider costs and
payments under both the capital and operating prospective payment
systems, but not costs and payments for graduate medical education,
outpatient services, or for any other services covered under Medicare
Part B. We will exclude 75 percent of operating prospective payment
system disproportionate share payments from the determination of the
Medicare operating prospective payments system payments in order to
account for the financial pressure that disproportionate share
hospitals experience in other parts of their operations.
Finally, we emphasize that these policies are subject to
reevaluation in the light of passage of comprehensive health care
reform by Congress. The hospitals for whom we are providing special
protection under this exceptions provision may no longer require such
protections after the implementation of comprehensive health care
financing reform. Therefore, we will carefully monitor the impact of
final health care reform legislation on the hospitals that would
receive special treatment under the policies above to determine whether
such legislation justifies revision of those policies.
We are making the following revisions to the regulations text to
implement the changes discussed above:
We are making a conforming technical change to
Sec. 412.308(c)(3).
Under new Sec. 412.348(a), we would define annual
operating expenses, average age of fixed assets, and fixed assets.
The new special exceptions requirements are set forth at
Sec. 412.348(g).
Current paragraphs (a) through (e) have been redesignated
as paragraphs (b) through (f), and current paragraph (f) has been
redesignated as paragraph (h).
We are also making conforming technical changes to
Sec. 412.348 to correct references.
D. Extraordinary Circumstances Exceptions Payments (Sec. 412.348(e))
Currently, Sec. 412.348(e) provides that a hospital may request an
additional payment during the capital transition period if the hospital
incurs an unanticipated capital expenditure in excess of $5 million
(net of insurance proceeds) due to extraordinary circumstances beyond
the hospital's control. Extraordinary circumstances include but are not
limited to a flood, fire, or earthquake. A hospital must apply to the
HCFA regional office, for a determination by the HCFA Administrator,
within 180 days of the extraordinary circumstance that caused the
unexpected expenditures in order to qualify for exceptions payments. We
proposed to revise Sec. 412.348 to clarify our policy and reconcile
conflicts between the regulation text and the language and intent of
the preamble to the August 30, 1991 final rule that implemented
prospective payment system for capital-related costs (56 FR 43411).
In Sec. 412.348(e)(1), we proposed that the minimum expenditure
criteria that the hospital must meet in order to qualify for payments
is the net amount of proceeds expected to be recovered by the hospital
in connection with the event from any other source including, but not
limited to, insurance, litigation, or other government relief funding.
Our discussion in the proposed rule (59 FR 27748) cited the August 30,
1991 final rule preamble's instruction to consider payments from other
sources in determining the threshold. However, in the original
regulations text we reflected our intention to establish the threshold
net of insurance but did not include the other comparable sources, such
as court awards for damages, or other governmental relief funds.
Since we clearly did not intend to replace or supplement other
payment sources that have an obligation to pay or provide special
authorization for funding in these same circumstances, we proposed to
revise current Sec. 412.348(e)(1) to conform with the preamble
instructions provided in the August 30, 1991 final rule concerning
application of the extraordinary circumstances exception policy and,
specifically, documentation of evidence of the extent of net loss.
We received no comments on this proposal; therefore, we are
adopting it as proposed.
We also proposed to correct the provision in current
Sec. 412.348(e)(2) regarding the level at which the determination of a
hospital's eligibility for an extraordinary circumstance exception
payment is made. Although the determination authority was reserved to
the HCFA Administrator, we proposed that the appropriate official to
make this decision is the Director of the Office of Payment Policy,
Bureau of Policy Development, Health Care Financing Administration.
This change is warranted because it is inappropriate that the HCFA
Administrator make a decision that he or she may be called on to review
if a hospital requests an administrative appeal of an adverse decision
on its exceptions application.
We received no comments on this proposal. However, we are modifying
the proposed change to Sec. 412.348(e)(2) by deleting the specific
reference to the Director of the Office of Payment Policy because a
reorganization of the Bureau of Policy Development is under
consideration and may make that designation obsolete during FY 1995.
E. Funding of Depreciation (Secs. 413.134 and 413.153)
Section 1861(v)(1)(A) of the Act gives the Secretary broad latitude
to prescribe regulations concerning Medicare payments to providers on a
reasonable cost basis. Under this authority, Sec. 413.134(e) provides
that, although we do not require the funding of depreciation, we
strongly recommend it as a means of conserving funds for the
replacement of depreciable assets.
1. Offset of Investment Income
To encourage the funding of depreciation, we have specified at
Secs. 413.134(e)(1) and 413.153(b)(2)(iii) that investment income
earned on funded depreciation will not be used to reduce allowable
interest expense. Further, Sec. 413.134(e) stipulates that additions to
the funded depreciation account must remain in the account for at least
6 months to be considered valid funding transactions and be eligible
for the benefits of a funded depreciation account. In response to a
comment in the August 30, 1991 final rule on the prospective payment
system for inpatient hospital capital-related costs (56 FR 43424), we
stated that interest on any funds that do not qualify as funded
depreciation account funds, which would include funded depreciation
deposits of less than 6 months duration, must be used to offset
interest expense. Section 226.3 of the Provider Reimbursement Manual
(HCFA Pub. 15-1) provides that investment income earned prior to the
elapse of the 6-month period will not be offset unless the deposits are
actually withdrawn during this period.
We proposed to revise Sec. 413.134(e)(1) to state specifically that
investment income earned during the 6-month period will not be used to
offset interest expense unless the funds are withdrawn for an improper
purpose during this period. Under this change, if a provider withdraws
funds from the funded depreciation account before the expiration of the
6-month time limit, and the withdrawal is made for an allowable purpose
as described in Sec. 413.134(e)(3)(i)(A), the investment income earned
on the funds is not offset against allowable interest expense.
2. Loans to the General Fund
We proposed to revise and clarify our policy regarding loans from
the provider's funded depreciation fund to the provider's general fund.
Sections 413.153(b)(3)(ii) and (c)(2) permit a provider to lend its
funded depreciation funds to its general fund. Moreover, these sections
provide that interest expense incurred on such loans are considered
allowable costs. Section 226.1 of the Manual amplifies this policy by
explaining that, in order for the interest expense incurred on such
loans to be allowable, the interest expense must meet the ``necessary
and proper'' tests (set forth in the regulations at Sec. 413.153(b) (2)
and (3), and in the Manual at sections 202.2 and 202.3). This section
of the Manual also explains that the funds loaned to the general fund
must not be used to acquire depreciable assets used to furnish patient
care because the provider is expected to use its funded depreciation,
rather than to lend it, for that purpose. Finally, this section of the
Manual explains that deposits to the funded depreciation fund will not
be recognized to the extent that loans of funded depreciation funds to
the general fund are outstanding. Rather, such deposits will be
considered repayments of the loan to the general fund.
Three other sections of the Manual address loans from a provider's
funded depreciation fund to the provider's general fund. Section 226.C
of the Manual, in discussing the availability of funded depreciation
funds, provides that loans made from funded depreciation do not alter
the requirement that funded depreciation must be available for the
acquisition of the provider's depreciable assets used to furnish
patient care, or for other capital purposes related to patient care.
Section 226.3 of the Manual, in discussing the application of the 6-
month rule for a deposit to become a valid funding transaction,
provides that a loan of funded depreciation funds to the general fund
is considered a withdrawal for purposes of applying the 6-month rule.
That is, if the provider borrows from funded depreciation for a working
capital purpose, and some or all of the funds borrowed were not on
deposit in the funded depreciation fund for at least 6 months, the
borrowing would be considered a withdrawal from the funded depreciation
account. In addition, if a deposit did not satisfy the 6-month rule any
investment income earned on the deposit would have to be used to offset
otherwise allowable interest expense. Section 226.4B of the Manual, in
an example of applying of the last-in, first-out basis to withdrawals
from funded depreciation for an improper purpose, also characterizes a
loan to the general fund from the funded depreciation fund as a
withdrawal.
In recent years, we have received a number of inquiries suggesting
that loans from the provider's funded depreciation fund to the
provider's general fund are characterized more appropriately as
investments of funded depreciation, rather than withdrawals. We agree
with the inquirers. The term ``withdrawal'' implies that the funds have
been removed from the funded depreciation account and used, either for
a proper purpose (for example, acquisition of a depreciable asset) or
an improper purpose (for example, to purchase office supplies). In
contrast, the term ``investment'' implies that the funds have not
actually been removed from the funded depreciation account and used;
rather, they have been temporarily converted to one or more income
producing vehicles (for example, the purchase of U.S. Treasury bills).
Because loans from the funded depreciation funds to the general fund
generate investment income for the funded depreciation fund, we believe
that such loans more properly should be considered as investments,
rather than withdrawals.
In conjunction with this change, we had to decide whether such
loans would have to meet the ``readily marketable'' test for allowable
funded depreciation investments expressed in Sec. 413.134(e) and
section 226 of the Manual. Loans made from funded depreciation do not
alter the requirement that the funded depreciation be available for the
acquisition of depreciable assets used to furnish patient care, or for
other capital purposes related to patient care; therefore, we believe
that application of the ``readily marketable'' test would be redundant.
That is, if a provider loans funded depreciation to the general fund,
and while that loan is outstanding the provider needs funds to acquire
a depreciable asset related to patient care, the provider may not
borrow funds to acquire the depreciable asset. Rather, the provider
must recall the funds from the general fund loan to use to acquire the
asset.
Accordingly, we proposed to add paragraph (e)(4) to Sec. 413.134 to
address loans from the funded depreciation account. New
Sec. 413.134(e)(4) would both consolidate the policies now set forth in
the manual sections cited above and revise our policy regarding the
characterization of loans from the funded depreciation account. Such
loans would be considered investments, rather than withdrawals.
3. Spenddown of ``Tainted'' Funded Depreciation
The preamble to the August 30, 1991 final rule also addressed the
issue of spenddown (56 FR 43421). ``Spenddown'' is a process whereby we
permit providers to ``cure'' borrowing that was found to be unnecessary
(because of available funded depreciation) by using those funded
depreciation funds for a proper purpose. Under spenddown, if additional
deposits are made to funded depreciation after the unnecessary
borrowing determination, withdrawals from the funded depreciation after
the determination are made on a last-in, first-out basis (typically,
withdrawals for a proper purpose are made on a first-in, first-out
basis). The result of this policy is that all additional deposits to
funded depreciation must be used before spending can be allotted to the
``tainted'' funds, that is, the portion of the funded depreciation that
resulted in the unnecessary borrowing. In addition, Medicare's policy
has been that any other funded depreciation funds in the account at the
time of the unnecessary borrowing must be used before the ``tainted''
funds can be spent down or cured.
Since the publication of the August 30, 1991 final rule, we have
received several inquiries asking why our policy on spenddown was not
incorporated into the regulations. These inquiries also have pointed
out that the last-in, first-out method set forth at
Sec. 413.134(e)(3)(i)(C) will not work properly when the unnecessary
borrowing is repaid from the funded depreciation account if that
account contained untainted funded depreciation at the time of the
unnecessary borrowing or received additional deposits after the
borrowing. The inquirers suggested that this situation may be rectified
by establishing an exception to the last-in, first-out rule when the
unnecessary borrowing that caused the ``tainting'' is repaid out of
funded depreciation. In this case, any use of funded depreciation to
repay the unnecessary borrowing will be deemed to be from ``tainted''
funded depreciation. We agreed and proposed to provide for such an
exception in Sec. 413.134(e)(2)(iv).
Similarly, where the provider repays part or all of the principal
of the unnecessary borrowing that caused the ``tainted'' funded
depreciation by using general funds, a corresponding amount of the
``tainted'' funded depreciation must be cured. This is necessary so
that the ``tainted'' portion of the funded depreciation does not exceed
the amount of the balance of the unnecessary borrowing that caused the
``tainting'' in the first place.
We proposed to revise Sec. 413.134(e) to incorporate the curing
process of ``tainted'' funded depreciation and also to provide that the
provider's subsequent repayment of the principal portion of the
unnecessary borrowing will be from the ``tainted'' funds in the funded
depreciation. Thus, neither the first-in, first-out nor the last-in,
first-out basis would be applicable for such repayments.
4. Necessary and Unnecessary Borrowing
In February 1977, HCFA published Sec. 203 of the Provider
Reimbursement Manual to address interest on loans in excess of asset
value acquired after 1970. Section 203.D of the Manual states that
``[r]epayments of the funds borrowed are applied first to reducing the
portion of the loan applied to the allowable cost of the patient care
assets, then to the tangible and intangible assets not considered
reasonably related to patient care, and lastly to goodwill.'' We have
applied this long-standing principle to cases where a provider repays
borrowed funds where some of these funds are deemed to be unnecessary.
In these circumstances, we have held that all of the necessary
borrowing must be repaid before any of the repayments may be applied to
the unnecessary borrowing.
We also apply this principle to unnecessary borrowing that causes
``tainted'' funded depreciation. When a portion of a provider's
borrowing is considered unnecessary because of the availability of
funded depreciation, subsequent repayments, whether from funded
depreciation or general funds, are first applied to the allowable
portion of the borrowing and, when all of the allowable borrowing is
repaid, to the unallowable portion of the loan. This places the
provider in the same position as if the available funded depreciation
had been used without any unnecessary borrowing.
These applications have not been clearly set forth in the
regulations. Therefore, we proposed to revise Secs. 413.134(e) and
413.153(d) to clearly address both situations.
We also proposed to make a technical change to Sec. 413.134(d)(1)
to correct a reference.
Comment: We received one comment on the proposals regarding the
funding of depreciation. The commenter recommended that we specify that
the policy changes set forth in Secs. 413.134 and 413.153 are effective
for cost reporting periods beginning on or after October 1, 1994. In
addition, the commenter made a series of recommendations related to the
proposed revisions to Secs. 413.134 and 413.153. The recommendations
are as follows:
Consistent with section 226.2 of the Provider
Reimbursement Manual, Sec. 413.134(e)(1) should explicitly state that,
in order for the investment income earned on a funded depreciation
account to be exempt from offset against interest expense, the
investment income must be deposited in, and become part of, the funded
depreciation account.
Consistent with section 226.D of the Manual,
Sec. 413.134(e)(4) should state that when a provider invests or
transfers assets of the fund to a related organization, these assets
continue to be treated as the provider's funds and are subject to all
the provisions governing funded depreciation, notwithstanding the
transfer.
Section 413.134(e)(4) should clarify that loans from the
provider's funded depreciation account may not be used to purchase
depreciable assets for that provider. The provider's funded
depreciation account must be used, rather than loaned, for that
purpose. Section 226.1 of the Manual reflects such a restriction with
regard to loans to the provider's own general fund, and the same
restriction should be extended to loans of funded depreciation funds to
related organizations.
Section 413.134(e)(4) should be revised to prohibit using
the proceeds of a loan from a provider's funded depreciation for the
purpose of acquiring depreciable assets of the related organization
borrowing the funds. The commenter believes that ``investing'' funded
depreciation in depreciable assets of a related organization is not an
appropriate interpretation of the concept of ``available funds.''
Section 413.153 should be revised to include a definition
of ``investment income.'' The commenter believes that our current
definition of investment income, which is set forth in the Manual
rather than in regulations, is inconsistent with generally accepted
accounting principles.
HCFA should revise Sec. 413.153(d)(3) to explain
explicitly how the allocation of repayments is made between the
principal and interest portions of the loan in paying off necessary
borrowing. The commenter believes that any repayments must be applied
to both the allowable principal and interest portions of the loan
before applying any repayments to the unallowable portion of the loan.
In addition, HCFA should include in the final rule an example
illustrating the application of the policy regarding repayments for the
necessary and unnecessary portions of a loan.
If any funds that are generated from the provider's
patient care activities are diverted to pay for an unallowable
borrowing, that diversion should be considered an investment of the
provider's patient-care-related funds, and any investment income
generated should be used to reduce the provider's otherwise allowable
interest expense. The commenter recommends that we revise
Sec. 413.153(d)(3) to reflect this concept.
Finally, the commenter suggested editorial changes to improve the
clarity of Sec. 413.153(d)(2) and (3).
Response: As noted by the commenter, the revisions to Sec. 413.134
and 413.153 are effective for cost reporting periods beginning on or
after October 1, 1994. Because the revisions to these sections involve
changes to the cost payment rules rather than the prospective payment
system rules, an effective date tied to the cost reporting period is
more appropriate than an effective date tied to discharges.
We also agree with several of the commenter's recommendations, and
have made the following changes in response to these comments:
We are revising Sec. 413.134(e)(1) to state that, in order
for the investment income earned on the funded depreciation account to
be exempt from offset against interest expense, the investment income
must be deposited in, and become part of, the funded depreciation
account at the time of receipt by the provider. This revision is
consistent with section 226.2 of the Manual, and it also incorporates
the requirement in section 226.3 of the Manual that the investment
income must be deposited, by the provider, in the funded depreciation
account at the time of receipt.
As recommended, we are revising the regulations to state
that when a provider invests or transfers assets of the fund to a
related organization, these assets are treated as the provider's funds
and are subject to all the provisions governing funded depreciation,
notwithstanding the transfer. However, because we believe this is a
pervasive principle of the funded depreciation rules, we are inserting
this statement in the introductory material of Sec. 413.134(e)(1),
rather than in Sec. 413.134(e)(4), as the commenter suggested.
We are revising Sec. 413.134(e)(4) to state that interest
expense incurred on loans from the providers's funded depreciation
account to purchase depreciable assets for that provider is not an
allowable cost. We agree that, consistent with section 226.1 of the
Manual, the provider's funded depreciation must be used, rather than
loaned, for that purpose.
We are adding the parenthetical phrase ``principal and
interest'' after both uses of the word ``loan'' in Sec. 413.153(d)(3)
to clarify that any repayments must be applied to both the allowable
principal and interest portions of the necessary portion of the loan
before the repayments can be applied to the unallowable portion of the
loan. However, we do not believe that it is appropriate to revise the
regulations to add an example illustrating the application of the
policy regarding repayments for the necessary and unnecessary portions
of a loan. Instead. we intend to incorporate the example into a section
203.D of the Provider Reimbursement Manual as part of the upcoming
revision of that manual.
We are revising Sec. 413.153(d)(3) to clarify that if any
funds that are generated from the provider's patient care activities
are diverted to pay an unallowable borrowing, that diversion is
considered an investment of the provider's patient care related funds,
and any investment income generated must be used to reduce the
provider's otherwise allowable interest expense.
We also adopted several of the commenter's editorial suggestions.
However, as discussed below, we did not agree with two of the
commenter's recommendations.
Since 1983, we have had several inquiries regarding whether a
provider may lend its funded depreciation to a related organization for
the purpose of acquiring depreciable assets to be used by the related
organization. We have responded to these inquiries by stating that
these loans are permissible as long as the funds remain available to
the provider making the loan. Thus, if a provider lends its funded
depreciation to a related organization, and subsequently borrows for a
purpose for which its funded depreciation should have been used, the
borrowing will be considered unnecessary to the extent of the funded
depreciation that should have been available, but was not, due to the
loan to the related organization. We are adding new
Sec. 413.134(e)(4)(iv) to incorporate this longstanding policy.
We do not believe that it would be appropriate to add a definition
of investment income to Sec. 413.153 in this final rule for the
following reasons. First, since we did not propose to add a new
definition of investment income to the regulations, there would be no
opportunity for public comment. Moreover, we would prefer to continue
to refine our definition of this term and propose it in a future
rulemaking document. In developing any changes to this definition, we
will fully consider the commenter's suggestions.
VI. Changes for Hospitals Excluded From the Prospective Payment Systems
A. New Requirements for Certain Long-Term Care Hospitals Excluded From
the Prospective Payment Systems (Sec. 412.23)
Section 1861(e) of the Act and the regulations at 42 CFR part 482
define a hospital as an institution that qualifies to participate in
Medicare because it meets certain health and safety standards, known as
``conditions of participation'' (COPs). A hospital must be surveyed for
compliance with the COPs by State agencies that work under agreement
with HCFA unless, under section 1865 of the Act and regulations at 42
CFR part 488, the hospital is presumed to meet the COPs on the basis of
accreditation by the Joint Commission on Accreditation of Healthcare
Organizations or the American Osteopathic Association.
Recently, some entities have discovered that the process for
becoming a provider under the COPs can be manipulated to permit them to
receive exclusion from the prospective payment systems. Specifically,
hospitals have begun to organize themselves under what they themselves
refer to as the ``hospital within a hospital'' model. Under this model,
an entity may operate in space leased from a hospital, and have most or
all services furnished under arrangements by employees of the lessor
hospital. The newly organized entity may be operated by a corporation
formed and controlled by the lessor hospital, or by a third entity that
controls both. In either case, the new entity seeks State licensure and
Medicare participation as a hospital, demonstrates that it has an
average length of stay of over 25 days, and obtains an exclusion from
the prospective payment systems. The effect of this process is to
extend the long-term care hospital exclusion to what is for all
practical purposes a long-term care hospital unit.
We believe it may not be appropriate for a long-term care
``hospital within a hospital'' to receive an exclusion from the
prospective payment systems. The considerations underlying exclusions
from the prospective payment systems may not apply to these entities.
Under the prospective payment systems, hospitals are paid for
inpatient services on the basis of prospectively determined rates.
Under section 1886(d)(1)(B) of the Act, certain hospitals and units are
excluded from the prospective payment systems, including psychiatric,
rehabilitation, children's, and long-term care hospitals, and
psychiatric and rehabilitation units. These hospitals and units are
excluded because they could not be paid appropriately under the
prospective payment systems.
The prospective payment systems are based on an averaging concept
that recognizes that some patients will stay longer and consume more
resources than expected, while others will have shorter, less costly
stays. We expect that an efficiently operated hospital will be able to
deliver quality care to Medicare patients at an aggregate cost no
greater than its aggregate Medicare payments under the prospective
payment systems for each cost reporting period.
The DRG system does not, however, apply to long-stay hospitals.
Those hospitals have few short-stay or low-cost cases, and might be
systematically underpaid if the prospective payment method applied.
Thus, exclusion of entire long-term care hospitals from the prospective
payment systems is appropriate. However, if an entity that provides
long-term care is part of a larger hospital, the reasons for exclusion
may not apply. A long-term care ``hospital within a hospital'' is
essentially a long-term care hospital unit that accounts for only a
part of the larger hospital's patient load. The principles underlying
the prospective payment systems do apply to the larger hospital, unlike
entire long-term care hospitals. Exclusion of long-term care units
could inadvertently encourage hospitals to try to abuse the prospective
payment systems, by diverting all long-stay cases to the excluded unit,
leaving only the shorter, less costly cases to be paid for under the
prospective payment systems. In such cases, hospitals would profit
inappropriately from prospective payments.
For these reasons, we believe it may be inappropriate to grant an
exclusion to a long-term care ``hospital within a hospital.'' Moreover,
exclusion of long-term care ``units'' is inconsistent with the
statutory scheme. Section 1886(d)(1)(B) of the Act clearly provides for
exclusions from the prospective payment systems for long-term care
hospitals, and also for psychiatric units and rehabilitation units, but
the statute does not provide for exclusion of long-term care units.
Because we believe such exclusions are contrary to the purpose and
scheme of section 1886(d)(1)(B) of the Act, we proposed to revise the
regulations to prevent inappropriate exclusions.
To avoid recognizing nominal hospitals, while allowing adequate
flexibility for legitimate networking and sharing of services, we
proposed additional criteria in 42 CFR part 412, subpart B for
determining whether an entity qualifies for exclusion from the
prospective payment systems as a long-term care hospital. Under the
proposed rule, the revised criteria would apply to entities seeking
exclusion as a long-term care hospital for cost reporting periods
beginning on or after October 1, 1994, including reapprovals of long-
term care exclusions for entities that are currently excluded.
We proposed that in addition to meeting any of the classification
requirements set forth in Sec. 412.23, for cost reporting periods
beginning on or after October 1, 1994, to be excluded from the
prospective payment systems, a hospital located in the same building or
in one or more entire buildings located on the same campus as another
hospital and seeking long-term care exclusion must meet the following
requirements:
Separate governing body. The hospital has a governing body
that is separate from the governing body of the hospital from which it
obtains space. The hospital's governing body is not under the control
of the hospital that provides space, or of any third entity that
controls both hospitals.
Separate chief medical officer. The hospital has a single
chief medical officer who reports directly to the governing body and
who is responsible for all medical staff activities of the hospital.
The chief medical officer of the hospital is not employed by or under
contract with either the hospital that provides space or any third
entity that controls both hospitals.
Separate medical staff. The hospital has a medical staff
that is separate from the medical staff of the hospital from which it
obtains space. The hospital's medical staff is directly accountable to
the governing body for the quality of medical care provided in the
hospital, and adopts and enforces bylaws governing medical staff
activities, including criteria and procedures for recommending to the
governing body the privileges to be granted to individual
practitioners.
Chief executive officer. The hospital has a single chief
executive officer through whom all administrative authority flows, and
who exercises control and surveillance over all administrative
activities of the hospital. The chief executive officer is not employed
by, or under contract with, either the hospital that provides space or
any third entity that controls both hospitals.
Performance of basic hospital functions. The hospital
performs the basic hospital functions specified in Secs. 482.21 through
482.27, 482.30, and 482.42 through the use of employees or under
contracts or other agreements with entities other than the hospital
from which it obtains space, or a third entity that controls both
hospitals. Food and dietetic services and housekeeping, maintenance,
and other services necessary to maintain a clean and safe physical
environment could be obtained under contracts or other agreements with
the hospital that provides space, or with a third entity that controls
both hospitals.
For purposes of these proposals, we considered ``control'' to exist
if an individual or organization has the power, directly or indirectly,
significantly to influence or direct the actions or policies of an
organization or institution. This definition of ``control'' is now
codified in the regulations at Sec. 413.17(b)(3), concerning allowable
Medicare costs, and we would apply the same criteria to determine
whether hospitals and hospital units should be excluded from the
prospective payment systems. Thus, most hospital managers and
administrators are familiar with this definition. We asked for comments
on this and other issues concerning the proposed exclusion criteria.
Finally, to ensure that hospitals that are excluded from the
prospective payment systems are not confused with the types of
facilities that can participate separately in Medicare as distinct-part
psychiatric hospitals or skilled nursing facilities, we proposed to
delete all references in the current prospective payment systems
regulations to excluded units as ``distinct part'' facilities.
We received a number of comments on these proposals and our
responses to them are as follows.
Comment: Some commenters expressed unqualified support for the new
criteria, saying they would help to limit long-term care exclusions to
only legitimately organized long-term care hospitals, and allow for
more equitable treatment of facilities.
Response: We continue to believe new criteria, as proposed in
Sec. 412.23(e)(3), are needed and are adopting them, subject to the
changes described below.
Comment: Several commenters questioned HCFA's authority to impose
new criteria for exclusion of long-term care hospitals. The commenters
stated that the term ``hospital'' is defined in section 1861(e) of the
Act and section 1886(d)(1)(B) of the Act provides an exclusion from the
prospective payment systems for a ``hospital'' having an average length
of stay over 25 days.
Response: As discussed above and in the proposed rule, we are
adding new criteria to prevent inappropriate exclusions from the
prospective payment system. The purpose of excluding entities from the
prospective payment system is to address situations in which the
principles of prospective payment do not apply well. The considerations
underlying exclusions may not apply to situations involving a
``hospital within a hospital.'' If an entity is effectively part of
another hospital and the principles of prospective payment do apply
well to the organization as a whole, then it would not be appropriate
to exclude part of that organization from the prospective payment
system.
Moreover, we believe that granting exclusion to a ``hospital within
a hospital'' may be contrary to the statutory scheme. The statute
provides for exclusion of certain types of hospitals and certain types
of hospital units. Significantly, the statute does not provide for
exclusion of long-term care units. A ``hospital within a hospital'' may
essentially be a long-term care unit of another hospital. We believe
these distinctions are meaningful and that it would undermine the
distinctions if we allowed exclusion of entities that are essentially
long-term care units.
Thus, in order to prevent exclusions that are contrary to the
purpose of the statute and to the statutory scheme, we proposed
additional criteria for entities seeking exclusion. Sections 1102 and
1871 of the Act confer authority on the Secretary to establish rules
and regulations as may be necessary to administer the Medicare program.
Comment: Some commenters indicated that the new criteria would not
eliminate the possibility that some entities may be able to circumvent
the prospective payment systems. Several commenters suggested that,
instead of imposing structural criteria for determining when an entity
qualifies as a bona fide separate hospital, we should develop criteria
that, like those for rehabilitation hospitals and units, are specific
to the types of care or services furnished. Another commenter
recommended that we accept individual States' standards for long-term
care hospitals instead of adopting the proposed requirements. Some
commenters stated that a facility being operated as a long-term care
unit rather than a separate hospital would be expected to receive most
of its patients on referral from the host hospital. Thus, one commenter
recommended that, in addition to meeting other criteria, a long-term
care hospital must show that it has some admissions from hospitals
other than the one with which it shares a building or campus. Another
commenter recommended that requiring a minimum percentage of admissions
from hospitals other than the one in which it is located be adopted as
an alternative to the proposed criteria. Still another commenter
recommended that a long-term care hospital be required to have at least
75 percent of its admissions from entities to which it is not related
by common control, as defined in Sec. 413.17(b)(3).
Response: Although we recognize that the proposed criteria may not
prevent all attempts to circumvent the prospective payment systems, we
do expect them to identify situations when exclusion is appropriate,
and thus address the potential abuses of the exclusion provisions. We
do not agree that the intended effect of the proposals could be
achieved through service-specific criteria. The problem the proposals
were designed to deal with does not relate to the scope or types of
services available in facilities, but to the organizational integrity
of entities seeking exclusion from the prospective payment systems as
separate hospitals. If a ``hospital within a hospital'' is really part
of another hospital and the principles of the prospective payment
system would apply to the organization as a whole, then the ``hospital
within a hospital'' should not receive an exclusion.
Also, although long-term care hospitals are required to comply with
licensure or other State laws affecting patient health and safety, we
do not agree that it would be appropriate simply to adopt whatever
requirements a particular State might impose on long-term care
hospitals as the basis for exclusion from the prospective payment
systems; on the contrary, we believe exclusion decisions should be made
under a uniform national policy.
With regard to the suggestions that we adopt a standard related to
the source of a hospital's patients, we agree that the extent to which
a facility accepts patients from outside sources can be an important
indicator of its status as a separate facility, not merely a unit of
another hospital. In general, a facility's functional separateness
should be reflected in its ability to attract patients from sources
other than the hospital that serves as its host. For example, if a
facility receives all (or nearly all) of its admissions independently
(that is, from outside sources), it can reasonably be assumed to be
functioning separately from the host hospital. In such a case, the fact
that it shared services and facilities with the host hospital would not
necessarily be an indication that exclusion is inappropriate. On the
other hand, if a facility has no more than a bare majority (for
example, 51 or 55 percent) of its admissions from other sources, and
does not meet the other criteria for separateness, the facility may be
dependent upon the host hospital for both services and patients. In
such cases, we do not believe it can or should be seen as functionally
or structurally separate from the host hospital; therefore, the payment
considerations underlying exclusion do not apply and exclusion would be
inappropriate.
On the other hand, the level of outside referrals required should
not be set so high as to discourage use of the facility by the host
facility as well as by others in the community. To balance these
opposing concerns, we are revising Sec. 412.23 to adopt a 75 percent
referral standard as an alternative criterion to the proposed criteria.
Under this approach, a hospital may obtain an exclusion either by
meeting the criteria relating to organizational and functional
separateness in Sec. 412.23(e)(3)(i), or by meeting the organizational
separateness criteria (that is, Sec. 412.23(e)(3)(i) (A) through (D))
and by showing that, during the qualifying period used to establish
compliance with the length of stay requirement, at least 75 percent of
the hospital's inpatient population were referred to it from a source
other than a hospital occupying space in the same building or on the
same campus. We believe allowing a hospital to qualify under either of
these alternatives will mitigate the concerns expressed by commenters
about cost-effectiveness and the status of satellite facilities
(discussed below), while still helping to avoid circumvention of the
rules governing exclusion from the prospective payment systems.
We recognize that in determining the level of outside referrals
needed to permit a long-term care exclusion for a hospital operating in
the same building or on the same campus as another, we could have
chosen a percentage higher or lower than 75 percent. We adopted this
level of outside referrals as a qualifying level not only because it
was recommended by a commenter but also because we believe it is
indicative of situations when a hospital is sufficiently separate so
that the reasons underlying exclusions do apply. At the same time, it
prevents exclusion for a facility that is not a functionally separate
hospital meeting community needs for long-term care, but may be a paper
entity for which the reasons underlying exclusions do not apply.
In adopting this criterion, we are aware of the possibility that
some facilities may attempt to adopt reciprocal referral arrangements
under which one so-called ``hospital within a hospital'' would refer
patients to another such entity, thus establishing ``hospitals'' that
are not true community institutions but in effect operate as mutually
supportive hospital units. We plan to monitor the referral patterns of
facilities that obtain prospective payment system exclusion under the
criterion based on their inpatient population, and may propose further
changes to the regulations or take other actions as needed.
Comment: Two commenters stated that the new exclusion criteria for
long-term care hospitals appear to have been designed to prevent
inappropriate exclusion of long-stay units of prospective payment
systems hospitals. As proposed, however, the criteria would also
prevent a current long-term care hospital from keeping its long-term
care exclusion if it sets up a separate rehabilitation hospital on its
campus or in its facility, in order to avoid actual and potential
problems. (One hospital apparently faces an actual problem in providing
rehabilitation services at costs less than its TEFRA limits, since
those limits reflect a base year during which it furnished virtually no
rehabilitative care. The hospital also faces a potential problem, in
that if it remains a single long-term care hospital it may not qualify
for payment under whatever prospective payment system is finally
adopted for rehabilitation hospitals and units.) To avoid this result,
one commenter recommended that the proposed regulations be revised to
apply only to applicant long-term care hospitals set up in the same
building or on the same campus as prospective payment systems
hospitals, or that existing long-term care hospitals be exempted from
the new criteria. Another commenter suggested that the new criteria be
applied more liberally in the case of applicant long-term care
hospitals that obtain space from hospitals excluded from the
prospective payment systems.
Response: The new exclusion criteria were developed in response to
situations involving prospective payment systems hospitals rather than
currently excluded hospitals. However, we recognize that there may be
other situations in which a hospital may want to reconfigure itself
solely to gain a reimbursement advantage, rather than to improve its
quality of care or efficiency of operation. Under these circumstances,
we believe it is appropriate to apply the revised long-term care
exclusion criteria as needed to ensure that a facility is not able to
circumvent the prospective payment systems or a TEFRA limitation simply
through a nominal restructuring. In addition, Sec. 413.40 contains
several provisions that allow for adjustments to accommodate changes
that occur after an excluded hospital's base year. For these reasons,
we have not revised the exclusion criteria for long-term care hospitals
as requested by these commenters.
Comment: Some commenters stated that the new exclusion criteria are
not necessary to prevent inappropriate utilization of long-term care
services, since PRO review of admissions already achieves this result.
Response: We recognize the importance of PRO activities in assuring
appropriate utilization, but we do not believe PRO review of specific
admissions can be effective in dealing with problems of inappropriate
exclusion of certain types of facilities.
Comment: A commenter stated that in some cases, long-term care
exclusions have been granted to hospitals that lease space from another
company to which they are related by common ownership. The commenter
recommended the final rules be clarified to state that long-term care
exclusions are available to hospitals that are separately operated but
are related through common ownership.
Response: A facility may qualify for exclusion as long as it meets
the criteria, even if it is owned by the same entity as a hospital with
which it shares a building or a campus. A separately operated hospital
is not ineligible for exclusion solely because it and the host facility
are under common ownership. We do not believe that it is necessary to
revise the regulations to clarify this point.
Comment: Some commenters stated that the new exclusion criteria
could adversely affect the quality of care patients receive, by
limiting access to care and by requiring transfers that could be
medically inappropriate. A commenter stated that the criteria could
lead to a shortage of long-term care beds in rural areas, and suggested
we either abandon the proposal or create an exception for rural
facilities.
Response: We agree that it would not be desirable to limit
patients' access to long-term care or to require medically
inappropriate transfers. However, none of the commenters presented any
data, studies, or other objective information to demonstrate that these
results would occur. Moreover, all hospitals are obligated under the
Medicare conditions of participation (Sec. 482.21(b)) to have an
effective, ongoing discharge planning program that facilitates the
provision of follow-up care. We believe this requirement is effective
in preventing premature or inappropriate discharges, but will
investigate fully any complaints we receive in this area. In this
context, we note that the new criteria are designed only to make
appropriate payments, not to affect medical practice.
We also considered the proposal to exempt rural facilities from the
requirements; however, we believe that the exclusion provisions can be
administered most efficiently and equitably if we use a single set of
standards for both urban and rural facilities. In addition, we do not
want to indirectly encourage the development of hospitals within
hospitals in rural areas. Therefore, we are not adopting this
suggestion.
Comment: A commenter expressed reservations about several of the
specific proposed criteria, saying that having a separate governing
body, chief medical officer, and chief executive officer could impede
coordination of care.
Response: As noted above, all hospitals are responsible for
discharge planning, and they typically develop referral and other
relationships with other facilities to fulfill this responsibility. In
general, there is no indication that the independence of these
facilities impedes the coordination of hospital and post-hospital care.
Thus, we do not believe that these criteria will impede the
coordination of patient care.
Comment: A commenter opposed the use of the definition of
``control'' incorporated into the proposed criteria. The commenter
stated that ``control'' is a reimbursement concept and that it is not
appropriate to apply this concept for purposes of determining whether
two facilities may be separately certified for Medicare participation.
Response: The purpose of the proposed criteria is not to determine
whether a facility seeking to participate in Medicare as a hospital is
qualified to do so under the conditions of participation. On the
contrary, the goal of the criteria is to limit exclusions to situations
when exclusion is warranted. We believe that it is appropriate to adopt
the definition of control under Sec. 413.17(b)(3), which currently
applies for reimbursement purposes, because it is a long-established
and well understood payment rule that can be readily applied to this
new situation.
Comment: Several commenters stated that the proposals would
increase costs by limiting hospitals' ability to share space and
services. Even some commenters who generally favored the ``core
services'' criteria (that is, the requirement under proposed
Sec. 412.23(e)(3)(v) that a hospital perform basic hospital functions
through the use of its employees or under contract with an entity other
than the hospital from which it obtains space) nevertheless suggested
that long-term care hospitals be allowed to buy laboratory and
radiology services from the host hospital.
Response: We understand the commenters' concerns, but also believe
that the ability to provide certain core services, including laboratory
and radiology services, needed by patients can be an important
indicator of the separateness of a facility seeking exclusion as a
long-term care hospital. Moreover, as noted elsewhere in this preamble,
hospitals that receive a certain percentage of their patients from
sources other than the hospital from which it obtains space are not
required to meet the ``core services'' requirement. Therefore, we did
not adopt the recommendation that laboratory and radiology be excluded
from the list of core services.
Comment: A commenter asked for clarification of whether the
additional criteria would apply only when an applicant long-term care
hospital obtains space from another hospital, or whether they also
would apply when the applicant long-term care hospital obtains space
from a third entity that controls both hospitals.
Response: The new criteria apply whenever a hospital seeking long-
term care exclusion occupies space in a building that is also used by
another hospital, or in a building that is located on the same campus
as one or more buildings used by another hospital. If these conditions
exist, the exclusion request must be evaluated under the new criteria,
regardless of whether the space occupied by the applicant long-term
care hospital is furnished by another hospital or by a third entity.
However, the criteria do not apply if the applicant long-term care
hospital is the only hospital to occupy space in the building or on the
campus.
The following examples illustrate this rule: if a hospital seeking
long-term care exclusion and another hospital each occupy five floors
of the same ten-story building, the new criteria apply. This is the
case even if the applicant long-term care hospital does not lease its
space from the other hospital, but from another source, such as a
private realty company that acts only as a lessor and does not have any
other association with the long-term care hospital. However, the
criteria do not apply if the applicant long-term care hospital occupies
the entire building, or if the other five floors are occupied by an
entity other than a hospital, such as a health maintenance organization
or physician professional corporation. Under these circumstances the
criteria do not apply, even if the space is provided to the applicant
long-term care hospital by a controlling third entity, such as a chain
organization that owns or controls it as well as one or more other
hospitals.
To clarify these points, we have revised Sec. 412.23(e) to remove
references to hospitals that provide or obtain space, and to refer
instead to hospitals that occupy space in the same building or on the
same campus.
Comment: A commenter asked whether a hospital seeking long-term
care exclusion would be disqualified if it purchased therapy services
and supplies, such as pharmaceuticals, from the hospital from which it
obtains space.
Response: In general, exclusion or non-exclusion of individual
facilities is determined on a facility-by-facility basis by the HCFA
regional office (RO), based on the facility's compliance with the
exclusion criteria. We note that pharmaceutical services are among the
core services that a hospital must provide directly, or obtain from an
entity other than the one with which it shares space in a building or
on a hospital campus. However, we also note that, if a hospital
satisfies the 75 percent referral standard, it would not be
disqualified simply because it purchased pharmaceutical services from
the host hospital.
Comment: A commenter suggested that the term ``campus'' be defined
more specifically as a continuous parcel of property owned by an
applicant long-term care hospital. The commenter believes that
``campus'' should not include any property owned by an excluded
hospital, even though it may adjoin the applicant hospital's property.
Response: We have not adopted an explicit definition of the term
``campus,'' but intend that decisions about whether facilities are on
the same campus be made by the ROs in the course of applying the new
provisions. In making these assessments, RO staff will consider not
only the ownership of a tract of land but its actual use. For example,
if a hospital owns one tract of land but holds an adjacent tract under
a long-term lease, and occupies and uses both tracts as if they were
one, the two tracts might be considered the hospital's campus
regardless of the ownership of the second tract. Thus, because of the
possibility of arrangements such as this, we do not believe that
ownership is the sole determinant of what constitutes a hospital's
campus.
Comment: A commenter recommended that the regulations be revised to
exclude situations in which a hospital has a majority of its beds
located in a single site, and incurs most of its costs at that site,
but has a satellite location at which some of its beds are located in
the same building as another hospital.
Response: We believe the proposed criteria should be applied in all
cases involving joint occupancy of a building or campus by an applicant
long-term care hospital and another hospital, and have not adopted this
comment. This means that if a hospital has established a satellite unit
within another hospital and has most or all basic hospital functions
for the unit performed by the host hospital or by a controlling third
entity, the hospital would not be able to qualify for a long-term care
exclusion under the criteria as proposed. However, the additional
criterion related to the sources of a long-term care hospital's
patients will be applied with respect to the total patient population a
hospital treats at all locations, including both base and satellite
facilities. A hospital which has a majority of its beds at a central
location and maintains only a small number of satellite beds probably
would attract patients from a variety of sources other than the
hospital(s) in which its satellite facilities are located, and thus may
be able to meet the alternative criterion related to the sources of its
patients.
Comment: Several commenters noted that some long-term care
hospitals have operated for many years by using space and services
obtained from other hospitals, and that the TEFRA rates for these
hospitals effectively prevent excess costs at these facilities. Because
of this, the commenters recommended that we exempt currently excluded
facilities from the new criteria, or provide a facility-by-facility
exceptions process.
Response: We understand that some facilities that have been
excluded under their current forms of organization for many years may
not meet the new exclusion criteria. We agree that it might be
inequitable to impose new criteria on them effective immediately.
However, we believe that the exclusion provisions can be administered
most efficiently and equitably if we use a single set of standards for
both currently excluded hospitals and those requesting exclusion for
the first time. We considered the suggestion that we adopt a case-by-
case exceptions process, but we are concerned about the administrative
burden involved in such a process, as well as the difficulty in setting
criteria. Therefore, to allow for equitable treatment of currently
excluded hospitals while ensuring that all similar hospitals eventually
will be subject to the same standards, we are adding paragraph (e)(4)
to Sec. 412.23 to allow hospitals with long-term care exclusions in
effect for cost reporting periods beginning on or after October 1,
1993, but before October 1, 1994, an additional 12 months before the
new exclusion criteria will apply. Thus, the new exclusion criteria
specified in Sec. 412.23(e)(3) will not apply to those hospitals until
the start of their first cost reporting period beginning on or after
October 1, 1995.
B. Miscellaneous Comments
Comment: Some commenters recommended that we revise the regulations
on exclusion of rehabilitation hospitals and units from the prospective
payment systems. They suggested that four new medical conditions--
oncology cases, pulmonary disorders, cardiac disorders, and chronic
pain--be added to the list of medical conditions, under
Sec. 412.23(b)(2), that is used to identify hospitals and hospital
units that are primarily engaged in intensive inpatient rehabilitation.
Response: Although this issue was not addressed in the May 27, 1994
proposed rule, we are interested in suggestions regarding changes in
this provision and will take them into consideration in deciding what,
if any, future changes are appropriate.
Comment: Some commenters stated that there is an increasing need
for subacute care, which is not now recognized as a distinct level of
care under Medicare. The commenters recommended that new coverage and
payment policies specific to subacute care be adopted to respond to
this need.
Response: These comments are similar to others we have recently
received from providers involved in treating long-stay patients. These
commenters suggested that a separate Medicare benefit, similar to the
hospital and SNF care benefits, be developed for care that is variously
described as ``transitional'' or ``subacute.'' We are reviewing these
suggestions carefully, and may propose new legislation or regulations
on this type of care in the future. However, there is currently no
Medicare benefit for subacute care, and we made no change in these
regulations based on these comments.
C. Removal of the 1986 Malpractice Rule (Sec. 413.56)
We proposed to remove from the regulations ``the 1986 malpractice
rule'', which is set forth at Sec. 413.56. We also proposed to remove
all cross-references to Sec. 413.56. This technical change is designed
to conform the regulations to the various authorities that have
previously established that the 1986 malpractice rule is invalid. See
the May 27, 1994 proposed rule for a detailed discussion of this
proposed change (59 FR 27751). We received no comments and are adopting
the proposal without change in this final rule. As a result, the
amended Medicare rules reflect the previously established legal
requirement that reasonable cost reimbursement for provider malpractice
insurance cost claims that are either open or the subject of properly
pending appeals, must be determined under the pre-1979 utilization
method.
D. Related Technical Changes (Secs. 412.20, 412.22, 412.25, 412.27,
412.29, 412.30, 412.96, 412.105, 412.108, 412.116, 412.130, 412.71,
413.40, 413.53, 413.174 and 482.66)
We proposed to remove the words ``distinct part'', wherever they
appear, in the following places:
(a) Section 412.20(b)(1);
(b) Section 412.22(b);
(c) The section title and paragraph (a) of Sec. 412.25;
(d) The undesignated introductory texts of Secs. 412.27 and 412.29;
(e) The section title of Sec. 412.30;
(f) Section 412.96(c)(1) and (c)(2);
(g) Section 412.105(b), (f)(5) and (g)(1)(iii);
(h) Section 412.108(a)(2);
(i) Section 412.116(a) and (b);
(j) The section title of 412.130;
(k) Section 412.130(a)(2) and (a)(3);
(l) Section 413.40(a)(2)(ii), (b)(1)(i) through (b)(1)(iii) and
(f)(2); and
(m) In Sec. 482.66(a)(7)(i), the second appearance of the words
``distinct part'' are removed.
We also proposed to revise the section titles of Secs. 412.27 and
412.29 to remove the words ``distinct part'' and replace them with the
word ``excluded''.
In addition, we proposed to make technical changes to
Secs. 412.71(b), 413.53 and 413.174(b)(4)(iv) to remove and replace
obsolete language and to correct references.
We received no comments on the technical changes described above.
Therefore, we are adopting those changes as proposed.
VII. ProPAC Recommendations
As required by law, we reviewed the March 1, 1994 report submitted
by ProPAC to Congress and gave its recommendations careful
consideration in conjunction with the proposals set forth in the
proposed rule. We also responded to the individual recommendations in
the proposed rule. The comments we received on the treatment of the
ProPAC recommendations are set forth below along with our responses to
those comments. However, if we received no comments from the public
concerning a ProPAC recommendation or our response to that
recommendation, we have not repeated the recommendation and response in
the discussion below. Recommendations 9, 12, and 13 concerning the
update factors for inpatient operating costs are discussed in Appendix
D to this final rule. Recommendations 10 and 11 concerning the update
factors for inpatient capital costs are discussed in Appendix E.
Recommendations 15 and 16 concerning hospital wage data and the
hospital wage index are discussed in section III of this preamble. The
remaining recommendations on which we received comments are discussed
below.
A. Update to the Composite Rate for Dialysis Services (Recommendation
14)
Recommendation: The FY 1995 update recommendation for the composite
rate for dialysis services accounts for the following:
The projected increase in the market basket for dialysis
services in FY 1995, estimated at 4.3 percent;
A positive adjustment of 0.7 percentage points to reflect
the additional costs associated with scientific and technological
advances;
A negative adjustment of 1.0 percentage points to
encourage productivity improvements; and
A negative discretionary adjustment of 4.0 percentage
points to reflect the relationship between payments and estimated FY
1994 costs.
This results in a net update recommendation of 0.0 percent.
Response in the Proposed Rule: We agree with ProPAC's
recommendation not to propose a payment rate increase for dialysis
services. The 1991 audited data support this decision. As the
Commission points out, these data show that independent renal facility
composite payment rates are higher than their Medicare allowable costs,
while hospital renal facilities continue to report costs in excess of
their payment rates. The audits did not provide an explanation for the
higher reported costs of hospital renal facilities relative to
independent renal facilities. However, auditors found that hospital
renal facilities often fail to maintain adequate records for allocation
costs in the renal department. Since hospitals' payments are not
affected by renal cost reports, Supplement Worksheet I of HCFA-2552,
hospitals do not always complete their cost reports accurately.
Although we realize the importance of regular renal audits, the
budget for audits continues to decline. Thus, we do not plan to conduct
renal audits in 1994 or 1995. We have requested funds to conduct renal
audits in 1996. During this 2-year interval, we would review the 1992
and 1993 cost report data for those renal facilities in the 1991 audit
sample.
We believe that this analysis will provide cost information about
the ESRD program in lieu of audited data for these years. Furthermore,
it will provide a basis for analyzing cost data over time and allow for
better comparison of audited and unaudited costs.
Comment: ProPAC believes that annual audits are necessary to
develop the data needed to monitor dialysis costs over time and to
ensure that payments for dialysis services are updated appropriately.
Response: We believe it is not feasible at this time to conduct
annual audits of renal facilities. The selection of a representative
sample of renal facilities nationally, the coordination of the audits
with fiscal intermediaries, and the review and analysis of data are
time consuming activities. The audit process takes about 12 months to
complete. Moreover, audits impose burdens on renal facilities, who have
limited staff resources. We believe that conducting audits on a 3-year
basis is a reasonable alternative to annual audits. During the
interval, unaudited data are available from HCRIS for ProPAC's
analysis. In addition, prior audit results can be used to account for
differences between reported and audited costs.
Comment: One commenter believes that the lack of a payment rate
increase for dialysis services is unfair to hospital-based renal
facilities, and claims that hospitals service a more resource-intensive
and consequently costlier patient population.
Response: In its report to Congress, ProPAC addressed the issue of
the cost differential between hospital-based renal facilities and
independent facilities (see p. 85-86). ProPAC's analyses of various
data failed to attribute the cost difference between hospital-based and
independent renal facilities to factors, such as patient mix, for which
the payment system should compensate. The data showed that higher costs
for hospital-based renal facilities may be due, in part, to ``richer
employee skill mix'' and the inclusion of inpatient dialysis service
costs in the outpatient department. Furthermore, ProPAC found that
audited cost data did not justify an increase and recommended no
payment rate update.
To date, no study has clearly demonstrated that hospitals treat a
more resource-intensive, and consequently costlier, ESRD patient
population than independent renal facilities. Until an ESRD case mix
index is developed to adjust payment rates, the exception process
provides a mechanism for adjusting payment rates to account for
differences in patient mix.
B. Level of the Indirect Medical Education Adjustment to PPS Operating
Payments (Recommendation 19)
Recommendation: The Commission recommends that the indirect medical
education adjustment to prospective payments for hospital inpatient
operating costs be reduced from its current level of 7.7 percent to 7.0
percent for fiscal year 1995. This reduction should be implemented with
the anticipated decrease in indirect medical education payments
returned to all hospitals through a proportionate increase in the
standardized payment amounts. The Commission also recommends
continuation of the indirect medical education adjustment to operating
payments until an alternative system of compensating appropriately for
the higher costs of patient care in teaching institutions is fully
operational.
Response in the Proposed Rule: The first part of this
recommendation is identical to ProPAC's recommendation on the level of
the IME adjustment for FY 1994, to which we responded in the May 26,
1993 proposed rule (58 FR 30255) and September 1, 1993 final rule (58
FR 46326) containing the changes to the prospective payment systems for
FY 1994. We agree that the IME adjustment should be reduced. Although
we have disagreed with ProPAC in the past over the degree of reduction,
we have proposed reductions as part of the President's budgets for the
last several years.
With respect to ProPAC's methodology for estimating the indirect
cost effect of teaching without accounting for the DSH adjustment, we
explained our opposition to this suggestion in the September 1, 1993
final rule (58 FR 46328). To reiterate, our analysis indicates that
there is evidence of significantly higher costs related to DSH among
urban hospitals with 100 or more beds (see O'Dougherty et al., Health
Care Financing Review, Winter 1992, p. 31). Since these hospitals
receive over 96 percent of all DSH payments, we believe ProPAC's claim
that ``DSH payments generally do not reflect differences in costs'' is
overstated. We do agree, however, that the current level of DSH
payments exceeds the measured cost effect of DSH even among urban
hospitals with 100 or more beds. In that regard, we point out that in
the regression model used to estimate the teaching effect, we did not
specify the DSH variable as the level of DSH payments, but instead set
it equal to the DSH percentage for urban hospitals with 100 or more
beds and zero for all other hospitals. (For a complete description of
our estimating model, see the August 30, 1991 final rule implementing
the capital prospective payment system, 56 FR 43370.) As ProPAC alludes
to in its report, not controlling for DSH leads to its higher IME cost
estimate relative to our IME cost estimate.
The remainder of ProPAC's recommendation raises policy issues
related to the appropriate level of IME funding as the transition is
made from the current system to the new health care system. Since these
transition issues are currently being addressed as part of the health
care reform debate, we are not responding in this document to this part
of ProPAC's recommendation.
Comment: In commenting on the proposed rule, ProPAC reiterated much
of its original recommendation, stating again that the IME adjustment
should be reduced to 7.0 in FY 1995. The Commission continues to argue
that further reductions should be gradual and occur only after
examination of the financial status of teaching hospitals. The
Commission expressed its appreciation for HCFA's explanation of the
methodology it uses to control for DSH when estimating indirect
teaching costs. The Commission also indicated its intent to continue
examining the level and the structure of the IME adjustment. Finally,
ProPAC indicated support for the explicit recognition of IME by all
payers under health care reform, and called for Medicare to retain the
IME adjustment until an alternative system was operational.
Response: We appreciate ProPAC's past contributions to the
understanding of the relationship between patient care costs and
graduate medical education, and anticipate that the Commission will
continue to be at the analytic forefront of this important issue.
C. Beneficiary Liability for Hospital Outpatient Services
(Recommendation 22)
Recommendation: Beneficiary coinsurance for hospital outpatient
services should be limited to 20 percent of the Medicare-allowed
payment, as it is in other settings. For services not paid on a
prospective basis, beneficiary copayment would need to be estimated
because it is not known at the time of service delivery.
Response in the Proposed Rule: We share ProPAC's concern that
beneficiaries may be paying a disproportionate share of the total
payment for hospital outpatient services under the current cost based
system. However, we are in the process of developing a prospective
payment system for hospital outpatient services that will be moving
away from costs and charges as a basis for payment. We believe that it
would be most appropriate to make any changes to beneficiary
coinsurance in conjunction with the implementation of this hospital
outpatient prospective payment system. Therefore, as we develop this
system, we are reviewing the issue of beneficiary liability and are
working to come up with an approach that will be fair to beneficiaries,
while minimizing the negative financial impact on the Medicare program.
Comment: ProPAC continues to believe that the Secretary should not
delay correcting beneficiary liability for outpatient services until
the implementation of prospective payment.
Response: We understand the concern expressed by ProPAC. However,
we continue to believe that a meaningful solution to the high level of
beneficiary liability can most appropriately be achieved with the
implementation of a prospective payment system for hospital outpatient
services in the near future. The time and effort needed to develop an
interim solution might detract from the development of the prospective
payment system that would make possible an equitable solution for all
parties, while minimizing the negative financial impact on the Medicare
program.
VIII. Other Required Information
A. Paperwork Reduction Act
As discussed in detail in section III.F of this preamble, we
proposed several changes to forms used to gather hospital wage data,
specifically the Worksheet S-3, Part II, of the Medicare cost report,
and the provider cost report questionnaire (HCFA-339). The current
information collection requirements associated with these items have
been approved by the Office of Management and Budget (OMB) under
approval numbers 0938-0050 and 0938-0301, respectively. We proposed
that the changes to these forms would be effective for cost reporting
periods beginning on or after October 1, 1994. However, these changes
will not be effective until OMB approval is received under the
authority of the Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et
seq.).
B. Requests for Data from the Public
In order to respond promptly to public requests for data related to
the prospective payment system, we have set up a process under which
commenters can gain access to the raw data on an expedited basis.
Generally, the data are available in computer tape format or
cartridges; however, some files are available on diskette. In our May
27, 1994 proposed rule, we published a list of data sets that are
available for purchase (59 FR 27756). We received no comments
concerning this process.
C. Waiver of Notice of Proposed Rulemaking and 30-Day Delay in the
Effective Date
We ordinarily publish a notice of proposed rulemaking for a rule to
provide a period for public comment. However, we may waive that
procedure if we find good cause that prior notice and comment are
impractical, unnecessary, or contrary to public interest. We find good
cause to implement this rule as a final rule with comment period
because the delay involved in prior notice and comment procedures for
the new provisions of this rule would be contrary to the public
interest.
The only provisions of this rule that were not part of our May 27,
1994, proposed rule are those eliminating the requirement in 42 CFR
412.230 that an individual hospital be located in an area adjacent to
the area to which it seeks geographic reclassification. As discussed in
section III.F of this preamble, the MGCRB is required, by statute, to
issue decisions on hospital applications no later than 180 days after
October 1, the first day of the Federal fiscal year preceding the
Federal fiscal year for which the hospital is seeking reclassification.
To be considered for reclassification for FY 1996, a hospital must
submit its application no later than October 1, 1994. In this rule, we
are revising Sec. 412.230 to eliminate the adjacency requirement for
individual hospitals seeking geographic reclassification for
prospective payment purposes. We believe that it is necessary to
implement this revision as part of this final rule to allow hospitals
that previously would not have qualified for reclassification an
opportunity to submit timely applications for the next MGCRB
adjudication period. We find that the delay involved in prior notice
and comment would be contrary to the public interest in that it would
diminish or eliminate some hospital's opportunities to file timely
applications for reclassification for FY 1996 and to receive the
potential benefits of reclassification.
Timely adjudication is essential not only to ensure that hospitals
are not deprived of the statutory right, subject to specified criteria,
to apply for reclassification for FY 1996, but also to ensure that the
budget neutrality requirement imposed by Congress in section
1886(d)(8)(D) of the Act can be met for FY 1996 prospective payment
system rates.
Therefore, we have concluded that it is appropriate to implement
the revisions to Sec. 412.230 as final in this instance. However, we
are providing a 60-day period for public comment, as indicated at the
beginning of this rule, on these changes to the reclassification
criteria.
We also normally provide a delay of 30 days in the effective date
of a regulation. However, if adherence to this procedure would be
impractical, unnecessary, or contrary to public interest, we may waive
the delay in the effective date. We may also waive the delay in the
case of a rule that grants an exemption or relieves a restriction. We
find good cause to waive the usual 30-day delay in this instance. As
explained above, it is essential that these provisions have immediate
effect, so that hospitals will be able to apply for reclassification
under the revised criteria set forth in this final rule with comment
period. A 30-day delay in the effective date could deprive some
hospitals of the opportunity to file timely applications and to receive
the potential benefits of reclassification. Moreover, the delay would
jeopardize the budget neutrality requirement described above. Thus, a
30-day delay in the effective date would be contrary to the public
interest. Therefore, we find good cause to waive the usual 30-day delay
in the effective date.
D. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the ``DATES''
section of this preamble, and we will respond to these comments in
subsequent rulemaking document. Comments on changes to the criteria for
geographic reclassification will be considered if we receive them by
the date specified in the ``DATES'' section of this preamble. We will
not consider comments concerning provisions that remain unchanged from
the May 27, 1994 proposed rule or that were changed based on public
comments.
List of Subjects
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 466
Grant programs-health, Health care, Health facilities, Health
professions, Peer Review Organizations (PRO), Reporting and
recordkeeping requirements.
42 FR Part 482
Grant programs-health, Hospitals, Medicaid, Medicare, Reporting and
recordkeeping requirements.
42 FR Part 485
Grant programs-health, Health facilities, Medicaid, Medicare,
Reporting and recordkeeping requirements.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
42 CFR chapter IV is amended as set forth below:
A. Part 412 is amended as follows:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102, 1815(e), 1820, 1871, and 1886 of the
Social Security Act (42 U.S.C. 1302, 1395g(e), 1395i-4, 1395hh, and
1395ww).
Subpart A--General Provisions
Sec. 412.2 [Amended]
2. In paragraph (e)(4) of Sec. 412.2, remove the words ``and
liver'' and add, in their place, the words ``liver, and lung''.
Subpart B--Hospital Services Subject to and Excluded From the
Prospective Payment Systems for Inpatient Operating Costs and
Inpatient Capital-Related Costs
3. In Sec. 412.23, paragraph (e) is revised to read as follows:
Sec. 412.23 Excluded hospitals: Classifications.
* * * * *
(e) Long-term care hospitals. A long-term care hospital must meet
the requirements of paragraphs (e)(1) and (e)(2) of this section, and,
where applicable, the additional requirements in paragraph (e)(3) of
this section.
(1) The hospital must have a provider agreement under part 489 of
this chapter to participate as a hospital.
(2) The hospital must have an average length of inpatient stay
greater than 25 days--
(i) As computed by dividing the number of total inpatient days
(less leave or pass days) by the number of total discharges for the
hospital's most recent complete cost reporting period; or
(ii) If a change in the hospital's average length of stay is
indicated, as computed by the same method for the immediately preceding
six-month period.
(3) Except as provided in paragraph (e)(4) of this section, for
cost reporting periods beginning on or after October 1, 1994, a
hospital that occupies space in a building also used by another
hospital, or in one or more entire buildings located on the same campus
as buildings used by another hospital, must meet either the criteria in
paragraph (e)(3)(i) or (e)(3)(ii) of this section.
(i) The hospital meets the following requirements:
(A) Separate governing body. The hospital has a governing body that
is separate from the governing body of the hospital occupying space in
the same building or on the same campus. The hospital's governing body
is not under the control of the hospital occupying space in the same
building or on the same campus, or of any third entity that controls
both hospitals.
(B) Separate chief medical officer. The hospital has a single chief
medical officer who reports directly to the governing body and who is
responsible for all medical staff activities of the hospital. The chief
medical officer of the hospital is not employed by or under contract
with either the hospital occupying space in the same building or on the
same campus or any third entity that controls both hospitals.
(C) Separate medical staff. The hospital has a medical staff that
is separate from the medical staff of the hospital occupying space in
the same building or on the same campus. The hospital's medical staff
is directly accountable to the governing body for the quality of
medical care provided in the hospital, and adopts and enforces bylaws
governing medical staff activities, including criteria and procedures
for recommending to the governing body the privileges to be granted to
individual practitioners.
(D) Chief executive officer. The hospital has a single chief
executive officer through whom all administrative authority flows, and
who exercises control and surveillance over all administrative
activities of the hospital. The chief executive officer is not employed
by, or under contract with, either the hospital occupying space in the
same building or on the same campus or any third entity that controls
both hospitals.
(E) Performance of basic hospital functions. The hospital performs
the basic hospital functions specified in Secs. 482.21 through 482.27,
482.30, and 482.42 of this chapter through the use of employees or
under contracts or other agreements with entities other than the
hospital occupying space in the same building or on the same campus, or
a third entity that controls both hospitals. Food and dietetic services
and housekeeping, maintenance, and other services necessary to maintain
a clean and safe physical environment could be obtained under contracts
or other agreements with the hospital occupying space in the same
building or on the same campus, or with a third entity that controls
both hospitals.
(ii) For the period of at least 6 months used to determine
compliance with the length-of-stay criterion in paragraph (e)(2) of
this section, the hospital meets the requirements of paragraphs
(e)(3)(i)(A) through (e)(3)(i)(D) of this section and has an inpatient
population of whom at least 75 percent were referred to the hospital
from a source other than another hospital occupying space in the same
building or on the same campus.
(4) If a hospital has been excluded from the prospective payment
systems under this paragraph for any cost reporting period beginning on
or after October 1, 1993, but before October 1, 1994, the criteria in
paragraphs (e)(3) of this section do not apply to the hospital until
the hospital's first cost reporting period beginning on or after
October 1, 1995.
(5) For purposes of this section, control exists if an individual
or an organization has the power, directly or indirectly, significantly
to influence or direct the actions or policies of an organization or
institution.
* * * * *
Sec. 412.27 [Amended]
4. In Sec. 412.27, the section heading is revised to read
``Excluded psychiatric units: Additional requirements.''
Sec. 412.29 [Amended]
5. In Sec. 412.29, the section heading is revised to read
``Excluded rehabilitation units: Additional requirements.''
Subpart D--Basic Methodology for Determining Prospective Payment
Federal Rates for Inpatient Operating Costs
6. In paragraph (d)(2) of Sec. 412.60, the second sentence is
revised to read as follows:
Sec. 412.60 DRG classification and weighting factors.
* * * * *
(d) * * *
(2) * * * If the intermediary decides that a higher-weighted DRG
should be assigned, the case will be reviewed by the appropriate PRO as
specified in Sec. 466.71(c)(2) of this chapter.
* * * * *
7. In Sec. 412.63, paragraph (m)(1), the paragraph heading of
paragraph (r), and paragraphs (r)(1) introductory text, (r)(1)(i),
(r)(2) introductory text, (r)(2)(i), and (s)(2) are revised to read as
follows:
Sec. 412.63 Federal rates for inpatient operating costs for fiscal
years after Federal fiscal year 1984.
* * * * *
(m) * * *
(1) Plus, for hospitals located in rural areas, the percentage
increase necessary so that the average standardized amounts computed
under paragraph (c) through (i) of this section are equal to the
average standardized amounts for hospitals located in an urban area
other than a large urban area.
* * * * *
(r) Computing Federal rates for inpatient operating costs for
hospitals located in large urban and other areas. * * *
(1) For hospitals located in a large urban area in the United
States or that region respectively, the rate equals the product of--
(i) The adjusted average standardized amount (computed under
paragraph (c) of this section) for the fiscal year for hospitals
located in a large urban area in the United States or in that region;
and
* * * * *
(2) For hospitals located in an other area in the United States or
that region respectively, the rate equals the product of--
(i) The adjusted average standardized amount (computed under
paragraph (c) of this section) for the fiscal year for hospitals
located in an other area in the United States or that region; and
* * * * *
(s) * * *
(2)(i) HCFA makes a midyear correction to the wage index for an
area only if a hospital can show that--
(A) The intermediary or HCFA made an error in tabulating the
hospital's data; and
(B) The hospital could not have known about the error, or did not
have the opportunity to correct the error, before the beginning of the
Federal fiscal year.
(ii) A midyear correction to the wage index is effective
prospectively from the date the change is made to the wage index.
* * * * *
Subpart E--Determination of Transition Period Payment Rates for the
Prospective Payment System for Inpatient Operating Costs
8. In Sec. 412.71, paragraph (b) introductory text is revised,
paragraph (b)(1) is removed and paragraphs (b)(2) through (b)(8) are
redesignated as paragraphs (b)(1) through (b)(7). The revision is to
read as follows:
Sec. 412.71 Determination of base-year inpatient operating costs.
* * * * *
(b) Modifications to base-year costs. Prior to determining the
hospital-specific rate, the intermediary will adjust the hospital's
estimated base-year inpatient operating costs, as necessary, to include
malpractice insurance costs in accordance with Sec. 413.53(a)(1)(i) of
this chapter, and exclude the following:
* * * * *
Subpart F--Payment for Outlier Cases
9. In Sec. 412.80, the introductory text of paragraphs (a)(1) and
(a)(1)(ii) are revised, and a new paragraph (a)(1)(iii) is added to
read as follows:
Sec. 412.80 General provisions.
(a) Basic rule. (1) For discharges before October 1, 1994, except
as provided in paragraph (a)(2) of this section concerning transferring
hospitals, HCFA provides for additional payment, approximating a
hospital's marginal cost of care beyond thresholds specified by HCFA,
to a hospital for covered inpatient hospital services furnished to a
Medicare beneficiary if either of the conditions specified in
paragraphs (a)(1)(i) and (a)(1)(ii) of this section is met. For
discharges occurring on or after October 1, 1994, except as provided in
paragraph (a)(2) of this section concerning transferring hospitals,
HCFA provides for additional payment, beyond standard DRG payments, to
a hospital for covered inpatient hospital services furnished to a
Medicare beneficiary if either of the conditions specified in
paragraphs (a)(1)(i) and (a)(1)(iii) of this section is met.
* * * * *
(ii) For discharges occurring before October 1, 1994, the
beneficiary's length of stay does not exceed criteria established under
paragraph (a)(1)(i) of this section, but the hospital's charges for
covered services furnished to the beneficiary, adjusted to operating
costs and, effective with cost reporting periods beginning on or after
October 1, 1991, capital costs, by applying cost-to-charge ratios as
described in Sec. 412.84(h), exceed the greater of the following: * * *
(iii) For discharges occurring on or after October 1, 1994, the
beneficiary's length of stay does not exceed criteria established under
paragraph (a)(1)(i) of this section, but the hospital's charges for
covered services furnished to the beneficiary, adjusted to operating
costs and capital costs by applying cost-to-charge ratios as described
in Sec. 412.84(h), exceed the DRG payment for the case plus a fixed
dollar amount (adjusted for geographic variation in costs) as specified
by HCFA.
* * * * *
10. In Sec. 412.82, paragraph (c) is revised to read as follows:
Sec. 412.82 Payment for extended length-of-stay cases (day outliers).
* * * * *
(c) Except as provided in Sec. 412.86, the per diem payment made
under paragraph (a) of this section is derived by taking a percentage
of the average per diem payment for the applicable DRG, as calculated
by dividing the Federal prospective payment rate for inpatient
operating costs and inpatient capital-related costs determined under
subpart D of this part, by the arithmetic mean length of stay for that
DRG. HCFA issues the applicable percentage of the average per diem
payment in the annual publication of the prospective payment rates in
accordance with Sec. 412.8(b).
* * * * *
Sec. 412.84 [Amended]
11. In paragraph (j) of Sec. 412.84, remove the words ``75
percent'' wherever they appear in the paragraph and add, in their
place, the words ``80 percent''.
Subpart G--Special Treatment of Certain Facilities Under the
Prospective Payment System for Inpatient Operating Costs
12. In Sec. 412.96, paragraph (d) is revised to read as follows:
Sec. 412.96 Special treatment: Referral centers.
* * * * *
(d) Payment to rural referral centers. Effective for discharges
occurring on or after April 1, 1988, and before October 1, 1994, a
hospital that is located in a rural area and meets the criteria of
paragraphs (b)(1), (b)(2) or (c) of this section is paid prospective
payments for inpatient operating costs per discharge based on the
applicable other urban payment rates as determined in accordance with
Sec. 412.63, as adjusted by the hospital's area wage index.
* * * * *
13. Section 412.105 is amended as follows:
a. Paragraph (b) is revised.
b. In paragraph (d)(1), the phrase ``set forth in paragraph (c)(1)
of this section.'' is revised to read ``set forth in paragraph (c) of
this section.''
The revision is to read as follows:
Sec. 412.105 Special treatment: Hospitals that incur indirect costs
for graduate medical education programs.
* * * * *
(b) Determination of number of beds. For purposes of this section,
the number of beds in a hospital is determined by counting the number
of available bed days during the cost reporting period, not including
nursery beds assigned to newborns that are not in intensive care areas,
custodial care beds, and beds in excluded distinct part hospital units,
and dividing that number by the number of days in the cost reporting
period.
* * * * *
14. In Sec. 412.109, a new paragraph (e) is added to read as
follows:
Sec. 412.109 Special treatment: Essential access community hospitals
(EACHs).
* * * * *
(e) Review of HCFA Determination. A determination by HCFA that a
hospital does not meet the criteria for EACH designation, or that a
hospital's EACH designation should be terminated, is subject to review
under part 405, subpart R of this chapter, including the time limits
for filing requests for hearings as specified in Secs. 405.1811(a) and
405.1841(a)(1) and (b) of this chapter.
Subpart H--Payments to Hospitals Under the Prospective Payment
Systems
Sec. 412.113 [Amended]
15. Section 412.113 is amended as follows:
a. In paragraph (b)(3), the phrase ``Except as provided in
Sec. 413.86(c)(1) of this chapter,'' is revised to read ``Except as
provided in Sec. 413.86(c) of this chapter,''.
b. In paragraph (d), remove the words ``and liver'' wherever they
appear and add, in their place, the words ``liver, and lung''.
Subpart L--The Medicare Geographic Classification Review Board
16. Section 412.230 is amended as follows:
a. Paragraph (a)(2) is removed and paragraphs (a)(3) through (a)(5)
are redesignated as paragraphs (a)(2) through (a)(4).
b. In redesignated paragraph (a)(2), ``(a)(4)'' is removed and
``(a)(3)'' is added in its place, and the word ``adjacent'' is removed.
c. Redesignated paragraph (a)(3)(i) is removed, redesignated
paragraphs (a)(3)(ii) through (a)(3)(v) are further redesignated as
(a)(3)(i) through (a)(3)(iv), in redesignated paragraph (a)(3)(iii)
remove ``(a)(4)'' and add, in its place, ``(a)(3)'', and redesignated
paragraph (a)(3)(iv) is revised.
d. In paragraphs (b), (c), and (d), the word ``adjacent'' is
removed wherever it appears.
e. In paragraph (e), the word ``adjacent'' is removed wherever it
appears, the introductory text of paragraph (e)(2) is republished, and
paragraphs (e)(2)(ii)(A) and (e)(2)(ii)(B) are revised.
The revisions read as follows:
Sec. 412.230 Criteria for an individual hospital seeking redesignation
to another rural area or an urban area.
(a) General-- * * *
(3) Special rules for sole community hospitals and rural referral
centers-- * * *
(iv) A hospital that is redesignated under paragraph (a)(3) of this
section may not be redesignated in the same fiscal year under paragraph
(a)(2) of this section.
* * * * *
(e) Use of urban or other rural area's wage index-- * * *
(2) Appropriate wage data. For a wage index change, the hospital
must submit appropriate data as follows:
* * * * *
(ii) * * *
(A) The average hourly wage in the area in which the hospital is
located and the average hourly wage in the area to which the hospital
seeks reclassification. The wage data are taken from the HCFA hospital
wage survey used to construct the wage index in effect for prospective
payment purposes during the fiscal year prior to the fiscal year for
which the hospital requests reclassification and;
(B) If the hospital is requesting reclassification under
Sec. 412.230(e)(1)(iv)(B), occupational-mix data to demonstrate the
average occupational mix for each employment category in the area to
which the hospital seeks reclassification. Occupational-mix data can be
obtained from surveys conducted by the American Hospital Association.
17. In Sec. 412.232, paragraph (c) is revised to read as follows:
Sec. 412.232 Criteria for all hospitals in a rural county seeking
urban redesignation.
* * * * *
(c) Wage criteria. In applying the following numeric criteria,
rounding of numbers to meet the qualifying percentages is not
permitted.
(1) Aggregate hourly wage. The aggregate average hourly wage for
all hospitals in the rural county must be equal to at least 85 percent
of the average hourly wage in the adjacent urban area; or
(2) Aggregate hourly wage weighted for occupational mix. The
aggregate average hourly wage for all hospitals in the rural county,
weighted for occupational categories, is at least 90 percent of the
average hourly wage in the adjacent urban area.
* * * * *
Subpart M--Prospective Payment System for Inpatient Hospital
Capital Costs
18. In Sec. 412.302, paragraph (c)(2)(i)(D) is revised to read as
follows:
Sec. 412.302 Introduction to capital costs.
* * * * *
(c) * * *
(2) * * *
(i) * * *
(D) The hospital put the asset into patient use on or before the
later of September 30, 1996 or 4 years from the date the certificate of
need was approved.
* * * * *
Sec. 412.308 [Amended]
19. In paragraph (c)(3) of Sec. 412.308, remove the phrase ``For FY
1992 through FY 2001,''.
20. Section 412.348 is revised to read as follows:
Sec. 412.348 Exception payments.
(a) Definitions. As used in this section--
Annual operating expenses. Annual operating expenses means the sum
of net expenses for all reimbursable cost centers for a 12 month cost
reporting period. Annual operating expenses are obtained from the
Medicare cost report.
Average age of fixed assets. The average age of fixed assets is the
ratio of accumulated depreciation for buildings and fixed equipment to
current depreciation expense for buildings and fixed equipment. The
average age of fixed assets is determined from information on the
Medicare cost report.
Fixed assets. Fixed assets mean buildings and fixed equipment.
(b) Criterion for additional payment during the transition period.
An additional payment is made to a hospital paid under either the fully
prospective payment methodology or the hold-harmless payment
methodology as determined under paragraph (c) of this section for cost
reporting periods beginning on or after October 1, 1991 and before
October 1, 2001.
(c) Minimum payment level by class of hospital. (1) HCFA
establishes a minimum payment level by class of hospital. The minimum
payment level for a hospital will equal a fixed percentage of the
hospital's capital-related costs. The minimum payment levels may be no
greater than the percentages of allowable capital-related costs that
follow:
(i) 90 percent for sole community hospitals.
(ii) 80 percent for hospitals located in an urban area for purposes
of Sec. 412.63(a) with at least 100 beds, as determined under
Sec. 412.105(b), that have a disproportionate share patient percentage
of at least 20.2 percent as determined under Sec. 412.106(b), and for
hospitals located in an urban area for purposes of Sec. 412.63(a) with
at least 100 beds that qualify for disproportionate share payments
under Sec. 412.106(c)(2).
(iii) 70 percent for all other hospitals.
(2) HCFA will issue the minimum payment levels for each class of
hospital in determining the additional exception payment in the annual
notice of capital prospective payment rates, published in accordance
with Sec. 412.8(b).
(d) Additional payments. A hospital is entitled to an additional
payment if its capital payments for the cost reporting period would
otherwise be less than the applicable minimum payment level. The
additional payment equals the difference between the applicable minimum
payment level and the capital payments that the hospital would
otherwise receive minus any offset amount determined under paragraph
(e)(2) of this section.
(e) Determining a hospital's exception payment amount--(1)
Cumulative comparison. For each cost reporting period beginning before
October 1, 2001, the hospital's exception payment is determined by
comparing the cumulative payments made to the hospital under the
capital prospective payment system to the cumulative minimum payment
levels applicable to the hospital for each cost reporting period
subject to the prospective payment system.
(2) Offsetting amounts. Any amount by which the hospital's
cumulative payments exceed its cumulative minimum payment levels is
deducted from the additional payment that would otherwise be payable
for a cost reporting period.
(f) Additional payment exception for extraordinary circumstances.
(1) A hospital may request an additional payment if the hospital incurs
unanticipated capital expenditures in excess of $5 million (net of
proceeds from other payment sources such as insurance, litigation
decisions and other State, local or Federal government funding
programs) due to extraordinary circumstances beyond the hospital's
control. Extraordinary circumstances include, but are not limited to, a
flood, fire, or earthquake.
(2) A hospital must apply to its HCFA Regional Office by the later
of October 1, 1992 or 180 days after the extraordinary circumstance
causing the unanticipated expenditures for a determination by HCFA of
whether the hospital is eligible for an additional payment based on the
nature of the circumstances and the amount of financial loss documented
by the hospital.
(3) Except for sole community hospitals, the additional payment is
based on a minimum payment amount of 85 percent for Medicare's share of
allowable capital-related costs attributable to the extraordinary
circumstances. For sole community hospitals, the minimum payment amount
is 100 percent.
(4) The minimum payment level applicable under paragraph (c)(1) of
this section is adjusted to take into account the 85 percent minimum
payment level (100 percent for sole community hospitals) under
paragraph (f)(3) of this section for the unanticipated capital-related
costs. The additional payment for the cost reporting period equals the
difference between the adjusted minimum payment level and the capital
payments the hospital would otherwise receive less any offset amount
determined under paragraph (e)(2) of this section.
(g) Special exceptions process. For eligible hospitals that meet a
project need requirement, a project size requirement, and, in the case
of certain urban hospitals, meet an excess capacity test, an additional
payment may be made for up to 10 years beyond the end of the capital
prospective payment system transition period.
(1) Eligible hospitals. The following classes of hospitals are
eligible to receive exceptions payments under this special exceptions
provision:
(i) Sole community hospitals.
(ii) Hospitals located in an urban area under Sec. 412.63(a) with
at least 100 beds, as determined under Sec. 412.105(b), that either
have a disproportionate share of at least 20.2 percent as determined
under Sec. 412.106(b) or qualify for disproportionate share payments
under Sec. 412.106(c)(2).
(iii) Hospitals with a combined inpatient Medicare and Medicaid
utilization of at least 70 percent.
(2) Project need requirement. A hospital must show that it has
obtained any required approval from a State or local planning
authority. If a hospital is not required to obtain approval from a
planning authority, it must satisfy the age of asset test specified in
paragraph (g)(3) of this section and, in the case of an urban hospital,
the excess capacity test under paragraph (g)(4) of this section.
(3) Age of assets test. A hospital must show that its average age
of fixed assets is at or above the 75th percentile for the hospital's
first cost reporting period beginning on or after October 1, 1991.
(4) Excess capacity test for urban hospitals. Urban hospitals that
are not required to receive approval from a State or local planning
authority must demonstrate that either--
(i) The overall average occupancy rate in its metropolitan
statistical area is at least 80 percent; or
(ii) After completion of the project, its capacity is no more than
80 percent of its prior capacity (in terms of bed size).
(5) Project size requirement. A hospital must complete, during the
period from the beginning of its first cost reporting period beginning
on or after October 1, 1991 to the end of its last cost reporting
period beginning before October 1, 2001, a project whose costs for
replacement and/or renovation of fixed assets related to patient care
are at least:
(i) $200 million; or
(ii) 100 percent of its operating cost during the first 12 month
cost reporting period beginning on or after October 1, 1991.
(6) Minimum payment level. The minimum payment level for qualifying
hospitals will be 70 percent.
(7) Limitation on the period for exception payments. A qualifying
hospital may receive an exceptions payment for up to 10 years from the
year in which it completes a project for replacement or renovation of
capital assets that meets project need and project size requirements
(and, if applicable, excess capacity test), provided that it completes
the project no later than the end of the hospital's last cost reporting
period beginning before October 1, 2001. A project is considered to be
completed when the assets are put into use for patient care.
(8) Determining a hospital's exception payment amount--(i)
Cumulative comparison. For each cost reporting period, the hospital's
exception payment is determined by comparing the cumulative payments
made to the hospital under the capital prospective payment system to
the cumulative minimum payment levels applicable to the hospital for
each cost reporting period subject to the prospective payment system.
(ii) Offsetting amounts. Offsetting amounts are applied in the
following order--(A) Any amount by which the hospital's cumulative
payments exceed its cumulative minimum payment levels is deducted from
the additional payment that would otherwise be payable for a cost
reporting period.
(B) Any amount by which the hospital's current year Medicare
inpatient operating and capital prospective payment system payments
(excluding, if applicable, 75 percent of the hospital's operating
prospective payment system disproportionate share payments) exceed its
Medicare inpatient operating and capital costs is deducted from the
additional payment that would otherwise be payable for the cost
reporting period. For purposes of calculating the offset, the costs and
payments for services that are not subject to the hospital inpatient
prospective payment system are excluded.
(h) Limit on exception payments. Total estimated payments under the
exception process may not exceed 10 percent of the total estimated
capital prospective payments (exclusive of hold-harmless payments for
old capital) for the same fiscal year.
Secs. 412.20, 412.22, 412.25, 412.27, 412.29, 412.30, 412.96, 412.105,
412.108, 412.116 and 412.130 [Amended]
21. In part 412, remove the words ``distinct part'', wherever they
appear, in the following places:
a. Section 412.20(b)(1);
b. Section 412.22(b);
c. Section heading of Sec. 412.25;
d. Section 412.25(a) introductory text;
e. Section 412.27, the introductory text for the section;
f. Section 412.29, the introductory text for the section;
g. Section heading of Sec. 412.30;
h. Section 412.96(c)(1) introductory text and (c)(2)(i)
introductory text;
i. Section 412.105(b), (f)(5) and (g)(1)(iii);
j. Section 412.108(a)(2);
k. Section 412.116(a) and (b)(1) introductory text;
l. Section heading of Sec. 412.130; and
m. Section 412.130(a)(2) and (a)(3).
B. Part 413 is amended as follows:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES
1. The authority citation for part 413 continues to read as
follows:
Authority: Secs. 1102, 1814(b), 1815, 1833 (a), (i), and (n),
1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42
U.S.C. 1302, 1395f(b), 1395g, 1395l (a), (i), and (n), 1395x(v),
1395hh, 1395rr, 1395tt, and 1395ww); sec. 104(c) of Public Law 100-
360 as amended by sec. 608(d)(3) of Public Law 100-485 (42 U.S.C.
1395ww (note)) and sec. 101(c) of Public Law 101-234 (42 U.S.C.
1395ww (note)).
Subpart C--Limits on Cost Reimbursement
Sec. 413.40 [Amended]
2. In paragraphs (a)(2)(ii), (b)(1)(i) through (b)(1)(iii) and
(f)(2) of Sec. 413.40, remove the words ``(distinct parts)'' and
``distinct part'', wherever they appear.
Subpart D--Apportionment
3. In Sec. 413.53, paragraph (a)(1)(i) is revised to read as
follows:
Sec. 413.53 Determination of cost of services to beneficiaries.
(a) * * *
(1) Departmental method--(i) Methodology. Except as provided in
paragraph (a)(1)(ii) of this section with respect to the treatment of
the private room cost differential for cost reporting periods starting
on or after October 1, 1982, the ratio of beneficiary charges to total
patient charges for the services of each ancillary department is
applied to the cost of the department; to this is added the cost of
routine services for program beneficiaries, determined on the basis of
a separate average cost per diem for general routine patient care areas
as defined in paragraph (b) of this section, taking into account, in
hospitals, a separate average cost per diem for each intensive care
unit, coronary care unit, and other intensive care type inpatient
hospital units.
* * * * *
Sec. 413.56 [Removed and Reserved]
4. Section 413.56 is removed and reserved.
Subpart F--Specific Categories of Costs
5. Section 413.86 is amended as follows:
a. In paragraph (f)(1)(ii), the third sentence is revised.
b. In paragraph (g)(1) introductory text, a new sentence is added
after the second sentence.
The revision and addition are to read as follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(f) * * *
(1) * * *
(ii) * * * A part-time resident counts as a partial FTE based on
the proportion of allowable time worked compared to the total time
necessary to fill a full-time internship or residency slot.
* * * * *
(g) * * *
(1) * * * Effective July 1, 1995, an initial residency period is
defined as the minimum number of years required for board eligibility.
* * *
* * * * *
Subpart G--Capital-Related Costs
6. Section 413.134 is amended as follows:
a. In paragraph (d)(1), the phrase ``where permitted under
Sec. 413.134(a)(3),'' is revised to read ``when permitted under
paragraph (a)(3) of this section,''.
b. Paragraphs (e)(1) and (e)(2)(ii) are revised, and paragraphs
(e)(2)(iii), (e)(2)(iv) and (e)(4) are added.
The revisions and additions are to read as follows:
Sec. 413.134 Depreciation: Allowance for depreciation based on asset
costs.
* * * * *
(e) * * *
(1) Incentive. As an incentive for funding, investment income on
funded depreciation is not treated as a reduction of allowable interest
expense provided such investment income is deposited in, and becomes
part of, the funded depreciation account at the time of receipt by the
provider. Investment income earned on deposits before the 6-month
period elapses are not offset unless the deposits are withdrawn for an
improper purpose during this period. If a provider transfers assets of
the funded depreciation account to a related organization (for example,
pooling of several chain organization providers' funded depreciation
accounts at the chain home office for investment purposes), these
assets shall be treated as the provider's funds and are subject to all
the requirements specified in paragraph (e) of this section.
(2) * * *
(ii) Borrowing for a purpose for which funded depreciation account
funds should have been used makes the borrowing unnecessary to the
extent that funded depreciation account funds were available at the
time of the borrowing. Available funds in the funded depreciation
account, to the extent of the unnecessary borrowing, are called
``tainted'' funds. Interest expense incurred on borrowing for a capital
purpose is not an allowable cost to the extent that funded depreciation
account funds were available at the time of the borrowing.
(iii) A provider can remove the ``unnecessary'' characterization of
borrowing, and thereby cure tainted funded depreciation, by using the
tainted funds for a proper purpose described in paragraph (e)(3)(i) of
this section. However, any funded depreciation that existed at the time
of the unnecessary borrowing and is not classified as tainted must be
used before any of the tainted funds.
(iv) When only a portion of the borrowing is considered unnecessary
under paragraph (e)(2)(ii) of this section, subsequent repayments of
such borrowing from general funds are applied first to the allowable
portion of the borrowing and then, when all of the allowable borrowing
is repaid, to the unallowable portion of the borrowing. When funds from
the funded depreciation account are used for the repayment of the
unnecessary borrowing, an equivalent amount of tainted funds is cured
without regard to the provisions of paragraphs (e)(2)(ii) and
(e)(3)(i)(C) of this section. Similarly, where general funds are used
to pay for the unallowable borrowing after the necessary borrowing has
been repaid, an equivalent amount of tainted funded depreciation is
cured without regard to the provisions of paragraphs (e)(2)(ii) and
(e)(3)(i)(C) of this section.
* * * * *
(4) Loans from funded depreciation. (i) When the general fund of
the provider borrows from the funded depreciation to obtain working
capital for normal operating expenses to furnish patient care, interest
incurred by the general fund is an allowable operating cost only if the
interest expense is supported by documents that evidence that the funds
were borrowed and that payment of interest and repayment of the funds
are required, is separately identified in the provider's accounting
records, and meets the necessary and proper tests described in
Secs. 413.153(b)(2) and (b)(3). However, if the general fund of the
provider borrows from the funded depreciation account to acquire
depreciable assets used in furnishing patient care, or for other
capital purposes related to patient care, interest expense paid by the
general fund to the funded depreciation account is not an allowable
cost. Providers are expected to use the funded depreciation for these
purposes.
(ii) Loans from funded depreciation to the general fund are
considered investments of funded depreciation, but do not have to meet
the readily marketable test described in paragraph (e) of this section.
Loans made from funded depreciation are subject to the requirement that
funded depreciation must be available for the acquisition of
depreciable assets used to furnish patient care, or for other capital
purposes related to patient care. Costs incurred to secure lines of
credit from lending institutions to ensure such availability are not
allowable costs.
(iii) Funding of depreciation from general funds will not be
recognized to the extent of any outstanding loans from the funded
depreciation account to the general fund. Deposits from the general
fund into the funded depreciation account must be first applied to
reduce any loans outstanding from the funded depreciation to the
general fund. When the loans are repaid in full, general funds
deposited in the funded depreciation account are considered as
repayments of the general fund. Therefore, any subsequent interest
expense of the general fund paid to the funded depreciation fund is not
an allowable cost.
(iv) A provider may loan its funded depreciation to a related
organization for any purpose subject to the following conditions:
(A) Authorization for such a loan by the provider's appropriate
managing body of the provider, such as Board of Trustees or Board of
Directors, must be on file.
(B) The funded depreciation loaned must remain available, as
specified in paragraph (e)(2) of this section, to the provider making
the loan. Costs incurred for lines of credit to assure such
availability are not allowable costs. During the period of time that
the loan is outstanding, if the provider making the loan resorts to
outside borrowing for a purpose for which its funded depreciation
should have been used, interest expense on an amount of the outside
borrowing up to the amount of the funded depreciation that should have
been available would be disallowed as unnecessary.
(C) Such loans shall be considered investments of the provider's
funded depreciation, but the requirement that funded depreciation be
invested in readily marketable investments as required in paragraph (e)
of this section is waived for such loans.
(D) The funded depreciation account must earn interest on such
loans at a rate that does not exceed the rate that would be charged for
a comparable loan from an independent lending institution. This
investment income will not be used to reduce the provider's interest
expense if all the other conditions in paragraph (e) of this section
are met. If the entity borrowing the funds is another provider
participating in the Medicare program, the interest expense incurred on
such loans would be allowable if the loan meets all of the interest
expense requirements specified in Sec. 413.153. (For purposes of
Sec. 413.153(b)(3)(ii), such loans are not considered to be with a
related lender.)
* * * * *
7. In Sec. 413.153, paragraph (d)(2) is revised and a new paragraph
(d)(3) is added to read as follows:
Sec. 413.153 Interest expense.
* * * * *
(d) * * *
(2) In determining whether a loan was made for the purpose of
acquiring a facility, we apply any owner's investment or funds first to
the tangible assets, then to the intangible assets other than goodwill,
and lastly to the goodwill. If the owner's investment or funds are not
sufficient to cover the cost allowed for tangible assets, we apply
funds borrowed to finance the acquisition to the portion of the allowed
cost of the tangible assets not covered by the owner's investment, then
to the intangible assets other than goodwill, and lastly to the
goodwill. Repayments of the funds borrowed are applied first to the
borrowing related to the tangible assets, then to the borrowing related
to the intangible assets other than goodwill, and lastly to the
borrowing related to the goodwill.
(3) When a provider borrows funds, but only some of the funds are
necessary, repayments of the loan (principal and interest portions) are
applied first to pay for the necessary portion of the loan. Only after
all of the necessary portion of the loan (principal and interest) has
been repaid are any repayments applied to the unnecessary portion of
the loan. Repayments toward non-allowable borrowing pertaining to
assets or activities not related to patient care are considered
investments, and the provisions of paragraph (b)(2)(iii) of this
section are applied.
* * * * *
Subpart H--Payment for End-Stage Renal Disease (ESRD) Services
8. In Sec. 413.174, paragraph (b)(4)(iv) is revised to read as
follows:
Sec. 413.174 Recordkeeping and cost reporting requirements for
outpatient maintenance dialysis.
* * * * *
(b) * * *
(4) * * *
(iv) Sections 413.64, Payments to providers, and Secs. 413.13,
413.30, 413.35, 413.40, 413.74, and Secs. 405.465 through 405.482 of
this chapter, Principles of reimbursement for services by hospital-
based physicians.
C. Part 466 is amended as follows:
PART 466--UTILIZATION AND QUALITY CONTROL REVIEW
1. The authority citation for part 466 continues to read as
follows:
Authority: Secs. 1102, 1154, 1159, 1866, and 1871 of the Social
Security Act (42 U.S.C. 1302, 1320c-3, 1320c-8, 1395cc, and 1395hh).
Subpart C--Review Responsibilities of Utilization and Quality
Control Peer Review Organizations (PROs)
2. In Sec. 466.71, paragraph (c)(2) is revised to read as follows:
Sec. 466.71 PRO review requirements.
* * * * *
(c) * * *
(2) As directed by HCFA, the PRO must review changes in DRG
assignment made by the intermediary under the provisions of
Sec. 412.60(d) that result in the assignment of a higher-weighted DRG.
The PRO's review must verify that the diagnostic and procedural
information supplied by the hospital is substantiated by the
information in the medical record.
* * * * *
3. In Sec. 466.78, paragraph (a) is revised to read as follows:
Sec. 466.78 Responsibilities of health care facilities.
(a) Every hospital seeking payment for services furnished to
Medicare beneficiaries must maintain a written agreement with a PRO
operating in the area in which the hospital is located. These
agreements must provide for the PRO review specified in Sec. 466.71.
* * * * *
D. Part 482 is amended as follows:
PART 482--CONDITIONS OF PARTICIPATION FOR HOSPITALS
1. The authority citation for part 482 continues to read as
follows:
Authority: Secs. 1102, 1136, 1138, 1814(a)(6), 1861 (e), (f),
(r), (v)(1)(G), (z), and (ee), 1864, 1871, 1883, 1886, 1902(a)(30),
and 1905(a) of the Social Security Act (42 U.S.C. 1302, 1320b-6,
1338, 1395f(a)(6), 1395x (e), (f), (k), (r), (v)(1)(G), (z), and
(ee), 1395aa, 1395hh, 1395tt, 1395ww, 1396a(a)(30), and 1396(a)).
Subpart E--Requirements for Specialty Hospitals
2. In paragraph (a)(7)(i) of Sec. 482.66, the second sentence is
revised to read as follows:
Sec. 482.66 Special requirements for hospital providers of long-term
care services (``swing-beds'').
(a) * * *
(7) * * *
(i) * * * Also excluded from the bed count are beds in separately
certified ``distinct part'' SNFs and NFs and beds in a psychiatric or
rehabilitation unit that is excluded from the prospective payment
system.
* * * * *
E. Part 485 is amended as follows:
PART 485--CONDITIONS OF PARTICIPATION AND CONDITIONS FOR COVERAGE:
SPECIALIZED PROVIDERS
1. The authority citation for part 485 continues to read as
follows:
Authority: Secs. 1102, 1124, 1138, 1820, 1861(aa), and (cc) and
1871 of the Social Security Act; (42 U.S.C. 1302, 1320a-3, 1320b-8,
1395i-4, 1395x(aa) and (cc) and 1395hh); and sec. 353 of the Public
Health Service Act (42 U.S.C. 263a).
Subpart F--Conditions of Participation: Rural Primary Care
Hospitals (RPCHs)
2. Section 485.602 is revised to read as follows:
Sec. 485.602 Definitions.
As used in this subpart, unless the context indicates otherwise:
Direct services means services provided by employed staff of the
RPCH, not services provided through arrangements or agreements.
3. In Sec. 485.635, paragraph (b) is revised to read as follows:
Sec. 485.635 Condition of participation: Provision of services.
* * * * *
(b) Standard: Direct services--(1) General. The RPCH staff
furnishes, as direct services, those diagnostic and therapeutic
services and supplies that are commonly furnished in a physician's
office or at another entry point into the health care delivery system,
such as a low intensity hospital outpatient department or emergency
department. These direct services include medical history, physical
examination, specimen collection, assessment of health status, and
treatment for a variety of medical conditions.
(2) Laboratory services. The RPCH provides, as direct services,
basic laboratory services essential to the immediate diagnosis and
treatment of the patient that meet the standards imposed under section
353 of the Public Health Service Act (42 U.S.C. 236a). (See the
laboratory requirements specified in part 493 of this chapter.) The
services provided include:
(i) Chemical examination of urine by stick or tablet method or both
(including urine ketones);
(ii) Hemoglobin or hematocrit;
(iii) Blood glucose:
(iv) Examination of stool specimens for occult blood;
(v) Pregnancy tests; and
(vi) Primary culturing for transmittal to a certified laboratory.
(3) Radiology services. Radiology services furnished at the RPCH
are provided as direct services by staff qualified under State law, and
do not expose RPCH patients or staff to radiation hazards.
(4) Emergency procedures. In accordance with the requirements of
Sec. 485.618, the RPCH provides as direct services medical emergency
procedures as a first response to common life-threatening injuries and
acute illness.
* * * * *
F. Part 489 is amended as follows:
PART 489--PROVIDER AND SUPPLIER AGREEMENTS
1. The authority citation for part 489 continues to read as
follows:
Authority: Secs. 1102, 1861, 1864, 1866, and 1871 of the Social
Security Act (42 U.S.C. 1302, 1395x, 1395aa, 1395cc, and 1395hh).
Subpart I--Advance Directives
2. In Sec. 489.102, paragraph (a) introductory text is revised to
read as follows:
Sec. 489.102 Requirements for providers.
(a) Hospitals, rural primary care hospitals, skilled nursing
facilities, nursing facilities, home health agencies, providers of home
health care (and for Medicaid purposes, providers of personal care
services), and hospices must maintain written policies and procedures
concerning advance directives with respect to all adult individuals
receiving medical care by or through the provider and are required to:
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: August 23, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: August 25, 1994.
Donna E. Shalala,
Secretary.
[Editorial Note: The following addendum and appendixes will not
appear in the Code of Federal Regulations.]
Addendum--Schedule of Standardized Amounts Effective with Discharges On
or After October 1, 1994 and Update Factors and Rate-of-Increase
Percentages Effective With Cost Reporting Periods Beginning On or After
October 1, 1994
I. Summary and Background
In this addendum, we are setting forth the amounts and factors for
determining prospective payment rates for Medicare inpatient operating
costs and Medicare inpatient capital-related costs. We are also setting
forth new rate-of-increase percentages for updating the target amounts
for hospitals and hospital units excluded from the prospective payment
system.
For discharges occurring on or after October 1, 1994, except for
sole community hospitals, hospitals located in Puerto Rico, and
hospitals subject to the regional floor, each hospital's payment per
discharge under the prospective payment system is based on 100 percent
of the Federal national rate.
Sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: the Federal
national rate, the updated hospital-specific rate based on FY 1982 cost
per discharge, or the updated hospital-specific rate based on FY 1987
cost per discharge. Hospitals in Puerto Rico are paid on the basis of a
rate per discharge comprised of 75 percent of a Puerto Rico rate and 25
percent of a national rate (section 1886(d)(9)(A) of the Act).
Hospitals affected by the regional floor are paid on the basis of 85
percent of the Federal national rate and 15 percent of the Federal
regional rate.
As discussed below in section II, we are making changes in the
determination of the prospective payment rates for Medicare inpatient
operating costs. The changes, to be applied prospectively, will affect
the calculation of the Federal rates. In section III we discuss changes
we are making in the determination of the prospective payment rates for
Medicare inpatient capital-related costs. Section IV sets forth our
changes for determining the rate-of-increase limits for hospitals
excluded from the prospective payment system. The tables to which we
refer in the preamble to the final rule are presented at the end of
this addendum in section V.
II. Changes to Prospective Payment Rates For Inpatient Operating Costs
for FY 1995
The basic methodology for determining prospective payment rates for
inpatient operating costs is set forth at Sec. 412.63 for hospitals
located outside of Puerto Rico. The basic methodology for determining
the prospective payment rates for inpatient operating costs for
hospitals located in Puerto Rico is set forth at Secs. 412.210 and
412.212. The Federal and Puerto Rico rate changes will be effective
with discharges occurring on or after October 1, 1994. Below, we
discuss the manner in which we are changing some of the factors used
for determining the prospective payment rates.
As discussed in section IV.C of this final rule, section
1886(d)(3)(A)(iii) specifies that for discharges occurring in the
fiscal year beginning October 1, 1994, the average standardized amount
for hospitals located in a rural area shall be equal to the average
standardized amount for hospitals located in any other urban area.
Pursuant to section 1886(b)(3)(B)(i)(X) of the Act, we will update the
rural standardized amount by the amount necessary to equate the rural
standardized amount with the other urban standardized amount. Since
there will no longer be separate other urban and rural standardized
amounts we will refer to the other urban and rural standardized amounts
that will be effective beginning with FY 1995 as the ``other
standardized amount.'' As required by section 1886(d)(4)(C) of the Act,
we must adjust the DRG classifications and relative weights for
discharges in FY 1995.
In summary, the standardized amounts set forth in Tables 1a, 1b,
and 1c of section V of this addendum reflect
Updates of 1.1 percent for large urban and other urban
hospitals (that is, the market basket percentage increase of 3.6
percent minus 2.5 percentage points) and an update for rural hospitals
of approximately 8.4 percent (that is, the amount required to equate
the rural standardized amount with the other urban standardized
amount);
Revised labor and nonlabor shares of the national average
standardized amounts to reflect the national average labor portion of
the standardized amounts for urban and rural hospitals (the revised
labor and nonlabor shares of the Puerto Rico standardized amounts
reflect the Puerto Rico average labor portion of the standardized
amounts for urban and rural hospitals);
An adjustment to ensure budget neutrality as provided for
in sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act by applying new
budget neutrality adjustment factors to the urban and other
standardized amounts;
An adjustment to ensure budget neutrality as provided for
in section 1886(d)(8)(D) of the Act by removing the FY 1994 budget
neutrality factor and applying a revised factor; and
An adjustment to apply the revised outlier offset by
removing the FY 1994 outlier offsets and applying a new offset.
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts. Section
1886(d)(2)(A) of the Act required the establishment of base-year cost
data containing allowable operating costs per discharge of inpatient
hospital services for each hospital. The preamble to the September 1,
1983 interim final rule (48 FR 39763) contains a detailed explanation
of how base-year cost data were established in the initial development
of standardized amounts for the prospective payment system and how they
are used in computing the Federal rates.
Section 1886(d)(9)(B)(i) of the Act required that Medicare target
amounts be determined for each hospital located in Puerto Rico for its
cost reporting period beginning in FY 1987. The September 1, 1987 final
rule contains a detailed explanation of how the target amounts were
determined and how they are used in computing the Puerto Rico rates (52
FR 33043, 33066).
The standardized amounts are based on per discharge averages of
adjusted hospital costs from a base period or, for Puerto Rico,
adjusted target amounts from a base period, updated and otherwise
adjusted in accordance with the provisions of section 1886(d) of the
Act. Sections 1886(d)(2)(C) and (d)(9)(B)(ii) of the Act required that
the updated base-year per discharge costs and, for Puerto Rico, the
updated target amounts, respectively, be standardized in order to
remove from the cost data the effects of certain sources of variation
in cost among hospitals. These include case mix, differences in area
wage levels, cost of living adjustments for Alaska and Hawaii, indirect
medical education costs, and payments to hospitals serving a
disproportionate share of low-income patients.
Since the standardized amounts have already been adjusted for
differences in case mix, wages, cost-of-living, indirect medical
education costs, and payments to hospitals serving a disproportionate
share of low-income patients, no additional adjustments for these
factors for FY 1995 were made. That is, the standardization adjustments
reflected in the FY 1995 standardized amounts are the same as those
reflected in the FY 1994 standardized amounts. Sections 1886(d)(2)(H)
and (d)(3)(E) of the Act require that, in making payments under the
prospective payment system, the Secretary adjust the proportion of
payments that are wage-related (as estimated by the Secretary from time
to time). Beginning with October 1, 1990, when the market basket was
rebased, we have considered 71.40 percent of costs to be labor-related
for purposes of the prospective payment system.
2. Computing Urban and Other Averages Within Geographic Areas.
Beginning in FY 1995, section 1886(d)(3) of the Act requires the
Secretary to compute two average standardized amounts for discharges
occurring in a fiscal year: one for hospitals located in large urban
areas; and one for hospitals located in other areas. In addition, under
section 1886(d)(9)(B)(iii) of the Act, the average standardized amount
per discharge must be determined for hospitals located in large urban
and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a
blend of 75 percent of the applicable Puerto Rico standardized amount
and 25 percent of a national standardized payment amount.
Section 1886(d)(2)(D) of the Act defines a ``large urban area'' as
an urban area with a population of more than 1,000,000. In addition,
section 4009(i) of Public Law 100-203 provides that a New England
County Metropolitan Area (NECMA) with a population of more than 970,000
is classified as a large urban area. As required by section
1886(d)(2)(D) of the Act, population size is determined by the
Secretary based on the latest population data published by the Bureau
of the Census. Urban areas that do not meet the definition of a ``large
urban area'' are referred to as ``other urban areas.'' Areas that are
not included in MSAs are considered ``rural areas'' under section
1886(d)(2)(D). Payment for discharges from hospitals located in large
urban areas will be based on the large urban standardized amount.
Payment for discharges from hospitals located in other urban and rural
areas will be based on the other standardized amount.
Based on 1992 population estimates published by the Bureau of the
Census, 56 large urban areas meet the criteria to be defined as large
urban areas for FY 1995. Since the publication of the proposed rule,
the Bureau of the Census has published revised population estimates so
that the Monmouth Ocean, NJ, MSA now meets the definition of a large
urban area. Large urban areas are identified by an asterisk in Table
4a.
Table 1a contains the two national standardized amounts that are
applicable to most hospitals. Table 1b sets forth the 18 regional
standardized amounts that continue to be applicable for hospitals
located in census areas subject to the regional floor. Under section
1886(d)(9)(A)(ii) of the Act, the national standardized payment amount
applicable to hospitals in Puerto Rico consists of the discharge-
weighted average of the national large urban standardized amount, and
the national other urban standardized amount (as set forth in Table
1a). The national average standardized amount for Puerto Rico is set
forth in Table 1c. This table also includes the two standardized
amounts that are applicable to most hospitals in Puerto Rico.
We note that on July 5, 1994, the Office of Management and Budget
announced the designation of Hattiesburg, Mississippi as a Metropolitan
Statistical Area (MSA).
3. Updating the Average Standardized Amounts. In accordance with
section 1886(d)(3)(A) of the Act, we are updating the large urban,
other urban, and rural average standardized amounts for FY 1995 using
the applicable percentage increases specified in section
1886(b)(3)(B)(i) of the Act. As explained earlier, there are currently
separate large urban, other urban and rural standardized payment
amounts. Section 1886(b)(3)(B)(i)(X) of the Act (as amended by section
13501(a) of Pub. L. 103-66) specifies the following update factors for
the standardized amounts for FY 1995:
For hospitals located in large urban and other urban
areas, the market basket percentage increase minus 2.5 percentage
points.
For hospitals located in rural areas, the market basket
percentage increase plus the amount necessary to make the rural
standardized amount equal the standardized amount for other urban
areas.
The percentage change in the market basket reflects the average
change in the price of goods and services purchased by hospitals to
furnish inpatient care. The most recent forecasted hospital market
basket increase for FY 1995 is 3.6 percent. For FY 1995, this yields an
update to the urban average standardized amounts of 1.1 percent (3.6
percent minus 2.5 percent). To satisfy the requirement of section
1886(b)(3)(i)(X) of the Act that the update for hospitals located in a
rural area be equal to that for hospitals located in an other urban
area beginning in FY 1995, we estimate that an overall update of the
market basket rate of increase (that is, 3.6 percent) plus
approximately 4.8 percentage points will be necessary. Thus, we are
establishing an update to the rural average standardized amount for FY
1995 of 8.4 percent.
We are adjusting the FY 1994 standardized amounts to remove the
effects of the FY 1994 geographic reclassifications and outlier
payments before applying the FY 1995 updates. That is, we are
increasing the standardized amounts to restore the reductions that were
made for the effects of geographic reclassification and outliers. As
these reductions were larger for urban than rural hospitals, restoring
the reductions results in a larger increase in the urban standardized
amounts than the rural standardized amounts. After applying an update
of 1.1 percent to the adjusted urban standardized amount, we estimate
that an overall update of 7.3 percent is required to equate the rural
and other urban standardized amounts.
However, the estimated actual increase in the standardized amounts
for rural hospitals will be less because we also have to reduce the
standardized amounts for the effects of geographic reclassification and
outliers. For FY 1995, there will be a single reduction to the
standardized amounts for each of these factors, rather than separate
adjustments to the urban and rural standardized amounts based on the
effect of geographic reclassification and outliers in each respective
area. For instance, in FY 1994, we reduced the urban standardized
amounts by 5.4 percent and the rural standardized amounts by 2.3
percent to account for outliers in each respective area. For FY 1995,
we will apply one adjustment for the effect of outliers--a single
reduction in the standardized amounts of 5.1 percent. Similarly, there
were separate reductions to the standardized amounts in FY 1994 for the
effects of geographic reclassification of 0.7 percent for urban
hospitals and 0.1 percent for rural hospitals. Our FY 1995 standardized
amounts reflect a single reduction for this factor of 0.6 percent.
With the phase-out of the separate rural standardized amount, rural
hospitals and other urban hospitals will be paid based on the same
standardized amount. Since Congress has mandated the elimination of
separate payment rates based on whether a hospital is located in an
urban or rural area, we believe it is appropriate to revise the
national average standardized amounts based on national average labor/
nonlabor shares. As explained in the proposed rule, we are adjusting
the labor and nonlabor proportions of the standardized amount to
reflect the national average. (We are revising the Puerto Rico
standardized amounts by the average labor share in Puerto Rico of 82.7
percent.) We are therefore adjusting the labor/nonlabor proportions of
the standardized amounts that will be applicable to both rural and
urban hospitals based on the national average. As a result, the
national average labor share (as reflected in the hospital market
basket) will equal 71.4 percent of the standardized payment amounts.
Although the update factor for FY 1995 is set by law, we were
required by section 1886(e)(3)(B) of the Act to report to Congress no
later than March 1, 1994 on our initial recommendation of update
factors for FY 1995 for both prospective payment hospitals and
hospitals excluded from the prospective payment system. For general
information purposes, we published the report to Congress as Appendix C
to the proposed rule. This recommendation was based on an earlier
forecast of the hospital market basket increase. Our final
recommendation on the update factors (which is required by sections
1886(e)(4)(A) and (e)(5)(A) of the Act), is set forth as Appendix D to
this final rule.
4. Other Adjustments to the Average Standardized Amounts. a.
Recalibration of DRG Weights and Updated Wage Index--Budget Neutrality
Adjustment. Section 1886(d)(4)(C)(iii) of the Act specifies that
beginning in FY 1991, the annual DRG reclassification and recalibration
of the relative weights must be made in a manner that assures that
aggregate payments to hospitals are not affected. As discussed in
section II of the preamble, we normalized the recalibrated DRG weights
by an adjustment factor, so that the average case weight after
recalibration is equal to the average case weight prior to
recalibration. While this adjustment is intended to ensure that
recalibration does not affect total payments to hospitals, our analysis
indicates that the normalization adjustment does not necessarily
achieve budget neutrality with respect to aggregate payments to
hospitals.
Section 1886(d)(3)(E) of the Act specifies that the hospital wage
index must be updated based on new survey data no later than October 1,
1990 and on an annual basis beginning October 1, 1993. This provision
also requires that any updates or adjustments to the wage index must be
made in a manner that assures that aggregate payments to hospitals are
not affected by the change in the wage index.
To comply with the requirement of section 1886(d)(4)(C)(iii) of the
Act that the DRG reclassification and recalibration of the relative
weights be budget neutral and the requirement in section 1886(d)(3)(E)
of the Act that the updated wage index be implemented in a budget
neutral manner, we compared aggregate payments using the FY 1994
relative weights and the wage index effective October 1, 1993 to
aggregate payments using the proposed FY 1995 relative weights and wage
index. The same methodology was used for the FY 1993 and FY 1994 budget
neutrality adjustment. (See the discussion in the September 1, 1992
final rule (57 FR 39832).) Based on this comparison, we computed a
proposed budget neutrality adjustment factor equal to 0.997647. The
final budget neutrality adjustment factor is equal to 0.998050. This
budget neutrality adjustment factor is applied to the standardized
amounts without removing the effects of the FY 1994 budget neutrality
adjustment. We do not remove the prior budget neutrality adjustment
because the statute requires that aggregate payments after the changes
in the DRG relative weights and wage index equal estimated payments
prior to the changes. If we removed the prior year adjustment, we would
not satisfy this condition.
In addition, we will continue to apply the same FY 1995 adjustment
factor to the hospital-specific rates that are effective October 1,
1994, in order to ensure that we meet the statutory requirement that
aggregate payments neither increase nor decrease as a result of the
implementation of the DRG weights and updated wage index. (See the
discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment. Section
1886(d)(8)(B) of the Act provides that certain rural hospitals are
deemed urban effective with discharges occurring on or after October 1,
1988. In addition, section 1886(d)(10) of the Act provides for the
reclassification of hospitals based on determinations by the Medicare
Geographic Classification Review Board (MGCRB). Under section
1886(d)(10) of the Act, a hospital may be reclassified for purposes of
the standardized amount or the wage index, or both.
Prior to FY 1995, section 1886(d)(8)(D) of the Act required the
Secretary to adjust the urban standardized amounts so as to ensure that
total aggregate payments under the prospective payment system after
implementation of the provisions of sections 1886(d)(8)(B) and (C) and
1886(d)(10) of the Act were equal to the aggregate prospective payments
that would have been made absent these provisions. The rural
standardized amounts were also adjusted to ensure that aggregate
payments to rural hospitals not affected by these provisions neither
increased nor decreased as a result of these provisions.
Beginning October 1, 1994, the Secretary is required to adjust the
standardized amounts by the same factor to account for the effects of
reclassification. In the proposed rule, we applied an adjustment of
0.993814 to ensure that the effects of reclassification are budget
neutral. The final budget neutrality adjustment is 0.994055.
The adjustment factors are applied to the standardized amounts
after removing the effects of the FY 1994 budget neutrality adjustment
factors. We note that the proposed FY 1995 adjustment reflected wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of March 14, 1994. The final budget neutrality
adjustment factor reflects the effects of all reclassification
decisions and changes in these decisions resulting from appeals and
review of the MGCRB's decisions for FY 1995, or from a hospital's
request for the withdrawal of a reclassification.
c. Outliers. Section 1886(d)(5)(A) of the Act provides that, in
addition to the basic prospective payment rates, payments must be made
for discharges involving day outliers and may be made for cost
outliers. Under section 1886(d)(3)(B) of the Act, the Secretary has
been required to separately reduce the urban and rural standardized
amounts by the proportion of estimated total DRG payments attributable
to outliers in each respective area. Beginning with FY 1995, section
1886(d)(3)(B) requires the Secretary to adjust both the large urban and
other standardized amounts by the same factor to account for the
estimated proportion of total DRG payments made to outlier cases.
Section 1886(d)(9)(B)(iv) of the Act requires that the urban and other
standardized amounts applicable to hospitals in Puerto Rico be reduced
by the proportion of estimated total DRG payments attributable to
estimated outlier payments. Furthermore, section 1886(d)(5)(A)(iv) of
the Act directs that outlier payments in any year ``may not be less
than 5 percent nor more than 6 percent of total payments projected or
estimated to be made'' based on the prospective payment rates.
Section 13501(c) of the Omnibus Budget Reconciliation Act of 1993
(Public Law 103-66) amended section 1886(d)(5)(A) with respect to
outliers beginning in FY 1995. With regard to cost outliers, section
13501(c) of Public Law 103-66 modifies the methodology for determining
the cost outlier threshold. For discharges occurring before October 1,
1994, a hospital may receive payment for a cost outlier if the adjusted
costs for a discharge exceed a fixed multiple of the DRG payment for
the case or a fixed dollar amount. Effective for discharges occurring
on or after October 1, 1994, a hospital may receive payment for a cost
outlier if adjusted costs exceed the DRG prospective payment rate plus
a fixed dollar amount. As discussed in section IV.D of the preamble, we
refer to this revised cost outlier threshold as ``fixed loss.''
Section 13501(c) of Public Law 103-66 also amended section
1886(d)(5)(A) of the Act with respect to day outliers. Beginning with
FY 1995, section 1886(d)(5)(A) requires the Secretary to reduce the
proportion of total outlier payments paid under the day outlier
methodology. Under the requirements of section 1886(d)(5)(A)(v), the
proportion of outlier payments made under the day outlier methodology,
relative to the proportion of outlier payments made under the day
outlier methodology in FY 1994 (which we estimated at 31.3 percent in
our September 1, 1993 final rule (58 FR 46348)), shall be 75 percent in
FY 1995, 50 percent in FY 1996 and 25 percent in FY 1997. After
September 30, 1997, the Secretary will no longer pay for day outliers
under the provisions of section 1886(d)(5)(A)(i). Again, the changes
required by section 1886(d)(5)(A) are discussed in detail in section
IV.D of the preamble to this final rule.
i. FY 1995 Outlier Thresholds. For FY 1994, the day outlier
threshold is the geometric mean length of stay for each DRG plus the
lesser of 23 days or 3.0 standard deviations. The marginal cost factor
for day outliers (or the percent of Medicare's average per diem payment
paid for each outlier day) is equal to 55 percent in FY 1994. The cost
outlier threshold is the greater of 2.0 times the prospective payment
rate for the DRG or $36,000 ($33,000 for hospitals that have not yet
entered the prospective payment system for inpatient capital-related
costs). The marginal cost factor for cost outliers (or the percent of
costs paid after costs for the case exceed the threshold) is 75
percent. We applied an outlier adjustment to the FY 1994 standardized
amounts of 0.945960 for the urban rates, 0.977157 for the rural rates,
and 0.9454 for the capital Federal rate.
