[Federal Register Volume 61, Number 106 (Friday, May 31, 1996)] [Proposed Rules] [Pages 27444-27708] From the Federal Register Online via the Government Publishing Office [www.gpo.gov] [FR Doc No: 96-13613] [[Page 27443]] _______________________________________________________________________ Part II Department of Health and Human Services _______________________________________________________________________ Health Care Financing Administration _______________________________________________________________________ 42 CFR Part 412, et al. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal year 1997 Rates; Proposed Rule Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules [[Page 27444]] DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Care Financing Administration 42 CFR Parts 412, 413, and 489 [BPD-847-P] RIN 0938-AH34 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 1997 Rates AGENCY: Health Care Financing Administration (HCFA), HHS. ACTION: Proposed rule. ----------------------------------------------------------------------- SUMMARY: We are proposing to revise 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 systems. In addition, in the addendum to this proposed rule, we are describing proposed 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 would be applicable to discharges occurring on or after October 1, 1996. We are also setting forth proposed rate-of- increase limits as well as proposing changes for hospitals and hospital units excluded from the prospective payment systems. DATES: Comments will be considered if received at the appropriate address, as provided below, no later than 5 p.m. on July 31, 1996. ADDRESSES: Mail written comments (an original and 3 copies) to the following address: Health Care Financing Administration, Department of Health and Human Services, Attention: BPD-847-P, P.O. Box 7517, Baltimore, MD 21207- 0517. If you prefer, you may deliver your written comments (an 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 C5-09-26, Central Building, 7500 Security Boulevard, Baltimore, MD 21244-1850. Because of staffing and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code BPD-847-P. 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). For comments that relate to information collection requirements, mail a copy of comments to: Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Allison Herron Eydt, HCFA Desk Officer. Copies: To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512- 2250. The cost for each copy is $8.00. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register. FOR FURTHER INFORMATION CONTACT: Nancy Edwards (410) 786-4531, Operating Prospective Payment, DRG, Wage Index Issues. Tzvi Hefter (410) 786-4529, Capital Prospective Payment, Excluded Hospitals. 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 care 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, 1995, we published a final rule with comment period (60 FR 45778) to implement changes to the prospective payment system for hospital operating costs beginning with Federal fiscal year (FY) 1996. 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. Major Contents of This Proposed Rule In this proposed rule, we are setting forth proposed changes to the Medicare hospital inpatient prospective payment systems for both operating costs and capital-related costs. This proposed rule would be effective for discharges occurring on or after October 1, 1996. Following is a summary of the major changes that we are proposing to make: 1. Changes to the DRG Classifications and Relative Weights As required by section 1886(d)(4)(C) of the Act, we must adjust the DRG classifications and relative weights at least annually. Our proposed changes for FY 1997 are set forth in section II of this preamble. 2. Changes to the Hospital Wage Index In section III of this preamble, we discuss revisions to the wage index and the annual update of the wage data. Specific issues addressed in this section include:FY 1997 wage index update. [[Page 27445]] Revisions to the wage index based on hospital redesignations. Solicitation of public comment on possible changes to the following: --Contract labor--expansion of allowable costs. --Revision in Puerto Rico labor market areas. Medicare Geographic Classification Review Board-- composition and criteria. 3. Rebasing and Revision of the Hospital Market Baskets In section IV of this preamble, we discuss our proposal to use a rebased and revised hospital market basket in developing the FY 1997 update factor for the operating prospective payment rates, the capital prospective payment rates, and the excluded hospital rate-of-increase limits. 4. Other Changes to the Prospective Payment System for Inpatient Operating Costs In section V of this preamble, we discuss several provisions of the regulations in 42 CFR parts 412, 413, and 489 and set forth certain proposed changes concerning the following: Sole community hospitals. Rural referral centers. Disproportionate share adjustment. Direct graduate medical education programs. Hospital distribution of ``An Important Message from Medicare.'' 5. Changes and Clarifications to the Prospective Payment System for Capital-Related Costs In section VI of this preamble, we discuss several provisions of the regulations in 42 CFR part 412 and set forth certain proposed changes concerning the following: Use of simplified cost accounting. The capital Federal and hospital-specific rates. 6. Changes for Hospitals and Hospital Units Excluded From the Prospective Payment Systems In section VII of this preamble, we discuss a clarification concerning the calculation of payments to hospitals excluded from the prospective payment system. 7. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits In the addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 1997 prospective payment rates for operating costs and capital-related costs. We are also proposing update factors for determining the rate- of-increase limits for cost reporting periods beginning in FY 1997 for hospitals and hospital units excluded from the prospective payment system. In addition, we have included a detailed discussion of our methodology for setting thresholds for outlier cases. We are inviting comments on our methodology and any suggestions for changes in that methodology that could help us better predict outlier payments. 8. Impact Analysis In Appendix A, we set forth an analysis of the impact that the proposed changes described in this rule would have on affected entities. 9. Capital Acquisition Model Appendix B contains the technical appendix on the proposed FY 1997 capital acquisition model. 10. Rebased Market Basket Data Sources Appendix C sets forth the data sources used to determine the market basket relative weights and choice of price proxies. 11. Report to Congress on the Update Factor for Prospective Payment Hospitals and Hospitals Excluded From the Prospective Payment System Section 1886(e)(3)(B) of the Act requires that the Secretary report to Congress on our initial estimate of an update factor for FY 1997 for both hospitals included in and hospitals excluded from the prospective payment systems. This report is included as Appendix D to this proposed rule. 12. Proposed Recommendation of Update Factor for Hospital Inpatient Operating Costs As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix E provides our recommendation of the appropriate percentage change for FY 1997 for the following: Large urban area and other area 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. 13. Discussion of Prospective Payment Assessment Commission Recommendations The Prospective Payment Assessment Commission (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 patients, 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 are printing ProPAC's March 1, 1996 report, which includes its recommendations, as Appendix F of this document. The recommendations, and the actions we are proposing to take with regard to them (when an action is recommended), are discussed in detail in the appropriate sections of this preamble, the addendum, or the appendices to this proposed rule. See section VIII of this preamble for specific information concerning where individual recommendations are addressed. For a brief summary of the ProPAC recommendations, we refer the reader to the beginning of the ProPAC report as set forth in Appendix F of this proposed rule. For further information relating specifically to the ProPAC report, contact ProPAC at (202) 401-8986. II. Proposed 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 all DRGs. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account [[Page 27446]] 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 proposed changes to the DRG classification system and the proposed recalibration of the DRG weights for discharges occurring on or after October 1, 1996 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 492 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 five 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, bone marrow, and lung transplant (DRGs 480, 481, and 495, 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. The changes we are proposing to make to the DRG classification system for FY 1997 and other decisions concerning DRGs are set forth below. 2. Pre-MDC DRGs Effective October 1, 1994, ICD-9-CM procedure code 41.04, Autologous hematopoietic stem cell transplant, was created to capture the transplantation of stem cells obtained from bone marrow or peripheral blood. At that time, we designated the code as non-OR. This transplant procedure was previously assigned to procedure code 99.73, Therapeutic erythrocytapheresis, which is designated as a non-OR procedure. When we created this code, we received comments requesting that it be designated as an OR procedure and assigned to DRG 481 (Bone Marrow Transplant) based on the resource use associated with the type of transplant. However, as we stated in the September 1, 1994 final rule (59 FR 45340), when a new code is introduced, our longstanding practice is to assign it to the same DRG 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 part of DRG reclassification and recalibration. Because we could not 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 were 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 were prevented from redesignating code 41.04 as an OR procedure or assigning it to a DRG. However, we stated that we would analyze the stem cell cases as soon as the FY 1995 cases were available. This year, the FY 1995 Medicare Provider Analysis and Review (MedPAR) file is available for use in DRG analysis and weight setting for FY 1997. In the December 1995 update to the FY 1995 MedPAR file, there are a total of 178 cases reporting the performance of a stem cell transplant. Of that number, 13 cases also reported the performance of a bone marrow transplant. Those cases were removed from our analysis because they are already classified to DRG 481. Of the remaining 165 cases, 100 cases did not meet the coverage criteria for Medicare payment. As set forth in the Medicare Coverage Issues Manual at section 35-30.1 (see Transmittal No. 84, April 1996), autologous stem cell transplants are not covered when performed for the following conditions: Acute leukemia not in remission (diagnosis codes 204.00, 205.00, 206.00, 207.00, and 208.00). Chronic granulocytic leukemia (diagnosis codes 205.10 and 205.11). Solid tumors (other than neuroblastomas) (diagnosis codes 140.0 through 199.1) Multiple myeloma (diagnosis codes 203.00, 203.01 and 238.6). After eliminating the noncovered cases, 65 cases of stem cell transplant remained. The average standardized charge for these cases was approximately $83,000. The average standardized charge for bone marrow transplant cases in the FY 1995 MedPAR file is approximately $98,000. Thus, since the average resource use associated with stem cell transplant is similar to that associated with bone marrow transplant, we are proposing to assign procedure code 41.04 to DRG 481 effective with discharges occurring on or after October 1, 1996. The overall average charge for stem cell and bone marrow combined is just under $93,000. In addition, we propose to designate stem cell transplant as an OR procedure. [[Page 27447]] 3. MDC 1 (Diseases and Disorders of the Nervous System) a. Sleep Apnea We have received correspondence requesting that we review the DRG assignment of cases in which surgery is performed to correct obstructive sleep apnea (diagnosis code 780.57). When coded as a principal diagnosis, sleep apnea is assigned to DRGs 34 and 35 (Other Disorders of the Nervous System)\1\ in MDC 1. --------------------------------------------------------------------------- \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 DRG 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. --------------------------------------------------------------------------- Recently, new surgical interventions to correct sleep apnea have been introduced. The procedures most frequently performed for this condition are the following: Code and Description 27.69 Other plastic repair of palate 29.4 Plastic operation on pharynx 29.59 Other repair of pharynx Since none of these surgical procedures is assigned to MDC 1, cases of sleep apnea treated with one of these surgeries are assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis) in the case of codes 25.59 and 78.49 or to DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis) in the case of code 29.4. We are proposing to address this situation by assigning the three surgical procedures to MDC 1. Based on the charges associated with these cases and the fact that they are not clinically similar to the other surgical DRGs in MDC 1, we are proposing to include them in DRGs 7 and 8 (Peripheral and Cranial Nerve and Other Nervous System Procedures). b. Guillain-Barre Syndrome Guillain-Barre syndrome (diagnosis code 357.0) is a post-infectious polyneuropathy in which severely affected patients may require ventilatory assistance and long stays in intensive care. In recognition of the high resource consumption associated with this diagnosis, effective with FY 1991, we reassigned code 357.0 from DRGs 18 and 19 (Cranial and Peripheral Nerve Disorders) to DRG 20 (Nervous System Infection Except Viral Meningitis). (See the September 4, 1990 final rule (55 FR 36024).) A commenter stated that although DRG 20 would provide a higher payment for these cases, it would still be inadequate to cover the costs of treating these patients, and we agreed that we would monitor this issue. We have recently received requests that we again review this assignment. These commenters stated that the treatment for these cases remains very costly and often entails long hospital stays. Therefore, we conducted an analysis of the cases assigned to DRG 20 using the 10 percent random sample of the FY 1995 MedPAR file that we use for analyzing possible classification changes. Cases