For FY 1995, we proposed to set the day outlier threshold at the
geometric mean length of stay for each DRG plus the lesser of 22 days
or 3.0 standard deviations. We also proposed to reduce the marginal
cost factor for each outlier day from 55 percent to 49 percent in FY
1995 in order to reduce the proportion of payments paid under the day
outlier methodology. The thresholds that we are establishing in this
final rule continue to be the geometric mean length of stay for each
DRG plus the lesser of 22 days or 3.0 standard deviations. However,
based on updated simulations we are establishing in this final rule a
marginal cost factor for each outlier day of 47 percent in FY 1995.
Our policy will reduce the proportion of outlier payments paid to
day outliers as required by section 1886(d)(5)(A) of the Act. We
proposed to establish a fixed loss cost outlier threshold in FY 1995
equal to the prospective payment rate for the DRG plus $23,300 ($21,400
for hospitals that have not yet entered the prospective payment system
for capital-related costs). Additionally, we proposed to increase the
marginal cost factor for cost outliers from 75 to 80 percent. In this
final rule, based on updated simulations, we are establishing a fixed
loss cost outlier threshold in FY 1995 equal to the prospective payment
rate for the DRG plus $20,500 ($18,800 for hospitals that have not yet
entered the prospective payment system for capital-related costs). We
are also establishing a marginal cost factor for cost outliers of 80
percent for FY 1995, as proposed.
Pursuant to section 1886(d)(5)(A)(iv) of the Act, we calculated
outlier thresholds so that estimated outlier payments equal 5.1 percent
of estimated DRG payments.
The model that we use to determine the outlier thresholds necessary
to target our desired outlier payment percentage for FY 1995 uses the
FY 1993 MedPAR file and the most recent available information on
hospital-specific payment parameters (such as the cost-to-charge
ratios). This information is based on the June 1994 update of the
provider-specific file used in the PRICER program. In estimating
payments we convert billed charges to costs for purposes of estimating
cost outlier payments. As we explained in the September 1, 1993 final
rule (58 FR 46347), before FY 1994, we used a charge inflation factor
to adjust charges to costs; beginning with FY 1994, we are using a cost
inflation factor to estimate costs. In other words, instead of
inflating the FY 1993 charge data by a charge inflation factor for 2
years in order to estimate FY 1995 charge data and then applying the
cost-to-charge ratio, we adjust the charges by the cost-to-charge ratio
and then inflate the estimated costs for 2 years of cost inflation. In
this manner, we automatically adjust for any changes in the cost-to-
charge ratios that may occur, since the relevant variable is the costs
estimated for a given case.
In setting the proposed FY 1995 outlier thresholds, we used a cost
inflation factor of 1.04735. In setting the final FY 1995 outlier
thresholds, we used a cost inflation factor of 1.025. The difference is
attributable to the use of the cost per case increase in PPS-9 (data
from cost reporting periods beginning in FY 92) in setting the final FY
95 outlier thresholds instead of the average increase in cost per case
between PPS-7 (data from cost reporting periods beginning in FY 1990)
and PPS-9. This modification was introduced after a preliminary review
of the cost per case increase of 2,500 hospitals in PPS-10 (data from
cost reporting periods beginning in FY 93). The cost per case increase
from PPS-9 to PPS-10 was much closer to the increase from PPS-8 to PPS-
9 than from PPS-7 to PPS-9. Thus, for FY 1995, we are using a cost
inflation factor based on the observed increase in hospital costs
between PPS-8 and PPS-9. In the future, we still plan to use 2-year
averages in computing the cost inflation factors, unless preliminary
data from more recent years indicate that the 2-year average may be
inaccurate.
When we modeled the combined operating and capital outlier
payments, we found that using a common set of thresholds resulted in a
slightly higher percentage of outlier payments for capital-related
costs than for operating costs. We estimate the final thresholds for FY
1995 will result in outlier payments equal to 5.1 percent of operating
DRG payments and 5.9 percent of capital payments based on the Federal
rate.
As stated in the September 1, 1993 final rule (58 FR 46348), we
have established outlier thresholds that would be applicable to both
inpatient operating costs and inpatient capital-related costs. As
explained earlier, we are applying a reduction of approximately 5.1
percent to the FY 1995 standardized amounts to account for the
proportion of prospective payments made to outliers. The proposed
outlier adjustment factors applied to the standardized amounts and the
capital Federal rate for FY 1995 are as follows:
Operating Standardized Amount-- 0.948772
Capital Federal Rate--0.9372
The final outlier adjustment factors applied to the standardized
amounts and the capital Federal rate for FY 1995 are as follows:
Operating Standardized Amount--0.948940
Capital Federal Rate--0.9414
As in the proposed rule, we will apply the outlier adjustment
factors after removing the effects of the FY 1994 outlier adjustment
factors on the standardized amounts and the capital Federal rate.
ii. Other Changes Concerning Outliers. Table 5 of section V of this
addendum contains the DRG relative weights, geometric and arithmetic
mean lengths of stay, as well as the day outlier threshold for each
DRG. When we recalibrate DRG weights, we set a threshold of 10 cases as
the minimum number of cases required to compute a reasonable weight and
geometric mean length of stay. DRGs that do not have at least 10 cases
are considered to be low volume DRGs. For the low volume DRGs, we use
the original geometric mean lengths of stay, because no arithmetic mean
length of stay was calculated based on the original data.
Table 8a in section V of this addendum contains the updated
Statewide average operating cost-to-charge ratios for urban hospitals
and for rural hospitals to be used in calculating cost outlier payments
for those hospitals for which the intermediary is unable to compute a
reasonable hospital-specific cost-to-charge ratio. These Statewide
average ratios replace the ratios published in the September 1, 1993
final rule (58 FR 46439), effective October 1, 1994. Table 8b contains
comparable Statewide average capital cost-to-charge ratios. These
average ratios will be used to calculate cost outlier payments for
those hospitals for which the intermediary computes operating cost-to-
charge ratios lower than 0.275 or greater than 1.310 and capital cost-
to-charge ratios lower than 0.013 or greater than 0.235. This range
represents 3.0 standard deviations (plus or minus) from the mean of the
log distribution of cost-to-charge ratios for all hospitals. The cost-
to-charge ratios in Tables 8a and 8b will be applied to all hospital-
specific cost-to-charge ratios based on cost report settlements
occurring during FY 1995.
Comment: One commenter expressed concern over the use of statewide
averages for those hospitals in which the intermediary computes
operating cost-to-charge ratios lower than the minimum acceptable ratio
(that is, minus 3 standard deviations from the mean). The commenter
stated that the minimum threshold created a clear incentive for
hospitals to artificially inflate their gross charges, and circumvent
the intent that hospitals only be paid marginal costs for outliers. The
commenter recommended elimination of the minimum cost-to-charge ratios.
Response: We use the statewide average operating cost-to-charge
ratios in cases where an intermediary is unable to compute a reasonable
hospital-specific cost-to-charge ratio. Our current definition of
reasonableness is based on a range of plus or minus 3.0 standard
deviations from the mean of the log distribution of cost-to-charge
ratios for all hospitals. We do not believe hospitals are setting their
charges just to manipulate their cost-to-charge ratios. In fact,
contrary to the commenter's contention, the incentives a hospital would
have to maximize outlier payments, if any, would be to lower charges in
order to increase its cost-to-charge ratio. Thus, we will continue to
use statewide cost-to-charge ratios where the cost-to-charge ratio for
any hospitals falls outside the prescribed ranges.
iii. FY 1993 and FY 1994 Outlier Payments. In the May 26, 1993
proposed rule (58 FR 30271), we estimated that actual FY 1993 outlier
payments would be approximately 4.5 percent of actual FY 1993 total DRG
payments. Our estimates of actual outlier payments were computed by
simulating payments using actual FY 1993 bill data available at the
time. Our current estimate is that actual FY 1993 outlier payments were
approximately 4.2 percent of total DRG payments. These estimates are
based on simulations using the August 1993 update of the provider-
specific file and the August 1993 update of the MedPAR file.
In the June 4, 1992 proposed rule (57 FR 23645), we discussed
several factors that could explain the difference between estimated
outlier payments and actual outlier payments, relative to total DRG
payments. With regard to FY 1993 outlier payments, we note that the
percentage increase in the Medicare case-mix index was 0.8 percent
between FY 1992 and FY 1993, which was a lower rate of increase than
for prior years. Although the case-mix index is not a factor in setting
the outlier thresholds, lower growth in FY 1993 indicates that the
average severity of Medicare cases increased less in FY 1993 than in
prior years.
We also believe that use of a charge inflation factor in setting
the FY 1993 outlier thresholds may account for some of the difference.
As we explained in our June 4, 1992 proposed rule, charges have
historically grown faster than costs. In setting thresholds for FY
1993, we used the most recently available Medicare data, but that data
contained 2-year old cost-to-charge ratios. Thus, the cost-to-charge
ratios used to set the FY 1993 outlier thresholds are higher than those
used to determine payments. Consequently, actual FY 1993 outlier
payments as a percent of actual total DRG payments may be lower than we
estimated when setting outlier thresholds.
To address this problem in FY 1994, we began using a cost inflation
factor rather than a charge inflation factor to update billed charges
for purposes of estimating outlier payments. We believed that this
refinement would improve our estimation methodology.
In the September 1, 1993 final rule, we set the outlier thresholds
so that estimated operating outlier payments were equal to 5.1 percent
of estimated total estimated operating prospective payments. We
currently estimate that actual FY 1994 outlier payments will be 3.9
percent of actual FY 1994 total DRG payments. This figure is based on a
computer simulation of payments in FY 1994 using FY 1993 bill data.
We believe that actual outlier payments as a percentage of actual
total DRG payments may be lower than estimated because actual hospital
costs may be lower than reflected in the estimation methodology. Our
most recent data on hospital costs show a significant trend in
declining rates of increase. Thus, the cost inflation factor of 8.3
percent (based on the best available data) used to estimate outlier
payments in setting FY 1994 outlier thresholds appears to have been
overstated. Based on more recent data, we are using a cost inflation
factor of 2.5 percent to set outlier payments for FY 1995. Also,
although we estimate that actual FY 1994 outlier payments will
approximate 3.9 percent of actual FY 1994 total DRG payments, we note
that the estimate of the market basket rate of increase used to set the
FY 1994 rates was 4.3 percentage points, while the latest FY 1994
market basket rate of increase estimate is 2.7 percent. Thus, the net
effect is that hospitals are receiving higher FY 1994 payments than
would have been established based on a more recent forecast of the
market basket rate of increase.
Comment: Some commenters are concerned about our projection that
the percentage of FY 1994 outlier payments will be lower than estimated
when we set the FY 1994 outlier thresholds. These commenters urge that
we establish a method of monitoring outlier payments during a fiscal
year, so that we can prospectively change the outlier thresholds in the
event that projected outlier payments are not between 5 and 6 percent
of total DRG payments.
Response: We responded to similar comments in the final rules for
FY 1993 (57 FR 39784) and FY 1994 (58 FR 46347). Section
1886(d)(5)(A)(iv) of the Social Security Act (the Act) requires that
outlier payments be between 5 and 6 percent of the total payments
``projected or estimated to be made'' based on diagnosis-related group
(DRG) prospective payment system rates for discharges in that year.
Pursuant to this provision, we calculated the FY 1994 outlier
thresholds so that estimated outlier payments were 5.1 percent of
estimated total DRG payments. We used the most recent Medicare
discharge and hospital-specific data available to estimate total
payments and outlier payments. This is necessarily a prospective
process, and the resulting estimate may prove to be inaccurate. We do
not believe that Congress envisioned we would revise in midyear any of
the estimates of factors used to set prospective payment amounts for a
given Federal fiscal year. These factors include not only the outlier
thresholds, but the market basket rate of increase used to establish
the update factors, the recalibration of the DRG rates, and the various
required budget neutrality provisions.
Our current estimate for FY 1994 outlier payments is 3.9 percent of
total DRG payments. We note that this result is mainly due to the
reduction in the cost inflation factor that we use to set the
thresholds, from the 8.3 percent level used to set the FY 94 thresholds
to the 2.5 percent level used to make this estimate. However, as
discussed in section IV.D. of the preamble to this final rule, we are
addressing this problem for FY 1995 as part of our continuing efforts
to refine the outlier estimation methodology. Normally, we would use
the average increase in cost per case between PPS-7 (data from cost
reporting periods beginning in FY 1990) and PPS-9 (data from cost
reporting periods in FY 1992) as the cost inflation factor in setting
the FY 1995 outlier thresholds. However, after reviewing the
preliminary data for 2500 hospitals from PPS-10 (data from cost
reporting periods in FY 1993) we found the cost per case increase to be
much closer to the PPS-9 data than the PPS-7 data, indicating a
continued downward trend in the rate of increase in hospitals costs.
Thus, for FY 95, we have decided to use solely the PPS-9 cost per case
increase of 2.5 percent.
B. Adjustments for Area Wage Levels and Cost of Living
This section contains an explanation of the application of two
types of adjustments to the adjusted standardized amounts that will be
made by the intermediaries in determining the prospective payment rates
as described in this addendum. For discussion purposes, it is necessary
to present the adjusted standardized amounts divided into labor and
nonlabor portions. Tables 1a, 1b, and 1c, as set forth in this
addendum, contain the actual labor-related and nonlabor-related shares
that will be used to calculate the prospective payment rates for
hospitals located in the 50 States, the District of Columbia, and
Puerto Rico.
1. Adjustment for Area Wage Levels. Sections 1886(d)(3)(E) and
1886(d)(9)(C)(iv) of the Act require that an adjustment be made to the
labor-related portion of the prospective payment rates to account for
area differences in hospital wage levels. This adjustment is made by
the intermediaries by multiplying the labor-related portion of the
adjusted standardized amounts by the appropriate wage index for the
area in which the hospital is located. In section III of the preamble,
we discuss certain revisions we are making to the wage index. This
index is set forth in Tables 4a through 4e of this addendum.
2. Adjustment for Cost of Living in Alaska and Hawaii. Section
1886(d)(5)(H) of the Act authorizes an adjustment to take into account
the unique circumstances of hospitals in Alaska and Hawaii. Higher
labor-related costs for these two States are taken into account in the
adjustment for area wages described above. For FY 1995, the adjustment
necessary for nonlabor-related costs for hospitals in Alaska and Hawaii
will be made by the intermediaries by multiplying the nonlabor portion
of the standardized amounts by the appropriate adjustment factor
contained in the table below.
Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
Alaska--All areas.............................................. 1.25
Hawaii:
County of Honolulu........................................... 1.225
County of Hawaii............................................. 1.15
County of Kauai.............................................. 1.175
County of Maui............................................... 1.225
County of Kalawao............................................ 1.225
(The above factors are based on data obtained from the U.S. Office of
Personnel Management.)
C. DRG Relative Weights
As discussed in section II of the preamble, we have developed a DRG
classification system for hospital inpatient discharges, and have
developed relative weights for each DRG that reflect the resource
utilization of cases in that DRG relative to Medicare cases in other
DRGs. The intermediary calculates the prospective payment amount by
multiplying the applicable standardized amount by the relative weight
for the DRG to which the discharge is assigned.
Table 5 of section V of this addendum contains the relative weights
that we will use for discharges occurring in FY 1995. These factors
have been recalibrated as explained in section II of the preamble.
D. Calculation of Prospective Payment Rates for FY 1995
General Formula for Calculation of Prospective Payment Rates for FY
1995:
Prospective payment rate for all hospitals located outside Puerto Rico
except sole community hospitals = Federal rate.
Prospective payment rate for sole community hospitals = Whichever of
the following rates yields the greatest aggregate payment: 100 percent
of the Federal rate, 100 percent of the FY 1982 hospital-specific rate,
or 100 percent of the FY 1987 hospital-specific rate.
Prospective payment rate for Puerto Rico = 75 percent of the Puerto
Rico rate + 25 percent of a discharge-weighted average of the large
urban, other urban, and rural national rates.
1. Federal Rate. For discharges occurring on or after October 1,
1994 and before October 1, 1995, except for sole community hospitals,
hospitals subject to the regional floor and hospitals in Puerto Rico,
the hospital's rate is comprised exclusively of the Federal national
rate. Section 1886(d)(1)(A)(iii) of the Act, as amended by section
13501(f) if Public Law 103-66, provides that the Federal rate is
comprised of 100 percent of the Federal national rate except for those
hospitals located in census regions that have a regional rate that is
higher than the national rate. The Federal rate for hospitals located
in census regions that have a regional rate that is higher than the
national rate equals 85 percent of the Federal national rate plus 15
percent of the Federal regional rate. For discharges occurring on or
after October 1, 1994, hospitals in regions I, IV, and VI are affected
by the regional floor.
The Federal rates are determined as follows:
Step 1--Select the appropriate regional or national adjusted
standardized amount considering the type of hospital and designation of
the hospital as large urban or other (see Tables 1a and 1b, section V
of this addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located (see Tables 4a, 4b, and 4c, section V of this
addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount (adjusted if appropriate under Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5, section V of
this addendum).
2. Hospital-Specific Rate (Applicable Only to Sole Community
Hospitals). Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide
that sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: The Federal
rate, the updated hospital-specific rate based on FY 1982 cost per
discharge, or the updated hospital-specific rate based on FY 1987 cost
per discharge.
Hospital-specific rates have been determined for each of these
hospitals based on both the FY 1982 cost per discharge and the FY 1987
cost per discharge. For a more detailed discussion of the calculation
of the FY 1982 hospital-specific rate and the FY 1987 hospital-specific
rate, we refer the reader to the September 1, 1983 interim final rule
(48 FR 39772); the April 20, 1990 final rule with comment (55 FR
15150); and the September 4, 1990 final rule (55 FR 35994).
a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for FY
1995. We are increasing the hospital-specific rates by 1.4 percent (the
hospital market basket percentage increase minus 2.2 percentage points)
for sole community hospitals located in all areas in FY 1995. Section
1886(b)(3)(C)(ii) of the Act, as amended by section 13501(a)(2) of
Public Law 103-66, provides that the update factor applicable to the
hospital-specific rates for sole community hospitals equals the update
factor under section 1886(b)(3)(B)(iv) of the Act, which for FY 1995,
is the market basket rate of increase minus 2.2 percentage points.
Prior to FY 1994, the update to the hospital-specific rates was applied
according to a hospital's cost reporting period. However, beginning
with FY 1994, the update to the hospital specific rate is applied on a
Federal fiscal year basis under amended section 1886(b)(3)(C)(ii). That
section required us to apply the FY 1994 update taking into account the
portion of the 12-month cost reporting period beginning during FY 1993
that occurred during FY 1994. In our September 1, 1993 final rule with
comment (58 FR 46308), we described a methodology for calculating a
``deemed FY 1993'' update that affected payment rates in FY 1994.
However as discussed in our June 23, 1994 final rule (59 FR 32381), we
have revised our interpretation of section 1886(b)(3)(C)(ii) and
decided to prorate the FY 1994 applicable update based on the number of
months after the end of a hospital's cost reporting period that
occurred in FY 1994.
b. Calculation of Hospital-Specific Rate. For sole community
hospitals, the applicable FY 1995 hospital-specific rate will be
calculated by multiplying a hospital's deemed hospital-specific rate
for the preceding cost reporting period by the applicable update factor
(that is, 1.4 percent). In addition, the hospital-specific rate will be
adjusted by the budget neutrality adjustment factor (that is, 0.99805)
as discussed in section II.A.4.b. of this addendum. This resulting rate
will be used in determining the rate a sole community hospital is paid
for its discharges beginning on or after October 1, 1994, based on the
formula set forth above.
3. General Formula for Calculation of Prospective Payment Rates for
Hospitals Located in Puerto Rico Beginning On or After October 1, 1994
and Before October 1, 1995. a. Puerto Rico Rate. The Puerto Rico
prospective payment rate is determined as follows:
Step 1--Select the appropriate adjusted average standardized amount
considering the large urban or other designation of the hospital (see
Table 1c, section V of the addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate wage index (see Tables 4a and 4b, section V
of the addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount.
Step 4--Multiply the result in Step 3 by 75 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
b. National Rate. The national prospective payment rate is
determined as follows:
Step 1--Multiply the labor-related portion of the national average
standardized amount (see Table 1c, section V of the addendum) by the
appropriate wage index.
Step 2--Add the amount from Step 1 and the nonlabor-related portion
of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 25 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Changes to Payment Rates for Inpatient Capital-Related Costs for
FY 1995
The prospective payment system for hospital inpatient capital-
related costs was implemented for cost reporting periods beginning on
or after October 1, 1991. Effective with that cost reporting period and
during a 10-year transition period extending through FY 2001, hospital
inpatient capital-related costs are paid on the basis of an increasing
proportion of the capital prospective payment system Federal rate and a
decreasing proportion of the historical costs for capital.
The basic methodology for determining Federal capital prospective
rates is set forth at Secs. 412.308 through 412.352 of the regulations.
Below we discuss the factors that we used to determine the Federal rate
and the hospital-specific rate for FY 1995. The rates will be effective
for discharges occurring on or after October 1, 1994.
For FY 1992, we computed the standard Federal payment rate for
capital-related costs under the prospective payment system by updating
the FY 1989 Medicare inpatient capital cost per case by an actuarial
estimate of the increase in Medicare inpatient capital costs per case.
Each year after FY 1992 we updated the standard Federal rate for
increases in capital-related costs as provided in Sec. 412.308(c)(1).
Also, Sec. 412.308(c)(2) provides that the Federal rate is adjusted
annually by a factor equal to the estimated additional payments under
the Federal rate for outlier cases, determined as a proportion of total
capital payments under the Federal rate. For FY 1992 through FY 2001,
Sec. 412.308(c)(3) requires that the Federal rate be reduced by an
adjustment factor equal to the estimated additional payments made for
exceptions under Sec. 412.348, and Sec. 412.308(c)(4)(ii) requires that
the Federal rate be adjusted so that the annual DRG reclassification
and the recalibration of DRG weights and changes in the geographic
adjustment factor are budget neutral. For FY 1992 through FY 1995,
Sec. 412.352 requires that the Federal rate also be adjusted by a
budget neutrality factor so that estimated aggregate payments for
inpatient hospital capital costs will equal 90 percent of the estimated
payments that would have been made for capital-related costs on a
reasonable cost basis during the fiscal year.
The hospital-specific rate for each hospital was calculated by
dividing the hospital's Medicare inpatient capital-related costs for a
specified base year by its Medicare discharges (adjusted for
transfers), and dividing the result by the hospital's case mix index
(also adjusted for transfers). The resulting case-mix adjusted average
cost per discharge was then updated to FY 1992 based on the national
average increase in Medicare's inpatient capital cost per discharge and
adjusted by the exceptions payment adjustment factor and the budget
neutrality adjustment factor to yield the FY 1992 hospital-specific
rate. The hospital-specific rate is updated each year after FY 1992 for
inflation and for changes in the exceptions payment adjustment factor
and the budget neutrality adjustment factor.
To determine the appropriate budget neutrality adjustment factors
and the exceptions payment adjustment factor, we developed a dynamic
model of Medicare inpatient capital-related costs, that is, a model
that projects changes in Medicare inpatient capital-related costs over
time. The model and its application are described more fully in
Appendix B.
In accordance with section 1886(d)(9)(A) of the Act, under the
prospective payment system for inpatient operating costs, hospitals
located in Puerto Rico are paid under a special payment formula. These
hospitals are paid a blended rate that is comprised of 75 percent of
the applicable standardized amount specific to Puerto Rico hospitals
and 25 percent of the applicable national average standardized amount.
Section 412.374 provides for the use of this blended payment system for
payments to Puerto Rico hospitals under the prospective payment system
for inpatient capital-related costs. Accordingly, for capital-related
costs we compute a separate payment rate specific to Puerto Rico
hospitals using the same methodology used to compute the national
Federal rate for capital. Hospitals in Puerto Rico are paid based on 75
percent of the Puerto Rico rate and 25 percent of the Federal rate.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
For FY 1994, the Federal rate was $378.34. In the proposed rule, we
stated that the proposed FY 1995 Federal rate was $353.87. In this
final rule, we are establishing an FY 1995 Federal rate of $376.83.
In the discussion that follows, we explain the factors that were
used to determine the FY 1995 Federal rate. In particular, we explain
why the FY 1995 Federal rate has decreased 0.40 percent compared to the
FY 1994 Federal rate, and why the rate has increased 6.49 percent
compared to the proposed FY 1995 Federal rate. We also explain that
aggregate payments for capital in FY 1995 are estimated to increase by
5.32 percent.
The major factor contributing to the decrease in the FY 1995 rate
in comparison to FY 1994 is the requirement at Sec. 412.352 that
estimated payments each year from FY 1992 through FY 1995 for capital
costs equal 90 percent of what would have been payable that year on a
reasonable cost basis. Accordingly, based on the most recent estimate
of FY 1995 costs, the rate must be reduced somewhat to assure that
system-wide payments will equal 90 percent of cost.
Based on the most recent data, we now estimate that capital
payments for FY 1992 equalled 93.14 percent of reasonable costs, that
capital payments for FY 1993 equal 96.45 percent of reasonable costs,
and that capital payments for FY 1994 will equal 90.32 percent of
reasonable costs. The data thus indicate that the budget neutrality
adjustments for FY 1992, FY 1993, and FY 1994 were not sufficient to
meet the 90 percent target and that, as a consequence, the Federal
rates for FY 1992, FY 1993, and FY 1994 were higher than they should
have been. While we do not retroactively adjust the budget neutrality
factor and the Federal rate for previous years to account for revised
estimates, we do employ the most recent information available to refine
the budget neutrality adjustment for subsequent years.
Two factors account for the 6.49 percent increase in the Federal
rate since the proposed rule. One factor is the 2.05 percent increase
in the budget neutrality target for FY 1995 over the target in the
proposed rule. As we describe in section III.A.4 below, this increase
is due to more recent cost report data on capital cost per case in FY
1992, partially offset by a very small decline in the actuarial
projections that we employ to project the FY 1995 capital cost per
case.
Another factor that has contributed to the increase in the Federal
rate since the proposed rule is a revision in our projection of the
rate of increase in case mix. As we discuss in Appendix B, we have
reduced our projected increase in case mix from 1.5 percent to .85
percent. The estimate of case-mix increase does not affect the cost-
per-case increase estimates that are used to set the budget neutrality
target. It does, however, affect the payment rate level necessary to
assure that estimated payments equal 90 percent of estimated reasonable
costs. All other things being equal, the Federal rate must be reduced
when case-mix increase projections accelerate to avoid exceeding the
budget neutrality target. Conversely, a reduction of case-mix increase
projections requires an increase in the Federal rate to assure that
estimated payments do not fall short of the target. The reduction in
our case-mix increase projections since the proposed rule thus requires
an increase in the Federal rate relative to the level in the proposed
rule.
Although the Federal rate for FY 1995 is 0.40 percent lower than
the FY 1994 Federal rate, we estimate that total capital payments per
case will increase 5.32 percent in FY 1995. The estimated increase in
total payments per case is due to the increase in the budget neutrality
target to equal 90 percent of estimated FY 1994 capital costs per case.
Since section 1886(g)(1)(A) of the Act requires that estimated payments
equal 90 percent of estimated reasonable costs for capital-related
expenses, payments under the capital prospective payment system can be
expected to increase as capital costs per case increase. The increase
in payments per case from FY 1994 to FY 1995 (5.32 percent) is less
than the total estimated increase in capital costs per case between FY
1994 and FY 1995 (5.70 percent) because estimated FY 1994 payments were
0.36 percent higher than the FY 1994 budget neutrality target. As a
result, payments must increase slightly less than the full increase in
costs to prevent estimated payments for FY 1995 from exceeding 90
percent of reasonable cost. Specifically, the increase in payments from
FY 1994 to FY 1995 is determined by dividing the increase in cost per
case by the excess of FY 1994 payments over the budget neutrality
target (that is, 1.0570/1.0036=1.0532, an increase of 5.32 percent). We
discuss the determination of the budget neutrality target in section
III.A.4 below.
Finally, it should be noted that total payments to hospitals under
the prospective payment system will be relatively insensitive to
changes in the Federal rate even after the expiration of the budget
neutrality provision in FY 1996. Since capital payments constitute
about 10 percent of hospital payments, a 1 percent change in the
Federal rate yields only about a 0.1 percent change in actual payments
to hospitals.
1. Standard Federal Rate Update. Section 412.308(c)(1)(i) provides
that for FY 1993 through FY 1995, the standard Federal rate is updated
on the basis of a lagged 2-year moving average of the actual increase,
adjusted for case-mix index change, in Medicare inpatient capital-
related costs per case for the fiscal years 3 and 4 years before the
fiscal year in question. For FY 1995, the increase is based on the
increase in Medicare inpatient capital-related costs per case from FY
1990 through FY 1992. These are the most recent fiscal years for which
cost report data are available. To determine the amount of the
increase, we apportioned a hospital's costs and discharges to each
fiscal year based on the number of months in the hospital's cost
reporting period that occurred during the applicable fiscal year. Thus,
an individual hospital may have more than one cost report included in
the calculation.
In the proposed rule, we stated that the proposed FY 1995 update
factor for the Federal rate would be 2.22 percent. In this final rule,
based on the most recent data, we are providing that the final FY 1995
update factor for the Federal rate is 3.44 percent. The following
chart, based on the June 1994 update of HCRIS, shows how this figure
was computed:
Capital Costs per Case Increase From Cost Report Data
Average 2- Update
Increase year (average
Increase Audit in increase CMI two year
Number Number Unadj. in cost adjusted adjusted in Observed adjusted increase
FY hospitals hospitals capital per case capital cost per adjusted CMI increase of CMI
1st HCR 2nd cost per (percent) cost per case cost per (percent) (percent) adjusted
HCR\1\ case case\2\ (percent) case rate of
(percent) increase)
(percent)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
--------------------------------------------------------------------------------------------------------------------------------------------------------
1990...................................... 4229 5413 $541.60 ......... $539.88 ......... ......... ......... ......... .........
1991...................................... 4170 5332 580.43 7.17 570.35 5.64 ......... 2.52 3.04 .........
1992...................................... 4112 4953 631.86 8.86 601.40 5.44 5.54 1.55 3.83 3.44
\1\Columns 1 and 2 represent the numbers of hospital cost reports used in developing capital costs per case figures in column 3. Since hospital cost
reporting periods do not all coincide with the Federal fiscal year, data for a given Federal fiscal year must be derived from more than one hospital
cost report, allocated proportionately to the Federal fiscal year. For example, for a hospital with a cost reporting period beginning January 1, one
quarter of its cost report for the period ending December 31, 1987 would be allocated to Federal fiscal year 1988, and three quarters of its cost
report for the period ending December 31, 1988 would be allocated to Federal fiscal year 1987. Column 1 represents the number of cost reports used
that ended in the Federal fiscal year in question. Column 2 represents the number of cost reports used that began in the Federal fiscal year in
question. Column 2 is greater than Column 1 because Column 2 includes cost reports for hospitals whose cost reporting period coincides with the
Federal year along with cost reports for those hospitals whose cost reporting periods do not coincide with the Federal fiscal year. Column 1 includes
only cost reports for hospitals whose cost reporting periods do not coincide with the Federal fiscal year.
\2\Figures in column 5 represent capital costs per case, adjusted for the anticipated effects of cost report audits and reopenings, from the June 1994
update of HCRIS. The following factors were used in adjusting capital costs per case figures from column 3 for the effects of audits and reopenings:
Audit Adjustment Applied to As-Submitted Cost Reports
Cost reporting periods beginning in:
FY 19900.9268
FY 19910.9220
FY 19920.9494
Audit Adjustment Applied to Settled Cost Reports
All years1.0045
The costs per case figures that result after the application of these audit adjustments to submitted and settled cost reports, respectively, are entered
in Column 5.
We note that the effect of the update on the Federal rate is limited by
the requirement of budget neutrality until FY 1996. Thus, although the
update factor for inflation is 3.44 percent, the FY 1995 Federal rate
is slightly lower than the FY 1994 Federal rate because of the effects
of the budget neutrality adjustment. We also note that the FY 1995
budget neutrality target is determined by the estimate of FY 1995
capital costs, not by the 2-year average update factor applied to the
FY 1995 Federal rate. We further discuss the basis for the budget
neutrality target in section III.A.4 below.
Comment: One commenter stated that the proposed decreases of 6.47
percent for the Federal rate and the 5.76 percent for the hospital-
specific rate are not tolerable. The commenter argued that the 1.0222
update factor does not match the market basket increases, even though
HCFA had predicted that these factors would be well above that proposed
for FY 1995. The commenter recommended that the update factor be
revisited to reflect a more appropriate increase in actual capital
costs to which the 90 percent goal could then be applied via the budget
neutrality factor.
Response: It is not clear what market basket increases the
commenter is referring to. The market basket used to develop the update
recommendation for the operating prospective payment system is not
applicable to the capital rate. As we discuss in Appendix E, a market
basket is under development for the capital prospective payment system.
A capital input price index will be part of the update framework that
will take effect in FY 1996. In the meantime, the regulations require
the use of a lagged two-year average of actual cost per case increases,
as shown in the table above. As we also noted above, the update factor
of 2.22 percent is not used to set the budget neutrality target. The
procedure that we follow in setting the budget neutrality target is
described in section IV.D below. This procedure involves developing a
budget neutrality target on the basis of an actuarial projection of
increases in Medicare capital costs per case. The FY 1995 budget
neutrality target reflects a projected 5.70 percent increase in
Medicare capital costs per case for FY 1995.
Comment: One commenter recommended that an add-on adjustment be
employed in setting the update factor to account for appropriate
changes in new technology prior to the adoption of an analytical update
framework in FY 1996.
Response: The present update factor is based on a 2-year moving
average of actual increases in Medicare inpatient capital-related costs
per discharge. Since the actual costs include spending for new
technology, the cost of new technology is already accounted for in the
update factor. A separate adjustment for new technology would
constitute double-counting and is therefore not appropriate, as long as
the update is determined by the average of actual cost increases in
recent years. However, we do believe that the cost of new technology is
a factor that should be accounted for in the capital analytical update
framework that will be used beginning in FY 1996. We discuss the
methodology for incorporating appropriate changes in cost for new
technology into the update framework in Appendix E.
2. Outlier Payment Adjustment Factor. Section 412.312(c)
establishes a unified outlier methodology for inpatient operating and
inpatient capital-related costs. A single set of thresholds is used to
identify outlier cases for both inpatient operating and inpatient
capital-related payments. Outlier payments are made only on the portion
of the Federal rate that is used to calculate the hospital's inpatient
capital-related payments (for example, 40 percent for cost reporting
periods beginning in FY 1995 for hospitals paid under the fully
prospective methodology). Section 412.308(c)(2) provides that the
standard Federal rate for inpatient capital-related costs be reduced by
an adjustment factor equal to the estimated additional payments under
the Federal rate for outlier cases, determined as a proportion of
inpatient capital-related payments under the Federal rate. The outlier
thresholds are set so that estimated outlier payments are 5.1 percent
of estimated inpatient operating payments. The inpatient capital-
related outlier reduction factor is then set according to the estimated
inpatient capital-related outlier payments that would be made if all
hospitals were paid according to 100 percent of the Federal rate. For
purposes of calculating the outlier thresholds and the outlier
reduction factor, we model all hospitals as if paid 100 percent of the
Federal rate because, as explained above, outlier payments are made
only on the portion of the Federal rate that is included in the
hospital's inpatient capital-related payments.
In the September 1, 1993 final rule, we estimated that outlier
payments for capital in FY 1994 would equal 5.46 percent of inpatient
capital-related payments based on the Federal rate. Accordingly, we
applied an outlier adjustment factor of 0.9454 to the Federal rate.
Based on the thresholds as set forth in section II.A.4.d of the
addendum, we estimate that outlier payments will equal 5.86 percent of
inpatient capital-related payments based on the Federal rate in FY
1995. We are therefore applying an outlier adjustment factor of 0.9414
to the Federal rate. Thus, capital outlier payments for FY 1995
represent a higher percentage of total capital standard payments than
in FY 1994.
The outlier reduction factors are not built permanently into the
rates; that is, they are not applied cumulatively in determining the
Federal rate. Therefore, the net change in the outlier adjustment to
the Federal rate for FY 1995 is .9958 (.9414/.9454). Thus, the outlier
adjustment reduces the FY 1995 Federal rate by 0.42 percent (.9958-1)
compared with the FY 1994 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG
Classification and Weights and the Geographic Adjustment Factor.
Section 412.308(c)(4)(ii) requires that the Federal rate be adjusted so
that estimated aggregate payments for the fiscal year based on the
Federal rate after any changes resulting from the annual
reclassification and recalibration of the DRG weights and changes in
the geographic adjustment factor equal estimated aggregate payments
that would have been made on the basis of the Federal rate without such
changes. We used the actuarial model described in Appendix B to
estimate the aggregate payments that would have been made on the basis
of the Federal rate without changes in the DRG classifications and
weights and in the geographic adjustment factor. We also used the model
to estimate aggregate payments that would be made on the basis of the
Federal rate as a result of those changes. We then used these figures
to compute the adjustment required to maintain budget neutrality for
changes in DRG weights and in the geographic adjustment factor.
For FY 1994, we calculated a GAF/DRG budget neutrality factor of
1.0053. In the proposed rule for FY 1995, we proposed a GAF/DRG budget
neutrality factor of 1.00115. In this final rule, based on calculations
using updated data, we are applying a factor of 0.9998 to meet this
requirement. The GAF/DRG budget neutrality factors are built
permanently into the rates; that is, they are applied cumulatively in
determining the Federal rate. This follows from the requirement that
aggregate payments each year be no more than it is estimated that they
would have been in the absence of the changes from the annual DRG
reclassification and recalibration and in the geographic adjustment
factor. The incremental change in the adjustment from FY 1994 to FY
1995 is 0.9998. The cumulative change in the rate due to this
adjustment is 1.0031 (the product of the factors for FY 1993, FY 1994,
and FY 1995: .9980 x 1.0053 x .9998 = 1.0031).
This factor accounts for DRG reclassifications and recalibration
and changes in the geographic adjustment factor. It also incorporates
the effects on the geographic adjustment factor of FY 1995 geographic
reclassification decisions made by the MGCRB compared to FY 1994
decisions. However, it does not account for changes in payments due to
changes in the disproportionate share and indirect medical education
adjustment factors or in the large urban add-on.
4. Budget Neutrality Adjustment Factor to Assure Aggregate Payments
Equal 90 Percent of Reasonable Cost Payments. Section 1886(g)(1)(A) of
the Act requires that aggregate payments made each year in FY 1992
through FY 1995 for hospital inpatient services be reduced in a manner
that results in payments equal to 90 percent of the amount the
Secretary estimates would have been payable on a reasonable cost basis
for inpatient capital-related costs in that year. No retroactive
adjustment is made if aggregate payments are greater than or less than
90 percent of actual Medicare inpatient capital-related costs for that
year. Section 412.352 of the regulations provides that HCFA determines
an adjustment to the hospital-specific rate and the Federal rate
proportionately, so that the estimated payments for capital in each
year from FY 1992 through FY 1995 will equal 90 percent of what would
have been payable that year on a reasonable cost basis. The effect of
this provision is that the reduction required under section
1886(g)(1)(A) of the Act is realized entirely through a reduction in
the prospective payments for capital costs (that is, no reduction is
made for this purpose in the reasonable cost payments for old capital)
in FY 1992 through FY 1995.
For FY 1994, we determined that a budget neutrality factor of
0.8947 was required so that estimated aggregate payments for inpatient
capital-related costs would equal 90 percent of what would have been
payable on a reasonable cost basis in that year. In the proposed rule
for FY 1995, we proposed a budget neutrality factor of 0.7986. In this
final rule, we are establishing a budget neutrality factor of 0.8432.
The budget neutrality adjustment factor for FY 1995 is 5.76 percent
lower than the FY 1994 budget neutrality adjustment (.8947), and 5.58
percent higher than the budget neutrality factory in the proposed rule
(.7986).
As we explain in Appendix B, we determine the budget neutrality
adjustment factor on the basis of a projected FY 1995 capital costs per
case budget neutrality target. We develop this target from available
data on average Medicare capital costs per case for all short-term
acute care hospitals subject to the capital prospective payment system
(that is, data from excluded and waiver hospitals were eliminated). For
the FY 1995 proposed rule, we had actual data for FY 1992 from the
December 1993 HCRIS update. For this final rule, we have actual data
for FY 1992 from the June 1994 HCRIS update. We also have revised
estimates of the rates of increase in Medicare capital costs per case
for the years FY 1993 through FY 1995.
At the time of the final rule for FY 1994, we had estimated that
there would be a 30.52 percent increase in Medicare inpatient capital
cost per case between FY 1992 and FY 1995. In the proposed rule for FY
1995, we estimated that there would be a 12.83 percent increase in
Medicare inpatient capital cost per case between FY 1992 and FY 1995, a
decline of 13.56 percent (1.1283/1.3052=.8644, or -13.56 percent) in
the estimated rate of increase since the final rule for FY 1994. In
this final rule for FY 1995, we are estimating that there will be a
12.49 percent increase in Medicare inpatient capital cost per case
between FY 1992 and FY 1995, a decline of 13.81 percent in the
estimated rate of increase since the final rule for FY 1994 (1.1249/
1.3052=.8619, or 13.81 percent), and a decrease of 0.30 percent since
the proposed rule for FY 1995 (1.1249/1.1283=-0.30 percent). The
following chart shows how the rate-of-increase estimates for FY 1992
through FY 1995 were calculated in the proposed rule and in this final
rule for FY 1995.
Comparison of Factors for Medicare Inpatient Capital Cost Per Case Increases: FY 1995 Proposed Rule (PR) and FY 1995 Final Rule (PR)
[In percentages]
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(1)Total inpatient (2)Medicare share (1) x (2)=(3)Medicare (4)Medicare enrollment (5)Admissions incidence (4) x (5)=(6)Medicare (3)/(6)=(7)Estimated
capital ------------------------- inpatient capital -------------------------------------------------- admissions increase in Medicare
------------------------- ------------------------- ------------------------- inpatient capital cost
Estimate for FY per case
FY95 FY95 Percent FY95 FY95 Percent FY95 FY95 Percent FY95 FY95 Percent FY95 FY95 Percent FY95 FY95 Percent ------------------------
PR FR change PR FR change PR FR change PR FR change PR FR change PR FR change FY95 FY95 Percent
PR FR change
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1993............. 5.23 5.23 0.00 0.52 0.23 -0.30 5.78 5.46 -0.30 2.67 2.67 0.00 1.00 1.00 0.00 3.70 3.70 0.00 2.00 1.70 -0.30
1994............. 7.00 7.00 0.00 1.00 1.00 0.00 8.07 8.07 0.00 2.13 2.13 0.00 1.11 1.11 0.00 3.26 3.26 0.00 4.65 4.65 0.00
1995............. 8.00 8.00 0.00 1.00 1.00 0.00 9.08 9.08 0.00 1.83 1.83 0.00 1.34 1.34 0.00 3.19 3.19 0.00 5.70 5.70 0.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
The chart shows the causes of the decline in the rate of increase
projections since the proposed rule. As the chart shows, the small
decline in the rate of increase projection is due entirely to a decline
in the rate of increase projections for Medicare share in FY 1993. (As
the chart also shows, the rate of increase projections for all other
factors are unchanged.)
In addition to the slight decline in the rate of increase estimates
since the proposed rule, there has been a 2.36 percent increase in the
FY 1992 cost per case in the June 1994 HCRIS data, compared to the
December 1993 HCRIS data, that we used in the proposed rule. The
following chart shows the combined effect of the reduced rates of
increase estimates and the reduced FY 1992 cost per case by comparing
the projections from FY 1992 to FY 1995 at the time of the proposed
rule and in this final rule for FY 1994:
Effect of Revised Rate of Increase Estimates on Calculation of FY 1995
Budget Neutrality Target
------------------------------------------------------------------------
Percent Percent
change change
Capital in rate in
cost per of capital
case increase cost per
case
------------------------------------------------------------------------
FY 1992 cost per case:
Proposed FY 95: 12/93 HCRIS............ \1\$590.8
7 N/A 2.36
Final FY 95: 6/94 HCRIS................ \2\$604.8
3 ........ ........
FY 1993 adjusted cost:
Proposed FY 95: 2.00%.................. $602.72 -0.30 2.05
Final FY 95: 1.70%..................... 615.10 ........ ........
FY 1994 adjusted cost:
Proposed FY 95: 4.65%.................. $630.78 0.00 2.05
Final FY 95: 4.65%..................... $643.75 ........ ........
FY 1995 adjusted cost:
Proposed FY 95: 5.70%.................. $666.75 0.00 2.05
Final FY 95: 5.70%..................... $680.43 ........
-0.30 ........
Cumulative:
------------------------------------------------------------------------
\1\FY 1992 cost per case based on December 1993 HCRIS data, audit-
adjusted, excluding waiver hospitals and PPS-excluded hospitals.
\2\FY 1992 cost per case based on June 1994 HCRIS data, audit-adjusted,
excluding waiver hospitals and PPS-excluded hospitals.
The chart shows that the cumulative effect of the revised rates of
increase is to lower the FY 1995 budget neutrality target by 0.30
percent. Together with the 2.36 percent increase due to updated HCRIS
data, this accounts for the 2.05 percent increase in the FY 1995 final
rule capital cost per case budget neutrality target compared to the
proposed rule for FY 1995.
We received several comments on the budget neutrality estimates
presented in the proposed rule.
Comment: Several commenters noted that the proposed regulation
included the effect of reductions in FY 1992, FY 1993 and FY 1994
capital costs per case estimates from previously published amounts. The
commenters contended that, to protect the prospective nature of the
system, HCFA should not be making retroactive changes over previously
published amounts.
Response: The prospective nature of the system is not threatened by
revising previous estimates of costs per case, since we use the revised
estimates only to set the budget neutrality factor and the rate for the
current year, not to revise the rates for the prior years. We make no
retroactive changes in rates or payment amounts for prior years.
However, it is necessary to revise our prior estimates of capital cost
per case increases as new information becomes available. Otherwise, we
would base the budget neutrality target for the current year on
information that we know to be inaccurate.
Comment: One commenter expressed concern about data in the proposed
regulations indicating that payments may be well below 90 percent of
costs in order to offset the estimated effects of payments in excess of
the 90 percent budget neutrality target in FY 1993 and FY 1994. The
commenter noted that many issues remain unresolved with the 1992 base
year audits and a number of providers have significant obligated
capital effects to be considered. The commenter asserted that HCFA's
forecasting methodologies do not properly reflect the capital cost
payments anticipated by Congress in their legislative approval.
Response: Contrary to the commenter's belief, we did not propose to
set the level of payments lower than 90 percent of costs in order to
offset payments greater than 90 percent of costs in previous years.
Rather, we stated that because we estimated that payments in FY 1994
exceeded the budget neutrality target, the increase in payments from FY
1994 to FY 1995 would have to be less than the full increase in
estimated costs. Otherwise, estimated payments in FY 1995 would exceed
the budget neutrality target. Both in the proposed rule and in this
final rule, we estimate that payments in FY 1995 will equal 90 percent
of estimated costs. The statutory language and regulations governing
the budget neutrality requirement do not mandate a dollar level of
capital cost payments, as the commenter seems to imply. Rather,
payments are tied to a percentage of estimated capital costs. We
estimate capital costs on the basis of the best information available,
and we revise our estimates regularly in order to account for new data.
The capital acquisition model, which is used to determine the
appropriate budget neutrality adjustment factor, does consider the
effects of obligated capital. The model also contains audit adjustments
which account for unaudited HCRIS provider data. The model and its
application are described more fully in appendix B.
Comment: Two commenters expressed concern over the unpredictability
of the Federal capital rate. One commenter expressed concern over the
accuracy of the budget neutrality estimates, asserting that HCFA's
inability to accurately estimate budget neutrality adjustments exposes
them to financial distress. This commenter also noted that this
situation will become more and more critical as the Federal rate
assumes a larger and larger proportion of the payment rate for
hospitals paid under the fully prospective payment method. Another
commenter expressed concern over the accuracy of HCFA's capital
projection model, stating that uncertainty regarding future capital
payments affects their ability to obtain capital funding, and at a
reasonable cost.
Response: We are sensitive to hospitals' need for predictability in
the levels of their capital payments. We recognize that uncertainty
regarding future capital payments affects planning for capital
purchases and obtaining capital funding. We therefore continually seek
to improve the accuracy and reliability of our estimates. The budget
neutrality estimates in this final rule have changed very little in
relation to the estimates in the proposed rule. However, we are
required by statute and regulations to set the rates according to our
best estimate of capital costs, and we change those estimates as the
data at our disposal warrants. We note that this budget neutrality
requirement expires in FY 1996.
Comment: One hospital questioned why the budget neutrality
adjustment resulted in a decrease in its payments. The commenter stated
the belief that, if the budget was actually neutral, then payments
would be identical to those in the previous year. The commenter
contended that HCFA is using funds allocated to capital payments to
providers for some other purpose.
Response: The commenter has mischaracterized the budget neutrality
requirement: the regulations do not require that payments in one year
should be identical to payments in the preceding year, either in the
aggregate or for individual hospitals. The regulations require that
aggregate payments made each year in FY 1992 through FY 1995 for
hospital inpatient services be reduced in a manner that results in
payments equal to 90 percent of the amount the Secretary estimates
would have been payable on a reasonable cost basis for inpatient
capital-related costs in that year. Thus, aggregate payments will
increase or decrease in any given year depending on the increase or
decrease in estimated Medicare inpatient capital-related costs.
As discussed above, we estimate that aggregate payments this year
will increase 5.32 percent. This increase in payments is less than the
estimated increase in costs (5.7 percent) because we estimate that
payments in FY 1994 exceeded the budget neutrality target by 0.32
percent. Although aggregate capital payments may increase in a
particular year, payments to an individual hospital may increase or
decrease for that same year. The way individual hospitals are affected
will vary, depending upon their current capital payment method. It is
possible that an individual hospital, especially a hospital paid based
on 100 percent of the Federal rate, could experience a decrease in
capital payment due to the reduction in the Federal rate. We have set
the capital rates at the level necessary to pay the full amount
required by the law and the regulations.
For FY 1995, we proposed a budget neutrality factor of 0.7986. In
this final rule, the budget neutrality adjustment factor is 0.8432. The
budget neutrality factors are not built permanently into the rates;
that is, the factors are not applied cumulatively in determining the
Federal rate. The FY 1994 budget neutrality factor was .8947. The net
adjustment to the FY 1994 Federal rate will therefore be .8432/.8947 or
0.9424.
5. Exceptions Payment Adjustment Factor. Section 412.308(c)(3)
requires that the standard Federal rate for inpatient capital-related
costs be reduced by an adjustment factor equal to the estimated
additional payments for exceptions under Sec. 412.348 determined as a
proportion of total payments under the hospital-specific rate and
Federal rate. The model developed for determining the budget neutrality
adjustment factor is also used to estimate payments under the
exceptions payment process and to determine the exceptions payment
adjustment factor.
For FY 1994, we estimated that exceptions payments would equal 5.15
percent of aggregate payments based on the Federal rate and the
hospital-specific rate. Therefore, we applied an exceptions reduction
factor of 0.9485 (1-.0515) in determining the Federal rate. For FY
1995, we estimated in the May 27, 1994, proposed rule that exceptions
payments would equal 2.03 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. Therefore, we proposed to
apply an exceptions reduction factor of 0.9797 (1-.0203) to determine
the FY 1995 Federal rate. For the final rule, we estimate that
exceptions payments for FY 1995 will equal 2.66 percent of aggregate
payments based on the Federal rate and the hospital-specific rate. We
are therefore applying an exceptions payment reduction factor of 0.9734
to the Federal rate for FY 1995.
The final exceptions reduction factor for FY 1995 is thus 2.63
percent higher than the factor for FY 1994, and 0.64 percent lower than
the factor in the FY 1995 proposed rule. We have generally expected
exceptions payments to increase during the transition period as
payments are based increasingly on the Federal rate. However, it is
also to be expected that the general tendency for exceptions payments
to increase could be reversed by lower rates of increase in capital
cost per case. In other words, as capital costs per case increase more
slowly, fewer hospitals than we previously estimated will qualify for
exceptions payments by falling below their minimum payment levels, and
those that still do qualify may receive somewhat smaller payments. We
believe that this explains the lower level of exceptions payments for
FY 1995 as compared to FY 1994.
The exceptions reductions factors are not built permanently into
the rates; that is, the factors are not applied cumulatively in
determining the Federal rate. The net adjustment to the FY 1995 Federal
rate is therefore .9734/.9485, or 1.0263.
6. Standard Federal Rate for FY 1995. For FY 1994, the Federal rate
was $378.34. With the changes we proposed to the factors used to
establish the Federal rate, we proposed that the FY 1995 Federal rate
would be $353.87. In this final rule, we are establishing an FY 1995
Federal rate of $376.83. The final Federal rate for FY 1995 was
calculated as follows:
The FY 1995 update factor is 1.0344.
The FY 1995 outlier adjustment factor is 0.9414.
The FY 1995 budget neutrality adjustment factor that is
applied to the standard Federal payment rate for changes in the DRG
relative weights and in the geographic adjustment factor is 0.9998.
The FY 1995 budget neutrality adjustment factor that is
applied to the standard Federal payment rate and the hospital-specific
rate to assure that aggregate payments equal 90 percent of payments
that would have been made on a reasonable cost basis is 0.8432.
The FY 1995 exceptions payments adjustment factor is
0.9734.
Since the Federal rate has already been adjusted for differences in
case mix, wages, cost of living, indirect medical education costs, and
payments to hospitals serving a disproportionate share of low-income
patients, we propose to make no additional adjustments in the standard
Federal rate for these factors other than the budget neutrality factors
for changes in the DRG relative weights and the geographic adjustment
factor.
Comment: Several commenters expressed concern about a proposed
reduction in capital payments. One commenter noted a decline of 6.47
percent in the proposed capital payment rate, and an overall decline of
14.9 percent from the inception of PPS capital rules.
Response: We are required to adjust the Federal rate and the
hospital-specific rate so that aggregate payments under the prospective
payment system for capital-related costs equal 90 percent of what it is
estimated would have been paid on the basis of reasonable costs. While
we did propose a reduction in the Federal rate to meet that
requirement, we did not propose a reduction in payments, as the
commenter states. In this final rule, we estimate that aggregate
payments will increase 5.32 percent despite a 0.40 percent decrease in
the Federal rate.
As for the overall decline in the Federal rate since FY 1992,
Public Law 103-66 required that, for discharges occurring after
September 30, 1993, the unadjusted standard Federal rate be reduced by
7.4 percent. Therefore, a large portion of the reduction to the Federal
rate was the result of a Congressional action. Congress took this
action on the basis of data that capital cost per case estimates used
in setting the rate were too high.
We are providing a chart that shows how each of the factors and
adjustments for FY 1995 affected the computation of the final FY 1995
Federal rate in comparison to the FY 1994 Federal rate. The FY final
1995 update factor has the effect of increasing the Federal rate 3.44
percent compared to the rate in FY 1994, while the final geographic and
DRG budget neutrality factor has the effect of decreasing the Federal
rate by 0.42 percent. The final FY 1995 exceptions reduction factor has
the effect of increasing the final Federal rate by 2.63 percent
compared to the exceptions reduction for FY 1994. The final FY 1995
budget neutrality adjustment factor has the effect of reducing the
final FY 1994 rate by 5.76 percent compared to the budget neutrality
reduction in FY 1994. The combined effect of all the changes is to
decrease the FY 1995 Federal rate by 0.40 percent compared to the
Federal rate for FY 1994.
Comparison of Factors and Adjustments: FY 1994 Federal Rate and FY 1995
Federal Rate
------------------------------------------------------------------------
Percent
Change change
------------------------------------------------------------------------
Update factor:\1\
FY 1994............................... 1.0304 ......... .........
FY 1995............................... 1.0344 1.0344 3.44
GAF/DRG adjustment factor:\1\
FY 1994............................... 1.0053 ......... .........
FY 1995............................... 0.9998 0.9998 -0.02
Outlier adjustment factor:\2\
FY 1994............................... 0.9454 ......... .........
FY 1995............................... 0.9414 0.9958 -0.42
Exceptions adjustment factor:
FY 1994\2\............................ 0.9485 ......... .........
FY 1995............................... 0.9734 1.0263 2.63
Budget neutrality adjustment factor:\2\
FY 1994............................... 0.8947 ......... .........
FY 1995............................... 0.8432 0.9424 -5.76
Federal Rate:
FY 1994............................... $378.34 ......... .........
FY 1995............................... $376.83 0.9960 -0.40
------------------------------------------------------------------------
\1\The update factor and the GAF/DRG budget neutrality factors are built
permanently into the rates. Thus, for example, the incremental change
from FY 1994 to FY 1995 resulting from the application of the 0.9998
GAF/DRG budget neutrality factor for FY 1995 is 0.9998.
\2\The outlier reduction factor, the exceptions reduction factor, and
the budget neutrality factor to assure that payments do not exceed 90
percent of what it is estimated would have been paid on the basis of
reasonable cost are not built permanently into the rates; that is,
these factors are not applied cumulatively in determining the rates.
Thus, for example, the net change resulting from the application of
the FY 1995 exceptions reduction factor is 0.9734/0.9485, or 1.0263.
We have refined our proposed budget neutrality and exceptions
reduction factors for FY 1995 on the basis of the best available data.
We have not retroactively adjusted the Federal rate for FY 1994 in
determining the rate for FY 1995.
We are also providing a chart that shows how the final FY 1995
Federal rate differs from the proposed FY 1995 Federal rate.
Comparison of Factors and Adjustments: Proposed FY 1995 Federal Rate and
Final FY 1995 Federal Rate
------------------------------------------------------------------------
Percent
Change change
------------------------------------------------------------------------
Update factor:
Proposed FY 1995........................ 1.0222 ......... .........
Final FY 1995........................... 1.0344 1.0119 1.19
GAF/DRG adjustment factor:
Proposed FY 1995........................ 1.0012 ......... .........
Final FY 1995........................... 0.9998 0.9987 -0.13
Outlier adjustment factor:
Proposed FY 1995........................ 0.9372 ......... .........
Final FY 1995........................... 0.9414 1.0045 0.45
Exceptions adjustment factor:
Proposed FY 1995........................ 0.9797 ......... .........
Final FY 1995........................... 0.9734 0.9936 -0.64
Budget neutrality adjustment factor:
Proposed FY 1995........................ 0.7986 ......... .........
Final FY 1995........................... 0.8432 1.0558 5.58
Federal Rate:
Proposed FY 1995........................ $353.87 ......... .........
Final FY 1995........................... $376.83 1.0649 6.49
------------------------------------------------------------------------
This chart shows that the major factor in the 6.49 percent increase
in the rate since the proposed rule is the 5.58 percent increase in the
budget neutrality factor. The other significant factor contributing to
the increase in the rate was the 1.19 percent increase in the update
factor.
6. Special Rate for Puerto Rico Hospitals. For FY 1994, the special
rate for Puerto Rico hospitals was $291.03. With the changes we
proposed making to the factors used to determine the rate, the proposed
FY 1995 special rate for Puerto Rico was $272.20. In this final rule,
the standard rate for Puerto Rico is $289.87.
B. Determination of Hospital-Specific Rate Update
Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 1995 be determined by adjusting the FY 1994
hospital-specific rate by the following factors:
1. Hospital-Specific Rate Update Factor. The hospital-specific rate
is updated in accordance with the update factor for the standard
Federal rate determined under Sec. 412.308(c)(1). For FY 1995, we
proposed that the hospital-specific rate be updated by a factor of
1.0222. In this final rule, we are updating the hospital- specific rate
by a factor of 1.0344.
2. Exceptions Payment Adjustment Factor. For FY 1992 through FY
2001, the updated hospital-specific rate is multiplied by an adjustment
factor to account for estimated exceptions payments for capital-related
costs under Sec. 412.348, determined as a proportion of the total
amount of payments under the hospital-specific rate and the Federal
rate. For FY 1995, we estimated in the proposed rule that exceptions
payments would be 2.03 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. We therefore proposed that
the updated hospital-specific rate be reduced by a factor of 0.9797. In
this final rule, we are applying an exceptions reduction factor of
0.9734 to the hospital-specific rate. The exceptions reductions factors
are not built permanently into the rates; that is, the factors are not
applied cumulatively in determining the hospital-specific rate. The net
adjustment to the FY 1995 hospital-specific rate is therefore .9734/
.9485, or 1.0263.
3. Budget Neutrality Adjustment Factor. For FY 1992 through FY
1995, the updated hospital-specific rate is adjusted by a budget
neutrality adjustment factor determined under Sec. 412.352, so that
estimated aggregate payments under the capital prospective payment
system will equal 90 percent of what would have been payable on a
reasonable cost basis. (The budget neutrality adjustment for changes in
the DRG relative weights and in the geographic adjustment factor is not
applied to the hospital-specific rate.) For FY 1994, the budget
neutrality adjustment was 0.8947. For FY 1995, we proposed a budget
neutrality factor of 0.7986. In this final rule, we are applying a
budget neutrality factor of 0.8432 to the hospital-specific rate. The
budget neutrality factor is not built permanently into the rates; that
is, the factor is not applied cumulatively in determining the hospital-
specific rate. The net adjustment to the FY 1995 hospital-specific rate
is therefore .8432/.8947, or 0.9424.
4. Net Change to Hospital-Specific Rate. We are providing a chart
below to show the net change to the hospital-specific rate. The chart
shows the factors for FY 1994 and FY 1995 and the net adjustment for
each factor. It also shows that the cumulative net adjustment from FY
1994 to FY 1995 is 1.0005, which represents an increase of 0.05 percent
to the hospital-specific rate, as opposed to the 5.76 percent decrease
to the hospital-specific rate in the proposed rule. The FY 1995
hospital-specific rate for each hospital is determined by multiplying
the FY 1994 hospital-specific rate by the cumulative net adjustment of
1.0005.
FY 1995 Update and Adjustments to Hospital-Specific Rates
------------------------------------------------------------------------
Net Percent
adjustment change
------------------------------------------------------------------------
Update factor:
FY 94................................ 1.0304 .......... .........
FY 95................................ 1.0344 1.0344 3.44
Exceptions payment adjustment factor:
FY 94................................ 0.9485 .......... .........
FY 95................................ 0.9734 1.0263 2.63
Budget neutrality factor:
FY 94................................ 0.8947 .......... .........
FY 95................................ 0.8432 0.9424 -5.76
Cumulative adjustments:
FY 94................................ 0.8744 .......... .........
FY 95................................ 0.8748 1.0005 0.05
------------------------------------------------------------------------
Note: The update factor for the hospital-specific rate is applied
cumulatively in determining the rates. Thus, the incremental increase
in the update factor from FY 1994 to FY 1995 is 1.0344. In contrast,
the exceptions payment adjustment factor and the budget neutrality
factor are not applied cumulatively. Thus, for example, the
incremental increase in the budget neutrality factor from FY 1994 to
FY 1995 is .8432/.8947, or .9424.
C. Calculation of Inpatient Capital-Related Prospective Payments for FY
1995
During the capital prospective payment system transition period, a
hospital is paid for the inpatient capital-related costs under one of
two alternative payment methodologies: The fully prospective payment
methodology or the hold-harmless methodology. The payment methodology
applicable to a particular hospital is determined when a hospital comes
under the prospective payment system for capital-related costs by
comparing its hospital-specific rate to the Federal rate applicable to
the hospital's first cost reporting period under the prospective
payment system. The applicable Federal rate was determined by
adjusting:
For outliers by dividing the standard Federal rate by the
outlier reduction factor for that fiscal year; and,
For the payment adjustment factors applicable to the
hospital (that is, the hospital's geographic adjustment factor, the
disproportionate share adjustment factor, and the indirect medical
education adjustment factor, when appropriate).
If the hospital-specific rate is above the applicable Federal rate,
the hospital is paid under the hold-harmless methodology. If the
hospital-specific rate is below the applicable Federal rate, the
hospital is paid under the fully prospective methodology.
For purposes of calculating payments for each discharge under both
the hold-harmless payment methodology and the fully prospective payment
methodology, the standard Federal rate is adjusted as follows:
(Standard Federal Rate) x (DRG weight) x (Geographic Adjustment
Factor) x (Large Urban Add-on, if applicable) x (COLA adjustment
for hospitals located in Alaska and Hawaii) x (1+Disproportionate
Share Adjustment Factor + Indirect Medical Education Adjustment Factor,
if applicable).
The result is termed the adjusted Federal rate.
Payments under the hold-harmless methodology are determined under
one to two formulas. A hold-harmless hospital is paid the higher of:
100 percent of the adjusted Federal rate for each
discharge; or
An old capital payment equal to 85 percent (100 percent
for sole community hospitals) of the hospital's allowable Medicare
inpatient old capital costs per discharge for the cost reporting period
plus a new capital payment based on a percentage of the adjusted
Federal rate for each discharge. The percentage of the adjusted Federal
rate equals the ratio of the hospital's allowable Medicare new capital
costs to its total Medicare inpatient capital-related costs in the cost
reporting period.
Once a hospital receives payment based on 100 percent of the
adjusted Federal rate in a cost-reporting period beginning on or after
October 1, 1994 (or the first cost reporting period after obligated
capital that is recognized as old capital under Sec. 412.302(c) is put
in use for patient care, if later), the hospital continues to receive
capital prospective payment system payments on that basis for the
remainder of the transition period.
Payment for each discharge under the fully prospective methodology
is the sum of:
The hospital-specific rate multiplied by the DRG relative
weight for the discharge and by the applicable hospital-specific
transition blend percentage for the cost reporting period; and
The adjusted Federal rate multiplied by the Federal
transition blend percentage.
The blend percentages for cost reporting periods beginning in FY
1995 or 40 percent of the adjusted Federal rate and 60 percent of the
hospital-specific rate.
Hospitals may also receive outlier payments for those cases that
qualify under the thresholds established for each fiscal year. Section
412.312(c) provides for a single set of thresholds to identify outlier
cases for both inpatient operating and inpatient capital-related
payments. Outlier payments are made only on that portion of the Federal
rate that is used to calculate the hospital's inpatient capital-related
payments. For fully prospective hospitals, that portion is 40 percent
of the Federal rate for discharges occurring in cost reporting periods
beginning during FY 1995. Thus, a fully prospective hospital will
receive 40 percent of the capital-related outlier payment calculated
for the case for discharges occurring in cost reporting periods
beginning in FY 1995. For hold-harmless hospitals paid 85 percent of
their reasonable costs for old inpatient capital, the portion of the
Federal rate that is included in the hospital's outlier payments is
based on the hospital's ratio of Medicare inpatient costs for new
capital to total Medicare inpatient capital costs. For hold-harmless
hospitals that are paid 100 percent of the Federal rate, 100 percent of
the Federal rate is included in the hospital's outlier payments.
The outlier thresholds for FY 1995 are published in section
II.A.4.c of the Addendum to this final rule. For FY 1995, a case
qualifies as a cost outlier if the cost for the case (after
standardization for the indirect teaching adjustment and
disproportionate share adjustment) is greater than the prospective
payment rate for the DRG plus $20,500. A case qualifies as a day
outlier for FY 1995 if the length of stay is greater than the geometric
mean length of stay for the DRG plus the lesser of three standard
deviations of the length of stay or 22 days.
During the capital prospective payment system transition period,
any hospital may also receive an additional payment under an exceptions
process if its total inpatient capital-related payments are less than a
minimum percentage of its allowable Medicare inpatient capital-related
costs. The minimum payment level is established by class of hospital
under Sec. 412.348. The minimum payment levels for portions of cost
reporting periods occurring in FY 1995 are:
Sole community hospitals (located in either an urban or
rural area), 90 percent;
Urban hospitals with at least 100 beds and a
disproportionate share patient percentage of at least 20.2 percent and
urban hospitals with at least 100 beds that qualify for
disproportionate share payments under Sec. 412.106(c)(2), 80 percent;
and,
All other hospitals, 70 percent. Under Sec. 412.348(d),
the amount of the exceptions payment is determined by comparing the
cumulative payments made to the hospital under the capital prospective
payment system to the cumulative minimum payment levels applicable to
the hospital for each cost reporting period subject to that system. Any
amount by which the hospital's cumulative payments exceed its
cumulative minimum payment is deducted from the additional payment that
would otherwise be payable for a cost reporting period.
New hospitals are exempted from the capital prospective payment
system for their first 2 years of operation and are paid 85 percent of
their reasonable costs during that period. A new hospital's old capital
costs are its allowable costs for capital assets that were put in use
for patient care on or before the later of December 31, 1990 or the
last day of the hospital's base year cost reporting period, and are
subject to the rules pertaining to old capital and obligated capital as
of the applicable date. Effective with the third year of operation, we
will pay the hospital under either the fully prospective methodology,
using the appropriate transition blend in that Federal fiscal year, or
the hold-harmless methodology. If the hold-harmless methodology is
applicable, the hold-harmless payment for assets in use during the base
period would extend for 8 years, even if the hold-harmless payments
extend beyond the normal transition period.
IV. Changes for Excluded Hospitals and Units
A. Rate-of-Increase Percentages for Excluded Hospitals and Units
The inpatient operating costs of hospitals and hospital units
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of
the Act, which is implemented in Sec. 413.40 of the regulations. Under
these limits, an annual target amount (expressed in terms of the
inpatient operating cost per discharge) is set for each hospital, based
on the hospital's own historical cost experience trended forward by the
applicable rate-of-increase percentages (update factors). The target
amount is multiplied by the number of Medicare discharges in a
hospital's cost reporting period, yielding the ceiling on aggregate
Medicare inpatient operating costs for the cost reporting period.
Effective with cost reporting periods beginning on or after October
1, 1991, a hospital that has Medicare inpatient operating costs in
excess of its ceiling is paid its ceiling plus 50 percent of its costs
in excess of the ceiling. Total payment may not exceed 110 percent of
the ceiling. A hospital that has inpatient operating costs less than
its ceiling will continue to be paid its costs plus the lower of--
Fifty percent of the difference between the allowable
inpatient operating costs and the ceiling; or
Five percent of the ceiling.
Each hospital's target amount is adjusted annually, at the
beginning of its cost reporting period, by an applicable rate-of-
increase percentage. Section 13502 of Public Law 103-66 amended section
1886(b)(3)(B) of the Act to provide that for cost reporting periods
beginning on or after October 1, 1993 and before October 1, 1994, the
applicable rate-of-increase percentage is the market basket percentage
increase minus the lesser of one percentage point, or the percentage
point difference between 10 percent and the hospital's ``update
adjustment percentage'' except for hospitals with an ``update
adjustment percentage'' of at least 10 percent. The rate-of-increase
percentage for hospitals in the latter case will be the market basket
percentage increase. The ``update adjustment percentage'' is the
percentage by which a hospital's allowable inpatient operating costs
exceeds the hospital's ceiling for the cost reporting period beginning
in Federal fiscal year 1990. For cost reporting periods beginning on or
after October 1, 1994 and before October 1, 1997, the update adjustment
percentage is the update adjustment percentage from the previous year
plus the previous year's applicable reduction. The applicable reduction
and applicable rate of increase percentage are then determined in the
same manner as for FY 1994. The most recent forecasted market basket
increase for FY 1995 for hospitals and hospital units excluded from the
prospective payment system is 3.7 percent.
B. Wage Index Exceptions for Excluded Hospitals and Units
In the August 30, 1991 final rule (56 FR 43232), we set forth our
policy for target amount adjustments for significant wage increases.
Effective with cost reporting periods beginning on or after April 1,
1990, significant increases in wages since the base period are
recognized as a basis for an adjustment in the target amount under
Sec. 413.40(g).
To qualify for an adjustment, the excluded hospital or hospital
unit must be located in a labor market area for which the average
hourly wage increased significantly more than the national average
hourly wage between the hospital's base period and the period subject
to the ceiling. We use the hospital wage index for prospective payment
hospitals to determine the rate of increase in the average hourly wage
in the labor market area. For a hospital to qualify for an adjustment,
the wage index value for the cost reporting period subject to the
ceiling must be at least 8 percent higher than the wage index based on
wage survey data collected for the base year cost reporting period. If
survey data are not available for one (or both) of the cost reporting
periods used in the comparison, the wage index based on the latest
available survey data collected prior to that cost reporting period
will be used. For example, to make the comparison between a 1983 base
period and a hospital's cost reporting period beginning in FY 1992, we
would use the rate of increase between the wage index based on 1982
wage data and the wage index based on the FY 1991 data, since the FY
1991 data are the most recent data that are currently available.
Further, the comparison is made without regard to geographic
reclassifications made by the MGCRB under sections 1886(d)(8) and (10)
of the Act. Therefore, the comparison is made based on the wage index
value of the labor market area in which the hospital is actually
located.
We determine the amount of the adjustment for wage increases by
considering three factors for the time between the base period and the
period for which an adjustment is requested: the rate of increase in
the hospital's average hourly wage; the rate of increase in the average
hourly wage in the labor market area in which the hospital is located;
and, the rate of increase in the national average hourly wage for
hospital workers. The adjustment is limited to the amount by which the
lower of the hospital's or the labor market area's rate of increase in
average hourly wages significantly exceeds the national increase (that
is, exceeds the national rate of increase by more than 8 percent). For
purposes of computing the adjustment, the relative rate of increase in
the average hourly wage for the labor market area is assumed to have
been the same over each of the intervening years between the wage
surveys.
To determine the rate of increase in the national average hourly
wage, we use the average hourly earnings (AHE) component of the wages
and salaries portion of the market basket. This measure is derived from
the 1982-based market basket since the 1987-based market basket uses
the employment cost index (ECI) for hospital workers as the price proxy
for this component. Unlike the AHE, the ECI for hospital workers can be
measured historically only back to 1986. In addition, the ECI does not
adjust for skill-mix shifts and, therefore, measures only the change in
wage rates per hour.
The average hourly earnings for hospital workers as measured by the
market basket show the following increases:
1992=4.8 percent
1993=3.7 percent
1994=2.8 percent
1995=3.4 percent
1996=4.3 percent
We note that this section merely provides updated information with
respect to areas that would qualify for the wage index adjustment under
Sec. 413.30(g). This information was calculated in accordance with
established policy and does not reflect any change in that policy. The
geographic areas in which the percentage difference in wage indexes was
sufficient to qualify for a wage index adjustment are listed in Table
10 of section V of the addendum to this final rule. The table is
constructed with old MSAs instead of the revised MSAs effective October
1, 1993 because current adjustment requests are for years prior to FY
1995.
V. Tables
This section contains the tables referred to throughout the
preamble to this final rule and in this addendum. For purposes of this
final rule, and to avoid confusion, we have retained the designations
of Tables 1 through 5 that were first used in the September 1, 1983
initial prospective payment final rule (48 FR 39844). Tables 1a, 1b,
1c, 1d, 3C, 4a, 4b, 4c, 4d, 4e, 5, 6a, 6b, 6c, 6d, 6e, 6f, 6g, 7A, 7B,
8a, 8b, 9 and 10 are presented below. The tables presented below are as
follows:
Table 1a--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1b--Regional Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1c--Adjusted Operating Standardized Amounts for Puerto Rico,
Labor/Nonlabor
Table 1d--Capital Standard Federal Payment Rate
Table 3C--Hospital Case Mix Indexes for Discharges Occurring in Federal
Fiscal Year 1993 and Hospital Average Hourly Wage for Federal Fiscal
Year 1995 Wage Index
Table 4a--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
Table 4b--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
Table 4c--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That Are Reclassified
Table 4d--Average Hourly Wage for Urban Areas
Table 4e--Average Hourly Wage for Rural Areas
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric Mean Length of Stay, and Length of Stay Outlier
Cutoff Points Used in the Prospective Payment System
Table 6a--New Diagnosis Codes
Table 6b--New Procedure Codes
Table 6c--Invalid Diagnosis Codes
Table 6d--Revised Diagnosis Code Titles
Table 6e--Revised Procedure Code Titles
Table 6f--Additions to the CC Exclusions List
Table 6g--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 93 MEDPAR Update 6/94 GROUPER V11.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 93 MEDPAR Update 6/94 GROUPER V12.0
Table 8a--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) April 1994
Table 8b--Statewide Average Capital Cost-to-Charge Ratios for Urban and
Rural Hospitals (Case Weighted) April 1994
Table 9--1993 Transfer Adjusted Case-Mix Index and Transfer Adjustment
to Discharges for Capital Hospital-Specific Rate Redeterminations
Table 10--Percentage Difference in Wage Indexes for Areas That Qualify
for a Wage Index Exception for Excluded Hospitals and Units
Table 1a.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Nonlabor- Labor- Nonlabor-
Labor-related related related related
------------------------------------------------------------------------
$2,709.42........................ $1,085.29 $2,666.52 $1,068.10
------------------------------------------------------------------------
Table 1b.--Regional Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other urban areas
-----------------------------------------------
Labor- Nonlabor- Labor- Nonlabor-
related related related related
------------------------------------------------------------------------
1. New England (CT, ME,
MA, NH, RI, VT)........ $2,840.62 $1,137.84 $2,795.63 $1,119.82
2. Middle Atlantic (PA,
NJ, NY)................ 2,592.46 1,038.44 2,551.42 1,022.00
3. South Atlantic (DE,
DC, FL, GA, MD, NC, SC,
VA, WV)................ 2,654.29 1,063.21 2,612.28 1,046.38
4. East North Central
(IL, IN, MI, OH, WI)... 2,892.31 1,158.55 2,846.52 1,140.20
5. East South Central
(AL, KY, MS, TN)....... 2,508.24 1,004.71 2,468.53 988.80
6. West North Central
(IA, KS, MN, MO, NE,
ND, SD)................ 2,711.20 1,085.99 2,668.26 1,068.80
7. West South Central
(AR, LA, OK, TX)....... 2,638.83 1,057.01 2,597.06 1,040.27
8. Mountain (AZ, CO, ID,
MT, NV, NM, UT, WY).... 2,621.88 1,050.22 2,580.37 1,033.59
9. Pacific (AK, CA, HI,
OR, WA)................ 2,680.57 1,073.72 2,638.13 1,056.73
------------------------------------------------------------------------
Table 1c.--Adjusted Operating Standardized Amounts for Puerto Rico,
Labor/Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
-----------------------------------------------
Labor- Nonlabor- Labor- Nonlabor-
related related related related
------------------------------------------------------------------------
National................ $2,682.96 $1,074.69 $2,682.96 1,074.69
Puerto Rico............. 2,416.27 503.53 2,378.02 495.56
------------------------------------------------------------------------
Table 1d.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National..................................................... $376.83
Puerto Rico.................................................. 289.87
------------------------------------------------------------------------
Table 3c.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1993; Hospital Average Hourly Wage for Federal Fiscal Year 1995 Wage Index
Page 1 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
010001............ 01.3442 15.05 010095............ 01.0795 09.76 020027............ 00.9878 ....... 030095............ 01.1917 ....... 040091............ 01.3720 19.00
010004............ 01.0487 10.14 010096............ 01.0307 ....... 030001............ 01.3699 18.78 040001............ 01.1281 11.01 040093............ 00.9699 10.69
010005............ 01.1176 13.17 010097............ 00.9084 11.13 030002............ 01.7746 19.83 040002............ 01.1992 13.30 040095............ 00.8490 10.35
010006............ 01.3877 13.78 010098............ 00.9527 12.29 030003............ 01.3832 19.56 040003............ 00.9791 12.33 040100............ 01.1199 12.90
010007............ 01.0801 11.93 010099............ 01.0409 11.87 030004............ 01.0299 11.84 040004............ 01.2828 13.41 040105............ 01.0224 11.67
010008............ 00.9889 09.72 010100............ 01.2265 13.10 030006............ 01.5786 16.65 040005............ 00.9403 10.85 040106............ 01.1860 09.69
010009............ 01.0719 14.87 010101............ 01.0924 13.51 030007............ 01.2290 14.86 040007............ 01.6632 16.45 040107............ 01.1690 15.19
010010............ 01.1136 11.37 010102............ 00.8912 11.19 030008............ 01.9726 19.55 040008............ 01.0916 10.26 040109............ 01.0815 12.01
010011............ 01.4690 17.34 010103............ 01.6306 14.92 030009............ 01.2212 14.70 040010............ 01.2155 12.51 040114............ 01.7801 15.12
010012............ 01.3013 13.75 010104............ 01.5986 15.37 030010............ 01.3714 17.87 040011............ 00.9928 10.69 040116............ 01.3712 17.33
010015............ 01.0329 12.67 010108............ 01.2436 12.94 030011............ 01.4628 18.72 040013............ 00.9538 10.97 040118............ 01.1420 12.62
010016............ 01.1882 12.69 010109............ 01.0737 12.62 030012............ 01.2287 15.25 040014............ 01.2059 14.37 040119............ 01.1531 12.60
010018............ 00.8766 14.94 010110............ 00.9976 10.56 030013............ 01.2275 16.12 040015............ 01.1102 11.30 040124............ 01.2008 12.65
010019............ 01.2446 12.48 010112............ 01.1606 12.89 030014............ 01.4712 18.10 040016............ 01.6978 14.44 040126............ 00.9931 10.09
010021............ 01.2841 13.82 010113............ 01.6227 12.67 030016............ 01.3398 21.17 040017............ 01.3329 11.19 040132............ 00.9040 11.45
010022............ 00.9852 14.35 010114............ 01.2586 14.30 030017............ 01.4213 16.52 040018............ 01.2816 15.40 050002............ 01.3599 24.36
010023............ 01.3996 14.63 010115............ 00.8731 13.94 030018............ 01.7379 19.49 040019............ 01.1973 11.70 050006............ 01.3569 18.76
010024............ 01.3249 14.19 010117............ 00.9039 17.92 030019............ 01.2374 19.51 040020............ 01.4992 12.86 050007............ 01.5315 24.12
010025............ 01.2163 11.22 010118............ 01.2144 14.55 030022............ 01.4990 17.29 040021............ 01.2777 13.19 050008............ 01.5683 24.13
010027............ 00.8697 12.83 010119............ 01.1022 14.41 030023............ 01.2779 15.17 040022............ 01.8439 12.85 050009............ 01.5121 22.22
010029............ 01.4519 13.86 010120............ 00.9922 13.31 030024............ 01.6768 18.15 040024............ 01.0193 10.84 050013............ 01.9683 21.58
010031............ 01.2731 12.35 010121............ 01.1798 12.93 030025............ 01.1273 13.58 040025............ 00.9299 10.28 050014............ 01.0992 19.15
010032............ 00.9123 13.01 010122............ 00.8442 ....... 030027............ 01.1398 14.27 040026............ 01.5777 14.46 050015............ 01.3294 20.74
010033............ 01.9003 17.10 010123............ 01.2698 15.56 030030............ 01.6884 21.32 040027............ 01.3022 12.52 050016............ 01.1475 19.69
010034............ 01.0490 12.98 010124............ 01.2786 14.78 030033............ 01.2464 14.70 040028............ 01.0200 08.78 050017............ 02.0513 22.70
010035............ 01.1935 13.35 010125............ 01.0379 11.83 030034............ 01.1126 15.82 040029............ 01.1562 12.86 050018............ 01.3054 16.74
010036............ 01.1318 14.33 010126............ 01.0647 11.19 030035............ 01.2953 18.75 040030............ 00.9105 11.23 050019............ 00.8715 ......
010038............ 01.2377 14.62 010127............ 01.5497 15.59 030036............ 01.1799 17.67 040031............ 00.7835 10.74 050021............ 01.3033 20.12
010039............ 01.6341 14.65 010128............ 00.9501 11.41 030037............ 01.9356 20.11 040032............ 00.9923 09.75 050022............ 01.4793 21.23
010040............ 01.4331 16.04 010129............ 01.0839 10.44 030038............ 01.5349 18.27 040035............ 00.9432 09.29 050024............ 01.4202 22.43
010043............ 01.0160 12.49 010130............ 01.0853 13.73 030040............ 01.0462 16.22 040036............ 01.3635 14.75 050025............ 01.6421 21.40
010044............ 01.0348 14.66 010131............ 01.2386 16.21 030041............ 00.9318 16.66 040037............ 01.1669 10.55 050026............ 01.4946 20.53
010045............ 01.1137 11.53 010134............ 00.8782 10.46 030043............ 01.1886 19.23 040039............ 01.2310 11.05 050028............ 01.3231 15.49
010046............ 01.3961 12.45 010136............ 00.9052 13.02 030044............ 01.0476 13.44 040040............ 01.1237 14.85 050029............ 01.2641 24.70
010047............ 00.9961 08.62 010137............ 01.2852 14.66 030046............ 00.9869 17.75 040041............ 01.3496 12.90 050030............ 01.3478 17.25
010049............ 01.0940 13.92 010138............ 00.9632 11.08 030047............ 00.9416 16.97 040042............ 01.2528 12.86 050032............ 01.2633 20.61
010050............ 00.9552 10.19 010139............ 01.6336 19.91 030049............ 00.9762 14.22 040044............ 00.9057 09.86 050033............ 01.4526 24.20
010051............ 00.9138 07.25 010143............ 01.1697 14.49 030054............ 00.8935 12.19 040045............ 01.0376 13.11 050036............ 01.7666 21.61
010052............ 00.9459 12.78 010144............ 01.3177 15.51 030055............ 01.2529 15.39 040047............ 00.9968 13.53 050038............ 01.4599 27.19
010053............ 01.0626 12.36 010145............ 01.2434 16.15 030059............ 01.3055 18.17 040048............ 01.2032 12.62 050039............ 01.6355 20.21
010054............ 01.1953 14.52 010146............ 01.1189 15.02 030060............ 01.0566 13.68 040050............ 01.1328 10.29 050040............ 01.2599 22.53
010055............ 01.3849 14.09 010148............ 00.9529 11.17 030061............ 01.5825 15.57 040051............ 01.0572 11.86 050041............ 01.2850 21.60
010056............ 01.3838 16.34 010149............ 01.4278 15.65 030062............ 01.3479 14.98 040053............ 01.1474 12.16 050042............ 01.2659 17.98
010058............ 01.0082 07.49 010150............ 01.0415 13.50 030064............ 01.5514 16.64 040054............ 01.0580 10.02 050043............ 01.5036 25.84
010059............ 01.0573 13.64 010152............ 01.3663 14.13 030065............ 01.5217 18.30 040055............ 01.3727 14.19 050045............ 01.2478 17.59
010061............ 01.0061 14.30 010153............ 02.6152 18.16 030067............ 01.0966 14.05 040058............ 01.1501 12.39 050046............ 01.1631 21.80
010062............ 00.9862 10.43 010155............ 00.9962 09.32 030068............ 00.9652 13.73 040060............ 00.9518 12.62 050047............ 01.7720 27.86
010064............ 01.8517 14.55 020001............ 01.4507 24.33 030069............ 01.3114 18.16 040062............ 01.5168 14.54 050051............ 01.1122 15.76
010065............ 01.4385 13.58 020002............ 00.9558 23.02 030071............ 00.8850 ....... 040063............ 01.5633 14.49 050052............ 01.8867 ......
010066............ 00.9149 08.90 020004............ 01.0660 23.25 030072............ 00.8597 ....... 040064............ 00.8951 09.17 050054............ 01.2695 19.42
010068............ 01.2877 17.41 020005............ 00.8704 22.74 030073............ 01.1453 ....... 040066............ 01.1042 12.97 050055............ 01.2753 24.47
010069............ 01.1427 12.42 020006............ 01.0780 22.50 030074............ 01.0022 ....... 040067............ 01.0697 10.71 050056............ 01.4260 21.51
010072............ 01.1757 11.43 020007............ 00.8969 18.20 030075............ 00.9370 ....... 040069............ 01.0133 11.34 050057............ 01.4685 18.64
010073............ 00.9111 08.91 020008............ 01.0533 25.53 030076............ 00.9436 ....... 040070............ 00.9906 10.66 050058............ 01.4153 21.51
010078............ 01.2300 14.44 020009............ 01.0441 19.58 030077............ 00.9796 ....... 040071............ 01.3836 15.71 050060............ 01.4793 17.85
010079............ 01.1397 13.10 020010............ 01.0273 26.51 030078............ 01.0876 ....... 040072............ 01.1038 13.20 050061............ 01.2803 19.57
010080............ 00.9877 11.70 020011............ 01.0005 21.11 030079............ 00.6249 ....... 040074............ 01.2103 13.36 050063............ 01.3995 19.94
010081............ 01.8414 16.28 020012............ 01.2962 22.42 030080............ 01.6470 18.80 040075............ 01.1241 10.83 050065............ 01.5226 22.66
010083............ 01.0473 15.00 020013............ 01.0087 28.18 030083............ 01.2863 19.53 040076............ 01.0883 12.49 050066............ 01.2416 22.96
010084............ 01.3966 16.55 020014............ 01.0943 24.09 030084............ 01.1358 ....... 040077............ 00.9164 09.81 050067............ 01.3641 21.76
010085............ 01.2000 14.98 020017............ 01.3855 23.44 030085............ 01.4462 17.81 040078............ 01.2703 14.53 050068............ 01.0990 16.87
010086............ 01.0091 11.41 020018............ 00.9915 ....... 030086............ 01.1453 17.91 040080............ 01.0472 14.19 050069............ 01.6099 22.39
010087............ 01.8168 14.94 020019............ 00.8136 ....... 030087............ 01.6386 16.84 040081............ 00.8861 09.28 050070............ 01.2333 27.81
010089............ 01.1454 14.71 020020............ 00.8059 ....... 030088............ 01.3584 17.48 040082............ 01.2292 13.01 050071............ 01.2930 27.45
010090............ 01.5670 15.24 020021............ 00.8018 ....... 030089............ 01.4014 17.92 040084............ 01.0813 14.12 050072............ 01.3285 27.78
010091............ 00.9593 11.17 020024............ 01.1141 21.11 030092............ 01.4750 16.73 040085............ 01.2332 13.61 050073............ 01.2469 27.89
010092............ 01.3576 14.56 020025............ 00.9507 21.76 030093............ 01.3592 17.22 040088............ 01.3066 13.30 050074............ 01.1070 26.44
010094............ 01.1695 16.12 020026............ 01.3131 ....... 030094............ 01.2928 17.50 040090............ 00.9106 11.44 050075............ 01.3692 27.54
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Page 2 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050076............ 01.5776 28.16 050170............ 01.4521 20.26 050277............ 01.4532 21.98 050390............ 01.3119 20.96 050502............ 01.6487 21.81
050077............ 01.5930 21.33 050172............ 01.3210 19.50 050278............ 01.4107 20.59 050391............ 01.3476 18.94 050503............ 01.2835 21.76
050078............ 01.3470 22.80 050173............ 01.2847 21.21 050279............ 01.2274 18.52 050392............ 00.9931 14.75 050506............ 01.4420 24.55
050079............ 01.4682 29.24 050174............ 01.6642 25.19 050280............ 01.5553 20.61 050393............ 01.4125 22.60 050510............ 01.3252 27.75
050080............ 01.3034 23.23 050175............ 01.3383 22.08 050281............ 01.4131 19.38 050394............ 01.4869 19.55 050512............ 01.3107 28.18
050081............ 01.6246 20.20 050177............ 01.2267 17.98 050282............ 01.3133 21.41 050396............ 01.5501 22.84 050515............ 01.2995 28.20
050082............ 01.5054 22.06 050179............ 01.2476 17.01 050283............ 01.2397 25.87 050397............ 01.0645 18.46 050516............ 01.6464 22.49
050084............ 01.5680 20.91 050180............ 01.5080 28.43 050286............ 00.9279 18.66 050401............ 01.2104 16.24 050517............ 01.2745 19.39
050088............ 01.1145 22.27 050181............ 01.2415 ....... 050289............ 01.7627 25.03 050404............ 01.2039 15.52 050522............ 01.3938 26.52
050089............ 01.3872 17.98 050183............ 01.1897 18.72 050290............ 01.6142 24.11 050406............ 01.1165 14.52 050523............ 01.2318 24.38
050090............ 01.2813 20.35 050186............ 01.5127 22.72 050291............ 01.2160 23.08 050407............ 01.2695 23.69 050526............ 01.3671 23.21
050091............ 01.2017 24.16 050188............ 01.4071 24.07 050292............ 01.0735 20.59 050410............ 01.0177 24.20 050528............ 01.2370 15.19
050092............ 00.9137 17.43 050189............ 00.9795 22.42 050293............ 01.1061 19.45 050411............ 01.3103 27.43 050531............ 01.3607 20.08
050093............ 01.5357 19.94 050191............ 01.4420 22.19 050295............ 01.4509 19.24 050414............ 01.2934 23.33 050534............ 01.4946 22.69
050095............ 01.2160 27.91 050192............ 01.2147 17.92 050296............ 01.2147 23.31 050417............ 01.2306 20.44 050535............ 01.3500 22.44
050096............ 01.2440 20.89 050193............ 01.3646 20.72 050298............ 01.1859 18.06 050418............ 01.3333 22.55 050537............ 01.3186 20.44
050097............ 01.4662 16.38 050194............ 01.2188 23.01 050299............ 01.2983 22.08 050419............ 01.3452 16.62 050539............ 01.1746 21.36
050099............ 01.5708 21.78 050195............ 01.5851 28.28 050300............ 01.2986 17.35 050420............ 01.4434 21.82 050541............ 01.5384 27.82
050100............ 01.8030 23.83 050196............ 01.3440 17.36 050301............ 01.3566 19.83 050421............ 01.4219 22.42 050542............ 01.1215 13.71
050101............ 01.3963 22.78 050197............ 01.9400 25.14 050302............ 01.3663 23.01 050423............ 00.9846 16.65 050543............ 00.9021 21.03
050102............ 01.3789 19.71 050199............ 01.3116 18.65 050305............ 01.5671 27.33 050424............ 01.7237 21.45 050545............ 00.8660 20.90
050103............ 01.6468 19.35 050204............ 01.3606 21.05 050307............ 01.4322 18.55 050425............ 01.2778 27.22 050546............ 00.8558 21.22
050104............ 01.3977 20.54 050205............ 01.3899 17.92 050308............ 01.5293 30.29 050426............ 01.3348 22.74 050547............ 00.9794 22.15
050107............ 01.2990 19.86 050207............ 01.2836 18.15 050309............ 01.3540 22.97 050427............ 00.8394 22.94 050549............ 01.7505 24.00
050108............ 01.4855 22.51 050208............ 01.2846 23.14 050310............ 01.2492 19.13 050430............ 01.0333 14.73 050550............ 02.3726 21.19
050109............ 02.1062 23.09 050211............ 01.3040 26.33 050312............ 01.8368 21.49 050431............ 01.1447 21.80 050551............ 01.3671 22.74
050110............ 01.2281 17.08 050213............ 01.3469 18.97 050313............ 01.1901 20.49 050432............ 01.5721 22.46 050552............ 01.2496 19.17
050111............ 01.3370 18.50 050214............ 01.5529 20.85 050315............ 01.3152 20.06 050433............ 01.2059 13.93 050557............ 01.6026 20.11
050112............ 01.4534 22.04 050215............ 01.5408 24.70 050317............ 01.2514 22.00 050434............ 01.0838 18.98 050559............ 01.3589 23.50
050113............ 01.1366 26.39 050217............ 01.2468 15.90 050320............ 01.3667 27.40 050435............ 01.2227 16.54 050560............ 01.4455 22.18
050114............ 01.4076 27.65 050219............ 01.3061 19.43 050324............ 01.8356 22.28 050436............ 01.0234 15.88 050561............ 01.1557 27.90
050115............ 01.5730 20.93 050220............ 01.6373 18.06 050325............ 01.2801 20.26 050438............ 01.5716 22.52 050564............ 01.2890 26.82
050116............ 01.4942 21.77 050222............ 01.5396 19.26 050327............ 01.5964 20.30 050440............ 01.3087 17.95 050565............ 01.2111 19.30
050117............ 01.2910 18.00 050224............ 01.5765 20.63 050328............ 01.4340 25.87 050441............ 01.8342 25.65 050566............ 00.9535 15.29
050118............ 01.2118 22.47 050225............ 01.3925 19.07 050329............ 01.2255 20.16 050443............ 00.9414 11.92 050567............ 01.6064 20.07
050121............ 01.4266 18.50 050226............ 01.3679 19.25 050331............ 01.3796 28.94 050444............ 01.2679 19.12 050568............ 01.3186 19.87
050122............ 01.5397 22.28 050228............ 01.3688 28.38 050333............ 00.9543 17.59 050446............ 00.9065 17.49 050569............ 01.2307 21.62
050124............ 01.1945 22.67 050230............ 01.3926 23.56 050334............ 01.5594 27.46 050447............ 01.0648 19.33 050570............ 01.7251 24.72
050125............ 01.3539 23.19 050231............ 01.4909 21.30 050335............ 01.2475 18.97 050448............ 01.1669 21.09 050571............ 01.4621 22.91
050126............ 01.3932 22.84 050232............ 01.8392 24.76 050336............ 01.3209 18.34 050449............ 01.3206 20.39 050573............ 01.6799 23.79
050127............ 01.3040 22.13 050233............ 01.2560 26.78 050337............ 01.3957 24.13 050451............ 00.8860 16.91 050575............ 01.2474 21.28
050128............ 01.5366 20.09 050234............ 01.2776 18.69 050342............ 01.4356 15.53 050454............ 01.8386 24.99 050577............ 01.2369 20.65
050129............ 01.4989 20.29 050235............ 01.4845 24.01 050343............ 01.0621 15.51 050455............ 01.8514 21.40 050578............ 01.3849 23.24
050131............ 01.2653 23.99 050236............ 01.5310 22.42 050345............ 01.4979 19.74 050456............ 01.3067 22.43 050579............ 01.3958 24.99
050132............ 01.3951 21.23 050238............ 01.5006 23.50 050348............ 01.5499 24.59 050457............ 01.9263 27.09 050580............ 01.4041 21.12
050133............ 01.3153 19.07 050239............ 01.4937 21.81 050349............ 00.9544 14.35 050458............ 00.8655 22.37 050581............ 01.4769 23.13
050135............ 01.2053 24.37 050240............ 01.4862 25.19 050350............ 01.3974 22.44 050459............ 01.2453 29.05 050583............ 01.6869 21.15
050136............ 01.3889 21.51 050241............ 01.3090 27.24 050351............ 01.5032 26.10 050464............ 01.8760 22.66 050584............ 01.3054 21.70
050137............ 01.2685 28.56 050242............ 01.3945 25.47 050352............ 01.3369 21.27 050468............ 01.4202 13.23 050585............ 01.3352 25.78
050138............ 01.7804 29.95 050243............ 01.5383 21.44 050353............ 01.5303 21.82 050469............ 01.1137 17.38 050586............ 01.3266 22.31
050139............ 01.3319 28.23 050245............ 01.4438 23.48 050355............ 00.9418 16.56 050470............ 01.1269 16.91 050587............ 01.2924 19.72
050140............ 01.3389 28.60 050248............ 01.1319 22.92 050357............ 01.9564 21.24 050471............ 01.7713 23.28 050588............ 01.2579 26.65
050144............ 01.5704 21.85 050251............ 01.0990 15.38 050359............ 01.0659 18.20 050476............ 01.2763 17.98 050589............ 01.3272 23.05
050145............ 01.3500 24.11 050253............ 00.9026 17.17 050360............ 01.4472 27.20 050477............ 01.4095 24.42 050590............ 01.2896 20.88
050146............ 01.3122 ....... 050254............ 01.1845 18.88 050363............ 02.1935 ....... 050478............ 01.0136 20.41 050591............ 01.2187 19.81
050147............ 00.6839 16.46 050256............ 01.7794 20.44 050366............ 01.3048 18.50 050481............ 01.4398 23.28 050592............ 01.2434 19.32
050148............ 01.0998 14.81 050257............ 01.0771 15.23 050367............ 01.2720 24.59 050482............ 00.9592 14.95 050593............ 01.4479 24.80
050149............ 01.3528 21.03 050258............ 01.3430 24.73 050369............ 01.2920 22.10 050483............ 01.1747 19.39 050594............ 02.0951 22.24
050150............ 01.2998 21.08 050260............ 00.9806 18.54 050373............ 01.3093 22.31 050485............ 01.6350 21.08 050597............ 01.2757 22.04
050152............ 01.3982 24.04 050261............ 01.1832 16.58 050376............ 01.3922 23.30 050486............ 01.3920 22.96 050598............ 01.4694 27.45
050153............ 01.6323 26.54 050262............ 01.7839 24.23 050377............ 00.8663 13.19 050488............ 01.3350 24.20 050599............ 01.6475 21.12
050154............ 01.3034 24.75 050263............ 01.3142 23.85 050378............ 01.0663 24.65 050489............ 01.0532 23.76 050601............ 01.3037 27.93
050155............ 01.1483 22.21 050264............ 01.4298 25.01 050379............ 01.1521 16.12 050491............ 01.3653 22.42 050603............ 01.4440 20.02
050158............ 01.5304 27.04 050267............ 01.5606 23.58 050380............ 01.6401 25.01 050492............ 01.1869 19.34 050604............ 01.4176 26.67
050159............ 01.3400 18.86 050270............ 01.3549 21.83 050382............ 01.4205 21.08 050494............ 01.0785 21.35 050607............ 01.2392 19.43
050167............ 01.3883 20.29 050272............ 01.3900 17.78 050385............ 01.3911 23.35 050496............ 01.7895 27.22 050608............ 01.1508 16.21
050168............ 01.5795 22.94 050274............ 01.1350 20.00 050387............ 00.9095 12.76 050497............ 00.9428 11.97 050609............ 01.3274 29.05
050169............ 01.5338 22.37 050276............ 01.2436 25.76 050388............ 00.8618 15.42 050498............ 01.3050 20.50 050613............ 01.0186 22.54
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Page 3 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050615............ 01.4446 21.07 060016............ 01.1675 10.83 070017............ 01.3674 22.45 100043............ 01.4152 19.25 100128............ 02.1689 18.89
050616............ 01.2691 20.04 060018............ 01.2497 14.35 070018............ 01.3498 25.96 100044............ 01.4413 17.72 100129............ 01.3602 17.02
050618............ 01.2205 15.89 060020............ 01.5142 14.61 070019............ 01.2567 21.49 100045............ 01.4554 14.39 100130............ 01.1726 17.79
050619............ 01.3454 19.03 060022............ 01.6484 17.08 070020............ 01.4074 22.22 100046............ 01.3482 16.46 100131............ 01.3011 18.69
050622............ 01.2594 21.36 060023............ 01.4622 16.23 070021............ 01.1805 22.73 100047............ 01.7883 17.88 100132............ 01.4788 14.76
050623............ 01.2563 21.16 060024............ 01.6640 22.87 070022............ 01.6437 22.82 100048............ 00.9927 11.41 100135............ 01.5000 14.95
050624............ 01.2605 23.39 060026............ 01.4335 18.36 070023............ 01.2106 20.41 100049............ 01.2748 16.51 100137............ 01.2387 15.05
050625............ 01.5236 22.82 060027............ 01.4674 18.10 070024............ 01.3163 20.12 100050............ 01.1771 14.96 100138............ 00.9841 10.25
050630............ 01.2823 23.63 060028............ 01.4158 18.91 070025............ 01.6942 22.92 100051............ 01.2647 15.10 100139............ 01.0428 16.00
050633............ 01.3236 20.93 060029............ 00.9748 13.15 070026............ 01.1741 22.90 100052............ 01.4138 14.18 100140............ 01.1929 16.26
050635............ 01.3019 27.91 060030............ 01.3480 16.98 070027............ 01.2085 22.98 100053............ 01.3034 17.73 100142............ 01.1733 15.12
050636............ 01.3894 21.83 060031............ 01.5082 16.61 070028............ 01.4692 21.94 100054............ 01.3318 16.83 100143............ 02.0565 ......