coded with 357.0 comprise approximately 20 percent of the cases assigned to DRG 20. As the commenters predicted, the average standardized charges for these cases, approximately $22,400, was higher than the average charge for the DRG, approximately $17,100. However, the length of stay was only slightly higher, 9.1 days compared to 8.4. We believe that DRG 20 is the appropriate assignment clinically for Guillain-Barre cases and the average charge is well within the variation in charges for this DRG. In addition, DRG 20 is the most resource-intensive, and, thus, the highest-weighted medical DRG in MDC 1. However, in reviewing the other cases assigned to DRG 20, we noted that the average charges for two diagnoses were significantly lower than the overall average charge. These diagnoses, herpes zoster of the nervous system (code 053.10) and herpes zoster of the nervous system, NEC (code 053.19) had average charges of only $7,700 and $7,100, respectively. They also had significantly lower average lengths of stay (4.4 and 4.2 days, respectively). Because these two diagnoses also account for approximately 20 percent of the cases in DRG 20, their low average charge has the effect of significantly lowering the average charge for the DRG. Removing these two codes from DRG 20 increases the average charge to approximately $20,000. After reviewing the remaining medical DRGs in MDC 1, we believe that reassigning codes 053.10 and 053.19 to DRGs 18 and 19 is appropriate both clinically and in terms of resource consumption. In the 10 percent MedPAR file, these DRGs had an average charge of approximately $8,000 and $5,300, respectively. Therefore, we are proposing to make this DRG classification change effective for FY 1997. This change would significantly increase the relative weight for DRG 20 and provide higher payment for the Guillain- Barre cases. The proposed weight for DRG 20 is 2.4782, an increase of 17 percent over the FY 1996 weight of 2.1157. 4. MDC 5 (Diseases and Disorders of the Circulatory System) Effective for discharges occurring on or after October 1, 1995, we created a new code for insertion of a coronary artery stent (procedure code 36.06). Until creation of the new code, insertion of coronary artery stent had been included in the codes for percutaneous transluminal coronary angioplasty (PTCA) (procedure codes 36.01, 36.02, and 36.05). As discussed above in section II.B.2, when a new code is introduced, our longstanding practice is to assign it to the same DRG category as its predecessor code or codes. Therefore, in the June 2, 1995 proposed rule, we assigned procedure code 36.06 to DRG 112 (Percutaneous Cardiovascular Procedures), the DRG to which PTCA is assigned. In response to comments received, in the September 1, 1995 final rule, we explained our policy on DRG assignment of new codes (60 FR 45785). We also stated that the resource use and other data associated with procedure code 36.06 will be available in the FY 1996 Medicare cases which are used for analysis as part of FY 1998 DRG changes. We will evaluate the DRG assignment of coronary artery stent insertion at that time. Since publication of the September 1, 1995 final rule, we have received data on stent cases provided by the manufacturer of one of the two stent devices currently approved by the Food and Drug Administration (FDA). In addition, the manufacturer has provided us with an analysis of the charges and length of stay of approximately 7,500 Medicare patients who received stents in FY 1995. Because there was no code for the procedure during that year, the manufacturer matched its list of stent recipients with the FY 1995 MedPAR file. The manufacturer's analysis found that the FY 1995 average charge for PTCA cases without stent is approximately $15,700 and the average charge for cases with stent is approximately $21,000. However, our analysis of the data shows that there is wide variation in the hospital standardized charges reported for cases with implant of coronary artery stent. Individual hospital average charges for these cases range from about $9,000 to over $45,000. This inconsistency in the data illustrates why our policy of not reassigning new codes until we have collected an entire year of coded Medicare data for analysis is prudent. The uncertainty associated with using incomplete data collected outside the [[Page 27448]] Medicare program that cannot be verified remains a problem. Therefore, we are not proposing any DRG assignment change for implant of coronary artery stent. As noted above, a full year of coded FY 1996 Medicare data will be available in early 1997 for analysis. We will review the data at that time, and any proposed DRG changes will be announced in the FY 1998 proposed rule. 5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) In the September 1, 1995 final rule (60 FR 45790), we responded to a comment we received regarding the DRG assignment in MDC 8 of bipolar hip replacement cases. The commenter requested that cases of bipolar hip replacement be assigned to DRGs 210, 211, and 212 (Hip and Femur Procedures Except Major Joint) rather than to its current assignment, DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity). The commenter stated that the procedure for partial hip replacement (code 81.52) is very similar to the procedure for open reduction of fracture of the femur with internal fixation (code 79.35), which is assigned to DRGs 210, 211, and 212. Further, the commenter believes that partial hip replacement patients are more frail individuals than the population that elects total hip replacement surgery and need longer hospital stays to recover. In the September 1, 1995 final rule, we stated that we would reexamine this assignment as part of our DRG agenda for FY 1997. Using the FY 1995 MedPAR file, we compared charges and lengths of stay for cases assigned to DRG 209 in which the procedures 81.51 (total hip replacement), 81.52, and 81.53 (revision of hip replacement) were performed with the charges for the entire DRG. The average standardized charges for these cases are very similar to each other as well as the other cases assigned to DRG 209. The average charge was $18,310 for partial hip replacement, $19,924 for total hip replacement, and $23,094 for revision of hip replacement. The $1,278 difference between the average charge for partial hip replacement cases in DRG 209 and the average charge of $19,588 for all cases in DRG 209 is within the normal range of charges for that DRG. However, the average charge for cases in DRG 210 was $15,119, or $2,157 less than the partial hip replacement charges. A comparison of lengths of stay yields slightly different results. The partial hip replacement cases in DRG 209 had an average stay of 8.6 days. The overall average lengths of stay for DRGs 209 and 210 were 6.7 days and 8.5 days, respectively. Based on these data alone, it would seem that the commenter is correct that partial hip replacement patients are more similar to the patients in DRG 210, in terms of hospital length of stay. However, we also must consider these cases' higher average charges. The higher charges of the partial hip replacement cases indicate that they are more resource-intense than the cases in DRG 210. The proposed relative weights for DRG 209 and 210 are 2.2617 and 1.8458, respectively. Therefore, we believe that DRG 209 is the most appropriate assignment for procedure code 81.52 so that payment will most closely relate to the costs of care for these patients. 6. 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 are proposing to modify the surgical hierarchy as set forth below. As we stated in the September 1, 1989 final rule (54 FR 36457), we are unable to test the effects of the proposed revisions to the surgical hierarchy and to reflect these changes in the proposed relative [[Page 27449]] weights due to the unavailability of revised GROUPER software at the time this proposed rule is prepared. Rather, we simulate most major classification changes to approximate the placement of cases under the proposed reclassification and then determine the average charge for each DRG. These average charges then serve as our best estimate of relative resource use for each surgical class. We test the proposed surgical hierarchy changes after the revised GROUPER is received and reflect the final changes in the DRG relative weights in the final rule. Further, as discussed below in section II.C of this preamble, we anticipate that the final recalibrated weights will be somewhat different from those proposed, since they will be based on more complete data. Consequently, further revision of the hierarchy, using the above principles, may be necessary in the final rule. At this time, we would revise the surgical hierarchy for the Pre- MDC DRGs, MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth and Throat), and MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders) as follows: In the Pre-MDC DRGs, we would reorder Tracheostomy Except for Face, Mouth and Neck Diagnoses (DRG 483) above Liver Transplant (DRG 480). In MDC 3, we would reorder Cleft Lip and Palate Repair (DRG 52) and Sinus and Mastoid Procedures (DRGs 53 and 54) above Tonsillectomy and Adenoidectomy, Except Tonsillectomy and/or Adenoidectomy Only (DRGs 57 and 58). In MDC 10, we would reorder Adrenal and Pituitary Procedures (DRG 286) above Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders (DRG 285). 7. 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 previous years, we have made changes to the standard list of CCs, either by adding new CCs or deleting CCs already on the list. At this time, we do not propose to delete any of the diagnosis codes on the CC list. In the September 1, 1995 final rule (60 FR 45782), we added diagnosis code 008.49 (Bacterial enteritis) to the CC list. In response to a request from one commenter that we also add diagnosis code 008.45 (Clostridium difficile), we stated that we would review that request as part of our DRG analysis for FY 1997. We have reevaluated diagnosis code 008.45 as well as the remainder of the ``family'' of codes assigned to Intestinal infections due to other specified bacteria (008.41, 008.42, 008.43, 008.44, 008.46, and 008.47). Our analysis shows that all of these diagnoses, when present as a secondary condition, do lead to higher resource use. Therefore, we are proposing to add the following diagnosis codes to the CC list: 008.41 Intestinal infections due to staphylococcus 008.42 Intestinal infections due to pseudomonas 008.43 Intestinal infections due to campylobacter 008.44 Intestinal infections due to yersinia enterocolitica 008.45 Intestinal infections due to clostridium difficile 008.46 Intestinal infections due to other anaerobes 008.47 Intestinal infections due to other gram-negative bacteria These diagnoses would be considered CCs for any principal diagnosis not shown in Table 6f, Additions to the CC Exclusions List (see discussion of CC Exclusions list in section V of the Addendum below). This same commenter also requested that we add the following codes to the CC list: 331.0 Alzheimer's disease 423.9 Unspecified disease of the pericardium 348.5 Cerebral edema 333.4 Huntington's chorea 458.0 Orthostatic hypotension 458.9 Hypotension, not otherwise specified Our analysis of these codes demonstrates that their presence as a secondary diagnosis does not significantly add to the resource use of the case. Therefore, we are not proposing to add them to the CC list. Finally, the commenter suggested that the following diagnoses be added as cardiovascular complications for DRG 121 (Circulatory Disorders with AMI and Cardiovascular Complications, Discharged Alive): 434.xx Occlusion of cerebral arteries 436 Acute, but ill-defined, cerebrovascular disease Using the 10 percent analysis file of the FY 1995 MedPAR data, we analyzed the cases assigned to DRG 121 that had these diagnoses coded as secondary conditions. The charges associated with those cases were indeed comparable to the other cases assigned to DRG 121. When we sought the advice of our medical specialists (physicians who work directly for or under contract with HCFA), however, they strongly opposed adding these codes to the list of conditions for DRG 121 based on the fact that these are not cardiovascular complications. Therefore, they are not clinically similar to other cases assigned to this DRG. However, our analysis of this DRG did reveal a large variation in the charges and lengths of stay within this DRG. We believe that a close examination of the list of complicating conditions assigned to DRG 121 is needed. Therefore, we plan to perform a thorough analysis of the cases assigned to that DRG as part of our DRG analysis agenda for FY 1998. In the meantime, we are not proposing any change to DRG 121. 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 [[Page 27450]] 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. (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 FY 1990 revision (54 FR 36552); the September 4, 1990 final rule for the FY 1991 revision (55 FR 36126); the August 30, 1991 final rule for the FY 1992 revision (56 FR 43209); the September 1, 1992 final rule for the FY 1993 revision (57 FR 39753); the September 1, 1993 final rule for the FY 1994 revisions (58 FR 46278); the September 1, 1994 final rule for the FY 1995 revisions (59 FR 45334); and the September 1, 1995 rule for the FY 1996 revisions (60 FR 45782).) We are proposing 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, 1996, as well as the proposed CC changes described above. (See section II.B.8, below, for a discussion of ICD-9-CM changes.) These proposed changes are being made in accordance with the principles established when we created the CC Exclusions List in 1987. The changes discussed above have been added to Table 6g, Additions to the CC Exclusions List, in section V of the Addendum to this proposed rule. Tables 6g and 6h in section V of the Addendum to this proposed rule contain the proposed revisions to the CC Exclusions List that would be effective for discharges occurring on or after October 1, 1996. Each table shows the principal diagnoses with proposed 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 6g--Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 1996, 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 6h--Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 1996, 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 $92.00 plus $6.00 shipping and handling and on microfiche for $20.50, plus $4.00 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, 1994, 1995, and 1996) and those in Tables 6g and 6h 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, 1996. 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 current DRG Definitions Manual, Version 13.0, is available for $195.00, which includes $15.00 for shipping and handling. Version 14.0 of this manual, which will include the final FY 1997 DRG changes, will be available in October 1996 for $195.