050637............ 01.1270 21.41 060032............ 01.4296 19.33 070029............ 01.2270 19.29 100055............ 01.3834 15.81 100144............ 01.3439 12.10
050638............ 00.9629 24.33 060033............ 01.0703 11.58 070030............ 01.2073 22.70 100056............ 01.4688 21.01 100145............ 01.3697 13.57
050641............ 01.1681 12.65 060034............ 01.4752 17.73 070031............ 01.2867 18.49 100057............ 01.3219 15.19 100146............ 01.1272 15.35
050643............ 00.9472 ....... 060036............ 01.1796 13.52 070033............ 01.2692 22.64 100059............ 01.6344 16.57 100147............ 01.1204 12.08
050644............ 00.9873 21.63 060037............ 01.0028 12.14 070034............ 01.3310 23.40 100060............ 01.6863 17.02 100150............ 01.3132 15.58
050660............ 01.1327 ....... 060038............ 01.0135 11.55 070035............ 01.3544 21.55 100061............ 01.5765 20.45 100151............ 01.8136 17.59
050661............ 00.9004 17.84 060041............ 00.9717 12.34 070036............ 01.2987 25.17 100062............ 01.7336 15.56 100154............ 01.6023 16.55
050662............ 00.8235 20.98 060042............ 00.9336 13.29 080001............ 01.6109 20.42 100063............ 01.2711 14.64 100156............ 01.1634 17.85
050663............ 01.1100 20.81 060043............ 01.0267 10.83 080002............ 01.2228 15.45 100067............ 01.4248 15.63 100157............ 01.5938 17.06
050666............ 00.9589 23.34 060044............ 01.2595 14.53 080003............ 01.3183 18.22 100068............ 01.4430 15.32 100159............ 01.0448 15.59
050667............ 01.0549 23.63 060046............ 01.0830 14.51 080004............ 01.3342 16.62 100069............ 01.3356 15.97 100160............ 01.2094 16.10
050668............ 01.1445 23.59 060047............ 00.9097 12.30 080005............ 01.3846 15.58 100070............ 01.4113 16.41 100161............ 01.4469 18.23
050671............ 01.1408 25.26 060049............ 01.0418 16.46 080006............ 01.2297 14.99 100071............ 01.2555 14.91 100162............ 01.4028 16.66
050672............ 00.6524 19.59 060050............ 01.2021 12.70 080007............ 01.2438 15.70 100072............ 01.2262 14.14 100165............ 01.2106 16.85
050674............ 01.1892 26.59 060052............ 01.1062 12.20 090001............ 01.4395 18.92 100073............ 01.7760 18.60 100166............ 01.4555 18.62
050675............ 01.5392 13.30 060053............ 00.9926 12.72 090002............ 01.1472 16.35 100074............ 01.2348 17.34 100167............ 01.3508 20.22
050676............ 01.0310 12.91 060054............ 01.2663 14.73 090003............ 01.3310 22.14 100075............ 01.6621 16.96 100168............ 01.3308 17.37
050677............ 01.3055 29.76 060056............ 00.9409 12.78 090004............ 01.5533 22.28 100076............ 01.4766 18.32 100169............ 01.8235 17.12
050678............ 01.1027 24.06 060057............ 00.9469 20.55 090005............ 01.2755 25.99 100077............ 01.3315 15.89 100170............ 01.4798 15.72
050680............ 01.2191 22.47 060058............ 00.9388 10.75 090006............ 01.3501 19.60 100078............ 01.1794 16.23 100172............ 01.3794 13.20
050682............ 00.9483 13.47 060060............ 01.0555 11.16 090007............ 01.3341 19.75 100079............ 01.1962 14.43 100173............ 01.6383 15.42
050684............ 01.2056 22.36 060062............ 00.9858 11.79 090008............ 01.5342 23.18 100080............ 01.5553 17.32 100174............ 01.4204 18.07
050685............ 01.1501 24.19 060063............ 01.1506 10.58 090010............ 00.9711 24.67 100081............ 01.1435 11.05 100175............ 00.9514 15.25
050686............ 01.3532 27.79 060064............ 01.4264 18.46 090011............ 01.9533 23.85 100082............ 01.5118 16.80 100176............ 01.9256 22.43
050688............ 01.2086 25.13 060065............ 01.3955 18.91 100001............ 01.4715 16.11 100083............ 01.2875 15.26 100177............ 01.3233 16.58
050689............ 01.4362 26.91 060066............ 00.9326 11.17 100002............ 01.4467 17.78 100084............ 01.4891 15.78 100179............ 01.6528 17.36
050690............ 01.3427 27.92 060068............ 01.2181 14.20 100004............ 01.0434 11.37 100085............ 01.3179 18.81 100180............ 01.4301 17.00
050693............ 01.2812 28.69 060070............ 01.0160 15.33 100005............ 01.1603 17.02 100086............ 01.4018 20.75 100181............ 01.6762 15.78
050694............ 01.3197 21.34 060071............ 01.2362 14.78 100006............ 01.5877 17.22 100087............ 01.7514 19.08 100183............ 01.3690 17.97
050695............ 01.2481 25.38 060072............ 00.9051 ....... 100007............ 01.8613 17.80 100088............ 01.6046 16.52 100186............ 01.3876 15.09
050696............ 02.1328 26.16 060073............ 01.0079 15.52 100008............ 01.6759 18.69 100089............ 01.2412 15.39 100187............ 01.3692 20.52
050697............ 01.1797 ....... 060075............ 01.2514 16.15 100009............ 01.5780 19.14 100090............ 01.3504 15.49 100189............ 01.2857 20.80
050698............ 01.0467 23.39 060076............ 01.4150 14.58 100010............ 01.3896 18.78 100092............ 01.5232 15.54 100191............ 01.3367 17.44
050699............ 00.8430 ....... 060085............ 00.9715 08.89 100012............ 01.5379 17.53 100093............ 01.4666 13.19 100196............ 01.5217 15.84
050700............ 01.3655 ....... 060087............ 01.6122 18.10 100014............ 01.2838 16.40 100098............ 01.2607 16.57 100199............ 01.2090 18.69
050701............ 01.2568 ....... 060088............ 01.0287 13.60 100015............ 01.2993 17.02 100099............ 01.2480 14.53 100200............ 01.3809 21.17
050702............ 01.2043 ....... 060090............ 00.9595 11.72 100017............ 01.6635 15.75 100100............ 01.4521 16.89 100203............ 01.1543 18.05
050703............ 00.8419 ....... 060096............ 01.0133 18.00 100018............ 01.3505 17.76 100102............ 01.0643 15.90 100204............ 01.5526 16.81
050704............ 01.2199 ....... 060100............ 01.3701 20.82 100019............ 01.4542 17.17 100103............ 01.0168 15.39 100206............ 01.3807 21.64
050705............ 02.6844 ....... 060103............ 01.2616 18.94 100020............ 01.3562 17.23 100105............ 01.4016 16.60 100207............ 01.3841 19.04
050706............ 00.9304 ....... 060104............ 01.3367 18.78 100022............ 01.6958 21.32 100106............ 01.0273 13.60 100208............ 01.7382 18.61
050707............ 00.8547 ....... 070001............ 01.7512 22.43 100023............ 01.3278 14.40 100107............ 01.2655 18.74 100209............ 01.5364 19.87
050708............ 00.8707 ....... 070002............ 01.8075 23.72 100024............ 01.3790 19.06 100108............ 01.0529 15.10 100210............ 01.7008 15.97
060001............ 01.4814 16.98 070003............ 01.1472 21.97 100025............ 01.5776 14.76 100109............ 01.3352 14.91 100211............ 01.2772 17.32
060003............ 01.2909 17.31 070004............ 01.1580 21.82 100026............ 01.4999 13.26 100110............ 01.4365 16.61 100212............ 01.6223 16.73
060004............ 01.0772 17.37 070005............ 01.3270 23.96 100027............ 00.8554 11.90 100112............ 00.9797 10.90 100213............ 01.6396 17.36
060006............ 01.2666 14.82 070006............ 01.3116 25.81 100028............ 01.2739 15.02 100113............ 02.0746 15.79 100217............ 01.1845 18.25
060007............ 01.2602 12.50 070007............ 01.3828 22.86 100029............ 01.4444 18.08 100114............ 01.4922 17.48 100220............ 01.8048 17.82
060008............ 01.0109 13.26 070008............ 01.2456 20.66 100030............ 01.2716 16.73 100117............ 01.2930 16.44 100221............ 01.4532 17.82
060009............ 01.4468 18.59 070009............ 01.2617 21.54 100032............ 01.8861 16.48 100118............ 01.1775 15.44 100222............ 01.2511 17.00
060010............ 01.5638 18.49 070010............ 01.4539 21.55 100034............ 01.6934 17.25 100121............ 01.2293 13.62 100223............ 01.4441 16.55
060011............ 01.2279 20.96 070011............ 01.2100 21.19 100035............ 01.5604 15.92 100122............ 01.3603 14.84 100224............ 01.4403 18.78
060012............ 01.4319 14.65 070012............ 01.1714 22.67 100038............ 01.6547 18.93 100124............ 01.3583 16.70 100225............ 01.3935 19.07
060013............ 01.2983 16.63 070013............ 01.3347 22.91 100039............ 01.7027 20.12 100125............ 01.1502 17.51 100226............ 01.3666 17.08
060014............ 01.7025 20.85 070015............ 01.3016 22.72 100040............ 01.6908 16.07 100126............ 01.4582 18.35 100227............ 00.9534 17.48
060015............ 01.5538 17.85 070016............ 01.2499 23.08 100042............ 01.2008 20.82 100127............ 01.6127 17.26 100228............ 01.2295 18.55
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Page 4 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
100229............ 01.3901 16.30 110029............ 01.3254 16.69 110114............ 01.0580 14.00 120001............ 01.7391 22.04 140008............ 01.4359 19.25
100230............ 01.3248 18.30 110030............ 01.2625 16.96 110115............ 01.6496 17.83 120002............ 01.2222 15.87 140010............ 01.3097 18.77
100231............ 01.7130 17.42 110031............ 01.2891 20.89 110117............ 00.9252 11.64 120003............ 00.9710 20.59 140011............ 01.1181 12.97
100232............ 01.2677 16.44 110032............ 01.1310 13.22 110118............ 01.0457 10.01 120004............ 01.2989 18.29 140012............ 01.2090 15.31
100234............ 01.3614 17.94 110033............ 01.4208 18.34 110120............ 01.0429 10.51 120005............ 01.2810 17.03 140013............ 01.5980 14.68
100235............ 01.3840 15.58 110034............ 01.4850 15.64 110121............ 01.1443 11.37 120006............ 01.1593 21.83 140014............ 01.0954 15.12
100236............ 01.4900 15.80 110035............ 01.3122 17.12 110122............ 01.2835 14.70 120007............ 01.6419 20.22 140015............ 01.2270 12.74
100237............ 02.1488 22.04 110036............ 01.6987 21.09 110124............ 01.0984 14.20 120009............ 00.9961 18.32 140016............ 00.9807 10.62
100238............ 01.3722 17.27 110037............ 01.0639 09.10 110125............ 01.1837 14.60 120010............ 01.7249 20.04 140018............ 01.4002 17.67
100239............ 01.4978 17.74 110038............ 01.3929 13.02 110127............ 00.9029 09.56 120011............ 01.2501 26.59 140019............ 00.9330 11.96
100240............ 00.8035 14.20 110039............ 01.3486 16.87 110128............ 01.1452 15.46 120012............ 00.8968 16.54 140024............ 01.0131 12.34
100241............ 00.9441 11.33 110040............ 01.0519 12.16 110129............ 01.5352 12.01 120014............ 01.2149 19.14 140025............ 01.1016 15.27
100242............ 01.3146 14.92 110041............ 01.1457 14.35 110130............ 01.0852 09.68 120015............ 00.8178 19.23 140026............ 01.1248 13.43
100243............ 01.4250 16.65 110042............ 01.0553 13.66 110132............ 01.1520 12.20 120016............ 00.9973 18.55 140027............ 01.2020 14.63
100244............ 01.3618 16.40 110043............ 01.5773 13.73 110134............ 00.8595 10.02 120018............ 00.9138 17.94 140029............ 01.3188 16.19
100246............ 01.3454 19.50 110044............ 01.1391 12.22 110135............ 01.1043 13.78 120019............ 01.2339 17.90 140030............ 01.5404 19.79
100248............ 01.6667 17.89 110045............ 01.1241 19.62 110136............ 01.1588 13.15 120021............ 00.8779 19.14 140031............ 01.0291 11.46
100249............ 01.2751 18.23 110046............ 01.2134 14.30 110140............ 00.8302 13.51 120022............ 01.6633 20.55 140032............ 01.2865 14.20
100252............ 01.1996 17.43 110048............ 01.1013 13.14 110141............ 00.8972 09.72 120024............ 01.0150 15.72 140033............ 01.2494 17.22
100253............ 01.3614 16.33 110049............ 01.0591 14.55 110142............ 01.0137 10.29 120026............ 01.2954 20.12 140034............ 01.1750 14.60
100254............ 01.6057 17.14 110050............ 01.0847 11.33 110143............ 01.2846 17.24 120027............ 01.3545 19.59 140035............ 01.1514 09.85
100255............ 01.3267 20.57 110051............ 00.9783 15.64 110144............ 01.1668 12.74 130001............ 01.0107 13.17 140036............ 01.1215 14.22
100256............ 01.8444 18.38 110052............ 00.9264 14.74 110146............ 00.9328 11.89 130002............ 01.3774 14.35 140037............ 01.0236 11.74
100258............ 01.7091 20.22 110054............ 01.2700 15.38 110149............ 01.0750 11.01 130003............ 01.2226 16.62 140038............ 01.1485 13.82
100259............ 01.4444 16.66 110056............ 00.8911 12.63 110150............ 01.2960 14.47 130005............ 01.3631 16.13 140039............ 01.0245 11.51
100260............ 01.3833 17.08 110059............ 01.3090 12.94 110152............ 01.1662 11.82 130006............ 01.7653 16.81 140040............ 01.2453 13.79
100262............ 01.3941 18.96 110061............ 01.0249 09.64 110153............ 00.9816 15.92 130007............ 01.5368 16.33 140041............ 01.1555 14.31
100263............ 01.3547 17.78 110062............ 00.9617 10.81 110154............ 00.9816 11.86 130008............ 00.9304 12.71 140042............ 01.1036 12.72
100264............ 01.3743 15.50 110063............ 01.0882 11.47 110155............ 01.0525 12.55 130009............ 00.9629 13.18 140043............ 01.2452 15.68
100265............ 01.3079 17.19 110064............ 01.2610 15.82 110156............ 00.9647 11.50 130010............ 00.9419 15.53 140045............ 01.0059 12.10
100266............ 01.3021 15.42 110065............ 00.9751 11.47 110157............ 01.1009 15.28 130011............ 01.3533 13.99 140046............ 01.2829 14.33
100267............ 01.3063 18.95 110066............ 01.3019 15.59 110161............ 01.2406 18.47 130012............ 00.9944 16.65 140047............ 01.2223 11.40
100268............ 01.2433 21.55 110069............ 01.1801 14.92 110162............ 00.8663 ....... 130013............ 01.2643 15.99 140048............ 01.3062 20.15
100269............ 01.3512 21.42 110070............ 00.9980 11.76 110163............ 01.4225 16.50 130014............ 01.3488 16.35 140049............ 01.3569 17.97
100270............ 00.8838 12.30 110071............ 01.0242 09.41 110164............ 01.3716 17.39 130015............ 00.8742 11.45 140051............ 01.3482 18.90
100271............ 01.6050 16.88 110072............ 01.0023 12.37 110165............ 01.2885 15.93 130016............ 00.8542 15.89 140052............ 01.2810 14.67
100273............ 01.0658 16.70 110073............ 01.2810 12.22 110166............ 01.4933 15.76 130017............ 01.0252 12.65 140053............ 01.7729 16.02
100275............ 01.3386 20.17 110074............ 01.4423 16.63 110168............ 01.6691 17.53 130018............ 01.5822 19.65 140054............ 01.3051 22.11
100276............ 01.3219 20.62 110075............ 01.1310 13.64 110169............ 00.7618 17.87 130019............ 01.1747 14.07 140055............ 00.9338 11.82
100277............ 01.0833 12.90 110076............ 01.3234 17.00 110171............ 01.3476 19.39 130021............ 00.9281 10.63 140058............ 01.1583 14.34
100278............ 00.8698 16.01 110078............ 01.5676 21.62 110172............ 01.2397 25.10 130022............ 01.1197 15.42 140059............ 01.0725 11.39
100279............ 01.4270 21.86 110079............ 01.3888 19.60 110174............ 01.0088 12.79 130024............ 01.1015 14.66 140061............ 01.1007 15.08
100280............ 01.4172 ....... 110080............ 01.1829 14.65 110176............ 01.1887 18.24 130025............ 01.1046 15.36 140062............ 01.2341 20.99
100281............ 01.2160 ....... 110082............ 02.0224 23.13 110177............ 01.3894 18.41 130026............ 01.1117 16.17 140063............ 01.3445 19.00
110001............ 01.2551 15.81 110083............ 01.6451 20.82 110178............ 01.4829 17.06 130027............ 00.8922 16.13 140064............ 01.1811 15.11
110002............ 01.2498 14.41 110086............ 01.0560 14.40 110179............ 01.1702 19.22 130028............ 01.1847 15.29 140065............ 01.4134 21.65
110003............ 01.3337 12.00 110087............ 01.2666 17.61 110181............ 01.0288 08.35 130029............ 01.0231 14.26 140066............ 01.1794 13.05
110004............ 01.2191 15.29 110088............ 00.8786 12.27 110183............ 01.2913 18.26 130030............ 01.0340 12.46 140067............ 01.7228 16.34
110005............ 01.1700 15.96 110089............ 01.2055 14.65 110184............ 01.0926 18.57 130031............ 01.0143 11.69 140068............ 01.4052 15.66
110006............ 01.2843 16.38 110091............ 01.3772 19.15 110185............ 01.1298 12.31 130034............ 01.0457 14.13 140069............ 01.0744 13.61
110007............ 01.4503 15.97 110092............ 01.0709 11.21 110186............ 01.3356 15.53 130035............ 01.0182 13.66 140070............ 01.3038 14.49
110008............ 01.1066 14.16 110093............ 00.9715 08.54 110187............ 01.1761 16.81 130036............ 01.2487 08.52 140074............ 01.0194 14.20
110009............ 01.0204 14.23 110094............ 01.0205 11.02 110188............ 01.4360 17.33 130037............ 01.1166 14.67 140075............ 01.4119 17.78
110010............ 02.0046 20.95 110095............ 01.2505 13.02 110189............ 01.0934 19.00 130043............ 01.0399 13.65 140077............ 01.2636 13.35
110011............ 01.1827 14.97 110096............ 01.0978 12.76 110190............ 01.0854 12.93 130044............ 00.9745 12.73 140079............ 01.2695 21.34
110013............ 01.1083 13.50 110097............ 01.1016 16.29 110191............ 01.2392 17.33 130045............ 00.9056 11.43 140080............ 01.7887 17.20
110014............ 01.1894 11.75 110098............ 01.0361 13.41 110192............ 01.3442 19.58 130048............ 01.1050 10.87 140081............ 01.1079 10.92
110015............ 01.1355 15.78 110100............ 01.0988 11.22 110193............ 01.1408 16.99 130049............ 01.2245 15.55 140082............ 01.4045 19.71
110016............ 01.2952 13.84 110101............ 01.0715 09.49 110194............ 00.9760 12.31 130054............ 00.9113 14.10 140083............ 01.2841 15.35
110017............ 00.9323 10.40 110103............ 00.9611 08.82 110195............ 01.2032 10.66 130056............ 00.9454 11.94 140084............ 01.2110 17.72
110018............ 01.1766 15.88 110104............ 01.1479 12.86 110198............ 01.3701 21.77 130058............ 00.9163 11.59 140086............ 01.1083 11.72
110020............ 01.1997 16.55 110105............ 01.1353 13.47 110200............ 01.9905 14.43 130060............ 01.1885 ....... 140087............ 01.4133 16.09
110023............ 01.2550 17.17 110107............ 01.6433 17.26 110201............ 01.4001 14.99 140001............ 01.2552 13.67 140088............ 01.5044 21.90
110024............ 01.3830 15.58 110108............ 01.0233 10.19 110203............ 00.9939 15.78 140002............ 01.2491 15.22 140089............ 01.2464 13.84
110025............ 01.3117 15.02 110109............ 01.1199 11.30 110204............ 00.8075 13.88 140003............ 01.0438 13.21 140090............ 01.4523 26.53
110026............ 01.1566 12.82 110111............ 01.1285 12.71 110205............ 01.0542 11.10 140004............ 00.9859 13.64 140091............ 01.6824 15.96
110027............ 01.0355 15.43 110112............ 00.9922 15.95 110207............ 01.1390 ....... 140005............ 00.9652 09.64 140093............ 01.1922 14.60
110028............ 01.6334 15.10 110113............ 01.0259 13.67 110208............ 00.9490 12.61 140007............ 01.4615 19.18 140094............ 01.3158 15.80
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Page 5 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
140095............ 01.2211 17.48 140182............ 01.2646 18.80 150006............ 01.2471 14.67 150082............ 01.4663 16.73 160033............ 01.4585 14.99
140097............ 00.9794 13.23 140184............ 01.1702 12.95 150007............ 01.2317 16.00 150084............ 01.8366 20.84 160034............ 00.9809 12.26
140098............ 01.2721 18.87 140185............ 01.4019 14.80 150008............ 01.3191 17.15 150085............ 00.9551 10.27 160035............ 00.9182 10.60
140100............ 01.4498 18.43 140186............ 01.1921 17.96 150009............ 01.2891 16.47 150086............ 01.2684 14.97 160036............ 01.0980 12.62
140101............ 01.1882 16.70 140187............ 01.4101 14.44 150010............ 01.1613 16.91 150088............ 01.1618 16.44 160037............ 01.0995 13.20
140102............ 01.0163 13.47 140188............ 00.9952 10.46 150011............ 01.2230 16.35 150089............ 01.3856 17.35 160039............ 01.0908 13.56
140103............ 01.3476 15.26 140189............ 01.1432 14.82 150012............ 01.6245 17.37 150090............ 01.2972 18.44 160040............ 01.2992 14.92
140105............ 01.3373 18.62 140190............ 01.1571 12.46 150013............ 01.1935 12.66 150091............ 01.0796 14.68 160041............ 01.1270 11.51
140107............ 01.1306 11.58 140191............ 01.4016 22.19 150014............ 01.3786 17.11 150092............ 01.0338 13.77 160043............ 01.0127 11.81
140108............ 01.3348 19.18 140192............ 01.0745 16.18 150015............ 01.2586 15.48 150094............ 01.0086 15.63 160044............ 01.1760 11.94
140109............ 01.0492 11.80 140193............ 01.0180 12.88 150017............ 01.7796 16.19 150095............ 01.0817 13.62 160045............ 01.6674 15.84
140110............ 01.2880 12.82 140197............ 01.3042 18.59 150018............ 01.3134 15.81 150096............ 01.0511 17.17 160046............ 01.0096 11.17
140112............ 01.0816 12.81 140199............ 01.0372 13.34 150019............ 01.0796 14.92 150097............ 01.0928 15.62 160047............ 01.3670 14.34
140113............ 01.4290 16.37 140200............ 01.4005 20.01 150020............ 01.0947 11.59 150098............ 01.1526 11.43 160048............ 01.0676 12.01
140114............ 01.2761 17.35 140202............ 01.2643 18.76 150021............ 01.6030 16.43 150099............ 01.2561 15.68 160049............ 00.9581 11.45
140115............ 01.1712 16.67 140203............ 01.2244 15.95 150022............ 01.1271 17.24 150100............ 01.7072 17.00 160050............ 01.0211 12.47
140116............ 01.2900 17.61 140205............ 00.8422 11.22 150023............ 01.4118 15.56 150101............ 01.1155 13.32 160051............ 01.2040 12.25
140117............ 01.2999 18.69 140206............ 01.0654 17.10 150024............ 01.2106 14.95 150102............ 01.0577 13.18 160052............ 01.0436 11.95
140118............ 01.6004 20.68 140207............ 01.3948 18.78 150025............ 01.5388 16.21 150103............ 01.0226 13.14 160054............ 01.1022 12.01
140119............ 01.6661 20.07 140208............ 01.4898 22.91 150026............ 01.1923 16.04 150104............ 01.0812 13.64 160055............ 00.9485 11.27
140120............ 01.4141 13.85 140209............ 01.6445 14.99 150027............ 01.0126 14.08 150105............ 01.1628 15.14 160056............ 01.0806 12.76
140121............ 01.5539 08.74 140210............ 01.0433 11.29 150029............ 01.2511 17.48 150106............ 01.0463 17.80 160057............ 01.3502 13.92
140122............ 01.4768 20.02 140211............ 01.1982 17.90 150030............ 01.0812 15.16 150109............ 01.3691 14.70 160058............ 01.6992 16.69
140123............ 01.2294 15.10 140212............ 01.1656 20.42 150031............ 01.0957 14.78 150110............ 00.9296 13.42 160059............ 01.2630 16.34
140124............ 01.1358 19.42 140213............ 01.2009 19.50 150032............ 01.7588 17.72 150111............ 01.0950 12.33 160060............ 01.0284 12.62
140125............ 01.2390 13.29 140215............ 01.1446 10.48 150033............ 01.5943 18.01 150112............ 01.2111 16.18 160061............ 00.9538 13.54
140127............ 01.2956 15.35 140217............ 01.2374 19.16 150034............ 01.2863 17.20 150113............ 01.1478 15.45 160062............ 00.9618 10.99
140128............ 01.0433 15.50 140218............ 00.9567 13.96 150035............ 01.4080 17.05 150114............ 00.9924 12.31 160063............ 01.1404 10.67
140129............ 01.0693 12.58 140220............ 01.1752 13.57 150036............ 01.0229 16.08 150115............ 01.3247 13.92 160064............ 01.5931 15.57
140130............ 01.1602 19.25 140223............ 01.5029 22.80 150037............ 01.1956 17.77 150122............ 01.1148 17.31 160065............ 01.0733 13.93
140132............ 01.5272 17.61 140224............ 01.3267 19.20 150038............ 01.1995 15.85 150123............ 01.0958 12.57 160066............ 01.0801 13.35
140133............ 01.3502 19.24 140228............ 01.6053 16.14 150039............ 00.9143 13.42 150124............ 01.1234 14.04 160067............ 01.3105 15.77
140135............ 01.2358 14.27 140229............ 00.9303 09.86 150042............ 01.1893 14.72 150125............ 01.3773 16.98 160068............ 01.0005 13.07
140137............ 01.0291 12.24 140230............ 00.9506 13.17 150043............ 01.0846 15.00 150126............ 01.5079 18.30 160069............ 01.3793 14.35
140138............ 01.0241 11.15 140231............ 01.5410 19.84 150044............ 01.2714 15.75 150127............ 01.2053 11.94 160070............ 01.0399 11.90
140139............ 01.0516 12.47 140233............ 01.7208 14.89 150045............ 01.1633 15.40 150128............ 01.2212 17.22 160072............ 01.1162 11.93
140140............ 01.1237 11.90 140234............ 01.2047 14.44 150046............ 01.5484 16.63 150129............ 01.2144 18.69 160073............ 01.0381 11.15
140141............ 00.9810 12.26 140236............ 01.0041 12.56 150047............ 01.6831 17.65 150130............ 01.1198 13.18 160074............ 01.0271 14.05
140143............ 01.0728 14.63 140239............ 01.5754 16.58 150048............ 01.1715 15.11 150132............ 01.3672 19.75 160075............ 01.0535 13.37
140144............ 00.9953 13.14 140240............ 01.4164 20.64 150049............ 01.1211 12.76 150133............ 01.1774 14.00 160076............ 01.0077 13.71
140145............ 01.1475 14.17 140242............ 01.5346 19.78 150050............ 01.1464 13.85 150134............ 01.1496 15.65 160077............ 00.9877 09.72
140146............ 00.9720 14.22 140245............ 01.0564 12.26 150051............ 01.3409 15.58 150136............ 00.8373 18.39 160079............ 01.3225 14.87
140147............ 01.1895 12.55 140246............ 01.0439 11.22 150052............ 01.0935 10.31 150137............ 02.8509 ....... 160080............ 01.1510 14.09
140148............ 01.6515 16.06 140250............ 01.2052 19.71 150053............ 01.0023 16.74 150897............ 04.9451 ....... 160081............ 01.1054 13.36
140150............ 01.4651 20.76 140251............ 01.3108 16.26 150054............ 01.0899 12.38 160001............ 01.1864 15.08 160082............ 01.6745 15.91
140151............ 01.1004 15.02 140252............ 01.3458 20.39 150056............ 01.7050 19.00 160002............ 01.1621 12.09 160083............ 01.5104 16.07
140152............ 01.0787 21.93 140253............ 01.3767 24.54 150057............ 02.3820 13.49 160003............ 01.0524 11.50 160085............ 01.0059 11.42
140155............ 01.1690 15.83 140258............ 01.3969 19.92 150058............ 01.6361 18.17 160005............ 01.0831 12.28 160086............ 00.9935 11.97
140158............ 01.4060 19.65 140271............ 00.9808 12.27 150059............ 01.1919 17.50 160007............ 00.9597 11.53 160088............ 01.1130 12.79
140159............ 01.2401 12.04 140275............ 01.2724 14.62 150060............ 01.1308 15.24 160008............ 01.1460 12.99 160089............ 01.2177 13.80
140160............ 01.1835 14.34 140276............ 02.0686 18.92 150061............ 01.1952 12.43 160009............ 01.2384 13.34 160090............ 01.0499 13.51
140161............ 01.1023 15.66 140280............ 01.2391 15.41 150062............ 01.0335 12.77 160012............ 01.1231 12.70 160091............ 01.0972 11.91
140162............ 01.6816 15.64 140281............ 01.5966 19.47 150063............ 01.0813 13.91 160013............ 01.2444 13.60 160092............ 00.9851 13.58
140164............ 01.2770 13.78 140285............ 01.3016 14.03 150064............ 01.0620 15.32 160014............ 00.9484 11.72 160093............ 01.1425 11.52
140165............ 01.0512 12.51 140286............ 01.1246 15.68 150065............ 01.0845 15.64 160016............ 01.2702 14.43 160094............ 01.1061 14.65
140166............ 01.2083 14.64 140288............ 01.6329 20.42 150066............ 01.0441 12.68 160018............ 00.8938 11.90 160095............ 01.1343 14.50
140167............ 01.1178 12.82 140289............ 01.2651 14.49 150067............ 01.0953 13.31 160020............ 01.0997 11.81 160097............ 01.1379 12.57
140168............ 01.1806 14.17 140290............ 01.3067 19.27 150069............ 01.2292 14.39 160021............ 01.0801 12.04 160098............ 00.9995 12.47
140170............ 01.0176 10.98 140291............ 01.3069 20.16 150070............ 01.0214 13.03 160023............ 01.0701 12.61 160099............ 01.0430 10.99
140171............ 00.9245 12.22 140292............ 01.1650 19.76 150071............ 01.1226 12.39 160024............ 01.5224 15.43 160101............ 01.1531 15.89
140172............ 01.4928 18.33 140294............ 01.1308 14.61 150072............ 01.2197 14.26 160025............ 01.8445 15.04 160102............ 01.4203 15.23
140173............ 01.0401 13.57 140297............ 01.2286 20.74 150073............ 00.9898 16.29 160026............ 01.1258 13.21 160103............ 00.9634 12.62
140174............ 01.4898 16.75 140299............ 00.8525 22.50 150074............ 01.5553 19.36 160027............ 01.1424 12.49 160104............ 01.2134 15.40
140176............ 01.2854 18.62 150001............ 01.0566 15.39 150075............ 01.1997 12.67 160028............ 01.2118 16.69 160106............ 01.0802 12.86
140177............ 01.5125 15.14 150002............ 01.3662 16.67 150076............ 01.0762 15.74 160029............ 01.5235 15.57 160107............ 01.2048 12.64
140179............ 01.2492 18.13 150003............ 01.6898 15.65 150077............ 01.2331 14.59 160030............ 01.3238 14.98 160108............ 01.0918 12.98
140180............ 01.5100 19.11 150004............ 01.4962 18.06 150078............ 01.1045 15.23 160031............ 01.1537 12.06 160109............ 00.9703 11.06
140181............ 01.2782 17.32 150005............ 01.1848 17.30 150079............ 01.1034 12.83 160032............ 01.1884 13.93 160110............ 01.4776 16.07
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Page 6 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
160111............ 01.0495 09.59 170050............ 00.7731 10.65 170133............ 01.1786 13.81 180047............ 01.0461 12.20 190008............ 01.5397 17.01
160112............ 01.4123 13.17 170051............ 00.9991 13.38 170134............ 01.0123 11.44 180048............ 01.1437 14.45 190009............ 01.2947 13.88
160113............ 01.0150 11.03 170052............ 01.0909 10.94 170137............ 01.1535 15.62 180049............ 01.3972 13.11 190010............ 01.0785 14.19
160114............ 01.0347 13.68 170053............ 00.8682 10.41 170139............ 01.0526 11.31 180050............ 01.2714 14.68 190011............ 01.1190 12.19
160115............ 01.0569 12.36 170054............ 01.0889 11.90 170140............ 01.0504 11.09 180051............ 01.3043 12.81 190013............ 01.2339 13.20
160116............ 01.1453 13.89 170055............ 00.9637 13.55 170142............ 01.3014 15.41 180053............ 01.2849 13.26 190014............ 01.0865 12.69
160117............ 01.2772 14.07 170056............ 00.9755 10.54 170143............ 01.1407 11.86 180054............ 01.0041 12.50 190015............ 01.1628 16.58
160118............ 01.0383 12.14 170057............ 01.0697 13.53 170144............ 01.4728 14.00 180055............ 01.0469 12.65 190017............ 01.2199 12.10
160120............ 00.9891 08.34 170058............ 01.0783 13.89 170145............ 01.1856 13.04 180056............ 01.0706 15.74 190018............ 01.2787 14.25
160122............ 01.1631 13.40 170060............ 01.0531 11.99 170146............ 01.3620 16.72 180058............ 00.8915 12.36 190019............ 01.4660 15.85
160123............ 01.0309 13.08 170061............ 01.1160 11.60 170147............ 01.1301 16.42 180059............ 00.8664 12.17 190020............ 01.1850 14.53
160124............ 01.2481 13.81 170062............ 00.9459 11.58 170148............ 01.4025 17.53 180063............ 01.0511 09.78 190025............ 01.2406 11.69
160126............ 01.0561 11.21 170063............ 00.9046 10.73 170150............ 01.0814 13.01 180064............ 01.1018 10.97 190026............ 01.3918 15.09
160129............ 01.0282 12.08 170064............ 00.9869 11.33 170151............ 01.0014 10.99 180065............ 00.9641 09.28 190027............ 01.4597 15.99
160130............ 01.0416 11.62 170066............ 00.9301 11.45 170152............ 00.9702 12.21 180066............ 01.2906 16.62 190029............ 01.1671 13.12
160131............ 01.1439 11.67 170067............ 00.8591 12.46 170159............ 00.9310 ....... 180067............ 01.8613 15.59 190033............ 00.9131 07.96
160133............ 01.0955 16.39 170068............ 01.2507 14.20 170160............ 00.9833 10.63 180069............ 01.0154 14.41 190034............ 01.2126 13.01
160134............ 01.0727 10.74 170069............ 01.0333 12.27 170164............ 00.9554 13.38 180070............ 01.0481 12.77 190035............ 01.4086 17.47
160135............ 00.9890 10.91 170070............ 00.9728 12.23 170166............ 01.0157 13.45 180072............ 01.0799 14.38 190036............ 01.6500 17.28
160138............ 01.1163 12.46 170072............ 00.9173 10.58 170168............ 00.9043 08.28 180075............ 00.9842 10.68 190037............ 01.0946 17.85
160140............ 01.0654 13.24 170073............ 01.1027 12.78 170171............ 01.1033 10.91 180078............ 01.0783 15.71 190039............ 01.4727 16.44
160141............ 00.8389 10.05 170074............ 01.0959 11.30 170172............ 00.9711 ....... 180079............ 00.9817 12.61 190040............ 01.4197 17.30
160142............ 01.0835 11.71 170075............ 00.8432 09.47 170174............ 00.8355 10.81 180080............ 01.1021 12.85 190041............ 01.5259 16.54
160143............ 01.0648 11.92 170076............ 01.1061 10.14 170175............ 01.2782 15.18 180081............ 01.5080 17.66 190043............ 01.1080 10.44
160145............ 01.0547 11.04 170077............ 00.9343 11.31 170176............ 01.4954 18.34 180085............ 01.3121 16.18 190044............ 01.0842 15.51
160146............ 01.3578 14.81 170079............ 01.0716 09.81 170180............ 00.9497 ....... 180087............ 01.0822 12.45 190045............ 01.2847 17.63
160147............ 01.1855 13.17 170080............ 01.0304 11.67 180001............ 01.2063 15.10 180088............ 01.6461 18.61 190046............ 01.5088 16.18
160151............ 01.1023 12.32 170081............ 01.0304 10.30 180002............ 01.0558 14.95 180092............ 01.1080 13.45 190047............ 01.1529 16.09
160152............ 00.9970 12.73 170082............ 01.0350 10.91 180004............ 01.1744 12.90 180093............ 01.3853 14.17 190048............ 01.0973 13.35
160153............ 01.6502 16.13 170084............ 00.8777 10.03 180005............ 01.0444 14.66 180094............ 00.9476 11.59 190049............ 01.0513 13.59
170001............ 01.2083 14.25 170085............ 00.9636 11.57 180006............ 00.9029 11.80 180095............ 01.1229 11.81 190050............ 01.0974 13.67
170004............ 01.0582 12.68 170086............ 01.7041 17.38 180007............ 01.4577 13.73 180099............ 01.0774 10.13 190053............ 01.0886 11.08
170006............ 01.1785 13.00 170087............ 01.3942 18.90 180009............ 01.2790 16.51 180101............ 01.2180 19.86 190054............ 01.4390 12.13
170008............ 01.0815 11.61 170088............ 00.8810 08.09 180010............ 01.8120 15.34 180102............ 01.4457 12.80 190059............ 00.9479 17.29
170009............ 01.2522 15.16 170089............ 01.0458 13.83 180011............ 01.2072 14.69 180103............ 01.9661 16.39 190060............ 01.4131 14.77
170010............ 01.2129 14.80 170090............ 01.0756 09.53 180012............ 01.3677 15.91 180104............ 01.4486 14.71 190064............ 01.5065 16.13
170011............ 01.4374 14.07 170092............ 00.7989 11.32 180013............ 01.3280 14.46 180105............ 00.9262 15.54 190065............ 01.4844 15.65
170012............ 01.3724 15.42 170093............ 00.9273 11.25 180014............ 01.5173 17.45 180106............ 00.8984 11.57 190071............ 00.8849 11.25
170013............ 01.3311 14.02 170094............ 01.0821 13.06 180015............ 01.1320 14.27 180108............ 00.8906 12.67 190075............ 01.4392 19.38
170014............ 01.0487 14.36 170095............ 01.1131 12.46 180016............ 01.2634 12.65 180115............ 01.0927 13.33 190077............ 00.9533 10.49
170015............ 01.0035 12.48 170097............ 00.9929 12.19 180017............ 01.3036 12.52 180116............ 01.3607 14.88 190078............ 01.2408 10.47
170016............ 01.5938 18.86 170098............ 01.0691 13.99 180018............ 01.1528 12.70 180117............ 01.1918 12.53 190079............ 01.2546 14.38
170017............ 01.1818 15.65 170099............ 01.2498 10.05 180019............ 01.3022 15.60 180118............ 01.0380 10.98 190081............ 00.8933 09.79
170018............ 01.0376 11.86 170100............ 00.9250 13.52 180020............ 01.0535 14.18 180120............ 00.9600 11.55 190083............ 00.9095 11.31
170019............ 01.1664 14.86 170101............ 00.9580 12.56 180021............ 01.2222 12.05 180121............ 01.1330 12.12 190086............ 01.2984 13.80
170020............ 01.2784 14.70 170102............ 01.0011 12.58 180023............ 00.8308 10.45 180122............ 01.0106 12.03 190088............ 01.2471 15.55
170022............ 01.2502 11.71 170103............ 01.2714 14.43 180024............ 01.3172 15.71 180123............ 01.4815 17.52 190089............ 01.0474 09.57
170023............ 01.3885 15.44 170104............ 01.4228 18.83 180025............ 01.1247 13.86 180124............ 01.3514 14.80 190090............ 01.2103 14.47
170024............ 01.1843 11.73 170105............ 00.9739 14.10 180026............ 01.1969 10.47 180125............ 01.0206 14.88 190092............ 01.2826 16.62
170025............ 01.2580 13.63 170106............ 00.9198 12.06 180027............ 01.1226 12.56 180126............ 01.0168 10.88 190095............ 01.0350 12.77
170026............ 01.0138 14.25 170108............ 00.9078 10.27 180028............ 01.0368 15.42 180127............ 01.2145 16.76 190098............ 01.4469 16.69
170027............ 01.1818 15.09 170109............ 01.0837 13.77 180029............ 01.2896 14.10 180128............ 01.1231 14.91 190099............ 01.1067 14.71
170030............ 00.9610 13.61 170110............ 00.9268 12.68 180030............ 01.1350 11.60 180129............ 01.1193 11.56 190102............ 01.5102 14.99
170031............ 00.9031 11.54 170112............ 00.8931 11.15 180031............ 00.9966 11.68 180130............ 01.4243 16.58 190103............ 00.8671 09.80
170032............ 01.0399 13.75 170113............ 01.1280 13.45 180032............ 01.0592 14.39 180132............ 01.1994 15.26 190106............ 01.1645 15.56
170033............ 01.2512 14.38 170114............ 01.0939 12.12 180033............ 01.0621 10.03 180133............ 01.2492 17.98 190109............ 01.2001 13.91
170034............ 00.9660 13.54 170115............ 01.0547 11.25 180034............ 00.9930 13.98 180134............ 00.9826 11.38 190110............ 00.9443 10.81
170035............ 00.9068 12.55 170116............ 01.0986 12.83 180035............ 01.5185 16.43 180136............ 01.3870 15.97 190111............ 01.5657 15.92
170036............ 00.8756 11.84 170117............ 01.0083 11.90 180036............ 01.1639 16.11 180137............ 01.6460 17.11 190112............ 01.4060 16.41
170037............ 01.1331 15.60 170119............ 00.9699 10.40 180037............ 01.2596 17.97 180138............ 01.2598 17.78 190113............ 01.3192 16.22
170038............ 00.9494 11.73 170120............ 01.3050 14.99 180038............ 01.3422 14.34 180139............ 01.0589 13.66 190114............ 00.9470 12.67
170039............ 01.0575 12.85 170121............ 00.9078 10.42 180040............ 01.9499 18.25 190001............ 00.9125 14.98 190115............ 01.3549 21.52
170040............ 01.4677 16.84 170122............ 01.8166 19.22 180041............ 01.0425 13.18 190002............ 01.5680 14.50 190116............ 01.2132 12.23
170041............ 01.0475 10.30 170123............ 01.7327 18.31 180042............ 01.0821 11.66 190003............ 01.4246 17.42 190118............ 01.0429 11.05
170043............ 00.9951 12.13 170124............ 00.9317 12.74 180043............ 01.1262 13.52 190004............ 01.3241 13.12 190120............ 00.9278 14.66
170044............ 01.1531 14.13 170126............ 00.9136 10.31 180044............ 01.0420 12.66 190005............ 01.4454 14.98 190122............ 01.2075 13.84
170045............ 01.0097 12.52 170128............ 00.9733 12.97 180045............ 01.1996 15.05 190006............ 01.1903 13.93 190124............ 01.4624 18.09
170049............ 01.3253 17.19 170131............ 01.1254 10.65 180046............ 01.0795 16.50 190007............ 01.0336 12.14 190125............ 01.3726 13.88
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Page 7 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
190127............ 01.4274 16.72 190222............ 01.7805 ....... 210030............ 01.0946 18.05 220064............ 01.1949 19.68 230017............ 01.5141 19.59
190128............ 00.9131 15.49 190223............ 00.4818 ....... 210031............ 01.7275 21.38 220065............ 01.2456 18.46 230019............ 01.5005 20.62
190130............ 00.9991 11.19 190227............ 00.7574 ....... 210032............ 01.2560 17.31 220066............ 01.3009 18.54 230020............ 01.6541 18.94
190131............ 01.2762 13.59 200001............ 01.2705 15.09 210033............ 01.1890 16.07 220067............ 01.2473 21.25 230021............ 01.5791 15.00
190133............ 01.0452 09.24 200002............ 01.0955 15.46 210034............ 01.3026 18.66 220068............ 00.5926 17.13 230022............ 01.2981 17.19
190134............ 00.9913 09.28 200003............ 01.0709 15.05 210035............ 01.1827 15.47 220070............ 01.1592 18.14 230024............ 01.5296 22.55
190135............ 01.3911 16.54 200006............ 01.1645 14.04 210036............ 01.2939 16.68 220071............ 01.8216 23.03 230027............ 01.0751 15.36
190136............ 01.0604 12.04 200007............ 01.0246 15.37 210037............ 01.2424 15.64 220073............ 01.3094 22.57 230029............ 01.5333 20.32
190138............ 00.7195 19.68 200008............ 01.2632 17.11 210038............ 01.4191 17.39 220074............ 01.2435 20.16 230030............ 01.2368 16.73
190140............ 00.9943 11.25 200009............ 01.6699 17.96 210039............ 01.1670 16.17 220075............ 01.1897 20.08 230031............ 01.4714 17.50
190142............ 00.9868 12.54 200012............ 01.1409 14.30 210040............ 01.3355 21.10 220076............ 01.2095 22.33 230032............ 01.7001 17.85
190144............ 01.1611 13.35 200013............ 01.0904 14.12 210043............ 01.2501 20.01 220077............ 01.6494 20.98 230034............ 01.1781 14.38
190145............ 00.9378 14.48 200015............ 01.2427 16.17 210044............ 01.2676 19.24 220079............ 01.1475 20.12 230035............ 01.1032 14.84
190146............ 01.5485 16.85 200016............ 00.9868 14.92 210045............ 01.0235 10.65 220080............ 01.2286 17.63 230036............ 01.2686 17.94
190147............ 00.9870 12.33 200017............ 01.2677 16.81 210046............ 01.1370 09.48 220081............ 00.9674 20.33 230037............ 01.2047 15.86
190148............ 00.9289 11.58 200018............ 01.1593 13.98 210048............ 01.1729 20.49 220082............ 01.2124 19.86 230038............ 01.5837 18.78
190149............ 00.9770 10.49 200019............ 01.2620 16.59 210049............ 01.1487 15.63 220083............ 01.1157 18.96 230040............ 01.2391 15.59
190151............ 01.0919 11.17 200020............ 01.1415 18.32 210051............ 01.2959 12.97 220084............ 01.2116 21.89 230041............ 01.1843 17.06
190152............ 01.3446 19.19 200021............ 01.1375 16.13 210054............ 01.2291 19.77 220086............ 01.5700 22.71 230042............ 01.1267 16.80
190155............ 00.9687 10.29 200023............ 00.8693 15.15 210055............ 01.2349 20.46 220088............ 01.5463 20.83 230043............ 00.5585 ......
190156............ 00.8916 11.29 200024............ 01.1926 17.76 210056............ 01.4390 16.01 220089............ 01.2495 21.22 230046............ 01.8416 26.35
190158............ 01.2679 20.55 200025............ 01.1723 17.84 210057............ 01.3107 21.17 220090............ 01.1872 20.89 230047............ 01.2979 18.15
190160............ 01.1622 14.70 200026............ 01.0477 14.44 210058............ 01.7975 17.16 220092............ 01.2679 20.27 230053............ 01.4890 23.31
190161............ 00.8950 13.49 200027............ 01.2545 15.42 210059............ 01.3193 20.43 220094............ 01.2229 18.24 230054............ 01.7235 17.38
190162............ 01.2743 15.63 200028............ 00.9644 13.99 210060............ 01.0661 19.25 220095............ 01.1984 18.77 230055............ 01.1856 15.21
190164............ 01.1577 14.42 200031............ 01.2783 14.04 210061............ 00.8608 ....... 220097............ 01.0484 21.81 230056............ 00.9564 13.41
190165............ 01.0022 10.72 200032............ 01.2729 16.82 220001............ 01.1826 19.14 220098............ 01.2234 17.36 230058............ 01.0954 15.65
190166............ 01.0293 11.98 200033............ 01.6732 18.43 220002............ 01.4334 19.70 220099............ 01.1610 19.90 230059............ 01.5458 18.06
190167............ 01.2778 15.44 200034............ 01.2070 17.64 220003............ 01.0778 15.29 220100............ 01.2409 21.09 230060............ 01.2794 15.46
190170............ 01.0716 12.52 200037............ 01.1799 15.05 220004............ 01.2325 21.14 220101............ 01.3956 22.89 230062............ 01.1726 13.45
190173............ 01.4217 18.02 200038............ 01.0132 17.44 220006............ 01.3029 21.22 220102............ 00.6305 19.91 230063............ 01.3822 17.52
190175............ 01.4664 ....... 200039............ 01.2818 15.86 220008............ 01.1498 18.22 220104............ 01.2399 22.48 230065............ 01.4862 17.15
190176............ 01.5426 17.76 200040............ 01.1008 14.71 220010............ 01.2172 19.75 220105............ 01.1431 19.59 230066............ 01.3530 17.66
190177............ 01.5260 19.77 200041............ 01.1588 17.08 220011............ 01.1527 25.18 220106............ 01.1359 21.34 230068............ 01.3995 18.55
190178............ 00.9755 10.27 200043............ 00.6462 15.00 220012............ 01.3065 26.56 220107............ 01.1159 16.97 230069............ 01.1139 16.62
190182............ 00.9997 20.51 200050............ 01.1422 15.39 220015............ 01.1847 18.96 220108............ 01.1537 19.66 230070............ 01.4871 18.10
190183............ 01.2016 11.91 200051............ 00.9967 17.08 220016............ 01.2550 19.03 220110............ 01.9834 28.62 230071............ 00.6183 19.34
190184............ 00.9813 12.28 200052............ 01.0217 13.98 220017............ 01.2595 22.56 220111............ 01.1929 18.46 230072............ 01.2474 17.07
190185............ 01.2328 22.78 200055............ 01.0672 13.86 220019............ 01.0809 18.15 220114............ 01.0022 18.76 230075............ 01.4793 17.70
190186............ 00.9005 10.73 200062............ 00.9717 14.41 220020............ 01.1734 17.95 220116............ 01.8026 22.66 230076............ 01.2750 19.48
190187............ 00.7986 14.06 200063............ 01.2053 16.48 220021............ 01.2662 20.51 220118............ 02.0761 24.00 230077............ 01.9986 17.18
190189............ 00.4825 15.10 200066............ 01.1911 14.22 220023............ 01.1628 16.29 220119............ 01.3309 22.40 230078............ 01.1509 14.20
190190............ 00.9967 19.64 210001............ 01.3273 16.34 220024............ 01.1753 18.21 220120............ 01.1833 18.85 230080............ 01.1782 16.44
190191............ 01.2357 18.16 210002............ 02.0004 14.40 220025............ 01.1050 17.54 220123............ 01.0262 21.84 230081............ 01.2181 15.62
190193............ 01.2706 21.05 210003............ 01.5187 20.58 220026............ 01.3873 20.26 220126............ 01.2273 19.55 230082............ 01.1409 14.70
190194............ 01.1226 17.88 210004............ 01.3029 23.87 220028............ 01.3997 19.75 220128............ 01.0828 21.45 230085............ 01.1124 16.73
190196............ 00.8076 16.52 210005............ 01.2274 15.89 220029............ 01.1470 20.21 220131............ 01.1501 17.81 230086............ 01.0042 12.96
190197............ 01.2720 16.76 210006............ 01.1113 15.52 220030............ 01.0906 18.23 220133............ 00.8081 32.44 230087............ 01.0384 14.20
190198............ 01.1347 19.92 210007............ 01.5132 17.96 220031............ 01.6471 24.26 220135............ 01.1540 22.28 230089............ 01.3553 21.44
190199............ 01.2829 13.69 210008............ 01.3475 19.28 220033............ 01.3333 19.31 220153............ 01.0148 16.24 230092............ 01.2759 17.05
190200............ 01.5353 18.48 210009............ 01.6717 17.62 220035............ 01.2157 18.93 220154............ 00.9165 18.82 230093............ 01.2451 16.96
190201............ 01.4081 17.53 210010............ 01.2345 14.61 220036............ 01.5922 21.53 220156............ 01.3009 19.03 230095............ 01.2168 15.30
190202............ 01.4911 18.80 210011............ 01.2678 18.56 220038............ 01.2361 23.00 220162............ 01.4283 ....... 230096............ 01.2423 16.62
190203............ 01.5344 19.81 210012............ 01.5499 19.80 220041............ 01.1752 20.17 220163............ 01.8447 25.11 230097............ 01.5436 17.27
190204............ 01.5003 19.33 210013............ 01.2857 20.56 220042............ 01.2688 22.59 220171............ 01.6792 20.19 230099............ 01.2443 17.18
190205............ 01.7944 16.25 210015............ 01.1955 18.69 220045............ 01.2560 19.58 220173............ 00.6336 ....... 230100............ 01.2151 14.53
190206............ 01.4383 22.87 210016............ 01.8141 17.94 220046............ 01.3821 22.07 220897............ 04.7812 ....... 230101............ 01.1090 16.09
190207............ 01.1983 19.24 210017............ 01.1032 13.97 220049............ 01.2323 21.24 230001............ 01.1909 16.33 230103............ 01.0248 14.39
190208............ 00.8194 09.75 210018............ 01.2806 19.36 220050............ 00.9707 15.98 230002............ 01.2722 18.31 230104............ 01.6288 20.01
190211............ 00.5866 11.07 210019............ 01.4061 16.06 220051............ 01.1964 19.14 230003............ 01.1367 16.51 230105............ 01.5479 17.41
190212............ 00.7212 09.55 210022............ 01.4209 18.96 220052............ 01.2009 20.82 230004............ 01.6989 18.57 230106............ 01.0959 16.74
190213............ 02.6746 10.83 210023............ 01.3472 22.27 220053............ 01.2833 20.22 230005............ 01.3315 16.98 230107............ 00.8939 10.39
190214............ 00.4476 11.33 210024............ 01.3347 19.84 220055............ 01.1986 17.51 230006............ 01.0618 14.61 230108............ 01.1695 14.76
190216............ 00.7615 ....... 210025............ 01.3064 15.79 220057............ 01.2906 18.41 230007............ 01.0773 16.37 230110............ 01.2680 14.49
190217............ 00.9100 ....... 210026............ 01.3091 18.97 220058............ 01.1247 19.41 230012............ 00.7031 14.26 230111............ 00.9760 14.53
190218............ 00.9222 ....... 210027............ 01.2370 14.83 220060............ 01.1423 22.58 230013............ 01.3012 20.34 230113............ 01.0293 17.37
190219............ 00.4818 ....... 210028............ 01.0904 14.70 220062............ 00.7219 18.20 230014............ 01.2674 13.29 230114............ 00.6562 20.94
190220............ 01.9831 ....... 210029............ 01.3166 16.25 220063............ 01.2105 17.96 230015............ 01.2351 17.21 230115............ 00.9721 14.26
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Page 8 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
230116............ 00.9313 13.79 230222............ 01.3030 16.28 240058............ 01.0092 09.62 240141............ 00.9930 18.54 250040............ 01.3036 14.79
230117............ 01.9236 20.87 230223............ 01.3443 18.13 240059............ 01.2100 17.26 240142............ 01.0475 13.23 250042............ 01.1639 13.22
230118............ 01.2684 15.27 230227............ 01.4180 18.92 240061............ 01.5649 20.05 240143............ 00.9200 09.58 250043............ 00.8793 11.24
230119............ 01.2374 20.41 230228............ 01.3346 17.04 240063............ 01.5312 19.77 240144............ 00.9469 14.36 250044............ 01.0257 11.99
230120............ 01.1310 16.19 230230............ 01.3499 18.21 240064............ 01.1862 17.45 240145............ 01.0236 10.16 250045............ 01.1858 14.86
230121............ 01.2738 17.52 230232............ 01.0269 15.35 240065............ 00.9615 11.40 240146............ 00.9792 13.78 250047............ 00.9690 09.06
230122............ 01.2966 17.18 230235............ 00.9287 12.87 240066............ 01.3761 17.16 240148............ 00.9367 10.13 250048............ 01.4260 13.20
230124............ 01.1212 15.55 230236............ 01.3267 18.37 240069............ 01.1315 16.35 240150............ 00.9295 10.19 250049............ 00.9223 10.78
230125............ 01.4034 13.28 230237............ 01.1209 18.78 240071............ 01.1252 16.43 240152............ 00.9629 15.64 250050............ 01.2364 10.90
230128............ 01.3674 20.20 230239............ 01.1815 15.59 240072............ 01.0470 14.61 240153............ 01.0283 13.43 250051............ 00.9053 09.10
230129............ 01.9337 19.47 230241............ 01.1452 15.34 240073............ 00.9857 11.34 240154............ 00.9850 14.51 250057............ 01.1384 11.55
230130............ 01.6192 20.80 230244............ 01.4473 19.18 240075............ 01.2235 17.19 240155............ 00.9704 13.26 250058............ 01.1748 11.42
230132............ 01.4471 19.39 230253............ 01.2209 16.09 240076............ 01.0812 17.80 240157............ 01.0271 13.38 250059............ 01.0249 10.92
230133............ 01.2099 14.69 230254............ 01.2119 20.53 240077............ 00.9540 12.78 240160............ 01.0223 13.44 250060............ 00.8086 10.54
230134............ 01.2065 14.24 230257............ 01.0308 16.29 240078............ 01.3986 20.24 240161............ 00.9919 12.77 250061............ 00.8723 09.07
230135............ 01.2848 17.71 230259............ 01.2056 18.24 240079............ 01.0466 12.37 240162............ 01.0410 14.61 250063............ 00.8607 10.84
230137............ 01.1498 16.37 230264............ 01.2863 17.31 240080............ 01.4245 19.24 240163............ 00.9238 12.90 250065............ 00.9000 10.30
230141............ 01.6104 19.10 230269............ 01.2254 19.90 240082............ 01.1766 13.75 240166............ 01.1521 14.56 250066............ 00.9710 09.70
230142............ 01.1810 23.19 230270............ 01.2495 18.39 240083............ 01.3174 15.80 240169............ 00.9629 13.10 250067............ 00.9668 11.74
230143............ 01.1721 13.64 230273............ 01.6929 18.16 240084............ 01.3441 15.28 240170............ 01.0631 13.78 250068............ 00.8967 12.25
230144............ 01.1897 19.77 230275............ 00.8457 15.29 240085............ 00.8935 12.80 240171............ 00.9851 13.00 250069............ 01.2085 12.00
230145............ 01.1687 14.34 230276............ 00.9634 14.84 240086............ 01.1767 14.11 240172............ 01.1034 14.02 250071............ 01.0495 10.98
230146............ 01.2787 18.56 230277............ 01.2058 18.72 240087............ 01.0594 13.50 240173............ 00.9808 14.21 250072............ 01.3428 14.40
230147............ 01.5731 18.29 230278............ 01.9299 17.95 240088............ 01.4614 16.70 240176............ 00.9959 11.09 250073............ 00.9818 09.92
230149............ 01.2363 14.09 240001............ 01.5709 19.57 240089............ 01.0424 14.41 240179............ 00.9910 13.73 250076............ 00.9532 09.20
230150............ 01.5558 19.01 240002............ 01.6583 18.05 240090............ 01.0898 13.05 240180............ 00.9751 10.20 250077............ 00.9312 10.22
230151............ 01.3819 18.80 240003............ 01.2260 22.55 240091............ 01.0285 10.83 240184............ 01.0000 10.98 250078............ 01.3952 13.14
230153............ 01.0545 14.86 240004............ 01.4565 19.95 240093............ 01.2745 15.33 240187............ 01.2855 17.00 250079............ 00.8711 12.23
230154............ 01.0145 12.31 240005............ 00.9226 12.75 240094............ 00.9733 15.34 240192............ 01.0414 12.40 250081............ 01.2179 14.37
230155............ 01.1301 12.02 240006............ 01.1607 18.19 240096............ 01.1233 13.37 240193............ 01.1285 14.01 250082............ 01.2194 11.07
230156............ 01.6572 20.20 240007............ 01.0727 14.10 240097............ 01.1103 16.27 240196............ 00.6073 18.87 250083............ 00.9415 11.25
230157............ 01.3264 18.63 240008............ 01.0423 13.25 240098............ 01.0163 13.46 240200............ 00.8775 12.53 250084............ 01.1268 13.13
230159............ 01.3241 17.40 240009............ 01.1501 12.81 240099............ 01.0446 11.38 240205............ 00.9269 ....... 250085............ 01.0493 11.04
230162............ 00.9761 13.97 240010............ 01.9877 18.88 240100............ 01.2773 16.95 240206............ 00.8339 ....... 250086............ 00.9820 12.08
230165............ 01.7408 18.96 240011............ 01.1026 14.63 240101............ 01.2198 15.26 240207............ 01.1892 21.20 250088............ 00.9881 13.26
230167............ 01.2063 18.27 240013............ 01.2265 15.49 240102............ 01.0632 12.97 240210............ 01.3002 21.21 250089............ 01.0398 10.86
230169............ 01.3445 19.72 240014............ 01.0877 16.06 240103............ 01.1255 14.27 250001............ 01.5597 13.55 250091............ 00.9638 10.48
230171............ 01.0360 12.36 240016............ 01.3843 14.67 240104............ 01.1698 19.04 250002............ 00.8108 11.80 250093............ 01.1476 11.22
230172............ 01.2642 17.17 240017............ 01.1252 14.24 240105............ 00.9307 13.40 250003............ 00.9261 12.12 250094............ 01.2731 13.27
230173............ 01.2653 17.18 240018............ 01.2112 15.09 240106............ 01.2288 21.48 250004............ 01.4355 13.66 250095............ 01.0352 11.59
230174............ 01.2966 16.15 240019............ 01.3072 18.63 240107............ 00.9027 13.16 250005............ 00.9909 08.78 250096............ 01.1186 14.83
230175............ 02.6575 14.97 240020............ 01.1766 16.41 240108............ 01.0205 10.01 250006............ 00.9784 12.45 250097............ 01.2120 12.30
230176............ 01.2103 20.13 240021............ 01.1289 13.70 240109............ 00.9590 13.51 250007............ 01.2263 15.01 250098............ 00.8689 09.46
230178............ 01.0454 14.99 240022............ 01.0734 15.34 240110............ 00.9611 15.47 250008............ 00.9896 11.21 250099............ 01.2528 11.75
230180............ 01.0835 14.16 240023............ 01.1016 15.19 240111............ 01.0310 11.74 250009............ 01.1394 12.14 250100............ 01.2444 11.80
230184............ 01.1304 14.57 240025............ 01.1440 14.38 240112............ 00.9869 12.95 250010............ 01.0681 10.06 250101............ 00.8813 08.70
230186............ 01.0962 14.08 240027............ 01.0252 11.62 240114............ 01.0385 10.60 250012............ 00.9557 12.30 250102............ 01.4950 13.33
230188............ 01.1138 15.94 240028............ 01.0995 15.09 240115............ 01.6058 21.44 250015............ 01.0527 09.37 250104............ 01.3329 14.08
230189............ 00.9189 13.54 240029............ 01.2110 14.23 240116............ 00.9244 12.14 250017............ 00.9473 13.08 250105............ 00.8949 11.28
230190............ 01.3785 18.04 240030............ 01.3289 15.33 240117............ 01.1189 15.35 250018............ 00.9046 10.20 250107............ 00.9558 13.72
230191............ 00.8881 13.06 240031............ 01.0538 13.01 240119............ 00.8879 14.25 250019............ 01.3901 14.82 250109............ 00.9646 10.30
230193............ 01.2619 16.40 240036............ 01.4910 17.88 240121............ 00.9040 16.37 250020............ 00.9777 08.74 250112............ 00.9603 11.79
230194............ 01.1983 13.91 240037............ 01.1014 15.67 240122............ 01.0987 15.27 250021............ 00.9506 07.83 250117............ 01.0673 12.06
230195............ 01.2973 19.72 240038............ 01.4942 21.20 240123............ 01.0561 13.47 250023............ 00.8516 09.86 250119............ 01.0942 10.32
230197............ 01.2661 17.75 240040............ 01.2590 16.06 240124............ 01.0496 14.28 250024............ 01.0275 07.74 250120............ 00.9973 10.44
230199............ 01.1337 15.53 240041............ 01.2707 13.37 240125............ 00.9045 10.46 250025............ 01.0231 12.94 250122............ 01.2232 15.54
230201............ 01.0707 12.87 240043............ 01.2186 15.65 240127............ 01.0109 11.10 250027............ 01.0461 10.39 250123............ 01.2141 18.71
230204............ 01.2813 19.02 240044............ 01.1936 15.06 240128............ 01.1627 15.73 250029............ 00.9638 10.16 250124............ 00.9091 10.51
230205............ 01.0786 14.68 240045............ 01.0165 16.58 240129............ 01.0178 12.94 250030............ 00.9948 10.01 250125............ 01.3004 14.95
230207............ 01.2236 18.62 240047............ 01.4158 15.84 240130............ 00.9797 13.39 250031............ 01.2574 16.18 250126............ 01.0603 11.53
230208............ 01.2154 13.74 240048............ 01.3229 20.23 240132............ 01.1820 22.17 250032............ 01.2336 14.64 250127............ 00.7931 ......
230211............ 00.9649 12.38 240049............ 01.7181 19.30 240133............ 01.1219 15.04 250033............ 00.9734 11.82 250128............ 00.9379 10.79
230212............ 01.0570 18.73 240050............ 01.1358 18.32 240135............ 00.9489 11.11 250034............ 01.4985 11.58 250131............ 01.0129 09.78
230213............ 01.0874 11.66 240051............ 00.9262 15.59 240136............ 00.8433 12.11 250035............ 00.8653 12.15 250134............ 01.0001 11.82
230216............ 01.3301 15.22 240052............ 01.2101 15.63 240137............ 01.1848 14.41 250036............ 00.9998 10.69 250136............ 00.8317 14.79
230217............ 01.1531 16.72 240053............ 01.4947 18.22 240138............ 00.8944 09.63 250037............ 00.9016 08.35 250138............ 01.2894 15.41
230219............ 01.0251 11.59 240056............ 01.2468 19.37 240139............ 00.9726 14.31 250038............ 00.9956 09.69 250140............ 00.9057 08.90
230221............ 01.3034 20.08 240057............ 01.7397 20.10 240140............ 00.9074 11.48 250039............ 00.9782 08.23 250141............ 01.2843 14.93
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Page 9 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
250144............ 00.9087 ....... 260086............ 01.0276 12.04 270003............ 01.1922 16.85 280021............ 01.1320 13.17 280108............ 01.0898 12.16
250145............ 00.7431 ....... 260089............ 01.0034 12.53 270004............ 01.6473 16.14 280022............ 00.9379 10.81 280109............ 00.8498 11.14
250146............ 01.0147 ....... 260091............ 01.6277 18.26 270006............ 00.9936 10.56 280023............ 01.3529 13.27 280110............ 00.9955 10.65
260001............ 01.6604 14.89 260092............ 01.0280 13.62 270007............ 00.9529 11.48 280024............ 00.9818 11.66 280111............ 01.2937 14.82
260002............ 01.3724 19.21 260094............ 01.0726 12.66 270009............ 01.0682 18.52 280025............ 01.0212 10.04 280114............ 01.0081 10.45
260003............ 01.0283 12.20 260095............ 01.3812 15.45 270011............ 01.1014 14.76 280026............ 01.0488 12.16 280115............ 01.0183 12.67
260004............ 01.0563 12.94 260096............ 01.4996 19.36 270012............ 01.4686 16.27 280028............ 01.0088 11.92 280117............ 01.0867 13.19
260005............ 01.5562 17.00 260097............ 01.1369 14.13 270013............ 01.2710 15.04 280029............ 00.8925 09.58 280118............ 01.0471 14.77
260006............ 01.5091 15.71 260100............ 01.0538 12.23 270014............ 01.6127 14.95 280030............ 01.8580 21.75 280119............ 00.8597 ......
260007............ 01.3660 15.19 260102............ 01.0829 14.83 270016............ 00.8137 09.83 280031............ 01.0559 12.06 280123............ 00.8035 13.91
260008............ 01.2489 14.14 260103............ 01.3961 16.34 270017............ 01.2385 15.69 280032............ 01.2486 14.22 290001............ 01.6545 20.33
260009............ 01.2556 14.91 260104............ 01.6527 17.76 270019............ 00.9621 10.82 280033............ 01.1060 13.61 290002............ 00.9094 16.20
260011............ 01.5675 16.81 260105............ 01.8628 17.57 270021............ 01.1288 13.12 280034............ 01.1970 13.53 290003............ 01.6628 20.74
260012............ 01.0755 10.76 260107............ 01.4005 16.71 270023............ 01.3333 16.04 280035............ 00.9221 11.06 290005............ 01.2576 18.60
260013............ 01.1777 13.00 260108............ 01.7809 17.07 270024............ 00.9949 12.25 280037............ 00.9970 10.57 290006............ 01.0379 17.56
260014............ 01.7042 17.03 260109............ 01.0304 10.83 270026............ 00.9248 14.52 280038............ 01.0946 12.32 290007............ 01.8706 22.26
260015............ 01.1455 13.06 260110............ 01.6218 13.93 270027............ 01.0069 11.19 280039............ 01.1507 11.46 290008............ 01.2910 19.77
260017............ 01.2244 13.75 260111............ 00.9167 10.33 270028............ 01.0198 14.70 280040............ 01.5951 17.67 290009............ 01.5071 20.23
260018............ 00.9461 08.71 260112............ 01.4058 17.17 270029............ 01.0302 14.41 280041............ 01.0360 10.18 290010............ 01.1549 16.04
260019............ 01.0189 12.36 260113............ 01.1613 11.99 270030............ 00.7612 ....... 280042............ 01.0397 12.52 290011............ 00.8724 11.94
260020............ 01.6648 18.00 260115............ 01.1921 13.38 270031............ 00.9294 10.86 280043............ 01.1304 13.48 290012............ 01.3601 18.32
260021............ 01.4508 16.18 260116............ 01.1508 12.40 270032............ 01.0819 15.20 280045............ 01.1224 12.49 290013............ 00.9998 15.06
260022............ 01.3952 14.44 260119............ 01.2581 13.25 270033............ 00.9108 14.51 280046............ 00.9991 10.16 290014............ 01.0364 15.84
260023............ 01.2376 14.14 260120............ 01.2378 14.81 270035............ 01.0176 13.97 280047............ 01.0890 14.84 290015............ 00.9368 14.63
260024............ 01.0546 11.04 260122............ 01.1796 12.00 270036............ 00.9100 11.20 280048............ 01.0516 10.70 290016............ 01.2040 13.62
260025............ 01.2444 13.10 260123............ 01.0269 10.37 270039............ 00.9364 17.94 280049............ 01.0245 12.20 290018............ 01.2698 17.15
260027............ 01.5773 17.97 260127............ 00.9726 13.39 270040............ 01.0843 15.30 280050............ 00.9501 11.55 290019............ 01.2290 17.04
260029............ 01.1914 16.89 260128............ 00.9655 08.66 270041............ 00.9648 10.47 280051............ 00.9747 12.15 290020............ 01.2552 16.81
260030............ 01.1698 10.05 260129............ 01.0658 12.87 270044............ 01.2502 12.55 280052............ 01.0428 10.45 290021............ 01.5764 20.70
260031............ 01.4920 17.49 260131............ 01.2902 15.02 270046............ 00.9153 13.91 280054............ 01.2385 15.23 290022............ 01.5911 20.10
260032............ 01.6988 18.87 260134............ 01.2830 13.25 270047............ 01.1693 09.98 280055............ 00.9076 11.10 290027............ 01.0014 16.54
260033............ 01.3199 14.53 260137............ 01.1775 13.64 270048............ 01.1046 13.59 280056............ 01.0467 09.44 290029............ 00.9610 ......
260034............ 01.0194 13.13 260138............ 01.8670 18.90 270049............ 01.7178 15.71 280057............ 01.0131 13.50 290032............ 01.3945 19.64
260035............ 01.1391 11.06 260141............ 01.9337 15.87 270050............ 01.0085 15.42 280058............ 01.2654 12.49 300001............ 01.3455 19.02
260036............ 01.0811 14.55 260142............ 01.2046 13.51 270051............ 01.3094 18.46 280060............ 01.5755 17.64 300003............ 01.7463 19.71
260037............ 01.2491 13.74 260143............ 01.0419 10.03 270052............ 01.0278 19.34 280061............ 01.3448 14.94 300005............ 01.2754 17.05
260039............ 01.2075 10.70 260146............ 01.5253 14.81 270053............ 01.1036 08.14 280062............ 01.1994 11.55 300006............ 01.1294 15.08
260040............ 01.4936 14.03 260147............ 01.0244 11.64 270055............ 00.7054 ....... 280064............ 01.0401 11.38 300007............ 01.1469 19.46
260042............ 01.1864 15.65 260148............ 00.9992 14.12 270057............ 01.1718 15.06 280065............ 01.2338 15.65 300008............ 01.2678 15.50
260044............ 01.0661 13.62 260158............ 01.0821 10.90 270058............ 00.9589 10.74 280066............ 01.0733 10.40 300009............ 01.1594 16.54
260047............ 01.2906 13.11 260159............ 01.1853 18.22 270059............ 00.8646 12.91 280068............ 00.9019 08.61 300010............ 01.2414 16.90
260048............ 01.2887 16.57 260160............ 01.1296 12.91 270060............ 00.9063 11.63 280070............ 01.0299 11.22 300011............ 01.2946 20.39
260050............ 01.0970 12.97 260162............ 01.1279 16.85 270063............ 00.8744 13.29 280073............ 01.0037 13.90 300012............ 01.2902 20.73
260051............ 01.0865 13.22 260163............ 01.1758 12.84 270067............ 01.1181 ....... 280074............ 01.0922 10.62 300013............ 01.2111 15.98
260052............ 01.2556 15.53 260164............ 01.0759 11.11 270068............ 00.8709 11.69 280075............ 01.2277 11.19 300014............ 01.2533 16.93
260053............ 01.1325 09.80 260166............ 01.2139 17.16 270072............ 00.8859 15.52 280076............ 01.1028 13.66 300015............ 01.1504 16.71
260054............ 01.2860 15.62 260172............ 00.9927 11.99 270073............ 01.1496 10.27 280077............ 01.2979 16.26 300016............ 01.2402 17.23
260055............ 01.0641 12.73 260173............ 00.9866 10.22 270074............ 00.8792 ....... 280079............ 00.9470 09.48 300017............ 01.1839 18.41
260057............ 01.2108 13.64 260175............ 01.1904 13.15 270075............ 00.9339 ....... 280080............ 01.2358 10.27 300018............ 01.2222 18.26
260059............ 01.1143 11.93 260176............ 01.5577 15.91 270076............ 00.7820 ....... 280081............ 01.4820 16.98 300019............ 01.2465 17.09
260061............ 01.1439 09.82 260177............ 01.2963 18.12 270079............ 00.9326 12.66 280082............ 01.2966 10.41 300020............ 01.2355 18.13
260062............ 01.1626 15.45 260178............ 01.5044 19.22 270080............ 01.1012 13.18 280083............ 01.0266 11.97 300021............ 01.1580 14.84
260063............ 01.1442 13.06 260179............ 01.5327 20.18 270081............ 00.9722 10.11 280084............ 01.0412 09.83 300022............ 01.1177 15.00
260064............ 01.3888 15.64 260180............ 01.5530 17.26 270082............ 00.9105 14.85 280085............ 00.8963 13.22 300023............ 01.2379 19.05
260065............ 01.6791 14.32 260183............ 01.6381 15.05 270083............ 01.0383 12.97 280088............ 01.6715 17.29 300024............ 01.2305 15.72
260066............ 01.1340 12.15 260186............ 01.1666 14.14 270084............ 00.9200 13.03 280089............ 01.0477 12.85 300028............ 01.2066 16.12
260067............ 00.9175 12.05 260188............ 01.3803 15.00 280001............ 01.0424 12.18 280090............ 00.9980 11.70 300029............ 01.3288 20.57
260068............ 01.7843 17.91 260189............ 00.8964 09.49 280003............ 01.8996 16.43 280091............ 01.0891 13.13 300033............ 01.0766 13.25
260070............ 01.2308 10.32 260190............ 01.2074 20.62 280005............ 01.4389 16.26 280092............ 00.9183 11.14 300034............ 01.7985 21.02
260073............ 01.0281 10.98 260191............ 01.2290 17.70 280009............ 01.5319 15.40 280094............ 01.1517 12.59 310001............ 01.6513 22.19
260074............ 01.2161 13.00 260193............ 01.2593 16.35 280011............ 00.9727 10.71 280097............ 00.9670 12.09 310002............ 01.7937 22.69
260077............ 01.5220 15.46 260195............ 01.1421 14.93 280012............ 01.2184 12.69 280098............ 00.9679 10.10 310003............ 01.2115 20.93
260078............ 01.1278 13.62 260197............ 01.2162 20.81 280013............ 02.0045 20.17 280101............ 01.1395 12.16 310005............ 01.1880 19.16
260079............ 01.0065 10.71 260198............ 01.2144 14.62 280014............ 01.0475 10.76 280102............ 00.9671 10.22 310006............ 01.2265 19.94
260080............ 01.0818 09.00 260200............ 01.2021 19.15 280015............ 01.1021 13.75 280104............ 01.0008 10.12 310008............ 01.2993 20.15
260081............ 01.4117 17.40 260202............ 01.2971 16.81 280017............ 01.1136 12.92 280105............ 01.2978 14.83 310009............ 01.1537 19.28
260082............ 01.1213 13.27 260204............ 00.8039 ....... 280018............ 00.9982 11.78 280106............ 01.0662 12.09 310010............ 01.2724 19.78
260085............ 01.5139 17.37 270002............ 01.1955 12.64 280020............ 01.4322 16.53 280107............ 01.0346 10.56 310011............ 01.2389 18.15
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Page 10 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
310012............ 01.5465 21.51 310105............ 01.3448 19.91 330012............ 01.5891 26.43 330115............ 01.2289 13.79 330221............ 01.2913 25.37
310013............ 01.3011 17.62 310108............ 01.3071 19.81 330013............ 01.9898 16.97 330116............ 00.9711 16.94 330222............ 01.2085 14.02
310014............ 01.6025 22.63 310110............ 01.1805 18.46 330014............ 01.4094 25.19 330118............ 01.5992 16.45 330223............ 01.0718 13.45
310015............ 01.6967 23.19 310111............ 01.2890 17.97 330016............ 01.0313 14.50 330119............ 01.7324 27.28 330224............ 01.2545 19.36
310016............ 01.2159 20.92 310112............ 01.2782 18.62 330019............ 01.2647 22.80 330121............ 01.0075 14.55 330225............ 01.1934 23.33
310017............ 01.3456 20.37 310113............ 01.2519 18.56 330020............ 01.0852 14.84 330122............ 01.2317 20.97 330226............ 01.2692 17.69
310018............ 01.2401 24.06 310115............ 01.1827 18.93 330023............ 01.2029 20.62 330125............ 01.6989 18.97 330229............ 01.3227 13.56
310019............ 01.6525 20.28 310116............ 01.2871 19.92 330024............ 01.8238 26.75 330126............ 01.2026 18.36 330230............ 01.5327 24.70
310020............ 01.2383 18.05 310118............ 01.2884 23.38 330025............ 01.1054 14.30 330127............ 01.3874 24.83 330231............ 01.1566 25.13
310021............ 01.3406 18.25 310119............ 01.5707 29.97 330027............ 01.5406 28.98 330128............ 01.4001 25.66 330232............ 01.2524 14.83
310022............ 01.2341 18.31 310120............ 01.0934 17.21 330028............ 01.3486 22.68 330132............ 01.1440 12.27 330233............ 01.5282 27.14
310024............ 01.2391 20.74 310121............ 01.1299 18.72 330029............ 01.1455 15.76 330133............ 01.3714 26.33 330234............ 02.0317 25.92
310025............ 01.1982 19.63 310898............ 00.4649 ....... 330030............ 01.1803 14.98 330135............ 01.2404 16.49 330235............ 01.1443 16.14
310026............ 01.3190 20.21 320001............ 01.4446 16.86 330033............ 01.1764 13.16 330136............ 01.2613 21.77 330236............ 01.3346 25.41
310027............ 01.3101 18.35 320002............ 01.3067 20.26 330034............ 01.0194 28.07 330140............ 01.6566 16.38 330238............ 01.1253 14.95
310028............ 01.1788 18.28 320003............ 01.2587 13.22 330036............ 01.2568 20.09 330141............ 01.3119 22.33 330239............ 01.2376 13.84
310029............ 01.7881 19.95 320004............ 01.1565 15.58 330037............ 01.0934 13.75 330144............ 01.0820 12.78 330240............ 01.3190 26.44
310031............ 02.5338 22.82 320005............ 01.2264 16.12 330038............ 01.1641 14.14 330148............ 00.9909 13.44 330241............ 01.8452 20.10
310032............ 01.2716 19.09 320006............ 01.3782 13.69 330039............ 00.8406 13.46 330151............ 01.0970 12.90 330242............ 01.3650 19.96
310034............ 01.2258 19.42 320009............ 01.5065 15.54 330041............ 01.3283 24.26 330152............ 01.4065 26.08 330245............ 01.2193 15.62
310036............ 01.2240 17.75 320011............ 00.9910 15.41 330043............ 01.2503 24.13 330153............ 01.6335 16.75 330246............ 01.2161 22.72
310037............ 01.2157 23.45 320012............ 01.0253 14.52 330044............ 01.1694 16.27 330154............ 01.4930 ....... 330247............ 00.6932 24.34
310038............ 01.7602 21.93 320013............ 01.0733 15.84 330045............ 01.4054 22.13 330157............ 01.2605 15.89 330249............ 01.2319 15.40
310039............ 01.2973 18.74 320014............ 00.9531 13.73 330046............ 01.5348 26.37 330158............ 01.3217 21.63 330250............ 01.2727 16.08
310040............ 01.2386 20.49 320016............ 01.1396 14.59 330047............ 01.2736 15.31 330159............ 01.3201 17.51 330252............ 00.9592 14.59
310041............ 01.2754 20.49 320017............ 01.1751 17.22 330048............ 01.2376 15.07 330160............ 01.4209 24.63 330254............ 01.0004 16.38
310042............ 01.1754 21.01 320018............ 01.4546 16.07 330049............ 01.2842 17.67 330161............ 00.9498 15.29 330258............ 01.3313 23.94
310043............ 01.2230 19.18 320019............ 01.3944 17.39 330053............ 01.1371 13.82 330162............ 01.3010 22.13 330259............ 01.4230 21.97
310044............ 01.3075 18.63 320021............ 01.6940 17.70 330055............ 01.4247 27.10 330163............ 01.1475 15.59 330261............ 01.2832 21.92
310045............ 01.2990 23.02 320022............ 01.2537 16.29 330056............ 01.4228 24.73 330164............ 01.3340 17.75 330263............ 01.0461 15.05
310047............ 01.2841 20.46 320023............ 01.0782 11.67 330057............ 01.6252 16.38 330166............ 00.9789 13.39 330264............ 01.1798 17.85
310048............ 01.2223 15.96 320030............ 01.0494 15.83 330058............ 01.2703 14.94 330167............ 01.5602 26.57 330265............ 01.2976 15.23
310049............ 01.3084 19.63 320031............ 00.9369 12.53 330059............ 01.5555 26.37 330169............ 01.4141 28.56 330267............ 01.3104 21.14
310050............ 01.1861 20.08 320032............ 00.9493 15.92 330061............ 01.3455 21.49 330171............ 01.2994 22.03 330268............ 01.1163 14.37
310051............ 01.2773 21.27 320033............ 01.1006 17.04 330062............ 01.0580 14.93 330175............ 01.0770 13.20 330270............ 01.9165 28.16
310052............ 01.2164 20.20 320035............ 01.3206 13.24 330064............ 01.4068 25.74 330177............ 01.0088 13.24 330273............ 01.3526 20.62
310054............ 01.2774 21.28 320037............ 01.1547 13.11 330065............ 01.1936 16.20 330179............ 00.8930 12.97 330275............ 01.2280 16.62
310056............ 01.1793 17.95 320038............ 01.2495 14.38 330066............ 01.2270 17.39 330180............ 01.1887 14.90 330276............ 01.2188 16.70
310057............ 01.2752 18.24 320046............ 01.0773 15.91 330067............ 01.3194 18.82 330181............ 01.2338 27.69 330277............ 01.1783 15.22
310058............ 01.1306 20.45 320048............ 01.2160 12.91 330072............ 01.3403 26.08 330182............ 02.3720 25.91 330279............ 01.2887 16.77
310060............ 01.1744 15.89 320056............ 00.9240 ....... 330073............ 01.2108 12.91 330183............ 01.3597 17.43 330281............ 00.5697 20.00
310061............ 01.1668 18.39 320057............ 01.0162 ....... 330074............ 01.2561 15.83 330184............ 01.3567 22.64 330285............ 01.7416 20.83
310062............ 01.3150 24.72 320058............ 00.7242 ....... 330075............ 01.0777 15.06 330185............ 01.1982 22.90 330286............ 01.3414 21.78
310063............ 01.3385 20.38 320059............ 01.0386 ....... 330078............ 01.3801 15.94 330186............ 01.0663 19.57 330288............ 01.0498 15.73
310064............ 01.2553 20.41 320060............ 00.9193 ....... 330079............ 01.2608 14.89 330188............ 01.2357 16.63 330290............ 01.7045 26.56
310067............ 01.2814 19.21 320061............ 01.3108 ....... 330080............ 01.3188 23.40 330189............ 00.7685 13.00 330293............ 01.1864 13.94
310069............ 01.1751 18.53 320062............ 00.8670 ....... 330082............ 01.2573 16.58 330191............ 01.2977 16.96 330304............ 01.2689 24.14
310070............ 01.3224 20.67 320063............ 01.2952 15.07 330084............ 00.9780 15.00 330193............ 01.3655 24.94 330306............ 01.4100 23.49
310071............ 00.7721 ....... 320065............ 01.1964 15.47 330085............ 01.3582 17.69 330194............ 01.8291 25.78 330307............ 01.2206 16.06
310072............ 01.2463 19.27 320067............ 00.9066 10.33 330086............ 01.2397 22.49 330195............ 01.5607 26.38 330308............ 01.2850 24.28
310073............ 01.4738 20.47 320068............ 01.0028 15.10 330088............ 01.1084 22.93 330196............ 01.3817 24.47 330309............ 01.2115 22.70
310074............ 01.2517 19.30 320069............ 01.0237 12.54 330090............ 01.6385 15.36 330197............ 01.0509 14.66 330314............ 01.2907 21.13
310075............ 01.3036 20.76 320070............ 00.9179 ....... 330091............ 01.3756 17.28 330198............ 01.3557 26.09 330315............ 01.1665 21.49
310076............ 01.3534 25.44 320074............ 01.1338 17.10 330092............ 01.0293 13.86 330199............ 01.2843 23.00 330316............ 01.2991 23.18
310077............ 01.5680 20.76 320076............ 01.2003 14.58 330094............ 01.1784 14.68 330201............ 01.4500 24.55 330327............ 00.9253 14.93
310078............ 01.2714 22.01 320079............ 01.1346 18.51 330095............ 01.1935 15.53 330202............ 01.4040 25.07 330331............ 01.2039 24.80
310081............ 01.2509 18.24 320080............ 00.5832 12.07 330096............ 01.0573 13.82 330203............ 01.3484 18.97 330332............ 01.2506 22.24
310083............ 01.2392 20.23 330001............ 01.1722 19.91 330097............ 01.1720 14.78 330204............ 01.3382 23.41 330333............ 01.3116 23.30
310084............ 01.1994 18.74 330002............ 01.4547 22.56 330100............ 00.7032 22.60 330205............ 01.2042 17.97 330336............ 01.3679 26.05
310085............ 01.1133 ....... 330003............ 01.2847 17.15 330101............ 01.7173 30.13 330208............ 01.2029 21.83 330338............ 01.1671 20.43
310086............ 01.1944 19.53 330004............ 01.3090 17.83 330102............ 01.3050 15.74 330209............ 01.2328 18.89 330339............ 00.7973 17.43
310087............ 01.2491 18.41 330005............ 01.7496 18.22 330103............ 01.1862 15.52 330211............ 01.1984 15.21 330340............ 01.1787 24.08
310088............ 01.1610 19.42 330006............ 01.3397 22.16 330104............ 01.3474 24.45 330212............ 01.2156 18.85 330350............ 01.8045 26.28
310090............ 01.2276 20.34 330007............ 01.3752 15.51 330106............ 01.5766 29.39 330213............ 01.1346 15.33 330353............ 01.3027 24.98
310091............ 01.2150 18.76 330008............ 01.1600 15.29 330107............ 01.1823 22.28 330214............ 01.7349 27.58 330354............ 01.4060 ......
310092............ 01.3769 18.31 330009............ 01.2687 26.03 330108............ 01.2065 16.53 330215............ 01.1490 15.94 330357............ 01.3696 29.57
310093............ 01.1876 18.84 330010............ 01.2305 14.08 330111............ 01.1373 13.22 330218............ 01.2150 16.58 330359............ 00.9253 19.30
310096............ 01.8968 22.27 330011............ 01.2148 16.40 330114............ 00.9949 15.08 330219............ 01.6147 18.45 330372............ 01.2703 21.37
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Page 11 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
330381............ 01.2440 23.70 340065............ 01.1402 13.03 340160............ 01.1146 12.75 360015............ 01.4740 17.62 360091............ 01.2664 17.38
330383............ 01.5047 ....... 340067............ 01.1674 12.63 340162............ 01.1558 16.49 360016............ 01.5341 17.05 360092............ 01.1787 16.42
330385............ 01.4091 29.11 340068............ 01.3530 12.17 340164............ 01.3548 17.07 360017............ 01.7224 18.91 360093............ 01.2189 15.15
330386............ 01.1674 17.11 340069............ 01.7583 17.39 340166............ 01.3222 17.47 360018............ 01.5058 17.63 360094............ 01.1798 18.37
330387............ 00.8496 23.22 340070............ 01.2688 15.12 340168............ 00.5447 14.80 360019............ 01.2310 17.21 360095............ 01.2746 15.08
330389............ 01.8827 27.58 340071............ 01.0358 13.49 350001............ 01.0315 11.25 360020............ 01.4312 16.47 360096............ 01.0991 14.95
330390............ 01.3011 24.47 340072............ 01.1025 13.40 350002............ 01.6951 16.15 360021............ 01.2185 16.31 360098............ 01.3837 17.84
330393............ 01.6207 22.84 340073............ 01.4664 18.47 350003............ 01.1489 14.21 360024............ 01.2366 16.75 360099............ 01.0624 15.49
330394............ 01.4091 16.96 340075............ 01.1532 14.80 350004............ 01.8730 17.07 360025............ 01.1899 17.00 360100............ 01.2993 15.02
330395............ 01.3622 25.96 340080............ 01.1422 09.88 350005............ 01.1089 11.21 360026............ 01.1855 15.01 360101............ 01.7474 19.63
330396............ 01.2287 26.91 340084............ 01.0553 13.62 350006............ 01.2745 17.95 360027............ 01.5371 17.37 360102............ 01.2642 17.18
330397............ 01.5173 26.69 340085............ 01.1922 14.33 350007............ 01.0060 09.21 360028............ 01.3748 15.02 360103............ 01.3969 18.47
330398............ 01.2377 24.94 340087............ 01.1725 14.86 350008............ 01.0659 13.30 360029............ 01.1187 14.74 360104............ 00.9491 16.76
330399............ 01.3658 28.62 340088............ 01.1225 14.92 350009............ 01.1443 14.36 360030............ 01.1943 14.51 360106............ 01.1455 12.63
340001............ 01.3618 17.90 340089............ 00.9771 10.77 350010............ 01.0952 11.07 360031............ 01.2736 16.00 360107............ 01.1824 15.07
340002............ 01.8293 16.29 340090............ 01.0764 14.15 350011............ 01.7258 16.96 360032............ 01.0786 15.27 360108............ 01.0347 13.97
340003............ 01.1755 14.86 340091............ 01.6452 17.60 350012............ 01.0654 11.31 360034............ 01.1979 12.84 360109............ 01.0463 16.12
340004............ 01.4936 15.33 340093............ 01.1216 11.99 350013............ 01.1237 13.52 360035............ 01.4871 18.47 360112............ 01.7808 19.41
340005............ 01.1924 12.35 340094............ 01.3282 15.81 350014............ 01.1283 10.67 360036............ 01.1922 16.47 360113............ 01.3411 17.59
340006............ 01.2405 13.41 340096............ 01.2409 14.57 350015............ 01.6098 15.71 360037............ 02.1054 18.67 360114............ 01.0986 14.97
340007............ 01.1630 13.78 340097............ 01.1145 11.48 350016............ 00.9575 11.10 360038............ 01.4843 16.89 360115............ 01.1640 16.96
340008............ 01.1836 15.73 340098............ 01.6380 16.25 350017............ 01.3376 15.09 360039............ 01.2818 14.64 360116............ 01.0704 14.50
340009............ 01.5128 18.76 340099............ 01.1377 11.89 350018............ 01.1527 09.40 360040............ 01.2237 16.01 360118............ 01.2778 15.25
340010............ 01.3133 14.82 340100............ 01.2221 ....... 350019............ 01.5855 17.49 360041............ 01.3449 16.68 360119............ 01.2596 17.14
340011............ 01.0666 12.63 340101............ 01.0389 09.36 350020............ 01.3945 16.19 360042............ 01.1135 14.26 360120............ 00.7469 17.54
340012............ 01.1413 14.03 340104............ 01.0198 07.49 350021............ 01.0494 10.29 360044............ 01.0728 14.26 360121............ 01.2395 16.08
340013............ 01.2006 14.24 340105............ 01.3469 17.54 350023............ 01.0025 11.13 360045............ 01.4747 19.21 360122............ 01.3784 16.72
340014............ 01.6068 18.81 340106............ 01.1325 15.13 350024............ 01.1555 09.39 360046............ 01.1337 16.35 360123............ 01.2396 16.88
340015............ 01.2374 14.74 340107............ 01.2480 15.74 350025............ 00.9831 11.59 360047............ 01.0766 12.46 360124............ 01.2023 16.36
340016............ 01.1048 13.82 340109............ 01.3004 14.37 350027............ 00.9928 12.22 360048............ 01.8291 20.28 360125............ 01.1405 14.91
340017............ 01.2631 13.87 340111............ 01.1326 12.76 350029............ 00.8768 09.62 360049............ 01.3148 17.96 360126............ 01.3140 15.84
340018............ 01.1928 13.17 340112............ 01.0464 13.95 350030............ 01.0239 14.92 360050............ 01.1785 12.14 360127............ 01.0833 14.17
340019............ 01.1077 13.33 340113............ 01.9082 18.50 350033............ 00.9352 13.57 360051............ 01.5018 18.53 360128............ 01.1316 13.72
340020............ 01.1827 18.53 340114............ 01.4397 18.30 350034............ 00.9722 12.92 360052............ 01.7050 16.61 360129............ 01.0195 13.03
340021............ 01.3166 13.89 340115............ 01.5014 16.58 350035............ 00.9150 09.26 360054............ 01.2823 14.56 360130............ 01.0625 13.04
340022............ 01.0900 13.65 340116............ 01.7657 19.73 350036............ 00.9025 09.81 360055............ 01.1928 16.86 360131............ 01.2097 15.01
340023............ 01.3151 16.32 340119............ 01.2890 13.80 350038............ 01.0215 15.62 360056............ 01.3100 15.51 360132............ 01.2467 16.73
340024............ 01.2484 13.00 340120............ 01.1005 12.06 350039............ 01.0200 12.62 360057............ 01.0723 12.52 360133............ 01.4538 16.50
340025............ 01.1576 13.18 340121............ 01.0702 12.96 350041............ 01.0704 12.85 360058............ 01.1505 15.01 360134............ 01.5573 17.39
340027............ 01.2165 13.68 340122............ 01.0063 10.85 350042............ 01.0638 12.64 360059............ 01.4957 18.80 360135............ 01.2170 14.57
340028............ 01.4178 15.42 340123............ 01.1582 13.69 350043............ 01.5278 14.64 360062............ 01.5712 17.01 360136............ 01.1243 13.87
340030............ 01.8722 17.35 340124............ 01.0999 13.00 350044............ 00.8327 08.90 360063............ 01.1058 14.42 360137............ 01.5686 18.00
340031............ 01.0154 11.45 340125............ 01.4091 16.81 350047............ 01.1831 15.32 360064............ 01.4694 17.62 360139............ 00.9743 12.05
340032............ 01.2736 16.39 340126............ 01.3403 15.76 350049............ 01.1917 09.83 360065............ 01.2442 15.02 360140............ 01.0780 14.54
340034............ 01.2686 16.12 340127............ 01.2586 15.62 350050............ 01.0158 11.38 360066............ 01.2236 14.92 360141............ 01.4099 18.14
340035............ 01.1562 15.17 340129............ 01.2571 17.74 350051............ 00.9788 12.48 360067............ 01.1075 11.39 360142............ 01.0062 13.89
340036............ 01.1861 15.00 340130............ 01.3265 14.86 350053............ 00.8959 11.10 360068............ 01.5775 18.67 360143............ 01.2491 16.84
340037............ 01.2293 15.38 340131............ 01.3162 15.31 350055............ 00.9074 11.18 360069............ 01.0213 15.38 360144............ 01.2708 18.65
340038............ 01.1347 13.31 340132............ 01.2827 12.54 350056............ 00.9586 11.87 360070............ 01.5546 15.73 360145............ 01.5305 15.26
340039............ 01.2821 16.55 340133............ 01.1553 14.11 350058............ 01.0392 11.16 360071............ 01.2517 14.03 360147............ 01.2000 14.87
340040............ 01.8061 16.34 340136............ 00.9837 16.24 350060............ 00.9417 07.24 360072............ 01.1876 14.87 360148............ 01.1722 14.28
340041............ 01.2486 14.67 340137............ 01.4444 12.18 350061............ 00.9976 12.32 360074............ 01.4123 16.37 360149............ 01.1040 15.84
340042............ 01.1515 13.14 340138............ 01.1751 14.43 350063............ 00.9146 ....... 360075............ 01.4347 19.23 360150............ 01.2634 16.63
340044............ 01.0459 10.39 340141............ 01.5719 17.23 350064............ 00.7287 ....... 360076............ 01.3232 15.96 360151............ 01.3390 15.61
340045............ 01.0286 09.87 340142............ 01.2200 14.37 350065............ 00.9497 10.34 360077............ 01.4129 16.81 360152............ 01.4837 16.15
340047............ 01.9040 16.64 340143............ 01.3553 17.58 350066............ 00.6282 ....... 360078............ 01.2635 17.46 360153............ 01.1782 12.99
340048............ 01.2550 07.91 340144............ 01.2895 17.53 360001............ 01.2318 15.77 360079............ 01.6716 18.23 360154............ 01.0398 11.51
340049............ 00.6445 15.08 340145............ 01.2739 17.27 360002............ 01.1534 14.33 360080............ 01.1335 14.11 360155............ 01.3267 17.47
340050............ 01.1703 14.78 340146............ 01.0497 12.17 360003............ 01.6359 18.41 360081............ 01.3223 17.76 360156............ 01.1304 16.04
340051............ 01.2070 15.20 340147............ 01.3448 15.57 360006............ 01.7543 18.70 360082............ 01.3216 17.76 360159............ 01.2104 16.45
340052............ 01.0038 16.81 340148............ 01.4339 15.52 360007............ 01.0831 15.64 360083............ 01.3053 15.20 360161............ 01.2553 18.08
340053............ 01.5864 17.14 340151............ 01.2056 13.47 360008............ 01.2059 14.53 360084............ 01.6031 16.81 360162............ 01.2698 15.67
340054............ 01.0825 12.08 340153............ 01.9188 19.98 360009............ 01.3259 17.41 360085............ 01.7507 18.24 360163............ 01.7578 18.19
340055............ 01.2212 15.33 340154............ 00.7612 14.62 360010............ 01.1667 14.40 360086............ 01.4164 15.83 360164............ 00.8600 13.58
340060............ 01.1257 14.49 340155............ 01.4494 20.53 360011............ 01.2476 16.40 360087............ 01.3185 15.92 360165............ 01.1166 13.53
340061............ 01.6405 17.49 340156............ 00.8025 ....... 360012............ 01.2386 17.96 360088............ 01.1425 14.18 360166............ 01.1834 15.77
340063............ 01.0344 11.52 340158............ 01.1027 15.90 360013............ 01.1028 16.12 360089............ 01.0943 15.10 360169............ 01.0871 16.28
340064............ 01.1708 14.10 340159............ 01.1214 14.10 360014............ 01.1275 15.02 360090............ 01.2463 17.34 360170............ 01.1101 16.93
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Page 12 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
360172............ 01.3501 15.73 370034............ 01.1511 11.98 370153............ 01.1505 13.77 380064............ 01.2983 18.01 390055............ 01.6951 19.09
360174............ 01.2039 14.63 370035............ 01.4865 14.39 370154............ 00.9983 11.80 380065............ 01.0296 17.02 390056............ 01.1105 15.26
360175............ 01.1487 15.64 370036............ 00.9836 08.68 370156............ 01.1475 12.70 380066............ 01.3878 15.59 390057............ 01.2599 17.60
360176............ 01.2231 12.33 370037............ 01.5519 15.41 370158............ 01.0613 12.52 380068............ 01.0179 18.42 390058............ 01.3006 16.59
360177............ 01.2790 16.76 370038............ 00.9814 10.14 370159............ 01.3848 14.16 380069............ 01.1849 15.99 390059............ 01.3068 15.15
360178............ 01.2346 14.42 370039............ 01.3170 17.93 370161............ 01.1867 16.35 380070............ 01.1736 18.67 390060............ 01.0954 14.69
360179............ 01.2754 17.80 370040............ 01.0365 09.92 370163............ 00.8697 09.85 380071............ 01.2557 21.69 390061............ 01.3869 17.33
360180............ 02.2165 20.03 370041............ 00.9739 12.74 370165............ 01.1600 10.92 380072............ 00.9976 13.01 390062............ 01.1690 14.09
360184............ 00.6996 14.70 370042............ 00.8919 10.84 370166............ 01.1736 16.00 380075............ 01.4436 18.03 390063............ 01.6704 17.69
360185............ 01.2021 15.85 370043............ 00.9414 10.62 370169............ 01.0442 10.00 380078............ 01.1587 16.41 390064............ 01.4469 15.00
360186............ 01.2453 14.82 370045............ 01.0557 10.20 370170............ 00.9497 ....... 380081............ 01.0971 15.77 390065............ 01.2240 17.69
360187............ 01.3438 16.16 370046............ 00.9896 12.64 370171............ 01.0047 ....... 380082............ 01.2171 18.63 390066............ 01.2517 16.74
360188............ 01.0363 14.70 370047............ 01.2384 12.34 370172............ 00.8760 ....... 380083............ 01.1325 16.57 390067............ 01.7140 17.24
360189............ 01.0689 14.46 370048............ 01.1242 11.45 370173............ 01.3875 ....... 380084............ 01.2186 19.45 390068............ 01.3575 16.97
360192............ 01.3454 17.97 370049............ 01.3478 14.08 370174............ 00.9106 ....... 380087............ 01.0498 12.17 390069............ 01.3063 16.98
360193............ 01.2980 14.54 370051............ 01.0263 10.47 370176............ 01.2597 17.68 380088............ 00.9537 14.76 390070............ 01.2732 18.91
360194............ 01.1427 14.46 370054............ 01.2804 14.57 370177............ 00.9686 09.39 380089............ 01.2716 19.78 390071............ 01.0913 11.99
360195............ 01.1534 16.45 370056............ 01.4467 14.44 370178............ 01.0643 11.08 380090............ 01.2968 18.73 390072............ 01.0770 14.85
360197............ 01.1662 15.43 370057............ 01.1446 13.92 370179............ 00.9625 12.90 380091............ 01.1835 22.18 390073............ 01.5256 17.40
360200............ 01.1548 10.65 370059............ 01.2056 12.34 370180............ 01.0308 ....... 380897............ 05.0059 ....... 390074............ 01.2084 15.50
360203............ 01.1387 14.52 370060............ 01.1681 11.89 370183............ 01.1562 11.67 390001............ 01.3124 16.25 390075............ 01.3120 14.60
360204............ 01.2181 15.73 370063............ 01.1628 11.88 370186............ 00.9969 09.16 390002............ 01.3148 16.65 390076............ 01.2692 18.60
360210............ 01.1414 17.25 370064............ 01.0038 08.92 370189............ 01.0572 09.26 390003............ 01.2013 15.23 390078............ 01.0384 15.47
360211............ 01.1987 15.45 370065............ 01.0730 13.47 370190............ 01.7487 18.02 390004............ 01.4003 15.76 390079............ 01.7125 15.49
360212............ 01.4238 17.91 370069............ 01.0292 12.62 380001............ 01.2816 17.45 390005............ 01.0353 13.42 390080............ 01.2033 17.54
360213............ 01.0795 14.45 370071............ 01.0864 10.25 380002............ 01.1913 16.54 390006............ 01.7625 16.22 390081............ 01.2631 18.98
360218............ 01.2589 15.27 370072............ 00.9423 11.20 380003............ 01.1784 16.59 390007............ 01.1940 16.97 390083............ 01.1639 20.47
360230............ 01.2987 18.07 370076............ 01.2221 10.80 380004............ 01.7899 20.49 390008............ 01.1381 15.38 390084............ 01.1674 14.93
360231............ 01.1015 14.13 370077............ 01.2835 16.00 380005............ 01.2162 17.60 390009............ 01.6008 16.25 390086............ 01.0807 14.19
360232............ 01.1465 19.54 370078............ 01.6115 15.06 380006............ 01.3029 16.06 390010............ 01.2451 16.77 390088............ 01.2601 18.26
360234............ 01.3213 17.45 370079............ 00.8642 11.46 380007............ 01.7970 20.52 390011............ 01.2162 15.72 390090............ 01.7269 18.51
360236............ 01.2256 16.91 370080............ 00.9710 10.78 380008............ 01.1211 16.02 390012............ 01.1715 18.00 390091............ 01.1490 17.98
360238............ 00.9264 12.13 370082............ 01.1282 11.98 380009............ 01.7538 21.31 390013............ 01.2003 15.66 390093............ 01.1607 14.74
360239............ 01.1692 18.24 370083............ 01.0320 10.50 380010............ 01.0442 19.43 390014............ 00.9655 13.70 390095............ 01.1991 12.94
360240............ 00.6112 13.30 370084............ 01.0554 09.02 380011............ 01.2294 13.31 390015............ 01.1704 11.85 390096............ 01.2562 15.43
360241............ 00.5726 16.05 370085............ 00.9051 12.29 380013............ 01.2257 18.80 390016............ 01.1675 14.71 390097............ 01.3078 19.40
360242............ 01.4552 ....... 370086............ 01.1848 09.55 380014............ 01.3465 17.78 390017............ 01.1817 13.65 390098............ 01.7371 18.83
360243............ 00.8582 15.30 370089............ 01.2778 11.60 380017............ 01.7404 20.25 390018............ 01.2110 17.81 390100............ 01.6715 17.60
360244............ 00.8716 15.00 370091............ 01.6302 14.59 380018............ 01.7752 17.51 390019............ 01.1292 14.54 390101............ 01.2777 15.00
360245............ 00.9364 ....... 370092............ 01.1135 11.69 380019............ 01.3337 17.00 390022............ 01.3753 19.40 390102............ 01.3193 19.48
360246............ 00.6407 ....... 370093............ 01.7767 18.82 380020............ 01.4155 17.79 390023............ 01.2519 18.52 390103............ 01.0539 14.93
370001............ 01.6763 15.99 370094............ 01.4243 16.65 380021............ 01.2001 18.54 390024............ 00.7670 20.53 390104............ 01.0670 14.28
370002............ 01.2402 12.02 370095............ 00.9144 10.73 380022............ 01.1495 18.26 390025............ 00.8539 14.06 390106............ 00.9835 14.65
370004............ 01.3474 12.31 370097............ 01.3461 18.53 380023............ 01.2610 17.05 390026............ 01.2263 18.67 390107............ 01.1973 17.38
370005............ 01.0827 10.63 370099............ 01.2014 12.43 380025............ 01.2684 19.95 390027............ 01.8636 21.73 390108............ 01.3352 18.98
370006............ 01.1941 14.06 370100............ 01.0390 11.67 380026............ 01.3583 15.93 390028............ 01.7410 18.13 390109............ 01.1639 13.33
370007............ 01.1085 12.64 370103............ 00.9238 10.13 380027............ 01.2532 18.02 390029............ 01.6984 20.55 390110............ 01.5611 17.01
370008............ 01.3576 15.20 370105............ 02.0562 13.71 380029............ 01.1894 15.62 390030............ 01.2226 15.45 390111............ 01.7401 24.12
370011............ 01.1189 12.74 370106............ 01.4740 16.23 380031............ 01.0192 15.90 390031............ 01.1580 15.93 390112............ 01.1451 11.94
370012............ 00.8871 10.18 370108............ 01.1804 09.27 380033............ 01.6618 19.92 390032............ 01.1990 16.58 390113............ 01.2517 15.48
370013............ 01.6817 17.44 370110............ 00.9905 12.01 380035............ 01.3229 16.28 390035............ 01.2759 16.49 390114............ 01.0987 19.32
370014............ 01.2968 16.19 370112............ 01.0335 12.14 380036............ 01.0848 16.10 390036............ 01.2444 16.78 390115............ 01.3002 20.16
370015............ 01.2131 13.44 370113............ 01.0858 12.37 380037............ 01.2695 18.94 390037............ 01.2074 17.47 390116............ 01.1726 18.88
370016............ 01.3651 13.98 370114............ 01.5710 14.55 380038............ 01.2293 20.44 390039............ 01.1180 15.31 390117............ 01.1666 14.44
370017............ 01.0434 10.30 370121............ 01.3260 12.36 380039............ 01.2853 17.76 390040............ 00.9419 12.20 390118............ 01.2353 15.42
370018............ 01.3096 15.49 370122............ 01.2328 08.56 380040............ 01.3016 17.85 390041............ 01.2543 17.32 390119............ 01.3573 16.18
370019............ 01.2298 10.56 370123............ 01.2636 13.79 380042............ 01.1269 15.46 390042............ 01.3018 18.62 390121............ 01.2805 16.71
370020............ 01.2834 11.37 370125............ 01.0162 10.72 380047............ 01.6536 16.43 390043............ 01.0198 13.85 390122............ 01.0573 14.83
370021............ 00.9852 09.49 370126............ 01.1444 08.72 380048............ 01.0343 13.09 390044............ 01.5555 16.77 390123............ 01.2230 18.51
370022............ 01.2994 13.75 370131............ 00.9804 11.32 380050............ 01.2488 15.78 390045............ 01.4370 16.03 390125............ 01.2550 13.82
370023............ 01.3328 13.57 370133............ 01.1332 09.86 380051............ 01.5073 17.52 390046............ 01.4394 16.75 390126............ 01.2706 19.96
370025............ 01.3962 13.86 370138............ 01.1179 14.59 380052............ 01.2272 15.01 390047............ 01.6934 22.77 390127............ 01.1649 19.13
370026............ 01.3733 15.30 370139............ 01.0286 11.63 380055............ 01.1953 22.55 390048............ 01.1651 14.69 390128............ 01.1286 17.07
370028............ 01.6703 15.88 370140............ 01.0181 10.01 380056............ 01.1050 14.28 390049............ 01.5137 18.00 390130............ 01.1470 15.37
370029............ 01.2134 11.58 370141............ 01.3874 19.42 380060............ 01.4527 20.35 390050............ 02.0268 19.37 390131............ 01.2141 16.10
370030............ 01.2926 12.91 370146............ 01.1131 10.05 380061............ 01.5814 19.88 390051............ 02.0948 21.73 390132............ 01.1887 19.61
370032............ 01.4018 14.36 370148............ 01.3470 17.30 380062............ 01.1223 12.73 390052............ 01.1507 15.00 390133............ 01.7111 19.44
370033............ 01.1205 10.55 370149............ 01.1830 13.75 380063............ 01.2123 21.13 390054............ 01.1338 12.61 390135............ 01.2420 19.44
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Page 13 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
390136............ 01.2231 15.15 390224............ 00.9339 12.60 400102............ 01.1571 07.50 420056............ 01.1036 12.61 430054............ 00.9870 11.56
390137............ 01.1502 15.82 390225............ 01.2209 15.00 400103............ 01.4620 08.99 420057............ 01.1808 13.51 430056............ 00.8973 09.09
390138............ 01.1896 17.08 390226............ 01.6978 20.96 400104............ 01.2361 07.79 420059............ 01.0104 12.84 430057............ 00.9116 10.70
390139............ 01.4319 22.21 390228............ 01.2064 17.13 400105............ 01.2043 07.09 420061............ 01.2115 14.38 430060............ 00.9919 08.54
390142............ 01.6525 23.32 390229............ 01.5645 17.58 400106............ 01.1958 07.10 420062............ 01.4202 16.13 430062............ 00.8284 10.11
390145............ 01.2597 18.61 390231............ 01.3312 21.13 400109............ 01.5763 08.48 420064............ 01.1426 12.20 430064............ 01.1199 10.40
390146............ 01.2356 15.78 390233............ 01.3486 16.52 400110............ 01.1548 07.68 420065............ 01.3357 15.64 430065............ 01.0518 10.46
390147............ 01.2429 17.19 390235............ 01.8132 22.16 400111............ 01.1442 07.53 420066............ 00.9708 13.59 430066............ 00.9866 11.12
390148............ 01.0573 16.31 390236............ 01.2367 15.25 400112............ 01.1294 06.36 420067............ 01.2409 15.33 430073............ 01.1130 12.81
390149............ 01.2014 16.23 390237............ 01.5158 18.07 400113............ 01.1748 06.45 420068............ 01.2133 14.59 430076............ 01.0517 08.42
390150............ 01.2188 17.11 390238............ 01.1068 16.03 400114............ 01.0550 07.83 420069............ 01.1289 12.28 430077............ 01.5274 14.81
390151............ 01.2333 16.00 390242............ 01.3139 17.49 400115............ 00.9692 06.66 420070............ 01.2809 14.64 430079............ 00.9599 10.06
390152............ 01.0829 15.09 390244............ 00.8984 12.14 400117............ 01.1822 07.29 420071............ 01.3513 15.19 430080............ 01.2387 09.20
390153............ 01.2559 20.26 390245............ 01.3591 21.15 400118............ 01.1587 07.27 420072............ 00.9360 09.89 430081............ 00.9416 ......
390154............ 01.1573 13.46 390246............ 01.1831 15.09 400120............ 01.3381 08.45 420073............ 01.3091 17.39 430082............ 00.8089 ......
390155............ 01.2416 20.35 390247............ 01.0548 17.29 400122............ 01.0084 ....... 420074............ 00.9671 10.42 430083............ 00.8805 ......
390156............ 01.3463 20.78 390249............ 01.0225 11.44 400123............ 01.1240 ....... 420075............ 00.9840 12.37 430084............ 00.8674 ......
390157............ 01.2153 16.84 390256............ 01.7622 18.11 400124............ 03.0498 ....... 420076............ 01.2166 20.07 430085............ 00.8849 ......
390158............ 01.2792 17.26 390258............ 01.2902 18.83 410001............ 01.3190 21.02 420078............ 01.7195 17.31 430086............ 00.8381 ......
390159............ 01.3235 19.13 390260............ 01.2455 16.31 410002............ 01.1241 18.61 420079............ 01.4784 15.84 430087............ 00.9523 08.98
390160............ 01.1786 17.04 390262............ 01.8505 16.11 410004............ 01.4017 18.86 420080............ 01.2105 16.23 430088............ 00.8629 10.78
390161............ 01.1982 13.09 390263............ 01.4938 18.44 410005............ 01.3471 20.92 420081............ 00.8136 17.83 440001............ 01.0923 11.94
390162............ 01.2774 17.98 390265............ 01.2991 16.95 410006............ 01.2044 19.91 420082............ 01.4316 16.58 440002............ 01.5969 14.74
390163............ 01.1520 16.65 390266............ 01.0944 15.78 410007............ 01.6561 19.87 420083............ 01.2217 16.12 440003............ 01.0918 13.82
390164............ 02.0309 18.51 390267............ 01.2116 18.58 410008............ 01.1989 19.67 420084............ 01.0603 11.81 440006............ 01.3790 16.17
390166............ 01.1026 16.02 390268............ 01.2841 18.08 410009............ 01.3190 19.81 420085............ 01.2758 16.15 440007............ 01.0212 10.86
390167............ 01.2717 19.78 390270............ 01.3192 15.08 410010............ 01.0217 23.33 420086............ 01.4243 16.19 440008............ 00.9794 13.80
390168............ 01.1840 16.49 390272............ 00.5344 21.19 410011............ 01.2093 20.92 420087............ 01.6204 15.15 440009............ 01.0389 11.29
390169............ 01.1978 16.06 390275............ 00.4818 ....... 410012............ 01.6437 18.74 420088............ 01.2297 14.81 440010............ 00.9651 11.46
390170............ 01.8159 19.83 390277............ 00.5113 17.97 410013............ 01.2298 23.20 420089............ 01.3302 19.45 440011............ 01.2455 14.86
390171............ 01.1343 15.68 390278............ 00.8250 15.98 420002............ 01.3554 19.58 420091............ 00.5742 ....... 440012............ 01.3188 15.12
390172............ 01.2634 18.70 390279............ 01.0946 ....... 420004............ 01.8451 16.90 430004............ 01.0741 13.84 440014............ 01.0847 11.29
390173............ 01.1582 16.62 400001............ 01.1952 06.56 420005............ 01.1443 12.82 430005............ 01.2632 13.13 440015............ 01.5392 14.85
390174............ 01.6021 22.13 400002............ 01.4051 08.59 420006............ 01.2294 15.90 430007............ 01.1784 11.22 440016............ 00.9769 10.44
390176............ 01.1447 15.39 400003............ 01.1723 08.08 420007............ 01.5344 15.37 430008............ 01.2470 13.36 440017............ 01.5557 16.57
390178............ 01.2721 16.67 400004............ 01.2055 07.64 420009............ 01.2447 14.71 430009............ 01.1039 10.57 440018............ 01.3772 16.57
390179............ 01.2329 21.05 400005............ 01.0596 05.93 420010............ 01.0667 13.24 430010............ 01.1656 08.61 440019............ 01.5520 17.86
390180............ 01.4620 21.29 400006............ 01.1804 06.79 420011............ 01.0843 13.76 430011............ 01.3343 12.88 440020............ 01.1738 16.04
390181............ 01.0520 19.17 400007............ 01.1941 06.70 420014............ 01.0271 11.42 430012............ 01.3016 13.57 440022............ 01.1395 12.73
390183............ 01.1218 26.56 400008............ 01.2294 06.13 420015............ 01.3035 16.41 430013............ 01.2225 14.39 440023............ 00.9979 10.57
390184............ 01.1498 16.80 400009............ 00.9723 06.84 420016............ 01.0820 15.23 430014............ 01.3146 15.40 440024............ 01.2945 14.98
390185............ 01.1490 15.23 400010............ 00.9425 07.03 420018............ 01.5696 16.53 430015............ 01.2066 13.41 440025............ 01.1031 12.43
390186............ 00.9988 15.14 400011............ 01.0339 07.66 420019............ 01.1579 13.94 430016............ 01.7294 16.10 440026............ 00.8359 15.50
390189............ 01.1270 20.06 400012............ 01.1223 07.74 420020............ 01.2261 14.85 430018............ 00.9495 12.97 440029............ 01.2461 14.99
390191............ 01.0680 13.79 400013............ 01.0714 07.16 420022............ 00.9931 15.20 430022............ 00.9637 09.90 440030............ 01.1295 12.38
390192............ 01.1108 15.96 400014............ 01.3436 07.22 420023............ 01.3521 17.43 430023............ 00.9377 08.41 440031............ 01.0301 12.09
390193............ 01.1718 14.58 400015............ 01.3019 09.68 420026............ 01.8623 17.53 430024............ 00.9725 11.02 440032............ 00.9747 10.65
390194............ 01.1110 17.87 400016............ 01.3266 09.18 420027............ 01.3224 14.19 430025............ 01.0084 09.69 440033............ 01.0740 16.12
390195............ 01.7068 20.60 400017............ 01.1463 ....... 420028............ 01.1146 11.11 430026............ 00.9375 10.09 440034............ 01.4230 17.40
390196............ 01.2145 ....... 400018............ 01.2630 09.43 420029............ 01.7591 13.19 430027............ 01.7460 15.94 440035............ 01.2710 14.48
390197............ 01.2696 18.10 400019............ 01.5568 08.81 420030............ 01.2045 16.33 430028............ 01.0503 11.61 440039............ 01.5860 17.12
390198............ 01.2361 13.92 400021............ 01.3669 07.92 420031............ 01.0195 10.68 430029............ 01.0075 12.71 440040............ 00.9527 13.60
390199............ 01.2454 14.23 400022............ 01.3140 08.71 420033............ 01.1522 17.58 430031............ 00.9785 10.28 440041............ 00.8479 13.66
390200............ 01.0135 14.23 400024............ 01.0591 07.19 420035............ 00.7751 11.27 430033............ 01.0808 12.29 440046............ 01.3194 13.16
390201............ 01.2876 17.68 400026............ 00.9117 06.15 420036............ 01.2327 14.69 430034............ 01.0286 10.85 440047............ 00.9167 11.74
390203............ 01.2606 19.47 400027............ 01.1389 07.18 420037............ 01.2485 18.15 430036............ 00.9902 08.36 440048............ 01.7477 15.49
390204............ 01.2923 17.60 400028............ 01.0784 06.70 420038............ 01.2217 12.41 430037............ 00.9860 11.79 440049............ 01.6483 15.27
390205............ 01.2589 20.89 400029............ 01.1183 06.21 420039............ 01.1048 13.26 430038............ 00.9978 08.43 440050............ 01.1715 14.53
390206............ 01.3311 18.69 400031............ 01.0008 07.72 420040............ 01.2006 13.54 430039............ 01.0023 09.15 440051............ 00.9316 12.36
390209............ 01.0001 13.32 400032............ 01.1314 07.65 420042............ 01.2096 11.67 430040............ 00.9160 11.35 440052............ 01.1894 13.51
390211............ 01.2333 16.85 400044............ 01.1746 08.66 420043............ 01.2497 15.44 430041............ 00.9265 11.35 440053............ 01.2488 14.72
390213............ 00.9999 13.22 400048............ 01.0480 07.77 420044............ 01.2167 15.58 430042............ 01.1134 15.25 440054............ 01.0527 13.96
390215............ 01.1275 20.18 400061............ 01.5946 11.46 420048............ 01.1525 13.91 430043............ 01.1510 13.05 440056............ 01.0871 11.91
390217............ 01.2163 17.46 400079............ 01.2811 09.22 420049............ 01.2237 14.11 430044............ 00.9290 11.74 440057............ 01.0223 12.82
390219............ 01.2171 16.47 400087............ 01.2290 06.69 420051............ 01.5551 16.53 430047............ 01.1156 11.70 440058............ 01.1756 14.16
390220............ 01.1604 17.46 400088............ 00.5413 06.69 420053............ 01.0939 14.06 430048............ 01.2381 14.21 440059............ 01.1607 12.77
390222............ 01.2521 18.22 400094............ 01.0012 06.74 420054............ 01.2267 16.05 430049............ 00.9249 10.80 440060............ 01.1756 12.90
390223............ 01.6770 20.79 400098............ 01.2601 07.55 420055............ 01.0766 13.01 430051............ 00.9629 11.03 440061............ 01.2131 13.36
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Page 14 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
440063............ 01.5138 16.30 440180............ 01.0624 15.21 450076............ 01.4717 ....... 450181............ 00.9547 13.38 450325............ 01.2675 08.99
440064............ 01.0929 13.98 440181............ 01.0104 10.47 450078............ 01.0114 12.31 450184............ 01.4935 19.07 450327............ 01.0103 10.48
440065............ 01.1853 15.06 440182............ 00.9547 13.66 450079............ 01.4787 19.22 450185............ 01.0617 08.32 450330............ 01.1725 15.70
440067............ 01.0909 15.26 440183............ 01.5121 16.14 450080............ 01.2485 16.13 450187............ 01.3045 14.52 450334............ 00.9992 11.28
440068............ 01.1912 15.49 440184............ 01.4429 17.96 450081............ 01.1290 11.51 450188............ 01.0288 11.94 450337............ 01.1923 14.08
440069............ 01.1399 13.16 440185............ 01.0961 16.67 450082............ 00.9955 11.00 450190............ 01.1300 18.27 450340............ 01.3265 14.37
440070............ 01.0038 12.32 440186............ 01.1340 18.54 450083............ 01.6360 16.05 450191............ 01.1515 15.56 450341............ 00.9963 14.42
440071............ 01.4109 14.79 440187............ 01.1847 15.17 450085............ 01.1242 12.97 450192............ 01.0649 17.15 450346............ 01.3544 15.28
440072............ 01.3557 15.41 440189............ 01.4992 15.23 450087............ 01.5114 19.75 450193............ 02.0715 18.54 450347............ 01.1744 15.06
440073............ 01.3107 15.18 440192............ 01.1110 13.88 450090............ 01.1148 11.65 450194............ 01.2566 15.44 450348............ 01.0156 10.55
440074............ 00.8046 12.15 440193............ 01.2560 17.17 450092............ 01.2034 13.55 450195............ 01.3153 17.30 450349............ 01.0999 23.66
440078............ 01.0165 11.32 440194............ 01.3012 18.28 450094............ 01.3955 19.86 450196............ 01.4334 14.92 450351............ 01.2648 22.84
440079............ 00.7294 ....... 440196............ 00.9401 14.86 450096............ 01.4495 16.16 450197............ 01.1655 16.99 450352............ 01.2137 20.49
440081............ 01.1643 12.85 440197............ 01.3707 17.37 450097............ 01.4276 17.31 450200............ 01.4943 13.71 450353............ 01.2269 15.17
440082............ 01.8429 19.28 440200............ 01.1142 16.36 450098............ 01.2082 12.67 450201............ 00.9942 13.72 450355............ 01.0818 12.14
440083............ 01.2537 09.96 440203............ 00.9909 13.79 450099............ 01.2009 17.78 450203............ 01.2816 14.24 450358............ 02.0420 18.56
440084............ 01.1852 10.14 440205............ 01.2436 12.39 450101............ 01.3497 14.40 450209............ 01.4242 15.63 450362............ 01.0638 10.60
440087............ 01.0430 12.08 440206............ 00.9017 07.60 450102............ 01.6894 17.28 450210............ 01.1084 13.40 450365............ 00.9342 ......