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road; Wallingford, Connecticut 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested. 8. 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 it would be appropriate to change the procedures 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 60.21 Transurethral prostatectomy 60.29 Other 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 prostatic 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, September 1, 1993, September 1, 1994, and September 1, 1995, we moved several other procedures from DRG 468 to 477. (See 55 FR 36135, 56 FR 43212, 57 FR 23625, 58 FR 46279, 59 FR 45336, and 60 FR 45783, 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. This year's review did not identify any necessary changes; therefore, we are not proposing [[Page 27451]] to move any procedures from DRG 468 or DRG 477 to one of the surgical DRGs. b. Reassignment of Procedures Among DRGs 468, 476, and 477 We also reviewed the list of procedures that produce assignments to DRGs 468, 476, and 477 to ascertain if any of those procedures should be moved from one of these DRGs to another 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 are proposing to move one procedure from DRG 468 to DRG 477. 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 one procedure--Closed endoscopic biopsy of lung (code 33.27), a needle biopsy--that is significantly less resource intensive than the other procedures assigned to DRG 468. Therefore, we are proposing to move procedure code 33.27 to the list of procedures that result in assignment to DRG 477. In reviewing the list of procedures assigned to DRG 477, we did not identify any procedures that should be assigned to either DRG 468 or 476. We did, however, identify the following procedures that we believe should be reassigned from an OR to a non-OR designation: 08.81 Linear repair of laceration of eyelid or eyebrow 08.82 Repair of laceration involving lid margin, partial-thickness 08.83 Other repair of laceration of eyelid, partial thickness 08.84 Repair of laceration involving lid margin, full-thickness 08.85 Other repair of laceration of eyelid, full-thickness 08.86 Lower eyelid rhytidectomy 08.87 Upper eyelid rhytidectomy 08.89 Other eyelid repair Our analysis of the data associated with these eyelid repair procedures leads us to conclude that the procedures are performed following accidental injury or falls, incurred while the patient is in the hospital. These procedures, which are normally performed at bedside and do not necessitate a trip to the operating room, are significantly less resource intensive than other procedures designated as OR procedures. Therefore, we are proposing to change the procedures from OR to non-OR procedures. We note that these procedures are assigned to surgical DRGs in MDCs 2, 9, 21, 22, and 24. With this proposed change, cases in which procedure codes 08.81 through 08.89 are the only OR procedure codes listed would no longer be assigned to a surgical DRG. All of these proposed changes would be effective with discharges occurring on or after October 1, 1996. 9. 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 5 and November 30, 1995, and finalized the coding changes after consideration of comments received at the meetings and in writing within 30 days following the November 1995 meeting. The initial meeting for consideration of coding issues for implementation in FY 1998 will be held on June 6, 1996. 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: Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, Maryland 20782. Comments may be sent by E-mail to: [email protected]. 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 Hospital Policy; Division of Prospective Payment System; C5-06-27; 7500 Security Boulevard; Baltimore, Maryland 21244-1850. Comments may be sent by E-mail to: [email protected]. The ICD-9-CM code changes that have been approved will become effective October 1, 1996. The new ICD-9-CM codes are listed, along with their proposed DRG classifications, in Tables 6a and 6b (New Diagnosis Codes and New Procedure Codes, respectively) in section V of the Addendum to this proposed 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, we are soliciting comments 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 procedure codes that have been replaced by expanded codes or have been deleted are in Table 6d (Invalid Procedure Codes). These invalid diagnosis and procedure codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 1996. The [[Page 27452]] corresponding new or expanded codes are included in Tables 6a and 6b. Revisions to diagnosis and procedure code titles are in Tables 6e (Revised Diagnosis Code Titles) and 6f (Revised Procedure Code Titles), which also include the proposed DRG assignments for these revised codes. C. Recalibration of DRG Weights We are proposing to use the same basic methodology for the FY 1997 recalibration as we did for FY 1996. (See the September 1, 1995 final rule (60 FR 45791).) That is, we would recalibrate the weights based on charge data for Medicare discharges. However, we would use the most current charge information available, the FY 1995 MedPAR file, rather than the FY 1994 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 are constructed from FY 1995 MedPAR data, based on bills received by HCFA through December 1995, from all hospitals subject to the prospective payment system and short-term acute care hospitals in waiver States. The FY 1995 MedPAR file includes data for approximately 10.6 million Medicare discharges. The methodology used to calculate the proposed DRG relative weights from the FY 1995 MedPAR file is as follows: To the extent possible, all the claims were regrouped using the proposed DRG classification revisions discussed above in section II.B of this preamble. As noted in section II.B.6, 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 criteria as was used in computing the current weights. That is, all cases that are outside of 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG. 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. A transfer case is counted as a fraction of a case based on the ratio of its length of stay to the geometric mean length of stay of the cases assigned to the DRG. That is, a 5-day length of stay transfer case assigned to a DRG with a geometric mean length of stay of 10 days is counted as 0.5 of a total case. We established the relative weight for heart and heart- lung, liver, and lung transplants (DRGs 103, 480, and 495) 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, heart-lung, liver, and lung transplant centers that have cases in the FY 1995 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from HCFA as transplant centers.) Acquisition costs for kidney, heart, heart-lung, liver, and lung transplants continue to be 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 for heart and heart-lung transplants); 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 propose to use that same case threshold in recalibrating the DRG weights for FY 1997. Using the FY 1995 MedPAR data set, there are 37 DRGs that contain fewer than 10 cases. We computed the weights for the 37 low-volume DRGs by adjusting the FY 1996 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs. We note that the FY 1996 weights for the low-volume DRGs were recalculated based on non-Medicare data we acquired from 19 States. This was the first update of the weights since they were initially calculated for FY 1984 based on data from Maryland and Michigan. For a complete description of this process, see the September 1, 1995 final rule (60 FR 45781). The weights developed according to the methodology described above, using the proposed 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. 