440090............ 01.0381 12.38 450002............ 1.4852 15.52 450104............ 01.2719 12.65 450211............ 01.3187 13.86 450366............ 01.4737 18.29
440091............ 01.5433 15.71 450004............ 01.1355 11.11 450107............ 01.5378 16.81 450213............ 01.3555 14.21 450369............ 01.1127 11.81
440095............ 01.0850 19.37 450005............ 01.1381 14.76 450108............ 01.0003 11.41 450214............ 01.4068 17.51 450370............ 01.2119 12.06
440100............ 01.1004 12.24 450007............ 01.2595 12.30 450109............ 01.2410 13.96 450217............ 01.0771 10.09 450371............ 01.1583 10.89
440102............ 01.0834 12.02 450008............ 01.3853 14.03 450110............ 01.2134 12.04 450219............ 01.0450 11.49 450372............ 01.3460 16.37
440103............ 01.2252 16.56 450010............ 01.3300 13.75 450111............ 01.2523 17.62 450221............ 01.0202 13.07 450373............ 01.1579 11.09
440104............ 01.5364 16.76 450011............ 01.5489 15.71 450112............ 01.2629 12.44 450222............ 01.6908 22.10 450374............ 00.9156 11.01
440105............ 01.2990 16.68 450014............ 01.1763 12.60 450113............ 01.2389 16.17 450224............ 01.3697 18.01 450376............ 01.4794 10.63
440109............ 01.1307 11.86 450015............ 01.5321 13.56 450118............ 01.4696 15.64 450229............ 01.4657 15.37 450378............ 01.1011 17.92
440110............ 00.9556 13.92 450016............ 01.7128 15.62 450119............ 01.3313 14.65 450231............ 01.5196 16.40 450379............ 01.6117 20.14
440111............ 01.2167 18.15 450018............ 01.5585 18.52 450121............ 01.4403 17.44 450233............ 00.9976 12.70 450381............ 00.9540 10.67
440114............ 01.0345 11.65 450020............ 01.0135 13.40 450123............ 01.0894 19.97 450234............ 00.9630 10.46 450388............ 01.6240 16.61
440115............ 01.0487 13.80 450021............ 01.9203 17.49 450124............ 01.5053 16.88 450235............ 00.9601 11.12 450389............ 01.2048 15.78
440120............ 01.4662 15.49 450023............ 01.3903 13.94 450126............ 01.3973 16.17 450236............ 01.1377 15.95 450393............ 01.2694 18.35
440121............ 01.0427 11.93 450024............ 01.3328 12.06 450127............ 00.9875 09.55 450237............ 01.4897 14.79 450395............ 01.0482 15.15
440125............ 01.4766 15.68 450025............ 01.4792 15.27 450128............ 01.2480 12.38 450239............ 01.1696 12.14 450399............ 01.0623 12.15
440130............ 01.1075 13.38 450027............ 01.4255 18.45 450130............ 01.5040 14.99 450241............ 00.8530 13.09 450400............ 01.1677 14.98
440131............ 01.0593 13.10 450028............ 01.4607 16.21 450131............ 01.2607 19.36 450243............ 00.8661 10.77 450403............ 01.2575 19.01
440132............ 01.1081 12.72 450029............ 01.4212 11.79 450132............ 01.4931 14.53 450246............ 00.9890 13.87 450410............ 01.1316 17.45
440133............ 01.4572 17.01 450031............ 01.6835 16.35 450133............ 01.5493 15.33 450249............ 00.9424 ....... 450411............ 00.9843 11.22
440135............ 01.4126 18.07 450032............ 01.2423 12.31 450135............ 01.7031 18.60 450250............ 01.0420 15.96 450417............ 01.0336 12.26
440136............ 01.0683 15.73 450033............ 01.6423 14.49 450137............ 01.4294 19.17 450253............ 01.1271 10.67 450418............ 01.3502 15.53
440137............ 01.0083 11.27 450034............ 01.5042 15.36 450140............ 00.7344 16.53 450258............ 01.1194 10.75 450419............ 01.2377 18.02
440141............ 01.1507 11.96 450035............ 01.4629 16.70 450142............ 01.3689 18.81 450259............ 01.1512 17.45 450422............ 00.6567 24.82
440142............ 01.0831 09.45 450037............ 01.5273 16.26 450143............ 01.0261 10.41 450264............ 00.8325 11.39 450423............ 01.2999 21.90
440143............ 01.0555 15.56 450039............ 01.4288 16.93 450144............ 01.1532 14.41 450269............ 01.0779 13.62 450424............ 01.2514 13.96
440144............ 01.1975 17.10 450040............ 01.5797 16.30 450145............ 00.8863 14.64 450270............ 01.0791 08.60 450429............ 01.0330 12.10
440145............ 01.0549 10.86 450042............ 01.6082 15.48 450146............ 00.9826 15.24 450271............ 01.1263 14.62 450431............ 01.5885 16.57
440146............ 01.0442 11.21 450043............ 01.4527 18.41 450147............ 01.3439 17.43 450272............ 01.2170 15.57 450438............ 01.0871 16.17
440147............ 00.8996 14.36 450044............ 01.5820 18.55 450148............ 01.2056 18.48 450276............ 01.0040 08.60 450446............ 00.9550 11.85
440148............ 01.2025 17.31 450046............ 01.3944 12.38 450149............ 01.3408 16.76 450278............ 01.0542 10.91 450447............ 01.3189 16.08
440149............ 01.2308 14.70 450047............ 01.1025 10.47 450150............ 00.9606 12.20 450280............ 01.3016 15.64 450450............ 01.0270 12.30
440150............ 01.2409 16.92 450050............ 01.1986 13.96 450151............ 01.1414 12.24 450283............ 01.0793 11.48 450451............ 01.0230 15.22
440151............ 01.2861 15.49 450051............ 01.5619 17.57 450152............ 01.2853 14.87 450286............ 01.0253 12.11 450457............ 01.6912 16.01
440152............ 01.6104 16.13 450052............ 01.1098 12.62 450153............ 01.5695 16.68 450288............ 01.2288 12.61 450460............ 01.0144 13.30
440153............ 01.2677 14.17 450053............ 01.0843 13.58 450154............ 01.1379 11.32 450289............ 01.3300 15.80 450462............ 01.8334 16.67
440154............ 00.7575 ....... 450054............ 01.6881 19.72 450155............ 01.0745 14.52 450292............ 01.3389 15.96 450464............ 00.9903 16.00
440156............ 01.4974 18.20 450055............ 01.1112 11.31 450157............ 01.0363 12.65 450293............ 00.9767 14.15 450465............ 01.2460 15.09
440157............ 01.0485 11.50 450056............ 01.6722 16.78 450160............ 00.8899 16.67 450296............ 01.2584 18.17 450467............ 01.0221 12.74
440159............ 01.2089 15.33 450058............ 01.5129 14.26 450162............ 01.2815 16.42 450297............ 01.1615 12.08 450469............ 01.3061 15.75
440160............ 00.8997 12.59 450059............ 01.3713 12.34 450163............ 01.0847 15.33 450299............ 01.4740 16.11 450473............ 00.9922 14.40
440161............ 01.5923 18.01 450060............ 01.3962 20.84 450164............ 01.0330 12.98 450303............ 00.8879 09.86 450475............ 01.1115 12.45
440166............ 01.4819 16.87 450063............ 01.0607 09.22 450165............ 01.0302 14.37 450306............ 01.0579 11.18 450484............ 01.5588 18.13
440168............ 01.0229 13.35 450064............ 01.5464 15.22 450166............ 01.0477 10.59 450307............ 01.0089 12.30 450488............ 01.2249 17.64
440170............ 01.2998 18.38 450065............ 01.0185 14.74 450169............ 00.8630 13.97 450309............ 01.1017 10.84 450489............ 00.9473 14.79
440173............ 01.4970 15.75 450068............ 01.7532 17.99 450170............ 01.0853 12.10 450315............ 01.1977 19.49 450497............ 01.1786 10.99
440174............ 00.9321 13.46 450070............ 01.1738 17.31 450176............ 01.2754 12.94 450320............ 01.4034 19.32 450498............ 01.0325 13.08
440175............ 01.1861 16.89 450072............ 01.2594 16.10 450177............ 01.1252 12.06 450321............ 00.8596 11.25 450508............ 01.6026 15.77
440176............ 01.2939 16.07 450073............ 01.1636 11.84 450178............ 01.1510 14.59 450322............ 00.9743 16.67 450514............ 01.1170 16.87
440178............ 01.2263 18.49 450074............ 01.2878 16.43 450179............ 00.9523 ....... 450324............ 01.5460 15.52 450517............ 00.9434 11.05
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Page 15 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450518............ 01.4144 16.16 450660............ 01.5790 18.85 450769............ 00.9320 09.57 470013............ 01.1467 18.22 490089............ 01.0505 14.04
450523............ 01.5387 19.98 450661............ 01.2547 18.21 450770............ 01.0700 12.31 470015............ 01.1877 18.87 490090............ 01.1894 13.06
450530............ 01.3085 23.01 450662............ 01.3950 17.00 450771............ 01.7568 15.16 470018............ 01.1282 18.39 490091............ 01.1790 18.85
450534............ 00.9786 13.79 450665............ 00.9778 10.88 450774............ 00.7228 ....... 470020............ 01.0126 12.85 490092............ 01.1790 13.48
450535............ 01.1992 14.83 450666............ 01.2580 17.39 450775............ 01.2516 15.68 470023............ 01.2324 16.33 490093............ 01.2862 14.17
450537............ 01.3952 15.96 450668............ 01.5927 17.53 450776............ 00.8655 ....... 470024............ 01.1338 16.25 490094............ 01.2211 15.14
450538............ 01.1922 19.68 450669............ 01.2426 18.67 450777............ 01.0269 ....... 490001............ 01.1182 17.17 490095............ 01.2315 15.14
450539............ 01.2053 15.30 450670............ 01.2996 15.92 450778............ 00.8848 ....... 490002............ 01.0320 13.41 490097............ 01.1433 12.72
450544............ 01.2967 20.24 450672............ 01.6463 18.49 450779............ 01.2579 ....... 490003............ 00.6533 15.73 490098............ 01.3158 11.12
450545............ 01.2474 16.20 450673............ 01.0975 10.02 450780............ 01.4717 ....... 490004............ 01.2171 15.40 490099............ 00.9625 13.59
450546............ 01.2729 18.68 450674............ 00.8239 19.25 450781............ 01.4634 ....... 490005............ 01.4576 15.40 490100............ 01.3151 14.13
450547............ 01.0006 12.78 450675............ 01.3903 18.32 450782............ 01.4054 ....... 490006............ 01.1427 11.75 490101............ 01.1133 20.90
450550............ 01.0579 19.47 450677............ 01.3377 16.32 450783............ 01.1067 ....... 490007............ 02.0127 15.62 490104............ 00.9622 14.01
450551............ 01.1795 12.60 450678............ 01.5651 20.04 450784............ 01.0594 ....... 490008............ 01.0542 20.97 490105............ 00.7039 14.74
450558............ 01.7511 17.98 450681............ 01.5756 15.51 450785............ 00.7492 ....... 490009............ 01.6789 17.21 490106............ 00.8313 15.97
450559............ 00.8716 11.92 450682............ 01.2603 17.44 450786............ 00.8128 ....... 490010............ 01.0908 15.40 490107............ 01.2642 19.56
450561............ 01.6595 16.21 450683............ 01.3244 19.60 450787............ 01.0967 ....... 490011............ 01.3318 16.32 490108............ 00.8124 15.00
450563............ 01.2509 19.54 450684............ 01.2661 17.89 450897............ 04.9148 ....... 490012............ 01.1150 13.90 490109............ 00.8790 14.56
450565............ 01.3451 13.56 450686............ 01.5880 15.55 460001............ 01.6481 18.22 490013............ 01.1660 13.67 490110............ 01.1805 16.71
450570............ 01.0638 12.07 450688............ 01.3829 17.26 460003............ 01.5838 17.26 490014............ 01.6015 19.87 490111............ 01.1901 14.35
450571............ 01.4721 13.89 450690............ 01.3692 21.21 460004............ 01.7182 18.05 490015............ 01.4062 13.85 490112............ 01.6117 18.29
450573............ 00.9884 11.89 450691............ 01.5252 17.57 460005............ 01.3774 17.46 490017............ 01.3798 15.60 490113............ 01.2900 19.16
450574............ 01.0190 13.95 450694............ 01.2113 16.02 460006............ 01.2683 17.00 490018............ 01.2067 15.63 490114............ 01.0733 13.76
450575............ 00.9777 20.31 450696............ 01.6328 20.21 460007............ 01.3036 16.89 490019............ 01.1148 13.78 490115............ 01.2167 12.44
450578............ 00.9309 14.41 450697............ 01.3794 15.11 460008............ 01.4573 16.76 490020............ 01.1572 13.14 490116............ 01.1799 16.33
450580............ 01.1561 12.24 450698............ 00.9368 10.48 460009............ 01.6847 16.97 490021............ 01.4354 15.75 490117............ 01.0841 11.43
450583............ 00.9523 11.81 450700............ 00.9251 11.65 460010............ 02.0637 18.28 490022............ 01.2461 15.68 490118............ 01.6559 19.99
450584............ 01.1670 10.95 450702............ 01.4889 18.28 460011............ 01.4136 15.96 490023............ 01.2265 15.58 490119............ 01.3127 15.33
450586............ 01.0115 12.39 450703............ 01.4711 19.68 460013............ 01.5168 17.24 490024............ 01.6107 15.30 490120............ 01.3657 15.93
450587............ 01.2735 17.28 450704............ 01.3988 16.67 460014............ 01.0224 11.67 490027............ 01.1661 12.49 490122............ 01.2879 20.07
450591............ 01.1456 13.04 450705............ 00.7976 15.32 460015............ 01.2597 17.66 490028............ 01.3351 17.29 490123............ 01.1181 14.53
450596............ 01.2539 16.69 450706............ 01.2191 21.01 460016............ 00.8736 12.40 490030............ 01.2487 10.92 490124............ 01.1848 15.29
450597............ 01.0357 13.57 450709............ 01.1547 17.85 460017............ 01.3132 15.07 490031............ 01.0973 11.91 490126............ 01.2602 13.61
450603............ 00.8565 13.23 450711............ 01.6884 16.47 460018............ 00.9433 11.56 490032............ 01.6879 18.77 490127............ 01.0434 13.33
450604............ 01.2523 12.49 450712............ 00.9561 12.74 460019............ 00.9335 15.01 490033............ 01.1437 14.76 490130............ 01.2044 14.96
450605............ 01.2746 18.23 450713............ 01.4165 17.31 460020............ 00.9188 12.14 490035............ 01.1319 11.43 490131............ 00.9682 12.94
450607............ 00.9751 14.12 450715............ 01.2952 21.28 460021............ 01.3942 17.12 490037............ 01.1566 11.92 500001............ 01.2917 20.32
450609............ 00.9014 09.27 450716............ 01.2075 16.91 460022............ 00.9647 17.88 490038............ 01.2792 12.36 500002............ 01.4148 17.35
450610............ 01.4555 16.09 450717............ 01.2316 20.68 460023............ 01.1761 18.70 490040............ 01.3644 19.78 500003............ 01.2762 18.46
450614............ 01.0603 11.94 450718............ 01.2065 19.69 460024............ 00.9286 13.00 490041............ 01.2136 14.32 500005............ 01.7781 21.33
450615............ 00.9577 09.40 450723............ 01.2859 17.26 460025............ 00.7859 11.54 490042............ 01.3582 14.34 500007............ 01.3290 18.20
450617............ 01.3512 17.98 450724............ 01.2170 18.65 460026............ 00.9389 17.49 490043............ 01.2426 17.27 500008............ 01.9169 20.34
450620............ 01.1047 08.97 450725............ 01.0629 17.55 460027............ 00.9938 16.69 490044............ 01.3138 15.46 500009............ 01.2963 19.68
450623............ 01.1715 16.27 450726............ 00.9033 11.21 460029............ 01.0714 16.94 490045............ 01.1785 16.83 500011............ 01.3316 18.64
450626............ 01.0472 14.93 450727............ 00.9057 08.79 460030............ 01.1618 19.40 490046............ 01.4643 16.26 500012............ 01.4961 18.45
450628............ 00.9576 11.42 450728............ 00.9012 15.06 460032............ 00.9842 15.30 490047............ 01.0832 14.15 500014............ 01.7362 20.69
450630............ 01.5476 23.91 450730............ 01.4095 19.15 460033............ 00.9693 20.50 490048............ 01.4868 15.77 500015............ 01.3111 20.70
450631............ 01.6445 16.88 450732............ 01.1562 16.76 460035............ 00.9174 14.06 490050............ 01.3516 19.03 500016............ 01.3511 20.11
450632............ 01.0110 09.73 450733............ 01.3764 16.49 460036............ 00.9084 17.97 490052............ 01.5248 14.03 500019............ 01.2895 18.38
450633............ 01.5521 17.13 450734............ 01.4829 15.76 460037............ 00.9966 15.82 490053............ 01.2446 12.69 500021............ 01.4453 18.44
450634............ 01.3935 20.07 450735............ 00.7508 10.25 460039............ 00.9376 19.39 490054............ 01.0624 16.12 500023............ 01.1876 17.72
450637............ 01.4224 18.37 450742............ 01.3064 20.55 460041............ 01.2061 17.85 490057............ 01.4278 15.27 500024............ 01.6274 20.14
450638............ 01.5916 21.33 450743............ 01.4100 18.11 460042............ 01.5101 14.92 490059............ 01.5179 16.77 500025............ 01.8019 20.46
450639............ 01.4516 19.76 450745............ 00.9354 17.81 460043............ 01.4113 19.64 490060............ 01.0740 17.38 500026............ 01.3594 20.11
450641............ 00.9887 10.24 450746............ 00.9637 12.33 460044............ 01.1434 18.02 490063............ 01.5911 21.01 500027............ 01.5307 20.29
450643............ 01.1398 16.08 450747............ 01.3085 15.66 460046............ 01.3442 10.37 490066............ 01.2283 16.33 500028............ 01.1173 13.44
450644............ 01.6173 20.13 450749............ 01.0665 12.76 460047............ 01.6644 17.76 490067............ 01.2791 13.99 500029............ 00.9747 11.90
450646............ 01.5763 18.06 450750............ 00.9694 10.69 460049............ 01.9396 ....... 490069............ 01.4003 13.38 500030............ 01.3190 20.51
450647............ 02.0318 20.54 450751............ 01.2886 15.02 460050............ 01.1824 ....... 490071............ 01.4828 17.01 500031............ 01.3011 18.25
450648............ 01.0958 10.99 450754............ 01.0756 10.22 470001............ 01.1496 16.20 490073............ 01.3416 22.26 500033............ 01.2637 16.60
450649............ 01.0262 14.87 450755............ 01.1690 14.46 470003............ 01.9350 18.36 490074............ 01.3089 15.43 500035............ 01.4790 ......
450651............ 01.8330 19.22 450757............ 00.9501 13.00 470004............ 01.0460 13.47 490075............ 01.2759 14.78 500036............ 01.2627 16.94
450652............ 00.9846 12.60 450758............ 01.7735 18.93 470005............ 01.1858 17.48 490077............ 01.1987 16.35 500037............ 01.1291 16.54
450653............ 01.2220 16.37 450760............ 01.2015 18.66 470006............ 01.1347 15.80 490079............ 01.3410 13.39 500039............ 01.2978 17.66
450654............ 00.9821 11.04 450761............ 01.1017 12.48 470008............ 01.1925 15.30 490083............ 00.6488 13.89 500041............ 01.2704 20.31
450656............ 01.3304 15.64 450763............ 01.0954 13.74 470010............ 01.0827 16.68 490084............ 01.1989 14.87 500042............ 01.3475 18.95
450658............ 01.0107 11.01 450765............ 00.9207 16.55 470011............ 01.1194 18.12 490085............ 01.1299 11.80 500043............ 01.2060 16.80
450659............ 01.4508 18.74 450766............ 01.9908 20.12 470012............ 01.2074 16.76 490088............ 01.2351 13.15 500044............ 01.9389 19.15
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Page 16 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
500045............ 01.0739 17.28 510007............ 01.4253 16.00 520021............ 01.2976 16.83 520113............ 01.1966 15.62 530029............ 00.9396 13.04
500048............ 00.9015 14.27 510008............ 01.1004 15.33 520024............ 01.0624 11.87 520114............ 01.1532 12.45 530031............ 00.8892 14.78
500049............ 01.3088 17.10 510009............ 00.9448 10.45 520025............ 01.1292 14.34 520115............ 01.3112 14.47 530032............ 01.1716 16.33
500050............ 01.4153 19.09 510012............ 01.0852 15.18 520026............ 01.0666 15.67 520116............ 01.2580 16.13
500051............ 01.6700 20.33 510013............ 01.1868 14.27 520027............ 01.1579 17.08 520117............ 01.0787 14.87
500052............ 01.2445 ....... 510015............ 00.9526 12.81 520028............ 01.3517 16.26 520118............ 00.9850 09.46
500053............ 01.2013 17.77 510016............ 01.0352 ....... 520029............ 00.9354 13.66 520120............ 01.0571 16.55
500054............ 01.8398 19.04 510018............ 01.0626 13.12 520030............ 01.6664 17.90 520121............ 00.9520 13.17
500055............ 01.0564 17.78 510020............ 01.0647 08.93 520031............ 01.0988 13.75 520122............ 00.9943 12.50
500057............ 01.2990 14.98 510022............ 01.6791 17.21 520032............ 01.1448 13.19 520123............ 01.0391 14.99
500058............ 01.5172 17.59 510023............ 01.0371 15.15 520033............ 01.2270 15.24 520124............ 01.1683 13.76
500059............ 01.1315 18.35 510024............ 01.3722 16.07 520034............ 01.1876 16.57 520130............ 01.0123 11.54
500060............ 01.3508 19.19 510025............ 00.9409 10.47 520035............ 01.2591 14.62 520131............ 01.0303 14.68
500061............ 01.0280 17.95 510026............ 00.9766 11.32 520037............ 01.6237 16.75 520132............ 01.1527 12.68
500062............ 01.0023 15.69 510027............ 01.0563 12.43 520038............ 01.3642 16.08 520134............ 01.0808 13.78
500064............ 01.5743 19.70 510028............ 01.1659 15.98 520039............ 00.9901 15.17 520135............ 00.9964 12.99
500065............ 01.3091 16.39 510029............ 01.2587 15.48 520040............ 01.4144 16.73 520136............ 01.5004 17.75
500068............ 01.0220 14.82 510030............ 01.1214 15.72 520041............ 01.2094 13.13 520138............ 01.8435 16.70
500069............ 01.0579 16.11 510031............ 01.3048 14.02 520042............ 01.1116 15.88 520139............ 01.2228 16.83
500071............ 01.3267 18.34 510033............ 01.2782 13.79 520044............ 01.3439 15.51 520140............ 01.4916 17.20
500072............ 01.1533 18.80 510035............ 00.9768 15.60 520045............ 01.6482 16.77 520141............ 01.1386 15.13
500073............ 01.0024 17.71 510036............ 00.9688 11.73 520047............ 01.0145 13.50 520142............ 00.9936 11.46
500074............ 01.1751 13.37 510038............ 01.0385 13.84 520048............ 01.3800 15.97 520144............ 01.0547 14.49
500075............ 01.1884 18.49 510039............ 01.3972 14.67 520049............ 01.9372 15.82 520145............ 01.0244 14.95
500076............ 01.3655 ....... 510043............ 01.0465 10.44 520051............ 01.8782 17.94 520146............ 01.1530 12.32
500077............ 01.2936 20.09 510046............ 01.2264 15.98 520053............ 01.0619 14.07 520148............ 01.1038 13.98
500079............ 01.2919 17.92 510047............ 01.1688 15.81 520054............ 01.0483 15.31 520149............ 00.9350 11.73
500080............ 00.8630 11.55 510048............ 01.0872 16.24 520056............ 01.3226 17.01 520151............ 01.1298 13.70
500084............ 01.1314 17.71 510050............ 01.2928 14.05 520057............ 01.0874 14.88 520152............ 01.1347 15.70
500085............ 01.0811 15.46 510053............ 01.0211 12.15 520058............ 01.0794 16.79 520153............ 00.9377 11.67
500086............ 01.4095 16.28 510055............ 01.2080 17.17 520059............ 01.2532 16.21 520154............ 01.1102 14.96
500088............ 01.2673 20.73 510058............ 01.2215 15.08 520060............ 01.2984 14.92 520156............ 01.0594 15.29
500089............ 01.0325 13.23 510059............ 01.3416 12.84 520062............ 01.2040 14.41 520157............ 00.9525 12.75
500090............ 00.9143 13.62 510060............ 01.0639 12.88 520063............ 01.1852 15.91 520159............ 00.9000 15.47
500092............ 01.1567 13.51 510061............ 01.0469 12.53 520064............ 01.6371 16.58 520160............ 01.7820 16.13
500094............ 00.9067 13.52 510062............ 01.2586 14.06 520066............ 01.2621 16.81 520161............ 01.0419 14.06
500096............ 00.9663 16.16 510063............ 01.0303 11.35 520068............ 00.9534 14.38 520170............ 01.2354 17.02
500097............ 01.1483 14.74 510065............ 00.9731 11.88 520069............ 01.2067 15.49 520171............ 01.0135 12.53
500098............ 00.8540 14.51 510066............ 01.1099 12.88 520070............ 01.4192 15.29 520173............ 01.1181 17.29
500101............ 00.9847 14.48 510067............ 01.1714 16.72 520071............ 01.1009 15.10 520174............ 01.4208 19.12
500102............ 00.9810 14.87 510068............ 01.0710 14.18 520074............ 01.1117 14.32 520176............ 00.7514 14.08
500104............ 01.2466 18.17 510070............ 01.1769 14.68 520075............ 01.4765 16.16 520177............ 01.5591 17.91
500106............ 00.9946 12.54 510071............ 01.2708 14.60 520076............ 01.1048 14.78 520178............ 01.0843 13.06
500107............ 01.1132 13.54 510072............ 01.0445 12.56 520077............ 00.9912 13.17 520180............ 00.9439 .......
500108............ 01.6213 19.87 510076............ 01.0756 ....... 520078............ 01.4344 14.81 530001............ 01.4675 13.50
500110............ 01.2021 17.29 510077............ 01.1408 13.24 520082............ 01.2824 14.80 530002............ 01.2050 15.32
500118............ 01.1170 18.17 510080............ 01.1368 10.05 520083............ 01.5777 19.35 530003............ 00.9244 08.83
500119............ 01.3365 19.79 510081............ 00.9892 12.93 520084............ 01.0838 15.01 530004............ 00.9650 12.56
500122............ 01.2708 17.54 510082............ 01.0716 10.95 520087............ 01.5714 15.92 530005............ 01.0990 12.06
500123............ 00.9911 13.48 510084............ 00.9836 11.33 520088............ 01.2573 16.27 530006............ 01.1693 14.95
500124............ 01.2764 19.76 510085............ 01.2709 17.35 520089............ 01.5028 17.22 530007............ 01.0343 11.54
500125............ 00.9832 11.02 510086............ 01.0198 12.23 520090............ 01.1701 14.69 530008............ 01.1909 16.73
500127............ 00.5986 14.25 520002............ 01.2827 15.62 520091............ 01.2712 15.62 530009............ 01.0331 14.78
500129............ 01.6511 19.35 520003............ 01.1234 13.96 520092............ 01.1129 15.12 530010............ 01.2984 15.83
500132............ 00.9546 15.33 520004............ 01.2040 15.11 520094............ 01.0910 15.78 530011............ 01.1439 14.63
500134............ 00.7355 16.03 520006............ 01.0371 15.92 520095............ 01.3730 16.94 530012............ 01.6806 15.32
500137............ 00.6377 16.87 520007............ 01.0579 12.43 520096............ 01.5478 15.50 530014............ 01.2753 13.81
500138............ 12.2535 ....... 520008............ 01.4766 17.90 520097............ 01.2842 16.40 530015............ 01.1417 15.80
500139............ 01.4098 21.58 520009............ 01.6330 16.23 520098............ 01.7821 18.16 530016............ 01.2002 11.83
500140............ 00.9994 14.50 520010............ 01.1200 16.81 520100............ 01.2514 14.46 530017............ 00.9299 13.78
500141............ 01.2988 19.75 520011............ 01.1716 16.58 520101............ 01.1180 14.26 530018............ 01.0214 13.10
500143............ 00.9927 17.55 520013............ 01.3297 16.24 520102............ 01.2045 16.89 530019............ 00.9986 15.03
500898............ 00.7881 ....... 520014............ 01.2288 14.17 520103............ 01.2815 16.41 530022............ 01.1653 15.74
510001............ 01.6367 15.70 520015............ 01.1841 15.42 520107............ 01.2815 15.17 530023............ 01.0026 15.88
510002............ 01.3716 16.27 520016............ 01.1230 12.12 520109............ 01.0395 14.86 530024............ 01.0512 12.11
510004............ 00.9755 10.17 520017............ 01.2054 15.10 520110............ 01.0918 15.27 530025............ 01.2808 16.17
510005............ 00.9400 13.48 520018............ 01.0639 14.58 520111............ 01.0981 12.09 530026............ 01.1212 13.08
510006............ 01.2072 16.70 520019............ 01.2859 14.27 520112............ 01.1606 16.29 530027............ 00.9446 09.41
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NOTE: CASE MIX INDEXES DO NOT INCLUDE DISCHARGES FROM PPS-EXEMPT UNITS.
NOTE: CASE MIX INDEXES INCLUDE CASES RECEIVED IN HCFA CENTRAL OFFICE THROUGH JUNE 1994.
Table 4a.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Urban area (Constituent counties or county Wage
equivalents) index GAF
------------------------------------------------------------------------
0040Abilene, TX..................................... 0.8892 0.9227
Taylor, TX
0060Aguadilla, PR................................... 0.4758 0.6013
Aguada, PR
Aguadilla, PR
Moca, PR
0080Akron, OH....................................... 0.9651 0.9760
Portage, OH
Summit, OH
0120Albany, GA...................................... 0.8821 0.9177
Dougherty, GA
Lee, GA
0160Albany-Schenectady-Troy, NY..................... 0.8871 0.9212
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200Albuquerque, NM................................. 0.9300 0.9515
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220Alexandria, LA.................................. 0.8302 0.8804
Rapides, LA
0240Allentown-Bethlehem-Easton, PA.................. 1.0114 1.0078
Carbon, PA
Lehigh, PA
Northampton, PA
0280Altoona, PA..................................... 0.9203 0.9447
Blair, PA
0320Amarillo, TX.................................... 0.8582 0.9006
Potter, TX
Randall, TX
0380Anchorage, AK................................... 1.3228 1.2112
Anchorage, AK
0440Ann Arbor, MI................................... 1.2593 1.1710
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450Anniston, AL.................................... 0.7959 0.8553
Calhoun, AL
0460Appleton-Oshkosh-Neenah, WI..................... 0.8842 0.9192
Calumet, WI
Outagamie, WI
Winnebago, WI
0470Arecibo, PR..................................... 0.3798 0.5153
Arecibo, PR
Camuy, PR
Hatillo, PR
0480Asheville, NC................................... 0.9171 0.9425
Buncombe, NC
Madison, NC
0500Athens, GA...................................... 0.9052 0.9341
Clarke, GA
Madison, GA
Oconee, GA
0520*Atlanta, GA.................................... 1.0261 1.0178
Barrow, GA
Bartow, GA
Carroll, GA
Cherokee, GA
Clayton, GA
Cobb, GA
Coweta, GA
De Kalb, GA
Douglas, GA
Fayette, GA
Forsyth, GA
Fulton, GA
Gwinnett, GA
Henry, GA
Newton, GA
Paulding, GA
Pickens, GA
Rockdale, GA
Spalding, GA
Walton, GA
0560Atlantic City-Cape May, NJ...................... 1.0878 1.0593
Atlantic City, NJ
Cape May, NJ
0600Augusta-Aiken, GA-SC............................ 0.8638 0.9046
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640Austin-San Marcos, TX........................... 0.9113 0.9384
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680Bakersfield, CA................................. 1.0883 1.0597
Kern, CA
0720*Baltimore, MD.................................. 0.9866 0.9908
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Annes, MD
0733Bangor, ME...................................... 0.9489 0.9647
Penobscot, ME
0743Barnstable-Yarmouth, MA......................... 1.3813 1.2476
Barnstable, MA
0760Baton Rouge, LA................................. 0.8617 0.9031
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840Beaumont-Port Arthur, TX........................ 0.8648 0.9053
Hardin, TX
Jefferson, TX
Orange, TX
0860Bellingham, WA.................................. 1.1232 1.0828
Whatcom, WA
0870Benton Harbor, MI............................... 0.8172 0.8709
Berrien, MI
0875*Bergen-Passaic, NJ............................. 1.1494 1.1000
Bergen, NJ
Passaic, NJ
0880Billings, MT.................................... 0.8718 0.9103
Yellowstone, MT
0920Biloxi-Gulfport-Pascagoula, MS.................. 0.8245 0.8762
Hancock, MS
Harrison, MS
Jackson, MS
0960Binghamton, NY.................................. 0.9183 0.9433
Broome, NY
Tioga, NY
1000Birmingham, AL.................................. 0.8832 0.9185
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010Bismarck, ND.................................... 0.8616 0.9030
Burleigh, ND
Morton, ND
1020Bloomington, IN................................. 0.8529 0.8968
Monroe, IN
1040Bloomington-Normal, IL.......................... 0.8463 0.8920
McLean, IL
1080Boise City, ID.................................. 0.9032 0.9327
Ada, ID
Canyon, ID
1123*Boston-Brockton-Nashua, MA-NH.................. 1.1733 1.1157
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125Boulder-Longmont, CO............................ 0.7979 0.8568
Boulder, CO
1145Brazoria, TX.................................... 0.8263 0.8775
Brazoria, TX
1150Bremerton, WA................................... 0.9647 0.9757
Kitsap, WA
1240Brownsville-Harlingen-San Benito, TX............ 0.8218 0.8742
Cameron, TX
1260Bryan-College Station, TX....................... 0.8673 0.9071
Brazos, TX
1280*Buffalo-Niagara Falls, NY...................... 0.9183 0.9433
Erie, NY
Niagara, NY
1303Burlington, VT.................................. 0.9939 0.9958
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310Caguas, PR...................................... 0.4373 0.5676
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320Canton-Massillon, OH............................ 0.8731 0.9113
Carroll, OH
Stark, OH
1350Casper, WY...................................... 0.8444 0.8906
Natrona, WY
1360Cedar Rapids, IA................................ 0.8457 0.8916
Linn, IA
1400Champaign-Urbana, IL............................ 0.8848 0.9196
Champaign, IL
1440Charleston-North Charleston, SC................. 0.8845 0.9194
Berkeley, SC
Charleston, SC
Dorchester, SC
1480Charleston, WV.................................. 0.9022 0.9319
Kanawha, WV
Putnam, WV
1520*Charlotte-Gastonia-Rock Hill, NC-SC............ 0.9598 0.9723
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
1540Charlottesville, VA............................. 0.9360 0.9557
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560Chattanooga, TN-GA.............................. 0.8959 0.9275
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580Cheyenne, WY.................................... 0.7478 0.8195
Laramie, WY
1600*Chicago, IL.................................... 1.0666 1.0451
Cook, IL
De Kalb, IL
Du Page, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620Chico-Paradise, CA.............................. 1.0434 1.0295
Butte, CA
1640*Cincinnati, OH-KY-IN........................... 0.9451 0.9621
Dearborn, IN
Ohio, IN
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Kenton, KY
Pendleton, KY
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
1660Clarksville-Hopkinsville, TN-KY................. 0.7515 0.8223
Christian, KY
Montgomery, TN
1680*Cleveland-Lorain-Elyria, OH.................... 0.9824 0.9879
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720Colorado Springs, CO............................ 0.9194 0.9441
El Paso, CO
1740Columbia, MO.................................... 0.9212 0.9453
Boone, MO
1760Columbia, SC.................................... 0.8989 0.9296
Lexington, SC
Richland, SC
1800Columbus, GA-AL................................. 0.7762 0.8407
Russell, AL
Chattanoochee, GA
Harris, GA
Muscogee, GA
1840*Columbus, OH................................... 0.9760 0.9835
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880Corpus Christi, TX.............................. 0.8372 0.8854
Nueces, TX
San Patricio, TX
1900Cumberland, MD-WV............................... 0.8165 0.8704
Allegany, MD
Mineral, WV
1920*Dallas, TX..................................... 0.9521 0.9669
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950Danville, VA.................................... 0.8093 0.8651
Danville City, VA
Pittsylvania, VA
1960Davenport-Rock Island-Moline, IA-IL............. 0.8226 0.8748
Scott, IA
Henry, IL
Rock Island, IL
2000Dayton-Springfield, OH.......................... 0.9195 0.9441
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020Daytona Beach, FL............................... 0.8605 0.9022
Flagler, FL
Volusia, FL
2030Decatur, AL..................................... 0.8074 0.8637
Lawrence, AL
Morgan, AL
2040Decatur, IL..................................... 0.7913 0.8519
Macon, IL
2080*Denver, CO..................................... 1.0611 1.0414
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120Des Moines, IA.................................. 0.8669 0.9068
Dallas, IA
Polk, IA
Warren, IA
2160*Detroit, MI.................................... 1.0916 1.0619
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180Dothan, AL...................................... 0.7974 0.8564
Dale, AL
Houston, AL
2190Dover, DE....................................... 0.9103 0.9377
Kent, DE
2200Dubuque, IA..................................... 0.7803 0.8438
Dubuque, IA
2240Duluth-Superior, MN-WI.......................... 0.9262 0.9489
St. Louis, MN
Douglas, WI
2281Dutchess County, NY............................. 1.0696 1.0472
Dutchess, NY
2290Eau Claire, WI.................................. 0.8477 0.8930
Chippewa, WI
Eau Claire, WI
2320El Paso, TX..................................... 0.8618 0.9032
El Paso, TX
2330Elkhart-Goshen, IN.............................. 0.8698 0.9089
Elkhart, IN
2335Elmira, NY...................................... 0.8648 0.9053
Chemung, NY
2340Enid, OK........................................ 0.8213 0.8739
Garfield, OK
2360Erie, PA........................................ 0.8959 0.9275
Erie, PA
2400Eugene-Springfield, OR.......................... 1.0585 1.0397
Lane, OR
2440Evansville-Henderson, IN-KY..................... 0.9031 0.9326
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520Fargo-Moorhead, ND-MN........................... 0.9217 0.9457
Clay, MN
Cass, ND
2560Fayetteville, NC................................ 0.8655 0.9058
Cumberland, NC
2580Fayetteville-Springdale-Rogers, AR.............. 0.6933 0.7781
Benton, AR
Washington, AR
2640Flint, MI....................................... 1.0252 1.0172
Genesee, MI
2650Florence, AL.................................... 0.7880 0.8495
Colbert, AL
Lauderdale, AL
2655Florence, SC.................................... 0.8620 0.9033
Florence, SC
2670Fort Collins-Loveland, CO....................... 0.9817 0.9874
Larimer, CO
2680*Ft. Lauderdale, FL............................. 1.0615 1.0417
Broward, FL
2700Fort Myers-Cape Coral, FL....................... 0.9619 0.9737
Lee, FL
2710Fort Pierce-Port St. Lucie, FL.................. 1.0107 1.0073
Martin, FL
St. Lucie, FL
2720Fort Smith, AR-OK............................... 0.7868 0.8486
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750Fort Walton Beach, FL........................... 0.8897 0.9231
Okaloosa, FL
2760Fort Wayne, IN.................................. 0.8759 0.9133
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800*Forth Worth-Arlington, TX...................... 0.9741 0.9822
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840Fresno, CA...................................... 1.0340 1.0232
Fresno, CA
Madera, CA
2880Gadsden, AL..................................... 0.8082 0.8643
Etowah, AL
2900Gainesville, FL................................. 0.8852 0.9199
Alachua, FL
2920Galveston-Texas City, TX........................ 1.0089 1.0061
Galveston, TX
2960Gary, IN........................................ 0.9334 0.9539
Lake, IN
Porter, IN
2975Glens Falls, NY................................. 0.9273 0.9496
Warren, NY
Washington, NY
2980Goldsboro, NC................................... 0.8453 0.8913
Wayne, NC
2985Grand Forks, ND-MN.............................. 0.9109 0.9381
Polk, MN
Grand Forks, ND
3000Grand Rapids-Muskegon-Holland, MI............... 0.9823 0.9878
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040Great Falls, MT................................. 0.8980 0.9290
Cascade, MT
3060Greeley, CO..................................... 0.9296 0.9512
Weld, CO
3080Green Bay, WI................................... 0.8817 0.9174
Brown, WI
3120*Greensboro-Winston-Salem-High..................
Point, NC 0.9165 0.9420
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150Greenville, NC.................................. 0.8948 0.9267
Pitt, NC
3160Greenville-Spartanburg-Anderson, SC............. 0.8883 0.9221
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180Hagerstown, MD.................................. 0.8947 0.9266
Washington, MD
3200Hamilton-Middletown, OH......................... 0.8238 0.8757
Butler, OH
3240Harrisburg-Lebanon-Carlisle, PA................. 0.9629 0.9744
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283*Hartford, CT................................... 1.2382 1.1576
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285Hattiesburg, MS................................. 0.6577 0.7506
Forrest, MS
Lamar, MS
3290Hickory-Morganton, NC........................... 0.7828 0.8456
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320Honolulu, HI.................................... 1.1683 1.1124
Honolulu, HI
3350Houma, LA....................................... 0.7769 0.8412
Lafourche, LA
Terrebonne, LA
3360*Houston, TX.................................... 0.9906 0.9936
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400Huntington-Ashland, WV-KY-OH.................... 0.8983 0.9292
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440Huntsville, AL.................................. 0.8142 0.8687
Limestone, AL
Madison, AL
3480*Indianapolis, IN............................... 0.9898 0.9930
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500Iowa City, IA................................... 0.9059 0.9346
Johnson, IA
3520Jackson, MI..................................... 0.9176 0.9428
Jackson, MI
3560Jackson, MS..................................... 0.7551 0.8250
Hinds, MS
Madison, MS
Rankin, MS
3580Jackson, TN..................................... 0.8122 0.8672
Madison, TN
3600Jacksonville, FL................................ 0.9019 0.9317
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605Jacksonville, NC................................ 0.7197 0.7983
Onslow, NC
3610Jamestown, NY................................... 0.7531 0.8235
Chautaqua, NY
3620Janesville-Beloit, WI........................... 0.8541 0.8976
Rock, WI
3640Jersey City, NJ................................. 1.1114 1.0750
Hudson, NJ
3660Johnson City-Kingsport-Bristol, TN-VA........... 0.8621 0.9034
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680Johnstown, PA................................... 0.8615 0.9029
Cambria, PA
Somerset, PA
3710Joplin, MO...................................... 0.7797 0.8433
Jasper, MO
Newton, MO
3720Kalamazoo-Battlecreek, MI....................... 1.0471 1.0320
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740Kankakee, IL.................................... 0.9381 0.9572
Kankakee, IL
3760*Kansas City, KS-MO............................. 0.9473 0.9636
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800Kenosha, WI..................................... 0.8809 0.9168
Kenosha, WI
3810Killeen-Temple, TX.............................. 1.0321 1.0219
Bell, TX
Coryell, TX
3840Knoxville, TN................................... 0.8572 0.8999
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850Kokomo, IN...................................... 0.9060 0.9346
Howard, IN
Tipton, IN
3870La Crosse, WI-MN................................ 0.8514 0.8957
Houston, MN
La Crosse, WI
3880Lafayette, LA................................... 0.7975 0.8565
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920Lafayette, IN................................... 0.8310 0.8809
Clinton, IN
Tippecanoe, IN
3960Lake Charles, LA................................ 0.8237 0.8756
Calcasieu, LA
3980Lakeland-Winter Haven, FL....................... 0.8570 0.8997
Polk, FL
4000Lancaster, PA................................... 0.9345 0.9547
Lancaster, PA
4040Lansing-East Lansing, MI........................ 1.0025 1.0017
Clinton, MI
Eaton, MI
Ingham, MI
4080Laredo, TX...................................... 0.6967 0.7808
Webb, TX
4100Las Cruces, NM.................................. 0.8797 0.9160
Dona Ana, NM
4120Las Vegas, NV-AZ................................ 1.1034 1.0697
Mohave, AZ
Clark, NV
Nye, NV
4150Lawrence, KS.................................... 0.8554 0.8986
Douglas, KS
4200Lawton, OK...................................... 0.8494 0.8942
Comanche, OK
4243Lewiston-Auburn, ME............................. 0.9698 0.9792
Androscoggin, ME
4280Lexington, KY................................... 0.8433 0.8898
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320Lima, OH........................................ 0.8664 0.9065
Allen, OH
Auglaize, OH
4360Lincoln, NE..................................... 0.8986 0.9294
Lancaster, NE
4400Little Rock-North Little Rock, AR............... 0.8323 0.8819
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420Longview-Marshall, TX........................... 0.8803 0.9164
Gregg, TX
Harrison, TX
Upshur, TX
4480*Los Angeles-Long Beach, CA..................... 1.2517 1.1662
Los Angeles, CA
4520Louisville, KY-IN............................... 0.9485 0.9644
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600Lubbock, TX..................................... 0.8644 0.9050
Lubbock, TX
4640Lynchburg, VA................................... 0.8310 0.8809
Amherst, VA
Bedford City, VA
Bedford, VA
Campbell, VA
Lynchburg City, VA
4680Macon, GA....................................... 0.9054 0.9342
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720Madison, WI..................................... 0.9910 0.9938
Dane, WI
4800Mansfield, OH................................... 0.8201 0.8730
Crawford, OH
Richland, OH
4840Mayaguez, PR.................................... 0.4533 0.5817
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880McAllen-Edinburg-Mission, TX.................... 0.8023 0.8600
Hidalgo, TX
4890Medford-Ashland, OR............................. 0.9917 0.9943
Jackson, OR
4900Melbourne-Titusville-Palm Bay Fl................ 0.8953 0.9271
Brevard, Fl
4920*Memphis, TN-AR-MS.............................. 0.8508 0.8953
Crittenden, AR
De Soto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940Merced, CA...................................... 1.0207 1.0141
Merced, CA
5000*Miami, FL...................................... 0.8570 0.8997
Dade, FL
5015*Middlesex-Somerset-Hunterdon, NJ............... 1.1008 1.0680
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080*Milwaukee-Waukesha, WI......................... 0.9326 0.9533
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120*Minneapolis-St Paul, MN-WI..................... 1.0844 1.0571
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5160Mobile, AL...................................... 0.7603 0.8289
Baldwin, AL
Mobile, AL
5170Modesto, CA..................................... 1.1348 1.0905
Stanislaus, CA
5190*Monmouth-Ocean, NJ............................. 1.0834 1.0564
Monmouth, NJ
Ocean, NJ
5200Monroe, LA...................................... 0.7723 0.8378
Ouachita, LA
5240Montgomery, AL.................................. 0.8045 0.8616
Autauga, AL
Elmore, AL
Montgomery, AL
5280Muncie, IN...................................... 0.9501 0.9656
Delaware, IN
5330Myrtle Beach, SC................................ 0.7951 0.8547
Horry, SC
5345Naples, FL...................................... 0.9727 0.9812
Collier, FL
5360*Nashville, TN.................................. 0.9312 0.9524
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380*Nassau-Suffolk, NY............................. 1.3069 1.2012
Nassau, NY
Suffolk, NY
5483*New Haven-Bridgeport-Stamford-.................
Danbury-Waterbury, CT 1.2281 1.1511
Fairfield, CT
New Haven, CT
5523New London-Norwich, CT.......................... 1.2020 1.1343
New London, CT
5560*New Orleans, LA................................ 0.9499 0.9654
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600*New York, NY................................... 1.4132 1.2672
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640*Newark, NJ..................................... 1.1128 1.0759
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660Newburgh, NY-PA................................. 0.8737 0.9117
Orange, NY
Pike, PA
5720*Norfolk-Virginia Beach-Newport.................
News, VA-NC 0.8313 0.8812
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
York, VA
5775*Oakland, CA.................................... 1.4658 1.2994
Alameda, CA
Contra Costa, CA
5790Ocala, FL....................................... 0.8781 0.9148
Marion, FL
5800Odessa-Midland, TX.............................. 0.8399 0.8874
Ector, TX
Midland, TX
5880Oklahoma City, OK............................... 0.8460 0.8918
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910Olympia, WA..................................... 1.1129 1.0760
Thurston, WA
5920Omaha, NE-IA.................................... 0.9796 0.9860
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945*Orange County, CA.............................. 1.0005 1.0003
Orange, CA
5960*Orlando, FL.................................... 0.9443 0.9615
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990Owensboro, KY................................... 0.7842 0.8466
Daviess, KY
6015Panama City, FL................................. 0.7538 0.8240
Bay, FL
6020Parkersburg-Marietta, WV-OH..................... 0.7963 0.8556
Washington, OH
Wood, WV
6080Pensacola, FL................................... 0.8232 0.8753
Escambia, FL
Santa Rosa, FL
6120Peoria-Pekin, IL................................ 0.8436 0.8901
Peoria, IL
Tazewell, IL
Woodford, IL
6160*Philadelphia, PA-NJ............................ 1.1129 1.0760
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200*Phoenix-Mesa, AZ............................... 1.0077 1.0053
Maricopa, AZ
Pinal, AZ
6240Pine Bluff, AR.................................. 0.8604 0.9022
Jefferson, AR
6280*Pittsburgh, PA................................. 0.9825 0.9880
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323Pittsfield, MA.................................. 1.1313 1.0882
Berkshire, MA
6360Ponce, PR....................................... 0.4518 0.5804
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403Portland, ME.................................... 0.9448 0.9619
Cumberland, ME
Sagadahoc, ME
York, ME
6440*Portland-Vancouver, OR-WA...................... 1.1181 1.0794
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483*Providence-Warwick, RI......................... 1.1136 1.0765
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520Provo-Orem, UT.................................. 0.9957 0.9971
Utah, UT
6560Pueblo, CO...................................... 0.8014 0.8593
Pueblo, CO
6580Punta Gorda, FL................................. 0.8677 0.9074
Charlotte, FL
6600Racine, WI...................................... 0.8328 0.8822
Racine, WI
6640Raleigh-Durham-Chapel Hill, NC.................. 0.9625 0.9742
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660Rapid City, SD.................................. 0.8110 0.8664
Pennington, SD
6680Reading, PA..................................... 0.9158 0.9415
Berks, PA
6690Redding, CA..................................... 1.1310 1.0880
Shasta, CA
6720Reno, NV........................................ 1.1080 1.0728
Washoe, NV
6740Richland-Kennewick-Pasco, WA.................... 0.9648 0.9758
Benton, WA
Franklin, WA
6760Richmond-Petersburg, VA......................... 0.9291 0.9509
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780*Riverside-San Bernardino, CA................... 1.1660 1.1109
Riverside, CA
San Bernardino, CA
6800Roanoke, VA..................................... 0.8364 0.8848
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820Rochester, MN................................... 1.0516 1.0351
Olmsted, MN
6840*Rochester, NY.................................. 0.9808 0.9868
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880Rockford, IL.................................... 0.8670 0.9069
Boone, IL
Ogle, IL
Winnebago, IL
6895Rocky Mount, NC................................. 0.8606 0.9023
Edgecombe, NC
Nash, NC
6920*Sacramento, CA................................. 1.2292 1.1518
El Dorado, CA
Placer, CA
Sacramento, CA
6960Saginaw-Bay City-Midland, MI.................... 0.9376 0.9568
Bay, MI
Midland, MI
Saginaw, MI
6980St. Cloud, MN................................... 0.9549 0.9689
Benton, MN
Stearns, MN
7000St. Joseph, MO.................................. 0.8602 0.9020
Andrews, MO
Buchanan, MO
7040*St. Louis, MO-IL............................... 0.9110 0.9382
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080Salem, OR....................................... 0.9552 0.9691
Marion, OR
Polk, OR
7120Salinas, CA..................................... 1.3750 1.2437
Monterey, CA
7160*Salt Lake City-Ogden, UT....................... 0.9542 0.9684
Davis, UT
Salt Lake, UT
Weber, UT
7200San Angelo, TX.................................. 0.7132 0.7934
Tom Green, TX
7240*San Antonio, TX................................ 0.8266 0.8777
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320*San Diego, CA.................................. 1.2060 1.1369
San Diego, CA
7360*San Francisco, CA.............................. 1.4120 1.2665
Marin, CA
San Francisco, CA
San Mateo, CA
7400*San Jose, CA................................... 1.4272 1.2758
Santa Clara, CA
7440*San Juan-Bayamon, PR........................... 0.4367 0.5670
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Ceiba, PR
Comerio, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trujillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Yabucoa, PR
7460San Luis Obispo-Atascadero-.....................
Paso Robles, CA 1.2413 1.1595
San Luis Obispo, CA
7480Santa Barbara-Santa Maria-Lompoc, CA............ 1.1515 1.1014
Santa Barbara, CA
7485Santa Cruz-Watsonville, CA...................... 1.0005 1.0003
Santa Cruz, CA
7490Santa Fe, NM.................................... 1.0782 1.0529
Los Alamos, NM
Santa Fe, NM
7500Santa Rosa, CA.................................. 1.3021 1.1981
Sonoma, CA
7510Sarasota-Bradenton, FL.......................... 0.9701 0.9794
Manatee, FL
Sarasota, FL
7520Savannah, GA.................................... 0.9447 0.9618
Bryan, GA
Chatham, GA
Effingham, GA
7560Scranton--Wilkes-Barre--Hazleton, PA............ 0.8638 0.9046
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600*Seattle-Bellevue-Everett, WA................... 1.1018 1.0686
Island, WA
King, WA
Snohomish, WA
7610Sharon, PA...................................... 0.8925 0.9251
Mercer, PA
7620Sheboygan, WI................................... 0.8046 0.8617
Sheboygan, WI
7640Sherman-Denison, TX............................. 0.8836 0.9187
Grayson, TX
7680Shreveport-Bossier City, LA..................... 0.9036 0.9329
Bossier, LA
Caddo, LA
Webster, LA
7720Sioux City, IA-NE............................... 0.8492 0.8941
Woodbury, IA
Dakota, NE
7760Sioux Falls, SD................................. 0.8658 0.9060
Lincoln, SD
Minnehaha, SD
7800South Bend, IN.................................. 0.9621 0.9739
St. Joseph, IN
7840Spokane, WA..................................... 1.0505 1.0343
Spokane, WA
7880Springfield, IL................................. 0.8725 0.9108
Menard, IL
Sangamon, IL
7920Springfield, MO................................. 0.7887 0.8500
Christian, MO
Greene, MO
Webster, MO
8003Springfield, MA................................. 1.0560 1.0380
Hampden, MA
Hampshire, MA
8050State College, PA............................... 0.9903 0.9933
Centre, PA
8080Steubenville-Weirton, OH-WV..................... 0.8367 0.8851
Jefferson, OH
Brooke, WV
Hancock, WV
8120Stockton-Lodi, CA............................... 1.1450 1.0972
San Joaquin, CA
8140Sumter, SC...................................... 0.8016 0.8595
Sumter, SC
8160Syracuse, NY.................................... 0.9733 0.9816
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200Tacoma, WA...................................... 0.9647 0.9757
Pierce, WA
8240Tallahassee, FL................................. 0.8411 0.8883
Gadsden, FL
Leon, FL
8280 *Tampa-St. Petersburg-Clearwater, FL........... 0.9402 0.9587
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320Terre Haute, IN................................. 0.8593 0.9014
Clay, IN
Vermillion, IN
Vigo, IN
8360Texarkana, AR-Texarkana, TX..................... 0.8091 0.8650
Miller, AR
Bowie, TX
8400Toledo, OH...................................... 0.9954 0.9968
Fulton, OH
Lucas, OH
Wood, OH
8440Topeka, KS...................................... 0.9884 0.9920
Shawnee, KS
8480Trenton, NJ..................................... 1.0251 1.0171
Mercer, NJ
8520Tucson, AZ...................................... 0.9393 0.9580
Pima, AZ
8560Tulsa, OK....................................... 0.8223 0.8746
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600Tuscaloosa, AL.................................. 0.8167 0.8705
Tuscaloosa, AL
8640Tyler, TX....................................... 0.9650 0.9759
Smith, TX
8680Utica-Rome, NY.................................. 0.8516 0.8958
Herkimer, NY
Oneida, NY
8720Vallejo-Fairfield-Napa, CA...................... 1.2534 1.1673
Napa, CA
Solano, CA
8735Ventura, CA..................................... 1.0005 1.0003
Ventura, CA
8750Victoria, TX.................................... 0.8703 0.9093
Victoria, TX
8760Vineland-Millville-Bridgeton, NJ................ 1.0294 1.0200
Cumberland, NJ
8780Visalia-Tulare-Porterville, CA.................. 1.0300 1.0204
Tulare, CA
8800Waco, TX........................................ 0.8029 0.8604
McLennan, TX
8840*Washington, DC-MD-VA-WV........................ 1.1096 1.0738
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpepper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
King George, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
8920Waterloo-Cedar Falls, IA........................ 0.8643 0.9050
Black Hawk, IA
8940Wausau, WI...................................... 0.9802 0.9864
Marathon, WI
8960West Palm Beach-Boca Raton, FL.................. 1.0005 1.0003
Palm Beach, FL
9000Wheeling, OH-WV................................. 0.7662 0.8333
Belmont, OH
Marshall, WV
Ohio, WV
9040Wichita, KS..................................... 0.9987 0.9991
Butler, KS
Harvey, KS
Sedgwick, KS
9080Wichita Falls, TX............................... 0.7906 0.8514
Archer, TX
Wichita, TX
9140Williamsport, PA................................ 0.8425 0.8893
Lycoming, PA
9160Wilmington-Newark, DE-MD........................ 1.0716 1.0485
New Castle, DE
Cecil, MD
9200Wilmington, NC.................................. 0.9138 0.9401
New Hanover, NC
Brunswick, NC
9260Yakima, WA...................................... 0.9541 0.9665
Yakima, WA
9270Yolo, CA........................................ 1.1844 1.1229
Yolo, CA
9280York, PA........................................ 0.9003 0.9306
York, PA
9320Youngstown-Warren, OH........................... 0.9422 0.9600
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340Yuba City, CA................................... 1.0192 1.0131
Sutter, CA
Yuba, CA
9360Yuma, AZ........................................ 0.8675 0.9072
Yuma, AZ
------------------------------------------------------------------------
Table 4b.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7009 0.7840
Alaska.............................................. 1.2592 1.1710
Arizona............................................. 0.8278 0.8786
Arkansas............................................ 0.6848 0.7716
California.......................................... 1.0005 1.0003
Colorado............................................ 0.7979 0.8568
Connecticut......................................... 1.2234 1.1481
Delaware............................................ 0.8430 0.8896
Florida............................................. 0.8570 0.8997
Georgia............................................. 0.7564 0.8260
Hawaii.............................................. 0.9521 0.9669
Idaho............................................... 0.8380 0.8860
Illinois............................................ 0.7364 0.8110
Indiana............................................. 0.7948 0.8545
Iowa................................................ 0.7270 0.8039
Kansas.............................................. 0.7270 0.8039
Kentucky............................................ 0.7487 0.8202
Louisiana........................................... 0.7358 0.8105
Maine............................................... 0.8414 0.8885
Maryland............................................ 0.8500 0.8947
Massachusetts....................................... 1.0744 1.0504
Michigan............................................ 0.8695 0.9087
Minnesota........................................... 0.8129 0.8677
Mississippi......................................... 0.6577 0.7506
Missouri............................................ 0.7291 0.8054
Montana............................................. 0.8146 0.8690
Nebraska............................................ 0.7282 0.8048
Nevada.............................................. 0.9078 0.9359
New Hampshire....................................... 0.9766 0.9839
New Jersey\1\.......................................
New Mexico.......................................... 0.8071 0.8635
New York............................................ 0.8737 0.9117
North Carolina...................................... 0.7828 0.8456
North Dakota........................................ 0.7347 0.8097
Ohio................................................ 0.8238 0.8757
Oklahoma............................................ 0.6842 0.7711
Oregon.............................................. 0.9227 0.9464
Pennsylvania........................................ 0.8588 0.9010
Puerto Rico......................................... 0.4364 0.5668
Rhode Island\1\.....................................
South Carolina...................................... 0.7645 0.8320
South Dakota........................................ 0.6953 0.7797
Tennessee........................................... 0.7435 0.8163
Texas............................................... 0.7510 0.8219
Utah................................................ 0.8867 0.9210
Vermont............................................. 0.9158 0.9415
Virginia............................................ 0.7807 0.8441
Washington.......................................... 0.9647 0.9757
West Virginia....................................... 0.8120 0.8671
Wisconsin........................................... 0.8328 0.8822
Wyoming............................................. 0.7977 0.8566
------------------------------------------------------------------------
\1\All counties within the State are classified urban.
Table 4c.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That Are Reclassified
------------------------------------------------------------------------
Wage
Area reclassified to... index GAF
------------------------------------------------------------------------
Albuquerque, NM..................................... 0.9300 0.9515
Alexandria, LA...................................... 0.8302 0.8804
Amarillo, TX........................................ 0.8582 0.9006
Anchorage, AK....................................... 1.3228 1.2112
Appleton-Oshkosh-Neenah, WI......................... 0.8842 0.9192
Asheville, NC....................................... 0.9171 0.9425
Atlanta, GA......................................... 1.0261 1.0178
Baton Rouge, LA..................................... 0.8617 0.9031
Benton Harbor, MI................................... 0.8172 0.8709
Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8695 0.9087
Bergen-Passaic, NJ.................................. 1.1494 1.1000
Biloxi-Gulfport-Pascagoula, MS...................... 0.7954 0.8549
Birmingham, AL...................................... 0.8832 0.9185
Bismarck, ND........................................ 0.8616 0.9030
Boise City, ID...................................... 0.9032 0.9327
Boston-Brockton-Nashua, MA-NH....................... 1.1733 1.1157
Brazoria, TX........................................ 0.8263 0.8775
Bremerton, WA....................................... 0.8591 0.9012
Bremerton, WA (Rural Wahington Hosp.)............... 0.9647 0.9757
Bryan-College Station, TX........................... 0.8673 0.9071
Casper, WY.......................................... 0.8444 0.8906
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9598 0.9723
Charlottesville, VA................................. 0.9201 0.9446
Chattanooga, TN-GA.................................. 0.8959 0.9275
Chicago, IL......................................... 1.0666 1.0451
Cincinnati, OH-KY-IN................................ 0.9451 0.9621
Cleveland-Lorain-Elyria, OH......................... 0.9824 0.9879
Columbia, MO........................................ 0.9076 0.9358
Columbus, GA-AL..................................... 0.7762 0.8407
Columbus, OH........................................ 0.9760 0.9835
Cumberland, MD-WV................................... 0.8165 0.8704
Dallas, TX.......................................... 0.9521 0.9669
Davenport-Rock Island-Moline, IA-IL................. 0.8226 0.8748
Dayton-Springfield, OH.............................. 0.9195 0.9441
Denver, CO.......................................... 1.0611 1.0414
Des Moines, IA...................................... 0.8533 0.8971
Detroit, MI......................................... 1.0916 1.0619
Dothan, AL.......................................... 0.7974 0.8564
Duluth-Superior, MN-WI.............................. 0.9262 0.9489
Dutchess County, NY................................. 1.0539 1.0366
Eau Claire, WI...................................... 0.8477 0.8930
El Paso, TX......................................... 0.8618 0.9032
Eugene-Springfield, OR.............................. 1.0585 1.0397
Fargo-Moorhead, ND-MN............................... 0.9051 0.9340
Fayetteville, NC.................................... 0.8385 0.8864
Flint, MI........................................... 1.0252 1.0172
Florence, AL........................................ 0.7880 0.8495
Florence, SC........................................ 0.8620 0.9033
Fort Lauderdale, FL................................. 1.0370 1.0252
Fort Pierce-Port St. Lucie, FL...................... 1.0107 1.0073
Fort Smith, AR-OK................................... 0.7868 0.8486
Fort Walton Beach, FL............................... 0.8744 0.9122
Fort Wayne, IN...................................... 0.8759 0.9133
Fort Worth-Arlington, TX............................ 0.9741 0.9822
Gadsden, AL......................................... 0.8082 0.8643
Gainesville, FL..................................... 0.8852 0.9199
Glens Falls, NY..................................... 0.9273 0.9496
Grand Forks, ND-MN.................................. 0.9109 0.9381
Great Falls, MT..................................... 0.8980 0.9290
Greeley, CO......................................... 0.9125 0.9392
Greenville-Spartanburg-Anderson, SC................. 0.8883 0.9221
Harrisburg-Lebanon-Carlisle, PA..................... 0.9629 0.9744
Hartford, CT........................................ 1.2226 1.1476
Houston, TX......................................... 0.9906 0.9936
Huntington-Ashland, WV-KY-OH........................ 0.8983 0.9292
Huntsville, AL...................................... 0.7942 0.8540
Indianapolis, IN.................................... 0.9898 0.9930
Jackson, MS......................................... 0.7551 0.8250
Jackson, TN......................................... 0.8122 0.8672
Johnson City-Kingsport-Bristol, TN-VA............... 0.8621 0.9034
Joplin, MO.......................................... 0.7797 0.8433
Kalamazoo-Battlecreek, MI........................... 1.0471 1.0320
Kansas City, KS-MO.................................. 0.9473 0.9636
Knoxville, TN....................................... 0.8572 0.8999
Lafayette, LA....................................... 0.7975 0.8565
Lansing-East Lansing, MI............................ 1.0025 1.0017
Las Cruces, NM...................................... 0.8797 0.9160
Las Vegas, NV-AZ.................................... 1.1034 1.0697
Lexington, KY....................................... 0.8433 0.8898
Lima, OH............................................ 0.8664 0.9065
Lincoln, NE......................................... 0.8765 0.9137
Little Rock-North Little Rock, AR................... 0.8323 0.8819
Longview-Marshall, TX............................... 0.8586 0.9009
Los Angeles-Long Beach, CA.......................... 1.2517 1.1662
Louisville, KY-IN................................... 0.9485 0.9644
Lubbock, TX......................................... 0.8644 0.9050
Macon, GA........................................... 0.8647 0.9052
Madison, WI......................................... 0.9910 0.9938
Mansfield, OH....................................... 0.8201 0.8730
Mansfield, OH (Rural Ohio only)..................... 0.8238 0.8757
Medford-Ashland, OR................................. 0.9917 0.9943
Memphis, TN-AR-MS................................... 0.8386 0.8864
Merced, CA.......................................... 1.0207 1.0141
Middlesex-Somerset-Hunterdon, NJ.................... 1.0770 1.0521
Milwaukee-Waukesha, WI.............................. 0.9326 0.9533
Minneapolis-St. Paul, MN-WI......................... 1.0844 1.0571
Modesto, CA......................................... 1.1348 1.0905
Monroe, LA.......................................... 0.7723 0.8378
Montgomery, AL...................................... 0.8045 0.8616
Nashville, TN....................................... 0.9176 0.9428
New London-Norwich, CT.............................. 1.2020 1.1343
New Orleans, LA..................................... 0.9499 0.9654
New York, NY........................................ 1.4132 1.2672
Newark, NJ.......................................... 1.0848 1.0573
Newburgh, NY-PA..................................... 0.9454 0.9623
Oakland, CA......................................... 1.4658 1.2994
Oklahoma City, OK................................... 0.8460 0.8918
Omaha, NE-IA........................................ 0.9796 0.9860
Orange County, CA................................... 1.5215 1.3330
Peoria-Pekin, IL.................................... 0.8436 0.8901
Philadelphia, PA-NJ................................. 1.1129 1.0760
Pittsburgh, PA...................................... 0.9825 0.9880
Portland-Vancouver, OR-WA........................... 1.1181 1.0794
Provo-Orem, UT...................................... 0.9601 0.9725
Raleigh-Durham-Chapel Hill, NC...................... 0.9625 0.9742
Roanoke, VA......................................... 0.8364 0.8848
Rochester, MN....................................... 1.0376 1.0256
Rockford, IL........................................ 0.8670 0.9069
Rocky Mount, NC..................................... 0.8606 0.9023
Saginaw-Bay City-Midland, MI,....................... 0.9376 0.9568
St. Cloud, MN....................................... 0.9549 0.9689
St. Louis, MO-IL.................................... 0.9110 0.9382
Salem, OR........................................... 0.9552 0.9691
Salt Lake City-Ogden, UT............................ 0.9542 0.9684
San Francisco, CA................................... 1.4120 1.2665
San Jose, CA........................................ 1.4272 1.2758
Sarasota-Bradenton, FL.............................. 0.9701 0.9794
Scranton-Wilkes-Barre-Hazelton, PA.................. 0.8638 0.9046
Seattle-Bellevue-Everett, WA........................ 1.0826 1.0559
Sherman-Denison, TX................................. 0.8836 0.9187
Sioux City, IA-NE................................... 0.8340 0.8831
Sioux Falls, SD..................................... 0.8658 0.9060
South Bend, IN...................................... 0.9621 0.9739
Springfield, IL..................................... 0.8725 0.9108
Syracuse, NY........................................ 0.9733 0.9816
Tampa-St. Petersburg-Clearwater, FL................. 0.9402 0.9587
Texarkana, TX-Texarkana, AR......................... 0.8091 0.8650
Topeka, KS.......................................... 0.9884 0.9920
Trenton, NJ......................................... 1.2495 1.1648
Tucson, AZ.......................................... 0.9393 0.9580
Tulsa, OK........................................... 0.8223 0.8746
Tyler, TX........................................... 0.9245 0.9477
Ventura, CA......................................... 1.2807 1.1846
Waco, TX............................................ 0.8029 0.8604
Washington, DC-MD-VA-WV............................. 1.1096 1.0738
Waterloo-Cedar Falls, IA............................ 0.8643 0.9050
Wausau, WI.......................................... 0.9385 0.9575
Wichita, KS......................................... 0.9694 0.9789
Rural Alabama....................................... 0.7009 0.7840
Rural Louisiana..................................... 0.7358 0.8105
Rural Missouri...................................... 0.7291 0.8054
Rural New Hampshire................................. 0.9766 0.9839
Rural Ohio.......................................... 0.8238 0.8757
Rural Virginia...................................... 0.7807 0.8441
Rural West Virginia................................. 0.8120 0.8671
Rural Wyoming....................................... 0.7977 0.8566
------------------------------------------------------------------------
Table 4d.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 16.2390
Aguadilla, PR................................................ 8.6888
Akron, OH.................................................... 17.2298
Albany, GA................................................... 16.1099
Albany-Schenectady-Troy, NY.................................. 16.1998
Albuquerque, NM.............................................. 16.9834
Alexandria, LA............................................... 15.1620
Allentown-Bethlehem-Easton, PA-NJ............................ 18.4715
Altoona, PA.................................................. 16.8070
Amarillo, TX................................................. 15.6736
Anchorage, AK................................................ 24.0896
Ann Arbor, MI................................................ 22.9974
Anniston, AL................................................. 14.5345
Appleton-Oshkosh-Neenah, WI.................................. 16.1474
Arecibo, PR.................................................. 6.9358
Asheville, NC................................................ 16.7477
Athens, GA................................................... 16.5317
Atlanta, GA.................................................. 18.7400
Atlantic City-Cape May, NJ................................... 19.8657
Augusta-Aiken, GA-SC......................................... 15.7746
Austin-San Marcos, TX........................................ 16.6425
Bakersfield, CA.............................................. 19.8748
Baltimore, MD................................................ 18.0181
Bangor, ME................................................... 17.3289
Barnstable-Yarmouth, MA...................................... 25.2260
Baton Rouge, LA.............................................. 15.7376
Beaumont-Port Arthur, TX..................................... 15.7934
Bellingham, WA............................................... 20.5119
Benton Harbor, MI............................................ 14.8759
Bergen-Passaic, NJ........................................... 21.0835
Billings, MT................................................. 15.9221
Biloxi-Gulfport-Pascagoula, MS............................... 15.0572
Binghamton, NY............................................... 16.7713
Birmingham, AL............................................... 16.1296
Bismarck, ND................................................. 15.7353
Bloomington, IN.............................................. 15.5760
Bloomington-Normal, IL....................................... 15.4563
Boise City, ID............................................... 16.4944
Boston-Brockton-Nashua, MA-NH................................ 21.4264
Boulder-Longmont, CO......................................... 17.9719
Brazoria, TX................................................. 15.9482
Bremerton, WA................................................ 17.6611
Brownsville-Harlingen-San Benito, TX......................... 15.0080
Bryan-College Station, TX.................................... 15.8389
Buffalo-Niagara Falls, NY.................................... 16.7713
Burlington, VT............................................... 18.1518
Caguas, PR................................................... 7.9854
Canton-Massillon, OH......................................... 15.9456
Casper, WY................................................... 15.3186
Cedar Rapids, IA............................................. 15.4439
Champaign-Urbana, IL......................................... 16.1590
Charleston-North Charleston, SC.............................. 16.1537
Charleston, WV............................................... 16.4759
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 17.4798
Charlottesville, VA.......................................... 17.0943
Chattanooga, TN-GA........................................... 16.3611
Cheyenne, WY................................................. 13.6561
Chicago, IL.................................................. 19.4782
Chico-Paradise, CA........................................... 19.0544
Cincinnati, OH-KY-IN......................................... 17.2605
Clarksville-Hopkinsville, TN-KY.............................. 13.7237
Cleveland-Lorain-Elyria, OH.................................. 17.9419
Colorado Springs, CO......................................... 16.7908
Columbia, MO................................................. 16.8243
Columbia, SC................................................. 16.4154
Columbus, GA-AL.............................................. 14.1755
Columbus, OH................................................. 17.8234
Corpus Christi, TX........................................... 15.2899
Cumberland, MD-WV............................................ 14.7426
Dallas, TX................................................... 17.3874
Danville, VA................................................. 14.7798
Davenport-Moline-Rock Island, IA-IL.......................... 15.0227
Dayton-Springfield, OH....................................... 17.1168
Daytona Beach, FL............................................ 15.7149
Decatur, AL.................................................. 14.7445
Decatur, IL.................................................. 14.4506
Denver, CO................................................... 19.3789
Des Moines, IA............................................... 15.8324
Detroit, MI.................................................. 19.9346
Dothan, AL................................................... 14.5621
Dover, DE.................................................... 16.6236
Dubuque, IA.................................................. 14.2498
Duluth-Superior, MN-WI....................................... 16.8727
Dutchess County, NY.......................................... 19.5331
Eau Claire, WI............................................... 15.3631
El Paso, TX.................................................. 15.7386
Elkhart-Goshen, IN........................................... 15.8850
Elmira, NY................................................... 15.7932
Enid, OK..................................................... 14.9984
Erie, PA..................................................... 16.3613
Eugene-Springfield, OR....................................... 19.3300
Evansville, Henderson, IN-KY................................. 16.4926
Fargo-Moorhead, ND-MN........................................ 16.8334
Fayetteville, NC............................................. 15.8069
Fayetteville-Springdale-Rogers, AR........................... 12.6619
Flint, MI.................................................... 18.8129
Florence, AL................................................. 13.9337
Florence, SC................................................. 15.7220
Fort Collins-Loveland, CO.................................... 17.9280
Fort Lauderdale, FL.......................................... 19.3863
Fort Myers-Cape Coral, FL.................................... 17.5672
Fort Pierce-Fort St. Lucie, FL............................... 18.2169
Fort Smith, AR-OK............................................ 14.3610
Fort Walton Beach, FL........................................ 16.2490
Fort Wayne, IN............................................... 15.9958
Fort Worth-Arlington, TX..................................... 17.7622
Fresno, CA................................................... 18.8835
Gadsden, AL.................................................. 14.7595
Gainesville, FL.............................................. 16.1250
Galveston-Texas City, TX..................................... 18.5274
Gary, IN..................................................... 17.6879
Glens Falls, NY.............................................. 16.6860
Goldsboro, NC................................................ 15.4377
Grand Forks, ND-MN........................................... 16.5506
Grand Rapids-Muskegon-Holland, MI............................ 17.9395
Great Falls, MT.............................................. 15.7811
Greeley, CO.................................................. 16.9775
Green Bay, WI................................................ 16.1023
Greensboro-Winston-Salem-High Point, NC...................... 16.7379
Greenville, NC............................................... 16.3414
Greenville-Spartanburg-Anderson, SC.......................... 16.2233
Hagerstown, MD............................................... 16.3387
Hamilton-Middletown, OH...................................... 16.0265
Harrisburg-Lebanon-Carlisle, PA.............................. 17.5548
Hartford, CT................................................. 22.6120
Hattiesburg, MS.............................................. 13.1174
Hickory-Morganton, NC........................................ 15.9128
Honolulu, HI................................................. 21.3363
Houma, LA.................................................... 14.1874
Houston, TX.................................................. 18.0712
Huntington-Ashland, WV-KY-OH................................. 16.4056
Huntsville, AL............................................... 14.8690
Indianapolis, IN............................................. 18.0754
Iowa City, IA................................................ 16.5438
Jackson, MI.................................................. 16.7570
Jackson, MS.................................................. 13.6437
Jackson, TN.................................................. 14.8324
Jacksonville, FL............................................. 16.4719
Jacksonville, NC............................................. 13.1433
Jamestown, NY................................................ 13.7544
Janesville-Beloit, WI........................................ 15.5973
Jersey City, NJ.............................................. 20.2964
Johnson City-Kingsport-Bristol, TN-VA........................ 15.7450
Johnstown, PA................................................ 15.7335
Joplin, MO................................................... 14.1549
Kalamazoo-Battle Creek, MI................................... 19.1226
Kankakee, IL................................................. 17.1314
Kansas City, KS-MO........................................... 17.3002
Kenosha, WI.................................................. 16.0882
Killeen-Temple, TX........................................... 18.8494
Knoxville, TN................................................ 15.6535
Kokomo, IN................................................... 16.5463
LaCrosse, WI-MN.............................................. 15.5484
Lafayette, LA................................................ 14.4264
Lafayette, IN................................................ 15.1766
Lake Charles, LA............................................. 15.0433
Lakeland-Winter Haven, FL.................................... 15.7741
Lancaster, PA................................................ 17.0658
Lansing-East Lansing, MI..................................... 18.3091
Laredo, TX................................................... 12.7235
Las Cruces, NM............................................... 16.0660
Las Vegas, NV-AZ............................................. 20.1498
Lawrence, KS................................................. 15.6222
Lawton, OK................................................... 15.5118
Lewiston-Auburn, ME.......................................... 17.7114
Lexington, KY................................................ 15.3464
Lima, OH..................................................... 15.8233
Lincoln, NE.................................................. 16.4101
Little Rock-North Little Rock, AR............................ 15.2008
Longview-Marshall, TX........................................ 16.0767
Los Angeles-Long Beach, CA................................... 22.8625
Louisville, KY-IN............................................ 17.3214
Lubbock, TX.................................................. 15.7866
Lynchburg, VA................................................ 15.1754
Macon, GA.................................................... 16.5340
Madison, WI.................................................. 18.0981
Mansfield, OH................................................ 14.9778
Mayaguez, PR................................................. 8.2780
McAllen-Edinburg-Mission, TX................................. 14.6517
Medford-Ashland, OR.......................................... 17.6815
Melbourne-Titusville-Palm Bay, FL............................ 16.3510
Memphis, TN-AR-MS............................................ 15.5377
Merced, CA................................................... 17.9988
Miami, FL.................................................... 18.6138
Middlesex-Somerset-Hunterdon, NJ............................. 19.4924
Milwaukee-Waukesha, WI....................................... 17.0313
Minneapolis-St. Paul, MN-WI.................................. 19.8042
Mobile, AL................................................... 14.0947
Modesto, CA.................................................. 20.7245
Monmouth-Ocean, NJ........................................... 19.7865
Monroe, LA................................................... 13.9777
Montgomery, AL............................................... 14.6928
Muncie, IN................................................... 17.3507
Myrtle Beach, SC............................................. 14.5213
Naples, FL................................................... 17.7633
Nashville, TN................................................ 17.0052
Nassau-Suffolk, NY........................................... 25.0266
New Haven-Bridgeport-Stamford-Danbury-Waterbury, CT.......... 22.7334
New London-Norwich, CT....................................... 21.7403
New Orleans, LA.............................................. 17.3485
New York, NY................................................. 25.6680
Newark, NJ................................................... 21.9178
Newburgh, NY-PA.............................................. 18.6175
Norfolk-Virginia Beach-Newport News, VA-NC................... 15.1815
Oakland, CA.................................................. 26.7287
Ocala, FL.................................................... 16.0357
Odessa-Midland, TX........................................... 15.3382
Oklahoma City, OK............................................ 15.4498
Olympia, WA.................................................. 20.3246
Omaha, NE-IA................................................. 17.8896
Orange County, CA............................................ 22.4725
Orlando, FL.................................................. 17.2448
Owensboro, KY................................................ 14.3219
Panama City, FL.............................................. 13.7657
Parkersburg-Marietta, WV-OH.................................. 14.5430
Pensacola, FL................................................ 15.0335
Peoria-Pekin, IL............................................. 15.4069
Philadelphia, PA-NJ.......................................... 20.3573
Phoenix-Mesa, AZ............................................. 18.4023
Pine Bluff, AR............................................... 15.7140
Pittsburgh, PA............................................... 17.9430
Pittsfield, MA............................................... 20.6597
Ponce, PR.................................................... 8.2504
Portland, ME................................................. 17.3007
Portland-Vancouver, OR-WA.................................... 20.4201
Providence-Warwick, RI....................................... 20.3374
Provo-Orem, UT............................................... 18.1838
Pueblo, CO................................................... 14.6354
Punta Gorda, FL.............................................. 16.4253
Racine, WI................................................... 15.7220
Raleigh-Durham-Chapel Hill, NC............................... 17.5768
Rapid City, SD............................................... 14.8116
Reading, PA.................................................. 16.7253
Redding, CA.................................................. 20.6553
Reno, NV..................................................... 20.2340
Richland-Kennewick-Pasco, WA................................. 17.6199
Richmond-Petersburg, VA...................................... 16.9685
Riverside-San Bernardino, CA................................. 21.4766
Roanoke, VA.................................................. 15.0995
Rochester, MN................................................ 19.2043
Rochester, NY................................................ 17.9126
Rockford, IL................................................. 15.8339
Rocky Mount, NC.............................................. 15.6891
Sacramento, CA............................................... 22.4479
Saginaw-Bay City-Midland, MI................................. 17.0878
St. Cloud, MN................................................ 17.4385
St. Joseph, MO............................................... 15.7097
St. Louis, MO-IL............................................. 16.6369
Salem, OR.................................................... 17.4562
Salinas, CA.................................................. 25.1117
Salt Lake City-Ogden, UT..................................... 17.4211
San Angelo, TX............................................... 13.0251
San Antonio, TX.............................................. 15.0956
San Diego, CA................................................ 22.0249
San Francisco, CA............................................ 25.7496
San Jose, CA................................................. 26.0635
San Juan-Bayamon, PR......................................... 7.9754
San Luis Obispo-Atascadero-Paso Robles, CA................... 22.6693
Santa Barbara-Santa Maria-Lompoc, CA......................... 21.0302
Santa Cruz-Watsonville, CA................................... 24.7020
Santa Fe, NM................................................. 19.6904
Santa Rosa, CA............................................... 23.5918
Sarasota-Bradenton, FL....................................... 17.7033
Savannah, GA................................................. 17.2535
Scranton-Wilkes Barre-Hazleton, PA........................... 15.6190
Seattle-Bellevue-Everett, WA................................. 20.1224
Sharon, PA................................................... 16.2992
Sheboygan, WI................................................ 14.6933
Sherman-Denison, TX.......................................... 16.1308
Shreveport-Bossier City, LA.................................. 16.5027
Sioux City, IA-NE............................................ 15.5079
Sioux Falls, SD.............................................. 15.8117
South Bend, IN............................................... 17.5707
Spokane, WA.................................................. 19.1855
Springfield, IL.............................................. 15.9339
Springfield, MO.............................................. 14.4034
Springfield, MA.............................................. 19.2856
State College, PA............................................ 18.0846
Steubenville-Weirton, OH-WV.................................. 15.2796
Stockton-Lodi, CA............................................ 20.9108
Sumter, SC................................................... 14.6395
Syracuse, NY................................................. 17.7747
Tacoma, WA................................................... 19.0089
Tallahassee, FL.............................................. 15.3608
Tampa-St. Petersburg-Clearwater, FL.......................... 17.1686
Terre Haute, IN.............................................. 15.6927
Texarkana, TX-Texarkana, AR.................................. 14.4473
Toledo, OH................................................... 18.4170
Topeka, KS................................................... 18.0500
Trenton, NJ.................................................. 18.7216
Tucson, AZ................................................... 17.1274
Tulsa, OK.................................................... 15.0169
Tuscaloosa, AL............................................... 14.9142
Tyler, TX.................................................... 17.6235
Utica-Rome, NY............................................... 15.5520
Vallejo-Fairfield-Napa, CA................................... 23.8150
Ventura, CA.................................................. 21.2188
Victoria, TX................................................. 15.8948
Vineland-Millville-Bridgeton, NJ............................. 18.7995
Visalia-Tulare-Porterville, CA............................... 18.8104
Waco, TX..................................................... 14.6634
Washington, DC-MD-VA-WV...................................... 20.2639
Waterloo-Cedar Falls, IA..................................... 15.7836
Wausau, WI................................................... 17.9018
West Palm Beach-Boca Raton, FL............................... 18.5566
Wheeling, WV-OH.............................................. 13.9932
Wichita, KS.................................................. 18.2393
Wichita Falls, TX............................................ 14.4379
Williamsport, PA............................................. 15.3868
Wilmington-Newark, DE-MD..................................... 19.5698
Wilmington, NC............................................... 16.6887
Yakima, WA................................................... 17.4240
Yolo, CA..................................................... 21.6301
York, PA..................................................... 16.4426
Youngstown-Warren, OH........................................ 17.2067
Yuba City, CA................................................ 18.6136
Yuma, AZ..................................................... 15.8434
------------------------------------------------------------------------
Table 4e.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
Average hourly
Nonurban area wage
------------------------------------------------------------------------
Alabama................................................. 12.7964
Alaska.................................................. 22.9951
Arizona................................................. 15.1182
Arkansas................................................ 12.5053
California.............................................. 18.2723
Colorado................................................ 14.5708
Connecticut............................................. 22.3424
Delaware................................................ 15.3947
Florida................................................. 15.6504
Georgia................................................. 13.8146
Hawaii.................................................. 17.3871
Idaho................................................... 15.3040
Illinois................................................ 13.4481
Indiana................................................. 14.5148
Iowa.................................................... 13.2762
Kansas.................................................. 13.2765
Kentucky................................................ 13.6733
Louisiana............................................... 13.4020
Maine................................................... 15.3657
Maryland................................................ 15.5228
Massachusetts........................................... 19.6216
Michigan................................................ 15.8784
Minnesota............................................... 14.8463
Mississippi............................................. 12.0121
Missouri................................................ 13.3156
Montana................................................. 14.8763
Nebraska................................................ 13.2995
Nevada.................................................. 16.5787
New Hampshire........................................... 17.8209
New Jersey\1\.
New Mexico.............................................. 14.7391
New York................................................ 15.9555
North Carolina.......................................... 14.2958
North Dakota............................................ 13.4168
Ohio.................................................... 15.0372
Oklahoma................................................ 12.4951
Oregon.................................................. 16.8507
Pennsylvania............................................ 15.6839
Puerto Rico............................................. 7.9697
Rhode Island\1\.
South Carolina.......................................... 13.9612
South Dakota............................................ 12.6982
Tennessee............................................... 13.5784
Texas................................................... 13.7144
Utah.................................................... 16.1932
Vermont................................................. 16.7241
Virginia................................................ 14.2474
Washington.............................................. 17.6177
West Virginia........................................... 14.7441
Wisconsin............................................... 15.2092
Wyoming................................................. 14.4896
------------------------------------------------------------------------
\1\All counties within the State are classified urban.
Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric Mean Length of Stay,
and Length of Stay Outlier Cutoff Points Used in the Prospective Payment System
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic Outlier
weights mean LOS mean LOS threshold
----------------------------------------------------------------------------------------------------------------
1....... 01 SURG CRANIOTOMY AGE >17 EXCEPT FOR 3.1565 9.6 13.5 32
TRAUMA.
2....... 01 SURG CRANIOTOMY FOR TRAUMA AGE >17.. 3.0968 9.8 13.9 32
3....... 01 SURG *CRANIOTOMY AGE 0-17........... 3.0398 12.7 12.7 35
4....... 01 SURG SPINAL PROCEDURES.............. 2.3292 7.2 11.0 29
5....... 01 SURG EXTRACRANIAL VASCULAR 1.5601 4.4 5.6 26
PROCEDURES.
6....... 01 SURG CARPAL TUNNEL RELEASE.......... .6339 2.2 3.2 24
7....... 01 SURG PERIPH & CRANIAL NERVE & OTHER 2.5005 10.1 17.4 32
NERV SYST PROC W CC.
8....... 01 SURG PERIPH & CRANIAL NERVE & OTHER .9185 2.9 4.7 25
NERV SYST PROC W/O CC.
9....... 01 MED SPINAL DISORDERS & INJURIES.... 1.2553 6.0 8.8 28
10...... 01 MED NERVOUS SYSTEM NEOPLASMS W CC.. 1.2618 6.7 9.7 29
11...... 01 MED NERVOUS SYSTEM NEOPLASMS W/O CC .7734 3.8 5.5 26
12...... 01 MED DEGENERATIVE NERVOUS SYSTEM .9574 6.3 9.0 28
DISORDERS.
13...... 01 MED MULTIPLE SCLEROSIS & CEREBELLAR .7813 5.7 7.2 28
ATAXIA.
14...... 01 MED SPECIFIC CEREBROVASCULAR 1.1956 6.4 8.7 28
DISORDERS EXCEPT TIA.
15...... 01 MED TRANSIENT ISCHEMIC ATTACK & .6909 3.8 4.9 26
PRECEREBRAL OCCLUSIONS.
16...... 01 MED NONSPECIFIC CEREBROVASCULAR 1.0488 5.8 7.8 28
DISORDERS W CC.
17...... 01 MED NONSPECIFIC CEREBROVASCULAR .6195 3.5 4.6 26
DISORDERS W/O CC.
18...... 01 MED CRANIAL & PERIPHERAL NERVE .9126 5.5 7.2 27
DISORDERS W CC.
19...... 01 MED CRANIAL & PERIPHERAL NERVE .5925 3.7 4.8 26
DISORDERS W/O CC.
20...... 01 MED NERVOUS SYSTEM INFECTION EXCEPT 2.0828 8.2 11.7 30
VIRAL MENINGITIS.
21...... 01 MED VIRAL MENINGITIS............... 1.4342 6.4 8.6 28
22...... 01 MED HYPERTENSIVE ENCEPHALOPATHY.... .7806 4.2 5.4 26
23...... 01 MED NONTRAUMATIC STUPOR & COMA..... .8004 4.0 5.6 26
24...... 01 MED SEIZURE & HEADACHE AGE >17 W CC .9647 4.8 6.6 27
25...... 01 MED SEIZURE & HEADACHE AGE >17 W/O .5515 3.2 4.1 25
CC.
26...... 01 MED SEIZURE & HEADACHE AGE 0-17.... .6270 2.8 4.3 25
27...... 01 MED TRAUMATIC STUPOR & COMA, COMA 1.3457 3.9 7.4 26
>1 HR.
28...... 01 MED TRAUMATIC STUPOR & COMA, COMA 1.2170 5.5 8.3 27
<1 HR AGE >17 W CC.
29...... 01 MED TRAUMATIC STUPOR & COMA, COMA .6200 3.2 4.6 25
<1 HR AGE >17 W/O CC.
30...... 01 MED *TRAUMATIC STUPOR & COMA, COMA .3687 2.0 2.0 17
<1 HR AGE 0-17.
31...... 01 MED CONCUSSION AGE >17 W CC........ .7627 4.0 5.6 26
32...... 01 MED CONCUSSION AGE >17 W/O CC...... .4635 2.5 3.4 23
33...... 01 MED *CONCUSSION AGE 0-17........... .2559 1.6 1.6 9
34...... 01 MED OTHER DISORDERS OF NERVOUS 1.0862 5.3 7.5 27
SYSTEM W CC.
35...... 01 MED OTHER DISORDERS OF NERVOUS .5866 3.5 4.9 26
SYSTEM W/O CC.
36...... 02 SURG RETINAL PROCEDURES............. .5989 1.5 1.8 8
37...... 02 SURG ORBITAL PROCEDURES............. .8089 2.6 3.9 25
38...... 02 SURG PRIMARY IRIS PROCEDURES........ .4005 2.0 2.7 16
39...... 02 SURG LENS PROCEDURES WITH OR WITHOUT .5055 1.5 1.9 9
VITRECTOMY.
40...... 02 SURG EXTRAOCULAR PROCEDURES EXCEPT .6241 2.3 3.6 24
ORBIT AGE >17.
41...... 02 SURG *EXTRAOCULAR PROCEDURES EXCEPT .3810 1.6 1.6 7
ORBIT AGE 0-17.
42...... 02 SURG INTRAOCULAR PROCEDURES EXCEPT .5687 1.7 2.2 12
RETINA, IRIS & LENS.
43...... 02 MED HYPHEMA........................ .3400 3.0 3.6 20
44...... 02 MED ACUTE MAJOR EYE INFECTIONS..... .5755 4.9 6.0 27
45...... 02 MED NEUROLOGICAL EYE DISORDERS..... .6211 3.5 4.3 25
46...... 02 MED OTHER DISORDERS OF THE EYE AGE .7553 4.4 6.1 26
>17 W CC.
47...... 02 MED OTHER DISORDERS OF THE EYE AGE .4331 3.0 3.9 25
>17 W/O CC.
48...... 02 MED *OTHER DISORDERS OF THE EYE AGE .4186 2.9 2.9 25
0-17.
49...... 03 SURG MAJOR HEAD & NECK PROCEDURES... 1.7106 4.9 6.8 27
50...... 03 SURG SIALOADENECTOMY................ .7131 1.9 2.3 11
51...... 03 SURG SALIVARY GLAND PROCEDURES .6838 2.0 3.0 22
EXCEPT SIALOADENECTOMY.
52...... 03 SURG CLEFT LIP & PALATE REPAIR...... .9152 2.3 3.0 20
53...... 03 SURG SINUS & MASTOID PROCEDURES AGE .8647 2.2 3.4 24
>17.
54...... 03 SURG *SINUS & MASTOID PROCEDURES AGE .7176 3.2 3.2 22
0-17.
55...... 03 SURG MISCELLANEOUS EAR, NOSE, MOUTH .6455 1.8 2.8 20
& THROAT PROCEDURES.
56...... 03 SURG RHINOPLASTY.................... .7684 2.2 3.1 24
57...... 03 SURG T&A PROC, EXCEPT TONSILLECTOMY 1.0174 3.4 5.2 25
&/OR ADENOIDECTOMY ONLY, AGE
>17.
58...... 03 SURG *T&A PROC, EXCEPT TONSILLECTOMY .3227 1.5 1.5 4
&/OR ADENOIDECTOMY ONLY, AGE 0-
17.
59...... 03 SURG TONSILLECTOMY &/OR .4602 1.5 1.9 9
ADENOIDECTOMY ONLY, AGE >17.
60...... 03 SURG *TONSILLECTOMY &/OR .2724 1.5 1.5 4
ADENOIDECTOMY ONLY, AGE 0-17.
61...... 03 SURG MYRINGOTOMY W TUBE INSERTION 1.0019 2.9 5.1 25
AGE >17.
62...... 03 SURG *MYRINGOTOMY W TUBE INSERTION .3217 1.3 1.3 5
AGE 0-17.
63...... 03 SURG OTHER EAR, NOSE, MOUTH & THROAT 1.1047 3.4 5.0 25
O.R. PROCEDURES.
64...... 03 MED EAR, NOSE, MOUTH & THROAT 1.1419 5.0 8.4 27
MALIGNANCY.
65...... 03 MED DYSEQUILIBRIUM................. .5067 3.0 3.8 22
66...... 03 MED EPISTAXIS...................... .5076 3.1 3.9 24
67...... 03 MED EPIGLOTTITIS................... .8381 3.8 4.7 26
68...... 03 MED OTITIS MEDIA & URI AGE >17 W CC .7100 4.4 5.4 26
69...... 03 MED OTITIS MEDIA & URI AGE >17 W/O .5133 3.5 4.2 22
CC.
70...... 03 MED OTITIS MEDIA & URI AGE 0-17.... .5812 3.6 4.4 24
71...... 03 MED LARYNGOTRACHEITIS.............. .6508 3.5 4.2 22
72...... 03 MED NASAL TRAUMA & DEFORMITY....... .6160 3.1 4.4 25
73...... 03 MED OTHER EAR, NOSE, MOUTH & THROAT .7616 4.1 5.5 26
DIAGNOSES AGE >17.
74...... 03 MED *OTHER EAR, NOSE, MOUTH & .3571 2.1 2.1 20
THROAT DIAGNOSES AGE 0-17.
75...... 04 SURG MAJOR CHEST PROCEDURES......... 3.0551 9.9 12.4 32
76...... 04 SURG OTHER RESP SYSTEM O.R. 2.5126 10.0 13.9 32
PROCEDURES W CC.
77...... 04 SURG OTHER RESP SYSTEM O.R. 1.0630 4.0 6.0 26
PROCEDURES W/O CC.
78...... 04 MED PULMONARY EMBOLISM............. 1.4211 7.8 9.2 30
79...... 04 MED RESPIRATORY INFECTIONS & 1.6955 8.3 10.7 30
INFLAMMATIONS AGE >17 W CC.
80...... 04 MED RESPIRATORY INFECTIONS & .9259 5.9 7.4 28
INFLAMMATIONS AGE >17 W/O CC.
81...... 04 MED RESPIRATORY INFECTIONS & 1.4323 5.7 7.1 28
INFLAMMATIONS AGE 0-17.
82...... 04 MED RESPIRATORY NEOPLASMS.......... 1.3237 6.3 8.9 28
83...... 04 MED MAJOR CHEST TRAUMA W CC........ .9530 5.5 7.2 28
84...... 04 MED MAJOR CHEST TRAUMA W/O CC...... .4996 3.2 4.3 25
85...... 04 MED PLEURAL EFFUSION W CC.......... 1.1890 6.2 8.2 28
86...... 04 MED PLEURAL EFFUSION W/O CC........ .6753 3.8 4.9 26
87...... 04 MED PULMONARY EDEMA & RESPIRATORY 1.3306 5.5 7.5 27
FAILURE.
88...... 04 MED CHRONIC OBSTRUCTIVE PULMONARY 1.0053 5.6 6.9 28
DISEASE.
89...... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE 1.1317 6.5 8.0 29
>17 W CC.
90...... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE .6924 4.9 5.7 27
>17 W/O CC.
91...... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE .6834 3.8 4.4 20
0-17.
92...... 04 MED INTERSTITIAL LUNG DISEASE W CC. 1.2084 6.4 8.1 28
93...... 04 MED INTERSTITIAL LUNG DISEASE W/O .7700 4.5 5.7 26
CC.
94...... 04 MED PNEUMOTHORAX W CC.............. 1.2427 6.5 8.5 28
95...... 04 MED PNEUMOTHORAX W/O CC............ .6146 3.9 4.9 26
96...... 04 MED BRONCHITIS & ASTHMA AGE >17 W .8488 5.2 6.2 27
CC.
97...... 04 MED BRONCHITIS & ASTHMA AGE >17 W/O .6122 4.1 4.9 24
CC.
98...... 04 MED BRONCHITIS & ASTHMA AGE 0-17... .5356 3.1 4.1 25
99...... 04 MED RESPIRATORY SIGNS & SYMPTOMS W .7019 3.2 4.1 25
CC.
100..... 04 MED RESPIRATORY SIGNS & SYMPTOMS W/ .5051 2.3 2.8 15
O CC.
101..... 04 MED OTHER RESPIRATORY SYSTEM .9055 4.6 6.2 27
DIAGNOSES W CC.
102..... 04 MED OTHER RESPIRATORY SYSTEM .5339 3.0 4.0 25
DIAGNOSES W/O CC.
103..... 05 SURG HEART TRANSPLANT............... 13.5495 25.4 35.8 47
104..... 05 SURG CARDIAC VALVE PROCEDURES W 7.6076 15.2 18.0 37
CARDIAC CATH.
105..... 05 SURG CARDIAC VALVE PROCEDURES W/O 5.7656 11.0 13.0 33
CARDIAC CATH.
106..... 05 SURG CORONARY BYPASS W CARDIAC CATH. 5.6683 12.1 13.6 34
107..... 05 SURG CORONARY BYPASS W/O CARDIAC 4.1974 9.3 10.4 31
CATH.
108..... 05 SURG OTHER CARDIOTHORACIC PROCEDURES 6.1081 11.4 14.7 33
109..... ....... ............ NO LONGER VALID................ .0000 .0 .0 0
110..... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES 4.0796 9.1 12.2 31
W CC.
111..... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES 2.3024 6.5 7.5 28
W/O CC.
112..... 05 SURG PERCUTANEOUS CARDIOVASCULAR 1.9881 3.9 5.3 26
PROCEDURES.
113..... 05 SURG AMPUTATION FOR CIRC SYSTEM 2.7765 12.7 17.2 35
DISORDERS EXCEPT UPPER LIMB &
TOE.
114..... 05 SURG UPPER LIMB & TOE AMPUTATION FOR 1.5385 7.9 10.9 30
CIRC SYSTEM DISORDERS.
115..... 05 SURG PERM CARDIAC PACEMAKER IMPLANT 3.5936 10.4 12.7 32
W AMI, HEART FAILURE OR SHOCK.
116..... 05 SURG OTH PERM CARDIAC PACEMAKER 2.4514 4.7 6.5 27
IMPLANT OR AICD LEAD OR
GENERATOR PROC.
117..... 05 SURG CARDIAC PACEMAKER REVISION 1.1671 3.3 4.9 25
EXCEPT DEVICE REPLACEMENT.
118..... 05 SURG CARDIAC PACEMAKER DEVICE 1.5582 2.3 3.5 24
REPLACEMENT.
119..... 05 SURG VEIN LIGATION & STRIPPING...... .9949 3.3 5.6 25
120..... 05 SURG OTHER CIRCULATORY SYSTEM O.R. 1.9616 6.3 10.7 28
PROCEDURES.
121..... 05 MED CIRCULATORY DISORDERS W AMI & 1.6022 7.0 8.6 29
C.V. COMP DISCH ALIVE.
122..... 05 MED CIRCULATORY DISORDERS W AMI W/O 1.1292 4.9 6.0 27
C.V. COMP DISCH ALIVE.
123..... 05 MED CIRCULATORY DISORDERS W AMI, 1.4286 2.9 5.1 25
EXPIRED.
124..... 05 MED CIRCULATORY DISORDERS EXCEPT 1.2657 4.2 5.5 26
AMI, W CARD CATH & COMPLEX
DIAG.
125..... 05 MED CIRCULATORY DISORDERS EXCEPT .8451 2.4 3.2 23
AMI, W CARD CATH W/O COMPLEX
DIAG.
126..... 05 MED ACUTE & SUBACUTE ENDOCARDITIS.. 2.7724 13.7 18.4 36
127..... 05 MED HEART FAILURE & SHOCK.......... 1.0239 5.5 7.1 27
128..... 05 MED DEEP VEIN THROMBOPHLEBITIS..... .7820 6.7 7.5 29
129..... 05 MED CARDIAC ARREST, UNEXPLAINED.... 1.1308 2.1 3.8 24
130..... 05 MED PERIPHERAL VASCULAR DISORDERS W .9177 5.8 7.4 28
CC.
131..... 05 MED PERIPHERAL VASCULAR DISORDERS W/ .5889 4.5 5.6 27
O CC.
132..... 05 MED ATHEROSCLEROSIS W CC........... .7296 3.6 4.7 26
133..... 05 MED ATHEROSCLEROSIS W/O CC......... .5348 2.7 3.5 21
134..... 05 MED HYPERTENSION................... .5761 3.5 4.4 25
135..... 05 MED CARDIAC CONGENITAL & VALVULAR .8507 4.3 5.8 26
DISORDERS AGE >17 W CC.
136..... 05 MED CARDIAC CONGENITAL & VALVULAR .5600 2.9 3.7 23
DISORDERS AGE >17 W/O CC.
137..... 05 MED *CARDIAC CONGENITAL & VALVULAR .6578 3.3 3.3 25
DISORDERS AGE 0-17.
138..... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION .7964 3.9 5.2 26
DISORDERS W CC.
139..... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION .4939 2.6 3.3 20
DISORDERS W/O CC.
140..... 05 MED ANGINA PECTORIS................ .6258 3.2 4.0 23
141..... 05 MED SYNCOPE & COLLAPSE W CC........ .7025 3.9 5.1 26
142..... 05 MED SYNCOPE & COLLAPSE W/O CC...... .5174 2.9 3.6 21
143..... 05 MED CHEST PAIN..................... .5169 2.4 3.0 16
144..... 05 MED OTHER CIRCULATORY SYSTEM 1.0580 4.5 6.4 27
DIAGNOSES W CC.
145..... 05 MED OTHER CIRCULATORY SYSTEM .6155 2.8 3.7 25
DIAGNOSES W/O CC.
146..... 06 SURG RECTAL RESECTION W CC.......... 2.5367 10.7 12.2 33
147..... 06 SURG RECTAL RESECTION W/O CC........ 1.5469 7.4 8.0 28
148..... 06 SURG MAJOR SMALL & LARGE BOWEL 3.2220 12.2 14.7 34
PROCEDURES W CC.
149..... 06 SURG MAJOR SMALL & LARGE BOWEL 1.5022 7.6 8.2 26
PROCEDURES W/O CC.
150..... 06 SURG PERITONEAL ADHESIOLYSIS W CC... 2.5652 10.5 12.8 32
151..... 06 SURG PERITONEAL ADHESIOLYSIS W/O CC. 1.1814 5.5 6.8 27
152..... 06 SURG MINOR SMALL & LARGE BOWEL 1.7829 8.3 9.7 30
PROCEDURES W CC.
153..... 06 SURG MINOR SMALL & LARGE BOWEL 1.1151 6.0 6.7 26
PROCEDURES W/O CC.
154..... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL 4.1740 13.3 17.0 35
PROCEDURES AGE >17 W CC.
155..... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL 1.3898 6.1 7.2 28
PROCEDURES AGE >17 W/O CC.
156..... 06 SURG *STOMACH, ESOPHAGEAL & DUODENAL .8732 6.0 6.0 28
PROCEDURES AGE 0-17.
157..... 06 SURG ANAL & STOMAL PROCEDURES W CC.. 1.0320 4.4 6.1 26
158..... 06 SURG ANAL & STOMAL PROCEDURES W/O CC .5445 2.3 3.0 18
159..... 06 SURG HERNIA PROCEDURES EXCEPT 1.1066 4.3 5.6 26
INGUINAL & FEMORAL AGE >17 W
CC.
160..... 06 SURG HERNIA PROCEDURES EXCEPT .6574 2.5 3.1 18
INGUINAL & FEMORAL AGE >17 W/O
CC.
161..... 06 SURG INGUINAL & FEMORAL HERNIA .9053 3.2 4.6 25
PROCEDURES AGE >17 W CC.
162..... 06 SURG INGUINAL & FEMORAL HERNIA .5156 1.8 2.2 11
PROCEDURES AGE >17 W/O CC.
163..... 06 SURG HERNIA PROCEDURES AGE 0-17..... .7275 3.9 4.8 24
164..... 06 SURG APPENDECTOMY W COMPLICATED 2.1645 8.8 10.2 31
PRINCIPAL DIAG W CC.
165..... 06 SURG APPENDECTOMY W COMPLICATED 1.1976 5.7 6.3 24
PRINCIPAL DIAG W/O CC.
166..... 06 SURG APPENDECTOMY W/O COMPLICATED 1.3465 5.2 6.3 27
PRINCIPAL DIAG W CC.
167..... 06 SURG APPENDECTOMY W/O COMPLICATED .7828 3.2 3.7 16
PRINCIPAL DIAG W/O CC.
168..... 03 SURG MOUTH PROCEDURES W CC.......... 1.0856 3.5 5.4 25
169..... 03 SURG MOUTH PROCEDURES W/O CC........ .6149 2.1 2.7 16
170..... 06 SURG OTHER DIGESTIVE SYSTEM O.R. 2.7813 9.8 14.6 32
PROCEDURES W CC.
171..... 06 SURG OTHER DIGESTIVE SYSTEM O.R. 1.0638 4.3 5.9 26
PROCEDURES W/O CC.
172..... 06 MED DIGESTIVE MALIGNANCY W CC...... 1.2990 6.5 9.4 29
173..... 06 MED DIGESTIVE MALIGNANCY W/O CC.... .6262 3.2 4.6 25
174..... 06 MED G.I. HEMORRHAGE W CC........... .9726 4.9 6.2 27
175..... 06 MED G.I. HEMORRHAGE W/O CC......... .5359 3.3 3.9 19
176..... 06 MED COMPLICATED PEPTIC ULCER....... 1.0436 5.3 6.9 27
177..... 06 MED UNCOMPLICATED PEPTIC ULCER W CC .8062 4.5 5.6 27
178..... 06 MED UNCOMPLICATED PEPTIC ULCER W/O .5807 3.3 3.9 19
CC.
179..... 06 MED INFLAMMATORY BOWEL DISEASE..... 1.1143 6.4 8.2 28
180..... 06 MED G.I. OBSTRUCTION W CC.......... .9139 5.2 6.8 27
181..... 06 MED G.I. OBSTRUCTION W/O CC........ .4975 3.4 4.2 23
182..... 06 MED ESOPHAGITIS, GASTROENT & MISC .7685 4.3 5.6 26
DIGEST DISORDERS AGE >17 W CC.
183..... 06 MED ESOPHAGITIS, GASTROENT & MISC .5356 3.1 3.8 22
DIGEST DISORDERS AGE >17 W/O
CC.
184..... 06 MED ESOPHAGITIS, GASTROENT & MISC .4240 2.6 3.4 21
DIGEST DISORDERS AGE 0-17.
185..... 03 MED DENTAL & ORAL DIS EXCEPT .8312 4.1 5.7 26
EXTRACTIONS & RESTORATIONS,
AGE >17.
186..... 03 MED *DENTAL & ORAL DIS EXCEPT .4282 2.9 2.9 23
EXTRACTIONS & RESTORATIONS,
AGE 0-17.
187..... 03 MED DENTAL EXTRACTIONS & .6350 2.8 3.8 25
RESTORATIONS.
188..... 06 MED OTHER DIGESTIVE SYSTEM 1.0201 4.9 6.8 27
DIAGNOSES AGE >17 W CC.
189..... 06 MED OTHER DIGESTIVE SYSTEM .5027 2.7 3.7 25
DIAGNOSES AGE >17 W/O CC.
190..... 06 MED OTHER DIGESTIVE SYSTEM .6707 3.2 4.5 25
DIAGNOSES AGE 0-17.
191..... 07 SURG PANCREAS, LIVER & SHUNT 4.4176 13.6 18.2 36
PROCEDURES W CC.
192..... 07 SURG PANCREAS, LIVER & SHUNT 1.7609 6.9 8.9 29
PROCEDURES W/O CC.
193..... 07 SURG BILIARY TRACT PROC EXCEPT ONLY 3.1497 12.9 15.7 35
CHOLECYST W OR W/O C.D.E. W CC.
194..... 07 SURG BILIARY TRACT PROC EXCEPT ONLY 1.6562 7.3 9.2 29
CHOLECYST W OR W/O C.D.E. W/O
CC.
195..... 07 SURG CHOLECYSTECTOMY W C.D.E. W CC.. 2.4576 9.7 11.4 32
196..... 07 SURG CHOLECYSTECTOMY W C.D.E. W/O CC 1.4861 6.5 7.5 29
197..... 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.0796 8.1 9.7 30
LAPAROSCOPE W/O C.D.E. W CC.
198..... 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.0930 4.6 5.3 24
LAPAROSCOPE W/O C.D.E. W/O CC.
199..... 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3603 9.9 13.2 32
PROCEDURE FOR MALIGNANCY.
200..... 07 SURG HEPATOBILIARY DIAGNOSTIC 2.9698 8.4 13.1 30
PROCEDURE FOR NON-MALIGNANCY.
201..... 07 SURG OTHER HEPATOBILIARY OR PANCREAS 3.2322 12.1 17.0 34
O.R. PROCEDURES.
202..... 07 MED CIRRHOSIS & ALCOHOLIC HEPATITIS 1.3087 6.4 8.7 28
203..... 07 MED MALIGNANCY OF HEPATOBILIARY 1.2384 6.3 8.9 28
SYSTEM OR PANCREAS.
204..... 07 MED DISORDERS OF PANCREAS EXCEPT 1.1376 5.7 7.3 28
MALIGNANCY.
205..... 07 MED DISORDERS OF LIVER EXCEPT 1.2284 6.1 8.4 28
MALIG, CIRR, ALC HEPA W CC.
206..... 07 MED DISORDERS OF LIVER EXCEPT .6220 3.4 4.7 25
MALIG, CIRR, ALC HEPA W/O CC.
207..... 07 MED DISORDERS OF THE BILIARY TRACT 1.0063 4.9 6.4 27
W CC.
208..... 07 MED DISORDERS OF THE BILIARY TRACT .5661 2.9 3.7 23
W/O CC.
209..... 08 SURG MAJOR JOINT & LIMB REATTACHMENT 2.3173 7.7 8.6 29
PROCEDURES OF LOWER EXTREMITY.
210..... 08 SURG HIP & FEMUR PROCEDURES EXCEPT 1.8427 9.0 10.6 31
MAJOR JOINT AGE >17 W CC.
211..... 08 SURG HIP & FEMUR PROCEDURES EXCEPT 1.2990 7.0 7.9 29
MAJOR JOINT AGE >17 W/O CC.
212..... 08 SURG HIP & FEMUR PROCEDURES EXCEPT .9084 3.6 4.1 19
MAJOR JOINT AGE 0-17.
213..... 08 SURG AMPUTATION FOR MUSCULOSKELETAL 1.7234 8.2 11.3 30
SYSTEM & CONN TISSUE DISORDERS.
214..... 08 SURG BACK & NECK PROCEDURES W CC.... 1.9237 6.5 8.2 28
215..... 08 SURG BACK & NECK PROCEDURES W/O CC.. 1.0977 3.9 4.8 24
216..... 08 SURG BIOPSIES OF MUSCULOSKELETAL 2.1046 9.3 13.3 31
SYSTEM & CONNECTIVE TISSUE.
217..... 08 SURG WND DEBRID & SKN GRFT EXCEPT 3.0084 12.3 18.9 34
HAND, FOR MUSCSKELET & CONN
TISS DIS.
218..... 08 SURG LOWER EXTREM & HUMER PROC 1.4028 5.7 7.4 28
EXCEPT HIP, FOOT, FEMUR AGE
>17 W CC.
219..... 08 SURG LOWER EXTREM & HUMER PROC .9132 3.6 4.4 23
EXCEPT HIP, FOOT, FEMUR AGE
>17 W/O CC.
220..... 08 SURG *LOWER EXTREM & HUMER PROC .9626 5.3 5.3 27
EXCEPT HIP, FOOT, FEMUR AGE 0-
17.
221..... 08 SURG KNEE PROCEDURES W CC........... 1.7911 6.7 9.3 29
222..... 08 SURG KNEE PROCEDURES W/O CC......... .9852 3.5 4.7 25
223..... 08 SURG MAJOR SHOULDER/ELBOW PROC, OR .8162 2.5 3.2 18
OTHER UPPER EXTREMITY PROC W
CC.
224..... 08 SURG SHOULDER, ELBOW OR FOREARM .6932 2.2 2.7 13
PROC, EXC MAJOR JOINT PROC, W/
O CC.
225..... 08 SURG FOOT PROCEDURES................ .9006 3.3 5.1 25
226..... 08 SURG SOFT TISSUE PROCEDURES W CC.... 1.3381 5.0 7.7 27
227..... 08 SURG SOFT TISSUE PROCEDURES W/O CC.. .6999 2.4 3.2 20
228..... 08 SURG MAJOR THUMB OR JOINT PROC, OR .8409 2.3 3.5 24
OTH HAND OR WRIST PROC W CC.
229..... 08 SURG HAND OR WRIST PROC, EXCEPT .5964 1.9 2.5 15
MAJOR JOINT PROC, W/O CC.
230..... 08 SURG LOCAL EXCISION & REMOVAL OF INT .9145 3.5 5.5 26
FIX DEVICES OF HIP & FEMUR.
231..... 08 SURG LOCAL EXCISION & REMOVAL OF INT 1.1275 3.5 5.4 25
FIX DEVICES EXCEPT HIP & FEMUR.
232..... 08 SURG ARTHROSCOPY.................... 1.1560 3.2 5.8 25
233..... 08 SURG OTHER MUSCULOSKELET SYS & CONN 1.9051 7.4 10.6 29
TISS O.R. PROC W CC.
234..... 08 SURG OTHER MUSCULOSKELET SYS & CONN .9529 3.5 4.8 26
TISS O.R. PROC W/O CC.
235..... 08 MED FRACTURES OF FEMUR............. .8964 5.7 8.8 28
236..... 08 MED FRACTURES OF HIP & PELVIS...... .7772 5.5 7.6 27
237..... 08 MED SPRAINS, STRAINS, & .5535 3.7 5.0 26
DISLOCATIONS OF HIP, PELVIS &
THIGH.
238..... 08 MED OSTEOMYELITIS.................. 1.4939 9.1 12.3 31
239..... 08 MED PATHOLOGICAL FRACTURES & 1.0338 6.8 9.0 29
MUSCULOSKELETAL & CONN TISS
MALIGNANCY.
240..... 08 MED CONNECTIVE TISSUE DISORDERS W 1.1889 6.4 8.7 28
CC.
241..... 08 MED CONNECTIVE TISSUE DISORDERS W/O .5835 3.9 5.2 26
CC.
242..... 08 MED SEPTIC ARTHRITIS............... 1.1440 7.0 9.3 29
243..... 08 MED MEDICAL BACK PROBLEMS.......... .7122 4.9 6.4 27
244..... 08 MED BONE DISEASES & SPECIFIC .7346 4.9 6.6 27
ARTHROPATHIES W CC.
245..... 08 MED BONE DISEASES & SPECIFIC .4813 3.4 4.7 25
ARTHROPATHIES W/O CC.
246..... 08 MED NON-SPECIFIC ARTHROPATHIES..... .5529 3.7 4.8 26
247..... 08 MED SIGNS & SYMPTOMS OF .5532 3.3 4.5 25
MUSCULOSKELETAL SYSTEM & CONN
TISSUE.
248..... 08 MED TENDONITIS, MYOSITIS & BURSITIS .7117 4.4 5.8 26
249..... 08 MED AFTERCARE, MUSCULOSKELETAL .6486 3.4 5.0 25
SYSTEM & CONNECTIVE TISSUE.
250..... 08 MED FX, SPRN, STRN & DISL OF .6950 4.1 5.7 26
FOREARM, HAND, FOOT AGE >17 W
CC.
251..... 08 MED FX, SPRN, STRN & DISL OF .4510 2.5 3.4 23
FOREARM, HAND, FOOT AGE >17 W/
O CC.
252..... 08 MED *FX, SPRN, STRN & DISL OF .3642 1.8 1.8 15
FOREARM, HAND, FOOT AGE 0-17.
253..... 08 MED FX, SPRN, STRN & DISL OF UPARM, .7617 5.0 7.0 27
LOWLEG EX FOOT AGE >17 W CC.
254..... 08 MED FX, SPRN, STRN & DISL OF UPARM, .4324 3.2 4.3 25
LOWLEG EX FOOT AGE >17 W/O CC.
255..... 08 MED *FX, SPRN, STRN & DISL OF .4831 2.9 2.9 25
UPARM, LOWLEG EX FOOT AGE 0-17.
256..... 08 MED OTHER MUSCULOSKELETAL SYSTEM & .6397 3.4 4.7 25
CONNECTIVE TISSUE DIAGNOSES.
257..... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY .8843 3.5 4.2 20
W CC.
258..... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY .6989 2.7 3.1 12
W/O CC.
259..... 09 SURG SUBTOTAL MASTECTOMY FOR .8291 2.8 4.1 25
MALIGNANCY W CC.
260..... 09 SURG SUBTOTAL MASTECTOMY FOR .5840 1.9 2.2 10
MALIGNANCY W/O CC.
261..... 09 SURG BREAST PROC FOR NON-MALIGNANCY .7432 2.0 2.5 12
EXCEPT BIOPSY & LOCAL EXCISION.
262..... 09 SURG BREAST BIOPSY & LOCAL EXCISION .6491 2.5 3.9 25
FOR NON-MALIGNANCY.
263..... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN 2.3540 12.5 17.6 35
ULCER OR CELLULITIS W CC.
264..... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN 1.1663 7.1 9.6 29
ULCER OR CELLULITIS W/O CC.
265..... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT 1.3953 5.4 8.3 27
FOR SKIN ULCER OR CELLULITIS W
CC.
266..... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT .7358 2.9 4.0 25
FOR SKIN ULCER OR CELLULITIS W/
O CC.
267..... 09 SURG PERIANAL & PILONIDAL PROCEDURES .6935 2.6 4.2 25
268..... 09 SURG SKIN, SUBCUTANEOUS TISSUE & .8356 2.5 3.9 25
BREAST PLASTIC PROCEDURES.
269..... 09 SURG OTHER SKIN, SUBCUT TISS & 1.7025 7.4 10.9 29
BREAST PROC W CC.
270..... 09 SURG OTHER SKIN, SUBCUT TISS & .6610 2.5 3.6 25
BREAST PROC W/O CC.
271..... 09 MED SKIN ULCERS.................... 1.1343 7.6 10.0 30
272..... 09 MED MAJOR SKIN DISORDERS W CC...... 1.0072 6.3 8.2 28
273..... 09 MED MAJOR SKIN DISORDERS W/O CC.... .6339 4.6 6.1 27
274..... 09 MED MALIGNANT BREAST DISORDERS W CC 1.1084 5.9 9.2 28
275..... 09 MED MALIGNANT BREAST DISORDERS W/O .5132 2.6 4.1 25
CC.
276..... 09 MED NON-MALIGANT BREAST DISORDERS.. .6137 4.0 5.4 26
277..... 09 MED CELLULITIS AGE >17 W CC........ .8804 6.2 7.6 28
278..... 09 MED CELLULITIS AGE >17 W/O CC...... .5850 4.8 5.7 27
279..... 09 MED CELLULITIS AGE 0-17............ .6708 3.7 4.3 22
280..... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS .6729 4.2 5.7 26
& BREAST AGE >17 W CC.
281..... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS .4344 2.9 3.9 25
& BREAST AGE >17 W/O CC.
282..... 09 MED *TRAUMA TO THE SKIN, SUBCUT .3566 2.2 2.2 19
TISS & BREAST AGE 0-17.
283..... 09 MED MINOR SKIN DISORDERS W CC...... .7155 4.8 6.3 27
284..... 09 MED MINOR SKIN DISORDERS W/O CC.... .4342 3.3 4.3 25
285..... 10 SURG AMPUTAT OF LOWER LIMB FOR 2.5270 12.6 17.5 35
ENDOCRINE, NUTRIT, & METABOL
DISORDERS.
286..... 10 SURG ADRENAL & PITUITARY PROCEDURES. 2.2621 7.6 9.3 30
287..... 10 SURG SKIN GRAFTS & WOUND DEBRID FOR 2.1035 11.4 16.4 33
ENDOC, NUTRIT & METAB
DISORDERS.
288..... 10 SURG O.R. PROCEDURES FOR OBESITY.... 1.9030 5.8 8.0 28
289..... 10 SURG PARATHYROID PROCEDURES......... 1.0063 3.2 4.6 25
290..... 10 SURG THYROID PROCEDURES............. .7931 2.4 3.0 15
291..... 10 SURG THYROGLOSSAL PROCEDURES........ .5102 1.6 2.0 9
292..... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB 2.7197 10.2 15.0 32
O.R. PROC W CC.
293..... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB 1.1604 4.7 6.6 27
O.R. PROC W/O CC.
294..... 10 MED DIABETES AGE >35............... .7463 5.2 6.5 27
295..... 10 MED DIABETES AGE 0-35.............. .7433 3.9 5.1 26
296..... 10 MED NUTRITIONAL & MISC METABOLIC .9179 5.4 7.4 27
DISORDERS AGE >17 W CC.
297..... 10 MED NUTRITIONAL & MISC METABOLIC .5305 3.7 4.7 26
DISORDERS AGE >17 W/O CC.
298..... 10 MED NUTRITIONAL & MISC METABOLIC .5421 2.7 4.3 25
DISORDERS AGE 0-17.
299..... 10 MED INBORN ERRORS OF METABOLISM.... .8118 4.3 6.1 26
300..... 10 MED ENDOCRINE DISORDERS W CC....... 1.0982 6.3 8.3 28
301..... 10 MED ENDOCRINE DISORDERS W/O CC..... .6003 3.7 4.9 26
302..... 11 SURG KIDNEY TRANSPLANT.............. 4.1394 12.6 14.6 35
303..... 11 SURG KIDNEY, URETER & MAJOR BLADDER 2.5739 9.7 11.6 32
PROCEDURES FOR NEOPLASM.
304..... 11 SURG KIDNEY, URETER & MAJOR BLADDER 2.3313 8.7 11.7 31
PROC FOR NON-NEOPL W CC.
305..... 11 SURG KIDNEY, URETER & MAJOR BLADDER 1.1366 4.5 5.6 26
PROC FOR NON-NEOPL W/O CC.
306..... 11 SURG PROSTATECTOMY W CC............. 1.2101 5.4 7.3 27
307..... 11 SURG PROSTATECTOMY W/O CC........... .6619 3.0 3.6 18
308..... 11 SURG MINOR BLADDER PROCEDURES W CC.. 1.4465 5.4 8.1 27
309..... 11 SURG MINOR BLADDER PROCEDURES W/O CC .7971 2.6 3.4 22
310..... 11 SURG TRANSURETHRAL PROCEDURES W CC.. .9159 3.5 5.0 25
311..... 11 SURG TRANSURETHRAL PROCEDURES W/O CC .5395 2.0 2.5 13
312..... 11 SURG URETHRAL PROCEDURES, AGE >17 W .8458 3.5 5.3 26
CC.
313..... 11 SURG URETHRAL PROCEDURES, AGE >17 W/ .4774 2.0 2.6 16
O CC.
314..... 11 SURG *URETHRAL PROCEDURES, AGE 0-17. .4503 2.3 2.3 24
315..... 11 SURG OTHER KIDNEY & URINARY TRACT 2.0323 6.0 10.7 28
O.R. PROCEDURES.
316..... 11 MED RENAL FAILURE.................. 1.2840 5.9 8.4 28
317..... 11 MED ADMIT FOR RENAL DIALYSIS....... .5149 2.8 3.9 25
318..... 11 MED KIDNEY & URINARY TRACT 1.1196 5.5 8.1 28
NEOPLASMS W CC.
319..... 11 MED KIDNEY & URINARY TRACT .5530 2.4 3.3 24
NEOPLASMS W/O CC.
320..... 11 MED KIDNEY & URINARY TRACT .9451 5.9 7.4 28
INFECTIONS AGE >17 W CC.
321..... 11 MED KIDNEY & URINARY TRACT .6109 4.4 5.2 26
INFECTIONS AGE >17 W/O CC.
322..... 11 MED KIDNEY & URINARY TRACT .5464 3.9 4.7 25
INFECTIONS AGE 0-17.
323..... 11 MED URINARY STONES W CC, &/OR ESW .7221 2.9 3.9 25
LITHOTRIPSY.
324..... 11 MED URINARY STONES W/O CC.......... .3872 1.9 2.3 12
325..... 11 MED KIDNEY & URINARY TRACT SIGNS & .6476 3.9 5.2 26
SYMPTOMS AGE >17 W CC.
326..... 11 MED KIDNEY & URINARY TRACT SIGNS & .4186 2.6 3.4 22
SYMPTOMS AGE >17 W/O CC.
327..... 11 MED *KIDNEY & URINARY TRACT SIGNS & .7222 3.1 3.1 25
SYMPTOMS AGE 0-17.
328..... 11 MED URETHRAL STRICTURE AGE >17 W CC .6732 3.5 4.8 26
329..... 11 MED URETHRAL STRICTURE AGE >17 W/O .4291 1.9 2.5 15
CC.
330..... 11 MED *URETHRAL STRICTURE AGE 0-17... .2903 1.6 1.6 9
331..... 11 MED OTHER KIDNEY & URINARY TRACT .9943 5.1 7.0 27
DIAGNOSES AGE >17 W CC.
332..... 11 MED OTHER KIDNEY & URINARY TRACT .6019 3.1 4.3 25
DIAGNOSES AGE >17 W/O CC.
333..... 11 MED OTHER KIDNEY & URINARY TRACT 1.0377 4.9 7.2 27
DIAGNOSES AGE 0-17.
334..... 12 SURG MAJOR MALE PELVIC PROCEDURES W 1.7172 6.8 7.5 24
CC.
335..... 12 SURG MAJOR MALE PELVIC PROCEDURES W/ 1.3447 5.6 6.1 19
O CC.
336..... 12 SURG TRANSURETHRAL PROSTATECTOMY W .8523 4.0 4.8 23
CC.
337..... 12 SURG TRANSURETHRAL PROSTATECTOMY W/O .6130 3.0 3.3 12
CC.
338..... 12 SURG TESTES PROCEDURES, FOR .9738 3.7 5.7 26
MALIGNANCY.
339..... 12 SURG TESTES PROCEDURES, NON- .8265 3.1 4.4 25
MALIGNANCY AGE >17.
340..... 12 SURG *TESTES PROCEDURES, NON- .4516 2.4 2.4 13
MALIGNANCY AGE 0-17.
341..... 12 SURG PENIS PROCEDURES............... 1.0192 2.9 3.8 24
342..... 12 SURG CIRCUMCISION AGE >17........... .6689 2.7 4.1 25
343..... 12 SURG *CIRCUMCISION AGE 0-17......... .3945 1.7 1.7 6
344..... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM .9941 2.7 3.6 25
O.R. PROCEDURES FOR MALIGNANCY.
345..... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM .7521 3.1 4.5 25
O.R. PROC EXCEPT FOR
MALIGNANCY.
346..... 12 MED MALIGNANCY, MALE REPRODUCTIVE .9598 5.3 7.7 27
SYSTEM, W CC.
347..... 12 MED MALIGNANCY, MALE REPRODUCTIVE .4899 2.5 3.7 25
SYSTEM, W/O CC.
348..... 12 MED BENIGN PROSTATIC HYPERTROPHY W .6724 3.7 5.1 26
CC.
349..... 12 MED BENIGN PROSTATIC HYPERTROPHY W/ .4094 2.4 3.2 22
O CC.
350..... 12 MED INFLAMMATION OF THE MALE .6787 4.5 5.4 27
REPRODUCTIVE SYSTEM.
351..... 12 MED *STERILIZATION, MALE........... .3472 1.3 1.3 5
352..... 12 MED OTHER MALE REPRODUCTIVE SYSTEM .5807 3.2 4.3 25
DIAGNOSES.
353..... 13 SURG PELVIC EVISCERATION, RADICAL 1.8865 8.0 9.8 30
HYSTERECTOMY & RADICAL
VULVECTOMY.
354..... 13 SURG UTERINE, ADNEXA PROC FOR NON- 1.3747 5.9 6.9 28
OVARIAN/ADNEXAL MALIG W CC.
355..... 13 SURG UTERINE, ADNEXA PROC FOR NON- .8773 4.0 4.3 12
OVARIAN/ADNEXAL MALIG W/O CC.
356..... 13 SURG FEMALE REPRODUCTIVE SYSTEM .7162 3.2 3.6 14
RECONSTRUCTIVE PROCEDURES.
357..... 13 SURG UTERINE & ADNEXA PROC FOR 2.2834 8.9 10.9 31
OVARIAN OR ADNEXAL MALIGNANCY.
358..... 13 SURG UTERINE & ADNEXA PROC FOR NON- 1.1018 4.7 5.4 20
MALIGNANCY W CC.
359..... 13 SURG UTERINE & ADNEXA PROC FOR NON- .7987 3.5 3.8 11
MALIGNANCY W/O CC.
360..... 13 SURG VAGINA, CERVIX & VULVA .8186 3.5 4.3 22
PROCEDURES.
361..... 13 SURG LAPAROSCOPY & INCISIONAL TUBAL 1.1047 3.1 4.8 25
INTERRUPTION.
362..... 13 SURG *ENDOSCOPIC TUBAL INTERRUPTION. .5189 1.4 1.4 5
363..... 13 SURG D&C, CONIZATION & RADIO- .6470 2.8 3.7 21
IMPLANT, FOR MALIGNANCY.
364..... 13 SURG D&C, CONIZATION EXCEPT FOR .6239 2.6 3.7 25
MALIGNANCY.
365..... 13 SURG OTHER FEMALE REPRODUCTIVE 1.7127 6.3 9.2 28
SYSTEM O.R. PROCEDURES.
366..... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE 1.2111 5.9 9.1 28
SYSTEM W CC.
367..... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE .4486 2.3 3.3 24
SYSTEM W/O CC.
368..... 13 MED INFECTIONS, FEMALE REPRODUCTIVE .9704 5.6 7.3 28
SYSTEM.
369..... 13 MED MENSTRUAL & OTHER FEMALE .5095 2.9 4.0 25
REPRODUCTIVE SYSTEM DISORDERS.
370..... 14 SURG CESAREAN SECTION W CC.......... .8976 4.9 5.9 24
371..... 14 SURG CESAREAN SECTION W/O CC........ .6340 3.6 3.8 9
372..... 14 MED VAGINAL DELIVERY W COMPLICATING .4902 2.7 3.4 17
DIAGNOSES.
373..... 14 MED VAGINAL DELIVERY W/O .3387 1.9 2.2 8
COMPLICATING DIAGNOSES.
374..... 14 SURG VAGINAL DELIVERY W .6152 2.4 3.1 16
STERILIZATION &/OR D&C.
375..... 14 SURG *VAGINAL DELIVERY W O.R. PROC .7101 4.4 4.4 26
EXCEPT STERIL &/OR D&C.
376..... 14 MED POSTPARTUM & POST ABORTION .3513 2.4 3.4 21
DIAGNOSES W/O O.R. PROCEDURE.
377..... 14 SURG POSTPARTUM & POST ABORTION .9762 3.4 5.7 25
DIAGNOSES W O.R. PROCEDURE.
378..... 14 MED ECTOPIC PREGNANCY.............. .7052 2.6 3.0 15
379..... 14 MED THREATENED ABORTION............ .3204 2.1 2.8 18
380..... 14 MED ABORTION W/O D&C............... .3481 1.6 2.1 11
381..... 14 SURG ABORTION W D&C, ASPIRATION .4063 1.7 2.2 12
CURETTAGE OR HYSTEROTOMY.
382..... 14 MED FALSE LABOR.................... .1856 1.3 1.5 5
383..... 14 MED OTHER ANTEPARTUM DIAGNOSES W .4060 3.0 4.0 25
MEDICAL COMPLICATIONS.
384..... 14 MED OTHER ANTEPARTUM DIAGNOSES W/O .2909 1.9 2.5 15
MEDICAL COMPLICATIONS.
385..... 15 ............ *NEONATES, DIED OR TRANSFERRED 1.2741 1.8 1.8 24
TO ANOTHER ACUTE CARE FACILITY.
386..... 15 ............ *EXTREME IMMATURITY OR 3.7999 17.9 17.9 40
RESPIRATORY DISTRESS SYNDROME,
NEONATE.
387..... 15 ............ *PREMATURITY W MAJOR PROBLEMS.. 1.9028 13.3 13.3 35
388..... 15 ............ *PREMATURITY W/O MAJOR PROBLEMS 1.2053 8.6 8.6 31
389..... 15 ............ FULL TERM NEONATE W MAJOR 1.2972 5.6 7.7 28
PROBLEMS.
390..... 15 ............ NEONATE W OTHER SIGNIFICANT .5385 3.1 4.8 25
PROBLEMS.
391..... 15 ............ *NORMAL NEWBORN................ .2311 3.1 3.1 11
392..... 16 SURG SPLENECTOMY AGE >17............ 3.2021 10.1 13.2 32
393..... 16 SURG *SPLENECTOMY AGE 0-17.......... 1.5839 9.1 9.1 31
394..... 16 SURG OTHER O.R. PROCEDURES OF THE 1.5713 5.0 8.5 27
BLOOD AND BLOOD FORMING ORGANS.
395..... 16 MED RED BLOOD CELL DISORDERS AGE .8118 4.3 6.0 26
>17.
396..... 16 MED RED BLOOD CELL DISORDERS AGE 0- .2859 1.7 2.1 13
17.
397..... 16 MED COAGULATION DISORDERS.......... 1.2490 5.0 6.9 27
398..... 16 MED RETICULOENDOTHELIAL & IMMUNITY 1.2139 5.8 7.4 28
DISORDERS W CC.
399..... 16 MED RETICULOENDOTHELIAL & IMMUNITY .6723 3.8 4.8 26
DISORDERS W/O CC.
400..... 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 2.5674 7.6 11.8 30
O.R. PROCEDURE.
401..... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W 2.4043 9.2 13.7 31
OTHER O.R. PROC W CC.
402..... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W .9212 3.2 4.8 25
OTHER O.R. PROC W/O CC.
403..... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W 1.6956 7.4 10.7 29
CC.
404..... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W/ .7571 3.7 5.2 26
O CC.
405..... 17 ............ *ACUTE LEUKEMIA W/O MAJOR O.R. 1.0840 4.9 4.9 27
PROCEDURE AGE 0-17.
406..... 17 SURG MYELOPROLIF DISORD OR POORLY 2.6496 9.4 12.8 31
DIFF NEOPL W MAJ O.R.PROC W CC.
407..... 17 SURG MYELOPROLIF DISORD OR POORLY 1.1262 4.1 5.3 26
DIFF NEOPL W MAJ O.R.PROC W/O
CC.
408..... 17 SURG MYELOPROLIF DISORD OR POORLY 1.5586 5.0 8.4 27
DIFF NEOPL W OTHER O.R.PROC.
409..... 17 MED RADIOTHERAPY................... .9785 5.4 7.7 27
410..... 17 MED CHEMOTHERAPY W/O ACUTE LEUKEMIA .6749 2.7 3.3 20
AS SECONDARY DIAGNOSIS.
411..... 17 MED HISTORY OF MALIGNANCY W/O .4476 2.7 3.7 25
ENDOSCOPY.
412..... 17 MED HISTORY OF MALIGNANCY W .4515 2.1 3.0 21
ENDOSCOPY.
413..... 17 MED OTHER MYELOPROLIF DIS OR POORLY 1.3595 6.8 9.9 29
DIFF NEOPL DIAG W CC.
414..... 17 MED OTHER MYELOPROLIF DIS OR POORLY .6704 3.7 5.4 26
DIFF NEOPL DIAG W/O CC.
415..... 18 SURG O.R. PROCEDURE FOR INFECTIOUS & 3.5136 13.4 18.7 35
PARASITIC DISEASES.
416..... 18 MED SEPTICEMIA AGE >17............. 1.4927 6.9 9.5 29
417..... 18 MED SEPTICEMIA AGE 0-17............ 1.4250 5.2 7.5 27
418..... 18 MED POSTOPERATIVE & POST-TRAUMATIC .9628 6.0 7.6 28
INFECTIONS.
419..... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 .9293 5.2 6.6 27
W CC.
420..... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 .6368 4.0 4.9 26
W/O CC.
421..... 18 MED VIRAL ILLNESS AGE >17.......... .6868 4.0 5.1 26
422..... 18 MED VIRAL ILLNESS & FEVER OF .5859 3.4 4.3 25
UNKNOWN ORIGIN AGE 0-17.
423..... 18 MED OTHER INFECTIOUS & PARASITIC 1.5846 7.1 10.0 29
DISEASES DIAGNOSES.
424..... 19 SURG O.R. PROCEDURE W PRINCIPAL 2.5573 13.5 22.6 36
DIAGNOSES OF MENTAL ILLNESS.
425..... 19 MED ACUTE ADJUST REACT & .7079 4.1 5.7 26
DISTURBANCES OF PSYCHOSOCIAL
DYSFUNCTION.
426..... 19 MED DEPRESSIVE NEUROSES............ .5960 4.6 6.5 27
427..... 19 MED NEUROSES EXCEPT DEPRESSIVE..... .5969 4.4 6.4 26
428..... 19 MED DISORDERS OF PERSONALITY & .7521 5.7 9.4 28
IMPULSE CONTROL.
429..... 19 MED ORGANIC DISTURBANCES & MENTAL .9269 7.0 10.4 29
RETARDATION.
430..... 19 MED PSYCHOSES...................... .8980 8.0 11.5 30
431..... 19 MED CHILDHOOD MENTAL DISORDERS..... .6316 5.2 7.6 27
432..... 19 MED OTHER MENTAL DISORDER DIAGNOSES .7538 4.6 7.2 27
433..... 20 ............ ALCOHOL/DRUG ABUSE OR .3356 2.8 4.1 25
DEPENDENCE, LEFT AMA.
434..... 20 ............ ALC/DRUG ABUSE OR DEPEND, DETOX .7235 4.9 6.7 27
OR OTH SYMPT TREAT W CC.
435..... 20 ............ ALC/DRUG ABUSE OR DEPEND, DETOX .4372 4.1 5.5 26
OR OTH SYMPT TREAT W/O CC.
436..... 20 ............ ALC/DRUG DEPENDENCE W .9156 14.5 17.2 36
REHABILITATION THERAPY.
437..... 20 ............ ALC/DRUG DEPENDENCE, COMBINED .9021 11.5 13.6 34
REHAB & DETOX THERAPY.
438..... ....... ............ NO LONGER VALID................ .0000 .0 .0 0
439..... 21 SURG SKIN GRAFTS FOR INJURIES....... 1.3295 5.6 8.9 28
440..... 21 SURG WOUND DEBRIDEMENTS FOR INJURIES 1.7495 7.0 11.2 29
441..... 21 SURG HAND PROCEDURES FOR INJURIES... .7840 2.3 3.5 24
442..... 21 SURG OTHER O.R. PROCEDURES FOR 2.0135 5.8 9.5 28
INJURIES W CC.
443..... 21 SURG OTHER O.R. PROCEDURES FOR .7547 2.4 3.3 24
INJURIES W/O CC.
444..... 21 MED TRAUMATIC INJURY AGE >17 W CC.. .7399 4.6 6.2 27
445..... 21 MED TRAUMATIC INJURY AGE >17 W/O CC .4640 3.1 4.0 25
446..... 21 MED *TRAUMATIC INJURY AGE 0-17..... .4995 2.4 2.4 22
447..... 21 MED ALLERGIC REACTIONS AGE >17..... .4676 2.3 3.1 20
448..... 21 MED *ALLERGIC REACTIONS AGE 0-17... .3614 2.9 2.9 17
449..... 21 MED POISONING & TOXIC EFFECTS OF .7801 3.5 5.1 26
DRUGS AGE >17 W CC.
450..... 21 MED POISONING & TOXIC EFFECTS OF .4168 2.0 2.7 17
DRUGS AGE >17 W/O CC.
451..... 21 MED *POISONING & TOXIC EFFECTS OF 1.0341 2.1 2.1 17
DRUGS AGE 0-17.
452..... 21 MED COMPLICATIONS OF TREATMENT W CC .8577 4.0 5.6 26
453..... 21 MED COMPLICATIONS OF TREATMENT W/O .4355 2.6 3.4 22
CC.
454..... 21 MED OTHER INJURY, POISONING & TOXIC .8864 4.1 6.4 26
EFFECT DIAG W CC.
455..... 21 MED OTHER INJURY, POISONING & TOXIC .4379 2.2 3.2 24
EFFECT DIAG W/O CC.
456..... 22 ............ BURNS, TRANSFERRED TO ANOTHER 2.1721 5.2 10.2 27
ACUTE CARE FACILITY.
457..... 22 MED EXTENSIVE BURNS W/O O.R. 1.6307 3.0 5.6 25
PROCEDURE.
458..... 22 SURG NON-EXTENSIVE BURNS W SKIN 3.5089 14.0 19.8 36
GRAFT.
459..... 22 SURG NON-EXTENSIVE BURNS W WOUND 1.7543 8.5 12.5 30
DEBRIDEMENT OR OTHER O.R. PROC.
460..... 22 MED NON-EXTENSIVE BURNS W/O O.R. 1.0023 5.6 8.0 28
PROCEDURE.
461..... 23 SURG O.R. PROC W DIAGNOSES OF OTHER .9432 2.5 5.2 24
CONTACT W HEALTH SERVICES.
462..... 23 MED REHABILITATION................. 1.6623 13.4 16.7 35
463..... 23 MED SIGNS & SYMPTOMS W CC.......... .7170 4.5 6.0 26
464..... 23 MED SIGNS & SYMPTOMS W/O CC........ .4740 3.1 4.1 25
465..... 23 MED AFTERCARE W HISTORY OF .4464 2.0 3.2 23
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466..... 23 MED AFTERCARE W/O HISTORY OF .5319 2.4 4.9 24
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467..... 23 MED OTHER FACTORS INFLUENCING .3722 2.6 5.1 25
HEALTH STATUS.
468..... ....... ............ EXTENSIVE O.R. PROCEDURE 3.5769 12.4 17.7 34
UNRELATED TO PRINCIPAL
DIAGNOSIS.
469..... ....... ............ **PRINCIPAL DIAGNOSIS INVALID .0000 .0 .0 0
AS DISCHARGE DIAGNOSIS.
470..... ....... ............ **UNGROUPABLE.................. .0000 .0 .0 0
471..... 08 SURG BILATERAL OR MULTIPLE MAJOR 3.7499 9.4 11.0 31
JOINT PROCS OF LOWER EXTREMITY.
472..... 22 SURG EXTENSIVE BURNS W O.R. 11.6375 15.9 30.4 38
PROCEDURE.
473..... 17 ............ ACUTE LEUKEMIA W/O MAJOR O.R. 3.6120 9.3 16.3 31
PROCEDURE AGE >17.
474..... ....... ............ NO LONGER VALID................ .0000 .0 .0 0
475..... 04 MED RESPIRATORY SYSTEM DIAGNOSIS 3.7005 9.5 13.7 31
WITH VENTILATOR SUPPORT.
476..... ....... SURG PROSTATIC O.R. PROCEDURE 2.2327 12.3 15.6 34
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477..... ....... SURG NON-EXTENSIVE O.R. PROCEDURE 1.5221 5.8 9.5 28
UNRELATED TO PRINCIPAL
DIAGNOSIS.
478..... 05 SURG OTHER VASCULAR PROCEDURES W CC. 2.2227 6.3 9.5 28
479..... 05 SURG OTHER VASCULAR PROCEDURES W/O 1.3503 3.9 5.1 26
CC.
480..... ....... SURG LIVER TRANSPLANT............... 18.2581 27.1 34.7 49
481..... ....... SURG BONE MARROW TRANSPLANT......... 15.3076 35.5 39.4 57
482..... ....... SURG TRACHEOSTOMY FOR FACE, MOUTH & 3.6730 13.0 17.4 35
NECK DIAGNOSES.
483..... ....... SURG TRACHEOSTOMY EXCEPT FOR FACE, 16.8772 41.9 54.1 64
MOUTH & NECK DIAGNOSES.
484..... 24 SURG CRANIOTOMY FOR MULTIPLE 5.9807 12.5 20.2 35
SIGNIFICANT TRAUMA.
485..... 24 SURG LIMB REATTACHMENT, HIP AND 3.1540 11.4 14.4 33
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TRAUM.
486..... 24 SURG OTHER O.R. PROCEDURES FOR 4.9514 10.5 16.8 32
MULTIPLE SIGNIFICANT TRAUMA.
487..... 24 MED OTHER MULTIPLE SIGNIFICANT 1.9336 6.9 10.2 29
TRAUMA.
488..... 25 SURG HIV W EXTENSIVE O.R. PROCEDURE. 4.3854 15.1 21.5 37
489..... 25 MED HIV W MAJOR RELATED CONDITION.. 1.8158 8.3 12.5 30
490..... 25 MED HIV W OR W/O OTHER RELATED 1.0630 5.1 8.0 27
CONDITION.
491..... 08 SURG MAJOR JOINT & LIMB REATTACHMENT 1.6235 4.4 5.3 24
PROCEDURES OF UPPER EXTREMITY.
492..... 17 MED CHEMOTHERAPY W ACUTE LEUKEMIA 3.6804 10.7 16.9 33
AS SECONDARY DIAGNOSIS.
493..... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/ 1.5813 4.3 6.1 26
O C.D.E. W CC.
494..... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/ .8462 1.7 2.3 14
O C.D.E. W/O CC.
495..... ....... SURG LUNG TRANSPLANT................ 12.8346 20.2 26.3 42
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from Maryland and Michigan for low volume DRGS.
**DRGS 469 and 470 contain cases which could not be assigned to valid DRGS.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is used only to determine payment for outlier cases.
Note: Relative Weights are based on Medicare patient data and may not be appropriate for other patients.
Table 6a.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosiscode Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
042........... Human immunodeficiency virus [HIV] disease Y 25 489, 490
070.22........ Chronic viral hepatitis B with hepatic Y 07 205, 206
coma without mention of hepatitis delta. 15 387, 389\1\
070.23........ Chronic viral hepatitis B with hepatic Y 07 205, 206
coma with hepatitis delta. 15 387, 389\1\
070.32........ Chronic viral hepatitis B without mention Y 07 205, 206
of hepatic coma without mention of 15 387, 389\1\
hepatitis delta.
070.33........ Chronic viral hepatitis B without mention Y 07 205, 206
of hepatic coma with hepatitis delta. 15 387, 389\1\
070.44........ Chronic hepatitis C with hepatic coma..... Y 07 205, 206
15 387, 389\1\
070.54........ Chronic hepatitis C without mention of Y 07 205, 206
hepatic coma. 15 387, 389\1\
312.81........ Conduct disorder, childhood onset type.... N 19 431
312.82........ Conduct disorder, adolescent onset type... N 19 431
312.89........ Other specified conduct disorder, not N 19 431
elsewhere classified.
333.92........ Neuroleptic malignant syndrome............ N 01 34, 35
333.93........ Benign shuddering attacks................. N 01 34, 35
342.00........ Flaccid hemiplegia and hemiparesis N 01 12
affecting unspecified side.
342.01........ Flaccid hemiplegia and hemiparesis N 01 12
affecting dominant side.
342.02........ Flaccid hemiplegia and hemiparesis N 01 12
affecting nondominant side.
342.10........ Spastic hemiplegia and hemiparesis N 01 12
affecting unspecified side.
342.11........ Spastic hemiplegia and hemiparesis N 01 12
affecting dominant side.
342.12........ Spastic hemiplegia and hemiparesis N 01 12
affecting nondominant side.
342.80........ Other specified hemiplegia and hemiparesis N 01 12
affecting unspecified side.
342.81........ Other specified hemiplegia and hemiparesis N 01 12
affecting dominant side.
342.82........ Other specified hemiplegia and hemiparesis N 01 12
affecting nondominant side.
342.90........ Unspecified hemiplegia and hemiparesis N 01 12
affecting unspecified side.
342.91........ Unspecified hemiplegia and hemiparesis N 01 12
affecting dominant side.
342.92........ Unspecified hemiplegia and hemiparesis N 01 12
affecting nondominant side.
344.00........ Quadriplegia, unspecified................. Y 01 9
344.01........ Quadriplegia, C1-C4, complete............. Y 01 9
344.02........ Quadriplegia, C1-C4, incomplete........... Y 01 9
344.03........ Quadriplegia, C5-C7, complete............. Y 01 9
344.04........ Quadriplegia, C5-C7, incomplete........... Y 01 9
344.09........ Other quadriplegia........................ Y 01 9
344.30........ Monoplegia of lower limb affecting N 01 34, 35
unspecified side.
344.31........ Monoplegia of lower limb affecting N 01 34, 35
dominant side.
344.32........ Monoplegia of lower limb affecting N 01 34, 35
nondominant side.
344.40........ Monoplegia of upper limb affecting N 01 34, 35
unspecified side.
344.41........ Monoplegia of upper limb affecting N 01 34, 35
dominant side.
344.42........ Monoplegia of upper limb affecting N 01 34, 35
nondominant side.
414.00........ Coronary atherosclerosis of unspecified N 05 132, 133
vessel.
414.01........ Coronary atherosclerosis of native N 05 132, 133
coronary vessel.
414.02........ Coronary atherosclerosis of autologous N 05 132, 133
vein bypass graft.
414.03........ Coronary atherosclerosis of nonautologous N 05 132, 133
biological bypass graft.
440.30........ Atherosclerosis of unspecified bypass N 05 130, 131
graft of the extremities.
440.31........ Atherosclerosis of autologous vein bypass N 05 130, 131
graft of the extremities.
440.32........ Atherosclerosis of nonautologous N 05 130, 131
biological bypass graft of the
extremities.
441.00........ Dissecting aortic aneurysm of unspecified Y 05 121, 130, 131
site.
441.01........ Dissecting thoracic aortic aneurysm....... Y 05 121, 130, 131
441.02........ Dissecting abdominal aortic aneurysm...... Y 05 121, 130, 131
441.03........ Dissecting thoracoabdominal aortic Y 05 121, 130, 131
aneurysm.
512.1......... Iatrogenic pneumothorax................... Y 04 94, 95
536.3......... Gastroparesis............................. N 06 182, 183, 184
556.0......... Ulcerative enterocolitis.................. N 06 179
556.1......... Ulcerative ileocolitis.................... N 06 179
556.2......... Ulcerative proctitis...................... N 06 179
556.3......... Ulcerative proctosigmoiditis.............. N 06 179
556.4......... Pseudopolyposis of colon.................. N 06 179
556.5......... Left-sided ulcerative colitis............. N 06 179
556.6......... Universal ulcerative colitis.............. N 06 179
556.8......... Other ulcerative colitis.................. N 06 179
556.9......... Ulcerative colitis, unspecified........... N 06 179
593.70........ Vesicoureteral reflux unspecified or N 11 331, 332, 333
without reflux nephropathy.
593.71........ Vesicoureteral reflux with reflux N 11 331, 332, 333
nephropathy, unilateral.
593.72........ Vesicoureteral reflux with reflux N 11 331, 332, 333
nephropathy, bilateral.
593.73........ Other vesicoureteral reflux with reflux N 11 331, 332, 333
nephropathy.
669.43........ Other complications of obstetrical surgery N 14 383, 384
and procedures, antepartum condition or
complication.
677........... Late effect of complication of pregnancy, N 14 469
childbirth, the puerperium.
702.11........ Inflamed seborrheic keratosis............. N 09 283, 284
702.19........ Other seborrheic keratosis................ N 09 283, 284
709.00........ Dyschromia, unspecified................... N 09 283, 284
709.01........ Vitiligo.................................. N 09 283, 284
709.09........ Other dyschromia.......................... N 09 283, 284
759.83........ Fragile X syndrome........................ N 15 390
760.76........ Diethylstilbestrol [DES] exposure N 15 390
affecting fetus or newborn via placenta
or breast milk.
781.8......... Neurologic neglect syndrome............... N 01 34, 35
787.01........ Nausea with vomiting...................... N 06 182, 183, 184
787.02........ Nausea alone.............................. N 06 182, 183, 184
787.03........ Vomiting alone............................ N 06 182, 183, 184
789.00........ Abdominal pain, unspecified site.......... N 06 182, 183, 184
789.01........ Abdominal pain, right upper quadrant...... N 06 182, 183, 184
789.02........ Abdominal pain, left upper quadrant....... N 06 182, 183, 184
789.03........ Abdominal pain, right lower quadrant...... N 06 182, 183, 184
789.04........ Abdominal pain, left lower quadrant....... N 06 182, 183, 184
789.05........ Abdominal pain, periumbilic............... N 06 182, 183, 184
789.06........ Abdominal pain, epigastric................ N 06 182, 183, 184
789.07........ Abdominal pain, generalized............... N 06 182, 183, 184
789.09........ Abdominal pain, other specified site...... N 06 182, 183, 184
789.30........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, unspecified site.
789.31........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, right upper quadrant.
789.32........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, left upper quadrant.
789.33........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, right lower quadrant.
789.34........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, left lower quadrant.
789.35........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, periumbilic.
789.36........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, epigastric.
789.37........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, generalized.
789.39........ Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump, other specified site.
789.40........ Abdominal rigidity, unspecified site...... N 06 188, 189, 190
789.41........ Abdominal rigidity, right upper quadrant.. N 06 188, 189, 190
789.42........ Abdominal rigidity, left upper quadrant... N 06 188, 189, 190
789.43........ Abdominal rigidity, right lower quadrant.. N 06 188, 189, 190
789.44........ Abdominal rigidity, left lower quadrant... N 06 188, 189, 190
789.45........ Abdominal rigidity, periumbilic........... N 06 188, 189, 190
789.46........ Abdominal rigidity, epigastric............ N 06 188, 189, 190
789.47........ Abdominal rigidity, generalized........... N 06 188, 189, 190
789.49........ Abdominal rigidity, other specified site.. N 06 188, 189, 190
789.60........ Abdominal tenderness, unspecified site.... N 06 182, 183, 184
789.61........ Abdominal tenderness, right upper quadrant N 06 182, 183, 184
789.62........ Abdominal tenderness, left upper quadrant. N 06 182, 183, 184
789.63........ Abdominal tenderness, right lower quadrant N 06 182, 183, 184
789.64........ Abdominal tenderness, left lower quadrant. N 06 182, 183, 184
789.65........ Abdominal tenderness, periumbilic......... N 06 182, 183, 184
789.66........ Abdominal tenderness, epigastric.......... N 06 182, 183, 184
789.67........ Abdominal tenderness, generalized......... N 06 182, 183, 184
789.69........ Abdominal tenderness, other specified site N 06 182, 183, 184
795.71........ Nonspecific serologic evidence of human N 16 398, 399
immunodeficiency virus [HIV].
795.79........ Other and unspecified nonspecific N 16 398, 399
immunological findings.
909.5......... Late effect of adverse effect of drug, N 21 454, 455
medicinal or biological substance.
996.04........ Mechanical complication of automatic Y 05 138, 139
implantable cardiac defibrillator.
998.81........ Emphysema (subcutaneous) resulting from N 21 452, 453
procedure.
998.82........ Cataract fragments in eye following N 02 46, 47, 48
cataract surgery.
998.89........ Other specified complications of Y 21 452, 453
procedures not elsewhere classified.
V03.81........ Prophylactic vaccination against N 23 467
Hemophilus influenza, type B [Hib].
V03.82........ Prophylactic vaccination against N 23 467
Streptococcus pneumoniae.
V03.89........ Other specified prophylactic vaccination N 23 467
against single bacterial disease.
V06.5......... Prophylactic vaccination against Tetanus- N 23 467
diphtheria [Td].
V06.6......... Prophylactic vaccination against N 23 467
Streptococcus pneumoniae and influenza.
V07.31........ Prophylactic fluoride administration...... N 23 467
V07.39........ Other prophylactic chemotherapy........... N 23 467
V08........... Asymptomatic human immunodeficiency virus N 18 421, 422
[HIV] infection status.
V12.00........ Personal history of unspecified infectious N 23 467
and parasitic disease.
V12.01........ Personal history of tuberculosis.......... N 23 467
V12.02........ Personal history of poliomyelitis......... N 23 467
V12.03........ Personal history of malaria............... N 23 467
V12.09........ Personal history of other specified N 23 467
infectious and parasitic disease.
V12.70........ Personal history of unspecified digestive N 23 467
disease.
V12.71........ Personal history of peptic ulcer disease.. N 23 467
V12.72........ Personal history of colonic polyps........ N 23 467
V12.79........ Personal history of other specified N 23 467
digestive system diseases.
V13.00........ Personal history of unspecified urinary N 23 467
disorder.
V13.01........ Personal history of urinary calculi....... N 23 467
V13.09........ Personal history of other specified N 23 467
urinary system disorders.
V15.82........ History of tobacco use.................... N 23 467
V29.2......... Observation and evaluation of newborn for N 23 467
suspected respiratory condition.
V43.60........ Unspecified joint replacement status...... N 08 256
V43.61........ Shoulder joint replacement status......... N 08 256
V43.62........ Elbow joint replacement status............ N 08 256
V43.63........ Wrist joint replacement status............ N 08 256
V43.64........ Hip joint replacement status.............. N 08 256
V43.65........ Knee joint replacement status............. N 08 256
V43.66........ Ankle joint replacement status............ N 08 256
V43.69........ Other joint replacement status............ N 08 256
V45.00........ Unspecified cardiac device in situ........ N 23 467
V45.01........ Cardiac pacemaker in situ................. N 23 467
V45.02........ Automatic implantable cardiac N 23 467
defibrillator in situ.
V45.09........ Other specified cardiac device in situ.... N 23 467
V45.51........ Presence of intrauterine contraceptive N 23 467
device.
V45.52........ Presence of subdermal contraceptive N 23 467
implant.
V45.59........ Presence of other contraceptive device.... N 23 467
V45.82........ Percutaneous transluminal coronary N 23 467
angioplasty status.
V49.60........ Unspecified level upper limb amputation N 23 467
status.
V49.61........ Thumb amputation status................... N 23 467
V49.62........ Other finger(s) amputation status......... N 23 467
V49.63........ Hand amputation status.................... N 23 467
V49.64........ Wrist amputation status................... N 23 467
V49.65........ Below elbow amputation status............. N 23 467
V49.66........ Above elbow amputation status............. N 23 467
V49.67........ Shoulder amputation status................ N 23 467
V49.70........ Unspecified level lower limb amputation N 23 467
status.
V49.71........ Great toe amputation status............... N 23 467
V49.72........ Other toe(s) amputation status............ N 23 467
V49.73........ Foot amputation status.................... N 23 467
V49.74........ Ankle amputation status................... N 23 467
V49.75........ Below knee amputation status.............. N 23 467
V49.76........ Above knee amputation status.............. N 23 467
V49.77........ Hip amputation status..................... N 23 467
V50.41........ Prophylactic breast removal............... N 09 276
V50.42........ Prophylactic ovary removal................ N 13 358, 359, 369
V50.49........ Other prophylactic organ removal.......... N 23 467
V53.31........ Fitting and adjustment of cardiac N 05 144, 145
pacemaker.
V53.32........ Fitting and adjustment of automatic N 05 144, 145
implantable cardiac defibrillator.
V53.39........ Fitting and adjustment of other cardiac N 05 144, 145
device.
V57.21........ Encounter for occupational therapy........ N 23 462
V57.22........ Encounter for vocational therapy.......... N 23 462
V58.41........ Encounter for planned post-operative wound N 23 465, 466
closure.
V58.49........ Other specified aftercare following N 23 465, 466
surgery.
V58.81........ Encounter for removal of vascular catheter N 23 465, 466
V58.89........ Other specified aftercare................. N 23 465, 466
V65.40........ Other unspecified counseling.............. N 23 467
V65.41........ Exercise counseling....................... N 23 467
V65.42........ Counseling on substance use and abuse..... N 23 467
V65.43........ Counseling on injury prevention........... N 23 467
V65.44........ Human immunodeficiency virus [HIV] N 23 467
counseling.
V65.45........ Counseling on other sexually transmitted N 23 467
diseases.
V65.49........ Other specified counseling................ N 23 467
V69.0......... Lack of physical exercise................. N 23 467
V69.1......... Inappropriate diet and eating habits...... N 23 467
V69.2......... High-risk sexual behavior................. N 23 467
V69.3......... Gambling and betting...................... N 23 467
V69.8......... Other problems related to lifestyle....... N 23 467
V69.9......... Unspecified problem related to lifestyle.. N 23 467
----------------------------------------------------------------------------------------------------------------
\1\Diagnosis code is classified as a ``major problem'' in these DRGs.
Table 6b.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure code
Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
34.05......... Creation of pleuroperitoneal shunt........ N .......... ..........................
41.04......... Autologous hematopoietic stem cell N .......... ..........................
transplant.
99.28......... Injection or infusion of biological N .......... ..........................
response modifier [BRM] as an
antineoplastic agent.
----------------------------------------------------------------------------------------------------------------
Table 6c.--Invalid Diagnosis Codes\1\
----------------------------------------------------------------------------------------------------------------
Diagnosis code
Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
042.0......... Human immunodeficiency virus infection Y 25 489, 490
with specified infections.
042.1......... Human immunodeficiency virus infection Y 25 489, 490
causing other specified infections.
042.2......... Human immunodeficiency virus infection Y 25 489, 490
with specified malignant neoplasms.
042.9......... Human immunodeficiency virus infection Y 25 489, 490
with acquired immuno- deficiency
syndrome, unspecified.
043.0......... Human immunodeficiency virus infection Y 25 489, 490
causing lymphadenopathy.
043.1......... Human immunodeficiency virus infection Y 25 489, 490
causing specified diseases of the central
nervous system.
043.2......... Human immunodeficiency virus infection Y 25 489, 490
causing other disorders involving the
immune mechanism.
043.3......... Human immunodeficiency virus infection Y 25 489, 490
causing other specified conditions.
043.9......... Human immunodeficiency virus infection Y 25 489, 490
causing acquired immuno- deficiency
syndrome-related complex, unspecified.
044.0......... Other human immunodeficiency virus Y 25 489, 490
infection causing specified acute
infections.
044.9......... Human immunodeficiency virus infection, Y 25 489, 490
unspecified.
305.10........ Tobacco use disorder, unspecified......... N 23 467
305.11........ Tobacco use disorder, continuous.......... N 23 467
305.12........ Tobacco use disorder, episodic........... N 23 467
305.13........ Tobacco use disorder, in remission........ N 23 467
312.8......... Other specified disturbances of conduct, N 19 431
not elsewhere classified.
342.0......... Flaccid hemiplegia........................ N 01 12
342.1......... Spastic hemiplegia........................ N 01 12
342.9......... Hemiplegia, unspecified................... N 01 12
344.0......... Quadriplegia, unspecified................. Y 01 9
344.3......... Monoplegia of lower limb.................. N 01 34, 35
344.4......... Monoplegia of upper limb.................. N 01 34, 35
414.0......... Coronary atherosclerosis.................. N 05 132, 133
441.0......... Dissecting aortic aneurysm................ Y 05 121, 144, 145
556........... Idiopathic proctocolitis................. N 06 179
593.7......... Vesicoureteral reflux..................... N 11 331, 332, 333
702.1......... Seborrheic keratosis...................... N 09 283, 284
709.0......... Dyschromia................................ N 09 283, 284
787.0......... Nausea and vomiting....................... N 06 182, 183, 184
789.0......... Abdominal pain............................ N 06 182, 183, 184
789.3......... Abdominal or pelvic swelling, mass, or N 06 182, 183, 184
lump.
789.4......... Abdominal rigidity........................ N 06 188, 189, 190
795.7......... Other nonspecific immunological findings.. N 16 398, 399
795.8......... Positive serological or viral culture N 18 421, 422
findings for human immuno- deficiency
virus (HIV).
998.8......... Other specified complications of Y 21 452, 453
procedures, not elsewhere classified.
V03.8......... Other specified vaccinations against N 23 467
single bacterial diseases.
V07.3......... Other prophylactic chemotherapy........... N 23 467
V12.0......... Personal history of infectious and N 23 467
parasitic diseases.
V12.7......... Personal history of diseases of the N 23 467
digestive system.
V13.0......... Personal history of disorders of the N 23 467
urinary system.
V43.6......... Joint replacement status.................. N 08 256
V45.0......... Cardiac pacemaker in situ................. N 23 467
V45.5......... Presence of intrauterine contraceptive N 23 467
device.
V53.3......... Fitting and adjustment of cardiac N 05 144, 145
pacemaker.
V57.2......... Occupational therapy and vocational N 23 462
rehabilitation.
V58.4......... Other aftercare following surgery......... N 23 465, 466
V58.8......... Other specified aftercare................. N 23 465, 466
V65.4......... Other aftercare following surgery......... N 23 465, 466034Y
----------------------------------------------------------------------------------------------------------------
\1\See Table 6a for new diagnosis codes that will be considered valid by the FY 1995 GROUPER.
Table 6d.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
DiagnosisCode Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
070.20........ Viral hepatitis B with hepatic coma, acute Y 07 205, 206
or unspecified, without mention of 15 387, 389\1\
hepatitis delta.
070.21........ Viral hepatitis B with hepatic coma, acute Y 07 205, 206
or unspecified, with hepatitis delta. 15 387, 389\1\
070.30........ Viral hepatitis B without mention of Y 07 205, 206
hepatic coma, acute or unspecified, 15 387, 389\1\
without mention of hepatitis delta.
070.31........ Viral hepatitis B without mention of Y 07 205, 206
hepatic coma, acute or unspecified, with 15 387, 389\1\
hepatitis delta.
070.41........ Acute or unspecified hepatitis C with Y 07 205, 206
hepatic coma. 15 387, 389\1\
070.42........ Hepatitis delta without mention of active Y 07 205, 206
hepatitis B disease with hepatic coma. 15 387, 389\1\
070.43........ Hepatitis E with hepatic coma............. Y 07 205, 206
15 387, 389\1\
070.49........ Other specified viral hepatitis with Y 07 205, 206
hepatic coma. 15 387, 389\1\
070.51........ Acute or unspecified hepatitis C without Y 07 205, 206
mention of hepatic coma. 15 387, 389\1\
070.52........ Hepatitis delta without mention of active Y 07 205, 206
hepatitis B disease or hepatic coma. 15 387, 389\1\
070.53........ Hepatitis E without mention of hepatic Y 07 205, 206
coma. 15 387, 389\1\
070.59........ Other specified viral hepatitis without Y 07 205, 206
mention of hepatic coma. 15 387, 389\1\
440.20........ Atherosclerosis of native arteries of N 05 130, 131
extremities, unspecified.
440.21........ Atherosclerosis of native arteries of N 05 130, 131
extremities with intermittent
claudication.
440.22........ Atherosclerosis of native arteries of N 05 130, 131
extremities with rest pain.
440.23........ Atherosclerosis of native arteries of N 05 130, 131
extremities with ulceration.
440.24........ Atherosclerosis of native arteries of Y 05 130, 131
extremities with gangrene. 15 387, 389\1\
440.29........ Other atherosclerosis of native arteries N 05 130, 131
of extremities.
770.1......... Meconium aspiration syndrome.............. Y 15 387, 389\1\
----------------------------------------------------------------------------------------------------------------
\1\Diagnosis code is classified as a ``major problem'' in these DRGs.
Table 6e.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
Procedurecode Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
36.01......... Single vessel percutaneous transluminal Y 05 106, 112
coronary angioplasty [PTCA] or coronary
atherectomy without mention of
thrombolytic agent.
36.02......... Single vessel percutaneous transluminal Y 05 106, 112
coronary angioplasty [PTCA] or coronary
atherectomy with mention of thrombolytic
agent.
36.05......... Multiple vessel percutaneous transluminal Y 05 106, 112
coronary angioplasty [PTCA] or coronary
atherectomy performed during the same
operation with or without mention of
thrombolytic agent.
----------------------------------------------------------------------------------------------------------------
Table 6f.--Additions to the CC Exclusions List
Page 1 of 3 Pages
CCs that are added to the list are in Table 6f--Additions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
*042 07052 *07041 07032 07054 *25072 34402 29583
042 07053 07022 07033 *07989 44100 34403 29584
*0700 07054 07023 07044 07022 44101 34404 29590
07022 07059 07032 07054 07023 44102 34409 29591
07023 0706 07033 *07054 07032 44103 44100 29592
07032 0709 07044 07020 07033 *25073 44101 29593
07033 78001 07054 07021 07044 44100 44102 29594
07044 78003 *07042 07022 07054 44101 44103 29604
07054 *07030 07022 07023 *07998 44102 *25092 29614
*0701 07022 07023 07030 07022 44103 34400 29634
07022 07023 07032 07031 07023 *25080 34401 29644
07023 07032 07033 07032 07032 34400 34402 29654
07032 07033 07044 07033 07033 34401 34403 29664
07033 07044 07054 07041 07044 34402 34404 2980
07044 07054 *07043 07042 07054 34403 34409 2983
07054 *07031 07022 07043 *07999 34404 44100 2984
*07020 07022 07023 07044 07022 34409 44101 29900
07022 07023 07032 07049 07023 44100 44102 29910
07023 07032 07033 07051 07032 44101 44103 29980
07032 07033 07044 07052 07033 44102 *25093 29990
07033 07044 07054 07053 07044 44103 34400 *31282
07044 07054 *07044 07054 07054 *25081 34401 29500
07054 *07032 07020 07059 *1398 34400 34402 29501
*07021 07020 07021 0706 042 34401 34403 29502
07022 07021 07022 0709 07022 34402 34404 29503
07023 07022 07023 78001 07023 34403 34409 29504
07032 07023 07030 78003 07032 34404 44100 29510
07033 07030 07031 *07059 07033 34409 44101 29511
07044 07031 07032 07022 07044 44100 44102 29512
07054 07032 07033 07023 07054 44101 44103 29513
*07022 07033 07041 07032 *25060 44102 *31281 29514
07020 07041 07042 07033 34400 44103 29500 29521
07021 07042 07043 07044 34401 *25082 29501 29522
07022 07043 07044 07054 34402 34400 29502 29523
07023 07044 07049 *0706 34403 34401 29503 29524
07030 07049 07051 07022 34404 34402 29504 29530
07031 07051 07052 07023 34409 34403 29510 29531
07032 07052 07053 07032 *25061 34404 29511 29532
07033 07053 07054 07033 34400 34409 29512 29533
07041 07054 07059 07044 34401 44100 29513 29534
07042 07059 0706 07054 34402 44101 29514 29540
07043 0706 0709 *0709 34403 44102 29521 29541
07044 0709 78001 07022 34404 44103 29522 29542
07049 78001 78003 07023 34409 *25083 29523 29543
07051 78003 *07049 07032 *25062 34400 29524 29544
07052 *07033 07022 07033 34400 34401 29530 29560
07053 07020 07023 07044 34401 34402 29531 29561
07054 07021 07032 07054 34402 34403 29532 29562
07059 07022 07033 *07888 34403 34404 29533 29563
0706 07023 07044 07022 34404 34409 29534 29564
0709 07030 07054 07023 34409 44100 29540 29570
78001 07031 *07051 07032 *25063 44101 29541 29571
78003 07032 07022 07033 34400 44102 29542 29572
*07023 07033 07023 07044 34401 44103 29543 29573
07020 07041 07032 07054 34402 *25090 29544 29574
07021 07042 07033 *07889 34403 34400 29560 29580
07022 07043 07044 07022 34404 34401 29561 29581
07023 07044 07054 07023 34409 34402 29562 29582
07030 07049 *07052 07032 *25070 34403 29563 29583
07031 07051 07022 07033 44100 34404 29564 29584
07032 07052 07023 07044 44101 34409 29570 29590
07033 07053 07032 07054 44102 44100 29571 29591
07041 07054 07033 *07988 44103 44101 29572 29592
07042 07059 07044 07022 *25071 44102 29573 29593
07043 0706 07054 07023 44100 44103 29574 29594
07044 0709 *07053 07032 44101 *25091 29580 29604
07049 78001 07022 07033 44102 34400 29581 29614
07051 78003 07023 07044 44103 34401 29582 29634
Page 2 of 3 Pages
29644 3432 34409 34409 34400 *3449 *4411 63411
29654 34400 *34290 *34400 34401 34400 44100 63412
29664 34401 3432 3432 34402 34401 44101 63420
2980 34402 34400 34400 34403 34402 44102 63421
2983 34403 34401 34401 34404 34403 44103 63422
2984 34404 34402 34402 34409 34404 *4412 63430
29900 34409 34403 34403 *34432 34409 44100 63431
29910 *34201 34404 34404 3432 *3488 44101 63432
29980 3432 34409 34409 34400 34400 44102 63440
29990 34400 *34291 *34401 34401 34401 44103 63441
*31289 34401 3432 3432 34402 34402 *4413 63442
29500 34402 34400 34400 34403 34403 44100 63450
29501 34403 34401 34401 34404 34404 44101 63451
29502 34404 34402 34402 34409 34409 44102 63452
29503 34409 34403 34403 *34440 *3489 44103 63460
29504 *34202 34404 34404 3432 34400 *4414 63461
29510 3432 34409 34409 34400 34401 44100 63462
29511 34400 *34292 *34402 34401 34402 44101 63470
29512 34401 3432 3432 34402 34403 44102 63471
29513 34402 34400 34400 34403 34404 44103 63472
29514 34403 34401 34401 34404 34409 *4415 63480
29521 34404 34402 34402 34409 *34989 44100 63481
29522 34409 34403 34403 *34441 34400 44101 63482
29523 *34210 34404 34404 3432 34401 44102 63490
29524 3432 34409 34409 34400 34402 44103 63491
29530 34400 *3430 *34403 34401 34403 *4416 63492
29531 34401 34400 3432 34402 34404 44100 6390
29532 34402 34401 34400 34403 34409 44101 6391
29533 34403 34402 34401 34404 *3499 44102 6392
29534 34404 34403 34402 34409 34400 44103 6393
29540 34409 34404 34403 *34442 34401 *4417 6394
29541 7817 34409 34404 3432 34402 44100 6395
29542 *34211 *3431 34409 34400 34403 44101 6396
29543 3432 34400 *34404 34401 34404 44102 6398
29544 34400 34401 3432 34402 34409 44103 6399
29560 34401 34402 34400 34403 *44023 *4419 64000
29561 34402 34403 34401 34404 7071 44100 64001
29562 34403 34404 34402 34409 *44100 44101 64003
29563 34404 34409 34403 *3445 44100 44102 64080
29564 34409 *3432 34404 34400 44101 44103 64081
29570 7817 34400 34409 34401 44102 *45989 64083
29571 *34212 34401 *34409 34402 44103 44100 64090
29572 3432 34402 3432 34403 4411 44101 64091
29573 34400 34403 34400 34404 4413 44102 64093
29574 34401 34404 34401 34409 4415 44103 64100
29580 34402 34409 34402 *34460 4416 *4599 64101
29581 34403 *3433 34403 34400 *44101 44100 64103
29582 34404 34400 34404 34401 44100 44101 64110
29583 34409 34401 34409 34402 44101 44102 64111
29584 7817 34402 *3441 34403 44102 44103 64113
29590 *34280 34403 34400 34404 44103 *5120 64130
29591 3432 34404 34401 34409 4411 5121 64131
29592 34400 34409 34402 *34461 4413 *5121 64133
29593 34401 *3434 34403 34400 4415 5120 64180
29594 34402 34400 34404 34401 4416 5121 64181
29604 34403 34401 34409 34402 *44102 5128 64183
29614 34404 34402 *3442 34403 44100 *5128 64190
29634 34409 34403 34400 34404 44101 5121 64191
29644 *34281 34404 34401 34409 44102 *5178 64193
29654 3432 34409 34402 *34481 44103 5121 64240
29664 34400 *3438 34403 34400 4411 *51889 64241
2980 34401 34400 34404 34401 4413 5121 64242
2983 34402 34401 34409 34402 4415 *5198 64243
2984 34403 34402 *34430 34403 4416 5121 64244
29900 34404 34403 3432 34404 *44103 *5199 64250
29910 34409 34404 34400 34409 44100 5121 64251
29980 *34282 34409 34401 *34489 44101 *5363 64252
29990 3432 *3439 34402 34400 44102 5370 64253
*33392 34400 34400 34403 34401 44103 *66943 64254
7817 34401 34401 34404 34402 4411 63400 64260
*33393 34402 34402 34409 34403 4413 63401 64261
7817 34403 34403 *34431 34404 4415 63402 64262
*34200 34404 34404 3432 34409 4416 63410 64263
Page 3 of 3 Pages
64264 66820 67511 *78931 9582 99602
64270 66821 67512 7895 9583 99603
64271 66822 *7100 *78932 9584 99604
64272 66823 7100 7895 9585 99609
64273 66824 *7101 *78933 9587 9961
64274 66880 7101 7895 9954 9962
64400 66881 *7103 *78934 99600 99630
64403 66882 7103 7895 99601 99639
64410 66883 *7104 *78935 99602 9964
64413 66884 7104 7895 99603 99660
64660 66890 *7108 *78936 99604 99661
64661 66891 7108 7895 99609 99662
64662 66892 *74259 *78937 9961 99663
64663 66893 34400 7895 9962 99664
64664 66894 34401 *78939 99630 99665
64670 66910 34402 7895 99639 99666
64671 66911 34403 *78940 9964 99667
64673 66912 34404 7895 99660 99669
64730 66913 34409 *78941 99661 99670
64731 66914 *7428 7895 99662 99671
64732 66930 34400 *78942 99663 99672
64733 66932 34401 7895 99664 99673
64734 66934 34402 *78943 99665 99674
64740 67000 34403 7895 99666 99675
64741 67002 34404 *78944 99667 99676
64742 67004 34409 7895 99669 99677
64743 67120 *7429 *78945 99670 99678
64744 67121 34400 7895 99671 99679
64800 67122 34401 *78946 99672 99690
64801 67123 34402 7895 99673 99691
64802 67124 34403 *78947 99674 99692
64803 67130 34404 7895 99675 99693
64804 67131 34409 *78949 99676 99694
64820 67133 *75983 7895 99677 99695
64821 67140 42971 *99604 99678 99696
64822 67142 42979 99600 99679 99699
64823 67144 74100 99604 99690 9970
64824 67300 74101 99660 99691 9971
64830 67301 74102 99661 99692 9972
64831 67302 74103 99662 99693 9973
64832 67303 74190 99669 99694 9974
64833 67304 74191 99670 99695 9975
64834 67310 74192 99672 99696 99762
64850 67311 74193 99674 99699 9979
64851 67312 7450 99679 9970 9980
64852 67313 74510 *99671 9971 9981
64853 67314 74511 V422 9972 9982
64854 67320 74512 *99680 9973 9983
64860 67321 74519 V420 9974 9984
64861 67322 7452 V421 9975 9985
64862 67323 7453 V426 99762 9986
64863 67324 7454 V427 9979 9987
64864 67330 74560 V428 9980 99889
65930 67331 74569 V432 9981 9989
65931 67332 7457 *99681 9982 *9989
65933 67333 74601 V420 9983 99604
66500 67334 74602 *99682 9984 99889
66501 67380 7461 V427 9985 *V421
66503 67381 7462 *99683 9986 V432
66510 67382 7463 V421 9987
66511 67383 7464 V432 99889
66632 67384 7465 *99684 9989
66634 67400 7466 V426 *99889
66800 67401 7467 *99686 9580
66801 67402 74681 V428 9581
66802 67403 74682 *99689 9582
66803 67404 74683 V428 9583
66804 67410 74684 *9979 9584
66810 67412 74686 99604 9585
66811 67420 74711 99889 9587
66812 67422 74722 *99881 9954
66813 67424 *78930 9580 99600
66814 67510 7895 9581 99601
Table 6g.--Deletions to the CC Exclusions List
Page 1 of 1 Page
CCs that are deleted from the list are in Table 6G-Deletions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
*0420 0433 0429 29540 3440 9582
0420 0439 0430 29541 *3443 9583
0421 0440 0431 29542 3432 9584
0422 0449 0432 29543 3440 9585
0429 *0432 0433 29544 *3444 9587
0430 0420 0439 29560 3432 9954
0431 0421 0440 29561 3440 99600
0432 0422 0449 29562 *3445 99601
0433 0429 *25060 29563 3440 99602
0439 0430 3440 29564 *34460 99603
0440 0431 *25061 29570 3440 99609
0449 0432 3440 29571 *34461 9961
*0421 0433 *25062 29572 3440 9962
0420 0439 3440 29573 *34481 99630
0421 0440 *25063 29574 3440 99639
0422 0449 3440 29580 *34489 9964
0429 *0433 *25070 29581 3440 99660
0430 0420 4410 29582 *3449 99661
0431 0421 *25071 29583 3440 99662
0432 0422 4410 29584 *3488 99663
0433 0429 *25072 29590 3440 99664
0439 0430 4410 29591 *3489 99665
0440 0431 *25073 29592 3440 99666
0449 0432 4410 29593 *34989 99667
*0422 0433 *25080 29594 3440 99669
0420 0439 3440 29604 *3499 99670
0421 0440 4410 29614 3440 99671
0422 0449 *25081 29634 *4410 99672
0429 *0439 3440 29644 4410 99673
0430 0420 4410 29654 4411 99674
0431 0421 *25082 29664 4413 99675
0432 0422 3440 2980 4415 99676
0433 0429 4410 2983 4416 99677
0439 0430 *25083 2984 *4411 99678
0440 0431 3440 29900 4410 99679
0449 0432 4410 29910 *4412 99690
*0429 0433 *25090 29980 4410 99691
0420 0439 3440 29990 *4413 99692
0421 0440 4410 *3420 4410 99693
0422 0449 *25091 3432 *4414 99694
0429 *0440 3440 3440 4410 99695
0430 0420 4410 *3421 *4415 99696
0431 0421 *25092 3432 4410 99699
0432 0422 3440 3440 *4416 9970
0433 0429 4410 7817 4410 9971
0439 0430 *25093 *3429 *4417 9972
0440 0431 3440 3432 4410 9973
0449 0432 4410 3440 *4419 9974
*0430 0433 *3128 *3430 4410 9975
0420 0439 29500 3440 *45989 99762
0421 0440 29501 *3431 4410 9979
0422 0449 29502 3440 *4599 9980
0429 *0449 29503 *3432 4410 9981
0430 0420 29504 3440 *74259 9982
0431 0421 29510 *3433 3440 9983
0432 0422 29511 3440 *7428 9984
0433 0429 29512 *3434 3440 9985
0439 0430 29513 3440 *7429 9986
0440 0431 29514 *3438 3440 9987
0449 0432 29521 3440 *7893 9988
*0431 0433 29522 *3439 7895 9989
0420 0439 29523 3440 *7894 *9989
0421 0440 29524 *3440 7895 9988
0422 0449 29530 3432 *9979
0429 *1398 29531 3440 9988
0430 0420 29532 *3441 *9988
0431 0421 29533 3440 9580
0432 0422 29534 *3442 9581
Table 7a.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY93 Medpar Update 06/94 Grouper V11.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arithmetic
DRG Numberdischarges mean LOS 10thpercentile 25thpercentile 50thpercentile 75thpercentile 90thpercentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
001................................... 30789 13.5837 3 6 10 17 28
002................................... 6029 13.9756 4 6 10 17 27
003................................... 2 41.5000 17 17 66 66 66
004................................... 5470 11.0845 2 4 7 14 23
005................................... 64742 5.8330 2 3 4 7 11
006................................... 526 3.1920 1 1 2 4 7
007................................... 6971 17.4116 2 5 10 19 35
008................................... 2267 4.5368 1 1 3 6 10
009................................... 1636 9.2219 2 4 6 11 17
010................................... 20813 9.7252 2 4 7 12 20
011................................... 3262 5.5880 1 2 4 7 11
012................................... 21908 9.3495 2 4 6 11 17
013................................... 6261 7.5787 3 4 6 9 13
014................................... 356433 8.9406 2 4 7 11 17
015................................... 132402 5.0854 2 2 4 6 9
016................................... 11159 8.2904 2 4 6 10 15
017................................... 3657 4.7060 1 2 4 6 9
018................................... 18848 7.3077 2 3 6 9 14
019................................... 7200 4.8607 1 2 4 6 9
020................................... 7645 11.7438 3 5 9 15 23
021................................... 1049 8.6883 2 4 7 11 17
022................................... 3836 5.5792 2 3 4 7 10
023................................... 4751 5.7925 1 2 4 7 11
024................................... 55823 6.8735 2 3 5 8 13
025................................... 21461 4.2265 1 2 3 5 8
026................................... 42 4.3095 1 2 2 4 9
027................................... 3097 7.8589 1 1 4 9 17
028................................... 9250 8.5083 2 3 6 10 18
029................................... 3423 4.6594 1 2 3 6 9
031................................... 3730 5.9056 1 2 4 7 12
032................................... 2173 3.5274 1 1 2 4 7
034................................... 15102 7.7488 2 3 5 9 15
035................................... 3477 4.9721 1 2 4 6 9
036................................... 16219 1.8739 1 1 1 2 3
037................................... 2345 4.1062 1 1 3 5 9
038................................... 479 2.7307 1 1 2 3 5
039................................... 5281 2.0364 1 1 1 2 4
040................................... 2167 3.6470 1 1 2 4 8
042................................... 13539 2.3944 1 1 1 3 5
043................................... 146 4.2466 1 2 3 5 7
044................................... 1707 6.0521 2 3 5 8 11
045................................... 2453 4.3343 1 2 4 6 8
046................................... 3000 6.3313 1 3 5 7 12
047................................... 1517 3.9064 1 2 3 5 8
049................................... 2298 6.9956 2 3 5 8 13
050................................... 4068 2.3446 1 1 2 3 4
051................................... 413 3.1017 1 1 2 3 7
052................................... 102 3.3431 1 1 2 4 7
053................................... 4619 3.5817 1 1 2 4 8
054................................... 1 1.0000 1 1 1 1 1
055................................... 2573 3.0377 1 1 1 3 7
056................................... 850 3.1753 1 1 2 4 7
057................................... 624 5.3333 1 2 3 6 11
059................................... 128 2.3750 1 1 1 2 4
060................................... 2 2.5000 2 2 3 3 3
061................................... 298 5.2148 1 1 2 7 12
063................................... 4536 5.3450 1 2 3 6 10
064................................... 3756 8.3568 1 2 5 10 18
065................................... 34411 3.8766 1 2 3 5 7
066................................... 7620 4.0371 1 2 3 5 7
067................................... 463 4.7451 2 3 4 6 9
068................................... 12598 5.4822 2 3 4 7 10
069................................... 3725 4.2545 2 2 4 5 7
070................................... 36 4.3056 1 2 4 5 7
071................................... 138 4.2174 2 2 3 5 8
072................................... 623 4.3900 1 2 3 5 9
073................................... 6364 5.6578 1 2 4 7 11
075................................... 37044 12.6528 5 7 9 15 24
076................................... 38643 14.2046 3 6 11 17 27
077................................... 2854 6.0266 1 2 4 8 13
078................................... 27188 9.3107 4 6 8 11 15
079................................... 176402 10.8266 3 5 8 13 20
080................................... 8662 7.4938 3 4 6 9 13
081................................... 11 7.0000 1 4 6 7 13
082................................... 68966 8.9400 2 4 7 11 18
083................................... 7393 7.4088 2 3 6 9 14
084................................... 1649 4.3475 1 2 3 5 8
085................................... 17273 8.2564 2 4 7 10 16
086................................... 1531 4.9458 1 2 4 6 10
087................................... 51836 7.5535 1 3 6 10 14
088................................... 335134 7.0079 3 4 6 8 12
089................................... 413711 8.1065 3 4 7 10 14
090................................... 41092 5.7549 2 3 5 7 10
091................................... 40 4.4000 2 3 4 5 8
092................................... 10461 8.1576 3 4 6 10 15
093................................... 1390 5.9029 2 3 5 7 11
094................................... 9988 8.6522 3 4 7 11 17
095................................... 1116 4.9615 2 3 4 6 9
096................................... 79116 6.3432 2 4 5 8 11
097................................... 28365 4.8693 2 3 4 6 8
098................................... 29 4.1034 1 2 3 4 7
099................................... 27622 4.2452 1 2 3 5 8
100................................... 11016 2.8297 1 1 2 3 5
101................................... 18841 6.3787 2 3 5 8 12
102................................... 3157 4.0602 1 2 3 5 8
103................................... 375 36.7733 10 14 23 46 83
104................................... 20761 18.1163 8 11 15 22 31
105................................... 18135 13.3385 7 8 10 15 23
106................................... 86394 13.8896 7 9 12 16 22
107................................... 57166 10.6348 6 7 9 12 17
108................................... 6384 14.6621 5 8 12 18 27
110................................... 56199 12.2987 3 7 10 15 23
111................................... 5540 7.5821 3 6 7 9 11
112................................... 166651 5.3420 1 2 4 7 11
113................................... 41621 17.4883 5 8 13 21 35
114................................... 8843 11.1036 3 5 8 14 22
115................................... 9528 12.8102 5 7 11 16 23
116................................... 74533 6.5235 2 3 5 8 13
117................................... 3788 5.0198 1 2 3 6 10
118................................... 7713 3.5309 1 1 2 4 8
119................................... 2438 5.7724 1 1 3 7 14
120................................... 37215 10.6674 1 3 6 14 24
121................................... 160886 8.7273 3 5 7 11 15
122................................... 95449 6.0310 2 3 6 8 10
123................................... 53564 5.1018 1 1 3 6 12
124................................... 135111 5.5606 1 2 4 7 11
125................................... 69007 3.2146 1 1 2 4 7
126................................... 4416 18.3338 5 8 14 25 38
127................................... 684379 7.2104 2 4 6 9 14
128................................... 22330 7.7058 4 5 7 9 12
129................................... 5431 3.8842 1 1 1 4 10
130................................... 79749 7.5461 2 4 6 9 13
131................................... 24506 5.6601 1 3 5 7 9
132................................... 17170 4.8175 1 2 4 6 9
133................................... 3818 3.5115 1 2 3 4 7
134................................... 30893 4.4949 1 2 3 5 8
135................................... 6243 6.0115 2 3 4 7 11
136................................... 1221 3.8878 1 2 3 5 7
138................................... 198569 5.3081 2 2 4 6 10
139................................... 68517 3.3781 1 2 3 4 6
140................................... 320756 4.0935 1 2 3 5 7
141................................... 76663 5.2949 2 2 4 6 10
142................................... 35435 3.6916 1 2 3 4 7
143................................... 134668 3.0822 1 2 2 4 6
144................................... 61548 6.5277 1 3 5 8 13
145................................... 7340 3.7722 1 2 3 5 7
146................................... 8207 12.3398 6 8 10 14 21
147................................... 1483 7.9845 4 6 8 9 11
148................................... 146601 14.9530 7 8 12 17 27
149................................... 14784 8.3103 5 6 8 9 12
150................................... 22866 12.9395 5 7 11 15 23
151................................... 4350 6.8198 2 4 6 9 12
152................................... 4940 9.9921 4 6 8 11 16
153................................... 1779 6.7482 3 5 6 8 10
154................................... 36964 17.1986 6 9 13 21 33
155................................... 3772 7.4467 3 4 7 9 12
156................................... 4 11.5000 2 2 9 13 22
157................................... 12614 6.3773 2 3 4 8 13
158................................... 7154 3.0415 1 1 2 4 6
159................................... 17551 5.8036 2 3 4 7 11
160................................... 11024 3.1692 1 2 3 4 6
161................................... 18354 4.8137 1 2 3 6 10
162................................... 11776 2.2116 1 1 2 3 4
163................................... 16 4.7500 2 2 3 6 8
164................................... 5026 10.3341 5 6 9 12 17
165................................... 1523 6.3020 3 4 6 8 10
166................................... 3221 6.4865 2 3 5 8 12
167................................... 2244 3.6925 2 2 3 5 6
168................................... 1916 5.6169 1 2 3 7 12
169................................... 1223 2.6917 1 1 2 3 6
170................................... 13027 14.7958 3 6 10 18 30
171................................... 1218 5.8662 1 3 5 8 11
172................................... 31171 9.4908 2 4 7 12 19
173................................... 2494 4.6684 1 2 3 6 9
174................................... 227976 6.3603 2 3 5 8 12
175................................... 25636 3.9298 2 2 3 5 7
176................................... 14948 7.0566 2 3 5 8 13
177................................... 13026 5.6763 2 3 5 7 10
178................................... 4996 3.9586 2 2 3 5 7
179................................... 9786 8.3933 3 4 6 10 16
180................................... 78727 6.9989 2 3 5 8 13
181................................... 20704 4.2217 1 2 4 5 7
182................................... 233792 5.7646 2 3 4 7 11
183................................... 72289 3.8397 1 2 3 5 7
184................................... 68 3.9853 1 2 3 4 5
185................................... 3706 5.9331 1 2 4 7 12
186................................... 5 4.0000 1 1 3 6 8
187................................... 962 3.9314 1 1 3 5 8
188................................... 53805 6.9627 2 3 5 8 14
189................................... 7894 3.7683 1 1 3 5 8
190................................... 58 4.4828 1 2 3 5 6
191................................... 10463 18.3336 6 9 14 22 36
192................................... 827 8.8295 2 5 8 11 16
193................................... 10468 15.8828 6 9 13 19 28
194................................... 916 9.1572 3 5 8 11 16
195................................... 12514 11.7907 5 7 10 14 20
196................................... 1041 7.5370 4 5 7 9 12
197................................... 34315 9.9735 4 6 8 12 17
198................................... 10471 5.3032 2 3 5 7 9
199................................... 2719 13.3553 4 6 10 17 26
200................................... 1717 13.2627 2 5 10 17 28
201................................... 1707 17.0949 4 7 12 22 35
202................................... 21167 8.7487 2 4 7 11 17
203................................... 29609 8.8798 2 4 7 11 18
204................................... 44863 7.5342 2 4 6 9 14
205................................... 21797 8.5004 2 4 6 10 17
206................................... 1815 4.6667 1 2 4 6 10
207................................... 36949 6.5511 2 3 5 8 12
208................................... 11536 3.6716 1 2 3 5 7
209................................... 306116 8.7749 5 6 8 10 13
210................................... 130491 10.9485 5 6 9 12 18
211................................... 25285 7.9929 4 5 7 9 12
212................................... 11 4.0909 1 3 4 5 6
213................................... 6425 11.7387 3 5 8 14 23
214................................... 49507 8.3687 3 4 6 10 15
215................................... 39923 4.7950 2 3 4 6 8
216................................... 6665 13.3539 3 6 10 17 27
217................................... 18210 19.1730 4 7 13 23 41
218................................... 21794 7.7061 2 4 6 9 14
219................................... 19004 4.4786 2 2 4 5 8
220................................... 5 6.2000 2 2 6 7 10
221................................... 4800 9.4481 2 4 7 11 19
222................................... 4034 4.6931 1 2 4 6 9
223................................... 18870 3.3388 1 2 2 4 6
224................................... 8486 2.6704 1 1 2 3 5
225................................... 7671 5.2045 1 2 3 6 12
226................................... 5654 7.8857 2 3 5 9 17
227................................... 5722 3.2242 1 1 2 4 6
228................................... 3548 3.6863 1 1 2 4 8
229................................... 1812 2.5204 1 1 2 3 5
230................................... 2869 5.8323 1 2 3 7 12
231................................... 10695 5.6342 1 2 3 7 13
232................................... 785 5.9121 1 1 3 6 16
233................................... 4945 10.7391 2 4 8 13 22
234................................... 2461 4.8058 1 2 3 6 10
235................................... 6207 9.0292 2 3 6 10 18
236................................... 38925 7.8457 2 3 6 9 15
237................................... 1622 5.3138 1 2 4 6 10
238................................... 6844 12.7509 3 6 9 15 26
239................................... 61512 9.2090 3 4 7 11 18
240................................... 11346 8.9992 2 4 7 11 17
241................................... 3300 5.1988 1 2 4 6 10
242................................... 2305 9.4898 3 4 7 11 18
243................................... 89931 6.5203 2 3 5 8 12
244................................... 11437 6.8429 2 3 5 8 13
245................................... 4627 4.9777 1 2 3 6 9
246................................... 1450 4.8428 2 2 4 6 9
247................................... 10123 4.6937 1 2 3 6 9
248................................... 6602 6.0048 2 3 4 7 11
249................................... 9534 5.2327 1 2 3 6 11
250................................... 3352 6.1516 1 2 4 7 12
251................................... 2556 3.4879 1 1 2 4 7
252................................... 2 6.0000 2 2 10 10 10
253................................... 17574 7.2871 2 3 5 8 14
254................................... 10464 4.4119 1 2 3 5 8
255................................... 1 10.0000 10 10 10 10 10
256................................... 9618 4.8292 1 2 3 6 9
257................................... 26910 4.2968 2 2 3 5 7
258................................... 22133 3.1103 1 2 3 4 5
259................................... 4389 4.4231 1 2 2 4 9
260................................... 5654 2.2264 1 1 2 3 4
261................................... 2679 2.5692 1 1 2 3 4
262................................... 886 4.0113 1 1 2 5 8
263................................... 30793 17.9259 5 7 13 21 36
264................................... 3928 9.8154 3 4 7 12 20
265................................... 4920 8.7287 1 3 6 10 18
266................................... 3361 4.0896 1 1 3 5 8
267................................... 233 4.1416 1 1 2 5 9
268................................... 1280 4.2203 1 1 2 5 9
269................................... 11534 11.1540 2 4 8 14 23
270................................... 4485 3.6990 1 1 2 4 8
271................................... 20964 10.3957 3 5 8 12 19
272................................... 6833 8.5440 3 4 6 10 16
273................................... 1772 6.1146 2 3 5 7 12
274................................... 2604 9.2212 2 3 6 11 18
275................................... 259 4.1158 1 1 2 5 9
276................................... 869 5.7250 1 2 4 7 10
277................................... 75672 7.8474 3 4 6 9 14
278................................... 26559 5.7748 2 3 5 7 10
279................................... 11 4.2727 1 3 4 5 7
280................................... 13522 6.0379 1 3 4 7 11
281................................... 6473 4.0403 1 2 3 5 8
282................................... 1 1.0000 1 1 1 1 1
283................................... 5461 6.5825 2 3 5 8 13
284................................... 1984 4.4622 1 2 3 5 8
285................................... 5012 17.6905 4 8 13 21 35
286................................... 1919 9.7410 4 5 7 11 18
287................................... 6559 16.7590 4 7 11 19 33
288................................... 681 8.2966 3 4 5 8 15
289................................... 4615 5.0550 1 2 3 5 11
290................................... 9268 3.1631 1 2 2 3 5
291................................... 113 1.9735 1 1 1 3 4
292................................... 5234 15.1471 3 6 11 19 31
293................................... 397 6.7809 1 2 5 8 14
294................................... 81554 6.7451 2 3 5 8 12
295................................... 3315 5.4163 2 2 4 6 10
296................................... 229396 7.5914 2 3 5 9 15
297................................... 40518 4.8318 2 2 4 6 9
298................................... 86 4.2791 1 2 2 4 10
299................................... 919 6.3972 1 2 4 8 13
300................................... 12823 8.5192 2 4 6 10 16
301................................... 1909 4.9602 1 2 4 6 10
302................................... 7421 14.9716 7 9 12 18 26
303................................... 18390 11.8336 5 7 9 14 21
304................................... 13592 11.9551 3 5 9 14 24
305................................... 2743 5.6132 2 3 5 7 10
306................................... 11934 7.5380 2 3 5 10 15
307................................... 3326 3.7081 1 2 3 4 6
308................................... 10015 8.2702 2 3 6 10 17
309................................... 3820 3.4382 1 2 3 4 7
310................................... 33148 5.1730 1 2 3 6 11
311................................... 14216 2.5036 1 1 2 3 5
312................................... 2566 5.4228 1 2 4 7 11
313................................... 1173 2.6326 1 1 2 3 5
314................................... 1 8.0000 8 8 8 8 8
315................................... 29860 10.9882 1 3 7 14 24
316................................... 58365 8.4963 2 3 6 11 17
317................................... 709 4.3202 1 2 3 4 8
318................................... 6274 8.2596 2 3 6 10 17
319................................... 551 3.2886 1 1 2 4 7
320................................... 169655 7.6216 3 4 6 9 14
321................................... 26478 5.3676 2 3 4 6 9
322................................... 75 4.6667 2 3 4 5 10
323................................... 19448 4.0346 1 2 3 5 8
324................................... 11001 2.3168 1 1 2 3 4
325................................... 8671 5.3905 1 2 4 6 10
326................................... 2855 3.4396 1 2 3 4 7
327................................... 3 3.0000 1 1 4 4 4
328................................... 1036 5.0097 1 2 4 6 10
329................................... 199 2.6834 1 1 2 3 5
331................................... 34069 7.1510 2 3 5 9 14
332................................... 4817 4.1391 1 2 3 5 8
333................................... 323 7.2136 1 3 5 10 16
334................................... 28803 7.6281 4 5 7 8 11
335................................... 12802 6.0783 4 5 6 7 9
336................................... 82570 4.9586 2 3 4 6 9
337................................... 59010 3.3024 2 2 3 4 5
338................................... 8907 5.8485 1 2 4 7 13
339................................... 3141 4.7450 1 2 3 5 10
340................................... 3 2.3333 1 1 2 4 4
341................................... 9306 4.0466 1 2 3 4 7
342................................... 304 4.0592 1 1 2 5 10
344................................... 6646 3.8432 1 1 3 5 7
345................................... 1830 4.8781 1 2 3 6 10
346................................... 6711 7.8051 2 3 5 9 16
347................................... 559 3.7084 1 1 3 5 8
348................................... 3711 5.1576 1 2 4 6 10
349................................... 1032 3.3304 1 1 2 4 6
350................................... 7511 5.5387 2 3 5 7 10
352................................... 766 4.8316 1 2 3 6 9
353................................... 2458 10.1644 4 5 8 11 19
354................................... 10030 7.2722 3 4 6 8 12
355................................... 5593 4.3152 3 3 4 5 6
356................................... 35013 3.7038 2 2 3 4 6
357................................... 6795 11.1837 4 6 9 13 21
358................................... 26727 5.6056 3 4 4 6 9
359................................... 26677 3.8030 2 3 4 4 5
360................................... 9550 4.5982 2 3 3 5 8
361................................... 522 4.9904 1 2 3 5 11
362................................... 3 1.3333 1 1 1 2 2
363................................... 5168 4.0035 1 2 3 4 7
364................................... 2105 3.7648 1 1 2 5 8
365................................... 2672 9.5236 2 3 6 12 20
366................................... 4705 9.1237 2 3 6 11 19
367................................... 633 3.8547 1 1 2 4 7
368................................... 1778 7.4156 2 4 6 9 15
369................................... 2362 4.0157 1 1 3 5 8
370................................... 926 6.1760 3 3 4 6 10
371................................... 926 3.9525 3 3 3 4 5
372................................... 626 3.5591 1 2 3 4 6
373................................... 3288 2.2202 1 1 2 2 3
374................................... 138 3.1667 1 2 2 3 5
375................................... 4 51.5000 2 2 3 11 190
376................................... 182 3.4835 1 2 2 4 7
377................................... 34 5.6765 1 1 3 10 13
378................................... 142 3.0282 1 2 3 4 5
379................................... 356 2.8792 1 1 2 3 6
380................................... 74 2.0676 1 1 1 3 4
381................................... 234 2.6068 1 1 1 3 5
382................................... 49 1.4898 1 1 1 1 2
383................................... 1239 4.1114 1 2 3 5 8
384................................... 133 2.7218 1 1 2 3 5
385................................... 2 2.5000 1 1 4 4 4
387................................... 1 96.0000 96 96 96 96 96
389................................... 12 7.6667 1 2 7 10 15
390................................... 11 4.8182 1 1 3 4 8
391................................... 1 4.0000 4 4 4 4 4
392................................... 2475 13.3208 5 6 10 16 26
393................................... 1 3.0000 3 3 3 3 3
394................................... 1875 9.1568 1 2 5 10 20
395................................... 67817 6.1000 1 3 4 7 12
396................................... 16 2.1250 1 1 1 3 4
397................................... 13912 6.9811 2 3 5 9 14
398................................... 16364 7.4887 3 4 6 9 14
399................................... 1472 4.7772 1 2 4 6 9
400................................... 8198 11.8862 2 4 8 15 26
401................................... 6474 13.7359 3 5 10 17 29
402................................... 1910 4.8005 1 2 3 6 10
403................................... 32109 10.7763 2 4 8 14 22
404................................... 4368 5.2097 1 2 4 7 10
406................................... 3699 13.0338 3 6 9 16 26
407................................... 824 5.3228 1 2 4 7 10
408................................... 3652 8.5783 1 2 5 10 20
409................................... 6951 7.8958 2 4 5 8 17
410................................... 116918 3.4340 1 2 3 4 6
411................................... 88 3.7159 1 1 3 4 6
412................................... 86 3.2791 1 1 2 4 6
413................................... 8708 9.9641 2 4 7 12 21
414................................... 1126 5.5320 1 2 4 7 11
415................................... 35127 18.8135 5 8 14 23 37
416................................... 166879 9.5806 2 5 8 12 18
417................................... 35 7.4571 2 3 5 7 17
418................................... 15991 7.7532 3 4 6 9 14
419................................... 16927 6.7616 2 3 5 8 12
420................................... 3110 5.0559 2 3 4 6 9
421................................... 13460 5.2491 2 3 4 6 10
422................................... 96 4.4479 2 2 3 5 8
423................................... 8140 10.1158 3 4 7 12 21
424................................... 2386 23.6282 3 8 15 27 47
425................................... 17702 5.9108 1 2 4 7 12
426................................... 5406 6.6595 2 3 5 8 13
427................................... 1967 6.5379 1 2 4 8 14
428................................... 1062 10.1224 1 3 6 12 21
429................................... 33360 11.1442 2 4 7 12 21
430................................... 57419 11.5978 2 5 9 15 23
431................................... 192 7.5938 2 3 5 9 16
432................................... 486 7.3519 1 2 4 9 16
433................................... 7105 4.1161 1 1 3 5 9
434................................... 19457 6.8855 2 3 5 8 13
435................................... 13392 5.6022 1 3 4 6 11
436................................... 2478 17.0282 5 10 16 24 28
437................................... 12667 13.5997 5 8 12 18 25
439................................... 885 9.6475 1 3 6 12 22
440................................... 4513 11.5203 2 4 7 14 25
441................................... 674 3.8353 1 1 2 4 7
442................................... 13113 9.7342 1 3 6 12 21
443................................... 4430 3.3151 1 1 2 4 7
444................................... 3326 6.5541 2 3 5 8 12
445................................... 1588 4.1159 1 2 3 5 8
447................................... 3389 3.1467 1 1 2 4 6
448................................... 1 2.0000 2 2 2 2 2
449................................... 29032 5.3059 1 2 4 6 11
450................................... 6523 2.7887 1 1 2 3 5
451................................... 7 2.0000 1 1 1 2 3
452................................... 19259 5.8733 1 2 4 7 12
453................................... 4247 3.4490 1 1 2 4 7
454................................... 4613 6.5808 1 2 4 7 14
455................................... 1135 3.5480 1 1 2 4 7
456................................... 191 10.2147 1 2 5 12 25
457................................... 129 5.6434 1 1 3 8 15
458................................... 1640 19.9061 5 9 15 25 39
459................................... 584 12.4640 3 5 9 15 28
460................................... 2319 8.3182 2 3 6 10 16
461................................... 4408 5.4226 1 1 2 4 14
462................................... 10437 16.6802 5 8 14 22 31
463................................... 9266 6.2893 2 3 5 7 12
464................................... 2296 4.1376 1 2 3 5 8
465................................... 314 3.1656 1 1 2 3 7
466................................... 2919 5.6262 1 1 2 4 9
467................................... 3026 5.1021 1 1 2 5 9
468................................... 65013 17.7402 4 8 13 22 35
471................................... 8389 11.3348 5 7 9 13 18
472................................... 154 30.3961 2 8 21 38 63
473................................... 8459 16.2898 2 4 9 25 39
475................................... 81206 13.7356 2 6 11 18 27
476................................... 8813 15.7757 5 9 13 19 27
477................................... 35802 9.8340 1 3 7 12 20
478................................... 112660 9.6443 2 4 7 12 20
479................................... 16364 5.1058 1 2 4 7 10
480................................... 290 36.0586 12 15 26 45 69
481................................... 127 38.8346 21 26 35 44 60
482................................... 7297 17.8390 6 8 13 20 34
483................................... 36182 53.5939 17 27 42 65 99
484................................... 329 20.1429 2 7 14 26 42
485................................... 2893 14.6619 6 7 11 17 27
486................................... 2178 16.7929 1 6 12 22 35
487................................... 3498 10.2704 2 4 8 13 21
488................................... 906 21.5088 6 9 15 26 40
489................................... 9555 12.5051 3 5 8 15 25
490................................... 3125 8.1600 2 3 5 9 16
491................................... 8305 5.3404 2 3 4 6 9
492................................... 1565 16.8863 3 5 8 27 37
493................................... 50329 6.2752 1 2 5 8 13
494................................... 31920 2.3314 1 1 1 3 5
------------------
10657022
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7b.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY93 Medpar Update 06/94 Grouper V12.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arithmetic
DRG Numberdischarges mean LOS 10thpercentile 25thpercentile 50thpercentile 75thpercentile 90thpercentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
001................................... 30789 13.5837 3 6 10 17 28
002................................... 6029 13.9756 4 6 10 17 27
003................................... 2 41.5000 17 17 66 66 66
004................................... 5470 11.0845 2 4 7 14 23
005................................... 64742 5.8330 2 3 4 7 11
006................................... 526 3.1920 1 1 2 4 7
007................................... 7929 17.9653 3 5 10 19 36
008................................... 2330 4.6991 1 1 3 6 11
009................................... 1636 9.2219 2 4 6 11 17
010................................... 20813 9.7252 2 4 7 12 20
011................................... 3262 5.5880 1 2 4 7 11
012................................... 21908 9.3495 2 4 6 11 17
013................................... 6261 7.5787 3 4 6 9 13
014................................... 356425 8.9404 2 4 7 11 17
015................................... 132399 5.0854 2 2 4 6 9
016................................... 11159 8.2904 2 4 6 10 15
017................................... 3657 4.7060 1 2 4 6 9
018................................... 18848 7.3077 2 3 6 9 14
019................................... 7200 4.8607 1 2 4 6 9
020................................... 7645 11.7438 3 5 9 15 23
021................................... 1049 8.6883 2 4 7 11 17
022................................... 3836 5.5792 2 3 4 7 10
023................................... 4751 5.7925 1 2 4 7 11
024................................... 55823 6.8735 2 3 5 8 13
025................................... 21460 4.2266 1 2 3 5 8
026................................... 42 4.3095 1 2 2 4 9
027................................... 3097 7.8589 1 1 4 9 17
028................................... 9249 8.5089 2 3 6 10 18
029................................... 3423 4.6594 1 2 3 6 9
031................................... 3730 5.9056 1 2 4 7 12
032................................... 2173 3.5274 1 1 2 4 7
034................................... 15102 7.7488 2 3 5 9 15
035................................... 3477 4.9721 1 2 4 6 9
036................................... 16219 1.8739 1 1 1 2 3
037................................... 2345 4.1062 1 1 3 5 9
038................................... 479 2.7307 1 1 2 3 5
039................................... 5281 2.0364 1 1 1 2 4
040................................... 3432 3.6005 1 1 2 4 8
042................................... 12274 2.2783 1 1 1 2 5
043................................... 146 4.2466 1 2 3 5 7
044................................... 1707 6.0521 2 3 5 8 11
045................................... 2453 4.3343 1 2 4 6 8
046................................... 2990 6.3164 1 3 5 7 12
047................................... 1512 3.9061 1 2 3 5 8
049................................... 2298 6.9956 2 3 5 8 13
050................................... 4065 2.3454 1 1 2 3 4
051................................... 412 3.1044 1 1 2 3 7
052................................... 102 3.3431 1 1 2 4 7
053................................... 4619 3.5817 1 1 2 4 8
054................................... 1 1.0000 1 1 1 1 1
055................................... 2573 3.0377 1 1 1 3 7
056................................... 854 3.1674 1 1 2 4 7
057................................... 624 5.3333 1 2 3 6 11
059................................... 128 2.3750 1 1 1 2 4
060................................... 2 2.5000 2 2 3 3 3
061................................... 298 5.2148 1 1 2 7 12
063................................... 4536 5.3450 1 2 3 6 10
064................................... 3756 8.3568 1 2 5 10 18
065................................... 34410 3.8767 1 2 3 5 7
066................................... 7619 4.0374 1 2 3 5 7
067................................... 463 4.7451 2 3 4 6 9
068................................... 12598 5.4822 2 3 4 7 10
069................................... 3725 4.2545 2 2 4 5 7
070................................... 36 4.3056 1 2 4 5 7
071................................... 138 4.2174 2 2 3 5 8
072................................... 623 4.3900 1 2 3 5 9
073................................... 6364 5.6578 1 2 4 7 11
075................................... 36955 12.6172 5 7 9 15 24
076................................... 38636 14.2058 3 6 11 17 27
077................................... 2861 6.0304 1 2 4 8 13
078................................... 27188 9.3107 4 6 8 11 15
079................................... 176400 10.8265 3 5 8 13 20
080................................... 8662 7.4938 3 4 6 9 13
081................................... 10 7.1000 1 4 6 10 13
082................................... 68966 8.9400 2 4 7 11 18
083................................... 7393 7.4088 2 3 6 9 14
084................................... 1649 4.3475 1 2 3 5 8
085................................... 17273 8.2564 2 4 7 10 16
086................................... 1531 4.9458 1 2 4 6 10
087................................... 51836 7.5535 1 3 6 10 14
088................................... 335129 7.0079 3 4 6 8 12
089................................... 413681 8.1066 3 4 7 10 14
090................................... 41082 5.7548 2 3 5 7 10
091................................... 39 4.4359 2 3 4 5 8
092................................... 10461 8.1576 3 4 6 10 15
093................................... 1390 5.9029 2 3 5 7 11
094................................... 9988 8.6522 3 4 7 11 17
095................................... 1116 4.9615 2 3 4 6 9
096................................... 79105 6.3437 2 4 5 8 11
097................................... 28358 4.8701 2 3 4 6 8
098................................... 29 4.1034 1 2 3 4 7
099................................... 27622 4.2452 1 2 3 5 8
100................................... 11016 2.8297 1 1 2 3 5
101................................... 18830 6.3780 2 3 5 8 12
102................................... 3168 4.0726 1 2 3 5 8
103................................... 374 36.8235 10 14 23 46 83
104................................... 20761 18.1163 8 11 15 22 31
105................................... 18135 13.3385 7 8 10 15 23
106................................... 86394 13.8896 7 9 12 16 22
107................................... 57166 10.6348 6 7 9 12 17
108................................... 6381 14.6552 5 8 12 18 27
110................................... 56196 12.2957 3 7 10 15 23
111................................... 5542 7.5832 3 6 7 9 11
112................................... 166651 5.3420 1 2 4 7 11
113................................... 41621 17.4883 5 8 13 21 35
114................................... 8843 11.1036 3 5 8 14 22
115................................... 9528 12.8102 5 7 11 16 23
116................................... 74533 6.5235 2 3 5 8 13
117................................... 3788 5.0198 1 2 3 6 10
118................................... 7713 3.5309 1 1 2 4 8
119................................... 2438 5.7724 1 1 3 7 14
120................................... 40179 10.8965 1 3 7 14 24
121................................... 160886 8.7273 3 5 7 11 15
122................................... 95449 6.0310 2 3 6 8 10
123................................... 53564 5.1018 1 1 3 6 12
124................................... 135111 5.5606 1 2 4 7 11
125................................... 69007 3.2146 1 1 2 4 7
126................................... 4416 18.3338 5 8 14 25 38
127................................... 684369 7.2104 2 4 6 9 14
128................................... 22330 7.7058 4 5 7 9 12
129................................... 5431 3.8842 1 1 1 4 10
130................................... 81875 7.5149 2 4 6 9 13
131................................... 24974 5.6244 1 3 5 7 9
132................................... 17170 4.8175 1 2 4 6 9
133................................... 3818 3.5115 1 2 3 4 7
134................................... 30893 4.4949 1 2 3 5 8
135................................... 6243 6.0115 2 3 4 7 11
136................................... 1221 3.8878 1 2 3 5 7
138................................... 198568 5.3081 2 2 4 6 10
139................................... 68516 3.3781 1 2 3 4 6
140................................... 320756 4.0935 1 2 3 5 7
141................................... 76663 5.2949 2 2 4 6 10
142................................... 35435 3.6916 1 2 3 4 7
143................................... 134666 3.0822 1 2 2 4 6
144................................... 59340 6.5381 1 3 5 8 13
145................................... 6947 3.7669 1 2 3 5 7
146................................... 8207 12.3398 6 8 10 14 21
147................................... 1483 7.9845 4 6 8 9 11
148................................... 146601 14.9530 7 8 12 17 27
149................................... 14784 8.3103 5 6 8 9 12
150................................... 22866 12.9395 5 7 11 15 23
151................................... 4350 6.8198 2 4 6 9 12
152................................... 4940 9.9921 4 6 8 11 16
153................................... 1779 6.7482 3 5 6 8 10
154................................... 36964 17.1986 6 9 13 21 33
155................................... 3772 7.4467 3 4 7 9 12
156................................... 4 11.5000 2 2 9 13 22
157................................... 12614 6.3773 2 3 4 8 13
158................................... 7154 3.0415 1 1 2 4 6
159................................... 17551 5.8036 2 3 4 7 11
160................................... 11024 3.1692 1 2 3 4 6
161................................... 18354 4.8137 1 2 3 6 10
162................................... 11776 2.2116 1 1 2 3 4
163................................... 16 4.7500 2 2 3 6 8
164................................... 5026 10.3341 5 6 9 12 17
165................................... 1523 6.3020 3 4 6 8 10
166................................... 3221 6.4865 2 3 5 8 12
167................................... 2244 3.6925 2 2 3 5 6
168................................... 1916 5.6169 1 2 3 7 12
169................................... 1223 2.6917 1 1 2 3 6
170................................... 13083 14.8143 3 6 11 18 30
171................................... 1226 5.8728 1 3 5 8 11
172................................... 31169 9.4910 2 4 7 12 19
173................................... 2494 4.6684 1 2 3 6 9
174................................... 227972 6.3604 2 3 5 8 12
175................................... 25636 3.9298 2 2 3 5 7
176................................... 14948 7.0566 2 3 5 8 13
177................................... 13026 5.6763 2 3 5 7 10
178................................... 4996 3.9586 2 2 3 5 7
179................................... 9786 8.3933 3 4 6 10 16
180................................... 78727 6.9989 2 3 5 8 13
181................................... 20704 4.2217 1 2 4 5 7
182................................... 233789 5.7645 2 3 4 7 11
183................................... 72286 3.8396 1 2 3 5 7
184................................... 68 3.9853 1 2 3 4 5
185................................... 3706 5.9331 1 2 4 7 12
186................................... 5 4.0000 1 1 3 6 8
187................................... 962 3.9314 1 1 3 5 8
188................................... 53804 6.9627 2 3 5 8 14
189................................... 7894 3.7683 1 1 3 5 8
190................................... 58 4.4828 1 2 3 5 6
191................................... 10463 18.3336 6 9 14 22 36
192................................... 827 8.8295 2 5 8 11 16
193................................... 10463 15.8892 6 9 13 19 28
194................................... 921 9.1205 3 5 8 11 16
195................................... 12514 11.7907 5 7 10 14 20
196................................... 1041 7.5370 4 5 7 9 12
197................................... 34315 9.9735 4 6 8 12 17
198................................... 10471 5.3032 2 3 5 7 9
199................................... 2719 13.3553 4 6 10 17 26
200................................... 1717 13.2627 2 5 10 17 28
201................................... 1707 17.0949 4 7 12 22 35
202................................... 21167 8.7487 2 4 7 11 17
203................................... 29609 8.8798 2 4 7 11 18
204................................... 44863 7.5342 2 4 6 9 14
205................................... 21708 8.5126 2 4 6 10 17
206................................... 1903 4.7078 1 2 4 6 10
207................................... 36948 6.5512 2 3 5 8 12
208................................... 11535 3.6717 1 2 3 5 7
209................................... 306116 8.7749 5 6 8 10 13
210................................... 130491 10.9485 5 6 9 12 18
211................................... 25285 7.9929 4 5 7 9 12
212................................... 11 4.0909 1 3 4 5 6
213................................... 6425 11.7387 3 5 8 14 23
214................................... 49507 8.3687 3 4 6 10 15
215................................... 39923 4.7950 2 3 4 6 8
216................................... 6665 13.3539 3 6 10 17 27
217................................... 18210 19.1730 4 7 13 23 41
218................................... 21794 7.7061 2 4 6 9 14
219................................... 19004 4.4786 2 2 4 5 8
220................................... 5 6.2000 2 2 6 7 10
221................................... 4800 9.4481 2 4 7 11 19
222................................... 4034 4.6931 1 2 4 6 9
223................................... 18870 3.3388 1 2 2 4 6
224................................... 8486 2.6704 1 1 2 3 5
225................................... 7671 5.2045 1 2 3 6 12
226................................... 5654 7.8857 2 3 5 9 17
227................................... 5722 3.2242 1 1 2 4 6
228................................... 3548 3.6863 1 1 2 4 8
229................................... 1812 2.5204 1 1 2 3 5
230................................... 2869 5.8323 1 2 3 7 12
231................................... 10695 5.6342 1 2 3 7 13
232................................... 785 5.9121 1 1 3 6 16
233................................... 4945 10.7391 2 4 8 13 22
234................................... 2461 4.8058 1 2 3 6 10
235................................... 6207 9.0292 2 3 6 10 18
236................................... 38922 7.8441 2 3 6 9 15
237................................... 1622 5.3138 1 2 4 6 10
238................................... 6842 12.7514 3 6 9 15 26
239................................... 61512 9.2090 3 4 7 11 18
240................................... 11345 8.9998 2 4 7 11 17
241................................... 3300 5.1988 1 2 4 6 10
242................................... 2305 9.4898 3 4 7 11 18
243................................... 89931 6.5203 2 3 5 8 12
244................................... 11437 6.8429 2 3 5 8 13
245................................... 4627 4.9777 1 2 3 6 9
246................................... 1449 4.8440 2 2 4 6 9
247................................... 10123 4.6937 1 2 3 6 9
248................................... 6602 6.0048 2 3 4 7 11
249................................... 9534 5.2327 1 2 3 6 11
250................................... 3352 6.1516 1 2 4 7 12
251................................... 2556 3.4879 1 1 2 4 7
252................................... 2 6.0000 2 2 10 10 10
253................................... 17574 7.2871 2 3 5 8 14
254................................... 10464 4.4119 1 2 3 5 8
255................................... 1 10.0000 10 10 10 10 10
256................................... 9618 4.8292 1 2 3 6 9
257................................... 26910 4.2968 2 2 3 5 7
258................................... 22133 3.1103 1 2 3 4 5
259................................... 4389 4.4231 1 2 2 4 9
260................................... 5654 2.2264 1 1 2 3 4
261................................... 2679 2.5692 1 1 2 3 4
262................................... 886 4.0113 1 1 2 5 8
263................................... 30793 17.9259 5 7 13 21 36
264................................... 3928 9.8154 3 4 7 12 20
265................................... 4920 8.7287 1 3 6 10 18
266................................... 3361 4.0896 1 1 3 5 8
267................................... 233 4.1416 1 1 2 5 9
268................................... 1280 4.2203 1 1 2 5 9
269................................... 11534 11.1540 2 4 8 14 23
270................................... 4485 3.6990 1 1 2 4 8
271................................... 20961 10.3949 3 5 8 12 19
272................................... 6833 8.5440 3 4 6 10 16
273................................... 1772 6.1146 2 3 5 7 12
274................................... 2604 9.2212 2 3 6 11 18
275................................... 259 4.1158 1 1 2 5 9
276................................... 869 5.7250 1 2 4 7 10
277................................... 75655 7.8471 3 4 6 9 14
278................................... 26553 5.7747 2 3 5 7 10
279................................... 11 4.2727 1 3 4 5 7
280................................... 13522 6.0379 1 3 4 7 11
281................................... 6472 4.0383 1 2 3 5 8
282................................... 1 1.0000 1 1 1 1 1
283................................... 5470 6.5856 2 3 5 8 13
284................................... 1989 4.4610 1 2 3 5 8
285................................... 5012 17.6905 4 8 13 21 35
286................................... 1919 9.7410 4 5 7 11 18
287................................... 6559 16.7590 4 7 11 19 33
288................................... 681 8.2966 3 4 5 8 15
289................................... 4615 5.0550 1 2 3 5 11
290................................... 9268 3.1631 1 2 2 3 5
291................................... 113 1.9735 1 1 1 3 4
292................................... 5234 15.1471 3 6 11 19 31
293................................... 397 6.7809 1 2 5 8 14
294................................... 81545 6.7447 2 3 5 8 12
295................................... 3315 5.4163 2 2 4 6 10
296................................... 229391 7.5914 2 3 5 9 15
297................................... 40516 4.8318 2 2 4 6 9
298................................... 86 4.2791 1 2 2 4 10
299................................... 919 6.3972 1 2 4 8 13
300................................... 12823 8.5192 2 4 6 10 16
301................................... 1909 4.9602 1 2 4 6 10
302................................... 7421 14.9716 7 9 12 18 26
303................................... 18390 11.8336 5 7 9 14 21
304................................... 13559 11.9655 3 5 9 14 24
305................................... 2776 5.6380 2 3 5 7 10
306................................... 11934 7.5380 2 3 5 10 15
307................................... 3326 3.7081 1 2 3 4 6
308................................... 10014 8.2706 2 3 6 10 17
309................................... 3821 3.4384 1 2 3 4 7
310................................... 33147 5.1730 1 2 3 6 11
311................................... 14217 2.5038 1 1 2 3 5
312................................... 2566 5.4228 1 2 4 7 11
313................................... 1173 2.6326 1 1 2 3 5
314................................... 1 8.0000 8 8 8 8 8
315................................... 29860 10.9882 1 3 7 14 24
316................................... 58364 8.4964 2 3 6 11 17
317................................... 709 4.3202 1 2 3 4 8
318................................... 6274 8.2596 2 3 6 10 17
319................................... 551 3.2886 1 1 2 4 7
320................................... 169648 7.6216 3 4 6 9 14
321................................... 26475 5.3671 2 3 4 6 9
322................................... 75 4.6667 2 3 4 5 10
323................................... 19448 4.0346 1 2 3 5 8
324................................... 11001 2.3168 1 1 2 3 4
325................................... 8671 5.3905 1 2 4 6 10
326................................... 2855 3.4396 1 2 3 4 7
327................................... 3 3.0000 1 1 4 4 4
328................................... 1036 5.0097 1 2 4 6 10
329................................... 199 2.6834 1 1 2 3 5
331................................... 33402 7.1800 2 3 5 9 14
332................................... 5484 4.3288 1 2 3 5 9
333................................... 323 7.2136 1 3 5 10 16
334................................... 28803 7.6281 4 5 7 8 11
335................................... 12802 6.0783 4 5 6 7 9
336................................... 82570 4.9586 2 3 4 6 9
337................................... 59010 3.3024 2 2 3 4 5
338................................... 8907 5.8485 1 2 4 7 13
339................................... 3141 4.7450 1 2 3 5 10
340................................... 3 2.3333 1 1 2 4 4
341................................... 9306 4.0466 1 2 3 4 7
342................................... 304 4.0592 1 1 2 5 10
344................................... 6646 3.8432 1 1 3 5 7
345................................... 1830 4.8781 1 2 3 6 10
346................................... 6711 7.8051 2 3 5 9 16
347................................... 559 3.7084 1 1 3 5 8
348................................... 3711 5.1576 1 2 4 6 10
349................................... 1032 3.3304 1 1 2 4 6
350................................... 7511 5.5387 2 3 5 7 10
352................................... 766 4.8316 1 2 3 6 9
353................................... 2458 10.1644 4 5 8 11 19
354................................... 10030 7.2722 3 4 6 8 12
355................................... 5593 4.3152 3 3 4 5 6
356................................... 35013 3.7038 2 2 3 4 6
357................................... 6795 11.1837 4 6 9 13 21
358................................... 26727 5.6056 3 4 4 6 9
359................................... 26677 3.8030 2 3 4 4 5
360................................... 9550 4.5982 2 3 3 5 8
361................................... 522 4.9904 1 2 3 5 11
362................................... 3 1.3333 1 1 1 2 2
363................................... 5168 4.0035 1 2 3 4 7
364................................... 2105 3.7648 1 1 2 5 8
365................................... 2672 9.5236 2 3 6 12 20
366................................... 4705 9.1237 2 3 6 11 19
367................................... 633 3.8547 1 1 2 4 7
368................................... 1778 7.4156 2 4 6 9 15
369................................... 2362 4.0157 1 1 3 5 8
370................................... 926 6.1760 3 3 4 6 10
371................................... 926 3.9525 3 3 3 4 5
372................................... 626 3.5591 1 2 3 4 6
373................................... 3288 2.2202 1 1 2 2 3
374................................... 138 3.1667 1 2 2 3 5
375................................... 4 51.5000 2 2 3 11 190
376................................... 182 3.4835 1 2 2 4 7
377................................... 34 5.6765 1 1 3 10 13
378................................... 142 3.0282 1 2 3 4 5
379................................... 356 2.8792 1 1 2 3 6
380................................... 74 2.0676 1 1 1 3 4
381................................... 234 2.6068 1 1 1 3 5
382................................... 49 1.4898 1 1 1 1 2
383................................... 1239 4.1114 1 2 3 5 8
384................................... 133 2.7218 1 1 2 3 5
385................................... 2 2.5000 1 1 4 4 4
387................................... 1 96.0000 96 96 96 96 96
389................................... 12 7.6667 1 2 7 10 15
390................................... 11 4.8182 1 1 3 4 8
391................................... 1 4.0000 4 4 4 4 4
392................................... 2475 13.3208 5 6 10 16 26
393................................... 1 3.0000 3 3 3 3 3
394................................... 1875 9.1568 1 2 5 10 20
395................................... 67817 6.1000 1 3 4 7 12
396................................... 16 2.1250 1 1 1 3 4
397................................... 13912 6.9811 2 3 5 9 14
398................................... 16364 7.4887 3 4 6 9 14
399................................... 1472 4.7772 1 2 4 6 9
400................................... 8198 11.8862 2 4 8 15 26
401................................... 6474 13.7359 3 5 10 17 29
402................................... 1910 4.8005 1 2 3 6 10
403................................... 32106 10.7768 2 4 8 14 22
404................................... 4368 5.2097 1 2 4 7 10
406................................... 3699 13.0338 3 6 9 16 26
407................................... 824 5.3228 1 2 4 7 10
408................................... 3652 8.5783 1 2 5 10 20
409................................... 6951 7.8958 2 4 5 8 17
410................................... 116918 3.4340 1 2 3 4 6
411................................... 88 3.7159 1 1 3 4 6
412................................... 86 3.2791 1 1 2 4 6
413................................... 8708 9.9641 2 4 7 12 21
414................................... 1126 5.5320 1 2 4 7 11
415................................... 35127 18.8135 5 8 14 23 37
416................................... 166877 9.5806 2 5 8 12 18
417................................... 35 7.4571 2 3 5 7 17
418................................... 15991 7.7532 3 4 6 9 14
419................................... 16926 6.7615 2 3 5 8 12
420................................... 3110 5.0559 2 3 4 6 9
421................................... 13460 5.2491 2 3 4 6 10
422................................... 95 4.4737 2 2 3 5 8
423................................... 8140 10.1158 3 4 7 12 21
424................................... 2386 23.6282 3 8 15 27 47
425................................... 17702 5.9108 1 2 4 7 12
426................................... 5405 6.6605 2 3 5 8 13
427................................... 1967 6.5379 1 2 4 8 14
428................................... 1062 10.1224 1 3 6 12 21
429................................... 33360 11.1442 2 4 7 12 21
430................................... 57419 11.5978 2 5 9 15 23
431................................... 192 7.5938 2 3 5 9 16
432................................... 486 7.3519 1 2 4 9 16
433................................... 7105 4.1161 1 1 3 5 9
434................................... 19456 6.8858 2 3 5 8 13
435................................... 13390 5.6025 1 3 4 6 11
436................................... 2478 17.0282 5 10 16 24 28
437................................... 12667 13.5997 5 8 12 18 25
439................................... 885 9.6475 1 3 6 12 22
440................................... 4513 11.5203 2 4 7 14 25
441................................... 674 3.8353 1 1 2 4 7
442................................... 13113 9.7342 1 3 6 12 21
443................................... 4430 3.3151 1 1 2 4 7
444................................... 3324 6.5548 2 3 5 8 12
445................................... 1587 4.1141 1 2 3 5 8
447................................... 3389 3.1467 1 1 2 4 6
448................................... 1 2.0000 2 2 2 2 2
449................................... 29032 5.3059 1 2 4 6 11
450................................... 6523 2.7887 1 1 2 3 5
451................................... 7 2.0000 1 1 1 2 3
452................................... 19259 5.8733 1 2 4 7 12
453................................... 4247 3.4490 1 1 2 4 7
454................................... 4613 6.5808 1 2 4 7 14
455................................... 1135 3.5480 1 1 2 4 7
456................................... 191 10.2147 1 2 5 12 25
457................................... 129 5.6434 1 1 3 8 15
458................................... 1640 19.9061 5 9 15 25 39
459................................... 584 12.4640 3 5 9 15 28
460................................... 2319 8.3182 2 3 6 10 16
461................................... 4408 5.4226 1 1 2 4 14
462................................... 10437 16.6802 5 8 14 22 31
463................................... 9266 6.2893 2 3 5 7 12
464................................... 2296 4.1376 1 2 3 5 8
465................................... 314 3.1656 1 1 2 3 7
466................................... 2917 5.6284 1 1 2 4 9
467................................... 3026 5.1021 1 1 2 5 9
468................................... 61267 17.8425 4 8 14 22 35
471................................... 8389 11.3348 5 7 9 13 18
472................................... 154 30.3961 2 8 21 38 63
473................................... 8459 16.2898 2 4 9 25 39
475................................... 81206 13.7356 2 6 11 18 27
476................................... 8813 15.7781 5 9 13 19 27
477................................... 35488 9.8159 1 3 7 12 20
478................................... 112660 9.6443 2 4 7 12 20
479................................... 16364 5.1058 1 2 4 7 10
480................................... 290 36.0586 12 15 26 45 69
481................................... 127 38.8346 21 26 35 44 60
482................................... 7297 17.8390 6 8 13 20 34
483................................... 36182 53.5939 17 27 42 65 99
484................................... 329 20.1429 2 7 14 26 42
485................................... 2893 14.6619 6 7 11 17 27
486................................... 2178 16.7929 1 6 12 22 35
487................................... 3498 10.2704 2 4 8 13 21
488................................... 903 21.4895 6 9 15 26 40
489................................... 9557 12.5103 3 5 8 15 25
490................................... 3125 8.1590 2 3 5 9 16
491................................... 8305 5.3404 2 3 4 6 9
492................................... 1565 16.8863 3 5 8 27 37
493................................... 50329 6.2752 1 2 5 8 13
494................................... 31920 2.3314 1 1 1 3 5
495................................... 105 28.0190 11 15 22 33 47
------------------
10656824
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8a.--Statewide Average Operating Cost-To-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) August 1994
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.447 0.517
ALASKA................................................ 0.515 0.801
ARIZONA............................................... 0.484 0.638
ARKANSAS.............................................. 0.585 0.516
CALIFORNIA............................................ 0.451 0.559
COLORADO.............................................. 0.533 0.605
CONNECTICUT........................................... 0.572 0.596
DELAWARE.............................................. 0.603 0.527
DISTRICT OF COLUMBIA.................................. 0.533 .......
FLORIDA............................................... 0.460 0.462
GEORGIA............................................... 0.555 0.553
HAWAII................................................ 0.547 0.633
IDAHO................................................. 0.590 0.672
ILLINOIS.............................................. 0.530 0.608
INDIANA............................................... 0.604 0.660
IOWA.................................................. 0.571 0.735
KANSAS................................................ 0.518 0.691
KENTUCKY.............................................. 0.539 0.575
LOUISIANA............................................. 0.506 0.560
MAINE................................................. 0.685 0.577
MARYLAND.............................................. 0.764 0.807
MASSACHUSETTS......................................... 0.656 0.643
MICHIGAN.............................................. 0.546 0.669
MINNESOTA............................................. 0.586 0.669
MISSISSIPPI........................................... 0.553 0.554
MISSOURI.............................................. 0.498 0.552
MONTANA............................................... 0.546 0.654
NEBRASKA.............................................. 0.558 0.706
NEVADA................................................ 0.419 0.522
NEW HAMPSHIRE......................................... 0.607 0.645
NEW JERSEY............................................ 0.676 .......
NEW MEXICO............................................ 0.544 0.551
NEW YORK.............................................. 0.625 0.731
NORTH CAROLINA........................................ 0.579 0.536
NORTH DAKOTA.......................................... 0.660 0.692
OHIO.................................................. 0.608 0.658
OKLAHOMA.............................................. 0.524 0.570
OREGON................................................ 0.599 0.645
PENNSYLVANIA.......................................... 0.464 0.592
PUERTO RICO........................................... 0.554 0.876
RHODE ISLAND.......................................... 0.606 .......