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 we have done in past years and as discussed in section II.A.4.b of the Addendum to this proposed rule, we are proposing to make a budget neutrality adjustment to assure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. III. Proposed Changes to the Hospital Wage Index A. Background Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must 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 Metropolitan Statistical Areas (MSAs) (and New England County Metropolitan Areas), issued by the Office of Management and Budget. In addition, as discussed below, we adjust the wage [[Page 27453]] 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. Furthermore, this section 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 the wages and wage-related costs incurred in furnishing skilled nursing services. B. FY 1997 Wage Index Update The proposed FY 1997 wage index (effective for hospital discharges occurring on or after October 1, 1996 and before October 1, 1997) is based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 1993 (the FY 1996 wage index is based on FY 1992 wage data). We propose to use the same categories of data that were used in the FY 1996 wage index. Therefore, the proposed FY 1997 wage index reflects the following: Total salaries and hours from short-term, acute care hospitals. Home office costs and hours. Fringe benefits associated with hospital and home office salaries. Direct patient care contract labor costs and hours. The exclusion of salaries and hours for nonhospital type services such as skilled nursing facility services, home health services, or other subprovider components that are not subject to the prospective payment system. Finally, we are also proposing to make a minor revision to Sec. 412.63(s)(1) to state clearly that we update the wage index annually as required by section 1886(d)(3)(E) of the Act. 1. Verification of Wage Data From the Medicare Cost Report The data for the proposed FY 1997 wage index were obtained from Worksheet S-3, Part II of the Medicare cost report. The data file used to construct the proposed wage index includes FY 1993 data submitted to the Hospital Cost Report Information System (HCRIS) file as of the end of January 1996. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data. Of the 5,222 hospitals in the data base, 2,814 hospitals had data elements that failed an initial edit. In mid-February 1996, intermediaries contacted hospitals to revise or verify data elements that resulted in the edit failures. Next, to check any revisions since the first edit, as well as to apply additional edits based on the distribution of the data, we subjected all of the data to edits a second time. The intermediaries were instructed to transmit any revisions in hospitals' wage data made as a result of this second review. As of March 14, 1996, only 21 hospitals still had unresolved data elements. These unresolved data elements are included in the calculation of the proposed FY 1997 wage index pending their resolution before calculation of the final FY 1997 wage index. We have instructed the intermediaries to complete their verification of questionable data elements and to transmit any changes to the wage data (through HCRIS) no later than June 17, 1996. We expect that all unresolved data elements will be resolved by that date, and that the revised data will be reflected in the final rule. 2. Computation of the Wage Index The method used to compute the proposed wage index is as follows: Step 1--As noted above, we are proposing to base the FY 1997 wage index on wage data reported on the FY 1993 cost reports. 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, 1992 and before October 1, 1993. In addition, we included data from a few hospitals that had cost reporting periods beginning in September 1992 and 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 these wage data as FY 1993 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 subprovider components not subject to the prospective payment system) from gross hospital salaries to determine net hospital salaries. To determine total salaries plus fringe benefits, we added direct patient care contract labor costs, hospital fringe benefits, and any home office salaries and fringe benefits reported by the hospital, to the net hospital salaries. Step 3--For each hospital, we adjusted 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, 1992 through September 15, 1994, for hospital industry workers from Standard Industry Classification 806, Bureau of Labor Statistics Employment and Earnings Bulletin. The annual inflation rates used were 4.8 percent for FY 1992, 3.6 percent for FY 1993, and 2.7 percent for FY 1994. 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 ------------------------------------------------------------------------ After Before Adjustment factor ------------------------------------------------------------------------ 10/14/92............... 11/15/92 1.044482 11/14/92............... 12/15/92 1.041408 12/14/92............... 01/15/93 1.038343 01/14/93............... 02/15/93 1.035287 02/14/93............... 03/15/93 1.032240 03/14/93............... 04/15/93 1.029203 04/14/93............... 05/15/93 1.026174 05/14/93............... 06/15/93 1.023154 06/14/93............... 07/15/93 1.020143 07/14/93............... 08/15/93 1.017141 08/14/93............... 09/15/93 1.014147 09/14/93............... 10/15/93 1.011163 10/14/93............... 11/15/93 1.008920 11/14/93............... 12/15/93 1.006683 12/14/93............... 01/15/94 1.004450 01/14/94............... 02/15/94 1.002223 02/14/94............... 03/15/94 1.000000 03/14/94............... 04/15/94 0.997782 04/14/94............... 05/15/94 0.995570 05/14/94............... 06/15/94 0.993362 06/14/94............... 07/15/94 0.991159 07/14/94............... 08/15/94 0.988961 08/14/94............... 09/15/94 0.986767 ------------------------------------------------------------------------ For example, the midpoint of a cost reporting period beginning January 1, 1993 and ending December 31, 1993 is June 30, 1993. An inflation adjustment factor of 1.020143 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 1993 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 [[Page 27454]] increased the net hours by the addition of any direct patient care contract labor hours and home office hours to determine total hours. Step 5--As part of our editing process, we deleted data for eight hospitals for which we lacked sufficient documentation to verify data that failed edits because the hospitals are no longer participating in the Medicare program or are in bankruptcy status. We retained the data for other hospitals that are no longer participating in the Medicare program because these hospitals reflected the relative wage levels in their labor market areas during their FY 1993 cost reporting period. Step 6--Each hospital was assigned to its appropriate urban or rural labor market area prior to any reclassifications under sections 1886(d)(8)(B) or 1886(d)(10) of the Act. 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 $19.5094. 