SOUTH CAROLINA........................................ 0.528 0.526
SOUTH DAKOTA.......................................... 0.569 0.648
TENNESSEE............................................. 0.541 0.569
TEXAS................................................. 0.507 0.611
UTAH.................................................. 0.596 0.654
VERMONT............................................... 0.619 0.621
VIRGINIA.............................................. 0.537 0.563
WASHINGTON............................................ 0.663 0.759
WEST VIRGINIA......................................... 0.585 0.523
WISCONSIN............................................. 0.651 0.707
WYOMING............................................... 0.617 0.759
------------------------------------------------------------------------
Table 8b.--Statewide Average Capital Cost-To-Charge Ratios (Case
Weighted) August 1994
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.059
ALASKA......................................................... 0.093
ARIZONA........................................................ 0.061
ARKANSAS....................................................... 0.050
CALIFORNIA..................................................... 0.044
COLORADO....................................................... 0.053
CONNECTICUT.................................................... 0.045
DELAWARE....................................................... 0.055
DISTRICT OF COLUMBIA........................................... 0.043
FLORIDA........................................................ 0.058
GEORGIA........................................................ 0.049
HAWAII......................................................... 0.056
IDAHO.......................................................... 0.073
ILLINOIS....................................................... 0.049
INDIANA........................................................ 0.063
IOWA........................................................... 0.060
KANSAS......................................................... 0.063
KENTUCKY....................................................... 0.056
LOUISIANA...................................................... 0.075
MAINE.......................................................... 0.043
MASSACHUSETTS.................................................. 0.065
MICHIGAN....................................................... 0.060
MINNESOTA...................................................... 0.055
MISSISSIPPI.................................................... 0.057
MISSOURI....................................................... 0.058
MONTANA........................................................ 0.068
NEBRASKA....................................................... 0.060
NEVADA......................................................... 0.038
NEW HAMPSHIRE.................................................. 0.062
NEW JERSEY..................................................... 0.056
NEW MEXICO..................................................... 0.060
NEW YORK....................................................... 0.059
NORTH CAROLINA................................................. 0.050
NORTH DAKOTA................................................... 0.070
OHIO........................................................... 0.062
OKLAHOMA....................................................... 0.062
OREGON......................................................... 0.054
PENNSYLVANIA................................................... 0.049
PUERTO RICO.................................................... 0.090
RHODE ISLAND................................................... 0.027
SOUTH CAROLINA................................................. 0.067
SOUTH DAKOTA................................................... 0.068
TENNESSEE...................................................... 0.060
TEXAS.......................................................... 0.065
UTAH........................................................... 0.052
VERMONT........................................................ 0.050
VIRGINIA....................................................... 0.061
WASHINGTON..................................................... 0.072
WEST VIRGINIA.................................................. 0.057
WISCONSIN...................................................... 0.048
WYOMING........................................................ 0.074
------------------------------------------------------------------------
Table 9.--1993 Transfer Adjusted Case Mix Index and Transfer Adjustment
to Discharges for Capital Hospital-Specific Rate Redeterminations
------------------------------------------------------------------------
Transfer Transfer
adjusted adjustment
ProviderNo. Begin End case mix to
index discharges
------------------------------------------------------------------------
010001...................... 10/01/92 09/30/93 1.3433 0.9993
010004...................... 10/01/92 09/30/93 1.0466 0.9444
010005...................... 10/01/92 09/30/93 1.1202 0.9733
010007...................... 10/01/92 09/30/93 1.0812 0.9620
010008...................... 10/01/92 09/30/93 0.9865 0.9718
010009...................... 08/01/92 07/31/93 1.0770 0.9671
010010...................... 10/01/92 09/30/93 1.1173 0.9597
010016...................... 10/01/92 09/30/93 1.1850 0.9771
010019...................... 10/01/92 09/30/93 1.2418 0.9832
010021...................... 10/01/92 09/30/93 1.2792 0.9748
010027...................... 10/01/92 09/30/93 0.8655 0.9506
010029...................... 10/01/92 09/30/93 1.4506 0.9970
010032...................... 01/01/93 12/31/93 0.9329 0.9496
010033...................... 10/01/92 09/30/93 1.8957 0.9967
010035...................... 10/01/92 09/30/93 1.1933 0.9826
010040...................... 01/01/93 12/31/93 1.4180 0.9937
010044...................... 10/01/92 09/30/93 1.0645 0.9735
010045...................... 10/01/92 09/30/93 1.1156 0.9635
010047...................... 10/01/92 09/30/93 1.0002 0.9642
010051...................... 10/01/92 09/30/93 0.9130 0.9802
010052...................... 10/01/92 09/30/93 0.9391 0.9434
010053...................... 10/01/92 09/30/93 1.0618 0.9563
010059...................... 10/01/92 09/30/93 1.0529 0.9472
010061...................... 10/01/92 09/30/93 1.0023 0.9678
010062...................... 10/01/92 09/30/93 0.9841 0.9684
010065...................... 01/01/93 12/31/93 1.4689 0.9719
010069...................... 10/01/92 09/30/93 1.1411 0.9614
010073...................... 10/01/92 09/30/93 0.9158 0.9593
010079...................... 10/01/92 09/30/93 1.1386 0.9727
010081...................... 09/01/92 08/31/93 1.8321 0.9961
010083...................... 10/01/92 09/30/93 1.0498 0.9697
010084...................... 01/01/93 12/31/93 1.3874 0.9955
010087...................... 10/01/92 09/30/93 1.8142 0.9989
010092...................... 10/01/92 09/30/93 1.3570 0.9996
010094...................... 09/01/92 08/31/93 1.1644 0.9693
010095...................... 10/01/92 09/30/93 1.0805 0.9399
010097...................... 10/01/92 09/30/93 0.9091 0.9652
010099...................... 10/01/92 09/30/93 1.0410 0.9597
010100...................... 10/01/92 09/30/93 1.2224 0.9808
010102...................... 10/01/92 09/30/93 0.8853 0.9411
010108...................... 11/01/92 10/31/93 1.2356 0.9716
010109...................... 10/01/92 09/30/93 1.0721 0.9841
010110...................... 10/01/92 09/30/93 0.9970 0.9451
010112...................... 10/01/92 09/30/93 1.1398 0.9660
010115...................... 10/01/92 09/30/93 0.8687 0.9507
010117...................... 10/01/92 09/30/93 0.9041 0.9982
010119...................... 10/01/92 09/30/93 1.1049 0.9774
010120...................... 10/01/92 09/30/93 0.9880 0.9516
010124...................... 09/01/92 08/31/93 1.2680 0.9745
010125...................... 10/01/92 09/30/93 1.0367 0.9706
010126...................... 10/01/92 09/30/93 1.0645 0.9698
010127...................... 09/01/92 08/31/93 1.5433 0.9978
010129...................... 10/01/92 09/30/93 1.0713 0.9610
010130...................... 10/01/92 09/30/93 1.0889 0.9744
010137...................... 10/01/92 09/30/93 1.2871 0.9953
010143...................... 10/01/92 09/30/93 1.1680 0.9602
010144...................... 01/01/93 12/31/93 1.3363 0.9877
010145...................... 10/01/92 09/30/93 1.2420 0.9945
010146...................... 10/01/92 09/30/93 1.1099 0.9673
010149...................... 09/01/92 08/31/93 1.4229 0.9894
010152...................... 10/01/92 09/30/93 1.3715 0.9757
010155...................... 10/01/92 09/30/93 0.9952 0.9359
020001...................... 01/01/93 12/31/93 1.4832 0.9986
020005...................... 10/01/92 09/30/93 0.8686 0.9075
020006...................... 01/01/93 12/31/93 1.0889 0.9812
020012...................... 01/01/93 12/31/93 1.2952 0.9877
020025...................... 01/01/93 12/31/93 1.0283 0.9359
030001...................... 01/01/93 12/31/93 1.3269 0.9853
030002...................... 01/01/93 12/31/93 1.7749 0.9970
030004...................... 10/01/92 09/30/93 1.0256 0.9655
030012...................... 01/01/93 12/31/93 1.2245 0.9818
030013...................... 10/01/92 09/30/93 1.2298 0.9841
030014...................... 01/01/93 12/31/93 1.4786 0.9982
030018...................... 01/01/93 12/31/93 1.7075 0.9953
030023...................... 01/01/93 12/31/93 1.3075 0.9883
030025...................... 01/01/93 12/31/93 1.1110 0.9598
030030...................... 09/01/92 08/31/93 1.6860 0.9974
030035...................... 01/01/93 12/31/93 1.2836 0.9937
030036...................... 01/01/93 12/31/93 1.1651 0.9907
030038...................... 10/01/92 09/30/93 1.5267 0.9998
030041...................... 01/01/93 12/31/93 0.9269 0.9509
030044...................... 10/01/92 09/30/93 1.0355 0.9394
030046...................... 01/01/93 12/31/93 1.0221 0.9778
030047...................... 01/01/93 12/31/93 0.9636 0.9575
030061...................... 01/01/93 12/31/93 1.5871 0.9982
030062...................... 01/01/93 12/31/93 1.2967 0.9677
030065...................... 01/01/93 12/31/93 1.5321 0.9986
030067...................... 10/01/92 09/30/93 1.0815 0.9406
030068...................... 01/01/93 12/31/93 0.9356 0.9499
030069...................... 01/01/93 12/31/93 1.3049 0.9781
030080...................... 10/01/92 09/30/93 1.6483 0.9989
030085...................... 09/01/92 08/31/93 1.4486 0.9968
030086...................... 09/01/92 08/31/93 1.1495 0.9740
030087...................... 10/01/92 09/30/93 1.6388 0.9989
030088...................... 01/01/93 12/31/93 1.3592 0.9827
030089...................... 01/01/93 12/31/93 1.3628 0.9808
030092...................... 01/01/93 12/31/93 1.4826 0.9929
030093...................... 01/01/93 12/31/93 1.3257 0.9663
030094...................... 09/01/92 08/31/93 1.2844 0.9738
030095...................... 01/01/93 12/31/93 1.1168 0.9895
040004...................... 01/01/93 12/31/93 1.3390 0.9947
040005...................... 10/01/92 09/30/93 0.9396 0.9612
040007...................... 09/01/92 08/31/93 1.6562 0.9993
040010...................... 01/01/93 12/31/93 1.2066 0.9908
040013...................... 01/01/93 12/31/93 1.0104 0.9472
040014...................... 09/01/92 08/31/93 1.2086 0.9932
040018...................... 01/01/93 12/31/93 1.2789 0.9850
040020...................... 10/01/92 09/30/93 1.4988 0.9982
040021...................... 01/01/93 12/31/93 1.2715 0.9879
040024...................... 10/01/92 09/30/93 1.0226 0.9409
040027...................... 01/01/93 12/31/93 1.2968 0.9832
040028...................... 10/01/92 09/30/93 1.0211 0.9593
040029...................... 01/01/93 12/31/93 1.1751 0.9616
040036...................... 01/01/93 12/31/93 1.3575 0.9924
040037...................... 01/01/93 12/31/93 1.1443 0.9745
040041...................... 09/01/92 08/31/93 1.3450 0.9875
040042...................... 01/01/93 12/31/93 1.2758 0.9836
040044...................... 01/01/93 12/31/93 0.9070 0.9504
040045...................... 01/01/93 12/31/93 1.0599 0.9560
040050...................... 10/01/92 09/30/93 1.1319 0.9805
040064...................... 01/01/93 12/31/93 0.8712 0.9469
040066...................... 01/01/93 12/31/93 1.0866 0.9612
040067...................... 10/01/92 09/30/93 1.0668 0.9709
040072...................... 12/01/92 11/30/93 1.1173 0.9739
040075...................... 01/01/93 12/31/93 1.1201 0.9883
040078...................... 01/01/93 12/31/93 1.3007 0.9925
040081...................... 10/01/92 09/30/93 0.8836 0.9222
040085...................... 01/01/93 12/31/93 1.2362 0.9676
040100...................... 01/01/93 12/31/93 1.1253 0.9842
040105...................... 10/01/92 09/30/93 1.0199 0.9663
040106...................... 10/01/92 09/30/93 1.1878 0.9657
040107...................... 10/01/92 09/30/93 1.1672 0.9729
040114...................... 01/01/93 12/31/93 1.7809 0.9994
040118...................... 01/01/93 12/31/93 1.1261 0.9892
040119...................... 10/01/92 09/30/93 1.1533 0.9884
050002...................... 10/01/92 09/30/93 1.3574 0.9879
050007...................... 01/01/93 12/31/93 1.5513 0.9981
050008...................... 01/01/93 12/31/93 1.5052 0.9981
050013...................... 01/01/93 12/31/93 1.9438 0.9973
050016...................... 01/01/93 12/31/93 1.1487 0.9877
050018...................... 01/01/93 12/31/93 1.2754 0.9907
050021...................... 09/01/92 08/31/93 1.2799 0.9936
050022...................... 01/01/93 12/31/93 1.4911 0.9975
050024...................... 01/01/93 12/31/93 1.4104 0.9897
050030...................... 12/01/92 11/30/93 1.3479 0.9836
050032...................... 09/01/92 08/31/93 1.2490 0.9853
050047...................... 01/01/93 12/31/93 1.7302 0.9971
050058...................... 10/01/92 09/30/93 1.4159 0.9967
050060...................... 09/01/92 08/31/93 1.4852 0.9990
050061...................... 09/01/92 08/31/93 1.2971 0.9899
050070...................... 01/01/93 12/31/93 1.2554 0.9788
050071...................... 01/01/93 12/31/93 1.2953 0.9849
050072...................... 01/01/93 12/31/93 1.3242 0.9848
050073...................... 01/01/93 12/31/93 1.2605 0.9859
050074...................... 01/01/93 12/31/93 1.1108 0.9715
050075...................... 01/01/93 12/31/93 1.3512 0.9925
050076...................... 01/01/93 12/31/93 1.6112 0.9605
050078...................... 01/01/93 12/31/93 1.3655 0.9867
050080...................... 01/01/93 12/31/93 1.3107 0.9910
050081...................... 09/01/92 08/31/93 1.6115 0.9958
050084...................... 01/01/93 12/31/93 1.5821 0.9984
050091...................... 09/01/92 08/31/93 1.1944 0.9946
050096...................... 01/01/93 12/31/93 1.0886 0.9870
050097...................... 01/01/93 12/31/93 1.4858 0.9928
050099...................... 12/27/92 12/25/93 1.5579 0.9968
050100...................... 10/01/92 09/30/93 1.8029 0.9979
050101...................... 01/01/93 12/31/93 1.3925 0.9835
050102...................... 01/01/93 12/31/93 1.4201 0.9880
050103...................... 01/01/93 12/31/93 1.6526 0.9956
050107...................... 12/01/92 11/30/93 1.3113 0.9930
050108...................... 01/01/93 12/31/93 1.4929 0.9825
050109...................... 01/01/93 12/31/93 2.1274 0.9977
050111...................... 01/01/93 12/31/93 1.3195 0.9995
050112...................... 10/01/92 09/30/93 1.4531 0.9978
050117...................... 01/01/93 12/31/93 1.3029 0.9947
050121...................... 01/01/93 12/31/93 1.4495 0.9833
050122...................... 01/01/93 12/31/93 1.6172 0.9986
050125...................... 01/01/93 12/31/93 1.3598 0.9989
050126...................... 11/01/92 10/31/93 1.3877 0.9973
050127...................... 10/01/92 09/30/93 1.2997 0.9863
050131...................... 01/01/93 12/31/93 1.2868 0.9934
050132...................... 10/01/92 09/30/93 1.3964 0.9869
050135...................... 10/01/92 09/30/93 1.2077 0.9899
050137...................... 01/01/93 12/31/93 1.2959 0.9777
050138...................... 01/01/93 12/31/93 1.7742 0.9946
050139...................... 01/01/93 12/31/93 1.3149 0.9909
050140...................... 01/01/93 12/31/93 1.3623 0.9818
050144...................... 09/01/92 08/31/93 1.5588 0.9955
050145...................... 01/01/93 12/31/93 1.3646 0.9803
050149...................... 10/01/92 09/30/93 1.3535 0.9930
050150...................... 01/01/93 12/31/93 1.3093 0.9799
050154...................... 10/01/92 09/30/93 1.3130 0.9727
050155...................... 10/01/92 09/30/93 1.1514 1.0000
050169...................... 10/01/92 09/30/93 1.5343 0.9846
050173...................... 09/01/92 08/31/93 1.2499 0.9903
050189...................... 10/01/92 09/30/93 0.9773 0.9706
050204...................... 10/01/92 09/30/93 1.3659 0.9868
050205...................... 01/01/93 12/31/93 1.3807 0.9981
050208...................... 01/01/93 12/31/93 1.3047 0.9971
050211...................... 01/01/93 12/31/93 1.3510 0.9918
050214...................... 01/01/93 12/31/93 1.5123 0.9955
050217...................... 01/01/93 12/31/93 1.2767 0.9670
050219...................... 01/01/93 12/31/93 1.3006 0.9805
050222...................... 10/01/92 09/30/93 1.5372 0.9957
050224...................... 09/13/92 09/11/93 1.5804 0.9960
050226...................... 10/01/92 09/30/93 1.3681 0.9972
050231...................... 01/01/93 12/31/93 1.5282 0.9974
050233...................... 10/01/92 09/30/93 1.2602 0.9763
050234...................... 10/01/92 09/30/93 1.2816 0.9783
050235...................... 01/01/93 12/31/93 1.4640 0.9984
050236...................... 01/01/93 12/31/93 1.5519 0.9809
050238...................... 01/01/93 12/31/93 1.5283 0.9964
050239...................... 01/01/93 12/31/93 1.4828 0.9971
050241...................... 01/01/93 12/31/93 1.3179 0.9816
050251...................... 01/01/93 12/31/93 1.0903 0.9744
050253...................... 10/01/92 09/30/93 0.9026 1.0000
050254...................... 11/01/92 10/31/93 1.1784 0.9700
050256...................... 11/01/92 10/31/93 1.8190 0.9965
050257...................... 01/01/93 12/31/93 1.1399 0.9977
050270...................... 10/01/92 09/30/93 1.3539 0.9883
050272...................... 10/01/92 09/30/93 1.3906 0.9935
050281...................... 10/01/92 09/30/93 1.4200 0.9839
050282...................... 10/01/92 09/30/93 1.3143 0.9890
050286...................... 08/01/92 07/31/93 0.9221 0.9535
050300...................... 01/01/93 12/31/93 1.2845 0.9915
050301...................... 01/01/93 12/31/93 1.3710 0.9809
050302...................... 01/01/93 12/31/93 1.3718 0.9824
050305...................... 12/27/92 12/25/93 1.6123 0.9973
050309...................... 01/01/93 12/31/93 1.3577 0.9945
050310...................... 09/01/92 08/31/93 1.2452 0.9920
050313...................... 01/01/93 12/31/93 1.2179 0.9634
050317...................... 01/01/93 12/31/93 1.2474 0.9882
050324...................... 10/01/92 09/30/93 1.8331 0.9961
050327...................... 01/01/93 12/31/93 1.6146 0.9959
050328...................... 10/01/92 09/30/93 1.4276 0.9760
050329...................... 01/01/93 12/31/93 1.2425 0.9892
050335...................... 01/01/93 12/31/93 1.2587 0.9755
050336...................... 01/01/93 12/31/93 1.3310 0.9794
050351...................... 01/01/93 12/31/93 1.5080 0.9989
050352...................... 01/01/93 12/31/93 1.3364 0.9676
050357...................... 10/01/92 09/30/93 1.9566 0.9984
050360...................... 01/01/93 12/31/93 1.4462 0.9944
050366...................... 01/01/93 12/31/93 1.3021 0.9556
050367...................... 01/01/93 12/31/93 1.2822 0.9711
050369...................... 01/01/93 12/31/93 1.2719 0.9910
050391...................... 01/01/93 12/31/93 1.3599 0.9888
050394...................... 01/01/93 12/31/93 1.4610 0.9985
050396...................... 01/01/93 12/31/93 1.5488 0.9991
050404...................... 01/01/93 12/31/93 1.2001 0.9710
050407...................... 01/01/93 12/31/93 1.2609 0.9961
050410...................... 01/01/93 12/31/93 1.0783 0.9874
050411...................... 01/01/93 12/31/93 1.3210 0.9872
050417...................... 01/01/93 12/31/93 1.2138 0.9660
050420...................... 01/01/93 12/31/93 1.4480 0.9939
050421...................... 01/01/93 12/31/93 1.4439 0.9867
050424...................... 10/01/92 09/30/93 1.7218 0.9987
050425...................... 01/01/93 12/31/93 1.2542 0.9804
050426...................... 09/01/92 08/31/93 1.3431 0.9925
050431...................... 09/01/92 08/31/93 1.1278 0.9983
050438...................... 10/01/92 09/30/93 1.5714 0.9969
050440...................... 01/01/93 12/31/93 1.3226 0.9704
050441...................... 09/01/92 08/31/93 1.8421 0.9972
050447...................... 09/01/92 08/31/93 1.0827 0.9881
050455...................... 01/01/93 12/31/93 1.8472 0.9983
050456...................... 01/01/93 12/31/93 1.3057 0.9989
050458...................... 01/01/93 12/31/93 0.8308 0.9604
050469...................... 01/01/93 12/31/93 1.0933 0.9669
050471...................... 09/01/92 08/31/93 1.7726 0.9950
050478...................... 01/01/93 12/31/93 1.0128 0.9656
050483...................... 10/01/92 09/30/93 1.1744 0.9987
050486...................... 10/01/92 09/30/93 1.3872 0.9981
050492...................... 09/01/92 08/31/93 1.1895 0.9889
050498...................... 01/01/93 12/31/93 1.3214 0.9719
050503...................... 10/01/92 09/30/93 1.2837 0.9896
050506...................... 08/01/92 07/31/93 1.4421 0.9890
050510...................... 01/01/93 12/31/93 1.3417 0.9852
050512...................... 01/01/93 12/31/93 1.3298 0.9813
050515...................... 01/01/93 12/31/93 1.3031 0.9877
050517...................... 10/01/92 09/30/93 1.2715 0.9941
050523...................... 01/01/93 12/31/93 1.1914 0.9756
050531...................... 09/01/92 08/31/93 1.3777 0.9962
050537...................... 01/01/93 12/31/93 1.2978 0.9776
050541...................... 01/01/93 12/31/93 1.5563 0.9864
050543...................... 01/01/93 12/31/93 0.9014 0.9830
050549...................... 01/01/93 12/31/93 1.7848 0.9971
050550...................... 09/01/92 08/31/93 2.4330 0.9844
050552...................... 01/01/93 12/31/93 1.2377 0.9927
050557...................... 10/01/92 09/30/93 1.5988 0.9983
050561...................... 01/01/93 12/31/93 1.1689 0.9883
050564...................... 12/24/92 12/31/93 1.2892 0.9852
050567...................... 01/01/93 12/31/93 1.5625 0.9947
050570...................... 11/01/92 10/31/93 1.7082 0.9967
050571...................... 10/01/92 09/30/93 1.4523 0.9964
050575...................... 10/01/92 09/30/93 1.2488 0.9949
050580...................... 01/01/93 12/31/93 1.3808 0.9927
050585...................... 01/01/93 12/31/93 1.3396 0.9737
050586...................... 09/01/92 08/31/93 1.3497 0.9734
050587...................... 01/01/93 12/31/93 1.3013 0.9877
050588...................... 09/01/92 08/31/93 1.2428 0.9836
050590...................... 01/01/93 12/31/93 1.3190 0.9821
050591...................... 09/01/92 08/31/93 1.2035 0.9944
050592...................... 09/01/92 08/31/93 1.2470 0.9791
050593...................... 01/01/93 12/31/93 1.5002 0.9647
050597...................... 10/01/92 09/30/93 1.2842 0.9726
050598...................... 12/01/92 11/30/93 1.5210 0.9795
050604...................... 01/01/93 12/31/93 1.4856 0.9661
050607...................... 09/01/92 08/31/93 1.2420 0.9877
050608...................... 01/01/93 12/31/93 1.1147 0.9908
050609...................... 01/01/93 12/31/93 1.3146 0.9858
050619...................... 01/01/93 12/31/93 1.3888 0.9899
050624...................... 10/01/92 09/30/93 1.2602 0.9831
050630...................... 01/01/93 12/31/93 1.2743 0.9865
050635...................... 01/01/93 12/31/93 1.2974 0.9876
050644...................... 09/01/92 08/31/93 0.9948 0.9968
050663...................... 10/01/92 09/30/93 1.1093 0.9967
050674...................... 01/01/93 12/31/93 1.2180 0.9916
050677...................... 01/01/93 12/31/93 1.3124 0.9876
050680...................... 01/01/93 12/31/93 1.2188 0.9649
050686...................... 01/01/93 12/31/93 1.3632 0.9896
050690...................... 01/01/93 12/31/93 1.3616 0.9863
050693...................... 09/01/92 08/31/93 1.2709 0.9843
050695...................... 01/01/93 12/31/93 1.1961 0.9452
050697...................... 01/01/93 12/31/93 1.1902 1.0000
050698...................... 01/01/93 12/31/93 0.9781 1.0000
050699...................... 10/01/92 09/30/93 0.8471 0.9883
050701...................... 10/01/92 09/30/93 1.2879 0.9753
050702...................... 01/01/93 12/31/93 1.0669 0.9987
060001...................... 01/01/93 12/31/93 1.4629 0.9985
060003...................... 01/01/93 12/31/93 1.3022 0.9893
060004...................... 01/01/93 12/31/93 1.0426 0.9756
060006...................... 01/01/93 12/31/93 1.2149 0.9849
060007...................... 01/01/93 12/31/93 1.2670 0.9710
060009...................... 01/01/93 12/31/93 1.4190 0.9970
060010...................... 01/01/93 12/31/93 1.5248 0.9971
060011...................... 01/01/93 12/31/93 1.2120 0.9911
060014...................... 09/01/92 08/31/93 1.7029 0.9977
060018...................... 01/01/93 12/31/93 1.2288 0.9798
060022...................... 01/01/93 12/31/93 1.6587 0.9982
060027...................... 01/01/93 12/31/93 1.4640 0.9946
060029...................... 01/01/93 12/31/93 0.9997 0.9531
060030...................... 01/01/93 12/31/93 1.3358 0.9914
060033...................... 01/01/93 12/31/93 1.0953 0.9707
060037...................... 01/01/93 12/31/93 1.0331 0.9593
060038...................... 01/01/93 12/31/93 1.0423 0.9493
060041...................... 01/01/93 12/31/93 0.8930 0.9266
060042...................... 01/01/93 12/31/93 0.9456 0.9418
060043...................... 01/01/93 12/31/93 1.0208 0.9616
060044...................... 01/01/93 12/31/93 1.2437 0.9754
060046...................... 01/01/93 12/31/93 1.1137 0.9742
060047...................... 01/01/93 12/31/93 0.9782 0.9457
060049...................... 01/01/93 12/31/93 1.0338 0.9583
060050...................... 01/01/93 12/31/93 1.2211 0.9507
060052...................... 01/01/93 12/31/93 1.0787 0.9507
060053...................... 01/01/93 12/31/93 0.9640 0.9566
060056...................... 01/01/93 12/31/93 0.9222 0.9398
060057...................... 01/01/93 12/31/93 0.9585 0.9708
060058...................... 01/01/93 12/31/93 0.9147 0.9629
060060...................... 01/01/93 12/31/93 1.0266 0.9686
060062...................... 01/01/93 12/31/93 0.9691 0.9304
060063...................... 01/01/93 12/31/93 1.1020 0.9840
060064...................... 01/01/93 12/31/93 1.4188 0.9950
060066...................... 01/01/93 12/31/93 0.9450 0.9469
060068...................... 01/01/93 12/31/93 1.1910 0.9815
060070...................... 01/01/93 12/31/93 1.0389 0.9685
060071...................... 01/01/93 12/31/93 1.2673 0.9777
060072...................... 10/01/92 10/08/93 0.8900 0.9406
060073...................... 01/01/93 12/31/93 1.0258 0.9472
060075...................... 01/01/93 12/31/93 1.2459 0.9923
060076...................... 01/01/93 12/31/93 1.3894 0.9813
060085...................... 01/01/93 12/31/93 0.9709 0.9513
060088...................... 01/01/93 12/31/93 0.9647 0.9306
060090...................... 01/01/93 12/31/93 0.8986 0.9781
060096...................... 11/01/92 10/31/93 0.9969 0.9391
060103...................... 01/01/93 12/31/93 1.2275 0.9914
070001...................... 10/01/92 09/30/93 1.7468 0.9995
070002...................... 10/01/92 09/30/93 1.8073 0.9993
070003...................... 10/01/92 09/30/93 1.1509 0.9801
070004...................... 10/01/92 09/30/93 1.1598 0.9783
070005...................... 10/01/92 09/30/93 1.3284 0.9903
070006...................... 10/01/92 09/30/93 1.3122 0.9965
070007...................... 10/01/92 09/30/93 1.3826 0.9906
070008...................... 10/01/92 09/30/93 1.2463 0.9916
070009...................... 10/01/92 09/30/93 1.2626 0.9944
070010...................... 10/01/92 09/30/93 1.4544 0.9992
070011...................... 10/01/92 09/30/93 1.2095 0.9915
070012...................... 10/01/92 09/30/93 1.1723 0.9940
070013...................... 10/01/92 09/30/93 1.3301 0.9769
070015...................... 10/01/92 09/30/93 1.3021 0.9867
070016...................... 10/01/92 09/30/93 1.2493 0.9933
070017...................... 10/01/92 09/30/93 1.3718 0.9831
070018...................... 10/01/92 09/30/93 1.3489 0.9965
070019...................... 10/01/92 09/30/93 1.2624 0.9817
070020...................... 10/01/92 09/30/93 1.4096 0.9896
070021...................... 10/01/92 09/30/93 1.1819 0.9891
070022...................... 10/01/92 09/30/93 1.6432 0.9987
070023...................... 10/01/92 09/30/93 1.2094 0.9976
070024...................... 10/01/92 09/30/93 1.3177 0.9864
070025...................... 10/01/92 09/30/93 1.6934 0.9994
070026...................... 10/01/92 09/30/93 1.1729 0.9793
070027...................... 10/01/92 09/30/93 1.2104 0.9883
070028...................... 10/01/92 09/30/93 1.4691 0.9995
070029...................... 10/01/92 09/30/93 1.2266 0.9920
070030...................... 10/01/92 09/30/93 1.2069 0.9948
070031...................... 10/01/92 09/30/93 1.2889 0.9855
070033...................... 10/01/92 09/30/93 1.2704 0.9917
070034...................... 10/01/92 09/30/93 1.3325 0.9943
070035...................... 10/01/92 09/30/93 1.3533 0.9911
070036...................... 10/01/92 09/30/93 1.3008 0.9858
080005...................... 10/01/92 09/30/93 1.3852 0.9945
090002...................... 01/01/93 12/31/93 1.1273 0.9940
090005...................... 01/01/93 12/31/93 1.2744 0.9982
090006...................... 01/01/93 12/31/93 1.3431 0.9959
090007...................... 10/01/92 09/30/93 1.3393 0.9852
090008...................... 01/01/93 12/31/93 1.5514 0.9904
100002...................... 10/01/92 09/30/93 1.4459 0.9871
100004...................... 10/01/92 09/30/93 1.0472 0.9329
100005...................... 10/01/92 09/30/93 1.1603 0.9981
100006...................... 10/01/92 09/30/93 1.5840 0.9981
100007...................... 01/01/93 12/31/93 1.8342 0.9979
100008...................... 10/01/92 09/30/93 1.6743 0.9974
100012...................... 10/01/92 09/30/93 1.5381 0.9991
100014...................... 10/01/92 09/30/93 1.2889 0.9777
100015...................... 08/01/92 07/31/93 1.3096 0.9966
100017...................... 10/01/92 09/30/93 1.6619 0.9945
100018...................... 10/01/92 09/30/93 1.3538 0.9819
100019...................... 10/01/92 09/30/93 1.4534 0.9994
100020...................... 01/01/93 12/31/93 1.3707 0.9925
100022...................... 10/01/92 09/30/93 1.6998 0.9977
100023...................... 10/01/92 09/30/93 1.3266 0.9862
100024...................... 10/01/92 09/30/93 1.3794 0.9797
100025...................... 01/01/93 12/31/93 1.5878 0.9995
100026...................... 10/01/92 09/30/93 1.5003 0.9995
100028...................... 10/01/92 09/30/93 1.2755 0.9798
100029...................... 10/01/92 09/30/93 1.4444 0.9962
100030...................... 10/01/92 09/30/93 1.2704 0.9829
100034...................... 01/01/93 12/31/93 1.7301 0.9993
100035...................... 09/01/92 08/31/93 1.5521 0.9982
100040...................... 01/01/93 12/31/93 1.6779 0.9977
100042...................... 01/01/93 12/31/93 1.2060 0.9947
100043...................... 10/01/92 09/30/93 1.4141 0.9899
100044...................... 10/01/92 09/30/93 1.4433 0.9905
100045...................... 10/01/92 09/30/93 1.4655 0.9793
100046...................... 01/01/93 12/31/93 1.4069 0.9689
100047...................... 01/01/93 12/31/93 1.7886 0.9975
100048...................... 10/01/92 09/30/93 0.9967 0.9975
100049...................... 10/01/92 09/30/93 1.2783 0.9726
100050...................... 01/01/93 12/31/93 1.2132 0.9957
100051...................... 10/01/92 09/30/93 1.2683 0.9531
100052...................... 10/01/92 09/30/93 1.4153 0.9868
100053...................... 10/01/92 09/30/93 1.3041 0.9965
100054...................... 08/01/92 07/31/93 1.3313 0.9782
100055...................... 10/01/92 09/30/93 1.3831 0.9934
100056...................... 01/01/93 12/31/93 1.4712 0.9896
100057...................... 01/01/93 12/31/93 1.3471 0.9685
100059...................... 01/01/93 12/31/93 1.6610 0.9951
100061...................... 09/01/92 08/31/93 1.5612 0.9979
100062...................... 10/01/92 09/30/93 1.7330 0.9987
100063...................... 01/01/93 12/31/93 1.2522 0.9876
100071...................... 10/01/92 09/30/93 1.2496 0.9838
100072...................... 10/01/92 09/30/93 1.2238 0.9844
100073...................... 01/01/93 12/31/93 1.7831 0.9978
100074...................... 10/01/92 09/30/93 1.2381 0.9861
100077...................... 09/01/92 08/31/93 1.3229 0.9891
100078...................... 10/01/92 09/30/93 1.1828 0.9782
100080...................... 10/01/92 09/30/93 1.5553 0.9993
100081...................... 10/01/92 09/30/93 1.1432 0.9986
100082...................... 10/01/92 09/30/93 1.5102 0.9974
100083...................... 01/01/93 12/31/93 1.3349 0.9879
100085...................... 01/01/93 12/31/93 1.3241 0.9901
100087...................... 10/01/92 09/30/93 1.7518 0.9993
100088...................... 10/01/92 09/30/93 1.6045 0.9976
100090...................... 10/01/92 09/30/93 1.3537 0.9883
100092...................... 10/01/92 09/30/93 1.5224 0.9980
100093...................... 10/01/92 09/30/93 1.4652 0.9949
100098...................... 10/01/92 09/30/93 1.2642 0.9706
100100...................... 01/01/93 12/31/93 1.4727 0.9958
100102...................... 10/01/92 09/30/93 1.0568 0.9658
100103...................... 10/01/92 09/30/93 1.0131 0.9690
100105...................... 10/01/92 09/30/93 1.4025 0.9884
100107...................... 09/01/92 08/31/93 1.2704 0.9670
100108...................... 10/01/92 09/30/93 1.0523 0.9699
100109...................... 01/01/93 12/31/93 1.3331 0.9712
100112...................... 10/01/92 09/30/93 0.9795 0.9377
100117...................... 10/01/92 09/30/93 1.2874 0.9724
100118...................... 11/01/92 10/31/93 1.1863 0.9688
100121...................... 10/01/92 09/30/93 1.2329 0.9813
100124...................... 11/01/92 10/31/93 1.3538 0.9825
100125...................... 10/01/92 09/30/93 1.1504 0.9841
100127...................... 10/01/92 09/30/93 1.6126 0.9997
100128...................... 10/01/92 09/30/93 2.1675 0.9975
100130...................... 10/01/92 09/30/93 1.1689 0.9788
100132...................... 01/01/93 12/31/93 1.4757 0.9832
100135...................... 10/01/92 09/30/93 1.4995 0.9984
100138...................... 10/01/92 09/30/93 0.9842 0.9370
100139...................... 10/01/92 09/30/93 1.0409 0.9711
100140...................... 10/01/92 09/30/93 1.1933 0.9704
100142...................... 10/01/92 09/30/93 1.1731 0.9741
100144...................... 10/01/92 09/30/93 1.3477 0.9877
100145...................... 01/01/93 12/31/93 1.4111 0.9934
100146...................... 10/01/92 09/30/93 1.1371 0.9615
100147...................... 10/01/92 09/30/93 1.1212 0.9676
100150...................... 09/01/92 08/31/93 1.3187 0.9811
100151...................... 01/01/93 12/31/93 1.8320 0.9993
100154...................... 10/01/92 09/30/93 1.6025 0.9994
100156...................... 11/01/92 10/31/93 1.1535 0.9730
100157...................... 10/01/92 09/30/93 1.5938 0.9990
100162...................... 10/01/92 09/30/93 1.4031 0.9876
100165...................... 01/01/93 12/31/93 1.1988 0.9946
100166...................... 01/01/93 12/31/93 1.4537 0.9894
100167...................... 09/01/92 08/31/93 1.3554 0.9952
100169...................... 11/01/92 10/31/93 1.8210 0.9976
100170...................... 10/01/92 09/30/93 1.4743 0.9948
100173...................... 10/01/92 09/30/93 1.6373 0.9989
100174...................... 10/01/92 09/30/93 1.4227 0.9923
100175...................... 10/01/92 09/30/93 0.9447 0.9558
100176...................... 10/01/92 09/30/93 1.9256 0.9976
100177...................... 10/01/92 09/30/93 1.3221 0.9918
100180...................... 09/01/92 08/31/93 1.4231 0.9936
100181...................... 01/01/93 12/31/93 1.5828 0.9942
100183...................... 01/01/93 12/31/93 1.3778 0.9938
100186...................... 01/01/93 12/31/93 1.3814 0.9932
100187...................... 01/01/93 12/31/93 1.3822 0.9936
100189...................... 01/01/93 12/31/93 1.2692 0.9872
100203...................... 10/01/92 09/30/93 1.1642 0.9816
100206...................... 12/01/92 11/30/93 1.3816 0.9920
100208...................... 01/01/93 12/31/93 1.5458 0.9823
100209...................... 01/01/93 12/31/93 1.5477 0.9989
100210...................... 01/01/93 12/31/93 1.7004 0.9972
100212...................... 09/01/92 08/31/93 1.6311 0.9979
100217...................... 09/01/92 08/31/93 1.1889 0.9809
100220...................... 01/01/93 12/31/93 1.7917 0.9992
100222...................... 01/01/93 12/31/93 1.2752 0.9901
100224...................... 01/01/93 12/31/93 1.4444 0.9813
100232...................... 10/01/92 09/30/93 1.2684 0.9834
100234...................... 09/01/92 08/31/93 1.3603 0.9932
100235...................... 10/01/92 09/30/93 1.3807 0.9868
100236...................... 01/01/93 12/31/93 1.4841 0.9914
100237...................... 10/01/92 09/30/93 2.1493 0.9979
100239...................... 01/01/93 12/31/93 1.4709 0.9938
100241...................... 10/01/92 09/30/93 0.9445 0.9787
100246...................... 01/01/93 12/31/93 1.3364 0.9907
100248...................... 08/01/92 07/31/93 1.6598 0.9987
100253...................... 10/01/92 09/30/93 1.3651 0.9875
100255...................... 01/01/93 12/31/93 1.3314 0.9908
100259...................... 09/01/92 08/31/93 1.4569 0.9751
100260...................... 10/01/92 09/30/93 1.3872 0.9861
100262...................... 10/01/92 09/30/93 1.4019 0.9919
100265...................... 10/01/92 09/30/93 1.3094 0.9779
100266...................... 10/01/92 09/30/93 1.3014 0.9865
100267...................... 01/01/93 12/31/93 1.3145 0.9893
100269...................... 09/01/92 08/31/93 1.3409 0.9860
100275...................... 01/01/93 12/31/93 1.3233 0.9933
100278...................... 10/01/92 09/30/93 0.8733 0.9570
100279...................... 01/01/93 12/31/93 1.4222 0.9878
100280...................... 10/01/92 09/30/93 1.4211 0.9729
110001...................... 10/01/92 09/30/93 1.2557 0.9913
110002...................... 01/01/93 12/31/93 1.2239 0.9897
110004...................... 10/01/92 09/30/93 1.2198 0.9930
110005...................... 12/04/92 12/31/93 1.1966 0.9642
110006...................... 10/01/92 09/30/93 1.2830 0.9953
110007...................... 08/01/92 07/31/93 1.4633 0.9956
110009...................... 11/01/92 10/31/93 1.0220 0.9558
110010...................... 09/01/92 08/31/93 2.0085 0.9981
110013...................... 10/01/92 09/30/93 1.1118 0.9622
110014...................... 08/01/92 07/31/93 1.1991 0.9753
110016...................... 10/04/92 10/02/93 1.2851 0.9877
110018...................... 01/01/93 12/31/93 1.1904 0.9650
110023...................... 01/01/93 12/31/93 1.2882 0.9525
110024...................... 01/01/93 12/31/93 1.3957 0.9891
110025...................... 10/01/92 09/30/93 1.3127 0.9845
110028...................... 12/28/92 12/26/93 1.6169 0.9992
110029...................... 10/01/92 09/30/93 1.3308 0.9869
110030...................... 09/01/92 08/31/93 1.2809 0.9652
110032...................... 10/01/92 09/30/93 1.1307 0.9731
110033...................... 08/01/92 07/31/93 1.4026 0.9851
110036...................... 01/01/93 12/31/93 1.6650 0.9980
110037...................... 01/01/93 12/31/93 1.0586 0.9861
110038...................... 10/01/92 09/30/93 1.3938 0.9944
110044...................... 10/01/92 09/30/93 1.1404 0.9614
110045...................... 08/01/92 07/31/93 1.1084 0.9685
110046...................... 11/01/92 10/31/93 1.2151 0.9675
110048...................... 10/01/92 09/30/93 1.1037 0.9637
110049...................... 10/01/92 09/30/93 1.0603 0.9632
110050...................... 01/01/93 12/31/93 1.0532 0.9796
110059...................... 10/01/92 09/30/93 1.3049 0.9743
110061...................... 10/01/92 09/30/93 1.0260 0.9546
110063...................... 12/01/92 11/30/93 1.0974 0.9625
110065...................... 01/01/93 12/31/93 0.9887 0.9903
110070...................... 11/01/92 10/31/93 1.0075 0.9301
110072...................... 01/01/93 12/31/93 1.0259 0.9669
110073...................... 08/01/92 07/31/93 1.2792 0.9642
110074...................... 10/01/92 09/30/93 1.4441 0.9967
110075...................... 10/01/92 09/30/93 1.1354 0.9812
110076...................... 10/01/92 09/30/93 1.3246 0.9874
110078...................... 09/01/92 08/31/93 1.5682 0.9981
110079...................... 01/01/93 12/31/93 1.3886 0.9974
110080...................... 10/01/92 09/30/93 1.1839 0.9935
110082...................... 01/01/93 12/31/93 2.0259 0.9976
110083...................... 01/01/93 12/31/93 1.6418 0.9989
110086...................... 09/01/92 08/31/93 1.0530 0.9697
110088...................... 01/01/93 12/31/93 0.9289 0.9184
110089...................... 01/01/93 12/31/93 1.2038 0.9736
110091...................... 10/01/92 09/30/93 1.3842 0.9811
110092...................... 10/01/92 09/30/93 1.0738 0.9734
110095...................... 10/01/92 09/30/93 1.2536 0.9781
110096...................... 01/01/93 12/31/93 1.0983 0.9678
110100...................... 01/01/93 12/31/93 1.0867 0.9680
110105...................... 10/01/92 09/30/93 1.1363 0.9780
110107...................... 10/01/92 09/30/93 1.6421 0.9953
110111...................... 10/01/92 09/30/93 1.1306 0.9828
110112...................... 09/01/92 08/31/93 1.0049 0.9872
110115...................... 01/01/93 12/31/93 1.6403 0.9981
110118...................... 10/01/92 09/30/93 1.0298 0.9359
110120...................... 10/01/92 09/30/93 1.0358 0.9465
110121...................... 10/01/92 09/30/93 1.1447 0.9699
110122...................... 10/01/92 09/30/93 1.2861 0.9855
110129...................... 01/01/93 12/31/93 1.5456 0.9985
110130...................... 12/01/92 11/30/93 1.0604 0.9714
110140...................... 01/01/93 12/31/93 0.8325 0.9662
110142...................... 10/01/92 09/30/93 1.0122 0.9633
110144...................... 10/01/92 09/30/93 1.1674 0.9602
110146...................... 01/01/93 12/31/93 0.8945 0.9345
110150...................... 10/01/92 09/30/93 1.2982 0.9766
110161...................... 10/01/92 09/30/93 1.2411 0.9934
110165...................... 11/01/92 10/31/93 1.2941 0.9894
110166...................... 10/01/92 09/30/93 1.4956 0.9877
110171...................... 11/01/92 10/31/93 1.3434 0.9958
110172...................... 10/01/92 09/30/93 1.2407 0.9925
110177...................... 09/01/92 08/31/93 1.3872 0.9958
110179...................... 01/01/93 12/31/93 1.1803 0.9799
110186...................... 01/01/93 12/31/93 1.2706 0.9920
110187...................... 01/01/93 12/31/93 1.1779 0.9592
110189...................... 01/01/93 12/31/93 1.0753 0.9563
110190...................... 01/01/93 12/31/93 1.0715 0.9599
110193...................... 01/01/93 12/31/93 1.1315 0.9781
110195...................... 10/01/92 09/30/93 1.2050 0.9902
110198...................... 11/01/92 10/31/93 1.3634 0.9879
110200...................... 10/01/92 09/30/93 1.9892 0.9929
110201...................... 09/01/92 08/31/93 1.3992 0.9960
110203...................... 10/01/92 09/30/93 0.9902 0.9674
110207...................... 01/01/93 12/31/93 1.1500 0.9919
120006...................... 01/01/93 12/31/93 1.1565 0.9885
120011...................... 01/01/93 12/31/93 1.2601 0.9934
120022...................... 01/01/93 12/31/93 1.6614 0.9969
130001...................... 12/01/92 11/30/93 1.0137 0.9690
130002...................... 10/01/92 09/30/93 1.3839 0.9869
130005...................... 01/01/93 12/31/93 1.3733 0.9878
130006...................... 10/01/92 09/30/93 1.7657 0.9990
130009...................... 10/01/92 09/30/93 0.9674 0.9312
130010...................... 10/01/92 09/30/93 0.9348 0.9694
130011...................... 01/01/93 12/31/93 1.3335 0.9682
130012...................... 10/01/92 09/30/93 0.9977 0.9500
130014...................... 10/01/92 09/30/93 1.3563 0.9643
130015...................... 10/01/92 09/30/93 0.8795 0.9297
130016...................... 10/01/92 09/30/93 0.8531 0.9874
130018...................... 10/01/92 09/30/93 1.5840 0.9977
130021...................... 12/01/92 11/30/93 0.9193 0.9682
130024...................... 09/01/92 08/31/93 1.0972 0.9446
130025...................... 10/01/92 09/30/93 1.1052 0.9865
130026...................... 01/01/93 12/31/93 1.1129 0.9667
130027...................... 10/01/92 09/30/93 0.8806 0.9553
130028...................... 10/01/92 09/30/93 1.1850 0.9908
130030...................... 10/01/92 09/30/93 1.0382 0.9856
130031...................... 10/01/92 09/30/93 1.0133 0.9752
130034...................... 10/01/92 09/30/93 1.0463 0.9396
130036...................... 01/01/93 12/31/93 1.2938 0.9778
130037...................... 10/01/92 09/30/93 1.1210 0.9516
130043...................... 10/01/92 09/30/93 1.0387 0.9800
130044...................... 10/01/92 09/30/93 0.9705 0.9546
130045...................... 10/01/92 09/30/93 0.8828 0.9445
130049...................... 12/01/92 11/30/93 1.2283 0.9847
130054...................... 10/01/92 09/30/93 0.8836 0.8705
130056...................... 10/01/92 09/30/93 0.9516 0.9433
130058...................... 09/01/92 08/31/93 0.9112 1.0000
130060...................... 10/01/92 09/30/93 1.1938 0.9698
140002...................... 01/01/93 12/31/93 1.2373 0.9883
140004...................... 10/01/92 09/30/93 0.9830 0.9617
140007...................... 09/01/92 08/31/93 1.4424 0.9959
140008...................... 01/01/93 12/31/93 1.4505 0.9934
140010...................... 10/01/92 09/30/93 1.3101 0.9979
140012...................... 01/01/93 12/31/93 1.2000 0.9930
140013...................... 01/01/93 12/31/93 1.6053 0.9966
140015...................... 10/01/92 09/30/93 1.2287 0.9923
140019...................... 09/01/92 08/31/93 0.9268 0.9558
140029...................... 01/01/93 12/31/93 1.3185 0.9964
140031...................... 01/01/93 12/31/93 1.0710 0.9461
140034...................... 01/01/93 12/31/93 1.1563 0.9871
140036...................... 10/01/92 09/30/93 1.1228 0.9780
140039...................... 01/01/93 12/31/93 1.0160 0.9441
140046...................... 01/01/93 12/31/93 1.2923 0.9737
140048...................... 01/01/93 12/31/93 1.3052 0.9916
140049...................... 11/01/92 10/31/93 1.3442 0.9912
140051...................... 10/01/92 09/30/93 1.3457 0.9893
140052...................... 01/01/93 12/31/93 1.2697 0.9908
140054...................... 09/27/92 09/30/93 1.3005 0.9883
140058...................... 10/01/92 09/30/93 1.1598 0.9859
140062...................... 01/01/93 12/31/93 1.2344 0.9889
140063...................... 01/01/93 12/31/93 1.3585 0.9933
140064...................... 10/01/92 09/30/93 1.1858 0.9839
140065...................... 01/01/93 12/31/93 1.4394 0.9967
140066...................... 01/01/93 12/31/93 1.1728 0.9839
140074...................... 10/01/92 09/30/93 1.0178 0.9501
140079...................... 01/01/93 12/31/93 1.2727 0.9943
140080...................... 01/01/93 12/31/93 1.7724 0.9945
140084...................... 01/01/93 12/31/93 1.2105 0.9897
140087...................... 01/01/93 12/31/93 1.3710 0.9944
140090...................... 01/01/93 12/31/93 1.4769 0.9985
140093...................... 09/01/92 08/31/93 1.1956 0.9866
140094...................... 01/01/93 12/31/93 1.2822 0.9955
140095...................... 09/01/92 09/30/93 1.2133 0.9819
140097...................... 01/01/93 12/31/93 0.9935 0.9497
140101...................... 12/01/92 11/30/93 1.1947 0.9779
140103...................... 01/01/93 12/31/93 1.3628 0.9923
140105...................... 01/01/93 12/31/93 1.3103 0.9966
140107...................... 01/01/93 12/31/93 1.1188 0.9561
140108...................... 01/01/93 12/31/93 1.3384 0.9877
140112...................... 10/01/92 09/30/93 1.0830 0.9686
140113...................... 01/01/93 12/31/93 1.4296 0.9979
140118...................... 01/01/93 12/31/93 1.6349 0.9973
140122...................... 01/01/93 12/31/93 1.5072 0.9961
140125...................... 01/01/93 12/31/93 1.2456 0.9907
140128...................... 10/01/92 09/30/93 1.0468 0.9665
140129...................... 01/01/93 12/31/93 1.0820 0.9774
140130...................... 01/01/93 12/31/93 1.1336 0.9932
140132...................... 10/01/92 09/30/93 1.5264 0.9988
140135...................... 10/01/92 09/30/93 1.2390 0.9816
140137...................... 01/01/93 12/31/93 1.0342 0.9589
140139...................... 10/01/92 09/30/93 1.0535 0.9668
140141...................... 08/01/92 07/31/93 1.0038 0.9738
140143...................... 10/01/92 09/30/93 1.0716 0.9865
140147...................... 12/01/92 11/30/93 1.2099 0.9856
140148...................... 10/01/92 09/30/93 1.6497 0.9990
140152...................... 01/01/93 12/31/93 1.0651 0.9938
140155...................... 01/01/93 12/31/93 1.1722 0.9897
140160...................... 08/01/92 07/31/93 1.1817 0.9806
140161...................... 10/01/92 09/30/93 1.0966 0.9651
140162...................... 10/01/92 09/30/93 1.6837 0.9965
140167...................... 10/01/92 09/30/93 1.1207 0.9864
140180...................... 01/01/93 12/31/93 1.5142 0.9976
140181...................... 01/01/93 12/31/93 1.2841 0.9922
140182...................... 11/01/92 10/31/93 1.2731 0.9952
140185...................... 01/01/93 12/31/93 1.4267 0.9885
140186...................... 01/01/93 12/31/93 1.2155 0.9855
140188...................... 09/01/92 08/31/93 0.9984 0.9194
140191...................... 01/01/93 12/31/93 1.4129 0.9980
140192...................... 10/01/92 09/30/93 1.0694 0.9953
140202...................... 01/01/93 12/31/93 1.2811 0.9868
140203...................... 10/01/92 09/30/93 1.2195 0.9690
140206...................... 10/01/92 09/30/93 1.0507 0.9878
140207...................... 01/01/93 12/31/93 1.4058 0.9955
140208...................... 01/01/93 12/31/93 1.5200 0.9979
140209...................... 01/01/93 12/31/93 1.6340 0.9992
140211...................... 09/01/92 08/31/93 1.1900 0.9880
140212...................... 01/01/93 12/31/93 1.1730 0.9959
140217...................... 09/01/92 08/31/93 1.2439 0.9958
140220...................... 10/01/92 09/30/93 1.1770 0.9785
140233...................... 10/01/92 09/30/93 1.7202 0.9983
140236...................... 10/01/92 09/30/93 1.0024 0.9854
140240...................... 01/01/93 12/31/93 1.3935 0.9986
140252...................... 11/01/92 10/31/93 1.3562 0.9940
140258...................... 01/01/93 12/31/93 1.4282 0.9977
140271...................... 01/01/93 12/31/93 0.9901 0.9449
140280...................... 01/01/93 12/31/93 1.2417 0.9953
140281...................... 09/01/92 08/31/93 1.5815 0.9960
140285...................... 01/01/93 12/31/93 1.2650 0.9875
140288...................... 01/01/93 12/31/93 1.6552 0.9965
140289...................... 01/01/93 12/31/93 1.2742 0.9829
140291...................... 01/01/93 12/31/93 1.3370 0.9812
140292...................... 01/01/93 12/31/93 1.2059 0.9676
140294...................... 01/01/93 12/31/93 1.1473 0.9749
150001...................... 01/01/93 12/31/93 1.0434 0.9806
150002...................... 01/01/93 12/31/93 1.4049 0.9956
150003...................... 01/01/93 12/31/93 1.6940 0.9967
150004...................... 01/01/93 12/31/93 1.4887 0.9965
150005...................... 01/01/93 12/31/93 1.1912 0.9772
150006...................... 01/01/93 12/31/93 1.2169 0.9833
150007...................... 01/01/93 12/31/93 1.2363 0.9823
150008...................... 01/01/93 12/31/93 1.3292 0.9991
150009...................... 01/01/93 12/31/93 1.2706 0.9938
150010...................... 01/01/93 12/31/93 1.1525 0.9823
150013...................... 01/01/93 12/31/93 1.1662 0.9702
150014...................... 09/01/92 08/31/93 1.3837 0.9981
150015...................... 01/01/93 12/31/93 1.2502 0.9878
150017...................... 01/01/93 12/31/93 1.7697 0.9997
150018...................... 01/01/93 12/31/93 1.3025 0.9836
150020...................... 10/01/92 09/30/93 1.0935 0.9913
150021...................... 01/01/93 12/31/93 1.6339 0.9970
150022...................... 01/01/93 12/31/93 1.1312 0.9744
150023...................... 09/01/92 08/31/93 1.4019 0.9959
150024...................... 01/01/93 12/31/93 1.2413 0.9946
150026...................... 01/01/93 12/31/93 1.1969 0.9691
150027...................... 01/01/93 12/31/93 1.0322 0.9625
150029...................... 01/01/93 12/31/93 1.2912 0.9905
150030...................... 01/01/93 12/31/93 1.0935 0.9736
150031...................... 10/01/92 09/30/93 1.0914 0.9590
150033...................... 01/01/93 12/31/93 1.5849 0.9988
150034...................... 01/01/93 12/31/93 1.3023 0.9926
150035...................... 01/01/93 12/31/93 1.4228 0.9983
150036...................... 01/01/93 12/31/93 1.0226 0.9707
150037...................... 01/01/93 12/31/93 1.1957 0.9791
150038...................... 01/01/93 12/31/93 1.2139 0.9833
150039...................... 10/01/92 09/30/93 0.9116 0.9511
150042...................... 01/01/93 12/31/93 1.1979 0.9933
150044...................... 01/01/93 12/31/93 1.2643 0.9912
150045...................... 10/01/92 09/30/93 1.1682 0.9685
150046...................... 09/01/92 08/31/93 1.5496 0.9954
150047...................... 01/01/93 12/31/93 1.6979 0.9983
150048...................... 01/01/93 12/31/93 1.1690 0.9853
150049...................... 01/01/93 12/31/93 1.1411 0.9753
150050...................... 01/01/93 12/31/93 1.1582 0.9748
150051...................... 10/01/92 09/30/93 1.3424 0.9925
150052...................... 01/01/93 12/31/93 1.1083 0.9377
150053...................... 01/01/93 12/31/93 1.0186 0.9627
150054...................... 01/01/93 12/31/93 1.0499 0.9573
150057...................... 01/01/93 12/31/93 2.4033 0.9953
150058...................... 01/01/93 12/31/93 1.6169 0.9983
150059...................... 01/01/93 12/31/93 1.2215 0.9845
150060...................... 01/01/93 12/31/93 1.1232 0.9730
150061...................... 01/01/93 12/31/93 1.1855 0.9688
150062...................... 01/01/93 12/31/93 1.0357 0.9696
150063...................... 01/01/93 12/31/93 1.1019 0.9790
150064...................... 10/01/92 09/30/93 1.0632 0.9709
150065...................... 01/01/93 12/31/93 1.0943 0.9795
150066...................... 01/01/93 12/31/93 1.0257 0.9701
150067...................... 01/01/93 12/31/93 1.0959 0.9677
150069...................... 01/01/93 12/31/93 1.2250 0.9743
150070...................... 01/01/93 12/31/93 1.0001 0.9505
150071...................... 01/01/93 12/31/93 1.2005 0.9482
150072...................... 01/01/93 12/31/93 1.2055 0.9744
150073...................... 01/01/93 12/31/93 0.9571 0.9699
150074...................... 10/01/92 09/30/93 1.5558 0.9996
150075...................... 10/01/92 09/30/93 1.2025 0.9892
150078...................... 01/01/93 12/31/93 1.0864 0.9793
150079...................... 10/01/92 09/30/93 1.1015 0.9673
150086...................... 01/01/93 12/31/93 1.3036 0.9789
150090...................... 01/01/93 12/31/93 1.2819 0.9914
150091...................... 01/01/93 12/31/93 1.0737 0.9679
150092...................... 01/01/93 12/31/93 1.0280 0.9395
150094...................... 01/01/93 12/31/93 0.9955 0.9868
150095...................... 10/01/92 09/30/93 1.0839 0.9701
150096...................... 01/01/93 12/31/93 1.0470 0.9686
150097...................... 01/01/93 12/31/93 1.0966 0.9730
150098...................... 01/01/93 12/31/93 1.1611 0.9600
150101...................... 01/01/93 12/31/93 1.1371 0.9621
150102...................... 01/01/93 12/31/93 1.0153 0.9706
150104...................... 01/01/93 12/31/93 1.0699 0.9675
150105...................... 01/01/93 12/31/93 1.1759 0.9705
150106...................... 01/01/93 12/31/93 1.0527 0.9690
150109...................... 01/01/93 12/31/93 1.4059 0.9725
150111...................... 01/01/93 12/31/93 1.1608 0.9801
150112...................... 01/01/93 12/31/93 1.2131 0.9840
150113...................... 01/01/93 12/31/93 1.1580 0.9826
150114...................... 01/01/93 12/31/93 0.9890 0.9612
150122...................... 01/01/93 12/31/93 1.1182 0.9381
150123...................... 08/01/92 07/31/93 1.0380 0.9957
150124...................... 10/01/92 09/30/93 1.1259 0.9737
150127...................... 10/01/92 09/30/93 1.2022 0.9659
150128...................... 10/01/92 09/30/93 1.2209 0.9887
150129...................... 09/01/92 08/31/93 1.2318 0.9896
150132...................... 01/01/93 12/31/93 1.3650 0.9988
150133...................... 01/01/93 12/31/93 1.1785 0.9722
150134...................... 01/01/93 12/31/93 1.1312 0.9716
150136...................... 09/01/92 08/31/93 0.8467 0.9934
160001...................... 11/01/92 10/31/93 1.1894 0.9775
160002...................... 10/01/92 09/30/93 1.1645 0.9704
160003...................... 01/01/93 12/31/93 1.0305 0.9630
160008...................... 10/01/92 09/30/93 1.1467 0.9756
160044...................... 01/01/93 12/31/93 1.1540 0.9755
160045...................... 09/01/92 08/31/93 1.6701 0.9985
160047...................... 10/01/92 09/30/93 1.3707 0.9846
160072...................... 01/01/93 12/31/93 1.1353 0.9788
160082...................... 08/01/92 07/31/93 1.6784 0.9994
160092...................... 01/01/93 12/31/93 0.9724 0.9567
160099...................... 10/01/92 09/30/93 1.0425 0.9820
160104...................... 12/01/92 11/30/93 1.1878 0.9871
160110...................... 01/01/93 12/31/93 1.4623 0.9960
160111...................... 09/01/92 08/31/93 1.0316 0.9754
160122...................... 10/01/92 09/30/93 1.1663 0.9614
160129...................... 01/01/93 12/31/93 1.0179 0.9483
160130...................... 10/01/92 09/30/93 1.0460 0.9689
160131...................... 01/01/93 12/31/93 1.1464 0.9849
160133...................... 01/01/93 12/31/93 1.1511 0.9898
160138...................... 01/01/93 12/31/93 1.1225 0.9753
160147...................... 01/01/93 12/31/93 1.1641 0.9742
170001...................... 01/01/93 12/31/93 1.2268 0.9753
170004...................... 01/01/93 12/31/93 1.0697 0.9774
170006...................... 10/01/92 09/30/93 1.1820 0.9891
170008...................... 01/01/93 12/31/93 1.0576 0.9881
170012...................... 10/01/92 09/30/93 1.3788 0.9842
170014...................... 01/01/93 12/31/93 1.0555 0.9654
170017...................... 01/01/93 12/31/93 1.1765 0.9703
170018...................... 01/01/93 12/31/93 1.0218 0.9688
170019...................... 01/01/93 12/31/93 1.1438 0.9806
170022...................... 10/01/92 09/30/93 1.2274 0.9712
170023...................... 01/01/93 12/31/93 1.3875 0.9894
170024...................... 10/01/92 09/30/93 1.1883 0.9844
170026...................... 10/01/92 09/30/93 1.0150 0.9881
170027...................... 10/01/92 09/30/93 1.1866 0.9623
170031...................... 01/01/93 12/31/93 0.9008 0.9882
170032...................... 10/01/92 09/30/93 1.0352 0.9858
170033...................... 01/01/93 12/31/93 1.2619 0.9802
170034...................... 01/01/93 12/31/93 0.9618 0.9685
170035...................... 01/01/93 12/31/93 0.8747 0.9107
170036...................... 01/01/93 12/31/93 0.9076 0.9893
170038...................... 01/01/93 12/31/93 0.9483 0.9423
170039...................... 01/01/93 12/31/93 1.0812 0.9760
170041...................... 01/01/93 12/31/93 1.0414 0.9655
170043...................... 01/01/93 12/31/93 1.0088 0.9582
170049...................... 01/01/93 12/31/93 1.3082 0.9814
170050...................... 01/01/93 12/31/93 0.9680 1.0000
170054...................... 01/01/93 12/31/93 1.0697 0.9728
170055...................... 01/01/93 12/31/93 0.9956 0.9615
170060...................... 01/01/93 12/31/93 1.0761 0.9766
170062...................... 10/01/92 09/30/93 0.9398 0.9544
170063...................... 01/01/93 12/31/93 0.9285 0.9495
170064...................... 01/01/93 12/31/93 0.9789 0.9734
170066...................... 01/01/93 12/31/93 0.9071 0.8999
170068...................... 01/01/93 12/31/93 1.2458 0.9832
170070...................... 01/01/93 12/31/93 0.9890 0.9670
170073...................... 01/01/93 12/31/93 1.0730 0.9730
170075...................... 10/01/92 09/30/93 0.8338 0.9546
170076...................... 01/01/93 12/31/93 1.1032 0.9842
170077...................... 01/01/93 12/31/93 0.9425 0.9661
170079...................... 01/01/93 12/31/93 1.0316 0.9758
170080...................... 01/01/93 12/31/93 1.0366 0.9525
170081...................... 01/01/93 12/31/93 1.0118 0.9417
170082...................... 01/01/93 12/31/93 1.0558 0.9627
170086...................... 10/01/92 09/30/93 1.7032 0.9994
170087...................... 10/01/92 09/30/93 1.3935 0.9985
170090...................... 01/01/93 12/31/93 1.0208 0.9415
170092...................... 01/01/93 12/31/93 0.8006 0.9401
170094...................... 01/01/93 12/31/93 1.0673 0.9696
170097...................... 01/01/93 12/31/93 0.9947 0.9596
170098...................... 01/01/93 12/31/93 1.0396 0.9891
170099...................... 01/01/93 12/31/93 1.2450 1.0000
170101...................... 10/01/92 09/30/93 0.9597 0.9877
170102...................... 01/01/93 12/31/93 1.0193 0.9571
170104...................... 01/01/93 12/31/93 1.4367 0.9978
170106...................... 09/01/92 08/31/93 0.9259 0.9418
170108...................... 01/01/93 12/31/93 0.8880 0.9331
170109...................... 01/01/93 12/31/93 1.0585 0.9768
170110...................... 01/01/93 12/31/93 0.9466 0.9756
170112...................... 01/01/93 12/31/93 0.9179 0.9583
170113...................... 01/01/93 12/31/93 1.1512 0.9777
170114...................... 01/01/93 12/31/93 1.0603 0.9690
170116...................... 01/01/93 12/31/93 1.0909 0.9665
170117...................... 01/01/93 12/31/93 0.9802 0.9401
170119...................... 01/01/93 12/31/93 1.0084 0.9479
170120...................... 01/01/93 12/31/93 1.3223 0.9650
170121...................... 01/01/93 12/31/93 0.9169 0.9735
170122...................... 10/01/92 09/30/93 1.8156 0.9987
170123...................... 01/01/93 12/31/93 1.7336 0.9981
170124...................... 01/01/93 12/31/93 0.9575 0.9596
170126...................... 10/01/92 09/30/93 0.9147 0.9774
170128...................... 01/01/93 12/31/93 0.9661 0.9047
170131...................... 01/01/93 12/31/93 1.1335 0.9814
170134...................... 01/01/93 12/31/93 1.0307 0.9772
170137...................... 01/01/93 12/31/93 1.1369 0.9803
170139...................... 01/01/93 12/31/93 1.0898 0.9820
170143...................... 01/01/93 12/31/93 1.1408 0.9612
170144...................... 10/01/92 09/30/93 1.4733 0.9931
170145...................... 01/01/93 12/31/93 1.1990 0.9850
170146...................... 01/01/93 12/31/93 1.3529 0.9975
170147...................... 10/01/92 09/30/93 1.1322 0.9827
170148...................... 10/01/92 09/30/93 1.4019 0.9974
170150...................... 01/01/93 12/31/93 1.1050 0.9796
170151...................... 01/01/93 12/31/93 1.0078 0.9635
170152...................... 01/01/93 12/31/93 0.9657 0.9795
170160...................... 01/01/93 12/31/93 1.0041 0.9600
170164...................... 01/01/93 12/31/93 0.9596 0.9715
170166...................... 01/01/93 12/31/93 1.0524 0.9883
170168...................... 01/01/93 12/31/93 0.8824 1.0000
170172...................... 01/01/93 12/31/93 0.9648 0.9298
170174...................... 01/01/93 12/31/93 0.8689 0.9200
170175...................... 09/01/92 08/31/93 1.2882 0.9680
180001...................... 01/01/93 12/31/93 1.2013 0.9959
180004...................... 10/01/92 09/30/93 1.1783 0.9743
180009...................... 10/01/92 09/30/93 1.2786 0.9956
180010...................... 09/01/92 08/31/93 1.7993 0.9986
180011...................... 09/01/92 08/31/93 1.1957 0.9619
180014...................... 09/01/92 08/31/93 1.5098 0.9990
180015...................... 01/01/93 12/31/93 1.1233 0.9898
180016...................... 01/01/93 12/31/93 1.2661 0.9904
180017...................... 10/01/92 09/30/93 1.3010 0.9898
180019...................... 12/01/92 11/30/93 1.3053 0.9794
180025...................... 09/01/92 08/31/93 1.1002 0.9638
180026...................... 01/01/93 12/31/93 1.1669 0.9851
180030...................... 10/01/92 09/30/93 1.1342 0.9862
180031...................... 10/01/92 09/30/93 0.9958 0.9883
180035...................... 01/01/93 12/31/93 1.5246 0.9992
180036...................... 01/01/93 12/31/93 1.1703 0.9848
180037...................... 09/01/92 08/31/93 1.2557 0.9921
180040...................... 01/01/93 12/31/93 1.9360 0.9989
180041...................... 10/01/92 09/30/93 1.0426 0.9521
180043...................... 10/01/92 09/30/93 1.1205 0.9656
180044...................... 10/01/92 09/30/93 1.0432 0.9766
180045...................... 01/01/93 12/31/93 1.2014 0.9919
180048...................... 10/01/92 09/30/93 1.1443 0.9834
180051...................... 12/01/92 11/30/93 1.3077 0.9783
180058...................... 01/01/93 12/31/93 0.8935 0.9537
180059...................... 01/01/93 12/31/93 0.8767 0.9710
180060...................... 01/01/93 12/31/93 0.8393 0.6199
180063...................... 10/01/92 09/30/93 1.0500 0.9706
180064...................... 10/01/92 09/30/93 1.0977 0.9646
180072...................... 10/01/92 09/30/93 1.0733 0.9766
180078...................... 10/01/92 09/30/93 1.0779 0.9685
180079...................... 10/01/92 09/30/93 0.9802 0.9717
180080...................... 09/01/92 08/31/93 1.1098 0.9819
180081...................... 01/01/93 12/31/93 1.5286 0.9959
180085...................... 01/01/93 12/31/93 1.3367 0.9970
180088...................... 01/01/93 12/31/93 1.6403 0.9979
180093...................... 01/01/93 12/31/93 1.3668 0.9997
180094...................... 01/01/93 12/31/93 0.9417 0.9828
180095...................... 10/01/92 09/30/93 1.1227 0.9728
180099...................... 10/01/92 09/30/93 1.0729 0.9728
180102...................... 01/01/93 12/31/93 1.4441 0.9983
180103...................... 09/01/92 08/31/93 1.9696 0.9975
180104...................... 09/01/92 08/31/93 1.4520 0.9987
180106...................... 09/01/92 08/31/93 0.8987 0.9801
180115...................... 11/01/92 10/31/93 1.0922 0.9705
180116...................... 09/01/92 08/31/93 1.3719 0.9880
180120...................... 01/01/93 12/31/93 0.9597 0.9708
180121...................... 01/01/93 12/31/93 1.1363 0.9781
180124...................... 10/01/92 09/30/93 1.3515 0.9943
180126...................... 11/01/92 10/31/93 1.0153 0.9668
180127...................... 08/01/92 07/31/93 1.2277 0.9824
180130...................... 09/01/92 08/31/93 1.4180 0.9977
190002...................... 10/01/92 09/30/93 1.5678 0.9985
190003...................... 09/01/92 08/31/93 1.4229 0.9748
190004...................... 10/01/92 09/30/93 1.3257 0.9885
190013...................... 01/01/93 12/31/93 1.2651 0.9882
190014...................... 01/01/93 12/31/93 1.0681 0.9731
190018...................... 10/01/92 09/30/93 1.2854 0.9725
190025...................... 10/01/92 09/30/93 1.2403 0.9856
190026...................... 10/01/92 09/30/93 1.3921 0.9976
190034...................... 01/01/93 12/31/93 1.1939 0.9792
190039...................... 01/01/93 12/31/93 1.4730 0.9995
190040...................... 10/01/92 09/30/93 1.4215 0.9980
190044...................... 10/01/92 09/30/93 1.0829 0.9750
190046...................... 01/01/93 12/31/93 1.5033 0.9989
190049...................... 01/01/93 12/31/93 1.0118 0.9714
190050...................... 11/01/92 10/31/93 1.0946 0.9756
190053...................... 12/01/92 11/30/93 1.0586 0.9508
190054...................... 10/01/92 09/30/93 1.4413 0.9696
190059...................... 11/01/92 10/31/93 0.9524 0.9561
190060...................... 01/01/93 12/31/93 1.4417 0.9983
190065...................... 10/01/92 09/30/93 1.4856 0.9985
190077...................... 01/01/93 12/31/93 0.9310 0.9626
190078...................... 01/01/93 12/31/93 1.2825 0.9787
190079...................... 08/01/92 07/31/93 1.2513 0.9935
190083...................... 10/01/92 09/30/93 0.9042 0.9603
190088...................... 09/01/92 08/31/93 1.2481 0.9744
190089...................... 10/01/92 09/30/93 1.0469 0.9819
190095...................... 10/01/92 09/30/93 1.0271 0.9749
190103...................... 11/01/92 10/31/93 0.8556 0.9681
190109...................... 10/01/92 09/30/93 1.2015 0.9780
190111...................... 10/01/92 09/30/93 1.5617 0.9986
190113...................... 01/01/93 12/31/93 1.3109 0.9993
190115...................... 01/01/93 12/31/93 1.3003 0.9958
190116...................... 01/01/93 12/31/93 1.2292 0.9853
190118...................... 10/01/92 09/30/93 1.0439 0.9629
190120...................... 09/01/92 08/31/93 0.9145 0.9331
190127...................... 10/01/92 09/30/93 1.4300 0.9936
190128...................... 10/01/92 09/30/93 0.9131 1.0000
190130...................... 10/01/92 09/30/93 0.9996 0.9601
190131...................... 01/01/93 12/31/93 1.2978 0.9870
190134...................... 10/01/92 09/30/93 0.9885 0.9803
190135...................... 10/01/92 09/30/93 1.3917 0.9996
190136...................... 10/01/92 09/30/93 1.0509 0.9686
190142...................... 11/01/92 10/31/93 0.9707 0.9838
190144...................... 09/01/92 08/31/93 1.1478 0.9792
190145...................... 10/01/92 09/30/93 0.9373 0.9930
190146...................... 01/01/93 12/31/93 1.5698 0.9992
190147...................... 10/01/92 09/30/93 0.9831 0.9746
190149...................... 10/01/92 09/30/93 0.9744 0.9770
190151...................... 10/01/92 09/30/93 1.0885 0.9854
190160...................... 09/01/92 08/31/93 1.1447 0.9967
190162...................... 01/01/93 12/31/93 1.2312 0.9951
190167...................... 09/01/92 08/31/93 1.2631 0.9731
190175...................... 01/01/93 12/31/93 0.8972 1.0000
190177...................... 01/01/93 12/31/93 1.5220 0.9969
190178...................... 09/01/92 08/31/93 0.9770 0.9674
190184...................... 10/01/92 09/30/93 0.9820 0.9759
190185...................... 01/01/93 12/31/93 1.2561 0.9965
190186...................... 10/01/92 09/30/93 0.9017 0.9706
190187...................... 01/01/93 12/31/93 0.8581 0.9774
190189...................... 01/01/93 12/31/93 0.4742 0.8735
190190...................... 01/01/93 12/31/93 0.9721 0.9805
190191...................... 01/01/93 12/31/93 1.2381 0.9838
190193...................... 01/01/93 12/31/93 1.2671 0.9799
190194...................... 10/01/92 09/30/93 1.1245 0.9748
190197...................... 01/01/93 12/31/93 1.2877 0.9936
190200...................... 09/01/92 08/31/93 1.5276 0.9990
190201...................... 09/01/92 08/31/93 1.4347 0.9868
190202...................... 09/01/92 08/31/93 1.4769 0.9941
190203...................... 01/01/93 12/31/93 1.5417 0.9992
190205...................... 09/01/92 08/31/93 1.7737 0.9934
190206...................... 09/01/92 08/31/93 1.4321 0.9995
190207...................... 09/01/92 08/31/93 1.1983 0.9830
190208...................... 01/01/93 12/31/93 0.8247 0.9224
190211...................... 01/01/93 12/31/93 0.6060 0.9575
190213...................... 01/01/93 12/31/93 5.3328 1.0000
200001...................... 01/01/93 12/31/93 1.2774 0.9932
200006...................... 10/01/92 09/30/93 1.1658 0.9848
200007...................... 11/01/92 10/31/93 1.0220 0.9662
200009...................... 10/01/92 09/30/93 1.6692 0.9973
200017...................... 09/01/92 08/31/93 1.2738 0.9955
200018...................... 01/01/93 12/31/93 1.1588 0.9906
200021...................... 10/01/92 09/30/93 1.1373 0.9853
200025...................... 01/01/93 12/31/93 1.1708 0.9904
200026...................... 10/01/92 09/30/93 1.0485 0.9846
200027...................... 01/01/93 12/31/93 1.2471 0.9695
200028...................... 12/01/92 11/30/93 0.9616 0.9691
200031...................... 01/01/93 12/31/93 1.2693 0.9916
200032...................... 01/01/93 12/31/93 1.2540 0.9770
200033...................... 09/27/92 09/25/93 1.6698 0.9966
200034...................... 01/01/93 12/31/93 1.2208 0.9883
200041...................... 01/01/93 12/31/93 1.1833 0.9846
200043...................... 01/01/93 12/31/93 0.6249 0.9903
200052...................... 10/01/92 09/30/93 1.0205 0.9900
200055...................... 01/01/93 12/31/93 1.0726 0.9739
200062...................... 01/01/93 12/31/93 0.9534 0.9675
200066...................... 10/01/92 09/30/93 1.1910 0.9786
210006...................... 01/01/93 12/31/93 1.1125 0.9856
210011...................... 01/01/93 12/31/93 1.2705 0.9901
210046...................... 01/01/93 12/31/93 1.1298 0.9677
210049...................... 01/01/93 12/31/93 1.1280 0.9794
220001...................... 10/01/92 09/30/93 1.1847 0.9857
220002...................... 10/01/92 09/30/93 1.4344 0.9965
220003...................... 10/01/92 09/30/93 1.0773 0.9828
220004...................... 10/01/92 09/30/93 1.2344 0.9901
220006...................... 10/01/92 09/30/93 1.3043 0.9893
220008...................... 10/01/92 09/30/93 1.1496 0.9853
220010...................... 10/01/92 09/30/93 1.2177 0.9905
220012...................... 10/01/92 09/30/93 1.3111 0.9732
220015...................... 10/01/92 09/30/93 1.1865 0.9901
220016...................... 10/01/92 09/30/93 1.2529 0.9813
220017...................... 10/01/92 09/30/93 1.2584 0.9936
220019...................... 10/01/92 09/30/93 1.0791 0.9862
220020...................... 10/01/92 09/30/93 1.1750 0.9912
220021...................... 10/01/92 09/30/93 1.2664 0.9922
220023...................... 10/01/92 09/30/93 1.1631 0.9948
220024...................... 10/01/92 09/30/93 1.1751 0.9936
220025...................... 10/01/92 09/30/93 1.0964 0.9880
220026...................... 10/01/92 09/30/93 1.3788 0.9888
220028...................... 10/01/92 09/30/93 1.4017 0.9978
220029...................... 10/01/92 09/30/93 1.1421 0.9881
220030...................... 10/01/92 09/30/93 1.0916 0.9794
220031...................... 09/27/92 09/25/93 1.6523 0.9974
220033...................... 10/01/92 09/30/93 1.3330 0.9930
220035...................... 10/01/92 09/30/93 1.2150 0.9918
220036...................... 10/01/92 09/30/93 1.5936 0.9968
220038...................... 10/01/92 09/30/93 1.2409 0.9813
220042...................... 10/01/92 09/30/93 1.2687 0.9835
220045...................... 10/01/92 09/30/93 1.2562 0.9951
220046...................... 10/01/92 09/30/93 1.3798 0.9941
220048...................... 10/01/92 09/30/93 0.7353 1.0000
220049...................... 10/01/92 09/30/93 1.2306 0.9794
220050...................... 10/01/92 09/30/93 0.9597 0.9753
220051...................... 10/01/92 09/30/93 1.1952 0.9933
220052...................... 10/01/92 09/30/93 1.2007 0.9881
220053...................... 10/01/92 09/30/93 1.2856 0.9832
220055...................... 10/01/92 09/30/93 1.1976 0.9892
220057...................... 10/01/92 09/30/93 1.2912 0.9922
220058...................... 10/01/92 09/30/93 1.1249 0.9770
220060...................... 10/01/92 09/30/93 1.1434 0.9800
220062...................... 10/01/92 09/30/93 0.7216 0.9874
220063...................... 10/01/92 09/30/93 1.2084 0.9902
220064...................... 10/01/92 09/30/93 1.1970 0.9867
220065...................... 10/01/92 09/30/93 1.2448 0.9790
220066...................... 10/01/92 09/30/93 1.3006 0.9949
220067...................... 10/01/92 09/30/93 1.2468 0.9910
220068...................... 10/01/92 09/30/93 0.5923 0.9887
220070...................... 10/01/92 09/30/93 1.1605 0.9854
220071...................... 10/01/92 09/30/93 1.8220 0.9987
220073...................... 10/01/92 09/30/93 1.3085 0.9884
220074...................... 10/01/92 09/30/93 1.2420 0.9787
220075...................... 10/01/92 09/30/93 1.1746 0.9883
220076...................... 10/01/92 09/30/93 1.2116 0.9826
220077...................... 10/01/92 09/30/93 1.6498 0.9987
220079...................... 10/01/92 09/30/93 1.1464 0.9901
220080...................... 10/01/92 09/30/93 1.2230 0.9920
220081...................... 10/01/92 09/30/93 0.9662 0.9696
220082...................... 10/01/92 09/30/93 1.2112 0.9916
220084...................... 10/01/92 09/30/93 1.2142 0.9643
220086...................... 09/27/92 09/25/93 1.5724 0.9988
220088...................... 10/01/92 09/30/93 1.5477 0.9888
220089...................... 10/01/92 09/30/93 1.2473 0.9907
220090...................... 10/01/92 09/30/93 1.1875 0.9820
220092...................... 10/01/92 09/30/93 1.2704 0.9818
220094...................... 10/01/92 09/30/93 1.2235 0.9859
220095...................... 10/01/92 09/30/93 1.1885 0.9827
220097...................... 10/01/92 09/30/93 1.0484 0.9750
220098...................... 10/01/92 09/30/93 1.2236 0.9826
220099...................... 10/01/92 09/30/93 1.1621 0.9858
220100...................... 10/01/92 09/30/93 1.2430 0.9830
220101...................... 10/01/92 09/30/93 1.3982 0.9899
220102...................... 10/01/92 09/30/93 0.6305 1.0000
220104...................... 10/01/92 09/30/93 1.2353 0.9907
220105...................... 10/01/92 09/30/93 1.1450 0.9854
220106...................... 10/01/92 09/30/93 1.1355 0.9829
220107...................... 10/01/92 09/30/93 1.1133 0.9905
220108...................... 10/01/92 09/30/93 1.1529 0.9873
220110...................... 10/01/92 09/30/93 1.9831 0.9968
220111...................... 10/01/92 09/30/93 1.1966 0.9762
220116...................... 09/27/92 09/25/93 1.8075 0.9993
220118...................... 10/01/92 09/30/93 2.0766 0.9988
220119...................... 10/01/92 09/30/93 1.3325 0.9901
220120...................... 10/01/92 09/30/93 1.1828 0.9965
220123...................... 10/01/92 09/30/93 1.0257 0.9582
220126...................... 10/01/92 09/30/93 1.2285 0.9728
220128...................... 10/01/92 09/30/93 1.0833 0.9888
220135...................... 10/01/92 09/30/93 1.1576 0.9760
220156...................... 10/01/92 09/30/93 1.3047 0.9853
220171...................... 10/01/92 09/30/93 1.6778 0.9966
230003...................... 10/01/92 09/30/93 1.1351 0.9871
230007...................... 01/01/93 12/31/93 1.0475 0.9717
230012...................... 01/01/93 12/31/93 0.6678 0.9838
230013...................... 01/01/93 12/31/93 1.3410 0.9933
230014...................... 01/01/93 12/31/93 0.8897 0.9225
230015...................... 01/01/93 12/31/93 1.2185 0.9842
230017...................... 01/01/93 12/31/93 1.5244 0.9994
230020...................... 01/01/93 12/31/93 1.6400 0.9952
230021...................... 10/01/92 09/30/93 1.5763 0.9977
230022...................... 01/01/93 12/31/93 1.2896 0.9795
230040...................... 10/01/92 09/30/93 1.2454 0.9804
230042...................... 01/01/93 12/31/93 1.1462 0.9767
230043...................... 01/01/93 12/31/93 0.4818 0.9762
230053...................... 01/01/93 12/31/93 1.4729 0.9982
230055...................... 01/01/93 12/31/93 1.2027 0.9879
230056...................... 10/01/92 09/30/93 0.9529 0.9689
230063...................... 01/01/93 12/31/93 1.3529 0.9922
230065...................... 01/01/93 12/31/93 1.5134 0.9961
230071...................... 11/01/92 10/31/93 0.6167 0.9979
230076...................... 01/01/93 12/31/93 1.3137 0.9973
230078...................... 10/01/92 09/30/93 1.1495 0.9823
230080...................... 10/01/92 09/30/93 1.1798 0.9854
230087...................... 01/01/93 12/31/93 0.9959 0.9779
230089...................... 09/01/92 08/31/93 1.3512 0.9954
230096...................... 10/01/92 09/30/93 1.2437 0.9772
230101...................... 10/01/92 09/30/93 1.1119 0.9653
230103...................... 01/01/93 12/31/93 1.0108 0.9878
230104...................... 01/01/93 12/31/93 1.6217 0.9981
230105...................... 01/01/93 12/31/93 1.5885 0.9979
230107...................... 01/01/93 12/31/93 0.8731 0.9578
230110...................... 10/01/92 09/30/93 1.2649 0.9889
230114...................... 01/01/93 12/31/93 0.6498 1.0000
230115...................... 01/01/93 12/31/93 0.9760 0.9484
230118...................... 10/01/92 09/30/93 1.2737 0.9649
230119...................... 10/01/92 09/30/93 1.2364 0.9942
230121...................... 01/01/93 12/31/93 1.3072 0.9740
230122...................... 10/01/92 09/30/93 1.3009 0.9929
230125...................... 10/01/92 09/30/93 1.4049 0.9820
230128...................... 01/01/93 12/31/93 1.4204 0.9969
230129...................... 01/01/93 12/31/93 1.9582 0.9974
230130...................... 01/01/93 12/31/93 1.6450 0.9994
230134...................... 01/01/93 12/31/93 1.2139 0.9745
230135...................... 01/01/93 12/31/93 1.2738 0.9873
230137...................... 10/01/92 09/30/93 1.1502 0.9880
230141...................... 10/01/92 09/30/93 1.6084 0.9978
230142...................... 01/01/93 12/31/93 1.1769 0.9881
230143...................... 01/01/93 12/31/93 1.1728 0.9841
230144...................... 01/01/93 12/31/93 1.1783 0.9828
230145...................... 10/01/92 09/30/93 1.1690 0.9697
230146...................... 01/01/93 12/31/93 1.2918 0.9803
230149...................... 01/01/93 12/31/93 1.2449 0.9578
230151...................... 01/01/93 12/31/93 1.3534 0.9907
230155...................... 01/01/93 12/31/93 1.1572 0.9740
230167...................... 01/01/93 12/31/93 1.2130 0.9940
230169...................... 10/01/92 09/30/93 1.3441 0.9858
230171...................... 01/01/93 12/31/93 1.0580 0.9767
230175...................... 10/01/92 09/30/93 2.6575 1.0000
230176...................... 01/01/93 12/31/93 1.1940 0.9818
230184...................... 10/01/92 09/30/93 1.1275 0.9777
230186...................... 01/01/93 12/31/93 1.1192 0.9865
230190...................... 01/01/93 12/31/93 1.3386 0.9522
230191...................... 01/01/93 12/31/93 0.8775 0.9654
230193...................... 10/01/92 09/30/93 1.2672 0.9875
230194...................... 01/01/93 12/31/93 1.1651 0.9644
230195...................... 10/01/92 09/30/93 1.2963 0.9862
230197...................... 10/01/92 09/30/93 1.2684 0.9896
230204...................... 10/01/92 09/30/93 1.2856 0.9925
230205...................... 10/01/92 09/30/93 1.0832 0.9478
230208...................... 01/01/93 12/31/93 1.2252 0.9726
230211...................... 01/01/93 12/31/93 0.9921 0.9431
230213...................... 01/01/93 12/31/93 1.0421 0.9762
230216...................... 01/01/93 12/31/93 1.3452 0.9965
230217...................... 01/01/93 12/31/93 1.1336 0.9660
230223...................... 01/01/93 12/31/93 1.3363 0.9907
230227...................... 01/01/93 12/31/93 1.4427 0.9970
230228...................... 01/01/93 12/31/93 1.3167 0.9901
230230...................... 01/01/93 12/31/93 1.3509 0.9884
230235...................... 01/01/93 12/31/93 0.9343 0.9696
230236...................... 10/01/92 09/30/93 1.3266 0.9996
230237...................... 10/01/92 09/30/93 1.1151 0.9947
230239...................... 10/01/92 09/30/93 1.1803 0.9701
230244...................... 10/01/92 09/30/93 1.4492 0.9853
230253...................... 10/01/92 09/30/93 1.2354 0.9631
230254...................... 01/01/93 12/31/93 1.2244 0.9914
230259...................... 01/01/93 12/31/93 1.2010 0.9811
230269...................... 01/01/93 12/31/93 1.2254 0.9940
230270...................... 01/01/93 12/31/93 1.2425 0.9809
230273...................... 01/01/93 12/31/93 1.6591 0.9990
230276...................... 01/01/93 12/31/93 0.9342 0.9944
230277...................... 01/01/93 12/31/93 1.2276 0.9870
240001...................... 01/01/93 12/31/93 1.5247 0.9984
240003...................... 09/01/92 08/31/93 1.2232 0.9790
240004...................... 01/01/93 12/31/93 1.4388 0.9855
240006...................... 01/01/93 12/31/93 1.1071 0.9627
240007...................... 10/01/92 09/30/93 1.0696 0.9577
240008...................... 10/01/92 09/30/93 1.0377 0.9567
240010...................... 01/01/93 12/31/93 1.9604 0.9945
240011...................... 10/01/92 09/30/93 1.1065 0.9801
240013...................... 10/01/92 09/30/93 1.2215 0.9670
240014...................... 01/01/93 12/31/93 1.0700 0.9447
240016...................... 10/01/92 09/30/93 1.3929 0.9696
240018...................... 10/01/92 09/30/93 1.2090 0.9728
240019...................... 01/01/93 12/31/93 1.2947 0.9994
240020...................... 10/01/92 09/30/93 1.1820 0.9757
240021...................... 10/01/92 09/30/93 1.1335 0.9511
240022...................... 01/01/93 12/31/93 1.0848 0.9577
240023...................... 01/01/93 12/31/93 1.1045 0.9557
240025...................... 01/01/93 12/31/93 1.1706 0.9735
240027...................... 10/01/92 09/30/93 1.0193 0.9730
240028...................... 10/01/92 09/30/93 1.1021 0.9795
240029...................... 10/01/92 09/30/93 1.2072 0.9740
240030...................... 01/01/93 12/31/93 1.3503 0.9807
240031...................... 01/01/93 12/31/93 1.0285 0.9263
240038...................... 01/01/93 12/31/93 1.4854 0.9975
240041...................... 10/01/92 09/30/93 1.2725 0.9740
240043...................... 01/01/93 12/31/93 1.2232 0.9628
240045...................... 10/01/92 09/30/93 1.0138 0.9514
240047...................... 01/01/93 12/31/93 1.3857 0.9976
240048...................... 09/01/92 08/31/93 1.3038 0.9887
240050...................... 09/01/92 08/31/93 1.1469 0.9492
240051...................... 10/01/92 09/30/93 0.9263 0.9330
240052...................... 10/01/92 09/30/93 1.2131 0.9813
240053...................... 01/01/93 12/31/93 1.4890 0.9969
240056...................... 01/01/93 12/31/93 1.2676 0.9848
240058...................... 10/01/92 09/30/93 1.0014 0.9534
240059...................... 10/01/92 09/30/93 1.2157 0.9668
240061...................... 01/01/93 12/31/93 1.5889 0.9940
240063...................... 09/01/92 08/31/93 1.5326 0.9919
240064...................... 01/01/93 12/31/93 1.1658 0.9686
240065...................... 10/01/92 09/30/93 0.9523 0.9624
240066...................... 09/01/92 09/30/93 1.3626 0.9814
240069...................... 01/01/93 12/31/93 1.1535 0.9645
240071...................... 01/01/93 12/31/93 1.1366 0.9700
240072...................... 01/01/93 12/31/93 1.0440 0.9354
240073...................... 01/01/93 12/31/93 1.0083 0.9457
240076...................... 01/01/93 12/31/93 1.0925 0.9610
240078...................... 01/01/93 12/31/93 1.4016 0.9962
240079...................... 10/01/92 09/30/93 1.0462 0.9693
240080...................... 01/01/93 12/31/93 1.3989 0.9958
240082...................... 01/01/93 12/31/93 1.1828 0.9851
240083...................... 01/01/93 12/31/93 1.3415 0.9597
240084...................... 01/01/93 12/31/93 1.3799 0.9618
240085...................... 01/01/93 12/31/93 0.8955 0.9550
240086...................... 10/01/92 09/30/93 1.1710 0.9530
240087...................... 01/01/93 12/31/93 1.0765 0.9797
240088...................... 01/01/93 12/31/93 1.4722 0.9720
240090...................... 10/01/92 09/30/93 1.0895 0.9628
240091...................... 01/01/93 12/31/93 0.9828 0.9350
240093...................... 10/01/92 09/30/93 1.2779 0.9816
240094...................... 10/01/92 09/30/93 0.9767 0.9484
240096...................... 01/01/93 12/31/93 1.1305 0.9726
240097...................... 01/01/93 12/31/93 1.0910 0.9763
240098...................... 10/01/92 09/30/93 1.0135 0.9703
240100...................... 12/01/92 11/30/93 1.2730 0.9795
240102...................... 01/01/93 12/31/93 1.0488 0.9680
240103...................... 10/01/92 09/30/93 1.1250 0.9565
240105...................... 10/01/92 09/30/93 0.9282 0.9558
240106...................... 01/01/93 12/31/93 1.2197 0.9936
240107...................... 01/01/93 12/31/93 0.9093 0.9800
240108...................... 10/01/92 09/30/93 1.0243 0.9570
240109...................... 01/01/93 12/31/93 0.9307 0.9733
240111...................... 01/01/93 12/31/93 1.0282 0.9485
240112...................... 01/01/93 12/31/93 1.0339 0.9885
240114...................... 01/01/93 12/31/93 1.0300 0.9028
240115...................... 01/01/93 12/31/93 1.6475 0.9966
240116...................... 10/01/92 09/30/93 0.9114 0.9293
240117...................... 11/01/92 10/31/93 1.1158 0.9532
240119...................... 01/01/93 12/31/93 0.9083 0.9582
240121...................... 10/01/92 09/30/93 0.9012 0.9539
240122...................... 10/01/92 09/30/93 1.0913 0.9546
240123...................... 01/01/93 12/31/93 1.0234 0.9498
240124...................... 01/01/93 12/31/93 1.0606 0.9707
240127...................... 01/01/93 12/31/93 1.0061 0.9841
240128...................... 01/01/93 12/31/93 1.1426 0.9627
240130...................... 01/01/93 12/31/93 0.9529 0.9454
240132...................... 01/01/93 12/31/93 1.1894 0.9881
240133...................... 01/01/93 12/31/93 1.1246 0.9543
240135...................... 10/01/92 09/30/93 0.9478 0.9943
240138...................... 10/01/92 09/30/93 0.8781 0.9699
240139...................... 10/01/92 09/30/93 0.9635 0.9567
240140...................... 01/01/93 12/31/93 0.9138 0.9348
240141...................... 01/01/93 12/31/93 1.0246 0.9460
240142...................... 01/01/93 12/31/93 1.0423 0.9486
240143...................... 10/01/92 09/30/93 0.9227 0.9554
240144...................... 01/01/93 12/31/93 0.9547 0.9552
240146...................... 10/01/92 09/30/93 0.9767 0.9466
240148...................... 01/01/93 12/31/93 0.9088 0.9552
240150...................... 10/01/92 09/30/93 0.9295 1.0000
240152...................... 01/01/93 12/31/93 0.9754 0.9400
240153...................... 10/01/92 09/30/93 1.0222 0.9635
240154...................... 01/01/93 12/31/93 1.0074 0.9768
240155...................... 10/01/92 09/30/93 0.9662 0.9246
240157...................... 09/01/92 08/31/93 1.0315 0.9309
240161...................... 10/01/92 09/30/93 0.9934 0.9694
240162...................... 01/01/93 12/31/93 0.9867 0.9517
240163...................... 01/01/93 12/31/93 0.9341 0.9557
240166...................... 10/01/92 09/30/93 1.1512 0.9532
240169...................... 01/01/93 12/31/93 0.9553 0.9585
240170...................... 01/01/93 12/31/93 1.0703 0.9768
240172...................... 01/01/93 12/31/93 1.1111 0.9735
240173...................... 01/01/93 12/31/93 0.9845 0.9621
240179...................... 01/01/93 12/31/93 0.9853 0.9729
240180...................... 01/01/93 12/31/93 0.9140 0.9456
240184...................... 10/01/92 09/30/93 0.9985 0.9792
240187...................... 01/01/93 12/31/93 1.2825 0.9615
240192...................... 01/01/93 12/31/93 1.0835 0.9796
240193...................... 10/01/92 09/30/93 1.1249 0.9900
240196...................... 01/01/93 12/31/93 0.6006 0.9976
240200...................... 01/01/93 12/31/93 0.8504 0.8770
240207...................... 01/01/93 12/31/93 1.1868 0.9792
240210...................... 09/01/92 08/31/93 1.2920 0.9832
250002...................... 10/01/92 09/30/93 0.8115 0.9597
250003...................... 10/01/92 09/30/93 0.9249 0.9650
250004...................... 10/01/92 09/30/93 1.4356 0.9987
250005...................... 10/01/92 09/30/93 0.9891 0.9805
250007...................... 10/01/92 09/30/93 1.2262 0.9925
250008...................... 10/01/92 09/30/93 0.9914 0.9410
250009...................... 10/01/92 09/30/93 1.1391 0.9841
250010...................... 10/01/92 09/30/93 1.0673 0.9621
250015...................... 10/01/92 09/30/93 1.0511 0.9612
250018...................... 10/01/92 09/30/93 0.9044 0.9900
250019...................... 10/01/92 09/30/93 1.3892 0.9973
250020...................... 10/01/92 09/30/93 0.9700 0.9571
250021...................... 10/01/92 09/30/93 0.9405 0.9169
250023...................... 01/01/93 12/31/93 0.8434 0.9634
250024...................... 10/01/92 09/30/93 1.0274 0.9549
250025...................... 10/01/92 09/30/93 1.0165 0.9612
250027...................... 10/01/92 09/30/93 1.0457 0.9437
250029...................... 01/01/93 12/31/93 0.9426 0.9495
250030...................... 01/01/93 12/31/93 0.9985 0.9567
250035...................... 10/01/92 09/30/93 0.8637 0.9585
250036...................... 10/01/92 09/30/93 0.9948 0.9593
250037...................... 10/01/92 09/30/93 0.8926 0.9569
250038...................... 10/01/92 09/30/93 0.9992 0.9701
250039...................... 10/01/92 09/30/93 0.9749 0.9684
250040...................... 10/01/92 09/30/93 1.3054 0.9909
250042...................... 10/01/92 09/30/93 1.1621 0.9808
250043...................... 10/01/92 09/30/93 0.8795 0.9434
250045...................... 10/01/92 09/30/93 1.1894 0.9586
250047...................... 10/01/92 09/30/93 0.9733 0.9610
250048...................... 01/01/93 12/31/93 1.4279 0.9987
250049...................... 10/01/92 09/30/93 0.9192 0.9814
250050...................... 10/01/92 09/30/93 1.2378 0.9828
250051...................... 10/01/92 09/30/93 0.9019 0.9700
250057...................... 10/01/92 09/30/93 1.1381 0.9694
250058...................... 10/01/92 09/30/93 1.1707 0.9880
250059...................... 10/01/92 09/30/93 1.0218 0.9529
250060...................... 10/01/92 09/30/93 0.8038 0.9701
250061...................... 10/01/92 09/30/93 0.8702 0.9876
250063...................... 10/01/92 09/30/93 0.8589 0.9604
250065...................... 10/01/92 09/30/93 0.8975 0.9768
250066...................... 10/01/92 09/30/93 0.9681 0.9740
250067...................... 10/01/92 09/30/93 0.9652 0.9756
250068...................... 10/01/92 09/30/93 0.8931 0.9620
250069...................... 01/01/93 12/31/93 1.2353 0.9961
250071...................... 10/01/92 09/30/93 1.0498 0.9620
250072...................... 01/01/93 12/31/93 1.3433 0.9948
250076...................... 10/01/92 09/30/93 0.9524 0.9366
250077...................... 10/01/92 09/30/93 0.9294 0.9768
250078...................... 10/01/92 09/30/93 1.3944 0.9981
250079...................... 10/01/92 09/30/93 0.8712 0.9527
250081...................... 10/01/92 09/30/93 1.2175 0.9966
250082...................... 10/01/92 09/30/93 1.2190 0.9925
250083...................... 01/01/93 12/31/93 0.9690 0.9766
250084...................... 10/01/92 09/30/93 1.1229 0.9965
250085...................... 10/01/92 09/30/93 1.0480 0.9700
250086...................... 10/01/92 09/30/93 0.9588 0.8833
250088...................... 10/01/92 09/30/93 0.9833 0.9583
250089...................... 01/01/93 12/31/93 1.0563 0.9892
250093...................... 10/01/92 09/30/93 1.1483 0.9859
250095...................... 10/01/92 09/30/93 1.0351 0.9835
250096...................... 10/01/92 09/30/93 1.1164 0.9907
250097...................... 10/01/92 09/30/93 1.2123 0.9787
250098...................... 10/01/92 09/30/93 0.8663 0.9638
250099...................... 10/01/92 09/30/93 1.2529 0.9839
250100...................... 10/01/92 09/30/93 1.2450 0.9870
250101...................... 10/01/92 09/30/93 0.8787 0.9757
250104...................... 10/01/92 09/30/93 1.3333 0.9988
250105...................... 10/01/92 09/30/93 0.8909 0.9545
250107...................... 10/01/92 09/30/93 0.9495 0.9745
250109...................... 10/01/92 09/30/93 0.9585 0.9612
250112...................... 10/01/92 09/30/93 0.9542 0.9486
250117...................... 01/01/93 12/31/93 1.0534 0.9632
250119...................... 10/01/92 09/30/93 1.0904 0.9694
250120...................... 10/01/92 09/30/93 0.9979 0.9862
250122...................... 09/01/92 08/31/93 1.2097 0.9939
250124...................... 01/01/93 12/31/93 0.8952 0.9762
250125...................... 01/01/93 12/31/93 1.3094 0.9869
250131...................... 01/01/93 12/31/93 1.0301 0.9704
250136...................... 01/01/93 12/31/93 0.8105 1.0000
250140...................... 10/01/92 09/30/93 0.9054 0.9893
260003...................... 09/01/92 08/31/93 1.0188 0.9625
260004...................... 01/01/93 12/31/93 1.0429 0.9842
260005...................... 01/01/93 12/31/93 1.5596 0.9747
260011...................... 01/01/93 12/31/93 1.5829 0.9959
260012...................... 10/01/92 10/31/93 1.0807 0.9669
260014...................... 01/01/93 12/31/93 1.7307 0.9988
260015...................... 01/01/93 12/31/93 1.1876 0.9559
260017...................... 01/01/93 12/31/93 1.2216 0.9752
260018...................... 10/01/92 09/30/93 0.9459 0.9523
260019...................... 01/01/93 12/31/93 1.0602 0.9611
260021...................... 10/01/92 09/30/93 1.4496 0.9958
260023...................... 10/01/92 09/30/93 1.2373 0.9898
260024...................... 12/01/92 11/30/93 1.0361 0.9810
260025...................... 10/01/92 09/30/93 1.2413 0.9814
260027...................... 01/01/93 12/31/93 1.5856 0.9990
260029...................... 10/01/92 09/30/93 1.1960 0.9707
260030...................... 10/01/92 09/30/93 1.1694 0.9684
260031...................... 01/01/93 12/31/93 1.4977 0.9992
260032...................... 01/01/93 12/31/93 1.6378 0.9975
260034...................... 01/01/93 12/31/93 1.0071 0.9650
260035...................... 12/01/92 11/30/93 1.0866 0.9745
260036...................... 01/01/93 12/31/93 1.0771 0.9650
260039...................... 09/01/92 08/31/93 1.2078 0.9774
260040...................... 10/01/92 09/30/93 1.4935 0.9986
260044...................... 01/01/93 12/31/93 1.0825 0.9766
260047...................... 10/01/92 09/30/93 1.2892 0.9903
260050...................... 01/01/93 12/31/93 1.1236 0.9666
260053...................... 10/01/92 09/30/93 1.1332 0.9929
260054...................... 01/01/93 12/31/93 1.2744 0.9931
260057...................... 10/01/92 09/30/93 1.2139 0.9756
260062...................... 01/01/93 12/31/93 1.1922 0.9866
260063...................... 01/01/93 12/31/93 1.1379 0.9604
260064...................... 01/01/93 12/31/93 1.3724 0.9843
260068...................... 01/01/93 12/31/93 1.7650 0.9991
260070...................... 01/01/93 12/31/93 1.2671 0.9222
260073...................... 01/01/93 12/31/93 1.0478 0.9814
260074...................... 01/01/93 12/31/93 1.2061 0.9651
260078...................... 01/01/93 12/31/93 1.1163 0.9725
260080...................... 09/01/92 08/31/93 1.0641 0.9332
260089...................... 01/01/93 12/31/93 1.0112 0.9936
260091...................... 01/01/93 12/31/93 1.6333 0.9982
260092...................... 01/01/93 12/31/93 1.0357 0.9422
260097...................... 10/01/92 09/30/93 1.1333 0.9630
260100...................... 10/01/92 09/30/93 1.0482 0.9549
260102...................... 01/01/93 12/31/93 1.0949 0.9733
260103...................... 01/01/93 12/31/93 1.3779 0.9933
260107...................... 01/01/93 12/31/93 1.4071 0.9984
260110...................... 01/01/93 12/31/93 1.6000 0.9962
260113...................... 10/01/92 09/30/93 1.1617 0.9868
260116...................... 01/01/93 12/31/93 1.1483 0.9891
260119...................... 01/01/93 12/31/93 1.2329 0.9797
260120...................... 12/01/92 11/30/93 1.2443 0.9694
260122...................... 11/01/92 10/31/93 1.1865 0.9682
260123...................... 01/01/93 12/31/93 1.0381 0.9786
260134...................... 01/01/93 12/31/93 1.2447 0.9695
260138...................... 01/01/93 12/31/93 1.8623 0.9989
260148...................... 11/01/92 10/31/93 0.9853 0.9646
260158...................... 01/01/93 12/31/93 1.1132 0.9801
260159...................... 01/01/93 12/31/93 1.2136 0.9671
260160...................... 01/01/93 12/31/93 1.1338 0.9750
260162...................... 01/01/93 12/31/93 1.1511 0.9750
260166...................... 01/01/93 12/31/93 1.2129 0.9834
260176...................... 10/01/92 09/30/93 1.5583 0.9976
260178...................... 01/01/93 12/31/93 1.5136 0.9962
260179...................... 01/01/93 12/31/93 1.5216 0.9988
260180...................... 01/01/93 12/31/93 1.5886 0.9976
260188...................... 01/01/93 12/31/93 1.3886 0.9825
260190...................... 01/01/93 12/31/93 1.2047 0.9860
260191...................... 01/01/93 12/31/93 1.2010 0.9794
260193...................... 01/01/93 12/31/93 1.2639 0.9645
260195...................... 09/25/92 09/30/93 1.1455 0.9858
260198...................... 01/01/93 12/31/93 1.2514 0.9871
260200...................... 01/01/93 12/31/93 1.1825 0.9712
270002...................... 10/01/92 09/30/93 1.1974 0.9797
270006...................... 10/01/92 09/30/93 0.9936 1.0000
270007...................... 10/01/92 09/30/93 0.9365 0.9776
270013...................... 01/01/93 12/31/93 1.2805 0.9929
270019...................... 01/01/93 12/31/93 0.9766 0.9767
270021...................... 10/01/92 09/30/93 1.1272 0.9854
270033...................... 01/01/93 12/31/93 0.9279 0.9817
270039...................... 01/01/93 12/31/93 0.9478 0.9790
270048...................... 11/01/92 10/31/93 1.0678 0.9688
270057...................... 01/01/93 12/31/93 1.1725 0.9778
270059...................... 11/01/92 10/31/93 0.8529 0.9620
270063...................... 10/01/92 09/30/93 0.8679 0.9383
270083...................... 01/01/93 12/31/93 1.0133 0.9245
270084...................... 01/01/93 12/31/93 0.9094 0.9392
280001...................... 10/01/92 09/30/93 1.0435 0.9578
280005...................... 09/01/92 08/31/93 1.4358 0.9919
280012...................... 01/01/93 12/31/93 1.2119 0.9793
280015...................... 10/01/92 09/30/93 1.0988 0.9663
280017...................... 08/01/92 07/31/93 1.1135 0.9651
280025...................... 09/01/92 08/31/93 1.0221 0.9607
280030...................... 09/01/92 08/31/93 1.8653 0.9992
280031...................... 10/01/92 09/30/93 1.0504 0.9754
280032...................... 01/01/93 12/31/93 1.2422 0.9848
280038...................... 10/01/92 09/30/93 1.0935 0.9739
280039...................... 10/01/92 09/30/93 1.1519 0.9703
280040...................... 01/01/93 12/31/93 1.5815 0.9976
280041...................... 01/01/93 12/31/93 1.0135 0.9827
280046...................... 01/01/93 12/31/93 1.0352 0.9755
280047...................... 01/01/93 12/31/93 1.0863 0.9682
280048...................... 10/01/92 09/30/93 1.0501 0.9951
280054...................... 10/01/92 09/30/93 1.2418 0.9683
280057...................... 10/01/92 09/30/93 1.0036 0.9628
280058...................... 10/01/92 09/30/93 1.2692 0.9609
280061...................... 01/01/93 12/31/93 1.3800 0.9857
280065...................... 01/01/93 12/31/93 1.2418 0.9843
280074...................... 10/01/92 09/30/93 1.0865 0.9517
280076...................... 08/01/92 07/31/93 1.0690 0.9674
280079...................... 08/01/92 07/31/93 1.0206 0.9505
280081...................... 10/01/92 09/30/93 1.4825 0.9966
280083...................... 11/01/92 10/31/93 1.0274 0.9608
280085...................... 01/01/93 12/31/93 0.7308 0.9156
280088...................... 09/21/92 09/19/93 1.6797 0.9996
280089...................... 10/01/92 09/30/93 1.0480 0.9849
280101...................... 10/01/92 09/30/93 1.1423 0.9719
280102...................... 01/01/93 12/31/93 0.9800 0.9422
280106...................... 08/01/92 07/31/93 1.0414 0.9934
280107...................... 11/01/92 10/31/93 1.0248 0.9501
280108...................... 01/01/93 12/31/93 1.0895 0.9875
280109...................... 08/01/92 07/31/93 0.8698 0.9725
280114...................... 08/01/92 07/31/93 0.9779 0.9786
280115...................... 01/01/93 12/31/93 1.0278 0.9723
290005...................... 09/01/92 08/31/93 1.2468 0.9949
290006...................... 01/01/93 12/31/93 1.0345 0.9616
290009...................... 01/01/93 12/31/93 1.4954 0.9974
290010...................... 01/01/93 12/31/93 1.1698 0.9837
290018...................... 01/01/93 12/31/93 1.2225 1.0000
290021...................... 01/01/93 12/31/93 1.5628 0.9982
290022...................... 10/01/92 09/30/93 1.5905 0.9994
290032...................... 01/01/93 12/31/93 1.3820 0.9837
300001...................... 10/01/92 09/30/93 1.3449 0.9947
300005...................... 10/01/92 09/30/93 1.2758 0.9863
300006...................... 10/01/92 09/30/93 1.1356 0.9714
300007...................... 10/01/92 09/30/93 1.1491 0.9675
300008...................... 10/01/92 09/30/93 1.2686 0.9801
300009...................... 10/01/92 09/30/93 1.1578 0.9560
300011...................... 01/01/93 12/31/93 1.2868 0.9904
300012...................... 10/01/92 09/30/93 1.2868 0.9850
300013...................... 10/01/92 09/30/93 1.2088 0.9837
300014...................... 10/01/92 09/30/93 1.2562 0.9899
300016...................... 10/01/92 09/30/93 1.2416 0.9884
300017...................... 07/31/92 07/31/93 1.1895 0.9810
300018...................... 01/01/93 12/31/93 1.2283 0.9925
300020...................... 10/01/92 09/30/93 1.2375 0.9930
300021...................... 10/01/92 09/30/93 1.1571 0.9834
300022...................... 01/01/93 12/31/93 1.1281 0.9643
300023...................... 10/01/92 09/30/93 1.2309 0.9880
300024...................... 10/01/92 09/30/93 1.2281 0.9739
300028...................... 10/01/92 09/30/93 1.2007 0.9737
300033...................... 10/01/92 09/30/93 1.0753 0.9760
310001...................... 01/01/93 12/31/93 1.6601 0.9984
310002...................... 01/01/93 12/31/93 1.7188 0.9983
310003...................... 01/01/93 12/31/93 1.1961 0.9939
310005...................... 01/01/93 12/31/93 1.1841 0.9864
310006...................... 01/01/93 12/31/93 1.2077 0.9952
310008...................... 01/01/93 12/31/93 1.3034 0.9950
310009...................... 01/01/93 12/31/93 1.1636 0.9964
310010...................... 01/01/93 12/31/93 1.2862 0.9898
310011...................... 01/01/93 12/31/93 1.2502 0.9833
310012...................... 01/01/93 12/31/93 1.5408 0.9992
310013...................... 01/01/93 12/31/93 1.3042 0.9971
310014...................... 01/01/93 12/31/93 1.6315 0.9978
310015...................... 01/01/93 12/31/93 1.7433 0.9990
310016...................... 01/01/93 12/31/93 1.2310 0.9954
310017...................... 01/01/93 12/31/93 1.3350 0.9930
310018...................... 01/01/93 12/31/93 1.2533 0.9936
310019...................... 01/01/93 12/31/93 1.6570 0.9981
310020...................... 01/01/93 12/31/93 1.2237 0.9973
310021...................... 01/01/93 12/31/93 1.3234 0.9919
310022...................... 01/01/93 12/31/93 1.2308 0.9936
310024...................... 01/01/93 12/31/93 1.2379 0.9912
310025...................... 01/01/93 12/31/93 1.2022 0.9898
310026...................... 01/01/93 12/31/93 1.2887 0.9959
310027...................... 01/01/93 12/31/93 1.3380 0.9958
310028...................... 01/01/93 12/31/93 1.1493 0.9859
310029...................... 01/01/93 12/31/93 1.8047 0.9967
310031...................... 01/01/93 12/31/93 2.5969 0.9979
310032...................... 01/01/93 12/31/93 1.2714 0.9856
310034...................... 01/01/93 12/31/93 1.2142 0.9933
310036...................... 01/01/93 12/31/93 1.2142 0.9909
310037...................... 01/01/93 12/31/93 1.2005 0.9927
310038...................... 01/01/93 12/31/93 1.7473 0.9978
310039...................... 01/01/93 12/31/93 1.2975 0.9948
310040...................... 01/01/93 12/31/93 1.2419 0.9970
310041...................... 01/01/93 12/31/93 1.2794 0.9937
310042...................... 01/01/93 12/31/93 1.1522 0.9916
310043...................... 01/01/93 12/31/93 1.2056 0.9950
310044...................... 01/01/93 12/31/93 1.3228 0.9894
310045...................... 01/01/93 12/31/93 1.2937 0.9982
310047...................... 01/01/93 12/31/93 1.2872 0.9868
310048...................... 01/01/93 12/31/93 1.2281 0.9931
310049...................... 01/01/93 12/31/93 1.2820 0.9961
310050...................... 10/01/92 09/30/93 1.1860 0.9931
310051...................... 01/01/93 12/31/93 1.2962 0.9970
310052...................... 01/01/93 12/31/93 1.2071 0.9930
310054...................... 01/01/93 12/31/93 1.2667 0.9949
310056...................... 01/01/93 12/31/93 1.1637 0.9800
310057...................... 01/01/93 12/31/93 1.2793 0.9925
310058...................... 01/01/93 12/31/93 1.1206 0.9980
310060...................... 01/01/93 12/31/93 1.1934 0.9922
310061...................... 01/01/93 12/31/93 1.1447 0.9901
310062...................... 01/01/93 12/31/93 1.2960 0.9975
310063...................... 01/01/93 12/31/93 1.3259 0.9939
310064...................... 01/01/93 12/31/93 1.2609 0.9900
310067...................... 01/01/93 12/31/93 1.2945 0.9919
310069...................... 01/01/93 12/31/93 1.1915 0.9850
310070...................... 01/01/93 12/31/93 1.3425 0.9951
310072...................... 01/01/93 12/31/93 1.2493 0.9862
310073...................... 01/01/93 12/31/93 1.4596 0.9968
310074...................... 01/01/93 12/31/93 1.2697 0.9943
310075...................... 01/01/93 12/31/93 1.2891 0.9948
310076...................... 01/01/93 12/31/93 1.3475 0.9973
310077...................... 01/01/93 12/31/93 1.5392 0.9983
310078...................... 01/01/93 12/31/93 1.2881 0.9978
310081...................... 01/01/93 12/31/93 1.2380 0.9894
310083...................... 01/01/93 12/31/93 1.2318 0.9960
310084...................... 01/01/93 12/31/93 1.2048 0.9917
310086...................... 01/01/93 12/31/93 1.2036 0.9916
310087...................... 01/01/93 12/31/93 1.2429 0.9864
310088...................... 01/01/93 12/31/93 1.1668 0.9823
310090...................... 01/01/93 12/31/93 1.2515 0.9927
310091...................... 01/01/93 12/31/93 1.2144 0.9854
310092...................... 01/01/93 12/31/93 1.3798 0.9947
310093...................... 01/01/93 12/31/93 1.1664 0.9924
310096...................... 01/01/93 12/31/93 1.8903 0.9985
310105...................... 01/01/93 12/31/93 1.3134 0.9921
310108...................... 01/01/93 12/31/93 1.3022 0.9958
310110...................... 01/01/93 12/31/93 1.1705 0.9910
310111...................... 01/01/93 12/31/93 1.2918 0.9911
310112...................... 01/01/93 12/31/93 1.2939 0.9960
310113...................... 01/01/93 12/31/93 1.2355 0.9846
310115...................... 01/01/93 12/31/93 1.2001 0.9962
310116...................... 01/01/93 12/31/93 1.2624 0.9931
310118...................... 10/01/92 09/30/93 1.2920 0.9896
310120...................... 01/01/93 12/31/93 1.0780 0.9907
310121...................... 01/01/93 12/31/93 1.0903 0.9480
320019...................... 09/01/92 08/31/93 1.3963 0.9994
320033...................... 01/01/93 12/31/93 1.0754 0.9854
320035...................... 01/01/93 12/31/93 1.3095 0.9681
320038...................... 09/01/92 08/31/93 1.2472 0.9754
320048...................... 01/01/93 12/31/93 1.2727 0.9897
320063...................... 09/01/92 08/31/93 1.2869 0.9768
330001...................... 01/01/93 12/31/93 1.1894 0.9870
330002...................... 01/01/93 12/31/93 1.4559 0.9965
330003...................... 01/01/93 12/31/93 1.3073 0.9958
330004...................... 01/01/93 12/31/93 1.2743 0.9926
330005...................... 01/01/93 12/31/93 1.7434 0.9988
330006...................... 01/01/93 12/31/93 1.3305 0.9956
330007...................... 01/01/93 12/31/93 1.3963 0.9940
330008...................... 01/01/93 12/31/93 1.1339 0.9902
330009...................... 01/01/93 12/31/93 1.2621 0.9980
330010...................... 01/01/93 12/31/93 1.2285 0.9846
330011...................... 01/01/93 12/31/93 1.2189 0.9918
330012...................... 01/01/93 12/31/93 1.5956 0.9966
330013...................... 01/01/93 12/31/93 2.0024 0.9973
330014...................... 01/01/93 12/31/93 1.3963 0.9887
330016...................... 01/01/93 12/31/93 1.0095 0.9831
330019...................... 01/01/93 12/31/93 1.2534 0.9943
330020...................... 01/01/93 12/31/93 1.0814 0.9808
330023...................... 01/01/93 12/31/93 1.2102 0.9881
330024...................... 01/01/93 12/31/93 1.8149 0.9992
330025...................... 01/01/93 12/31/93 1.1072 0.9938
330027...................... 01/01/93 12/31/93 1.5291 0.9891
330028...................... 01/01/93 12/31/93 1.3393 0.9945
330029...................... 01/01/93 12/31/93 1.1169 0.9906
330030...................... 01/01/93 12/31/93 1.1617 0.9868
330033...................... 01/01/93 12/31/93 1.1867 0.9702
330034...................... 01/01/93 12/31/93 0.9912 0.9859
330036...................... 01/01/93 12/31/93 1.2903 0.9922
330037...................... 01/01/93 12/31/93 1.1241 0.9882
330038...................... 01/01/93 12/31/93 1.1873 0.9851
330039...................... 01/01/93 12/31/93 0.8384 0.9778
330041...................... 01/01/93 12/31/93 1.3294 0.9964
330043...................... 01/01/93 12/31/93 1.2433 0.9932
330044...................... 01/01/93 12/31/93 1.1762 0.9940
330045...................... 01/01/93 12/31/93 1.3898 0.9915
330046...................... 01/01/93 12/31/93 1.5243 0.9986
330047...................... 01/01/93 12/31/93 1.2286 0.9917
330048...................... 01/01/93 12/31/93 1.2814 0.9904
330049...................... 01/01/93 12/31/93 1.2592 0.9824
330053...................... 01/01/93 12/31/93 1.1449 0.9860
330055...................... 01/01/93 12/31/93 1.4212 0.9904
330056...................... 01/01/93 12/31/93 1.4030 0.9963
330057...................... 01/01/93 12/31/93 1.6012 0.9987
330058...................... 01/01/93 12/31/93 1.2728 0.9941
330059...................... 01/01/93 12/31/93 1.5704 0.9985
330061...................... 01/01/93 12/31/93 1.3280 0.9943
330062...................... 01/01/93 12/31/93 1.0201 0.9764
330064...................... 01/01/93 12/31/93 1.4153 0.9945
330065...................... 01/01/93 12/31/93 1.2079 0.9914
330066...................... 01/01/93 12/31/93 1.2260 0.9960
330067...................... 01/01/93 12/31/93 1.3175 0.9881
330072...................... 01/01/93 12/31/93 1.3479 0.9960
330073...................... 01/01/93 12/31/93 1.2028 0.9842
330074...................... 01/01/93 12/31/93 1.2323 0.9879
330075...................... 01/01/93 12/31/93 1.0670 0.9872
330078...................... 01/01/93 12/31/93 1.3908 0.9975
330079...................... 01/01/93 12/31/93 1.2888 0.9935
330082...................... 01/01/93 12/31/93 1.2319 0.9936
330084...................... 01/01/93 12/31/93 0.9486 0.9680
330085...................... 01/01/93 12/31/93 1.3435 0.9899
330086...................... 01/01/93 12/31/93 1.2299 0.9966
330088...................... 01/01/93 12/31/93 1.0911 0.9742
330090...................... 01/01/93 12/31/93 1.5912 0.9961
330091...................... 01/01/93 12/31/93 1.3674 0.9957
330092...................... 01/01/93 12/31/93 0.9944 0.9762
330094...................... 01/01/93 12/31/93 1.1908 0.9873
330095...................... 01/01/93 12/31/93 1.2007 0.9964
330096...................... 01/01/93 12/31/93 1.0627 0.9837
330097...................... 01/01/93 12/31/93 1.1617 0.9864
330100...................... 01/01/93 12/31/93 0.6958 0.9974
330101...................... 01/01/93 12/31/93 1.7564 0.9985
330102...................... 01/01/93 12/31/93 1.2866 0.9975
330103...................... 01/01/93 12/31/93 1.2142 0.9759
330104...................... 01/01/93 12/31/93 1.3804 0.9931
330106...................... 01/01/93 12/31/93 1.5648 0.9989
330107...................... 01/01/93 12/31/93 1.1988 0.9764
330108...................... 01/01/93 12/31/93 1.1914 0.9949
330111...................... 01/01/93 12/31/93 1.1351 0.9786
330114...................... 01/01/93 12/31/93 0.9654 0.9770
330115...................... 01/01/93 12/31/93 1.2261 0.9777
330118...................... 01/01/93 12/31/93 1.5846 0.9966
330119...................... 01/01/93 12/31/93 1.7654 0.9989
330121...................... 01/01/93 12/31/93 1.0023 0.9681
330122...................... 01/01/93 12/31/93 1.2258 0.9954
330125...................... 01/01/93 12/31/93 1.7087 0.9985
330126...................... 01/01/93 12/31/93 1.2031 0.9902
330132...................... 01/01/93 12/31/93 1.0897 0.9743
330133...................... 01/01/93 12/31/93 1.3627 0.9965
330135...................... 01/01/93 12/31/93 1.2331 0.9799
330136...................... 01/01/93 12/31/93 1.2828 0.9924
330140...................... 01/01/93 12/31/93 1.6770 0.9993
330141...................... 01/01/93 12/31/93 1.3075 0.9945
330144...................... 01/01/93 12/31/93 1.0658 0.9852
330148...................... 01/01/93 12/31/93 0.9870 0.9644
330151...................... 01/01/93 12/31/93 1.0803 0.9791
330152...................... 01/01/93 12/31/93 1.3840 0.9959
330153...................... 01/01/93 12/31/93 1.6352 0.9987
330157...................... 01/01/93 12/31/93 1.2567 0.9929
330158...................... 01/01/93 12/31/93 1.3014 0.9959
330159...................... 01/01/93 12/31/93 1.3249 0.9937
330160...................... 01/01/93 12/31/93 1.4099 0.9967
330161...................... 01/01/93 12/31/93 0.9059 0.9927
330162...................... 01/01/93 12/31/93 1.2970 0.9906
330163...................... 01/01/93 12/31/93 1.1479 0.9898
330164...................... 01/01/93 12/31/93 1.3437 0.9929
330166...................... 01/01/93 12/31/93 0.9855 0.9524
330167...................... 01/01/93 12/31/93 1.5754 0.9978
330169...................... 01/01/93 12/31/93 1.4175 0.9980
330171...................... 01/01/93 12/31/93 1.3259 0.9901
330175...................... 01/01/93 12/31/93 1.0948 0.9949
330177...................... 01/01/93 12/31/93 1.0171 0.9691
330179...................... 01/01/93 12/31/93 0.8781 0.9674
330180...................... 01/01/93 12/31/93 1.2009 0.9943