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. 3. 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 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, as provided in 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. If including the wage data for the redesignated hospitals increases the MSA wage index value, the MSA and the redesignated hospitals receive the combined wage index value. 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 values increase as a result of excluding the wage data for the hospitals that have been redesignated to another area have their wage indexes 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. 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 those urban areas whose wage index values are already below the rural wage index and would be reduced by redesignations, 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. These areas receive the prereclassified wage index value. The prereclassified wage index value will apply as long as the MSA remains empty. The proposed revised wage index values for FY 1997 are shown in Tables 4a, 4b, and 4c in the Addendum to this proposed 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, prior to the redesignation of hospitals, based on the FY 1993 wage data. (We note that in Tables 4a, 4c, and 4d, we have revised several of the titles for urban areas to be consistent with OMB titles. For example, the title for urban area 1123 is changed from Boston-Brockton-Nashua, MA-NH to Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH. These are nomenclature changes only.) In addition, Table 3C in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital based on the FY 1993 data. The MGCRB will use the average hourly wage published in the final rule to evaluate a hospital's application for reclassification, unless that average hourly wage is later revised in accordance with the wage data correction policy described in Sec. 412.63(s)(2). In such cases, the MGCRB will use the most recent revised data used for purposes of the hospital wage index. Hospitals that choose to apply before publication of the final rule can use the proposed wage data in applying to the MGCRB for wage index reclassifications that would be effective for FY 1998. We note that in [[Page 27455]] adjudicating these wage reclassification requests during FY 1997, the MGCRB will use the average hourly wages for each hospital and labor market area that are reflected in the final FY 1997 wage index. At the time this proposed wage index was constructed, the MGCRB had completed its review. The proposed FY 1997 wage index values incorporate all 391 hospitals redesignated for purposes of the wage index (hospitals redesignated under section 1886(d)(8)(B) or 1886(d)(10) of the Act) for FY 1997. The final number of reclassifications may be different because some MGCRB decisions are still under review by the Administrator and because some hospitals may withdraw their requests for reclassification. Any changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process will be incorporated into the wage index values published in the final rule. The changes may affect not only the wage index value for specific geographic areas, but also whether redesignated hospitals receive the wage index value for the area to which they are redesignated, or a wage index that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected. Under Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of this Federal Register document. The request for withdrawal of an application for reclassification that would be effective in FY 1997 must be received by the MGCRB by July 15, 1996. A hospital that requests to withdraw its application may not later request that the MGCRB decision be reinstated. C. Requests for Wage Data Corrections To allow hospitals more time to evaluate the wage data used to construct the proposed FY 1997 hospital wage index, we have made available to the public a diskette containing the FY 1993 hospital wage data. In a memorandum dated March 1, 1996, we instructed all Medicare intermediaries to inform the prospective payment hospitals they serve that the diskette would be available approximately mid-March 1996. The intermediaries were also instructed to advise hospitals of the alternative availability of these data either through their representative hospital organizations or directly from HCFA (using order forms provided by the intermediary). Additional details on ordering this data file are discussed below in section VIII.B of this preamble, ``Requests for Data from the Public.'' In addition, as discussed above in section III.B.3 of this preamble, Table 3C, in the Addendum to this proposed rule, contains each hospital's adjusted average hourly wage used to construct the proposed wage index values. A hospital can verify its average hourly wage as reflected on its cost report (after taking into account any adjustments made by the intermediary) by dividing the adjusted average hourly wage in Table 3C by the applicable wage inflation adjustment factors as set forth above in Step 3 of the computation of the wage index. An updated Table 3C (along with applicable wage inflation adjustment factors) will be included in the final rule. We believe hospitals have had ample time to ensure the accuracy of their FY 1993 wage data. Moreover, the ultimate responsibility for accurately completing the cost report rests with the hospital, which must attest to the accuracy of the data at the time the cost report is filed. However, if after review of the diskette or Table 3C, a hospital believes that its FY 1993 wage data have been incorrectly reported, the hospital must submit corrections along with complete supporting documentation to its intermediary by May 15, 1996. To be reflected in the final wage index, any wage data corrections must be reviewed by the intermediary and transmitted to HCFA (through HCRIS) on or before June 17, 1996. These deadlines, which correspond to the deadlines we used last year for the FY 1996 wage index, are necessary to allow sufficient time to review and process the data so that the final wage index calculation can be completed for development of the final prospective payment rates to be published by September 1, 1996. We cannot guarantee that corrections transmitted to HCFA after June 17, 1996, will be reflected in the final wage index. After reviewing requested changes submitted by hospitals, intermediaries will transmit any revised cost reports to HCRIS and forward a copy of the revised Worksheet S-3, Part II to the hospitals. If requested changes are not accepted, fiscal intermediaries will notify hospitals in writing of reasons why the changes were not accepted. This procedure will ensure that hospitals have every opportunity to verify the data that will be used to construct their wage index values. We believe that fiscal intermediaries are generally 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, if a hospital disagrees with the intermediary's resolution of a requested change, the hospital may contact HCFA in an effort to resolve the dispute. We note that the June 17 deadline also applies to these requested changes. We have created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 1997 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage corrections or to dispute the intermediary's decision with respect to requested changes. We intend to make another diskette available in mid-August that will contain the wage