330181...................... 01/01/93 12/31/93 1.2403 0.9904
330182...................... 01/01/93 12/31/93 2.3782 0.9979
330183...................... 01/01/93 12/31/93 1.3794 0.9922
330184...................... 01/01/93 12/31/93 1.3702 0.9896
330185...................... 01/01/93 12/31/93 1.1881 0.9878
330186...................... 01/01/93 12/31/93 1.0021 0.9908
330188...................... 01/01/93 12/31/93 1.2072 0.9945
330189...................... 01/01/93 12/31/93 0.8028 0.9907
330191...................... 01/01/93 12/31/93 1.3034 0.9961
330193...................... 01/01/93 12/31/93 1.3739 0.9952
330194...................... 01/01/93 12/31/93 1.8101 0.9987
330195...................... 01/01/93 12/31/93 1.5801 0.9980
330197...................... 01/01/93 12/31/93 1.0444 0.9960
330198...................... 01/01/93 12/31/93 1.3225 0.9950
330201...................... 01/01/93 12/31/93 1.4601 0.9987
330203...................... 01/01/93 12/31/93 1.3416 0.9981
330205...................... 01/01/93 12/31/93 1.1914 0.9786
330208...................... 01/01/93 12/31/93 1.2131 0.9927
330209...................... 01/01/93 12/31/93 1.2105 0.9869
330211...................... 01/01/93 12/31/93 1.2504 0.9866
330212...................... 01/01/93 12/31/93 1.2120 0.9969
330213...................... 01/01/93 12/31/93 1.1238 0.9714
330214...................... 01/01/93 12/31/93 1.7401 0.9999
330215...................... 01/01/93 12/31/93 1.1501 0.9920
330218...................... 01/01/93 12/31/93 1.2029 0.9913
330219...................... 01/01/93 12/31/93 1.6567 0.9974
330221...................... 01/01/93 12/31/93 1.3191 0.9964
330222...................... 01/01/93 12/31/93 1.2196 0.9826
330223...................... 01/01/93 12/31/93 1.0789 0.9692
330224...................... 01/01/93 12/31/93 1.3020 0.9898
330225...................... 01/01/93 12/31/93 1.1726 0.9946
330226...................... 01/01/93 12/31/93 1.2814 0.9900
330229...................... 01/01/93 12/31/93 1.3639 0.9846
330230...................... 01/01/93 12/31/93 1.5616 0.9950
330232...................... 01/01/93 12/31/93 1.2514 0.9947
330233...................... 01/01/93 12/31/93 1.5212 0.9960
330235...................... 01/01/93 12/31/93 1.1352 0.9966
330236...................... 01/01/93 12/31/93 1.3332 0.9947
330238...................... 01/01/93 12/31/93 1.1025 0.9828
330239...................... 01/01/93 12/31/93 1.2427 0.9951
330241...................... 01/01/93 12/31/93 1.8532 0.9977
330242...................... 01/01/93 12/31/93 1.3939 0.9956
330245...................... 01/01/93 12/31/93 1.2160 0.9868
330246...................... 01/01/93 12/31/93 1.2319 0.9946
330247...................... 01/01/93 12/31/93 0.7018 0.9952
330249...................... 01/01/93 12/31/93 1.1765 0.9836
330250...................... 01/01/93 12/31/93 1.2628 0.9933
330252...................... 01/01/93 12/31/93 0.9389 0.9233
330254...................... 01/01/93 12/31/93 0.9941 0.9823
330258...................... 01/01/93 12/31/93 1.3795 0.9914
330259...................... 01/01/93 12/31/93 1.4018 0.9905
330261...................... 01/01/93 12/31/93 1.2622 0.9924
330263...................... 01/01/93 12/31/93 1.0248 0.9738
330264...................... 01/01/93 12/31/93 1.1798 0.9870
330265...................... 01/01/93 12/31/93 1.2755 0.9958
330267...................... 01/01/93 12/31/93 1.3114 0.9922
330268...................... 01/01/93 12/31/93 1.0965 0.9423
330270...................... 01/01/93 12/31/93 1.9337 0.9944
330273...................... 01/01/93 12/31/93 1.3635 0.9896
330275...................... 01/01/93 12/31/93 1.2271 0.9969
330276...................... 01/01/93 12/31/93 1.2167 0.9835
330277...................... 01/01/93 12/31/93 1.1664 0.9762
330279...................... 01/01/93 12/31/93 1.3076 0.9967
330281...................... 01/01/93 12/31/93 0.5646 0.9970
330285...................... 01/01/93 12/31/93 1.7124 0.9976
330286...................... 01/01/93 12/31/93 1.3459 0.9927
330288...................... 01/01/93 12/31/93 1.0464 0.9769
330290...................... 01/01/93 12/31/93 1.6767 0.9993
330293...................... 01/01/93 12/31/93 1.1766 0.9835
330304...................... 01/01/93 12/31/93 1.2789 0.9911
330306...................... 01/01/93 12/31/93 1.4296 0.9943
330307...................... 01/01/93 12/31/93 1.2056 0.9862
330309...................... 01/01/93 12/31/93 1.1831 0.9897
330314...................... 01/01/93 12/31/93 1.3382 0.9956
330315...................... 01/01/93 12/31/93 1.1681 0.9876
330316...................... 01/01/93 12/31/93 1.3027 0.9952
330327...................... 01/01/93 12/31/93 0.9053 0.9572
330331...................... 01/01/93 12/31/93 1.1843 0.9909
330332...................... 01/01/93 12/31/93 1.2501 0.9916
330333...................... 01/01/93 12/31/93 1.3022 0.9995
330336...................... 01/01/93 12/31/93 1.3303 0.9799
330338...................... 01/01/93 12/31/93 1.1762 0.9891
330339...................... 01/01/93 12/31/93 0.8046 0.9894
330340...................... 01/01/93 12/31/93 1.1780 0.9757
330350...................... 01/01/93 12/31/93 1.7709 0.9974
330353...................... 01/01/93 12/31/93 1.2943 0.9938
330357...................... 01/01/93 12/31/93 1.3589 0.9882
330359...................... 01/01/93 12/31/93 0.9238 0.9734
330372...................... 01/01/93 12/31/93 1.2708 0.9907
330381...................... 01/01/93 12/31/93 1.2770 0.9967
330386...................... 01/01/93 12/31/93 1.1750 0.9753
330387...................... 01/01/93 12/31/93 0.8423 0.9787
330389...................... 01/01/93 12/31/93 1.9113 0.9958
330390...................... 01/01/93 12/31/93 1.2556 0.9978
330393...................... 01/01/93 12/31/93 1.6160 0.9980
330394...................... 01/01/93 12/31/93 1.4328 0.9988
330395...................... 01/01/93 12/31/93 1.3564 0.9915
330397...................... 01/01/93 12/31/93 1.5229 0.9959
330398...................... 01/01/93 12/31/93 1.2836 0.9807
330399...................... 01/01/93 12/31/93 1.3668 0.9955
340001...................... 10/01/92 09/30/93 1.3629 0.9899
340002...................... 10/01/92 09/30/93 1.8306 0.9977
340003...................... 10/01/92 09/30/93 1.1793 0.9573
340004...................... 10/01/92 09/30/93 1.4919 0.9978
340005...................... 10/01/92 09/30/93 1.1679 0.9691
340006...................... 10/01/92 09/30/93 1.2412 0.9596
340007...................... 10/01/92 09/30/93 1.1651 0.9773
340008...................... 10/01/92 09/30/93 1.1796 0.9760
340009...................... 10/01/92 09/30/93 1.5066 0.9777
340010...................... 10/04/92 10/02/93 1.3159 0.9836
340011...................... 10/01/92 09/30/93 1.0639 0.9730
340012...................... 10/01/92 09/30/93 1.1393 0.9845
340013...................... 10/01/92 09/30/93 1.2035 0.9743
340015...................... 10/01/92 09/30/93 1.2381 0.9750
340016...................... 10/01/92 09/30/93 1.1056 0.9892
340017...................... 10/01/92 09/30/93 1.2652 0.9854
340018...................... 10/01/92 09/30/93 1.1934 0.9772
340021...................... 10/01/92 09/30/93 1.3176 0.9871
340022...................... 10/01/92 09/30/93 1.0840 0.9652
340023...................... 01/01/93 12/31/93 1.3259 0.9890
340024...................... 10/01/92 09/30/93 1.2481 0.9630
340025...................... 10/01/92 09/30/93 1.1573 0.9853
340027...................... 10/01/92 09/30/93 1.2165 0.9970
340028...................... 10/01/92 09/30/93 1.4172 0.9951
340031...................... 10/01/92 09/30/93 1.0153 0.9512
340034...................... 10/01/92 09/30/93 1.2717 0.9628
340035...................... 10/01/92 09/30/93 1.1569 0.9646
340036...................... 10/01/92 09/30/93 1.1793 0.9763
340037...................... 10/01/92 09/30/93 1.2314 0.9840
340038...................... 10/01/92 09/30/93 1.1357 0.9792
340039...................... 10/01/92 09/30/93 1.2816 0.9815
340040...................... 10/01/92 09/30/93 1.8038 0.9993
340041...................... 10/01/92 09/30/93 1.2549 0.9680
340042...................... 10/01/92 09/30/93 1.1501 0.9794
340044...................... 10/01/92 09/30/93 1.0440 0.9626
340045...................... 10/01/92 09/30/93 1.0232 0.9605
340048...................... 10/01/92 09/30/93 1.2551 1.0000
340049...................... 10/01/92 09/30/93 0.6445 1.0000
340050...................... 10/01/92 09/30/93 1.1695 0.9666
340051...................... 10/01/92 09/30/93 1.2050 0.9777
340053...................... 10/01/92 09/30/93 1.5869 0.9983
340054...................... 10/01/92 09/30/93 1.0732 0.9682
340055...................... 10/01/92 09/30/93 1.2086 0.9882
340060...................... 10/01/92 09/30/93 1.1183 0.9616
340063...................... 10/01/92 09/30/93 1.0139 0.9598
340064...................... 10/01/92 09/30/93 1.1725 0.9762
340065...................... 10/01/92 09/30/93 1.1391 0.9580
340067...................... 10/01/92 09/30/93 1.1634 0.9469
340068...................... 10/01/92 09/30/93 1.3548 0.9724
340069...................... 10/01/92 09/30/93 1.7566 0.9953
340070...................... 10/01/92 09/30/93 1.2694 0.9687
340071...................... 10/01/92 09/30/93 1.0301 0.9481
340072...................... 10/01/92 09/30/93 1.0980 0.9839
340075...................... 10/01/92 09/30/93 1.1543 0.9841
340080...................... 10/01/92 09/30/93 1.1411 0.9822
340084...................... 10/01/92 09/30/93 1.0582 0.9827
340085...................... 10/01/92 09/30/93 1.1942 0.9879
340087...................... 10/01/92 09/30/93 1.1740 0.9870
340088...................... 10/01/92 09/30/93 1.1213 0.9759
340089...................... 10/01/92 09/30/93 0.9657 0.9729
340090...................... 10/01/92 09/30/93 1.0747 0.9577
340091...................... 10/01/92 09/30/93 1.6453 0.9989
340093...................... 10/01/92 09/30/93 1.1232 0.9786
340094...................... 10/01/92 09/30/93 1.3301 0.9847
340096...................... 10/01/92 09/30/93 1.2399 0.9646
340097...................... 10/01/92 09/30/93 1.1151 0.9671
340098...................... 09/27/92 09/25/93 1.6286 0.9979
340099...................... 10/01/92 09/30/93 1.1369 0.9684
340100...................... 10/01/92 09/30/93 1.2221 1.0000
340101...................... 01/01/93 12/31/93 1.0349 0.9874
340104...................... 10/01/92 09/30/93 1.0167 0.9775
340105...................... 10/01/92 09/30/93 1.3463 0.9959
340106...................... 10/01/92 09/30/93 1.1316 0.9806
340107...................... 01/01/93 12/31/93 1.2580 0.9762
340109...................... 10/01/92 09/30/93 1.3000 0.9867
340111...................... 10/01/92 09/30/93 1.1302 0.9581
340112...................... 10/01/92 09/30/93 1.0452 0.9269
340113...................... 01/01/93 12/31/93 1.9406 0.9991
340114...................... 10/01/92 09/30/93 1.4375 0.9987
340115...................... 10/01/92 09/30/93 1.5009 0.9964
340119...................... 10/01/92 09/30/93 1.2907 0.9784
340120...................... 10/01/92 09/30/93 1.0983 0.9746
340121...................... 10/01/92 09/30/93 1.0666 0.9643
340122...................... 10/01/92 09/30/93 1.0123 0.9735
340123...................... 10/01/92 09/30/93 1.1626 0.9633
340124...................... 10/01/92 09/30/93 1.0939 0.9607
340125...................... 10/01/92 09/30/93 1.4097 0.9918
340126...................... 10/01/92 09/30/93 1.3418 0.9845
340127...................... 10/01/92 09/30/93 1.2563 0.9731
340129...................... 10/01/92 09/30/93 1.2567 0.9778
340130...................... 10/01/92 09/30/93 1.3320 0.9736
340131...................... 10/01/92 09/30/93 1.3182 0.9877
340132...................... 10/01/92 09/30/93 1.2779 0.9634
340133...................... 10/01/92 09/30/93 1.1506 0.9562
340141...................... 10/01/92 09/30/93 1.5710 0.9975
340142...................... 10/01/92 09/30/93 1.2220 0.9743
340145...................... 10/01/92 09/30/93 1.2801 0.9512
340146...................... 10/01/92 09/30/93 1.0441 0.9583
340147...................... 10/04/92 10/02/93 1.3425 0.9946
340151...................... 10/01/92 09/30/93 1.2034 0.9819
340159...................... 10/01/92 09/30/93 1.1149 0.9765
340166...................... 01/01/93 12/31/93 1.3753 0.9879
340168...................... 10/01/92 09/30/93 0.5447 1.0000
350004...................... 10/01/92 09/30/93 1.8723 0.9987
350007...................... 10/01/92 09/30/93 1.0045 0.9554
350015...................... 01/01/93 12/31/93 1.6193 0.9939
350016...................... 01/01/93 12/31/93 0.9935 0.9883
350018...................... 10/01/92 09/30/93 1.1459 0.9884
350019...................... 01/01/93 12/31/93 1.5986 0.9959
350020...................... 01/01/93 12/31/93 1.3682 0.9837
350023...................... 01/01/93 12/31/93 0.8092 0.9572
350024...................... 10/01/92 09/30/93 1.1536 0.9644
350027...................... 10/01/92 09/30/93 0.9973 0.9879
350033...................... 01/01/93 12/31/93 0.9214 0.9617
350036...................... 07/01/92 07/31/93 0.8994 0.9341
350038...................... 01/01/93 12/31/93 1.0108 0.9501
350041...................... 01/01/93 12/31/93 1.0813 0.9744
350042...................... 01/01/93 12/31/93 1.0496 0.9909
350051...................... 01/01/93 12/31/93 0.9614 0.9685
350055...................... 01/01/93 12/31/93 0.9295 0.9671
350066...................... 10/01/92 09/30/93 0.6321 0.9741
360001...................... 01/01/93 12/31/93 1.2264 0.9885
360002...................... 01/01/93 12/31/93 1.1550 0.9755
360007...................... 01/01/93 12/31/93 1.0658 0.9853
360009...................... 01/01/93 12/31/93 1.3346 0.9858
360010...................... 01/01/93 12/31/93 1.1682 0.9754
360012...................... 01/01/93 12/31/93 1.2374 0.9873
360013...................... 01/01/93 12/31/93 1.0975 0.9830
360016...................... 01/01/93 12/31/93 1.5514 0.9987
360018...................... 01/01/93 12/31/93 1.5419 0.9988
360019...................... 01/01/93 12/31/93 1.2405 0.9844
360020...................... 01/01/93 12/31/93 1.4449 0.9975
360021...................... 01/01/93 12/31/93 1.2443 0.9814
360024...................... 01/01/93 12/31/93 1.2697 0.9896
360025...................... 01/01/93 12/31/93 1.1983 0.9778
360026...................... 01/01/93 12/31/93 1.1596 0.9911
360027...................... 01/01/93 12/31/93 1.5294 0.9978
360030...................... 01/01/93 12/31/93 1.1469 0.9774
360031...................... 01/01/93 12/31/93 1.2509 0.9837
360032...................... 01/01/93 12/31/93 1.0799 0.9495
360034...................... 01/01/93 12/31/93 1.2068 0.9595
360036...................... 01/01/93 12/31/93 1.1787 0.9724
360037...................... 01/01/93 12/31/93 2.0513 0.9923
360038...................... 01/01/93 12/31/93 1.4670 0.9989
360039...................... 01/01/93 12/31/93 1.2739 0.9919
360041...................... 01/01/93 12/31/93 1.3489 0.9909
360042...................... 01/01/93 12/31/93 1.1441 0.9569
360044...................... 01/01/93 12/31/93 1.0655 0.9766
360046...................... 01/01/93 12/31/93 1.1008 0.9710
360047...................... 01/01/93 12/31/93 1.0611 0.9694
360049...................... 01/01/93 12/31/93 1.3268 0.9933
360051...................... 01/01/93 12/31/93 1.5044 0.9989
360055...................... 01/01/93 12/31/93 1.1902 0.9870
360056...................... 01/01/93 12/31/93 1.3361 0.9899
360057...................... 01/01/93 12/31/93 1.0502 0.9638
360059...................... 01/01/93 12/31/93 1.5065 0.9982
360062...................... 01/01/93 12/31/93 1.5303 0.9935
360063...................... 01/01/93 12/31/93 1.0271 0.9666
360064...................... 01/01/93 12/31/93 1.4480 0.9965
360065...................... 01/01/93 12/31/93 1.2464 0.9836
360066...................... 01/01/93 12/31/93 1.2311 0.9853
360067...................... 01/01/93 12/31/93 1.1145 0.9589
360068...................... 01/01/93 12/31/93 1.5975 0.9988
360069...................... 01/01/93 12/31/93 1.0290 0.9555
360070...................... 01/01/93 12/31/93 1.5703 0.9938
360071...................... 01/01/93 12/31/93 1.2675 0.9793
360072...................... 01/01/93 12/31/93 1.2047 0.9712
360074...................... 10/01/92 09/30/93 1.4118 0.9928
360075...................... 01/01/93 12/31/93 1.4359 0.9964
360076...................... 01/01/93 12/31/93 1.2892 0.9808
360077...................... 01/01/93 12/31/93 1.4009 0.9969
360078...................... 01/01/93 12/31/93 1.2753 0.9884
360079...................... 01/01/93 12/31/93 1.6481 0.9986
360080...................... 01/01/93 12/31/93 1.1169 0.9927
360081...................... 01/01/93 12/31/93 1.3331 0.9938
360082...................... 01/01/93 12/31/93 1.3029 0.9876
360083...................... 01/01/93 12/31/93 1.2935 0.9848
360084...................... 01/01/93 12/31/93 1.6169 0.9956
360086...................... 01/01/93 12/31/93 1.4381 0.9838
360087...................... 01/01/93 12/31/93 1.3196 0.9950
360088...................... 01/01/93 12/31/93 1.1788 0.9713
360089...................... 01/01/93 12/31/93 1.0998 0.9749
360091...................... 01/01/93 12/31/93 1.2440 0.9849
360092...................... 01/01/93 12/31/93 1.2249 0.9604
360093...................... 01/01/93 12/31/93 1.2008 0.9717
360094...................... 01/01/93 12/31/93 1.1841 0.9968
360095...................... 01/01/93 12/31/93 1.2898 0.9817
360096...................... 01/01/93 12/31/93 1.0954 0.9837
360098...................... 01/01/93 12/31/93 1.3551 0.9842
360099...................... 10/01/92 09/30/93 1.0586 0.9806
360100...................... 01/01/93 12/31/93 1.2921 0.9825
360101...................... 01/01/93 12/31/93 1.7626 0.9888
360102...................... 01/01/93 12/31/93 1.2546 0.9943
360103...................... 01/01/93 12/31/93 1.4047 0.9977
360104...................... 01/01/93 12/31/93 0.9425 0.9920
360106...................... 01/01/93 12/31/93 1.1227 0.9619
360107...................... 09/01/92 08/31/93 1.1911 0.9764
360108...................... 01/01/93 12/31/93 1.0609 0.9793
360109...................... 01/01/93 12/31/93 1.0261 0.9694
360112...................... 01/01/93 12/31/93 1.7627 0.9976
360113...................... 01/01/93 12/31/93 1.3625 0.9894
360114...................... 01/01/93 12/31/93 1.0742 0.9707
360115...................... 01/01/93 12/31/93 1.2036 0.9882
360116...................... 01/01/93 12/31/93 1.0762 0.9529
360118...................... 01/01/93 12/31/93 1.3112 0.9853
360119...................... 01/01/93 12/31/93 1.2381 0.9909
360120...................... 01/01/93 12/31/93 0.6543 0.9709
360121...................... 10/01/92 09/30/93 1.2414 0.9793
360122...................... 01/01/93 12/31/93 1.3423 0.9890
360123...................... 01/01/93 12/31/93 1.2333 0.9907
360124...................... 01/01/93 12/31/93 1.2156 0.9784
360125...................... 01/01/93 12/31/93 1.1263 0.9787
360126...................... 01/01/93 12/31/93 1.2973 0.9863
360127...................... 01/01/93 12/31/93 1.0982 0.9694
360128...................... 01/01/93 12/31/93 1.1371 0.9735
360129...................... 01/01/93 12/31/93 0.9950 0.9543
360130...................... 01/01/93 12/31/93 1.0580 0.9817
360131...................... 01/01/93 12/31/93 1.1928 0.9787
360132...................... 01/01/93 12/31/93 1.2901 0.9866
360133...................... 01/01/93 12/31/93 1.4585 0.9955
360135...................... 01/01/93 12/31/93 1.1777 0.9691
360136...................... 01/01/93 12/31/93 1.1119 0.9432
360137...................... 01/01/93 12/31/93 1.5705 0.9972
360140...................... 01/01/93 12/31/93 1.0638 0.9612
360141...................... 01/01/93 12/31/93 1.4207 0.9978
360142...................... 01/01/93 12/31/93 0.9906 0.9520
360143...................... 01/01/93 12/31/93 1.2845 0.9941
360144...................... 01/01/93 12/31/93 1.2950 0.9926
360145...................... 01/01/93 12/31/93 1.5210 0.9971
360147...................... 10/01/92 09/30/93 1.2051 0.9667
360148...................... 01/01/93 12/31/93 1.1115 0.9811
360149...................... 01/01/93 12/31/93 1.0941 0.9897
360150...................... 01/01/93 12/31/93 1.3046 0.9856
360151...................... 01/01/93 12/31/93 1.3601 0.9854
360152...................... 01/01/93 12/31/93 1.4961 0.9965
360153...................... 01/01/93 12/31/93 1.1685 0.9830
360154...................... 01/01/93 12/31/93 1.0315 0.9806
360155...................... 01/01/93 12/31/93 1.3124 0.9935
360156...................... 10/01/92 09/30/93 1.1318 0.9685
360159...................... 01/01/93 12/31/93 1.1922 0.9721
360162...................... 01/01/93 12/31/93 1.2868 0.9941
360163...................... 01/01/93 12/31/93 1.7877 0.9950
360164...................... 01/01/93 12/31/93 0.8772 0.9713
360165...................... 11/01/92 10/31/93 1.1284 0.9662
360166...................... 01/01/93 12/31/93 1.2007 0.9906
360169...................... 01/01/93 12/31/93 1.0948 0.9379
360170...................... 01/01/93 12/31/93 1.1145 0.9719
360172...................... 01/01/93 12/31/93 1.3708 0.9864
360174...................... 01/01/93 12/31/93 1.2169 0.9900
360175...................... 01/01/93 12/31/93 1.1859 0.9657
360176...................... 01/01/93 12/31/93 1.2106 0.9749
360177...................... 01/01/93 12/31/93 1.2303 0.9546
360179...................... 12/27/92 12/25/93 1.2854 0.9938
360180...................... 01/01/93 12/31/93 2.2030 0.9986
360184...................... 01/01/93 12/31/93 0.6334 1.0000
360186...................... 01/01/93 12/31/93 1.2108 0.9670
360188...................... 01/01/93 12/31/93 1.0393 0.9608
360189...................... 01/01/93 12/31/93 1.0656 0.9872
360192...................... 01/01/93 12/31/93 1.3360 0.9867
360193...................... 01/01/93 12/31/93 1.2875 0.9928
360194...................... 10/01/92 09/30/93 1.1413 0.9434
360195...................... 01/01/93 12/31/93 1.1604 0.9546
360197...................... 01/01/93 12/31/93 1.1537 0.9596
360200...................... 01/01/93 12/31/93 1.1839 0.9559
360203...................... 01/01/93 12/31/93 1.1371 0.9751
360204...................... 01/01/93 12/31/93 1.2116 0.9903
360210...................... 01/01/93 12/31/93 1.1593 0.9794
360211...................... 01/01/93 12/31/93 1.1906 0.9908
360212...................... 01/01/93 12/31/93 1.4069 0.9962
360213...................... 01/01/93 12/31/93 1.1036 0.9814
360218...................... 01/01/93 12/31/93 1.2293 0.9835
360230...................... 01/01/93 12/31/93 1.2895 0.9895
360231...................... 01/01/93 12/31/93 1.0878 0.9848
360232...................... 01/01/93 12/31/93 1.1730 0.9712
360234...................... 01/01/93 12/31/93 1.3079 0.9901
360236...................... 01/01/93 12/31/93 1.2283 0.9861
360239...................... 01/01/93 12/31/93 1.1463 0.9805
360240...................... 01/01/93 12/31/93 0.5818 0.9722
360241...................... 01/01/93 12/31/93 0.5907 0.9759
370001...................... 01/01/93 12/31/93 1.6720 0.9977
370002...................... 01/01/93 12/31/93 1.2297 0.9609
370006...................... 10/01/92 09/30/93 1.1944 0.9840
370007...................... 01/01/93 12/31/93 1.1134 0.9761
370014...................... 10/01/92 09/30/93 1.2983 0.9759
370017...................... 01/01/93 12/31/93 1.0811 0.9448
370018...................... 11/01/92 10/31/93 1.3083 0.9884
370020...................... 10/01/92 09/30/93 1.2848 0.9748
370021...................... 09/01/92 08/31/93 0.9887 0.9409
370025...................... 10/01/92 09/30/93 1.3960 0.9909
370032...................... 11/01/92 10/31/93 1.4123 0.9986
370033...................... 10/01/92 09/30/93 1.1169 0.9874
370037...................... 01/01/93 12/31/93 1.5354 0.9991
370039...................... 11/01/92 10/31/93 1.3192 0.9791
370040...................... 10/01/92 09/30/93 1.0365 0.9797
370049...................... 01/01/93 12/31/93 1.3617 0.9735
370051...................... 10/01/92 09/30/93 1.0330 0.9544
370054...................... 01/01/93 12/31/93 1.2740 0.9730
370057...................... 01/01/93 12/31/93 1.1250 0.9742
370071...................... 01/01/93 12/31/93 1.0728 0.9672
370077...................... 01/01/93 12/31/93 1.3011 0.9852
370078...................... 01/01/93 12/31/93 1.6361 0.9982
370092...................... 10/01/92 09/30/93 1.1134 0.9542
370093...................... 09/01/92 08/31/93 1.7856 0.9991
370094...................... 01/01/93 12/31/93 1.4036 0.9957
370095...................... 01/01/93 12/31/93 0.9035 0.9775
370105...................... 10/01/92 09/30/93 2.0588 0.9940
370106...................... 11/01/92 10/31/93 1.4729 0.9988
370108...................... 10/01/92 09/30/93 1.1880 0.9595
370114...................... 10/01/92 09/30/93 1.5704 0.9988
370121...................... 09/01/92 08/31/93 1.3201 0.9664
370141...................... 09/01/92 08/31/93 1.3981 0.9919
370146...................... 01/01/93 12/31/93 1.1792 0.9306
370148...................... 09/01/92 08/31/93 1.3489 0.9834
370149...................... 10/01/92 09/30/93 1.1873 0.9758
370161...................... 11/01/92 10/31/93 1.2069 0.9799
370165...................... 10/01/92 09/30/93 1.1641 0.9751
370169...................... 01/01/93 12/31/93 1.0176 0.9703
370176...................... 01/01/93 12/31/93 1.2186 0.9750
370179...................... 10/01/92 09/30/93 0.9611 0.9190
370189...................... 01/01/93 12/31/93 1.0859 0.9952
370190...................... 01/01/93 12/31/93 1.7244 1.0000
380004...................... 01/01/93 12/31/93 1.6808 0.9795
380006...................... 01/01/93 12/31/93 1.2953 0.9795
380010...................... 01/01/93 12/31/93 1.0559 0.9862
380014...................... 01/01/93 12/31/93 1.3367 0.9917
380018...................... 10/01/92 09/30/93 1.7734 0.9978
380019...................... 01/01/93 12/31/93 1.3578 0.9787
380021...................... 10/01/92 09/30/93 1.2014 0.9883
380026...................... 01/01/93 12/31/93 1.3569 0.9653
380029...................... 10/01/92 09/30/93 1.1914 0.9810
380036...................... 01/01/93 12/31/93 1.0826 0.9368
380038...................... 08/01/92 07/31/93 1.2313 0.9773
380039...................... 01/01/93 12/31/93 1.2889 0.9890
380042...................... 01/01/93 12/31/93 1.1210 0.9694
380047...................... 01/01/93 12/31/93 1.6608 0.9979
380050...................... 10/01/92 09/30/93 1.2442 0.9858
380051...................... 10/01/92 09/30/93 1.5093 0.9953
380052...................... 01/01/93 12/31/93 1.2058 0.9819
380055...................... 01/01/93 12/31/93 1.1902 0.9909
380056...................... 01/01/93 12/31/93 1.0793 0.9777
380060...................... 01/01/93 12/31/93 1.4558 0.9876
380061...................... 01/01/93 12/31/93 1.5570 0.9982
380064...................... 08/01/92 07/31/93 1.3134 0.9841
380068...................... 10/01/92 09/30/93 1.0233 0.9296
380070...................... 01/01/93 12/31/93 1.2442 0.9497
380075...................... 01/01/93 12/31/93 1.4611 0.9945
380082...................... 01/01/93 12/31/93 1.2131 0.9926
380091...................... 01/01/93 12/31/93 1.1609 0.9839
390028...................... 01/01/93 12/31/93 1.7552 0.9991
390054...................... 01/01/93 12/31/93 1.1025 0.9815
390059...................... 07/01/92 08/06/93 1.3245 0.9924
390060...................... 01/01/93 12/31/93 1.0940 0.9907
390169...................... 01/01/93 12/31/93 1.1971 0.9973
390186...................... 01/01/93 12/31/93 1.0253 0.9756
390237...................... 01/01/93 12/31/93 1.5243 0.9976
390272...................... 09/01/92 08/31/93 0.5433 0.9850
400002...................... 01/01/93 12/31/93 1.3882 0.9992
400005...................... 01/01/93 12/31/93 1.0596 0.9995
400007...................... 01/01/93 12/31/93 1.1966 0.9992
400008...................... 01/01/93 12/31/93 1.1693 1.0000
400010...................... 10/01/92 09/30/93 0.9384 0.9679
400011...................... 01/01/93 12/31/93 1.0597 0.9976
400014...................... 01/01/93 12/31/93 1.3737 0.9988
400016...................... 10/01/92 09/30/93 1.3265 0.9995
400017...................... 01/01/93 12/31/93 1.1709 0.9982
400019...................... 01/01/93 12/31/93 1.5238 0.9990
400022...................... 01/01/93 12/31/93 1.2971 0.9999
400024...................... 01/01/93 12/31/93 1.0171 0.9951
400032...................... 01/01/93 12/31/93 1.1280 0.9991
400094...................... 01/01/93 12/31/93 1.0247 0.9897
400098...................... 01/01/93 12/31/93 1.3015 0.9991
400106...................... 10/01/92 09/30/93 1.1958 0.9997
400109...................... 10/01/92 09/30/93 1.5764 0.9944
400111...................... 01/01/93 12/31/93 1.1395 0.9982
400113...................... 10/01/92 09/30/93 1.1758 0.9977
400115...................... 01/01/93 12/31/93 0.9888 0.9980
400117...................... 01/01/93 12/31/93 1.2070 0.9993
400118...................... 01/01/93 12/31/93 1.1391 0.9976
400120...................... 01/01/93 12/31/93 1.3350 0.9996
400122...................... 09/01/92 08/31/93 0.9826 0.9876
410001...................... 10/01/92 09/30/93 1.3195 0.9903
410004...................... 10/01/92 09/30/93 1.4030 0.9944
410005...................... 10/01/92 09/30/93 1.3467 0.9967
410006...................... 10/01/92 09/30/93 1.2063 0.9836
410007...................... 10/01/92 09/30/93 1.6561 0.9977
410008...................... 10/01/92 09/30/93 1.2013 0.9842
410009...................... 10/01/92 09/30/93 1.3174 0.9946
410010...................... 10/01/92 09/30/93 1.0107 0.9846
410011...................... 10/01/92 09/30/93 1.2098 0.9949
410012...................... 10/01/92 09/30/93 1.6436 0.9983
410013...................... 10/01/92 09/30/93 1.2322 0.9817
420005...................... 01/01/93 12/31/93 1.1534 0.9724
420007...................... 10/04/92 10/02/93 1.5331 0.9982
420009...................... 10/01/92 09/30/93 1.2494 0.9627
420010...................... 10/01/92 09/30/93 1.0665 0.9608
420011...................... 10/01/92 09/30/93 1.0781 0.9689
420014...................... 10/01/92 09/30/93 1.0232 0.9708
420015...................... 10/01/92 09/30/93 1.3033 0.9867
420016...................... 10/01/92 09/30/93 1.0799 0.9852
420018...................... 09/27/92 09/25/93 1.5712 0.9978
420019...................... 10/01/92 09/30/93 1.1517 0.9785
420020...................... 10/01/92 09/30/93 1.2236 0.9688
420022...................... 10/04/92 10/02/93 0.9916 0.9467
420023...................... 01/01/93 12/31/93 1.3606 0.9962
420026...................... 09/06/92 09/04/93 1.8690 0.9979
420027...................... 09/27/92 09/25/93 1.3256 0.9922
420028...................... 10/01/92 09/30/93 1.1069 0.9743
420029...................... 10/01/92 09/30/93 1.7591 1.0000
420030...................... 01/01/93 12/31/93 1.1906 0.9591
420031...................... 10/01/92 09/30/93 1.0152 0.9303
420033...................... 10/01/92 09/30/93 1.1551 0.9688
420036...................... 10/01/92 09/30/93 1.2291 0.9693
420037...................... 10/01/92 09/30/93 1.2544 0.9689
420038...................... 10/01/92 09/30/93 1.2145 0.9735
420039...................... 10/01/92 09/30/93 1.1045 0.9798
420040...................... 10/01/92 09/30/93 1.2002 0.9926
420042...................... 10/01/92 09/30/93 1.1998 0.9765
420043...................... 10/01/92 09/30/93 1.2516 0.9743
420044...................... 10/01/92 09/30/93 1.2132 0.9906
420048...................... 10/01/92 09/30/93 1.1511 0.9661
420049...................... 10/01/92 09/30/93 1.2267 0.9789
420051...................... 10/01/92 09/30/93 1.5554 0.9967
420054...................... 09/01/92 08/31/93 1.2026 0.9591
420055...................... 10/01/92 09/30/93 1.0770 0.9824
420056...................... 10/01/92 09/30/93 1.1005 0.9335
420057...................... 10/01/92 09/30/93 1.1822 0.9744
420059...................... 10/01/92 09/30/93 0.9977 0.9593
420061...................... 10/01/92 09/30/93 1.2231 0.9483
420064...................... 10/01/92 09/30/93 1.1418 0.9555
420065...................... 09/01/92 08/31/93 1.3439 0.9991
420066...................... 10/01/92 09/30/93 0.9710 0.9744
420067...................... 10/01/92 09/30/93 1.2502 0.9669
420068...................... 10/01/92 09/30/93 1.2132 0.9898
420069...................... 10/01/92 09/30/93 1.1278 0.9613
420070...................... 10/01/92 09/30/93 1.2808 0.9826
420071...................... 10/01/92 09/30/93 1.3525 0.9860
420072...................... 10/01/92 09/30/93 0.9324 0.9622
420073...................... 10/01/92 09/30/93 1.3094 0.9932
420074...................... 10/01/92 09/30/93 0.9667 0.9717
420075...................... 10/01/92 09/30/93 0.9842 0.9699
420076...................... 01/01/93 12/31/93 1.1801 0.9947
420078...................... 10/01/92 09/30/93 1.7184 0.9959
420081...................... 10/01/92 09/30/93 0.8117 0.9924
420086...................... 10/01/92 09/30/93 1.4254 0.9918
420087...................... 10/01/92 09/30/93 1.6197 0.9993
420088...................... 10/01/92 09/30/93 1.2311 0.9847
420089...................... 09/01/92 08/31/93 1.3630 0.9893
420091...................... 10/01/92 09/30/93 0.5742 1.0000
430008...................... 01/01/93 12/31/93 1.1650 0.9709
430013...................... 10/01/92 09/30/93 1.2240 0.9799
430014...................... 10/01/92 09/30/93 1.3094 0.9876
430015...................... 08/01/92 07/31/93 1.1905 0.9737
430016...................... 10/01/92 09/30/93 1.7329 0.9971
430023...................... 09/01/92 08/31/93 0.9304 0.9557
430024...................... 01/01/93 12/31/93 0.9432 0.9222
430026...................... 01/01/93 12/31/93 0.9208 0.9536
430031...................... 01/01/93 12/31/93 0.9508 0.9713
430034...................... 01/01/93 12/31/93 1.0333 0.9321
430036...................... 01/01/93 12/31/93 1.0147 0.9891
430038...................... 01/01/93 12/31/93 0.9989 0.9884
430040...................... 10/01/92 09/30/93 0.9127 0.9710
430041...................... 01/01/93 12/31/93 0.9569 0.9472
430043...................... 01/01/93 12/31/93 1.1638 0.9854
430044...................... 01/01/93 12/31/93 0.9474 0.9028
430047...................... 01/01/93 12/31/93 1.0816 0.9812
430048...................... 01/01/93 12/31/93 1.2262 0.9789
430049...................... 01/01/93 12/31/93 0.9245 0.9397
430051...................... 01/01/93 12/31/93 0.9633 0.9442
430056...................... 01/01/93 12/31/93 0.8731 0.9506
430057...................... 01/01/93 12/31/93 0.9348 0.9789
430060...................... 01/01/93 12/31/93 1.0147 0.9511
430064...................... 12/01/92 11/30/93 1.1226 0.9736
430065...................... 10/01/92 09/30/93 1.0255 0.8930
430073...................... 10/01/92 09/30/93 1.1134 0.9935
430076...................... 01/01/93 12/31/93 1.0247 0.9436
430079...................... 01/01/93 12/31/93 0.9761 0.9826
430080...................... 10/01/92 09/30/93 1.2387 1.0000
430087...................... 01/01/93 12/31/93 0.9221 0.9708
440008...................... 01/01/93 12/31/93 0.9794 0.9778
440018...................... 11/01/92 10/31/93 1.4130 0.9599
440020...................... 10/01/92 09/30/93 1.1717 0.9782
440026...................... 10/01/92 09/30/93 0.8359 1.0000
440034...................... 01/01/93 12/31/93 1.4209 0.9982
440041...................... 10/01/92 09/30/93 0.8462 0.9631
440046...................... 01/01/93 12/31/93 1.3260 0.9976
440047...................... 09/01/92 08/31/93 0.9144 0.9767
440048...................... 10/01/92 09/30/93 1.7487 0.9989
440049...................... 01/01/93 12/31/93 1.6519 0.9991
440050...................... 01/01/93 12/31/93 1.1542 0.9816
440058...................... 01/01/93 12/31/93 1.2336 0.9682
440061...................... 10/01/92 09/30/93 1.2070 0.9798
440064...................... 01/01/93 12/31/93 1.1053 0.9711
440068...................... 10/01/92 09/30/93 1.1887 0.9811
440071...................... 01/01/93 12/31/93 1.4120 0.9987
440072...................... 01/01/93 12/31/93 1.3516 0.9604
440078...................... 10/01/92 09/30/93 1.0157 0.9814
440081...................... 01/01/93 12/31/93 1.1484 0.9825
440083...................... 01/01/93 12/31/93 1.2326 0.9641
440091...................... 09/01/92 08/31/93 1.5298 0.9987
440095...................... 01/01/93 12/31/93 1.1343 0.9634
440100...................... 01/01/93 12/31/93 1.0463 0.9658
440105...................... 09/01/92 08/31/93 1.2872 0.9925
440110...................... 01/01/93 12/31/93 0.9412 0.9463
440120...................... 01/01/93 12/31/93 1.4507 0.9991
440125...................... 01/01/93 12/31/93 1.4743 0.9986
440145...................... 10/01/92 09/30/93 1.0532 0.9637
440146...................... 01/01/93 12/31/93 1.2989 1.0000
440148...................... 01/01/93 12/31/93 1.2023 0.9616
440149...................... 11/01/92 10/31/93 1.2315 0.9669
440150...................... 01/01/93 12/31/93 1.2427 0.9929
440157...................... 01/01/93 12/31/93 1.0441 0.9560
440159...................... 10/01/92 09/30/93 1.2072 0.9899
440161...................... 01/01/93 12/31/93 1.5903 0.9990
440168...................... 01/01/93 12/31/93 1.0412 0.9635
440173...................... 09/01/92 08/31/93 1.4925 0.9968
440174...................... 01/01/93 12/31/93 0.9408 0.9626
440181...................... 01/01/93 12/31/93 0.9992 0.9641
440182...................... 01/01/93 12/31/93 0.9613 0.9818
440184...................... 01/01/93 12/31/93 1.4234 0.9888
440185...................... 09/01/92 08/31/93 1.0731 0.9858
440186...................... 11/01/92 10/31/93 1.1264 0.9457
440189...................... 08/01/92 07/31/93 1.4808 0.9909
440194...................... 09/01/92 08/31/93 1.3072 0.9781
440200...................... 12/01/92 11/30/93 1.1187 0.9526
440203...................... 01/01/93 12/31/93 0.9433 0.9724
440205...................... 01/01/93 12/31/93 1.2744 0.9686
450002...................... 01/01/93 12/31/93 1.4832 0.9994
450005...................... 09/01/92 08/31/93 1.1391 0.9751
450010...................... 10/01/92 09/30/93 1.3295 0.9983
450011...................... 01/01/93 12/31/93 1.5169 0.9978
450014...................... 01/01/93 12/31/93 1.1514 0.9516
450015...................... 10/01/92 09/30/93 1.5321 0.9984
450016...................... 01/01/93 12/31/93 1.6864 0.9979
450018...................... 09/01/92 08/31/93 1.5604 0.9993
450020...................... 01/01/93 12/31/93 1.0254 0.9592
450024...................... 10/01/92 09/30/93 1.3651 0.9896
450025...................... 01/01/93 12/31/93 1.4491 0.9979
450028...................... 01/01/93 12/31/93 1.4760 0.9938
450032...................... 10/01/92 09/30/93 1.2406 0.9752
450033...................... 09/01/92 08/31/93 1.6381 0.9988
450037...................... 10/01/92 09/30/93 1.5251 0.9966
450039...................... 10/01/92 09/30/93 1.4428 0.9980
450046...................... 10/01/92 09/30/93 1.3906 0.9966
450047...................... 01/01/93 12/31/93 1.0976 0.9677
450050...................... 01/01/93 12/31/93 1.1957 0.9643
450053...................... 01/01/93 12/31/93 1.0808 0.9066
450054...................... 09/01/92 08/31/93 1.6655 0.9980
450055...................... 10/01/92 09/30/93 1.0953 0.9631
450058...................... 09/01/92 08/31/93 1.5071 0.9986
450059...................... 01/01/93 12/31/93 1.3557 0.9803
450063...................... 10/01/92 09/30/93 1.0534 0.9139
450065...................... 10/01/92 09/30/93 1.0161 0.9656
450068...................... 10/01/92 09/30/93 1.7522 0.9985
450072...................... 01/01/93 12/31/93 1.2769 0.9631
450073...................... 01/01/93 12/31/93 1.1753 0.9575
450080...................... 10/01/92 09/30/93 1.2486 0.9720
450081...................... 01/01/93 12/31/93 1.1280 0.9641
450082...................... 10/01/92 09/30/93 0.9873 0.9644
450083...................... 11/01/92 10/31/93 1.6333 0.9954
450085...................... 10/01/92 09/30/93 1.1216 0.9685
450087...................... 09/01/92 08/31/93 1.5025 0.9952
450094...................... 01/01/93 12/31/93 1.4235 0.9936
450097...................... 01/01/93 12/31/93 1.4090 0.9941
450098...................... 11/01/92 10/31/93 1.2299 0.9667
450101...................... 09/01/92 08/31/93 1.3508 0.9967
450104...................... 01/01/93 12/31/93 1.2856 0.9820
450107...................... 01/01/93 12/31/93 1.5098 0.9993
450108...................... 10/01/92 09/30/93 0.9920 0.9503
450110...................... 10/01/92 09/30/93 1.2126 0.9813
450111...................... 01/01/93 12/31/93 1.2314 0.9807
450112...................... 01/01/93 12/31/93 1.2644 0.9851
450118...................... 09/01/92 08/31/93 1.4703 0.9995
450119...................... 10/01/92 09/30/93 1.3323 0.9792
450121...................... 10/01/92 09/30/93 1.4392 0.9959
450123...................... 01/01/93 12/31/93 1.0602 0.9765
450124...................... 10/01/92 09/30/93 1.5024 0.9994
450127...................... 10/01/92 09/30/93 0.9903 0.9672
450130...................... 01/01/93 12/31/93 1.5092 0.9981
450131...................... 08/01/92 07/31/93 1.2609 0.9834
450132...................... 10/01/92 09/30/93 1.4911 0.9969
450133...................... 10/01/92 09/30/93 1.5495 0.9977
450135...................... 10/01/92 09/30/93 1.7013 0.9977
450137...................... 10/01/92 09/30/93 1.4321 0.9984
450140...................... 10/01/92 09/30/93 0.7344 1.0000
450142...................... 09/01/92 08/31/93 1.3794 0.9909
450144...................... 10/01/92 09/30/93 1.1596 0.9889
450145...................... 01/01/93 12/31/93 0.8709 0.9877
450146...................... 10/01/92 09/30/93 0.9840 0.9445
450148...................... 10/01/92 09/30/93 1.2113 0.9678
450149...................... 11/01/92 10/31/93 1.3300 0.9948
450150...................... 10/01/92 09/30/93 0.9584 0.9347
450151...................... 10/01/92 09/30/93 1.1366 0.9870
450152...................... 10/01/92 09/30/93 1.2880 0.9802
450153...................... 01/01/93 12/31/93 1.5695 0.9982
450154...................... 10/01/92 09/30/93 1.1411 0.9705
450155...................... 10/01/92 09/30/93 1.0793 0.9725
450160...................... 10/01/92 09/30/93 0.8873 0.9636
450162...................... 10/01/92 09/30/93 1.2792 0.9883
450163...................... 01/01/93 12/31/93 1.1244 0.9613
450164...................... 10/01/92 09/30/93 1.0264 0.9673
450165...................... 01/01/93 12/31/93 1.0287 0.9837
450166...................... 01/01/93 12/31/93 1.0260 0.9615
450169...................... 01/01/93 12/31/93 0.8496 0.9265
450176...................... 10/01/92 09/30/93 1.2799 0.9768
450178...................... 01/01/93 12/31/93 1.1402 0.9688
450181...................... 01/01/93 12/31/93 0.9665 0.9649
450185...................... 10/01/92 09/30/93 1.0535 0.9620
450187...................... 01/01/93 12/31/93 1.3229 0.9763
450191...................... 01/01/93 12/31/93 1.1428 0.9738
450193...................... 10/01/92 09/30/93 2.0729 0.9992
450194...................... 01/01/93 12/31/93 1.2606 0.9919
450196...................... 01/01/93 12/31/93 1.4483 0.9963
450197...................... 09/01/92 08/31/93 1.1771 0.9905
450200...................... 10/01/92 09/30/93 1.4946 0.9978
450201...................... 01/01/93 12/31/93 0.9767 0.9204
450203...................... 10/01/92 09/30/93 1.2856 0.9619
450209...................... 10/01/92 09/30/93 1.4245 0.9967
450210...................... 01/01/93 12/31/93 1.1430 0.9671
450211...................... 01/01/93 12/31/93 1.3259 0.9921
450213...................... 01/01/93 12/31/93 1.3590 0.9976
450214...................... 09/01/92 08/31/93 1.4156 0.9859
450224...................... 10/01/92 09/30/93 1.3844 0.9705
450229...................... 09/01/92 08/31/93 1.4522 0.9938
450231...................... 01/01/93 12/31/93 1.5217 0.9989
450234...................... 10/01/92 09/30/93 0.9595 0.9540
450236...................... 10/01/92 09/30/93 1.1361 0.9855
450237...................... 01/01/93 12/31/93 1.4952 0.9965
450239...................... 08/01/92 07/31/93 1.1632 0.9704
450243...................... 09/01/92 08/31/93 0.8553 0.9541
450246...................... 10/01/92 09/30/93 0.9664 0.9090
450249...................... 01/01/93 12/31/93 0.9763 0.9776
450253...................... 01/01/93 12/31/93 1.1186 0.9796
450259...................... 01/01/93 12/31/93 1.1308 0.9880
450264...................... 10/01/92 09/30/93 0.8332 0.9947
450271...................... 01/01/93 12/31/93 1.1021 0.9527
450272...................... 01/01/93 12/31/93 1.2218 0.9668
450276...................... 10/01/92 09/30/93 0.9955 0.9731
450280...................... 01/01/93 12/31/93 1.3367 0.9872
450283...................... 11/01/92 10/31/93 1.0850 0.9363
450286...................... 01/01/93 12/31/93 1.0435 0.9828
450292...................... 10/01/92 09/30/93 1.3346 0.9721
450293...................... 01/01/93 12/31/93 1.0136 0.8852
450296...................... 01/01/93 12/31/93 1.2727 0.9654
450297...................... 01/01/93 12/31/93 1.0763 0.9868
450303...................... 01/01/93 12/31/93 0.9032 0.9655
450306...................... 01/01/93 12/31/93 1.0461 0.9323
450315...................... 09/01/92 08/31/93 1.1804 0.9905
450320...................... 01/01/93 12/31/93 1.4131 0.9889
450321...................... 01/01/93 12/31/93 0.8983 0.9347
450322...................... 01/01/93 12/31/93 0.9826 0.9521
450327...................... 10/01/92 09/30/93 1.0680 0.9805
450330...................... 01/01/93 12/31/93 1.1839 0.9767
450334...................... 10/01/92 09/30/93 0.9974 0.9890
450337...................... 11/01/92 10/31/93 1.2181 0.9732
450340...................... 01/01/93 12/31/93 1.3536 0.9902
450346...................... 09/01/92 08/31/93 1.3487 0.9979
450347...................... 01/01/93 12/31/93 1.1849 0.9745
450348...................... 09/01/92 08/31/93 1.0046 0.9535
450351...................... 10/01/92 09/30/93 1.2674 0.9821
450352...................... 10/01/92 09/30/93 1.2141 0.9699
450353...................... 09/01/92 08/31/93 1.2262 0.9717
450355...................... 08/01/92 07/31/93 1.0721 0.9598
450358...................... 01/01/93 12/31/93 2.0537 0.9987
450366...................... 11/01/92 10/31/93 1.4859 0.9943
450369...................... 10/01/92 09/30/93 1.1163 0.9684
450371...................... 01/01/93 12/31/93 1.1441 0.9907
450373...................... 11/01/92 10/31/93 1.1871 0.9591
450374...................... 10/01/92 09/30/93 0.9045 0.9294
450378...................... 09/01/92 08/31/93 1.1012 0.9822
450388...................... 10/01/92 09/30/93 1.6238 0.9989
450389...................... 11/01/92 10/31/93 1.1982 0.9778
450399...................... 10/01/92 09/30/93 1.0512 0.9375
450410...................... 10/01/92 10/28/93 1.0995 0.9794
450417...................... 01/01/93 12/31/93 1.0336 0.9620
450418...................... 01/01/93 12/31/93 1.3571 0.9795
450419...................... 10/01/92 09/30/93 1.2376 0.9700
450422...................... 10/01/92 09/30/93 0.6567 1.0000
450423...................... 09/01/92 08/31/93 1.2947 0.9967
450424...................... 01/01/93 12/31/93 1.2230 0.9831
450429...................... 12/01/92 11/30/93 1.0429 0.9769
450431...................... 01/01/93 12/31/93 1.5594 0.9981
450438...................... 01/01/93 12/31/93 1.1015 0.9603
450446...................... 01/01/93 12/31/93 0.9424 0.9991
450450...................... 10/01/92 09/30/93 1.0317 1.0000
450462...................... 10/01/92 09/30/93 1.8303 0.9993
450464...................... 10/01/92 09/30/93 0.9909 0.9595
450465...................... 10/01/92 09/30/93 1.2418 0.9733
450475...................... 10/01/92 09/30/93 1.1162 0.9792
450488...................... 10/01/92 09/30/93 1.2245 0.9716
450514...................... 01/01/93 12/31/93 1.1370 0.9844
450518...................... 01/01/93 12/31/93 1.4441 0.9961
450523...................... 01/01/93 12/31/93 1.4932 0.9954
450530...................... 12/01/92 11/30/93 1.3072 0.9871
450534...................... 10/01/92 09/30/93 0.9752 0.9694
450535...................... 01/01/93 12/31/93 1.1633 0.9785
450538...................... 01/01/93 12/31/93 1.2042 0.9607
450544...................... 08/01/92 07/31/93 1.2769 0.9936
450546...................... 10/01/92 09/30/93 1.2723 0.9875
450547...................... 10/01/92 09/30/93 1.0015 0.9683
450550...................... 01/01/93 12/31/93 1.0494 0.9948
450559...................... 10/01/92 09/30/93 0.8866 0.8683
450561...................... 01/01/93 12/31/93 1.6628 0.9989
450565...................... 10/01/92 09/30/93 1.3484 0.9787
450570...................... 01/01/93 12/31/93 1.0703 0.9809
450571...................... 10/01/92 09/30/93 1.4719 0.9985
450574...................... 10/01/92 09/30/93 1.0200 0.9397
450575...................... 10/01/92 09/30/93 0.9748 0.9712
450578...................... 10/01/92 09/30/93 0.9341 0.9348
450580...................... 10/01/92 09/30/93 1.1558 0.9891
450583...................... 10/01/92 09/30/93 0.9511 0.9938
450584...................... 10/01/92 09/30/93 1.1657 0.9814
450587...................... 09/01/92 08/31/93 1.2707 0.9782
450591...................... 10/01/92 09/30/93 1.1453 0.9770
450596...................... 10/01/92 09/30/93 1.2575 0.9742
450597...................... 10/01/92 09/30/93 1.0343 0.9849
450604...................... 01/01/93 12/31/93 1.2793 0.9670
450605...................... 01/01/93 12/31/93 1.3119 0.9880
450607...................... 10/01/92 09/30/93 0.9595 0.9761
450609...................... 10/01/92 09/30/93 0.9097 0.9701
450614...................... 10/01/92 09/30/93 1.0651 0.9303
450615...................... 01/01/93 12/31/93 0.9485 0.9606
450620...................... 10/01/92 09/30/93 1.0977 0.9505
450623...................... 10/01/92 09/30/93 1.1686 0.9580
450626...................... 10/01/92 09/30/93 1.0407 0.9510
450628...................... 10/01/92 09/30/93 0.9528 0.9494
450631...................... 09/01/92 08/31/93 1.6508 0.9992
450632...................... 10/01/92 09/30/93 1.0081 0.9743
450634...................... 01/01/93 12/31/93 1.4317 0.9910
450637...................... 09/01/92 08/31/93 1.4337 0.9785
450639...................... 10/01/92 09/30/93 1.4535 0.9960
450644...................... 09/01/92 08/31/93 1.6076 0.9966
450646...................... 01/01/93 12/31/93 1.5501 0.9969
450648...................... 10/01/92 09/30/93 1.0880 0.9681
450652...................... 10/01/92 09/30/93 0.9808 0.9578
450654...................... 10/01/92 09/30/93 0.9830 0.9911
450656...................... 01/01/93 12/31/93 1.3583 0.9870
450659...................... 01/01/93 12/31/93 1.4444 0.9973
450661...................... 01/01/93 12/31/93 1.1990 0.9907
450662...................... 09/01/92 08/31/93 1.3959 0.9793
450672...................... 08/01/92 07/31/93 1.6183 0.9991
450673...................... 10/01/92 09/30/93 1.1056 0.9488
450677...................... 01/01/93 12/31/93 1.3598 0.9933
450686...................... 01/01/93 12/31/93 1.5699 0.9956
450690...................... 09/01/92 08/31/93 1.3647 0.9980
450696...................... 11/01/92 10/31/93 1.7050 0.9872
450697...................... 01/01/93 12/31/93 1.3499 0.9948
450698...................... 10/01/92 09/30/93 0.9337 0.9197
450700...................... 01/01/93 12/31/93 0.9273 0.9721
450702...................... 09/01/92 08/31/93 1.4787 0.9958
450703...................... 01/01/93 12/31/93 1.4690 0.9912
450705...................... 10/01/92 09/30/93 0.7885 0.9353
450706...................... 01/01/93 12/31/93 1.2043 0.9836
450711...................... 10/01/92 09/30/93 1.6887 0.9986
450712...................... 11/01/92 10/31/93 0.9574 0.9827
450713...................... 01/01/93 12/31/93 1.4404 0.9981
450715...................... 09/01/92 08/31/93 1.3023 0.9930
450716...................... 01/01/93 12/31/93 1.2254 0.9727
450717...................... 01/01/93 12/31/93 1.2321 0.9698
450718...................... 01/01/93 12/31/93 1.2390 0.9834
450724...................... 01/01/93 12/31/93 1.2022 0.9943
450726...................... 10/01/92 09/30/93 0.8996 0.9687
450727...................... 10/01/92 09/30/93 0.9013 0.9666
450728...................... 10/01/92 09/30/93 0.9002 0.9897
450733...................... 09/01/92 08/31/93 1.3816 0.9799
450734...................... 09/01/92 08/31/93 1.5033 0.9916
450735...................... 01/01/93 12/31/93 0.8222 0.9044
450745...................... 01/01/93 12/31/93 0.8306 0.9924
450746...................... 10/01/92 09/30/93 0.9600 0.9131
450747...................... 01/01/93 12/31/93 1.3013 0.9898
450751...................... 01/01/93 12/31/93 1.3089 0.9604
450754...................... 10/01/92 09/30/93 1.0744 0.9731
450757...................... 01/01/93 12/31/93 0.9753 0.9523
450760...................... 01/01/93 12/31/93 1.2135 0.9820
450761...................... 10/01/92 09/30/93 1.0987 0.9728
450763...................... 10/01/92 09/30/93 1.0960 0.9665
450766...................... 01/01/93 12/31/93 2.1686 0.9984
450769...................... 10/01/92 09/30/93 0.9394 0.9809
450771...................... 10/01/92 09/30/93 1.7787 0.9913
450775...................... 01/01/93 12/31/93 1.2367 0.9928
450778...................... 01/01/93 12/31/93 0.8795 0.9700
450779...................... 10/01/92 09/30/93 1.2407 0.9753
450781...................... 01/01/93 12/31/93 1.4260 1.0000
460001...................... 01/01/93 12/31/93 1.6662 0.9986
460004...................... 01/01/93 12/31/93 1.6966 0.9972
460006...................... 01/01/93 12/31/93 1.2825 0.9864
460007...................... 01/01/93 12/31/93 1.2450 0.9673
460010...................... 01/01/93 12/31/93 2.0494 0.9990
460011...................... 01/01/93 12/31/93 1.4116 0.9660
460013...................... 09/01/92 08/31/93 1.5270 0.9819
460014...................... 01/01/93 12/31/93 0.9603 0.9104
460015...................... 01/01/93 12/31/93 1.2705 0.9730
460016...................... 01/01/93 12/31/93 0.8869 0.9799
460017...................... 09/01/92 08/31/93 1.3493 0.9576
460018...................... 01/01/93 12/31/93 0.9364 0.9708
460019...................... 01/01/93 12/31/93 0.9010 0.9478
460020...................... 01/01/93 12/31/93 0.9660 0.9778
460021...................... 01/01/93 12/31/93 1.3717 0.9870
460022...................... 01/01/93 12/31/93 1.0070 0.9786
460023...................... 01/01/93 12/31/93 1.1527 0.9704
460024...................... 01/01/93 12/31/93 0.9599 0.8976
460025...................... 01/01/93 12/31/93 0.8122 0.9970
460026...................... 01/01/93 12/31/93 0.9555 0.9176
460027...................... 01/01/93 12/31/93 0.9862 1.0000
460029...................... 01/01/93 12/31/93 1.0516 0.9022
460033...................... 01/01/93 12/31/93 0.9359 0.8857
460036...................... 01/01/93 12/31/93 0.9067 0.9566
460039...................... 01/01/93 12/31/93 0.9762 0.9536
460041...................... 09/01/92 08/31/93 1.2303 0.9770
460042...................... 10/01/92 09/30/93 1.5075 0.9907
460043...................... 01/01/93 12/31/93 1.3975 0.9754
460044...................... 01/01/93 12/31/93 1.1367 0.9654
460046...................... 01/01/93 12/31/93 1.5177 1.0000
460047...................... 11/01/92 10/31/93 1.6668 0.9995
460049...................... 01/01/93 12/31/93 1.9488 0.9855
470001...................... 10/01/92 09/30/93 1.1529 0.9788
470003...................... 10/01/92 09/30/93 1.9353 0.9987
470004...................... 10/01/92 09/30/93 1.0444 0.9721
470005...................... 10/01/92 09/30/93 1.1868 0.9855
470006...................... 10/01/92 09/30/93 1.1341 0.9682
470008...................... 10/01/92 09/30/93 1.1875 0.9795
470010...................... 10/01/92 09/30/93 1.0823 0.9560
470011...................... 10/01/92 09/30/93 1.1180 0.9840
470012...................... 10/01/92 09/30/93 1.2081 0.9827
470013...................... 10/01/92 09/30/93 1.1462 0.9885
470015...................... 10/01/92 09/30/93 1.1905 0.9828
470018...................... 10/01/92 09/30/93 1.1276 0.9761
470020...................... 10/01/92 09/30/93 1.0117 0.9955
470023...................... 10/01/92 09/30/93 1.2259 0.9673
470024...................... 10/01/92 09/30/93 1.1281 0.9521
490001...................... 10/01/92 09/30/93 1.1212 0.9724
490002...................... 10/01/92 09/30/93 1.0303 0.9805
490003...................... 10/01/92 09/30/93 0.6533 1.0000
490004...................... 01/01/93 12/31/93 1.1926 0.9916
490005...................... 01/01/93 12/31/93 1.4747 0.9975
490006...................... 10/01/92 09/30/93 1.1342 0.9784
490011...................... 01/01/93 12/31/93 1.3154 0.9931
490012...................... 08/01/92 07/31/93 1.1102 0.9597
490013...................... 09/01/92 08/31/93 1.1656 0.9907
490014...................... 01/01/93 12/31/93 1.5210 0.9746
490015...................... 01/01/93 12/31/93 1.4380 0.9952
490017...................... 09/01/92 08/31/93 1.3682 0.9906
490018...................... 01/01/93 12/31/93 1.2061 0.9755
490019...................... 10/01/92 09/30/93 1.1170 0.9708
490020...................... 01/01/93 12/31/93 1.1625 0.9756
490021...................... 01/01/93 12/31/93 1.4381 0.9975
490023...................... 10/01/92 09/30/93 1.2276 0.9890
490024...................... 10/01/92 09/30/93 1.6106 0.9987
490027...................... 10/01/92 09/30/93 1.1662 0.9822
490030...................... 10/01/92 09/30/93 1.2489 0.9933
490031...................... 01/01/93 12/31/93 1.1272 0.9696
490033...................... 01/01/93 12/31/93 1.1625 0.9743
490037...................... 01/01/93 12/31/93 1.1563 0.9844
490038...................... 10/01/92 09/30/93 1.2792 0.9815
490040...................... 09/28/92 09/30/93 1.3654 0.9977
490041...................... 01/01/93 12/31/93 1.2177 0.9836
490042...................... 10/01/92 09/30/93 1.3528 0.9906
490044...................... 10/01/92 09/30/93 1.3149 0.9891
490045...................... 10/01/92 09/30/93 1.1794 0.9915
490047...................... 10/01/92 09/30/93 1.0797 0.9693
490048...................... 01/01/93 12/31/93 1.4825 0.9989
490050...................... 01/01/93 12/31/93 1.3697 0.9969
490052...................... 01/01/93 12/31/93 1.5252 0.9980
490054...................... 10/01/92 09/30/93 1.0583 0.9626
490057...................... 01/01/93 12/31/93 1.4443 0.9995
490059...................... 09/01/92 08/31/93 1.5040 0.9983
490063...................... 01/01/93 12/31/93 1.5830 0.9977
490066...................... 01/01/93 12/31/93 1.2601 0.9679
490067...................... 01/01/93 12/31/93 1.2726 0.9901
490069...................... 10/01/92 09/30/93 1.3977 0.9991
490071...................... 01/01/93 12/31/93 1.4564 0.9987
490073...................... 09/01/92 08/31/93 1.3336 0.9901
490074...................... 01/01/93 12/31/93 1.2696 0.9964
490075...................... 01/01/93 12/31/93 1.2758 0.9881
490077...................... 09/01/92 09/30/93 1.1976 0.9930
490079...................... 01/01/93 12/31/93 1.3247 0.9864
490083...................... 10/01/92 09/30/93 0.6598 0.9872
490084...................... 01/01/93 12/31/93 1.2540 0.9275
490085...................... 10/01/92 09/30/93 1.1265 0.9743
490088...................... 10/01/92 09/30/93 1.2348 0.9678
490089...................... 10/01/92 09/30/93 1.0421 0.9685
490091...................... 10/01/92 09/30/93 1.1800 0.9950
490092...................... 01/01/93 12/31/93 1.1719 0.9841
490095...................... 01/01/93 12/31/93 1.2308 0.9927
490097...................... 09/01/92 08/31/93 1.1397 0.9801
490099...................... 09/01/92 08/31/93 0.9543 0.9747
490100...................... 10/01/92 09/30/93 1.3135 0.9962
490101...................... 01/01/93 12/31/93 1.1168 0.9865
490107...................... 01/01/93 12/31/93 1.2403 0.9884
490110...................... 10/01/92 09/30/93 1.1815 0.9958
490112...................... 09/01/92 08/31/93 1.6120 0.9981
490113...................... 11/01/92 10/31/93 1.3151 0.9737
490115...................... 10/01/92 09/30/93 1.2135 0.9776
490116...................... 09/01/92 08/31/93 1.1768 0.9831
490117...................... 12/01/92 11/30/93 1.0905 0.9829
490122...................... 01/01/93 12/31/93 1.2940 0.9931
490126...................... 10/01/92 09/30/93 1.2624 0.9847
490130...................... 01/01/93 12/31/93 1.2343 0.9794
500001...................... 01/01/93 12/31/93 1.2956 0.9811
500002...................... 01/01/93 12/31/93 1.4166 0.9925
500003...................... 01/01/93 12/31/93 1.2748 0.9867
500005...................... 01/01/93 12/31/93 1.7752 0.9988
500007...................... 01/01/93 12/31/93 1.3853 0.9783
500009...................... 01/01/93 12/31/93 1.2846 0.9910
500011...................... 01/01/93 12/31/93 1.3627 0.9857
500012...................... 01/01/93 12/31/93 1.4992 0.9983
500014...................... 01/01/93 12/31/93 1.7478 0.9980
500015...................... 01/01/93 12/31/93 1.3100 0.9839
500016...................... 01/01/93 12/31/93 1.3521 0.9895
500019...................... 01/01/93 12/31/93 1.2908 0.9735
500024...................... 01/01/93 12/31/93 1.6333 0.9975
500025...................... 01/01/93 12/31/93 1.8081 0.9993
500026...................... 01/01/93 12/31/93 1.3471 0.9861
500027...................... 01/01/93 12/31/93 1.5375 0.9985
500028...................... 01/01/93 12/31/93 1.0891 0.9784
500029...................... 01/01/93 12/31/93 0.9736 0.9645
500031...................... 01/01/93 12/31/93 1.3115 0.9648
500033...................... 01/01/93 12/31/93 1.2382 0.9664
500036...................... 11/01/92 10/31/93 1.2606 0.9953
500037...................... 01/01/93 12/31/93 1.1316 0.9741
500042...................... 01/01/93 12/31/93 1.3298 0.9813
500043...................... 01/01/93 12/31/93 1.2137 0.9517
500044...................... 01/01/93 12/31/93 1.9182 0.9987
500045...................... 01/01/93 12/31/93 1.0800 0.9877
500048...................... 07/31/92 07/31/93 0.8958 0.9850
500049...................... 01/01/93 12/31/93 1.3649 0.9884
500050...................... 10/01/92 09/30/93 1.4158 0.9929
500051...................... 10/01/92 09/30/93 1.6705 0.9974
500052...................... 01/01/93 12/31/93 1.2445 0.9956
500053...................... 01/01/93 12/31/93 1.1791 0.9835
500054...................... 01/01/93 12/31/93 1.8311 0.9981
500055...................... 07/31/92 07/31/93 1.0777 0.9624
500057...................... 10/01/92 09/30/93 1.2986 0.9895
500058...................... 01/01/93 12/31/93 1.4679 0.9829
500059...................... 01/01/93 12/31/93 1.1381 0.9508
500060...................... 01/01/93 12/31/93 1.3623 0.9776
500061...................... 01/01/93 12/31/93 1.0214 0.9299
500062...................... 01/01/93 12/31/93 1.0006 0.9582
500065...................... 01/01/93 12/31/93 1.2467 0.9554
500068...................... 01/01/93 12/31/93 1.0086 0.9877
500069...................... 01/01/93 12/31/93 1.0708 0.9479
500071...................... 01/01/93 12/31/93 1.3154 0.9610
500072...................... 01/01/93 12/31/93 1.1679 0.9717
500073...................... 01/01/93 12/31/93 1.0310 0.9704
500074...................... 01/01/93 12/31/93 1.1535 0.9698
500075...................... 01/01/93 12/31/93 1.2607 0.9876
500077...................... 07/31/92 07/31/93 1.2964 0.9900
500079...................... 10/01/92 09/30/93 1.2913 0.9806
500080...................... 01/01/93 12/31/93 0.8502 0.9649
500084...................... 01/01/93 12/31/93 1.1419 0.9770
500085...................... 01/01/93 12/31/93 1.0406 0.9797
500088...................... 01/01/93 12/31/93 1.2767 0.9932
500089...................... 01/01/93 12/31/93 1.0438 0.9382
500090...................... 01/01/93 12/31/93 0.9151 0.9491
500092...................... 01/01/93 12/31/93 1.1053 0.9900
500094...................... 01/01/93 12/31/93 0.8820 0.9436
500096...................... 01/01/93 12/31/93 0.9566 0.9114
500097...................... 01/01/93 12/31/93 1.1511 0.9917
500098...................... 01/01/93 12/31/93 0.8613 0.9796
500101...................... 01/01/93 12/31/93 0.9791 0.9257
500102...................... 01/01/93 12/31/93 0.9557 0.9646
500106...................... 01/01/93 12/31/93 0.9810 1.0000
500107...................... 01/01/93 12/31/93 1.1299 0.9650
500110...................... 01/01/93 12/31/93 1.1962 0.9660
500118...................... 01/01/93 12/31/93 1.1366 0.9566
500119...................... 01/01/93 12/31/93 1.3361 0.9850
500122...................... 01/01/93 12/31/93 1.2758 0.9671
500123...................... 01/01/93 12/31/93 0.9518 0.9693
500124...................... 01/01/93 12/31/93 1.2620 0.9862
500125...................... 01/01/93 12/31/93 0.9871 0.9753
500129...................... 01/01/93 12/31/93 1.6213 0.9969
500132...................... 01/01/93 12/31/93 0.9812 0.9778
500134...................... 01/01/93 12/31/93 0.7564 0.9908
500140...................... 10/01/92 09/30/93 0.9994 1.0000
500143...................... 01/01/93 12/31/93 0.9606 1.0000
510001...................... 01/01/93 12/31/93 1.6692 0.9967
510004...................... 11/01/92 10/31/93 0.9852 0.9357
510005...................... 01/01/93 12/31/93 0.9215 0.9664
510006...................... 10/01/92 09/30/93 1.2082 0.9927
510007...................... 10/01/92 09/30/93 1.4251 0.9996
510008...................... 01/01/93 12/31/93 1.1030 0.9879
510009...................... 01/01/93 12/31/93 0.9489 0.9634
510012...................... 10/01/92 09/30/93 1.0837 0.9814
510013...................... 10/01/92 09/30/93 1.1870 0.9961
510016...................... 01/01/93 12/31/93 1.0547 0.9523
510018...................... 10/01/92 09/30/93 1.0655 0.9715
510022...................... 01/01/93 12/31/93 1.6800 0.9988
510028...................... 01/01/93 12/31/93 1.1789 0.9959
510029...................... 10/01/92 09/30/93 1.2601 0.9857
510030...................... 10/01/92 09/30/93 1.1186 0.9742
510031...................... 01/01/93 12/31/93 1.2811 0.9915
510033...................... 01/01/93 12/31/93 1.2676 0.9909
510038...................... 10/01/92 09/30/93 1.0372 0.9627
510039...................... 01/01/93 12/31/93 1.3804 0.9927
510047...................... 01/01/93 12/31/93 1.1575 0.9871
510048...................... 01/01/93 12/31/93 1.0964 0.9891
510050...................... 10/01/92 09/30/93 1.2948 0.9897
510053...................... 10/01/92 09/30/93 1.0235 0.9571
510055...................... 10/01/92 09/30/93 1.2079 0.9958
510059...................... 01/01/93 12/31/93 1.1021 0.9868
510060...................... 09/01/92 08/31/93 1.0778 0.9850
510063...................... 01/01/93 12/31/93 1.0425 0.9849
510065...................... 01/01/93 12/31/93 0.9752 0.9547
510066...................... 01/01/93 12/31/93 1.1037 0.9925
510068...................... 10/01/92 09/30/93 1.0689 0.9797
510076...................... 01/01/93 12/31/93 1.0921 1.0000
510077...................... 10/01/92 09/30/93 1.1403 0.9825
510081...................... 10/01/92 09/30/93 0.9906 0.9820
510082...................... 01/01/93 12/31/93 1.0537 0.9579
510084...................... 01/01/93 12/31/93 0.9892 0.9632
510085...................... 10/01/92 09/30/93 1.2735 0.9811
520002...................... 10/01/92 09/30/93 1.2890 0.9818
520003...................... 01/01/93 12/31/93 1.1050 0.9683
520008...................... 10/01/92 09/30/93 1.4769 0.9960
520010...................... 01/01/93 12/31/93 1.1270 0.9507
520014...................... 10/01/92 09/30/93 1.2316 0.9837
520018...................... 10/01/92 09/30/93 1.0667 0.9711
520019...................... 10/01/92 09/30/93 1.2893 0.9819
520021...................... 10/01/92 09/30/93 1.2964 0.9904
520024...................... 10/01/92 09/30/93 1.0642 0.9702
520026...................... 01/01/93 12/31/93 1.0323 0.9758
520029...................... 10/01/92 09/30/93 0.9338 0.9580
520031...................... 10/01/92 09/30/93 1.0938 0.9763
520032...................... 10/01/92 09/30/93 1.1463 0.9725
520033...................... 09/01/92 08/31/93 1.2266 0.9595
520034...................... 10/01/92 09/30/93 1.1916 0.9779
520035...................... 01/01/93 12/31/93 1.2612 0.9868
520037...................... 10/01/92 09/30/93 1.6234 0.9986
520038...................... 01/01/93 12/31/93 1.3704 0.9765
520039...................... 01/01/93 12/31/93 0.9783 0.9535
520042...................... 10/01/92 09/30/93 1.1130 0.9735
520045...................... 01/01/93 12/31/93 1.6036 0.9969
520048...................... 10/01/92 09/30/93 1.3810 0.9963
520049...................... 10/01/92 09/30/93 1.9371 0.9962
520053...................... 01/01/93 12/31/93 1.0585 0.9423
520054...................... 01/01/93 12/31/93 1.0702 0.9753
520056...................... 10/01/92 09/30/93 1.3230 0.9887
520057...................... 01/01/93 12/31/93 1.0970 0.9732
520058...................... 10/01/92 09/30/93 1.0794 0.9581
520059...................... 10/01/92 09/30/93 1.2539 0.9852
520060...................... 10/01/92 09/30/93 1.3107 0.9574
520062...................... 10/01/92 09/30/93 1.2092 0.9629
520064...................... 12/27/92 12/31/93 1.6474 0.9943
520069...................... 01/01/93 12/31/93 1.2191 0.9893
520070...................... 01/01/93 12/31/93 1.4103 0.9815
520071...................... 10/01/92 09/30/93 1.1051 0.9747
520077...................... 10/01/92 09/30/93 0.9968 0.9757
520078...................... 01/01/93 12/31/93 1.4378 0.9934
520082...................... 08/01/92 07/31/93 1.2970 0.9855
520083...................... 01/01/93 12/31/93 1.5952 0.9992
520084...................... 10/01/92 09/30/93 1.0802 0.9738
520089...................... 01/01/93 12/31/93 1.5188 0.9972
520090...................... 10/01/92 09/30/93 1.1714 0.9667
520095...................... 01/01/93 12/31/93 1.3687 0.9769
520100...................... 01/01/93 12/31/93 1.2380 0.9857
520101...................... 10/01/92 09/30/93 1.1212 0.9571
520102...................... 01/01/93 12/31/93 1.1948 0.9665
520103...................... 10/01/92 09/30/93 1.2877 0.9748
520107...................... 01/01/93 12/31/93 1.2787 0.9811
520109...................... 10/01/92 09/30/93 1.0413 0.9618
520110...................... 01/01/93 12/31/93 1.0906 0.9666
520113...................... 10/01/92 09/30/93 1.1974 0.9771
520115...................... 10/01/92 09/30/93 1.3121 0.9651
520116...................... 10/01/92 09/30/93 1.2580 0.9670
520117...................... 09/01/92 08/31/93 1.0937 0.9691
520118...................... 01/01/93 12/31/93 0.9813 0.9424
520123...................... 10/01/92 09/30/93 1.0403 0.9570
520130...................... 10/01/92 09/30/93 1.0053 0.9478
520131...................... 01/01/93 12/31/93 1.0173 0.9332
520132...................... 01/01/93 12/31/93 1.1589 0.9583
520135...................... 01/01/93 12/31/93 1.0036 0.9704
520138...................... 12/26/92 12/31/93 1.8543 0.9984
520139...................... 08/31/92 08/29/93 1.2257 0.9809
520140...................... 01/01/93 12/31/93 1.4922 0.9974
520144...................... 10/01/92 09/30/93 1.0560 0.9699
520145...................... 01/01/93 12/31/93 1.0227 0.9840
520146...................... 01/01/93 12/31/93 1.1404 0.9575
520148...................... 01/01/93 12/31/93 1.1299 0.9744
520149...................... 01/01/93 12/31/93 0.9074 0.9356
520152...................... 10/01/92 09/30/93 1.1361 0.9660
520153...................... 10/01/92 09/30/93 0.9318 0.9436
520154...................... 10/01/92 09/30/93 1.1043 0.9690
520156...................... 01/01/93 12/31/93 1.0618 0.9488
520157...................... 01/01/93 12/31/93 0.9858 0.9626
520160...................... 01/01/93 12/31/93 1.7738 0.9982
520171...................... 01/01/93 12/31/93 1.0070 0.9663
520173...................... 10/01/92 09/30/93 1.1165 0.9713
520174...................... 01/01/93 12/31/93 1.4505 0.9901
520177...................... 01/01/93 12/31/93 1.5704 0.9936
530008...................... 01/01/93 12/31/93 1.1828 0.9768
530010...................... 01/01/93 12/31/93 1.3037 0.9781
530023...................... 01/01/93 12/31/93 0.9412 0.9082
530032...................... 01/01/93 12/31/93 1.1791 0.9448
------------------------------------------------------------------------
Table 10.--Percentage Difference in Wage Indexes for Areas That Qualify for a Wage Index Exception for Excluded
Hospitals and Units
----------------------------------------------------------------------------------------------------------------
1982-1991 1984-1991 1988-1991 1990-1991
Area percentage percentage percentage percentage
difference difference difference difference
----------------------------------------------------------------------------------------------------------------
Rural Connecticut........................................... 17.895 20.236
Rural Massachusetts......................................... 20.640 24.568 8.239
Rural New Hampshire......................................... ........... 9.986
Rural Vermont............................................... ........... 8.798
Albany, GA.................................................. 8.660 13.220 9.482
Anchorage, AK............................................... ........... ........... ........... 8.008
Anderson, SC................................................ ........... ........... ........... 15.455
Ann Arbor, MI............................................... ........... 12.237 14.069
Athens, GA.................................................. 9.131 14.730
Atlanta, GA................................................. ........... 11.062 ........... 9.275
Atlanta City, NJ............................................ ........... 10.448
Bergen-Passaic, NJ.......................................... 8.272 10.120 12.033
Boston-Lowell-Brockton-Lawrence-Salem, MA................... ........... 10.987
Bridgeport-Stamford-Norwalk-Danbury, CT..................... ........... 11.339
Burlington, NC.............................................. 8.991 12.261
Caguas, PR.................................................. ........... 10.068
Charlotte-Gastonia-Rock Hill, NC-SC......................... ........... 14.308
Clarksville-Hopkinsville, TN-KY............................. ........... ........... ........... 9.997
Decatur, AL................................................. ........... 9.167
Eugene-Springfield, OR...................................... ........... ........... ........... 11.538
Florence, SC................................................ 12.905 11.747
Fort Walton Beach, FL....................................... ........... 8.739
Hartford-Middletown-New Britain, CT......................... 8.891 12.615
Houma-Thibodaux, LA......................................... ........... ........... 8.143
Kankakee, IL................................................ ........... ........... 10.417 10.808
Killeen-Temple, TX.......................................... 17.565
Las Cruse, NM............................................... ........... ........... 11.129
Macon-Warner Robins, GA..................................... ........... 16.032
Manchester-Nashua, NH....................................... 13.145 14.543
Monmouth-Ocean, NJ.......................................... 10.035 15.415 9.335
Muncie, IN.................................................. ........... ........... 17.659 11.058
Nassau-Suffolk, NY.......................................... ........... 13.191
New Bedford-Fall River-Attleboro, MA........................ 8.973 11.721
New Haven-West Haven-Waterbury, CT.......................... 10.226 14.515
New London-Norwich, CT...................................... 8.071 11.576
Newark, NJ.................................................. ........... 11.177
Omaha, NE-IA................................................ ........... ........... 8.881
Orange County, NY........................................... 10.504 14.539
Pine Bluff, AR.............................................. 8.281 ........... 9.202
Pittsfield, MA.............................................. 11.294 10.468
Portsmouth-Dover-Rochester, RH.............................. 10.388 9.214
Poughkeepsie, NY............................................ ........... 9.951
Providence-Pawtucket-Woonsocket, RI......................... ........... 14.391
Redding, CA................................................. ........... 14.231
Salinas-Seaside-Monterey, CA................................ 10.247 9.283
Santa Cruz, CA.............................................. 9.664 9.744
Santa Fe, NM................................................ 10.789 13.638 17.875
Sarasota, FL................................................ ........... 8.860
Savannah, GA................................................ ........... 12.264 13.341 8.786
Wilmington, NC.............................................. ........... 13.339
Worcester-Fitchburg-Leominster, MA.......................... 13.671 20.877 ........... 8.214
----------------------------------------------------------------------------------------------------------------
Appendix A--Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA)(5 U.S.C. 601
through 612), unless the Secretary certifies that a final rule would
not have a significant economic impact on a substantial number of small
entities. For purposes of the RFA, we consider all hospitals to be
small entities.
Also, section 1102(b) of the Act requires the Secretary to prepare
a regulatory impact analysis for any final rule that may have a
significant impact on the operations of a substantial number of small
rural hospitals. Such an analysis must conform to the provisions of
section 603 of the RFA. With the exception of hospitals located in
certain New England counties, for purposes of section 1102(b) of the
Act, we define a small rural hospital as a hospital with fewer than 100
beds that is located outside of a Metropolitan Statistical Area (MSA)
or New England County Metropolitan Area (NECMA). Section 601(g) of the
Social Security Amendments of 1983 (Public Law 98-21) designated
hospitals in certain New England counties as belonging to the adjacent
New England County Metropolitan Area. Thus, for purposes of the
prospective payment system, we classified these hospitals as urban
hospitals.
It is clear that the changes being implemented in this document
will affect both a substantial number of small rural hospitals as well
as other classes of hospitals, and the effects on some may be
significant. Therefore, the discussion below, in combination with the
rest of this final rule, constitutes a combined regulatory impact
analysis and regulatory flexibility analysis.
II. Changes in the Final Rule
For the most part, the policies set forth in this final rule with
comment period are the same as those in the proposed rule. For impact
analysis purposes, the only significant alteration from the proposed
rule is that we have decided not to change the definition and the
payment methodology for transfer cases. In the proposed rule, the net
effect on all payments of these changes were budget neutral compared to
total payments under current transfer policy. The distributional
effects of these changes were to increase payments to rural hospitals
by 0.5 percent and decrease urban hospitals' payments by 0.1 percent.
Otherwise, the differences in this final rule impact analysis
compared to that in the proposed rule are the result of using more
recent or more complete hospital data. For example, a more complete FY
1993 MedPAR file (June 1994 update) is now available compared to the
one available at the time of the proposed rule. In addition, more
recent hospital-specific data, including cost reports, are used in this
analysis.
Our most recent hospital market basket forecasts are unchanged from
the forecasts reported in the proposed rule: 3.6 percent for
prospective payment system hospitals and 3.7 percent for hospitals
excluded from the prospective payment system. Therefore, the applicable
update factors for inpatient hospital operating payments are unchanged
from the proposed rule.
We note that one other change implemented in this final rule is the
revision of the criteria used by the MGCRB to decide on applications by
hospitals for geographic reclassification for prospective payment
purposes. As discussed in section III.F of this final rule with comment
period, we are eliminating the requirement that an individual hospital
be located in an area adjacent to the area to which it seeks
reclassification. This change is effective for hospitals seeking
reclassification for FY 1996 and thus has no economic effect in FY
1995.
III. Limitations of Our Analysis
As has been the case in previously published regulatory impact
analyses, the following quantitative analysis presents the projected
effects of our policy changes, as well as statutory changes effective
for FY 1995, on various hospital groups. We estimate the effects of
each policy change by estimating payments while holding all other
payment variables constant. We use the best data available, but we do
not attempt to predict behavioral responses to our policy changes, and
we do not make adjustments for future changes in such variables as
admissions, lengths of stay, or case mix.
We received no comments on the methodology used for the impact
analysis in the proposed rule.
IV. Hospitals Included In and Excluded From the Prospective Payment
System
The prospective payment systems for hospital inpatient operating
and capital-related costs encompass nearly all general, short-term,
acute care hospitals that participate in the Medicare program. We have
included in our analysis only hospitals paid under these systems. There
were 48 Indian Health Service Hospitals in our database, which we
excluded from the analysis due to the special characteristics of the
payment method for these hospitals. Only 55 short-term, acute care
hospitals remain excluded from the prospective payment system under
section 1814(b)(3) of the Act (in Maryland) or a demonstration project
(in the Finger Lakes region of New York State). Thus, as of August
1994, just over 5,200 hospitals were receiving prospectively based
payments for furnishing inpatient services. This represents about 81
percent of all Medicare-participating hospitals. The majority of this
impact analysis focuses on this set of hospitals.
The remaining 19 percent are specialty hospitals that are excluded
from the prospective payment system and continue to be paid on the
basis of their reasonable costs, subject to a rate-of-increase ceiling
on their inpatient operating costs. These hospitals include
psychiatric, rehabilitation, long-term care, children's, and cancer
hospitals. The impact on these hospitals of the changes implemented in
this final rule is discussed below.
V. Impact on Excluded Hospitals and Units
As of August 1994, just under 2,000 specialty hospitals are
excluded from the prospective payment system and are instead paid on a
reasonable cost basis subject to the rate-of-increase ceiling under
Sec. 413.40. In addition, 1,932 psychiatric and rehabilitation units in
hospitals that are subject to the prospective payment system and 9
hospitals extensively involved either in the treatment of cancer or in
cancer research are also excluded from the prospective payment system
and paid in accordance with Sec. 413.40.
In accordance with section 13502 of Public Law 103-66, the update
factor applicable to the rate-of-increase limit for excluded hospitals
and units for FY 1995 is the hospital market basket minus 1.0
percentage point, adjusted to account for the relationship between the
hospital's allowable operating cost per case and its target amounts. We
are projecting an increase in the excluded hospital market basket of
3.7 percent.
The impact on excluded hospitals and units of the update in the
rate-of-increase limit depends on the cumulative cost increases
experienced by each excluded hospital and excluded unit since its
applicable base period. For excluded hospitals and units that have
maintained their cost increases since their base period at a level
below the percentage increases in the rate-of-increase limits, the
major effect will be on the level of incentive payments these hospitals
and units receive. Conversely, for excluded hospitals and units with
per-case cost increases above the cumulative update in their rate-of-
increase limit, the major effect will be the amount of excess costs
that the hospitals will have to absorb.
In this context, we note that Sec. 413.40(d)(3) allows an excluded
hospital or unit whose costs exceed the rate-of-increase limit to
receive the lower of its rate-of-increase ceiling plus 50 percent of
reasonable costs in excess of the ceiling, or 110 percent of its
ceiling. In addition, under the various provisions set forth in
Sec. 413.40, excluded hospitals and units can obtain substantial relief
from the rate-of-increase limit for significant, yet justifiable,
increases in operating costs that exceed the limit. At the same time,
however, by generally limiting payment increases to the growth rate in
the hospital market basket, we continue to provide an incentive for
excluded hospitals and units to restrain the growth in their spending
for patient services.
In this final rule, we are establishing new exclusion criteria for
long-term care hospitals that define a minimum level of independence a
new hospital must meet to qualify for exclusion from the prospective
payment system (see section VI.A. of the preamble). We anticipate that
this change will slow the proliferation of entities qualifying for
exclusion as long-term care hospitals. Thus, these entities will be
paid under the prospective payment system rather than on a reasonable
cost basis subject to the rate-of-increase ceiling. Although we cannot
quantify the impact of this change on Medicare payments to hospitals,
we anticipate that it will result in a small decrease in aggregate
payment levels.
In addition, we are removing from the regulations the ``1986
malpractice rule'' as explained in section VI.B of the preamble. This
technical change is necessary to conform the codified Medicare
regulations to the various authorities that have previously established
that the malpractice rule is invalid. This conforming change would not,
standing alone, have significant economic effects.
VI. Quantitative Impact Analysis of the Policy Changes In the
Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this final rule, we are implementing policy changes and payment
rate updates for the prospective payment systems for operating and
capital-related costs. We have prepared separate analyses of the
changes to each system, beginning with changes to the operating
prospective payment system.
The data used in developing the quantitative analyses presented
below are taken from the FY 1993 MedPAR file (as of June 1994) and the
most current provider-specific file that is used for payment purposes.
Although the analyses of the changes to the operating prospective
payment system do not incorporate any cost data, we did use the most
recently available hospital cost report data to create some of the
variables by which hospitals are categorized. Our analysis is subject
to several qualifications. First, we do not make adjustments for
behavioral changes that hospitals may adopt in response to these policy
changes. Second, due to the interdependent nature of the prospective
payment system, it is very difficult to precisely quantify the impact
associated with a given change. Third, we draw upon various sources for
the data used to categorize hospitals in the tables. In some cases,
particularly the number of beds, there is a fair degree of variation in
the data from different sources. We have attempted to construct these
variables with the best available source overall. For individual
hospitals, however, some miscategorizations are possible.
The simulations estimate total payments under the operating
prospective payment system given various combinations of payment
parameters. Any short-term, acute care hospitals not paid under the
general prospective payment systems (Indian Health Service Hospitals,
hospitals in the New York Finger Lakes demonstration project, and
hospitals in Maryland) are excluded from the simulations. Payments
under the capital prospective payment system, or payments for costs
other than inpatient operating costs, are not estimated here. Estimated
payment impacts of the FY 1995 changes to the capital prospective
payment system are discussed later in this impact analysis. The changes
discussed separately below are the following:
The effects of eliminating the separate rural standardized
amount by setting it equal to the other urban amount, as required by
section 1886(b)(3)(B)(i)(X) of the Act.
The effects of the annual reclassification of diagnoses
and procedures and the recalibration of the DRG relative weights
required by section 1886(d)(4)(C) of the Act.
The effects of changes in hospitals' wage index values
reflecting the FY 1991 wage data.
The effects of geographic reclassifications by the
Medicare Geographic Classification Review Board (MGCRB) that are
effective in FY 1995.
The effects of phasing out payments for extraordinarily
lengthy cases (day outlier cases) by 25 percent (with a corresponding
increase in payments for extraordinarily costly cases (cost outliers))
and establishing a fixed-loss threshold for cost outliers, in
accordance with section 13501(c) of Public Law 103-66, as well as the
effects of increasing the marginal cost factor applicable to cost
outlier payments from 75 to 80 percent.
The total change in payments based on estimated FY 1995
total payments relative to estimated FY 1994 total payments.
To illustrate the impacts of the FY 1995 changes, our FY 1995
baseline simulation model uses: the FY 1994 GROUPER (version 11.0);
wage indexes based on FY 1990 wage data; no effects of FY 1995
reclassifications; and current outlier policy. To illustrate the
effects of eliminating the rural standardized amount, the rural amount
in the FY 1995 baseline is updated by the same update applied to the
urban amounts (1.1 percent), to maintain the current differential. The
FY 1995 baseline also includes two statutory changes effective
beginning in FY 1995: higher disproportionate share hospital (DSH)
payments for some DSH hospitals, and the elimination of the special
protection for Medicare-dependent, small rural hospitals (MDHs).
Outlier payments are estimated to be 5.1 percent of total FY 1995 DRG
payments.
Each policy change is then added incrementally to this baseline,
finally arriving at an FY 1995 model incorporating all of the changes.
This allows us to isolate the effects of each change, as shown in the
columns of Table I.
Finally, we also compare the changes in payments per case from FY
1994 to FY 1995. In this comparison, our FY 1994 baseline reflects
payment policies during the current Federal fiscal year, compared to
the FY 1995 simulation, which reflects the combination of the statutory
and regulatory changes to go into effect during FY 1995. As described
above, several policy changes that occur in FY 1995 are not modeled
separately but are shown as combined changes from FY 1994 to FY 1995.
These changes (which are included in the FY 1995 baseline, as described
above) are:
The update factor applied to the standardized amounts
(other than the differential update to the rural amount that is modeled
separately, as described above).
Effective for discharges occurring on or after October 1,
1994, section 1886(d)(5)(F)(vii)(I)(d) of the Act requires an increase
in the DSH payment adjustment to urban hospitals with 100 or more beds
and for rural hospitals with 500 or more beds, that have a DSH patient
percentage greater than 20.2.
The special payment protection for MDHs is not applicable
after FY 1994. (Section 1886(d)(5)(G)(i) of the Act as amended by
section 13501(e) of Public Law 103-66).
When comparing our estimated FY 1994 payments to FY 1995 payments,
another significant consideration is that we currently estimate that
outlier payments during FY 1994 will be 3.9 percent of total DRG
payments. When the FY 1994 final rule was published September 1, 1993
(58 FR 46270), we estimated FY 1994 outlier payments would be 5.1
percent of total DRG payments. The effects of the lower than expected
outlier payments during FY 1994 are reflected in the analyses below
comparing our current estimates of FY 1994 total payments to estimated
FY 1995 payments.
Finally, another significant impact on payments in FY 1994 compared
to FY 1995 is the effect of changes in hospitals' geographic
classification from one year to the next. In particular, as hospitals
are reclassified by the MGCRB, or as they lose their reclassification,
significant payment impacts occur.
Table I demonstrates the results of our analysis. The table
categorizes hospitals by various geographic and special payment
consideration groups to illustrate the varying impacts on different
types of hospitals. The top row of the table shows the overall impact
on the 5,254 hospitals included in the analysis. This is 48 fewer
hospitals than were included in the impact analysis in the FY 1994
final rule (58 FR 46270). (Data for 80 hospitals that were included in
last year's analysis were not available for analysis this year;
however, data were available this year for 32 hospitals for which data
were not available last year.) The next four rows of Table I contain
hospitals categorized according to their geographic location (all
urbans as well as large urban and other urban or rural). There are
2,956 hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,629 hospitals located in large urban
areas (populations over 1 million), and 1,327 hospitals in other urban
areas (populations of 1 million or fewer). In addition, there are 2,298
hospitals in rural areas. The next two groupings are by bed size
categories, shown separately for urban and rural hospitals. The final
groupings by geographic location are by census divisions, also shown
separately for urban and rural hospitals.
The second part of Table I shows changes in payments based on
hospitals' FY 1995 payment classifications, including any
reclassifications under sections 1886(d)(8) and (10) of the Act. For
example, the rows labeled urban, large urban, other urban, and rural,
show the numbers of hospitals being paid based on these
categorizations, after consideration of geographic reclassifications,
are 3,248, 1,835, 1,413, and 2,006, respectively.
The next three groupings examine the impacts of the changes on
hospitals grouped by whether or not they have graduate medical
education residency programs (teaching hospitals that receive an
indirect medical education (IME) adjustment), receive DSH payments, or
some combination of these two adjustments. There are 4,198 nonteaching
hospitals in our analysis, 831 with fewer than 100 residents, and 225
with 100 or more residents.
In the DSH categories, hospitals are grouped according to their DSH
payment status based on how they will be paid during FY 1995. That is,
hospitals located in rural counties that have been reclassified as
urban by the MGCRB for purposes of assigning the standardized amount
are categorized here as urban, since they are considered urban in
determining the amount of their DSH adjustment. The rural DSH
hospitals, therefore, including those in the rural referral center and
sole community hospital categories, represent hospitals that were not
reclassified for purposes of the standardized amount. The next category
groups hospitals paid on the basis of the urban standardized amount in
terms of whether they receive the IME adjustment, the DSH adjustment,
both, or neither.
The next five rows examine the impacts of the changes on rural
hospitals by special payment groups (sole community hospitals, rural
referral centers, and MDHs). Rural hospitals reclassified for FY 1995
for purposes of the standardized amount are not included here with the
exception of the MDH row. This row includes all hospitals that were
paid under the MDH provision during FY 1994 in order to isolate the
impact of ending this provision.
The rural referral centers (137), sole community hospitals (591),
and rural referral center/sole community hospitals (56) shown here were
not reclassified for purposes of the standardized amount. There are 17
rural referral centers and 29 sole community hospitals that are
reclassified for the standardized amount in FY 1995 and are therefore
not included in these rows. In addition, three hospitals that are both
rural referral centers and sole community hospitals will be
reclassified for the standardized amount.
The next two groupings are based on type of ownership and the
hospital's Medicare utilization expressed as a percent of total patient
days. These data are taken from the latest available Medicare cost
report files. Data needed to calculate Medicare utilization percentages
were unavailable for 29 hospitals. For the most part, these are either
new hospitals or hospitals filing manual cost reports that are not yet
entered into the data base.
The next series of groupings reflect the geographic reclassication
status of hospitals. The first three rows display hospitals that were
reclassified by the MGCRB for either FY 1994 or FY 1995, or for both
years. The next rows illustrate the overall number of
reclassifications, as well as the numbers and types of reclassified
hospitals grouped by urban and rural location. We have combined Table
II from the proposed rule into Table I for this final rule. The added
rows can be found here. The final row in Table I contains hospitals
located in rural counties but deemed to be urban under section
1886(d)(8)(B) of the Act.
Table I.--Impact Analysis of Changes for FY 1995 Operating Prospective Payment System
[Percent Changes in Payments per Case]
Eliminate Day Cost
No. of rural DRG New wage MGCRB outlier outlier All FY 95
hosps.\1\ standard recalibration\3\ data\4\ reclassification\5\ policy policy changes\8\
amount\2\ changes\6\ changes\7\
(0) (1) (2) (3) (4) (5) (6) (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Geographic Location)
All Hospitals............................... 5,254 0.7 0.0 0.0 0.0 0.0 0.0 3.3
Urban Hospitals............................. 2,956 0.3 0.1 0.0 -0.3 0.0 0.0 3.3
Large Urban............................. 1,629 0.4 0.1 0.1 -0.5 -0.1 0.0 3.3
Other Urban............................. 1,327 0.3 0.1 -0.1 0.0 0.1 0.0 3.2
Rural Hospitals............................. 2,298 3.0 -0.1 -0.1 2.2 0.1 -0.1 3.6
Bed Size (Urban)
0-99 Beds................................... 741 0.3 -0.1 -0.3 -0.3 0.1 -0.2 2.5
110-199 Beds................................ 923 0.3 0.0 -0.2 -0.4 0.1 -0.2 3.0
200-299 Beds................................ 610 0.3 0.0 -0.1 -0.3 0.0 0.0 3.1
300-499 Beds................................ 493 0.3 0.1 0.1 -0.4 0.0 0.1 3.4
500 or more Beds............................ 189 0.4 0.2 0.2 -0.3 -0.2 0.2 3.7
Bed Size (Rural)
0-49 Beds................................... 1,188 4.7 -0.2 -0.2 -0.1 0.1 -0.1 3.7
50-99 Beds.................................. 685 4.2 -0.2 -0.2 0.7 0.1 -0.2 4.0
Pacific..................................... 145 2.1 -0.1 0.3 1.7 0.2 -0.2 3.7
Puerto Rico................................. 5 18.1 -0.1 -11.1 -0.6 0.2 -0.2 -0.9
(By Payment Categories)
Urban Hospitals............................. 3,248 0.4 0.1 0.0 -0.2 0.0 0.0 3.3
Large Urban............................. 1,835 0.4 0.1 0.1 -0.2 -0.1 0.0 3.4
Other Urban............................. 1,413 0.4 0.1 -0.2 -0.2 0.1 0.0 3.1
Rural Hospitals............................. 2,006 2.8 -0.1 -0.1 1.5 0.0 -0.1 3.5
Teaching Status
Non-Teaching................................ 4,198 1.0 0.0 -0.2 0.3 0.1 -0.1 3.3
Less than 100 Res........................... 831 0.3 0.1 0.0 -0.3 0.0 0.1 3.2
100+ Residents.............................. 225 0.4 0.2 0.4 -0.3 -0.3 0.2 3.6
Disproportionate Share Hospitals (DSH)
Non-DSH..................................... 3,311 0.8 0.0 0.0 0.0 0.1 0.0 3.3
Urban DSH:
100 Beds or More........................ 1,381 0.4 0.1 0.1 -0.1 -0.1 0.0 3.3
Fewer than 100 Beds..................... 142 1.2 -0.3 -0.5 -0.3 0.1 -0.1 2.7
Rural DSH:
Sole Community (SCH).................... 145 3.3 -0.2 -0.3 0.0 0.0 -0.1 4.0
Referral Centers (RRC).................. 46 0.1 0.0 -0.1 3.1 0.0 -0.1 2.7
Other Rural DSH Hosp.:
100 Beds or More........................ 67 6.1 -0.1 -0.3 0.8 0.1 -0.2 4.6
Fewer than 100 Beds..................... 162 6.1 -0.3 -0.3 0.1 0.1 -0.1 5.7
100-149 Beds............................ 229 3.0 -0.1 -0.1 3.2 0.1 -0.2 3.2
150-199 Beds............................ 103 1.7 0.0 -0.1 3.0 0.1 -0.2 3.5
200 or more Beds........................ 93 1.0 0.0 0.1 4.4 0.0 -0.1 3.2
Urban by Region
New England................................. 170 0.4 0.1 1.5 -0.3 -0.2 -0.1 4.0
Middle Atlantic............................. 442 0.4 0.1 0.3 -0.4 -0.5 0.0 3.0
South Atlantic.............................. 436 0.3 0.1 0.2 -0.3 0.1 0.0 3.7
East North Central.......................... 491 0.3 0.1 0.0 -0.2 0.1 0.0 3.4
East South Central.......................... 170 0.2 0.1 -0.1 -0.3 0.1 0.2 3.6
West North Central.......................... 199 0.3 0.1 -0.3 -0.5 0.2 0.0 2.9
West South Central.......................... 385 0.3 0.0 -0.6 -0.4 0.2 0.2 3.4
Mountain.................................... 121 0.3 0.1 -1.3 -0.4 0.2 0.0 2.0
Pacific..................................... 493 0.4 0.0 -0.1 -0.2 0.1 0.0 3.4
Puerto Rico................................. 49 0.8 0.1 -7.4 -0.5 0.1 0.1 -4.3
Rural by Region
New England................................. 53 1.8 0.0 0.0 1.7 0.1 -0.3 3.0
Middle Atlantic............................. 84 1.6 0.0 0.0 0.7 -0.2 -0.1 1.3
South Atlantic.............................. 298 3.2 -0.1 0.1 3.1 0.0 -0.1 5.3
East North Central.......................... 310 3.1 0.0 0.2 1.8 0.1 -0.2 3.0
East South Central.......................... 283 3.7 -0.2 -0.5 3.1 0.0 -0.1 4.6
West North Central.......................... 536 3.2 -0.1 -0.1 2.2 0.1 -0.1 3.0
West South Central.......................... 360 3.6 -0.2 -0.2 2.5 0.1 -0.2 2.8
Mountain.................................... 224 1.7 -0.1 -0.2 0.1 0.1 -0.1 2.8
Urban Teaching and DSH
Both Teaching and DSH....................... 647 0.3 0.1 0.2 -0.4 -0.2 0.1 3.2
Teaching and No DSH......................... 361 0.4 0.1 0.2 -0.3 0.0 0.2 3.7
No Teaching and DSH......................... 876 0.5 0.0 -0.1 0.3 0.1 -0.1 3.5
No Teaching and No DSH...................... 1,364 0.5 0.0 -0.2 -0.2 0.1 -0.1 3.0
Rural Hospital Types
Nonspecial Status Hospitals................. 843 5.8 -0.1 -0.2 0.8 0.1 -0.2 5.2
RRC......................................... 137 0.2 0.0 0.0 4.3 0.1 -0.1 2.7
SCH......................................... 591 1.8 -0.2 -0.3 0.2 0.0 -0.1 3.5
Medicare-Dependent Hospital................. 393 6.0 -0.2 -0.2 0.0 0.1 -0.2 -0.7
SCH and RRC................................. 56 0.0 -0.1 0.0 1.0 0.0 -0.1 3.5
Type of Ownership
Voluntary................................... 3,291 0.6 0.1 0.1 -0.1 0.0 0.0 3.3
Proprietary................................. 747 0.7 -0.1 -0.4 0.2 0.2 -0.1 3.5
Government.................................. 1,216 1.2 0.0 0.0 0.1 -0.1 0.0 3.5
Medicare Utilization as a Percent of
Inpatient Days
0-25........................................ 319 0.4 0.0 -0.3 -0.2 -0.2 0.0 3.0
25-50....................................... 1,428 0.5 0.1 0.0 -0.1 -0.1 0.1 3.4
50-65....................................... 2,276 0.7 0.0 0.1 0.1 0.0 0.0 3.4
Over 65..................................... 1,202 1.1 0.0 -0.1 -0.1 0.0 -0.2 2.9
Unknown..................................... 29 0.6 0.0 -1.0 -0.3 -0.9 0.0 1.4
Hospitals Reclassified by the Medicare
Geographic Review Board
Reclassification Status during FY 94 and FY
95
Reclassified during both FY 94 and FY 95.... 479 1.3 0.0 -0.1 4.1 0.0 0.0 3.3
Urban................................... 191 0.4 0.0 -0.1 2.2 0.0 0.0 3.5
Rural................................... 288 3.2 0.0 0.1 8.2 0.1 -0.1 2.8
Reclassified during FY 95 Only.............. 207 1.2 0.0 0.3 4.3 0.1 -0.1 10.1
Urban................................... 43 0.4 0.1 0.5 2.9 0.3 0.0 10.4
Rural................................... 164 2.1 -0.1 0.0 5.8 0.0 -0.1 9.8
Reclassified during FY 94 Only.............. 220 1.3 0.0 0.1 -0.8 -0.1 -0.1 -1.9
Urban................................... 65 0.4 0.1 0.4 -1.1 -0.2 -0.1 -0.9
Rural................................... 155 2.5 -0.1 -0.2 -0.4 0.1 -0.1 -3.2
FY 95 Reclassifications
All Reclassified Hosp....................... 686 1.2 0.0 0.0 4.2 0.1 0.0 4.9
Stand. Amount Only...................... 287 2.0 0.0 0.4 1.6 0.1 -0.1 2.9
Wage Index Only......................... 207 1.1 0.0 0.0 7.6 0.0 0.0 6.6
Both.................................... 192 0.8 0.0 -0.3 3.6 0.1 0.0 5.0
Nonreclassified......................... 4,541 0.6 0.1 0.0 -0.6 0.0 0.0 3.1
All Urban Reclass........................... 234 0.4 0.1 0.0 2.4 0.1 0.0 4.9
Stand. Amount Only...................... 62 0.4 0.1 0.6 0.6 0.1 0.0 3.1
Wage Index Only............................. 26 0.4 0.1 0.2 5.9 -0.2 0.2 8.6
Both.................................... 146 0.4 0.0 -0.3 2.3 0.2 0.0 4.6
Nonreclassified............................. 2,722 0.3 0.1 0.0 -0.6 -0.1 0.0 3.2
All Rural Reclass........................... 452 2.8 0.0 0.1 7.4 0.1 -0.1 4.9
Stand. Amount Only...................... 225 4.4 0.0 0.2 3.0 0.1 -0.2 2.6
Wage Index Only......................... 181 1.5 0.0 -0.1 8.5 0.0 -0.1 5.6
Both.................................... 46 4.6 -0.1 0.3 16.2 0.1 -0.1 8.3
Nonreclassified......................... 1,819 3.1 -0.1 -0.1 -0.4 0.1 -0.1 2.9
Other Reclassified Hospitals (Section
1886(d)(8)(B))............................. 27 0.4 0.0 -1.0 0.2 0.1 -0.3 1.8
\1\Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national
total. Hospital-specific data and discharge data are from FY 1993, and hospital cost report data are from reporting periods beginning in FY 1992 and
FY 1993.
\2\This column illustrates the changes in FY 1995 payments per case due to the elimination of the separate rural standardized amount by adjusting the
rural amount to equal the other urban amount, in accordance with section 1886(d)(3)(A) of the Act.
\3\This column displays the payment impacts of the recalibration of the DRG weights and the classification changes, based on FY 1993 MedPAR data, in
accordance with section 1886(d)(4)(C) of the Act.
\4\This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1991 cost reports.
\5\Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The effects shown
here are exclusive of payment changes from FY 1994 to FY 1995, and therefore do not factor into the percent changes shown in Column 7.
\6\This column illustrates the payment impacts of our changes affecting payments for day outliers, in accordance with section 13501(c) of Pub. L. 103-
66.
\7\This column displays the impacts of implementing the fixed loss threshold and other changes to our policy for cost outliers, in accordance with
section 13501(c) of Pub. L. 103-66.
\8\This column shows changes in payments from FY 1994 to FY 1995. It incorporates all of the changes displayed in columns 1 through 6 (although the
percent changes from Column 4 do not factor into the percent changes here. It also displays the impacts of the update to the FY 1995 standardized
amounts, change in hospitals' reclassification status in FY 1995 compared to FY 1994, the effects of the higher DSH payments for urban hospitals with
100 or more beds and rural hospitals with 500 or more beds, the elimination of the Medicare-dependent, small rural hospital provision, and the
difference in projected outlier payments from FY 1994 to FY 1995. The sum of the first six columns (less Column 4) plus these effects may be slightly
different from the percentage changes shown here, due to rounding errors and interactive effects.
B. The Elimination of the Separate Rural Standardized Amount (Column 1)
Section 1886(d)(3)(A) of the Act provides that, beginning in FY
1995, the rural standardized amount is to be equal to the other urban
standardized amount. Section 1886(b)(3)(B)(i)(X) of the Act, as amended
by section 13501(a)(1) of Public Law 103-66, provides that the update
to the urban standardized amounts for FY 1995 will equal the market
basket rate of increase minus 2.5 percentage points, and the update to
the rural standardized amount is the amount necessary to set the rural
amount equal to the other urban amount. We project the market basket
increase to be 3.6 percent, so the update to the large and other urban
standardized amounts is 1.1 percent. The update to the rural
standardized amount is 8.4 percent.
The process undertaken to set the rural amount equal to the other
urban amount, as well as the overall methodology used to determine the
FY 1995 standardized payment amounts, is described in the Addendum to
this final rule. As described there, the net increase in rural
hospitals' FY 1995 standardized payment amount compared to FY 1994 is
less than 8.4 percent. The difference between the FY 1995 standardized
amount for rural hospitals and their FY 1994 amount is 4.7 percent.
This smaller net increase can primarily be attributed to changing from
separate urban and rural outlier offsets (applicable to the previously
separate rates) to a single offset after the rural rate is eliminated.
To illustrate, for FY 1994, the difference between the other urban
and rural final standardized amounts was 3.1 percent. These amounts
reflected the differential outlier adjustment factors applied to the
urban and rural standardized amounts of 0.945960 and 0.977157,
respectively (See the September 1, 1993 final rule (58 FR 46349.).
Similarly, section 1886(d)(8)(D) of the Act necessitated different
urban and rural budget neutrality factors for geographic
reclassification. Removing these differential adjustments from the FY
1994 standardized amounts, and updating the urban amounts by 1.1
percent, increases the difference between the other urban and rural
amounts from 3.1 percent to 8.4 percent.
Section 1886(d)(3)(B) requires the Secretary to adjust both the
large urban and other national standardized amounts by the same outlier
adjustment factor beginning in FY 1995. Estimated outlier payments
equal 5.1 percent of estimated total DRG payments, so a 5.1 percent
offset is applied to the standardized amounts. For FY 1994, the rural
outlier offset was 2.3 percent rather than the 5.1 percent offset for
FY 1995. For FY 1995, the increase in the size of the outlier offset
for rural hospitals mitigates the effect of the higher standardized
amount.
Our FY 1995 baseline simulation employs differential outlier
offsets to the separate urban and rural amounts. The net difference
between the rural and other urban amounts after applying these
differential offsets to the FY 1995 baseline rates (without any of the
other budget neutrality factors) is 4.5 percent. Because the urban
standardized amounts increase by 0.3 percent when the 5.1 national
outlier offset is applied rather than the larger urban outlier offset,
the increase in the rural standardized amount to bring it up to the
other urban amount (prior to applying any budget neutrality
adjustments) is 4.8 percent.
Finally, in addition to equating the other urban and rural amounts
through a higher rural update and a single outlier offset, a national
labor share (the portion of the standardized amounts adjusted by the
wage index) is necessary to maintain the elimination of the separate
amounts. For FY 1994, the rural labor share represents 75.6 percent of
the rural standardized amount, while the urban labor share comprises
about 70.8 percent of the large and other urban amounts. For FY 1995,
we are determining the labor portion of the standardized amounts based
on a national average labor share of 71.4 percent.
Column 1 displays the payment changes resulting from eliminating
the rural amount, modeled by comparing payments simulated using our FY
1995 baseline model described earlier to simulated payments after
eliminating the separate rural amount. The impacts of the higher update
to the standardized amount for rural hospitals are evident. Overall,
hospitals located in rural counties experience a 3.0 percent increase
in payments from this change, compared to a 0.3 percent rise in
payments to urban hospitals. Nationally, payments per case are
estimated to rise 0.7 percent as a result of this change.
The 3.0 percent increase for hospitals in rural areas is below the
increase in the standardized amount as discussed above for several
reasons. First, this row includes all hospitals that are located in
rural areas, but some rural hospitals already receive the higher urban
payment rate. This is reflected in the ``Rural Hospital Types'' rows.
Rural referral centers (RRCs) have only a 0.2 percent payment increase
resulting from this change. These hospitals currently receive the other
urban amount and, therefore, do not gain directly from the elimination
of the rural amount. They do apparently benefit slightly from the
smaller outlier offset applied to the urban standardized amounts.
Another rural hospital group experiencing only a relatively small
impact from this change is sole community hospitals (SCHs). Their
payments rise 1.8 percent, well below that for most other rural
hospital groups. Because these hospitals are paid based on the greater
of their applicable Federal rate or their hospital-specific rate,
increasing the Federal rate has an impact upon only those SCHs that
would be paid based on that rate. Of the 591 SCHs in this row, 414 are
paid on the basis of their hospital-specific rate in our FY 1995
baseline model. When the rural amount is eliminated by making it equal
to the other urban amount, only 65 SCHs switch from their hospital-
specific rate to the Federal rate. This explains the below average
payment change compared to other rural hospitals.
Conversely, nonspecial status rural hospitals, MDHs, and rural
hospitals receiving DSH all experience above average payment gains
(between 5.8 percent and 6.1 percent). This effect appears to be
primarily attributable to the decrease in the labor share of the
standardized amount. In fact, our analysis indicates that substituting
the current higher rural labor share on both models in this comparison
reduces the simulated payment gains for these hospital groups by
roughly 1.5 percentage points.
The row demonstrating the largest benefit from this change is rural
Puerto Rico, with an 18.1 percent increase. This stems from the
calculation of separate payment rates for Puerto Rico's hospitals,
which are equal to 75 percent of the Puerto Rico rate plus 25 percent
of the discharge-weighted average of the urban and rural national
prospective payment system rates. For FY 1994, for example, the Puerto
Rico rate for other urban areas was 26.6 percent greater than the
Puerto Rico rural rate. The increase in the national Puerto Rico amount
is much smaller, however, so that the payment effect is less than the
full increase in the rural Puerto Rico rate. Urban hospitals in Puerto
Rico also receive an added increase in payments above those of other
urban hospitals, due to the higher national portion. However, it is far
below the rural Puerto Rico increase (0.8 percent vs. 18.1 percent).
For urban hospitals nationally, the change in payments is slightly
above the percentage change in the outlier offsets when moving to a
single 5.1 percent offset. The FY 1994 urban outlier adjustment factor
was 0.945960, which results in a 5.404 percent offset. To lower the
offset to 5.1 percent, an adjustment factor of 0.949 is applied to the
standardized amounts. The difference between these two adjustment
factors is 0.3 percent. The increase in the labor share also has a
generally favorable impact on urban hospitals due to their above
average wage index values.
Eliminating the separate rural amount also has the effect of
redistributing outlier payments, primarily due to the higher
standardized amount paid to rural hospitals. The average rural outlier
payment per case falls by 3.2 percent after eliminating the separate
rural amount, and the average urban outlier payment per case rises by
0.8 percent. This occurs because relatively fewer rural cases qualify
for outlier payments under the 8.4 percent update required to set the
rural standardized amount equal to the other urban standardized amount.
This leads to additional outlier payments going to outlier cases in
urban hospitals.
The fact that many of these cases are in teaching hospitals and DSH
hospitals leads to what we consider an anomalous impact on total
payments. Pursuant to section 1886(d)(5)(A)(iv) of the Act, outlier
payment policies are set so that estimated outlier payments are 5.1
percent of estimated total DRG payments. Under the statute, estimated
outlier payments do not encompass IME and DSH payments made for outlier
cases. The amounts of IME and DSH payments are affected by the level of
outlier payments, so a redistribution of outlier payments to teaching
and DSH hospitals has the effect of generating a net increase in total
payments.
C. The Impact of the Changes to the DRG Weights (Column 2)
In column 2 of Table I, we present the combined effects of the
revised DRG classification system, and the subsequent recalibration of
the DRG weights incorporating these revised DRGs, as discussed in
section II of the preamble to this final rule. Section 1886(d)(4)(C)(i)
of the Act requires us each year to make appropriate classification
changes and to recalibrate the DRG weights in order to reflect changes
in treatment patterns, technology, and any other factors that may
change the relative use of hospital resources. The impact of
reclassification and recalibration on aggregate payments is required by
section 1886(d)(4)(C)(iii) of the Act to be budget neutral.
The first row of Table I shows that the overall effect of these
changes is budget neutral. That is, the percentage change when adding
the FY 1995 GROUPER (version 12.0) to the FY 1995 baseline is 0.0.
Since the changes illustrated in the columns of Table I are cumulative,
this column reflects the elimination of the separate rural amount in
both simulations. Only the version of the GROUPER is different.
Consistent with the minor changes we are implementing for the FY
1995 GROUPER, the redistributional impacts across hospital groups are
very small (an increase of 0.1 for urban hospitals and a decrease of
0.1 for rural hospitals). Among other hospital categories, the net
effects are slightly negative changes for small hospitals and slightly
positive changes for larger hospitals. The largest single effect on any
of the hospital categories examined is a 0.3 percent decrease in
payments for DSH hospitals with fewer than 100 beds.
D. The Impact of Updating the Wage Data (Column 3)
Section 1886(d)(3)(E) of the Act requires that, beginning October
1, 1993, we annually update the wage data used to calculate the wage
index. In accordance with this requirement, the wage index for FY 1995
is based on data submitted for hospital cost reporting periods
beginning on or after October 1, 1990 and before October 1, 1991.
As with the previous two columns, the impact of the new data on
hospital payments is isolated by holding the other payment parameters
constant in the simulations. That is, the table shows the percentage
changes in payments when going from our FY 1995 baseline--using the FY
1994 wage index before geographic reclassifications based on FY 1990
wage survey data, eliminating the separate rural rate and incorporating
the FY 1995 GROUPER--to a model substituting the FY 1995 pre-
reclassification wage index based on FY 1991 data as described above.
Section 1886(d)(3)(E) of the Act also requires that any updates or
adjustments to the wage index be made in a manner that ensures that
aggregate payments to hospitals are not affected by the change in the
wage index. To comply with the requirements that the DRG and wage index
changes must be implemented in a budget neutral manner, we compute a
budget neutrality adjustment factor to apply to the standardized
amounts. For the FY 1995 amounts, this adjustment factor is 0.998050.
This factor is applied to the standardized amounts in this column to
ensure that the overall effect of the wage index changes are budget
neutral.
The results indicate that the new wage data do not have a
significant overall impact on urban and rural hospitals. As discussed
in section III of the preamble to this final rule, 91 percent of all
prospective payment system hospitals would experience a change in their
wage index of less than 5 percent. This column demonstrates that
hospitals with significant changes in their wage indexes are not
concentrated within any particular hospital group. In contrast, the
impact analysis of the final FY 1994 operating prospective payment
system changes displayed numerous hospital groups with payment changes
in excess of 2.0 percent due to the new wage survey data (58 FR 46459).
For FY 1995, some of the largest changes are evident among urban
hospitals grouped by census division. New England urban hospitals'
payments rise 1.5 percent, while payments per case for urban hospitals
in the West South Central and Mountain census divisions fall by 0.6 and
1.3 percent, respectively. The most dramatic shifts occur in Puerto
Rico, where payments decline by 11.1 percent in rural hospitals and 7.4
percent in urban hospitals. These effects are attributable to data
corrections. We note that the FY 1994 payment effect of the new wage
data was an 11.6 percent increase for rural Puerto Rico hospitals.
This decline in the wage index values for Puerto Rico hospitals
also appears to be the main cause for the 0.4 percent drop in payments
among proprietary hospitals. The 20 hospitals with the greatest drop in
their wage index within this category are all located in Puerto Rico.
Also experiencing a significant decline in payments per case of 1.0
percent are hospitals in rural counties deemed to be urban under
section 1886(d)(8)(B) of the Act. This impact appears to be primarily
related to 2 hospitals experiencing nearly 20 percent declines in their
wage index values.
E. Impacts of MGCRB Reclassifications (Column 4)
By March 30 of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year, which
begins on October 1. For FY 1995, the MGCRB may reclassify a hospital
to an adjacent urban area or to a rural area with which the hospital
has a close proximity, for the purposes of assigning to the
reclassified hospital the other area's standardized amount, wage index
value, or both. (An RRC or an SCH may be redesignated to an area that
is not an adjacent county.)
Column 4 reflects changes in payments after accounting for the
MGCRB's reclassification decisions that will be effective for FY 1995,
including all decisions made by the HCFA Administrator through the
appeals and review process for MGCRB decisions and any reclassification
withdrawal requests that were received by the MGCRB. These
Administrator's decisions and withdrawals may affect the number of
reclassified hospitals relative to those shown in the May 27, 1994
proposed rule. They may also determine whether a redesignated hospital
receives the wage index of the area to which it is redesignated or a
combined wage index that includes the data for both the hospitals
already in the area and the redesignated hospitals.
To this point, all of the simulation models have assumed hospitals
are paid on the basis of their geographic location (with the exception
of ongoing policies that provide that certain hospitals receive
payments on bases other than where they are geographically located,
such as RRCs and hospitals in rural counties that are deemed urban
under section 1886(d)(8)(B) of the Act). The changes in column 4
reflect the per case payment impact of incorporating the MGCRB
decisions for FY 1995 into our simulation model. As noted above, these
decisions affect hospitals' standardized amount and wage index area
assignments. In addition, rural hospitals reclassified to an urban area
for the standardized amount also qualify to be treated as urban for
purposes of the DSH adjustment.
The overall effect of geographic reclassification is required to be
budget neutral by section 1886(d)(8)(D) of the Act. Prior to FY 1995,
the Secretary was required to adjust the urban standardized amounts so
as to ensure that total aggregate payments under the prospective
payment system after geographic reclassification were equal to the
aggregate payments that would have been made absent these provisions.
The rural standardized amounts were also adjusted to ensure that
aggregate payments to rural hospitals were not affected by
reclassifications. Due to the elimination of the separate rural amount
beginning October 1, 1994, the Secretary is required to provide a
single budget neutrality adjustment to the standardized amounts for the
effects of reclassification. We applied an adjustment of 0.994055 to
ensure that the effects of reclassification are budget neutral.
Rural hospitals benefit disproportionately from geographic
reclassification. Their payments rise 2.2 percent, while payments to
urban hospitals decline 0.3 percent. Rural referral centers experience
a 4.3 percent increase overall as a result of reclassification. Of the
137 hospitals in this category, 51 are reclassified for purposes of the
wage index. This positive impact on RRCs also appears in the category
of rural hospitals with 200 or more beds, which have a 4.4 percent
increase in payments.
Hospitals in large urban areas lose 0.5 percent because, as a
group, they have the smallest percentage of hospitals that are
reclassified, fewer than 6 percent. There are enough hospitals in other
urban areas that are reclassified so that the net impact on payments
per case for this group is zero. Among urban hospital groups generally,
payments fall between 0.3 and 0.5 percent.
Among hospitals grouped by reclassification status, the changes are
largely predictable. Hospitals reclassified for FY 1995 have increases
in their payments per case, ranging from 0.6 for urban hospitals
reclassified for the standardized amount, to 16.2 percent for rural
hospitals reclassified for both the standardized amount and the wage
index. In addition, rural hospitals reclassified for the wage index
only receive an 8.5 percent payment increase, and urban hospitals
reclassified for the wage index have 5.9 percent higher payments. The
overall impact on reclassified hospitals is to increase their payments
per case by an average of 4.2 percent for FY 1995.
The reclassification of hospitals primarily affects payment to
nonreclassified hospitals through changes in the wage index and the
geographic reclassification budget neutrality adjustment required by
section 1886(d)(8)(D) of the Act. Among hospitals that were not
reclassified, the overall impact of hospital reclassifications would be
an average decrease in payments per case of about 0.6 percent,
essentially the geographic reclassification budget neutrality factor.
The number of reclassifications for purposes of the standardized
amount have not declined from FY 1994. The payment impact upon
hospitals reclassified for the standardized amount only is
significantly lower than it is for hospitals reclassifying either for
only wage indexes, or for purposes of both the wage index and the
standardized amount.
F. Outlier Changes (Columns 5 and 6)
Medicare provides extra payment in addition to the regular DRG
payment amount for extremely costly or extraordinarily lengthy cases
(cost outliers and day outliers, respectively). Section 13501(c) of
Public Law 103-66 requires the Secretary to phase out payment for day
outliers in 25 percent increments beginning in FY 1995. This reduction
in day outlier payments will be offset by an increase in payments for
cost outliers. The statute also requires the Secretary to establish a
fixed loss per case threshold for cost outliers instead of a threshold
based on a fixed multiple of the DRG payment amount or other fixed
dollar amount. For FY 1995, a case will receive cost outlier payment if
costs exceed the DRG amount plus $20,500. We are also increasing the
marginal cost factor for cost outliers from 75 to 80 percent.
Columns 5 and 6 of Table I display the changes to day and cost
outlier policy separately. In column 5, the day outlier policy changes
are modeled. The cost outlier thresholds in this simulation are based
on current policy (threshold based on the lesser of a fixed multiple of
the DRG payment amount or a fixed dollar loss). The payment impacts of
this change are minimal. The largest impacts appear to be related to
geographic location in terms of census divisions. Urban hospitals in
the Middle Atlantic census division have payment reductions of 0.5
percent per case. Rural Middle Atlantic hospitals have a 0.2 percent
decline. In New England, urban hospitals experience a payment decrease
of 0.2 percent. Since the changes to the day outlier policy result in a
shift in payments from cases paid as day outliers to cases paid as cost
outliers, these areas evidently have higher percentages of day outliers
than other areas. This is consistent with our previous analysis
indicating above average impacts related to day outlier policy changes
in the northeastern portion of the country (see the June 4, 1992
proposed rule, 57 FR 23824). Also experiencing a negative impact are
major teaching hospitals (100 or more residents), with a 0.3 percent
decline in payments. The largest negative impact occurs among hospitals
for which we could not determine Medicare utilization rates. This group
experiences a 0.9 percent fall in payments per case. A number of these
hospitals are urban hospitals in the Middle Atlantic census division.
In fact, because these are generally large hospitals with many outlier
cases, they have a significant effect in the overall decline in the
Middle Atlantic division.
Column 6 models the changes in cost outlier policy. The net effects
of the combined outlier changes can be determined by the sum of the
percentage changes in these two columns. Once again, the relative
payment impacts here are minimal. Major teaching hospitals recoup 0.2
percent of the 0.3 percent their payments fell due to the day outlier
changes. Urban Middle Atlantic hospitals' payments are unchanged here,
consequently the net effect of the outlier policy changes on them is a
0.5 percent decline in payments. This is the same percentage change for
this hospital group that we estimated in the proposed rule.
G. All Changes (column 7)
Column 7 compares our estimate of payments per case for FY 1995 to
our estimate of payments per case for FY 1994. It includes the changes
discussed in the previous columns, although the changes due to MGCRB
reclassifications in column 4 do not factor into the changes shown
here. This is because column 4 shows the effects of reclassifications
relative to an FY 1995 baseline without reclassifications, rather than
in comparison with FY 1994 reclassifications. Changes in hospitals'
reclassification status from FY 1994 to FY 1995 are shown here, and
have a significant effect on payments.
This column includes the impacts of statutory differences from FY
1994 to FY 1995 that are not shown in the previous columns. These
differences were noted in the introduction. Specifically, they are: an
increase in DSH payments to urban hospitals with 100 or more beds and
to rural hospitals with 500 or more beds, and the elimination of the
MDH provision. This column also displays the impact of the 1.2 percent
lower than estimated outlier payments during FY 1994, also described in
the introduction and the Addendum.
Another change from FY 1994 is that there is no budget neutrality
adjustment to account for midyear wage index corrections. Last year's
adjustment factor was 0.998188. In addition, a single geographic
reclassification budget neutrality factor was applied to the FY 1995
standardized amounts of 0.994055. The FY 1994 factors applied to the
urban and rural amounts, respectively, were 0.992529 and 0.999472.
Finally, the budget neutrality adjustment factor for the updated wage
index and the DRG recalibration is 0.998050. Although the net effect of
these changes are small, they do impact the payment differences shown
in this column.
Column 7 also reflects the 1.1 percent updates to the urban
standardized amounts. The increase in differential payments to rural
hospitals that results from eliminating the rural standardized amount
is shown in Column 1. There may also be interactive effects among the
various factors comprising the payment system that we are not able to
isolate. For these reasons, the values in column 7 may not equal the
sum of the previous columns (less Column 4) plus the other impacts that
we are able to identify.
The impact on all hospitals is a 3.3 percent increase in payments
from FY 1994. The net change in total payments due to the changes for
FY 1995 shown in columns 1 through 6 is 0.7 percent, due to the
elimination of the rural standardized amount. After accounting for the
1.1 percent update to the urban standardized amounts, the move to a
single outlier offset, and a smaller overall geographic
reclassification budget neutrality factor, the difference between the
FY 1994 final standardized amounts and the FY 1995 standardized amounts
is 1.6 percent. As described in the discussion of the impacts of
eliminating the rural standardized amount, the portion of this increase
due to the smaller outlier offset is already reflected in the changes
shown in column 1. In addition, the update to the hospital-specific
rate for SCHs is 1.4 percent in FY 1995. The average increase in
payments due to updates, apart from elimination of the rural
standardized amount, is about 1.3 percent.
Other significant changes that have not been isolated in the
previous columns include the following:
A 1.2 percent higher level of outlier payments is
estimated for FY 1995.
The increase in the DSH formula for FY 1995 results in
approximately a 0.1 percent increase in total payments.
The effect of eliminating the MDH provision is a 3.5
percent decline in payments for this group of hospitals, and a 0.1
percent decline for rural hospitals. The impact on total payments is
less than 0.1 percent.
As a group, hospitals in rural areas experience the largest payment
increase, a 3.6 percent rise in payments per case over FY 1994. The
increase in estimated outlier payments over FY 1994 for rural hospitals
is 0.6 percent, below the 1.2 percent difference for all hospitals. As
we noted in the discussion of column 4, eliminating the rural
standardized amount would be expected to reduce the numbers and effects
of geographic reclassification. While the number of FY 1995
reclassifications does not appear to have fallen, however, the payment
effects are less than they would have been without eliminating the
rural standardized amount. This effect is shown in Column 7 when
examining the rows containing rural hospitals reclassified during both
FY 1994 and FY 1995 and rural hospitals reclassified during FY 1994
only. The 288 hospitals in the former category experience an overall
increase in payments per case of 2.8 percent, closer to that of urban
hospitals, and the 155 hospitals in the latter category experience a
3.2 percent decline.
Hospitals in both large and other urban areas experience 3.3
percent increases. Urban hospitals are affected the most by the change
in outlier payments from FY 1994 to FY 1995, a 1.3 percent increase.
They also receive the bulk of the increase in DSH payments, a 0.1
percent increase. Urban hospitals receive a net increase due to FY 1995
geographic reclassifications relative to FY 1994 reclassifications.
Again, examining the rows grouping hospitals by their reclassification
status for FY 1994 and FY 1995, urban hospitals reclassified for both
years have payment increases above those of rural hospitals, and urban
hospitals reclassified for FY 1994 but not FY 1995 do not experience as
great a decline as rural hospitals.
Among urban bed size groups, column 7 shows changes in payments
ranging from 2.5 percent for the smallest hospitals to 3.7 percent for
the largest hospitals. The relatively smaller increases for the smaller
urban hospitals appear to be due to the negative impacts of the new
wage data, as shown in column 3. Larger urban hospitals appear to
benefit from the large increase due to geographic reclassifications in
FY 1995 for 4 hospitals that were not reclassified in FY 1994.
The reverse occurs for rural hospitals. Among the smallest rural
hospitals (fewer than 50 beds), the effects of changes in
reclassification from FY 1994 to FY 1995 are negated by similar numbers
of hospitals gaining and losing reclassification from one year to the
next. The payment changes for larger rural hospitals are smaller
primarily because they do not benefit to the same extent from the
elimination of the rural standardized amount. They do, however, tend to
benefit from geographic reclassification in FY 1995 compared to FY
1994.
Table II.--Impact Analysis of Changes for FY 1995 Operating Prospective
Payment System
[Payments per Case]
Average Average
Number of FY 1994 FY 1995 All
hospitals payment payment changes
per case per case
(1) (2)\1\ (3)\1\ (4)
------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION)
ALL HOSPITALS............... 5,254 6.077 6.279 3.3
URBAN HOSPITALS............. 2,956 6,565 6,782 3.3
LARGE URBAN AREAS........... 1,629 7,073 7,309 3.3
OTHER URBAN AREAS........... 1,327 5,887 6,077 3.3
RURAL AREAS................. 2,298 4,041 4,185 3.6
BED SIZE (URBAN)
0-99 BEDS................... 741 4,498 4,611 2.5
100-199 BEDS................ 923 5,589 5,755 3.0
200-299 BEDS................ 610 6,056 6,245 3.1
300-499 BEDS................ 493 6,935 7,174 3.4
500 OR MORE BEDS............ 189 8,475 8,787 3.7
BED SIZE (RURAL)
0-49 BEDS................... 1,188 3,356 3,481 3.7
50-99 BEDS.................. 685 3,745 3,893 4.0
100-149 BEDS................ 229 4,202 4,337 3.2
150-199 BEDS................ 103 4,261 4,411 3.5
200 OR MORE BEDS............ 93 4,949 5,109 3.2
URBAN BY REGION
NEW ENGLAND................. 170 6,886 7,162 4.0
MIDDLE ATLANTIC............. 442 7,319 7,541 3.0
SOUTH ATLANTIC.............. 436 6,228 6,458 3.7
EAST NORTH CENTRAL.......... 491 6,311 6,523 3.4
EAST SOUTH CENTRAL.......... 170 5,748 5,958 3.6
WEST NORTH CENTRAL.......... 199 6,216 6,399 2.9
WEST SOUTH CENTRAL.......... 385 6,017 6,223 3.4
MOUNTAIN.................... 121 6,390 6,519 2.0
PACIFIC..................... 493 7,476 7,731 3.4
PUERTO RICO................. 49 2,594 2,482 -4.3
RURAL BY REGION
NEW ENGLAND................. 53 4,792 4,938 3.0
MIDDLE ATLANTIC............. 84 4,565 4,622 1.3
SOUTH ATLANTIC.............. 298 4,122 4,341 5.3
EAST NORTH CENTRAL.......... 310 4,063 4,187 3.0
EAST SOUTH CENTRAL.......... 283 3,656 3,824 4.6
WEST NORTH CENTRAL.......... 536 3,792 3,907 3.0
WEST SOUTH CENTRAL.......... 360 3,727 3,831 2.8
MOUNTAIN.................... 224 4,375 4,500 2.8
PACIFIC..................... 145 4,916 5,096 3.7
PUERTO RICO................. 5 1,902 1,885 -0.9
(BY PAYMENT CATEGORIES)
URBAN HOSPITALS............. 3,248 6,470 6,685 3.3
LARGE URBAN AREAS........... 1,835 6,935 7,172 3.4
OTHER URBAN AREAS........... 1,413 5,736 5,917 3.1
RURAL AREAS................. 2.006 4,020 4,159 3.5
TEACHING STATUS
NON-TEACHING................ 4,198 5,018 5,184 3.3
FEWER THAN 100 RESIDENTS.... 831 6,498 6,704 3.2
100 OR MORE RESIDENTS....... 225 10,065 10,430 3.6
DISPROPORTIONATE SHARE
HOSPITALS (DSH)
NON-DSH..................... 3,311 5,347 5,523 3.3
URBAN DSH:
100 BEDS OR MORE.......... 1,381 7,141 7,379 3.3
FEWER THAN 100 BEDS....... 142 4,263 4,378 2.7
RURAL DSH: SOLE COMMUNITY
(SCH)...................... 145 3,879 4,036 4.0
REFERRAL CENTERS (RRC)...... 46 5,020 5,156 2.7
OTHER RURAL DSH HOSP.:
100 BEDS OR MORE.......... 67 3,695 3,863 4.6
FEWER THAN 100 BEDS....... 162 3,211 3,396 5.7
URBAN TEACHING AND DSH
BOTH TEACHING AND DSH....... 647 8,170 8,435 3.2
TEACHING AND NO DSH......... 361 6,625 6,867 3.7
NO TEACHING AND OSH......... 876 5,681 5,880 3.5
NO TEACHING AND NO DSH...... 1,364 5,182 5,338 3.0
RURAL HOSPITAL TYPES
NONSPECIAL STATUS HOSPITALS. 843 3,507 3,688 5.2
RRC......................... 137 4,711 4,839 2.7
SCH......................... 591 4,080 4,221 3.5
MEDICARE-DEPENDENT HOSPITALS
(MDH)...................... 393 3,377 3,352 -0.7
SCH AND RRC................. 56 4,943 5,118 3.5
TYPE OF OWNERSHIP
VOLUNTARY................... 3,291 6,203 6,407 3.3
PROPRIETARY................. 747 5,542 5,734 3.5
GOVERNMENT.................. 1,216 5,796 5,998 3.5
MEDICARE UTILIZATION AS A
PERCENT OF INPATIENT DAYS
0-25........................ 319 8,312 8,559 3.0
25-50....................... 1,428 7,226 7,474 3.4
50-65....................... 2,276 5,538 5,728 3.4
OVER 65..................... 1,202 4,877 5,017 2.9
UNKNOWN..................... 29 7,724 7,833 1.4
HOSPITALS RECLASSIFIED BY
THE MEDICARE GEOGRAPHIC
REVIEW BOARD
RECLASSIFICATION STATUS
DURING FY 94 AND FY 95
RECLASSIFIED DURING BOTH FY
94 AND FY 95:.............. 479 5,741 5,929 3.3
URBAN................... 191 6,631 6,864 3.5
RURAL................... 288 4,519 4,645 2.8
RECLASSIFIED DURING FY 95
ONLY....................... 207 5,011 5,517 10.1
URBAN................... 43 6,124 6,758 10.4
RURAL................... 164 4,154 4,561 9.8
RECLASSIFIED DURING FY 94
ONLY....................... 220 5,644 5,536 -1.9
URBAN................... 65 7,263 7,199 -0.9
RURAL................... 155 4,405 4,263 -3.2
FY 95 RECLASSIFICATIONS
ALL RECLASSIFIED HOSP....... 686 5,552 5,822 4.9
STAND. AMT. ONLY........ 287 5,028 5,185 2.9
WAGE INDEX ONLY......... 207 5,403 5,761 6.6
BOTH.................... 192 6,148 6,456 5.0
NONRECLASS.............. 4,541 6,165 6,357 3.1
ALL URBAN RECLASS........... 234 6,525 6,842 4.9
STAND. AMT. ONLY........ 62 6,166 6,357 3.1
WAGE INDEX ONLY......... 26 7,686 8,350 8.6
BOTH.................... 146 6,429 6,726 4.6
NONRECLASS.............. 2,722 6,569 6,776 3.2
ALL RURAL RECLASS........... 452 4,402 4,618 4.9
STAND. AMT. ONLY........ 225 4,006 4,112 2.6
WAGE INDEX ONLY......... 181 4,676 4,937 5.6
BOTH.................... 46 4,482 4,853 8.3
NONRECLASS.............. 1,819 3,862 3,973 2.9
OTHER RECLASSIFIED HOSPITALS
(SECTION 1886(d)(8)(B)).... 27 4,350 4,427 1.8
\1\These payment amounts per case do not reflect any estimates of annual
case mix increase.
Table II presents the projected average payments per case under the
changes for FY 1995 for urban and rural hospitals and for the different
categories of hospitals shown in Table I. It compares the projected
payments for FY 1995 with the average estimated per case payments for
FY 1994. Thus, this table presents, in terms of the average dollar
amounts paid per discharge, the combined effects of the changes
presented in Table I. The percentage changes shown in the last column
of Table I equal the percentage changes in average payments from
October 1, 1993 to October 1, 1994.
VII. Impact of Changes in the Capital Prospective Payment System
A. General Considerations
We now have data that were unavailable in previous impact analyses.
Specifically, we have cost report data for the first year of the
capital prospective payment system (cost reports beginning in FY 1992)
available through the June 1994 update of the Hospital Cost Report
Information System (HCRIS). We also have information on the aggregate
amount of obligated capital approved by the fiscal intermediaries.
However, our impact analysis of payment changes for capital-related
costs is still limited by the lack of hospital-specific data on several
items. These are the hospital's projected new capital costs for each
year, its projected old capital costs for each year, and the actual
amounts of obligated capital that will be put in use for patient care
and recognized as Medicare old capital costs in each year. The lack of
such information affects our impact analysis in the following ways:
Major investment in hospital capital assets (for example
in building and major fixed equipment) occurs at irregular intervals.
As a result, there can be significant variation in the growth rates of
Medicare capital-related costs per case among hospitals. We do not have
the necessary hospital-specific budget data to project the hospital
capital growth rate for an individual hospital.
Moreover, our policy of recognizing certain obligated
capital as old capital complicates the problem of projecting future
capital-related costs for individual hospitals. Under Sec. 412.302(c),
a hospital is required to notify its intermediary that it has obligated
capital, no later than the later of October 1, 1992 or 90 days after
the beginning of the hospital's first cost reporting period under the
capital prospective payment system. The intermediary must then notify
the hospital of its determination whether the criteria for recognition
of obligated capital have been met by the later of the end of the
hospital's first cost reporting period subject to the capital
prospective payment system or 9 months after the receipt of the
hospital's notification. The amount that is recognized as old capital
is limited to the lesser of the actual allowable costs when the asset
is put in use for patient care or the estimated costs of the capital
expenditure at the time it was obligated. We have substantial
information regarding intermediary determinations of aggregate
projected obligated capital amounts. However, we still do not know when
these projects will actually be put into use for patient care, the
amount that will be recognized as obligated capital when the project is
put into use, or the Medicare share of the recognized costs. Therefore,
we do not know actual obligated capital commitments to be used in the
FY 1995 capital cost projections. We discuss in Appendix B the
assumptions and computations we employ to generate the amount of
obligated capital commitments for use in the FY 1995 capital cost
projections.
In Table III of this appendix, we present the redistributive
effects that are expected to occur between ``hold-harmless'' hospitals
and ``fully prospective'' hospitals in FY 1995. In addition, we have
integrated sufficient hospital-specific information into our actuarial
model to project the impact of FY 1995 capital payment policies by the
standard prospective payment system hospital groupings. We caution that
while we now have actual information on the effects of the transition
payment methodology and interim payments under the capital prospective
payment system and cost report data for most hospitals, we need to
generate random numbers for the change in old capital costs, new
capital costs for each year, and obligated amounts that will be put in
use for patient care services and recognized as old capital each year.
This means that we continue to be unable to predict accurately an
individual hospital's FY 1995 capital costs; however, with the more
recent data on hospitals' experience to date under the capital
prospective payment system, there is adequate information to estimate
the aggregate impact on most hospital groupings.
We present the transition payment methodology by hospital grouping
in Table IV. In Table V we present the results of the cross-sectional
analysis using the results of our actuarial model. This table presents
the aggregate impact of the FY 1995 payment policies. We proposed
omitting the cross-sectional analysis of changes in the Federal rate
(referred to as Table VII in the proposed rule 59 FR 27867). We
requested comments on the utility of this table and its continued use
in future impact statements. Since we received no comments on this
issue, we are omitting this table and corresponding descriptive text
from the impact statement.
B. Projected Impact Based on the FY 1995 Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the
capital prospective payment system from FY 1994 to FY 1995 using a
capital acquisition model. The FY 1995 model, described in Appendix B
of this final rule, integrates actual data from individual hospitals
with randomly generated capital cost amounts. We have available capital
cost data from cost reports beginning in FY 1989, FY 1990, FY 1991 and
FY 1992 received through the June 1994 update of HCRIS, interim payment
data for hospitals already receiving capital prospective payments
through PRICER, and data reported by the intermediaries that include
the hospital-specific rate determinations that have been made through
July 1, 1994 in the Provider-Specific file. We used this data to
determine the FY 1995 capital rates. However, we do not have individual
hospital data on old capital changes, new capital formation, and actual
obligated capital costs. We have data on costs for capital in use in FY
1992, and we age that capital by a formula described in Appendix B. We
therefore need to generate randomly only new capital acquisitions for
any year after FY 1992. All Federal rate payment parameters are
assigned to the applicable hospital.
For purposes of this impact analysis, the FY 1995 actuarial model
includes the following assumptions:
Medicare inpatient capital costs per discharge will
increase at the following rates during these periods:
Average Percentage Increase in Capital
------------------------------------------------------------------------
Costs per
Fiscal year discharge
------------------------------------------------------------------------
1994........................................................ $4.65
1995........................................................ 5.70
------------------------------------------------------------------------
The Medicare case-mix index will increase by 0.85 percent
in FY 1994.
The Federal capital rate as well as the hospital-specific
rate will be updated by the 2-year moving average increase in Medicare
capital costs per case, net of case-mix change increase, between FY
1990 and FY 1992. The FY 1995 update factor for inflation is 3.44
percent (see Addendum, Part III).
Consistent with the budget neutrality constraints provided
in section 1886(g)(1)(A) of the Act, estimated aggregate Medicare
payments for capital costs in FY 1995 will equal 90 percent of the
amount that would have been payable on a reasonable cost basis. The
budget neutrality adjustment factor will be applied to the Federal and
hospital-specific rates only and not to the hold-harmless payment for
old capital.
2. Results
We have used the actuarial model to estimate the change in payment
for capital-related costs from FY 1994 to FY 1995. To show the effect
of the capital prospective payment system on low capital cost hospitals
and high capital cost hospitals, we are presenting separately in Table
III the results of our simulation for these hospitals. We consider a
hospital to be a low capital cost hospital if, based on a comparison of
its initial hospital-specific rate and the applicable Federal rate, it
will be paid under the fully prospective payment methodology. A high
capital cost hospital is a hospital that, based on its initial
hospital-specific rate, will be paid under the hold-harmless payment
methodology. Based on our actuarial model, the breakdown of hospitals
is as follows:
Capital Transition Payment Methodology
------------------------------------------------------------------------
FY 1995 FY 1995
Percent FY 1995 percent percent
Type of hospital of percent of of of
hospitals discharges capital capital
costs payments
------------------------------------------------------------------------
Low cost hospital............ 64 59 47 49
High cost hospital........... 36 41 53 51
------------------------------------------------------------------------
A low capital cost hospital may request to have its hospital-
specific rate redetermined based on old capital costs in the current
year, through the later of the hospital's cost reporting period
beginning in FY 1994 or the first cost reporting period beginning after
obligated capital comes into use (within the limits established in
Sec. 412.302(e) for putting obligated capital in use for patient care).
If the redetermined hospital-specific rate is greater than the adjusted
Federal rate, these hospitals will be paid under the hold-harmless
payment methodology. Regardless of whether the hospital became a hold-
harmless payment hospital as a result of a redetermination, we have
continued to show these hospitals as low capital cost hospitals in
Table III.
Assuming no behavioral changes in capital expenditures, Table III
displays the percentage change in payments from FY 1994 to FY 1995
using the above described actuarial model.
Table III.--Impact of Changes for FY 1995 on Payments per Discharge
----------------------------------------------------------------------------------------------------------------
Number of Adjusted Average Hospital Hold-
hospitals Discharges Federal Federal specific harmless Exceptions Total
payment percent payment payment payment payment
----------------------------------------------------------------------------------------------------------------
FY 1994 payments per discharge
----------------------------------------------------------------------------------------------------------------
Low Cost Hospitals.. 3,332 6,137,315 $201.48 33.77 $240.85 $25.76 $7.72 $475.80
Fully
Prospective.... 1,879 3,553,295 180.86 30.00 272.81 ......... 3.27 456.94
Rebase--Fully
Prospective.... 1,141 1,956,526 174.89 30.00 260.04 ......... 17.90 452.84
Rebase--100%
Federal Rate... 144 342,220 621.36 100.00 ......... ......... ........... 621.46
Rebase--Hold
Harmless....... 168 285,273 136.86 23.53 ......... 554.10 2.52 693.49
High Cost Hospitals. 1,897 4,209,462 320.53 52.59 ......... 409.88 5.11 735.52
100% Federal
Rate........... 654 1,556,520 637.05 100.00 ......... ......... 0.10 637.15
Hold Harmless... 1,243 2,652,942 134.82 22.72 ......... 650.36 8.05 793.23
Total
hospitals.. 5,229 10,346,777 249.91 41.52 142.86 182.03 6.66 581.46
----------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of Adjusted Average Hospital Hold-
hospitals Discharges Federal Federal specific harmless Exceptions Total Percent
payment percent payment payment payment payment change
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 1995 payments per discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low Cost Hospitals................................ 3,332 6,137,315 $259.44 42.89 $208.32 $27.00 $14.26 $509.02 6.98
Fully Prospective............................. 1,879 3,553,295 244.06 40.00 235.97 ......... 5.97 486.00 6.36
Rebase--Fully Prospective..................... 1,141 1,956,526 236.55 40.00 224.94 ......... 33.25 494.74 9.25
Rebase--100% Federal Rate..................... 147 346,144 634.80 100.00 ......... ......... .......... 634.80 2.15
Rebase--Hold Harmless......................... 165 281,350 151.08 25.36 ......... 588.89 4.30 744.27 7.32
High Cost Hospitals............................... 1,897 4,209,462 360.43 57.05 ......... 394.93 7.74 763.09 3.75
100% Federal Rate............................. 721 1,725,736 652.13 100.00 ......... ......... 0.30 652.43 2.40
Hold Harmless................................. 1,176 2,483,726 157.75 25.54 ......... 669.33 12.91 839.98 5.89
Total hospitals........................... 5,229 10,346,777 300.52 48.80 123.57 176.68 11.60 612.38 5.32
--------------------------------------------------------------------------------------------------------------------------------------------------------
Under section 1886(g)(1)(A) of the Act, aggregate payments under
the capital prospective payment system for FY 1992 through 1995
respectively, are to equal 90 percent of what would have been payable
on a reasonable cost basis in each year. (See Addendum, Part III for a
full discussion of the capital budget neutrality provision.) Currently,
we project that in FY 1994 aggregate payments under the capital
prospective payment system will be 90.32 percent of reasonable costs,
or 0.32 percentage points higher than the 90 percent target. We also
estimate an increase in capital cost per case of 5.70 percent from FY
1994 to FY 1995. To achieve budget neutrality in FY 1995, we estimate
there would be an aggregate 5.32 percent increase in FY 1995 Medicare
capital payments over the FY 1994 payments.
We project that low capital cost hospitals will experience an
average case-weighted increase in payments of 6.98 percent, and high
capital cost hospitals will experience an average increase of 3.75
percent.
For hospitals paid under the fully prospective payment methodology,
the Federal rate payment percentage will increase from 30 percent to 40
percent and the hospital-specific rate payment percentage will decrease
from 70 to 60 percent in FY 1995.
The Federal rate payment percentage for a hospital paid under the
hold-harmless payment methodology is based on the hospital's ratio of
new capital costs to total capital costs. The average Federal rate
payment percentage for those hospitals receiving a hold-harmless
payment for old capital will increase from 22.72 percent to 25.54
percent. We estimate the percentage of hold-harmless hospitals paid
based on 100 percent of the Federal rate will increase from 34.5
percent to 38.0 percent.
The average hospital-specific rate payment per discharge falls from
$142.86 in FY 1994 to $123.57 in FY 1995. A decline in the average
hospital-specific rate payment per discharge from FY 1994 to FY 1995 is
to be expected because of the reduction in the hospital-specific rate
blend percentage from FY 1994 to FY 1995.
We are implementing no changes in our exceptions policies that
affect exceptions payments for FY 1995. As a result, the minimum
payment levels would be:
90 percent for sole community hospitals;
80 percent for urban hospitals with 100 or beds and a
disproportionate share patient percentage of 20.2 percent or more; or,
70 percent for all other hospitals.
We estimate that exceptions payments will increase from 1.1 percent
of payments in FY 1994 to 1.9 percent of payments in FY 1995. The
projected distribution of the payments is shown in the table below:
Estimated FY 1995 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital No. of exceptions
hospitals payments
------------------------------------------------------------------------
Low capital cost................................ 361 73
High capital cost............................... 176 27
-----------------------
Total....................................... 537 100
------------------------------------------------------------------------
C. Cross-Sectional Comparison of Capital Prospective Payment
Methodologies
Table V presents a cross-sectional summary of hospital groupings by
capital prospective payment methodology. This distribution is generated
by our actuarial model.
Table IV.--Distribution by Method of Payment (Hold-Harmless/Fully
Prospective) of Hospitals Receiving Capital Payments
------------------------------------------------------------------------
(2) Hold-harmless
------------------------ (3)
(1) Total Percentage Percentage Percentage
No. of paid hold- paid fully paid fully
hospitals harmless federal prospective
(A) (B) rate
------------------------------------------------------------------------
By Geographic Location:
All hospitals...... 5,229 25.6 16.6 57.8
Large urban areas
(populations over
1 million)........ 1,613 29.8 21.3 48.9
Other urban areas
(populations or 1
million of fewer). 1,320 31.4 20.0 48.6
Rural areas........ 2,296 19.4 11.3 69.3
Urban hospitals.... 2,933 30.5 20.7 48.8
0-99 beds........ 719 28.7 20.3 51.0
100-199 beds..... 922 37.0 19.4 43.6
200-299 beds..... 610 31.3 20.0 48.7
300-499 beds..... 493 22.9 24.5 52.5
500 or more beds. 189 23.3 21.2 55.6
Rural hospitals.... 2,296 19.4 11.3 69.3
0-49 beds........ 1,186 14.2 8.9 77.0
50-99 beds....... 685 23.4 12.3 64.4
100-149 beds..... 229 26.6 20.1 53.3
150-199 beds..... 103 23.3 12.6 64.1
200 or more beds. 93 35.5 12.9 51.6
By Region:
Uban by Region..... 2,933 30.5 20.7 48.8
New England...... 170 11.8 20.6 67.6
Middle Atlantic.. 442 20.4 24.0 55.7
South Atlantic... 436 41.1 21.1 37.8
East North
Central......... 490 24.7 15.3 60.0
East South
Central......... 170 43.5 14.7 41.8
West North
Central......... 197 32.0 15.2 52.8
West South
Central......... 372 49.2 26.3 24.5
Mountain......... 120 30.0 30.8 39.2
Pacific.......... 488 24.4 21.5 54.1
Puerto Rico...... 48 20.8 10.4 68.8
Rural by Region.... 2,296 19.4 11.3 69.3
New England...... 53 13.2 13.2 73.6
Middle Atlantic.. 84 16.7 19.0 64.3
South Atlantic... 298 25.5 11.1 63.4
East North
Central......... 310 16.5 7.4 76.1
East South
Central......... 282 25.2 16.7 58.2
West North
Central......... 536 13.6 9.0 77.4
West South
Central......... 359 19.2 16.2 64.6
Mountain......... 224 21.4 8.9 69.6
Pacific.......... 145 24.8 4.8 70.3
By Payment
Classification:
All hospitals...... 5,229 25.6 16.6 57.8
Large urban areas
(populations over
1 million)........ 1,819 29.4 21.1 49.5
Other urban areas
(populations of 1
million or fewer). 1,406 31.4 17.9 50.7
Rural areas........ 2,004 18.2 11.6 70.2
Teaching Status:
Non-teaching..... 4,174 26.1 16.2 57.6
Fewer than 100
residents....... 830 25.9 17.5 56.6
100 or more
Residents....... 225 15.6 20.4 64.0
Disproportionate
share hospitals
(DSH):
Non-DSH.......... 3,291 23.9 15.2 60.9
Urban DSH:
100 or more
beds........ 1,381 30.6 21.5 47.9
Less than 100
beds........ 137 33.6 16.8 49.6
Rural DSH:
Sole
Community
(SCH)....... 145 19.3 6.2 74.5
Referral
Center (RRC) 46 28.3 17.4 54.3
Other Rural:
100 or more
beds...... 67 26.9 20.9 52.2
Less than
100 beds.. 162 17.3 10.5 72.2
Urban teaching and
DSH:
Both teaching and
DSH............. 647 23.3 19.6 57.0
Teaching and no
DSH............. 360 23.3 16.9 59.7
No teaching and
DSH............. 871 36.4 22.2 41.4
No teaching and
no DSH.......... 1,347 31.6 18.9 49.6
Rural Hospital
Types:
Non special
status hospitals 838 16.7 13.4 69.9
RRC.............. 137 27.0 14.6 58.4
SCH.............. 56 28.6 14.3 57.1
Medicare-
dependent
hospitals (MDH). 412 9.5 11.2 79.4
SCH or MDH....... 56 28.6 14.3 57.1
Type of Ownership:
Voluntary........ 3,268 24.4 16.8 58.7
Proprietary...... 745 46.0 24.6 29.4
Government....... 1,216 16.4 11.1 72.5
Medicare
Utilization as a
Percent of
Inpatient Days:
0-25............. 296 30.7 19.9 49.3
25-50............ 1,422 28.3 18.6 53.0
50-65............ 2,274 25.9 15.5 58.5
Over 65.......... 1,198 21.0 15.4 63.7
------------------------------------------------------------------------
As we explain in Appendix B, we were not able to determine a
hospital-specific rate for 25 of the 5,254 hospitals in our data base.
Consequently, the payment methodology distribution is based on 5,229
hospitals. This data should be fully representative of the payment
methodologies that will be applicable to hospitals.
The cross-sectional distribution of hospital by payment methodology
is presented by: (1) geographic location, (2) region, and (3) payment
classification. This provides an indication of the percentage of
hospitals within a particular hospital grouping that will be paid under
the fully prospective payment methodology and under the hold-harmless
methodology.
Table IV indicates that 57.8 percent of hospitals are paid under
the fully prospective payment methodology. (This figure, unlike the
figure of 64 percent for low cost capital hospitals in the previous
section, takes into account the effects of redeterminations. In other
words, this figure does not include low cost hospitals that, following
a hospital-specific rate redetermination, are now paid under the hold-
harmless methodology.) As expected, a relatively higher percentage of
rural and governmental hospitals (69.3 percent and 72.5 percent,
respectively) are being paid under the fully prospective methodology.
This is a reflection of their lower than average capital costs per
case. In contrast, only 29.4 percent of proprietary hospitals are being
paid under the fully prospective methodology. This is a reflection of
their higher than average capital costs per case. (We found at the time
of the August 30, 1991 final rule (56 FR 43430) that 62.7 percent of
proprietary hospitals had a capital cost per case above the national
average cost per case.)
D. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 1995 actuarial model to estimate the potential
impact of our changes for FY 1995 on total capital payments per case,
using a universe of 5,229 hospitals. The individual hospital payment
parameters are taken from the best available data, including: the July
1, 1994 update to the Provider-Specific file, cost report data, and
audit information supplied by intermediaries. Table V presents a
comparison of payments per case for FY 1994 and FY 1995. It also
presents the portion of total percentage change in payments that can be
attributed to Federal rate changes alone. Federal rate changes include
the 0.04 percent decrease in the Federal rate, a 0.85 percent increase
in case mix, changes in the adjustments to the Federal rate (for
example, the effect of the new hospital wage index on the geographic
adjustment factor), changes in capital outlier payments and
reclassifications by the Medicare Geographic Classification Review
Board. The residual increase in the total percentage change in payments
over the change attributable to the Federal rate changes can be
attributed to the effects of transition changes, which include: the
change from 30 percent to 40 percent in the portion of the Federal rate
for fully prospective hospitals, the hospital-specific rate update,
changes in the proportion of new to total capital for hold-harmless
hospitals, changes in old capital (for example, obligated capital put
in use), hospital-specific rate redeterminations, and exceptions. The
comparisons are provided by: (1) geographic location and (2) payment
classification and payment region.
The simulation results show that, on average, payments per case can
be expected to increase 5.3 percent in FY 1995. The results show that
the effect of the Federal rate changes alone is to increase payments by
1.0 percent. The remainder of the increase (4.3 percent) is
attributable to the effects of transition changes and budget
neutrality.
Our comparison by geographic location shows that urban and rural
hospitals experience similar rates of increase (5.3 percent and 5.4
percent, respectively). Urban hospitals will gain more than rural
hospitals (1.1 percent compared to 0.5 percent) from the Federal rate
changes. However, urban hospitals will gain slightly less than rural
hospitals (4.2 percent compared to 4.9 percent) from the effects of
transition changes.
By region, rural hospitals of the New England region have the
highest rate of increase (15.7 percent, all of which is due to the
effects of transition changes, with Federal rate changes having no
impact). Puerto Rico hospitals fare worst: these hospitals will
experience a 1.1 percent decline attributable to Federal rate changes,
which is offset by a 2.7 percent increase attributable to the effects
of transition changes, resulting in only a 1.6 percent increase in
payments.
By type of ownership, government hospitals are projected to have
the highest rate of increase (6.1 percent, of which 0.8 percent is due
to Federal rate changes and 5.3 percent to the effects of transition
changes). Payments to proprietary hospitals will increase 3.0 percent
(1.0 percent due to the Federal rate changes and 2.0 percent
attributable to the effects of transition changes) and payments to
voluntary hospitals will increase 5.6 percent (1.0 percent due to
Federal rate changes and 4.6 percent to the effects of transition
changes).
Section 1886(d)(10) of the Act established the Medicare Geographic
Review Board (MGCRB). Hospitals may apply for reclassification for the
purpose of the wage index, standardized payment amount, or both.
Although there is no difference with respect to the Federal capital
rate, a hospital's geographic classification for purposes of the
operating standardized amount does affect a hospital's capital payments
as a result of the large urban adjustment factor and the
disproportionate share adjustment for urban hospitals with 100 or more
beds. Reclassification for wage index purposes affects the geographic
adjustment factor since that factor is constructed from the hospital
wage index.
To present the effects of the hospitals being reclassified for FY
1995 compared to the FY 1994 effects of reclassification, we show the
average payment percentage increase for hospitals reclassified in each
fiscal year and in total. For FY 1995 reclassifications, we are
indicating those hospitals reclassified for standardized amount
purposes only, for wage index purposes only, and for both purposes. The
reclassified groups are compared to all other nonreclassified
hospitals. These categories are further identified by urban and rural
designation.
Hospitals reclassified for FY 1995 as a whole are projected to
experience a 5.2 percent increase in payments (1.3 percent attributable
to Federal rate changes and 3.9 percent attributable to the effects of
transition changes). Nonreclassified hospitals will gain slightly more
(5.3 percent) than reclassified hospitals (5.2 percent) overall. While
nonreclassified hospitals will gain less (0.9 percent compared to 1.3
percent) than reclassified hospitals from the Federal rate changes,
they will gain more (4.4 percent to 3.9 percent) from the effects of
transition changes.
Table V.--Comparison of Total Payments Per Case
[FY 1994 Payments Compared to FY 1995 Payments]
----------------------------------------------------------------------------------------------------------------
Average FY
Average FY 1995 Portion
Number of 1994 payments/ All changes attibutable
hospitals payments/ case after to Federal
case OBRA rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location
All hospitals.............................. 5,229 581 612 5.3 1.0
Large urban areas (populations over 1
million).................................. 1,613 662 700 5.7 1.0
Other urban areas (populations of 1 million
of fewer)................................. 1,320 584 612 4.8 1.1
Rural areas................................ 2,296 384 404 5.4 0.5
Urban hospitals............................ 2,933 629 662 5.3 1.1
0-99 beds.............................. 719 480 502 4.5 0.7
100-199 beds........................... 922 579 603 4.1 0.9
200-299 beds........................... 610 605 631 4.3 0.9
300-499 beds........................... 493 633 664 4.9 1.1
500 or more beds....................... 189 762 825 8.2 1.4
Rural hospitals............................ 2,296 384 404 5.4 0.5
0-49 beds.............................. 1,186 281 302 7.4 0.3
50-99 beds............................. 685 357 373 4.5 0.5
100-149 beds........................... 229 421 438 4.0 0.5
150-199 beds........................... 103 391 410 4.9 0.5
200 or more beds....................... 93 492 525 6.8 0.6
By Region
Urban By Region............................ 2,933 629 662 5.3 1.1
New England............................ 170 567 613 8.2 1.4
Middle Atlantic........................ 442 647 692 7.0 0.8
South Atlantic......................... 436 657 685 4.4 1.2
East North Central..................... 490 580 609 5.0 1.1
East South Central..................... 170 594 621 4.5 1.1
West North Central..................... 197 626 657 5.0 0.8
West South Central..................... 372 683 704 3.1 1.6
Mountain............................... 120 647 663 2.4 0.6
Pacific................................ 488 674 716 6.3 1.0
Puerto Rico............................ 48 236 240 1.6 -1.1
Rural by Region............................ 2,296 384 404 5.4 0.5
New England............................ 53 473 547 15.7 0.0
Middle Atlantic........................ 84 390 418 7.0 0.9
South Atlantic......................... 298 405 421 4.1 0.7
East North Central..................... 310 367 383 4.5 0.7
East South Central..................... 282 364 380 4.4 0.4
West North Central..................... 536 350 371 6.0 0.1
West South Central..................... 359 370 390 5.5 0.2
Mountain............................... 224 451 466 3.4 0.6
Pacific................................ 145 425 456 7.4 0.6
Payment Classification
All hospitals.............................. 5,229 581 612 5.3 1.0
Large urban areas (populations over 1
million).................................. 1,819 652 688 5.6 1.0
Other urban areas (populations of 1 million
or fewer)................................. 1,406 571 599 4.7 1.0
Rural areas................................ 2,004 376 397 5.7 0.5
Teaching Status:...........................
Non-teaching........................... 4,174 518 540 4.1 0.8
Fewer than 100 Residents............... 830 604 636 5.3 1.2
100 or more Residents.................. 225 825 900 9.0 1.1
Disproportionate share hospitals (DSH):
Non-DSH.................................... 3,291 535 562 5.1 1.0
Urban DSH:
100 or more beds....................... 1,381 657 694 5.6 1.0
Less than 100 beds..................... 137 433 446 2.9 0.5
Rural DSH:
Sole Community (SCH)................... 145 360 370 3.0 0.2
Referral Center (RRC).................. 46 454 476 4.8 0.6
Other Rural:...........................
100 or more beds................... 67 363 383 5.6 0.2
Less than 100 beds................. 162 297 310 4.5 0.6
Urban teaching and DSH:
Both teaching and DSH...................... 647 707 754 6.7 1.0
Teaching and no DSH........................ 360 615 654 6.2 1.5
No teaching and DSH........................ 871 584 606 3.8 1.0
No teaching and no DSH..................... 1.347 562 584 3.9 0.8
Rural Hospital Types:
Non special status hospitals............... 838 330 347 5.1 0.3
RRC........................................ 137 458 485 6.0 0.7
SCH........................................ 591 378 399 5.4 0.3
Medicare-dependent hospital (MDH).......... 412 282 297 5.3 0.4
SCH and MDH................................ 56 464 497 7.2 0.6
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY94 and
FY95:
Reclassification During Both FY94 and
FY95.................................. 479 583 608 4.2 0.8
Reclassification During FY95 Only...... 207 497 540 8.6 3.2
Reclassification During FY94 Only...... 197 489 505 3.1 -1.4
FY95 Reclassifications:
All Reclassified Hospitals............. 686 561 590 5.2 1.3
All Nonreclassified Hospitals.......... 4,516 585 616 5.3 0.9
All Urban Reclassified Hospitals....... 234 663 696 4.9 1.4
Urban Nonreclassified Hospitals........ 2,699 626 659 5.3 1.0
All Reclassified Rural Hospitals....... 452 440 465 5.7 1.2
Rural Nonreclassified Hospitals........ 1,817 356 374 5.2 0.1
Other Reclassified Hospitals (Section
1886(D)(8)(B))............................ 27 433 450 4.1 0.3
Type of Ownership:
Voluntary.................................. 3,268 591 624 5.6 1.0
Proprietary................................ 745 628 647 3.0 1.0
Government................................. 1,216 479 509 6.1 0.8
Medicare Utilization as a Percent of Inpatient
Days:
0-25....................................... 296 633 680 7.6 0.8
25-50...................................... 1,422 670 714 6.5 1.0
50-65...................................... 2,274 544 568 4.3 1.0
Over 65.................................... 1,198 505 529 4.6 0.7
----------------------------------------------------------------------------------------------------------------
E. Impact of Changes to the MGCRB Criteria for FY 1996 Hospital
Reclassifications
As discussed in detail in section III.F of the preamble, this final
rule with comment period revises the criteria for individual hospitals
seeking geographic reclassification by eliminating the requirement that
a hospital be located in an area adjacent to the area to which it seeks
reclassification effective for FY 1996 reclassifications. Hospitals
that are able to qualify for reclassification as a result of this final
rule will receive increased Medicare payments. However, in accordance
with the budget neutrality requirement of section 1886(d)(8)(D) of the
Act, proportional adjustments will be made to the large urban and other
area standardized amounts, thereby eliminating any effect of the
increased hospital payments on aggregate Medicare payments.
Because we cannot predict which hospitals will apply for geographic
reclassification or how the MGCRB will rule on applications, we are
unable to estimate the economic impact that the revised
reclassification criteria will have on prospective payment system
hospitals.
However, in the past, the number of hospitals who have been denied
reclassification for failure to meet the adjacency requirement has not
been significant. For example, the MGCRB received 1343 applications for
reclassification for FY 1994. Of that number, only two applications
were denied on the basis of the adjacency provision alone. Thus, we do
not anticipate that the elimination of the adjacency requirement will
result in a significant increase in the number of hospitals that
qualify for reclassification. However, we note that we are unable to
estimate how many additional hospitals might have applied for
reclassification had the adjacency requirement not been in effect.
In some instances, geographic reclassification may result in a
substantial increase in revenues for a hospital and may also represent
a boost to the local economy through an increase in employment and
additional purchases of goods and services. Therefore, there may be
significant effects on a small number of hospitals that are
reclassified as a result of our elimination of the adjacency
requirement. If these hospitals are able to spend additional funds for
patient care services, then access to care may also increase. Finally,
while we are unable to reach any specific, quantifiable conclusions
regarding potential effects of this rule, we note that some
redistributive effects on hospital payments will result from MGCRB
decisions to approve requests for reclassification based on the
elimination of the adjacency requirement.
Appendix B: Technical Appendix on the Capital Acquisition Model and
Budget Neutrality Adjustment
Section 1886(g)(1)(A) of the Act requires that for FY 1992 through
FY 1995 aggregate prospective payments for operating costs under
section 1886(d) of the Act and prospective payments for capital costs
under section 1886(g) of the Act be adjusted each year in a manner that
results in a 10 percent reduction of the amount that would have been
payable on a reasonable cost basis for capital-related costs in that
year. Under Sec. 412.352, the 10 percent reduction is generated
entirely from the capital prospective payments. A budget neutrality
adjustment factor is applied to the Federal rate and hospital-specific
rate so that total capital payments for each year from FY 1992 through
FY 1995 equal 90 percent of Medicare inpatient capital costs in each
year.
To calculate the budget neutrality adjustment, we must project the
rates at which old capital will be depreciated and written off and new
capital will be acquired and depreciated. (Old capital costs include
depreciation, lease, interest expenses, and other capital-related costs
defined in Sec. 412.302 for depreciable assets that are in use for
patient care or obligated on or before December 31, 1990.)
In developing the FY 1992 prospective payment rates, there were
limited capital data available that could be used to project payments
under the capital prospective payment system and develop the budget
neutrality adjustment factor. Consequently, we developed a capital
acquisition model that relied on Monte Carlo random simulation
techniques to project capital costs for 6000 hypothetical hospitals.
This model is described in detail in the August 30, 1991 final rule (56
FR 43517-43522).
We now have cost report data for the first year of the capital
prospective payment system. These cost reports begin in FY 1992 (PPS-9)
and provide a break-out of old and new capital for the first time. We
used the June 1994 update of the PPS-9 cost reports, the July 1994
update of the provider-specific file, and the March 1994 update of the
intermediary audit file as data sources.
The available data still lack certain items that are required for
the determination of budget neutrality, including a hospital's
projected new capital costs for each year, its projected old capital
costs for each year, and the projected obligated capital amounts that
will be put in use for patient care services and recognized as old
capital each year.
For FY 1993 and FY 1994, we implemented an integrated model that
starts with the available data for existing hospitals and back-fills
the missing items with results from the capital acquisition model that
was used to develop the FY 1992 payment rates. Since we now have data
for FY 1992, we no longer need to use the integrated model, and,
consequently, we are no longer using the model that developed the FY
1992 rates.
Since hospitals under alternative payment system waivers (that is,
hospitals in Maryland and hospitals in the Finger Lakes Area Hospital
Corporation in New York) are currently excluded from the capital
prospective payment system, we excluded these hospitals from our model.
We first developed FY 1992, FY 1993, and FY 1994 hospital-specific
rates using the provider-specific file, the intermediary audit file,
and when available, cost reports. (We used the cumulative provider-
specific file, which includes all updates to each hospital's records,
and chose the latest record for each fiscal year.) We checked the
consistency between the provider-specific file and the intermediary
audit file. We also ensured that the FY 1993 increase in the hospital-
specific rate was at least 0.62 percent (the net FY 1993 update) and
that the FY 1994 hospital-specific rate was at least as large as the FY
1993 hospital-specific rate decreased by 2.16 percent (the net FY 1994
update). We were able to match hospitals to the files as shown in the
following table.
------------------------------------------------------------------------
Number of
Source hospitals
------------------------------------------------------------------------
Provider Specific File Only................................ 66
Provider Specific and Audit File........................... 5188
Total.................................................. 5254
------------------------------------------------------------------------
Forty-six of these hospitals had unusable or missing data. We were able
to back-fill a hospital-specific rate for 21 of these hospitals from
the cost reports as shown in the following table.
------------------------------------------------------------------------
Number of
Source hospitals
------------------------------------------------------------------------
PPS-5 Cost Reports......................................... 2
PPS-6 Cost Reports......................................... 1
PPS-7 Cost Reports......................................... 2
PPS-8 Cost Reports......................................... 3
PPS-9 Cost Reports......................................... 13
Total.................................................. 21
------------------------------------------------------------------------
We did not have data for 25 hospitals, and had to eliminate them from
the capital analysis. Most of these hospitals are new hospitals or
hospitals with very few Medicare admissions. This leaves us with 5229
hospitals and should not affect the precision of the budget neutrality
determination.
We then determined old and new capital amounts for FY 1992 using
the PPS-9 cost reports as the first source of data. Since we matched
only 4,873 PPS-9 cost reports, we also used the provider-specific file
for old capital information. Even in cases where a cost report was
available, the break out of old and new capital was not always
available. In these cases, we used the old capital amounts and new
capital ratios from the provider-specific file. If these were missing
we derived the old capital amount from the hospital-specific rate.
Finally, we used the intermediary audit file to develop obligated
capital amounts. Some hospitals had indicated that they could not bring
the obligated capital on line before the expiration of this provision,
so we excluded the obligated amounts for these hospitals from the
budget neutrality determination. Since the obligated amounts are
aggregate projected amounts, we computed a Medicare capital cost per
admission associated with these amounts. We adjusted the aggregate
amounts by the following factors:
(1) Medicare inpatient share of capital. This was derived from cost
reports and was limited to the Medicare share of total inpatient days.
It was necessary to limit the Medicare share because of data integrity
problems. Medicare share of inpatient days is a reasonably good proxy
for allocating capital. However, it may be understated if Medicare
utilization is high, and may be overstated because it ignores the
outpatient share of capital.
(2) Capitalization factor. This factor allocates the aggregate
amount of obligated capital to depreciation and interest amounts.
Consistent with the assumptions in the capital input price index, we
used a 25-year life for fixed capital and a 10-year life for movable
capital, and an average projected interest rate of 6.7 percent. We also
assumed that fixed capital acquisitions are about one-half of total
capital. In conjunction with the useful life and interest rate
assumptions, the resulting capitalized fixed capital is about one-half
of total capitalization. This is consistent with the allocations
between fixed and movable capital found on the cost reports. The ratio
we developed is 0.137, which produces the first year capitalization
based on the aggregate amount.
(3) A divisor of Medicare admissions to derive the capital per
discharge amount. Since we must project capital amounts for each
hospital, we continued to use a Monte Carlo simulation to develop these
amounts. The Monte Carlo simulation is now used only to project capital
costs per discharge amounts for each hospital. We analyzed the
distributions of capital increases, and noted a slightly negative
correlation between the dollar level of capital per admission, and the
rate of increase in capital. To determine the rate of increase in
capital cost per admission, we multiplied the lesser of $3,000 or the
capital cost per admission by .00006 and subtracted this result from
1.2. (Increases for capital levels over $3,000 were not influenced by
the level of capital, so this part of the calculation was capped at
$3,000.) We selected a random number from the normal distribution,
multiplied it by 0.17 (the standard deviation) and added it to -0.04
(the mean) and then added 1 to create a multiplier. This random result
was multiplied by the previous result to assign a rate of increase
factor which was multiplied by the prior year's capital per discharge
amount to develop a capital per discharge amount for the projected
year.
To model a projected year, we used the old and new capital for the
prior year multiplied by 0.96 (aging factor). The 0.96 aging factor is
the average of changes in capital over its life. The aged new and old
capital is subtracted from the projected capital described in the
previous paragraph. The difference represents newly acquired capital.
We assume that the hospital would accrue only a half year of costs for
newly acquired capital in the year in which the capital comes on line.
This is because, on average, new capital will come on line in the
middle of the year. We make the same assumption for obligated capital.
If the hospital has obligated capital, the lesser of one half of the
adjusted costs (as described in the succeeding paragraph) for newly
acquired capital or one half of the costs for obligated capital are
deemed to apply to the current year. The full year's costs for new or
obligated capital are assumed to apply for the following year. For FY
1994, one half of the costs for any outstanding obligated capital were
deemed to apply to FY 1994; a full year's costs were deemed to apply to
FY 1995. With the exception of certain hospitals about whom we have
information to the contrary, we assume that hospitals would meet the
expiration dates provided under the obligated capital provision. The
on-line obligated amounts are added to old capital and subtracted from
the newly acquired capital to yield residual newly acquired capital,
which is then added to new capital. The residual newly acquired capital
is never permitted to be less than zero.
Next, we computed the average total capital cost per discharge from
the capital costs that were generated by the model and compared the
results to total capital costs per discharge that we had projected
independently of the model. We adjusted the newly acquired capital
amounts proportionately, so that the total capital costs per discharge
generated by the model match the independently projected capital costs
per discharge.
Once each hospital's capital-related costs are generated, the model
projects capital payments. We use the actual payment parameters (for
example, the case-mix index and the geographic adjustment factor), that
are applicable to the specific hospital.
To project capital payments, the model first assigns the applicable
payment methodology (fully prospective or hold-harmless) to the
hospital. If available, the model uses the payment methodology
indicated in the PPS-9 cost reports or the provider-specific file.
Otherwise, the model determines the methodology by comparing the
hospital's FY 1992 hospital-specific rate to the adjusted Federal rate
applicable to the hospital. The model simulates Federal rate payments
using the assigned payment parameters and hospital-specific estimated
outlier payments. The case-mix index for a hospital is derived from the
1993 MedPAR file using the final FY 1995 DRG relative weights published
in this rule. The case-mix index is increased each year after FY 1993
consistent with the continuing trend in case-mix increase.
We analyzed the case-mix increases for the recent past and found
that case-mix increases have decelerated to about 1.55 percent in FY
1992 and 0.85 percent in FY 1993. Even though FY 1994 is not complete,
it appears from examination of the data through July 1994 that the
case-mix increase for FY 1994 will be about 0.85 percent. Since case-
mix increases appear to have decelerated, we have reduced our projected
long-term increase of 2 percent to 0.85 percent for FY 1995. We will
continue to monitor case-mix increases and make appropriate adjustments
to our projections. (Since we are using FY 1993 cases for our analysis,
the FY 1993 increase in case mix has no effect on the FY 1995 Federal
rate. It does affect the estimated update for the FY 1996 Federal rate
displayed in the projection table in this appendix.)
Changes in geographic classification and corrections in the
hospital wage data used to establish the hospital wage index affect the
geographic adjustment factor. Changes in the DRG classification system
and the relative weights affect the case-mix index.
Section 13501(a)(3) of Public Law 103-66 requires that, for
discharges occurring after September 30, 1993, the unadjusted standard
Federal rate be reduced by 7.4 percent. Consequently, the model reduces
the unadjusted standard Federal rate by 7.4 percent effective in FY
1994. Because of the budget neutrality provisions in effect through FY
1995, this provision does not reduce aggregate payments for capital in
FY 1994 and FY 1995.
Section 412.308(c)(4)(ii) requires that the estimated aggregate
payments for the fiscal year, based on the Federal rate after any
changes resulting from DRG reclassifications and recalibration and the
geographic adjustment factor, equal the estimated aggregate payments
based on the Federal rate that would have been made without such
changes. For FY 1994, the budget neutrality adjustment factor was
1.0033. To determine the factor for FY 1995, we first determined the
portion of the Federal rate that would be paid for each hospital in FY
1995 based on its applicable payment methodology. We then compared
estimated aggregate Federal rate payments based on the FY 1994 DRG
relative weights and FY 1994 geographic adjustment factor to estimated
aggregate Federal rate payments based on the FY 1995 relative weights
and the FY 1995 geographic adjustment factor. In making the comparison,
we held the FY 1995 Federal rate portion constant and set the other
budget neutrality adjustment factor and exceptions reduction factor to
1.00. We determined that to achieve budget neutrality for the changes
in the geographic adjustment factor and DRG classifications and
relative weights, an incremental budget neutrality adjustment of 0.9998
for FY 1995 should be applied to the previous cumulative FY 1994
adjustment of 1.0033 (the product of the FY 1993 incremental adjustment
of 0.9980 and the FY 1994 incremental adjustment of 1.0053), yielding a
cumulative adjustment of 1.0031 through FY 1995.
The methodology used to determine the recalibration and geographic
(DRG/GAF) budget neutrality adjustment factor is similar to that used
in establishing budget neutrality adjustments under the prospective
payment system for operating costs. One difference is that under the
operating prospective payment system, the budget neutrality adjustments
for the effect of geographic reclassifications are determined
separately from the effects of other changes in the hospital wage index
and the DRG weights. Under the capital prospective payment system,
there is a single DRG/GAF budget neutrality adjustment factor for
changes in the geographic adjustment factor (including geographic
reclassification) and the DRG relative weights. In addition, there is
no adjustment for the effects that geographic reclassification has on
the other payment parameters, such as the payments for serving low
income patients or the large urban add-on.
In addition to computing the DRG/GAF budget neutrality adjustment
factor, we used the model to project total aggregate payments under the
prospective payment system and to compute the budget neutrality
adjustment factor that would result in estimated payments under the
capital prospective payment system equal to 90 percent of the amount
that would have been payable on a reasonable cost basis. This budget
neutrality factor is applied to the Federal and hospital-specific
rates, but not to the hold-harmless payments.
Additional payments under the exceptions process are accounted for
through a reduction in the Federal and hospital-specific rates.
Therefore, we used the model to calculate estimated exceptions payments
and the exceptions reduction factor. This exceptions reduction factor
ensures that estimated aggregate payments under the capital prospective
payment system, including exceptions payments, equal estimated
aggregate payments under the capital prospective payment system without
an exceptions process. Since changes in the level of the payment rates
change the level of payments under the exceptions process, the budget
neutrality and exceptions adjustments factors must be determined
through iteration. Further, these two factors interact with each other
so that they must be determined simultaneously. We successfully
determined values for these factors so that the exceptions adjustment
factor is correct, and estimated payments under the capital prospective
payment system equal 90 percent of estimated Medicare inpatient capital
costs.
In the August 30, 1991 final rule (56 FR 43517), we indicated that
we would publish each year the estimated payment factors generated by
the model to determine payments for the next 5 years. The table below
provides the actual factors for FYs 1992 through FY 1995, and the
estimated factors that would be applicable through FY 1999. We caution
that the projections for FY 1996 and thereafter are estimates only, and
are subject to revisions resulting from continued methodological
refinements, more recent data, and any payment policy changes that may
occur. In this regard, we note that in making these projections we have
assumed that the cumulative DRG/GAF adjustment factor will remain at
1.0031 for FY 1995 and later because we do not have sufficient
information to estimate the change that will occur in the factor for
years after FY 1995.
The projections are as follows:
----------------------------------------------------------------------------------------------------------------
Increase in Exceptions Budget Federal rate
Fiscal year cost per Update factor reduction neutrality (after outlier
discharge\1\ factor factor reduction)
----------------------------------------------------------------------------------------------------------------
1992............................ 3.83 N/A 0.9813 0.9602 415.59
1993............................ 0.84 6.07 .9756 .9162 \2\417.29
1994............................ 3.78 3.04 .9485 .8947 \3\378.34
1995............................ 4.81 3.44 .9734 .8432 \4\376.83
1996............................ 5.04 2.33 .9784 N/A 459.67
1997............................ 5.29 2.30 .9662 N/A 464.38
1998............................ 5.47 4.29 .9541 N/A 478.24
1999............................ 5.55 4.92 .9378 N/A 493.19
----------------------------------------------------------------------------------------------------------------
\1\Note: Adjusted for estimated 1.55 percent annual increase in case mix for FY 1992, 0.85 percent for FY 1993
and later.
\2\Note: Includes the DRG/GAF adjustment factor of 0.9980 and the change in the outlier adjustment for 0.9497 in
FY 1992 to 0.9496 in FY 1993.
\3\Note: Includes the 7.4 percent reduction in the unadjusted standard Federal rate. Also includes the DRG/GAF
adjustment factor of 1.0033 and the change in the outlier adjustment from 0.9496 in FY 1993 to 0.9454 in FY
1994.
\4\Note: Includes the DRG/GAF adjustment factor of 1.0031 and the change in the outlier adjustment from 0.9454
in FY 1994 to 0.9414 in FY 1995. Future adjustments are, for purposes of this projection, assumed to remain at
the same level.
Appendix C: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
Several provisions of the Act address the setting of update factors
for services furnished in FY 1995 by hospitals subject to the
prospective payment system and those excluded from the prospective
payment system. Section 1886(b)(3)(B)(i)(IX) of the Act sets the
applicable percentage increases for prospective payment hospitals for
FY 1995 as the market basket percentage increase minus 2.5 percentage
points for prospective payment hospitals located in urban areas. For
hospitals located in rural areas, section 1886(b)(3)(B)(i)(X) requires
the Secretary to make the rural national average standardized amounts
equal to the other urban national average standardized amount. Section
1886(b)(3)(iv) sets the FY 1995 percentage increase to the hospital-
specific rate applicable to sole community hospitals equal to the rate
of increase in the hospital market basket minus 2.2 percentage points.
Section 1886(b)(3)(B)(ii) sets the FY 1995 percentage increase in the
rate-of-increase limits for hospitals and hospital units excluded from
the prospective payment system equal to the rate of increase in the
hospital market basket minus a reduction factor (not to exceed -1.0
percent) depending on the hospital's operating costs and target
amounts.
In accordance with section 1886(d)(3)(A) of the Act, we are
updating the average standardized amounts, the hospital-specific rates,
and the rate-of-increase limits for hospitals excluded from the
prospective payment system as provided for in section 1886(b)(3)(B) of
the Act. Based on the currently forecasted market basket increase of
3.6 percent for hospitals subject to the prospective payment system,
the updates in the standardized amounts are 1.1 percent for hospitals
in urban areas and 8.4 percent for hospitals in rural areas. The update
in the hospital-specific rate applicable to sole community hospitals is
1.4 percent (that is, the market basket rate of increase of 3.6 percent
minus 2.2 percentage points). The update for hospitals excluded from
the prospective payment system is based on the percentage increase in
the excluded hospital market basket (currently estimated at 3.7
percent) minus an appropriate reduction factor (not to exceed -1.0
percent) .
Sections 1886(e)(2)(A) and (3)(A) of the Act require that the
Prospective Payment Assessment Commission (ProPAC) recommend to the
Congress by March 1, 1994 an update factor for FY 1995 that takes into
account changes in the market basket index, hospital productivity,
technological and scientific advances, the quality of health care
provided in hospitals, and long-term cost effectiveness in the
provision of inpatient hospital services.
Section 1886(e)(4) of the Act requires that the Secretary, taking
into consideration the recommendations of ProPAC, recommend update
factors for FY 1995 that take into account the amounts necessary for
the efficient and effective delivery of medically appropriate and
necessary care of high quality. As required by section 1886(e)(5) of
the Act, we published the recommended FY 1995 update factors under
section 1886(e)(4) of the Act as Appendix D of the May 27, 1994
proposed rule (59 FR 27873).
II. Secretary's Final Recommendations for Updating the Prospective
Payment System Standardized Amounts
We received several public comments concerning our proposed
recommendation. After consideration of the arguments presented, we have
decided that our final recommendation will be the same as our proposed
recommendation. That is, we are recommending that the standardized
amounts be increased by an average amount equal to the market basket
percentage increase minus 2.5 percentage points for hospitals located
in urban areas and the market basket percentage increase plus 4.8
percentage points for hospitals located in rural areas (before the
effects of adjustments for outlier, geographic reclassification and
recalibration of the DRG relative weights). Our recommendation for a
higher update to the rural standardized amount is intended to eliminate
the differential between the standardized amounts for other urban and
rural hospitals, as required by section 1886(b)(3)(B)(i)(X) of the Act.
We are also recommending an update equal to the market basket rate of
increase minus 2.2 percentage points for the hospital-specific rate for
sole community hospitals. We believe that the hospital-specific rate
should be updated by the update factor that approximates the percentage
increase in the urban standardized amounts. These figures are
consistent with the President's budget recommendation, given the
current market basket forecast of 3.6 percent.
In recommending these increases, we have followed section
1886(e)(4) of the Act, which requires that we take into account the
amounts necessary for the efficient and effective delivery of medically
appropriate and necessary care of high quality. In addition, as
required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of ProPAC. We believe our analyses,
which measure changes in hospital productivity, scientific and
technological advances, practice patterns changes, and changes in case
mix, support our recommendations.
Comment: A few commenters agree with ProPAC's recommendation that
the share of hospital wages in the market basket should be increased.
Response: We responded to this same comment in detail in the
September 4, 1990 final rule (55 FR 36047), when the current hospital
market basket was implemented. In addition, as we stated in the FY 1994
proposed and final rules (58 FR 30445 and 58 FR 46488), respectively,
we believe that it would be equally inappropriate to use 100 percent
internal (that is, hospital industry-specific) price proxies or 100
percent external price proxies. We prefer to use economy-wide proxies
for those occupations that are generally employed both inside and
outside hospitals, such as managers, administrators, clerical and
maintenance workers. We believe that the economy-wide rate of increase
is the more appropriate measure for these types of employees, since
that is the relevant labor market for these employees. In contrast, we
use hospital-industry proxies for those categories of workers, such as
registered nurses, that are not hired in large numbers in other sectors
of the economy.
Comment: One commenter stated that current law should be changed to
include an allowance for scientific and technological advances. The
commenter believes that this change would provide additional funds for
hospitals to adopt quality-enhancing health care advances.
Response: The update framework accounts for the role of new
technologies in two ways. First, we account for cost-increasing,
quality-enhancing new technologies in the intensity component of our
update recommendation (which is an add-on to the market basket rate of
increase). Second, we account for cost-decreasing new technologies
through a productivity adjustment. This adjustment allows for those
technologies that allow hospitals to treat their patients at lower
cost.
Comment: One commenter states that urban hospitals should continue
to receive a higher standardized amount than rural hospitals because of
the higher operating costs of urban facilities.
Response: Section 1886(d)(3)(A)(iii) of the Act requires that the
rural standardized amount be set equal to the other urban standardized
amount effective for discharges occurring on or after October 1, 1994.
We note that even though rural hospitals and other urban hospitals will
now receive the same standardized amount payment, hospitals in other
urban areas will receive a higher standardized amount than they would
have otherwise received because they benefit from the effects of
applying a single outlier offset rather than separate rural and urban
offsets. The reduction applied to the other standardized amount for FY
1995 is 5.1 percent compared to the separate urban offset of 5.4
percent that was applied to the other urban rate in FY 1994.
Comment: One commenter stated that reductions from the market
basket are no longer necessary and that Congress should begin granting
hospitals the full market basket payments once more. Another commenter
asks that sole community hospitals be granted the full market basket
increase because of their importance to the Medicare population.
Response: Section 1886(b)(3)(i)(X) of the Act sets the FY 1995
percentage increases in the operating cost standardized amounts and
hospital-specific rates applicable to sole community hospitals.
Therefore, we have no discretion in this regard. However, we believe
that payments under the prospective payment system are sufficient to
ensure the continued availability of efficient high quality care for
Medicare beneficiaries and that the updates established by Congress are
appropriate.
Comment: ProPAC has several concerns about the single intensity
adjustment included in HCFA's update framework and believes that each
element should be quantified separately. In addition, ProPAC believes
that it is inappropriate to adjust for changes in the use of services
due to reductions in cost-ineffective practices or practice patterns.
Response: We continue to disagree with ProPAC that accounting
separately for changes in within-DRG complexity, science and technology
changes, and practice patterns would be more accurate. In view of the
interactive nature of the three elements, we believe it is difficult to
measure accurately the effects of each element separately. Instead, we
believe that it is more appropriate and accurate to account for all
three elements in a single measure. Thus, our intensity measure is
designed to encompass the net effect of all three changes. With regard
to practice pattern changes, which are also reflected in our intensity
adjustment, we do not adjust for changes that have not taken place.
Comment: ProPAC states that since its framework already accounts
for case-mix index changes, it is inappropriate for HCFA to make
prospective payments for case-mix index changes that HCFA attributes to
reclassification or recalibration either through changing the weights
or the standardized amounts. The Commission states that its framework
already accounts for this.
Response: We believe that it is appropriate to account for case-mix
index changes attributed to reclassification or recalibration within
the update framework, since these changes reflect changes in relative
resource requirements, not absolute resource requirements. We note that
section 1886(d)(4)(C)(iv) of the Act requires that the Secretary
include recommendations with respect to adjustments to weighting
factors in our update recommendation.
Comment: Several commenters questioned why HCFA changed from using
actual case-mix change to using projected case mix change in the update
formula.
Response: Our update analysis takes into account changes in case
mix adjusted for changes attributable to improved coding practices and
DRG reclassification and recalibration. In the past, we used the
observed increase in case mix for the most recent year available. For
example we based our FY 1994 update on the observed increase in case
mix from FY 1992. Recent data on case-mix change demonstrates that the
growth in case mix has slowed.
The use of projected case mix allows us to take into account
emerging trends in case mix more quickly. We note that ProPAC uses an
estimate of the total case-mix index in the year prior to the update as
part of its update framework. In our framework, we have decided to use
our estimate of what case-mix change will be in the year of the update,
which is consistent with the other components of the update framework.
III. Secretary's Final Recommendation for Updating the Rate-of-Increase
Limits for Excluded Hospitals and Units
We received no public comments concerning our proposed
recommendation on the update factor for excluded hospitals and hospital
units. Therefore, our final recommendation will be that hospitals and
hospital units excluded from the prospective payment system receive an
update equal to the percentage increase in the market basket that
measures input price increases for services furnished by excluded
hospitals minus 1.0 percentage point. Thus, given the current estimate
of the change in the market basket for excluded hospitals of 3.7
percent, our final recommendation is an update of 2.7 percent. We note
that the updates for hospitals and units excluded from the prospective
payment system as set in Public Law 103-66 is the market basket rate of
increase minus 1.0 percentage point, adjusted to account for the
relationship between the provider's allowable operating cost per case
and its target amount.
Appendix D: Development of Update Framework for Prospective Payment
System for Inpatient Hospital Capital-Related Costs
I. Introduction
For FY 1992 through FY 1995, Sec. 412.308(c)(1) provides that the
update for the capital prospective payment rates (Federal rate and
hospital-specific rate) will be based on a 2-year moving average of
actual increases in Medicare inpatient capital costs per discharge. The
regulations provide that, beginning in FY 1996, HCFA will determine the
update in the capital prospective payment rates based on an analytical
framework that will take into account (1) changes in the price of
capital (which we will incorporate into a capital input price index),
and (2) appropriate changes in capital requirements resulting from
development of new technologies and other factors (such as the
diffusion of existing technologies and existing hospital capacity and
utilization). The objective of the capital update framework is to
determine a rate of increase in aggregate capital prospective payments
that, along with a rate of increase in DRG operating payments, ensures
a joint flow of capital and operating services for efficient and
effective care for Medicare patients.
Although the analytical framework will not be employed to determine
the annual update factor until FY 1996, we are presenting a series of
preliminary models, using available data and concepts, of an update
framework for the prospective payment system for hospital inpatient
capital-related costs. We have presented a series of models in our FY
1992, FY 1993, FY 1994, and FY 1995 rulemaking documents. We received
one comment, from the Prospective Payment Assessment Commission, on
elements of the most recent model framework, which appeared in the May
27, 1994 proposed rule (59 FR 27876). Below we discuss the current
version of the model, based on our previously published version and our
continued analysis of the data and concepts incorporated into the
framework. We also respond to the comment from ProPAC.
The model update framework includes a capital input price index
(CIPI) that parallels the operating input price index. The CIPI
measures the pure price changes associated with changes in capital-
related costs (prices x ``quantities''). The composition of capital-
related costs is maintained at base-year FY 1987 proportions in the
CIPI. As such, the composition of capital reflects the underlying
capital acquisition process. We selected FY 1987 as the base year for
this preliminary CIPI for consistency with the operating input price
index. We would periodically update both the operating and the capital
input price indexes to reflect the changing composition of inputs for
capital and operating costs. We expect to have rebased the capital and
operating input price indexes by the time we implement the final
capital update framework for FY 1996. The CIPI below illustrates the
methodology we propose to employ.
The model capital update framework, like the revised operating
update framework, incorporates several policy adjustments in addition
to the CIPI. We would adjust for case-mix index-related changes, for
intensity, and for the efficient and cost-effective use of capital
(such as movable equipment, buildings and fixed equipment) in the
hospital industry, as well as for error in the capital input price
index forecast.
In developing the model framework, we are attempting to maximize
consistency with the current operating framework, in order to
facilitate the eventual development of a single prospective payment
system update framework. We are also concerned with promoting the goals
that motivated the adoption of the capital prospective payment system,
especially the goals of promoting more effective and efficient
utilization of capital resources in the hospital industry and
establishing incentives for hospitals to make cost-effective decisions
regarding acquisition of new capital resources.
It is important to emphasize that this presentation represents our
current thinking, and that we continue to encourage submission of
comments and recommendations for further improvements. We are
interested in suggestions regarding the CIPI, the proposed policy
adjustment factors, and alternative methodologies for deriving the
factors. We also welcome information concerning empirical studies and
sources of data that could be useful in developing the framework. We
will consider comments and recommendations on any aspect of the model
framework in making any further developments. We will formally propose
an analytical update framework for implementation in FY 1996 during the
rulemaking process for that year. To assure consideration in the
development of our formal proposal, comments should be sent by December
31, 1994 to: Update Framework, Division of Hospital Payment Policy,
Health Care Financing Administration, 1-H-1 East Low Rise, Baltimore,
Maryland 21207.
II. ProPAC Recommendation for Updating the Capital Prospective Payment
System Federal Rate
ProPAC recommends the use of an update framework that includes a
capital market basket component that measures 1-year changes in the
purchase prices of a fixed basket of capital goods purchased by
hospitals. The ProPAC framework also includes several policy adjustment
factors. A forecast error correction factor adjusts payment rates so
that the effects of past errors are not perpetuated. A financing policy
adjustment accounts for the effects of substantial deviations from
long-term trends in interest rates on hospital capital costs. The
capital update framework also includes adjustments for scientific and
technological advances, productivity, and case-mix change similar to
those employed in the ProPAC operating update framework. ProPAC also
recommends the development and use of a combined update framework for
the prospective payment systems for operating and capital-related costs
for FY 1995.
Our long-term goal is to develop a single prospective payment
system update framework. Currently, the regulations provide for the
determination of the capital prospective payment update by means of a
lagged 2-year average of actual Medicare capital cost increases. Once
we have completed work on an analytical framework for the capital
prospective payment update, we will begin to study development of a
unified framework. In the meantime, we will continue to maintain
consistency as much as possible with the current operating framework in
order to facilitate the eventual development of a unified framework.
The basic objectives of the ProPAC and HCFA update frameworks are
compatible. The goal of each framework is to provide a rate of increase
in capital prospective payments that, along with the rate of increase
in operating prospective payments, will ensure a flow of capital and
operating resources that will allow for efficient and effective care
for Medicare patients. Both frameworks are designed to provide
increases for the purchase of quality-enhancing new technologies. Both
frameworks provide for case-mix adjustments to remove the effects of
upcoding and to adjust for changes in within-DRG severity. Both
frameworks also seek to encourage efficient capital spending behavior
and to adjust the overall size of capital stock to appropriate levels.
Although the frameworks adopt different methodologies for promoting
some of these goals, they are philosophically compatible to the degree
that they share these goals.
However, there is one important substantive difference between the
ProPAC and HCFA frameworks. ProPAC's framework is based on the premise
that capital prospective payments are only for future capital purchases
and do not reflect the vintage nature of capital. Thus, ProPAC's
proposed capital market basket reflects the projected increase in the
purchase price of capital goods from one year to the next. HCFA's
framework is based on the premise that capital prospective payments are
for hospitals' future capital-related expenses, which include the
expenses related to future capital-related purchases. That is, HCFA's
framework addresses the input price component of expenses associated
with hospitals' given stock of capital in a particular fiscal year;
ProPAC's framework ignores hospitals' present stock of capital and
focuses on changes in input prices associated with capital purchases
that hospitals will make in a particular fiscal year.
There is a sound economic reason why the current purchase price of
capital assets alone is an inadequate measure of the price of capital.
The crucial distinguishing feature of capital assets is that they are
consumed over time. A satisfactory measure of the change in capital
input prices must therefore account for this fact. Consideration of the
costs for all capital currently in use for patient care, not just the
costs for current capital purchases, is necessary for this purpose. The
ProPAC index cannot adequately capture this aspect of changes in
capital input prices.
In addition to the disagreement with ProPAC over whether the CIPI
should reflect the vintage nature of capital, we also disagree with
ProPAC over the treatment of interest. The pure price aspects of
interest costs (that is, the interest rate and the purchase price that
is represented in the amount of loan principal) are typically beyond
the control of the hospital industry. To be sure, the actual decision
to purchase capital assets or acquire debt is a ``quantity'' decision
and typically is discretionary for a particular span of time. However,
measuring the actual expected price per unit of real capital,
independently of any evaluation of the propriety of any actual purchase
decisions, is essential to recognize that the industry has little or no
control over the amount of capital it purchases but no control over the
price it pays for capital. Thus, the pure price aspect of interest cost
changes must be incorporated into the CIPI. Otherwise, the CIPI will
not accurately reflect the prices faced by hospitals who must borrow to
finance necessary capital acquisitions. Limitations on the quantity of
capital are appropriately implemented through policy adjustment
factors. The ProPAC approach artificially eliminates pure price changes
related to interest costs from the CIPI and incorporates them into a
discretionary adjustment factor. The HCFA CIPI retains all price
components of increase in interest costs as one measure of inflation in
capital-related expenses. It thereby keeps price and quantity aspects
distinct, allowing separate analysis of each factor of increases in
capital expenses.
We will continue to study the ProPAC recommendations in preparation
for developing our formal proposal for an analytical update framework
in the proposed rule for FY 1996. We provide further comments on
particular ProPAC recommendations in section III of this appendix.
III. Measurement of Capital Input Price Increases
A. Introduction
HCFA proposed a capital input price index as one component in
developing future update factors for the Federal rate in the September
1, 1992 Federal Register (57 FR 40016). We have presented revised
versions of the capital input price index in the May 26, 1993 (58 FR
30448), September 1, 1993 (58 FR 46490), and May 27, 1994 (59 FR 27876)
issues of the Federal Register. The developing capital input price
index parallels the operating input price index. Both the developing
capital input price index and the operating input price index are
designed to measure input price changes for hospitals' current year
expenses, that is, to separate pure price changes from quantity and
expenditure changes. The operating sector input price index measures
input price changes for operating-related expenses. The capital input
price index measures input price changes for capital-related expenses.
Capital-related expenses include depreciation, interest, and other
expenses (taxes and insurance related to capital goods).
B. Review of the HCFA Capital Input Price Index Methodology
The current version of the CIPI is based on the following
assumptions:
The Federal rate is based on the concept of capital-
related expenses of capital assets used for patient care in the fiscal
year and, therefore, any change in the Federal rate should take into
account expected changes in the input price aspects of capital-related
expenses;
Capital-related expenses are defined as the sum of
depreciation expense, capital-related interest costs, and other
capital-related costs, including taxes, insurance, and leases; and
The input prices related to capital-related expenses are
typically beyond the control of the hospital industry (that is, the
hospital is a price-taker, not a price-setter).
These assumptions lead directly to a definition of a CIPI that
takes into account the price aspects of changes in depreciation
expense, interest costs, and other capital-related costs. Further, the
assumptions lead directly to input prices for depreciation expense and
interest costs that, unlike operating costs, have a time dimension that
must be captured in the CIPI. HCFA includes three categories of
capital-related expenses in the CIPI: depreciation expense, interest
costs, and other capital-related costs (taxes and insurance).
Current depreciation expenses represent the summed depreciation
charges for all past purchases of fixed capital assets that are still
depreciable in the current period. The input prices associated with
these depreciation expenses are the purchase prices attached to all
past and current capital purchases for capital still depreciable in the
current period. A weighted average of these purchase prices thus
represents the input price associated with depreciation expenses in the
current period. Thus, the depreciation input price for the current
period measures price aspects of current depreciation expenses for
capital just as the operating input price index for the current period
measures price aspects of current operating expenses for labor and non-
capital goods and services. The depreciation input price differs from
the operating input price in that the depreciation input price is a
composite of all past capital purchase prices while the operating index
input price measures purchase prices for current periods only.
Current interest expenses represent the total interest charges for
all still-active past debt instruments associated with the purchase of
fixed capital assets. The input prices associated with these interest
expenses are the interest rates attached to all past debt instruments
that are still active in the current period. A weighted average of
these interest rates thus represents the input price associated with
interest expenses in the current period. Thus, the interest input price
for the current period measures price aspects of current interest
expenses just as the operating input price index for the current period
measures price aspects of current operating expenses for labor and non-
capital goods and services. The interest input price appropriately
differs from the operating input price in that the depreciation input
price is a composite of all past interest rates for debt instruments
still active while the operating index input price measures purchase
prices for current periods only.
Current year capital-related expenses for taxes and insurance have
an annual time dimension and, therefore, prices associated with these
expenses are, like operating input prices, current year prices only.
A commenter on a previous version of the CIPI recommended that
constant annual weights for capital price proxies be replaced by
variable annual weights that reflect the vintage purchases of capital.
The commenter pointed out that annual purchases of real capital tend to
increase over time. As annual purchases of capital increase, the later
years in the moving average of depreciation costs should be weighted
more heavily than the earlier years.
We agree with this comment. Accordingly, a special data base was
prepared to provide appropriate historical weights for depreciation and
interest input prices. The data base starts with financial variables
from the American Hospital Association (AHA) Panel Survey. These are
enhanced with data from Medicare cost reports and from the Department
of Commerce Capital Expenditure Survey. The data base provides annual
estimates of nominal purchases for building and fixed equipment and for
movable equipment. Leasing amounts were converted to nominal purchases
using the same relationships as appear for owner-operated capital.
Nominal purchases were then converted to annual real (that is, constant
dollar) purchases by dividing nominal expenditures by an appropriate
purchase price proxy.
Expected life for building and fixed equipment and for movable
equipment were derived from Medicare cost reports by dividing book
value of assets by current year depreciation amounts. The relative
distribution of real capital purchases within the respective life for
building and fixed equipment (25 years) and for movable equipment (10
years) were derived from the special data base. These relative
distributions are shown in Table 1. Relative distributions for a number
of different time periods were averaged to obtain the distributions in
Table 1. These distributions were all very similar regardless of the
periods chosen and, therefore, we selected an average of the
distributions in order to simplify the calculations.
Table 1.--Relative Weights for Capital Price Proxies Depreciation
Building and Fixed Equipment Expected Life: 25 years
------------------------------------------------------------------------
1............................................................ 0.015
2............................................................ 0.019
3............................................................ 0.022
4............................................................ 0.024
5............................................................ 0.023
6............................................................ 0.022
7............................................................ 0.020
8............................................................ 0.021
9............................................................ 0.025
10........................................................... 0.030
11........................................................... 0.033
12........................................................... 0.034
13........................................................... 0.034
14........................................................... 0.035
15........................................................... 0.038
16........................................................... 0.043
17........................................................... 0.049
18........................................................... 0.053
19........................................................... 0.056
20........................................................... 0.057
21........................................................... 0.060
22........................................................... 0.066
23........................................................... 0.071
24........................................................... 0.075
25........................................................... 0.077
------------------------------------------------------------------------
Total.................................................... 1.000
----------
Movable Equipment Expected Life: 10 years
------------------------------------------------------------------------
1............................................................ 0.064
2............................................................ 0.072
3............................................................ 0.077
4............................................................ 0.085
5............................................................ 0.095
6............................................................ 0.101
7............................................................ 0.109
8............................................................ 0.122
9............................................................ 0.132
10........................................................... 0.142
----------
Total.................................................... 1.000
----------
Interest Expected Life: 22 years
------------------------------------------------------------------------
1........................................................... 0.007
2............................................................ 0.009
3............................................................ 0.010
4............................................................ 0.011
5............................................................ 0.013
6............................................................ 0.015
7............................................................ 0.017
8............................................................ 0.020
9............................................................ 0.023
10........................................................... 0.027
11........................................................... 0.032
12........................................................... 0.038
13........................................................... 0.043
14........................................................... 0.050
15........................................................... 0.057
16........................................................... 0.064
17........................................................... 0.074
18........................................................... 0.083
19........................................................... 0.090
20........................................................... 0.098
21........................................................... 0.105
22........................................................... 0.114
----------
Total.................................................... 1.000
Source: Health Care Financing Administration, Office of the Actuary.
Table 2 shows the historical percentage changes in the capital
price proxies employed in the CIPI. These proxies are: the building
cost index maintained by the Engineering News-Record (ENR) for the
costs of fixed assets; the machinery and equipment component of the
Producer Price Index (PPI-11) for moveable equipment; the average yield
on domestic municipal bonds from the Bond Buyer index of 20 bonds
(Muni); the average yield on Moody's corporate bonds (AAA); a composite
of Muni and AAA indexes (Combined Muni/AAA); and the residential rent
component of the Consumer Price Index (CPI Rent) for other capital
costs.
We applied the relative weights from Table 1 to the appropriate
historical percent changes in capital price proxies listed in Table 2
to generate the current year prices for the CIPI depreciation sector
listed in Table 3. For example, the FY 1995 moveable equipment index
component percentage change of 1.9 percent in Table 3 represents the
average of the percentage changes in the movable equipment price proxy
(PPI-11 in Table 2) for the previous 10 years (that is, FY 1985 through
1994), weighted by the relative weights listed for movable equipment in
Table 1.
Table 2.--Annual Percent Changes for Capital Input Price Proxies, 1949 to 1999\1\
Proxy name: ENRBCI--Building Cost Index--Average of 20 U.S. cities PPI--11--Machinery and equipment muni--
Average yield on domestic municipal bonds--Bond buyer (20 bonds) AAA--Average yield on Moody's AAA corporate
bonds CPI (All Urban)--Residential rent
----------------------------------------------------------------------------------------------------------------
Percent changes
---------------------------------------------------
Fiscal Year ENRBCI PPI-11 Combined
Muni AAA muni/AAA CPI rent
----------------------------------------------------------------------------------------------------------------
1949.............................. 5.08 7.35 -4.43 -3.14 -4.20 4.41
1950.............................. 2.79 0.46 -9.36 -4.16 -8.43 3.87
1951.............................. 9.96 13.64 -5.81 7.10 -3.39 3.73
1952.............................. 2.43 1.60 12.93 5.70 11.43 4.25
1953.............................. 4.20 0.79 25.86 7.29 22.21 4.70
1954.............................. 3.67 2.73 -8.20 -6.32 -7.87 4.79
1955.............................. 4.37 1.90 -0.41 1.08 -0.15 1.43
1956.............................. 5.26 7.46 7.82 7.65 7.79 1.69
1957.............................. 3.55 7.99 24.03 18.02 22.96 1.94
1958.............................. 4.55 3.22 -3.73 -1.10 -3.29 1.90
1959.............................. 4.53 1.56 11.54 13.29 11.85 1.33
1960.............................. 2.67 1.53 1.71 4.93 2.28 1.58
1961.............................. 1.49 -0.30 -3.14 -3.24 -3.16 1.30
1962.............................. 1.93 0.00 -6.42 0.81 -5.11 1.28
1963.............................. 2.18 0.00 -3.43 -2.82 -3.31 1.01
1964.............................. 3.21 0.91 3.23 3.30 3.25 1.00
1965.............................. 2.32 0.60 -0.50 1.55 -0.10 0.99
1966.............................. 3.65 2.69 16.52 11.02 15.44 1.23
1967.............................. 2.90 3.78 2.41 8.26 3.51 1.69
1968.............................. 6.22 2.80 14.68 14.50 14.64 2.38
1969.............................. 10.25 3.27 21.50 9.83 19.20 2.79
1970.............................. 5.43 4.22 22.18 17.95 21.41 4.07
1971.............................. 11.52 4.30 -13.93 -4.94 -12.34 4.78
1972.............................. 12.53 2.18 -5.81 -3.77 -5.42 3.53
1973.............................. 8.78 2.61 -1.76 0.81 -1.26 4.01
1974.............................. 5.76 9.95 12.58 12.46 12.56 4.82
1975.............................. 8.04 19.37 19.17 7.95 16.94 5.33
1976.............................. 8.97 6.70 -1.15 -3.23 -1.53 5.24
1977.............................. 8.55 5.95 -15.84 -6.37 -14.13 5.80
1978.............................. 8.74 7.49 1.12 5.59 2.00 6.74
1979.............................. 7.98 8.85 7.27 8.90 7.60 7.05
1980.............................. 8.12 11.47 26.89 22.89 26.07 8.64
1981.............................. 7.04 10.65 32.94 20.74 30.49 8.84
1982.............................. 7.41 7.03 16.17 5.46 14.18 8.00
1983.............................. 6.46 3.23 -22.52 -17.72 -21.69 6.23
1984.............................. 2.83 2.25 4.76 6.85 5.14 5.06
1985.............................. 0.18 2.20 -5.27 -7.13 -5.61 5.87
1986.............................. 1.87 1.50 -18.08 -19.64 -18.36 6.18
1987.............................. 2.42 1.48 -5.49 -5.31 -5.46 4.45
1988.............................. 2.48 2.18 7.12 9.94 7.62 3.85
1989.............................. 1.42 3.47 -6.67 -4.78 -6.33 3.79
1990.............................. 2.67 3.18 -1.19 -2.04 -1.34 4.18
1991.............................. 1.52 2.25 -2.67 -2.60 -2.65 3.87
1992.............................. 2.80 0.49 -7.39 -8.18 -7.54 2.60
1993.............................. 5.10 0.50 -10.60 -8.90 -4.00 2.33
1994.............................. 3.80 1.10 -6.10 -7.50 3.00 3.15
1995.............................. 2.60 2.40 3.80 4.80 -0.56 5.06
1996.............................. 3.20 2.50 -5.30 -0.80 -1.76 3.21
1997.............................. 3.80 2.30 3.10 1.00 2.82 3.23
1998.............................. 3.60 2.20 9.30 6.90 0.18 3.42
1999.............................. 3.00 2.30 5.30 5.50 0.09 2.69
----------------------------------------------------------------------------------------------------------------
Source: Data Resources Inc.
Table 3.--Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1979 to 1999\1\
----------------------------------------------------------------------------------------------------------------
Depreciation
building and Movable
Fiscal year Total Total fixed equipment Interest Other
equipment
----------------------------------------------------------------------------------------------------------------
Weights.......................... 1.0000 0.6510 0.3054 0.3456 0.3274 0.0216
----------------------------------------------------------------------------------------------------------------
Price Changes
----------------------------------------------------------------------------------------------------------------
1979............................. 6.3 7.8 6.9 8.6 3.4 7.0
1980............................. 7.3 7.9 7.0 8.7 6.0 8.6
1981............................. 8.0 7.7 7.0 8.3 8.8 8.8
1982............................. 8.2 7.5 7.0 7.9 9.6 8.0
1983............................. 7.0 7.4 7.0 7.6 6.3 6.2
1984............................. 6.7 6.9 6.8 7.1 6.3 5.1
1985............................. 5.8 6.2 6.3 6.0 5.0 5.9
1986............................. 4.5 5.6 6.0 5.2 2.3 6.2
1987............................. 3.8 5.2 5.7 4.6 1.2 4.5
1988............................. 3.7 4.8 5.5 4.1 1.6 3.9
1989............................. 3.1 4.3 5.2 3.5 0.6 3.8
1990............................. 2.8 4.0 5.1 3.1 0.1 4.2
1991............................. 2.3 3.7 4.9 2.6 -0.4 3.9
1992............................. 1.8 3.5 4.7 2.4 -1.4 2.6
1993............................. 1.4 3.2 4.7 1.8 -2.2 2.4
1994............................. 1.0 3.0 4.6 1.7 -3.2 1.7
1995............................. 0.9 3.1 4.4 1.9 -3.6 2.6
1996............................. 1.1 3.0 4.2 2.0 -3.0 5.4
1997............................. 0.9 3.0 4.1 2.0 -3.3 2.9
1998............................. 1.1 2.9 3.9 2.0 -2.6 4.6
1999............................. 1.6 2.9 3.9 2.1 -1.2 5.5
----------------------------------------------------------------------------------------------------------------
\1\Index prices for 1994 through 1999 projected by Data Resources Inc.
Source: Health Care Financing Administration, Office of the Actuary.
As we have discussed in connection with previous versions of the
CIPI, stability is an important criterion for evaluating such an index.
This is because excessive volatility in a price index deprives the
index of predictability, and thus inhibits the ability of institutions
to plan for changes in capital payments resulting from changes in the
CIPI. We graphically demonstrated the stability of the HCFA vintage-
weighted CIPI compared to annual changes in capital purchase prices in
Figures 1 and 2 in our discussion of May 27, 1994 (59 FR 27882).
ProPAC recommends a capital input price index based on annual
changes in current capital purchase prices excluding consideration of
weighted historical capital purchase prices. We previously argued that
the ProPAC index was not logically consistent with the operating input
index that is currently used to assist updating DRG payment rates. We
would add that the volatility in annual purchase prices shown in
Figures 1 and 2 of our May 27, 1994 proposed rule (59 FR 27882) would
introduce an unacceptable degree of volatility in prospective capital
payments.
Another commenter on a previous version of the CIPI recommended
that data from Securities Data Inc. be incorporated into the CIPI
interest computations. This source provides information on hospital
issuances of municipal and commercial bonds. From this data base, we
incorporated information that shows that the average expected life of
hospital bond debt instruments (that is, the time interval between the
issue date and the maturation date) was about 13 years for municipal
serial bonds and about 25 years for municipal term bonds. The weighted
average life for the 2 types of bonds was 22 years.
The relative nominal capital purchases within various 22-year
periods provided appropriate annual weights for annual changes in
interest rates. Not all capital purchases are funded by debt. Medicare
cost reports suggest that about 80 percent of new capital acquisitions
are financed by debt and about 20 percent by equity financing. However,
if the proportion of total purchases financed by debt does not change
substantially from year to year, then it is irrelevant whether we use
the full amount or a constant proportion of the full amount of nominal
capital acquisitions as weights for relative amounts of the debt
instruments still active in the current period.
Relative interest weights derived from our procedure are shown in
Table 1. When combined with percent changes in annual interest rates
from Table 2, the weights provide current year estimates of interest
rate changes in the CIPI in Table 3. Thus, for example, the interest
rate component change of -3.2 percent in Table 3 for FY 1995 represents
the average of the previous 22 years in the interest rate proxy
(Combined Muni/AAA) in Table 2, weighted by the interest weights listed
in Table 1. We use a percent change in a combined municipal and AAA
commercial bond interest rate (shown in Table 2 as Combined Muni/AAA),
giving the municipal rate an 85 percent weight and the AAA rate a 15
percent weight, reflecting the relative hospital debts of the
government/non-profit hospital sector and the for-profit sector.
Although Medicare cost reports show that only 60 percent of current
hospital debt is in the form of notes or bonds (about 40 percent is in
the form of mortgages), we assumed that the relative annual weights for
all debt and the relative annual changes in interest rates for all debt
were the same as bond-related weights and price changes. We are still
searching for an appropriate source of information on hospital
commercial mortgage data. We do not expect that the discovery of such
data will materially alter our current conclusions about trends in
effective interest rates over time.
D. Projection of the CIPI for Fiscal Year 1995
We project a 0.9 percent increase in the CIPI for FY 1995 (Table
3). This is the outcome of a 3.1 percent increase in projected weighted
depreciation prices in FY 1995, partially offset by a 3.6 percent
decline in vintage- weighted interest rates in FY 1995.
E. ProPAC Input Price Index
1. Introduction
Three major differences distinguish ProPAC's CIPI from HCFA's CIPI:
The ProPAC CIPI measures changes in capital asset purchase
prices in the year the asset is purchased. HCFA's CIPI is designed to
measure changes in a vintage-weighted composite of capital asset
purchase prices.
The ProPAC CIPI uses capital asset purchase price proxies
that differ from HCFA's.
The ProPAC CIPI has no interest component. PROPAC treats
interest rate changes as a separate update factor component. Through
1995, for example, ProPAC expects that long term interest rates will
remain stable and, therefore, believes that it is not appropriate to
adjust capital payments for forecasted changes in interest rates in the
target year.
HCFA incorporates a vintage-weighted composite of interest rates in
its CIPI for the target year.
2. Depreciation
ProPAC states that its CIPI is analogous to the prospective payment
operating price index. We disagree. The components of the operating
index represent price changes in ongoing hospital expenses for labor
and non- capital goods and services. The analogous capital expenses in
this context are current depreciation costs, interest costs, and other
capital-related expenses (taxes and insurance). Current depreciation
and interest costs are a cumulative composite of segments of expenses
incurred in current and prior periods. Current interest costs are a
cumulative composite of segments of past and current year debt costs.
Since both depreciation and interest costs have a vintage component,
the price aspect of these costs must have a vintage component as well.
The HCFA CIPI attempts to capture these vintage components.
Differences between HCFA and ProPAC with respect to choices for
annual rates of change in capital purchase price proxies appear to be
minimal:
Changes in alternative price proxies for building and
fixed equipment are nearly coincidental. (See Table 3 above, and Figure
7 in the May 27, 1994 proposed rule (59 FR 27890).) We are still
considering adoption of the price proxy recommended by ProPAC, but we
do not anticipate any material difference in the HCFA CIPI if we do
adopt this alternative proxy.
Changes in alternative price proxies for moveable
equipment, although not as close as those for building and fixed
equipment, are nevertheless nearly coincidental for much of the
historical period. (See Table 3 above, and Figure 8 in the May 27, 1994
proposed rule (59 FR 27890).)
As noted in our September 1, 1992 final rule, one basic criterion
for accepting price proxies is public availability of documentation on
data sources and methodology (57 FR 40018-40019). Despite repeated
efforts, neither we nor Data Resources Inc. have been able to obtain
documentation on the moveable price proxy recommended by ProPAC that
explains how it is derived and what sampling frame and sampling error
attach to the estimates. In the absence of such information we cannot
adopt the ProPAC alternative.
HCFA's assumption is that prices for hospital moveable equipment
change at about the same rate as general prices for all machinery and
equipment. This assumption is justified in part by the fact that not
all moveable equipment purchased by hospitals is medical equipment: it
stands to reason that the prices for non-medical equipment purchased by
hospitals would change at the same rate as prices for all machinery and
equipment. To examine this assumption further, we measured the rate of
change in the HCFA moveable price proxy relative to prices for medical
equipment only by preparing a composite index of medical prices from
the Bureau of Labor Statistics Producer Price Index (PPI) for two
commodity categories--medical instruments/equipment and X-ray/electro-
medical equipment. The two PPI commodity indexes were then merged using
their respective PPI weights. Price change trends for the period for
which information is available are shown in Table 3 above and Figure 8
(Inset) of our May 27, 1994 discussion (59 FR 27891). Price changes for
this index are not available for years prior to 1984. Annual price
changes for medical equipment were less than the annual HCFA price
proxy in all but the most recent 2 years and were about the same as the
ProPAC price proxy in the last 2 years. The medical equipment price was
substantially less than the ProPAC index for most of the historical
period. We will continue to monitor trends in these indexes to ensure
that appropriate price proxies are incorporated in the CIPI.
3. Interest
ProPAC has proposed to project annual interest rates to future
periods and then to decide whether to allow an add-on to the Federal
capital rate depending on the magnitude of the projection. ProPAC has
presented no objective criteria for determining when an interest
adjustment is appropriate. We previously noted that a single-year
projection for interest rates is conceptually inappropriate since
interest costs must be vintage-weighted. In addition to this conceptual
problem, the ProPAC approach is impractical because future annual
interest rates are volatile, vulnerable to unpredictable market forces,
and subject to exogenous influences (such as Federal Reserve Board
decisions) that are difficult to anticipate. Thus, any projection of
future annual interest rates is likely to be inaccurate, resulting in
underpayment or overpayment of the Federal capital rate relative to the
capital-related expenses that the rate is supposed to compensate. The
resulting uncertainty in payments under future Federal capital rates
further complicates future capital expenditure decisions by hospitals.
On the other hand, the projected HCFA CIPI interest component for the
target year is the weighted average change over 22 years of interest
rate history, of which 20 years experience is historical. The projected
experience in the HCFA index for the most recent 2 years may be as
inaccurate as any ProPAC projection, but any error will have minimal
effects on Federal rates due to the appropriately weighted effect of
the historical data in the HCFA CIPI. This stability in the interest
rate component of the HCFA CIPI provides hospital planners with a
degree of certainty about future Federal rate payments, other things
remaining equal. Annual and weighted annual rates of change are
compared in Table 3.
4. The Composite HCFA CIPI
Annual percentage changes in the historical and projected HCFA and
ProPAC CIPIs differ markedly. (See Figure 9 in our proposed rule of May
27, 1994 (59 FR 27893).) The ProPAC CIPI is much more volatile than the
HCFA CIPI in the historical period through 1993 because it has no
vintage-weighted capital input price factors for depreciation.
Further, the ProPAC CIPI omits interest rates. The cumulative
effect of declining interest rates for all debt instruments in recent
years has driven the rate of change in the HCFA interest rate component
downward, a trend projected into future rate years. The declining
interest rate component drags the HCFA CIPI below the ProPAC CIPI in
the projection period. Other things being equal, the ProPAC index would
result in overpayment through the Federal rate because anticipated
actual capital-related expenses will be less than ProPAC projects due
to the effects of lower interest rates on capital-related expenses.
IV. Case-Mix Adjustment and Adjustment for Forecast Error
The case-mix index (CMI) is the measure of the average DRG weight
for cases paid under the prospective payment system. Because the DRG
weight determines the prospective payment for each case, any percentage
increase in the CMI corresponds to an equal percentage increase in
hospital payments.
The CMI can change for any of several reasons: because the average
resource use of Medicare patients changes (``real'' case-mix change);
because changes in hospital coding of patient records result in higher
weight DRG assignments (``coding effects''); and because the annual DRG
reclassification and recalibration changes may not be budget neutral
(``reclassification effect''). In the update framework for the
prospective payment system for operating costs, we adjust the update
upwards to allow for real case-mix change, but remove the effects of
coding changes on the CMI. We also remove the effect on total payments
of prior changes to the DRG classifications and relative weights, in
order to retain budget neutrality for all CMI-related changes other
than patient severity. (For example, we adjusted for the effects of the
FY 1992 DRG reclassification and recalibration as part of our FY 1994
update recommendation.) The operating adjustment consists of a
reduction for total observed case-mix change, an increase for the
portion of case-mix change that we determine is due to real case-mix
change rather than coding modifications, and an adjustment for the
effect of prior DRG reclassification and recalibration changes. We
proposed to adopt this CMI adjustment as well in the capital update
framework.
The current operating update framework contains an adjustment for
forecast error. The input price index forecast is based on historical
trends and relationships ascertainable at the time the update factor is
established for the following year. In any given year there can be
unanticipated price fluctuations that can result in differences between
the actual increase in prices faced by hospitals and the forecast used
in calculating the update factors. We continue to believe that the
capital update framework should include a forecast error adjustment
factor. In setting a prospective payment rate under the proposed
framework, we would make an adjustment for forecast error only if our
estimate of the capital input price index rate of increase for any year
is off by 0.25 percentage points or more. There is a 2-year lag between
the forecast and the measurement of the forecast error. Thus, for
example, we would adjust for a forecast error made in FY 1996 through
an adjustment to the FY 1998 update.
V. Policy Adjustment Factors
The capital input price index measures the pure price changes
associated with changes in capital-related costs (prices x
``quantities''). The composition of capital-related costs is maintained
at base-year 1987 proportions in the capital input price index. We
would address appropriate changes in the amount and composition of
capital stock through the policy adjustment factors.
The current update framework for the prospective payment system for
operating costs includes factors designed to adjust the input price
index rate of increase for policy considerations. Under the revised
operating framework, we adjust for service productivity (the efficiency
with which providers produce individual services such as laboratory
tests and diagnostic procedures) and intensity (the amount of services
used to produce a discharge). The service productivity factor for the
operating update framework reflects a forward-looking adjustment for
the changes that hospitals can be expected to make in service-level
productivity during the year. A hospital retains any productivity
increases above the average.
The intensity factor for the operating update framework reflects
how hospital services are utilized to produce the final product, that
is, the discharge. This component accounts for changes in the use of
quality-enhancing services, changes in within-DRG severity, and
expected modification of practice patterns to remove cost-ineffective
services. We originally proposed that the intensity adjustment factor
in the revised operating framework be adopted in the capital update
framework. That factor remains a part of our developing framework.
Under the revised operating update framework, we calculate case-mix
constant intensity as the change in total charges per admission,
adjusted for price level changes (the CPI hospital component) and
changes in real case mix. The use of total charges in the calculation
of the proposed intensity factor makes it a total intensity factor,
that is, charges for capital services are already built into the
calculation of the factor. We can therefore incorporate the proposed
intensity adjustment from the operating update framework into the
capital update framework. In the absence of reliable estimates of the
proportions of the overall annual intensity increases that are due,
respectively, to ineffective practice patterns and to the combination
of quality-enhancing new technologies and within-DRG complexity, we
would assume, as in the revised operating update framework, that one-
half of the annual increase is due to each of these factors. The
capital update framework would thus provide an add-on to the input
price index rate of increase of one-half of the estimated annual
increase in intensity to allow for within-DRG severity increases and
the adoption of quality-enhancing technology.
In our previous discussions of an efficiency adjustment, we
suggested that the adjustment should take into account two
considerations. One is that capital inputs, unlike operating inputs,
are generally fixed in the short run. The productivity target in the
revised operating framework operates on a short-term, year-to-year
basis. Targets for capital efficiency and cost-effectiveness, however,
must operate on a longer term basis. The other consideration is that,
prior to the adoption of the capital prospective payment system,
Medicare payment policy for capital-related costs, as well as the
policies of other payers, did not provide sufficient incentives for
efficient and cost-effective capital spending. As a result, capital
costs per case, and therefore base year prospective capital rates, may
be higher than would have been consistent with capital acquisition
policy in more efficiency-oriented markets. A guiding principle in
devising an efficiency adjustment is therefore that Medicare capital
prospective payment rates should not provide for maintenance of capital
in excess of the level that would be produced in an efficiency-oriented
competitive market.
As a preliminary examination of this issue, we analyzed the change
in actual Medicare capital cost per case for FYs 1986-1991 in relation
to the change in the capital input price index (which accounts for
change in the input prices for capital-related costs), and the other
adjustment factors that we were then proposing to include in the
framework. (The other adjustment factors are the increase in real case
mix and the increase in intensity due to quality-enhancing
technological change and within-DRG complexity.) We found rates of
increase in spending per case that exceeded the rate of increase
attributable to inflation in capital input prices, quality-enhancing
intensity increases, and real case-mix growth.
Economic theory suggests that an industry with a guaranteed return
on capital (such as the hospital industry prior to prospective payment
for capital-related costs) would have a tendency to be overly
capitalized relative to more competitive industries. This is because
the incentive for firms in such an industry is to compete on the basis
of more capital-intensive production processes than firms in other
industries. As a result, capital costs per case, and therefore base
year prospective capital rates, may be higher than would have been
consistent with capital acquisition policy in more efficiency-oriented
competitive markets.
Our analysis was designed to examine whether hospitals had in fact
responded to the incentives of the cost-based payment system for
capital by expanding beyond what was necessary for efficient and cost-
effective delivery of services. The analysis confirmed that volume and
intensity of capital acquisition far outpaced the increase in capital
input prices during the years between the implementation of the
prospective payment system for operating costs and the introduction of
the capital prospective payment system. Even accounting for real CMI
increases and increases in intensity attributable to cost-increasing
but quality-enhancing new technologies, there remains a large excess of
capital-related spending.
The following table shows the results of our most recent analysis,
based on the most current data available and the most recent
projections. Differences between this table and the tables in previous
discussions in the Federal Register are due to revised figures for
average capital cost per case increases, based on the most recent data
and projections, and on our revised CIPI. We have also expanded the
analysis incorporated in this table to include FY 1985 and FY 1992,
thus encompassing all but 1 year of the period from the implementation
of the prospective payment system for operating costs to the
implementation of the prospective payment system for capital costs.
(For FY 1984, sufficient data is not available to compute capital cost
per case increases and intensity increases.) The results of the
analysis in Table 4 are substantially similar to the results of
previous analyses. In Table 4, real case-mix increase is assumed to be
1.0 percent annually.
Table 4.--Cumulative Percentage Change in Capital-Related Cost Per Case Due to Inflation, Real CMI, and
Intensity, 1985-1992
----------------------------------------------------------------------------------------------------------------
Percent
Year CIPI\1\ Real CMI\2\ Allowable Resulting change cost/ Residual\6\
intensity\3\ increase\4\ case\5\
----------------------------------------------------------------------------------------------------------------
1985............................. 5.8 1.0 3.7 10.8 12.6 1.6
1986............................. 4.5 1.0 2.1 7.7 20.2 11.5
1987............................. 3.8 1.0 2.5 7.5 15.0 7.0
1988............................. 3.7 1.0 1.5 6.3 7.2 0.9
1989............................. 3.1 1.0 0.5 4.7 7.7 2.9
1990............................. 2.8 1.0 0.2 4.0 6.8 2.7
1991............................. 2.3 1.0 0.1 3.4 5.6 2.2
1992............................. 1.8 1.0 -0.7 2.1 5.4 3.2
Cumulative (compounded)...... ........... ........... ............ 56.7 113.6 36.4
----------------------------------------------------------------------------------------------------------------
\1\Figures from Table 1, section III.
\2\Assuming that real CMI increase is 1.0 percent annually.
\3\One half of observed intensity increase, as determined by the joint operating/capital intensity measure.
\4\The increase attributable to inflation, real CMI, and allowable intensity, calculated as the product of the
rates of increase of those factors (that is, 1.038 x 1.01 x 1.025=1.075 for 1987).
\5\Figures supplied by HCFA's Office of the Actuary.
\6\The actual increase in average cost per case divided by the increase attributable to inflation, real CMI, and
allowable intensity (that is, 1.150/1.075=1.070, a 7.0 percent residual for 1987).
We believe that the adjustment for capital efficiency and cost-
effectiveness should take into account the efficiency and effectiveness
of the capital resources present in the base year for the capital
prospective payment system. We do not believe that Medicare capital
payment rates should provide for maintenance of capital in excess of
the level that would be produced in an efficiency-oriented competitive
market. The capital efficiency adjustment should be designed to give
hospitals an incentive to reduce inefficiency and ineffectiveness in
capital resources. The analysis in Table 4 suggests that, in order to
restore the Federal rate to the level at which it would have been if
capital costs had not been excessive in the years before the
implementation of capital prospective payment, a cumulative reduction
in the rate of 26.6 percent (1.567/2.136=0.7336, or -26.6 percent)
would be necessary.
[FR Doc. 94-21488 Filed 8-31-94; 8:45 am]
BILLING CODE 4120-03-P