data that will be used to construct the wage index values in the final rule. As with the diskette made available in March 1996, HCFA will make the August diskette available to hospital associations and the public. This August diskette, however, is being made available only for the limited purpose of identifying any potential errors made by HCFA or the intermediary in the entry of the final wage data that result from the process described above, not for the initiation of new wage data correction requests. Hospitals are encouraged to review their hospital wage data promptly after the release of the second diskette. If, after reviewing the August diskette, a hospital believes that its wage data are incorrect due to a fiscal intermediary or HCFA error in the entry or tabulation of the final wage data, it should 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 and the intermediaries no later than September 16, 1996. We have set this year's deadline one week earlier than last year's deadline because we found the later deadline made it difficult to evaluate the requests and recalculate the wage index values before the start of FY 1997 (that is, October 1, 1996). Requests should be sent to: Health Care Financing Administration; Office of Hospital Policy; Attention: Stephen Phillips, Technical Advisor; Division of Prospective Payment System; C5-06-27; 7500 Security Boulevard; Baltimore, Maryland 21244-1850. 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. [[Page 27456]] After mid-August, we will make changes to the hospital wage data only in those very limited situations involving an error by the intermediary or HCFA that the hospital could not have known about before its review of the August diskette. Specifically, after that point, neither the intermediary nor HCFA will accept the following types of requests in conjunction with this process: Requests for wage data corrections that were submitted too late to be included in the data transmitted to the HCRIS system on or before June 17, 1996; Requests for correction of errors made by the hospital that were not, but could have been, identified during the hospital's review of the March 1996 data; or, Requests to revisit factual determinations or policy interpretations made by the intermediary or HCFA during the wage data correction process. Verified corrections to the wage index received timely (that is, by September 16, 1996) will be effective October 1, 1996. Again, we believe the wage data correction process described above provides hospitals with sufficient opportunity to bring errors made during the preparation of the Worksheet S-3 to the intermediary's attention. Moreover, because hospitals will have access to the wage data in mid-August, they will have the opportunity to detect any data entry or tabulation errors made by the intermediary or HCFA before the implementation of the FY 1997 wage index on October 1, 1996. If hospitals avail themselves of this opportunity, the wage index implemented on October 1 should be free of such errors. Nevertheless, in the unlikely event that such errors should occur, we retain the right to make midyear changes to the wage index under very limited circumstances. Specifically, in accordance with Sec. 412.63(s)(2), we 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 an error in tabulating its data, and (2) that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of FY 1997 (that is, by the September 16, 1996 deadline). As indicated earlier, since a hospital will have the opportunity to verify its data, and the intermediary will notify the hospital of any changes, we do not foresee 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 effective prospectively from the date the correction is made. D. Contract Labor--Costs Included in the Hospital Wage Index Our policy concerning inclusion of contract labor costs for purposes of calculating the wage index has evolved over the past several years. Primarily, this has occurred as we recognized the role of contract labor in meeting special personnel needs of many hospitals. In addition, improvements in the wage data have allowed us to more accurately identify contract labor costs and hours. As a result, effective with the FY 1994 wage index, we included the costs of direct patient care contract services in the wage index calculation. Effective with the FY 1999 wage index, which will use data from FY 1995 cost reports, we will begin to include the costs and hours of certain management contract services. In this proposed rule, we are soliciting comments from the public regarding further expansion of the types of contract labor costs included in the wage index. The following background discussion provides a general overview of the issues related to including contract labor costs in the wage index calculation. We also list nine specific issues for which we are seeking public comment. In the May 9, 1990 proposed rule (55 FR 19442), we reported the results of the 1988 wage index survey which collected, among other information, data on the costs and hours associated with direct patient care contract labor. All prospective payment hospitals completed the wage survey for their cost reporting periods ending in calendar year 1988. The survey data indicated that hospitals had difficulty in tracking and recording the actual hours worked associated with the contract labor. In addition, there were reporting inconsistencies. For example, some hospitals inappropriately reported patient care services furnished directly by physicians, which are not included in the wage data because they are paid under Medicare Part B rather than Part A. In the May 9, 1990 proposed rule, we also discussed public comments we received in response to issues we raised related to including contract labor costs in the wage index. Specifically, in the May 8, 1989 proposed rule (54 FR 19647), we requested comment on the following issues: Should the wage index include data on contract labor? Should the definition of contract services in the wage index survey be expanded to include services indirectly related to patient care, such as billing or housekeeping services? A majority of the commenters supported the inclusion of contract services, and many argued for the expansion of contract labor services to include indirect patient care services. Those opposed to including contract services, in addition to some commenters who supported including contract service costs, were concerned about the difficulty of accurately tracking and recording hours worked for all types of contract labor. Other commenters were also concerned that if a hospital contracts for services from outside its labor market area, the contract wages could artificially increase or decrease the hospital's area wage index. Based on the comments and the overall poor quality of the 1988 survey data, we decided to exclude all contract labor from the FY 1991 wage index. We stated that we would continue our analysis of contract labor. In addition, we announced that we would develop a new wage index survey with improved instructions and auditing criteria to facilitate the inclusion of contract labor in future wage index updates. The new survey, Worksheet S-3, Part II, was included in the hospital cost report effective with cost reporting periods beginning on or after October 1, 1989. The Worksheet S-3, Part II consists of detailed information for use in the hospital wage index including contract labor for direct patient care services. In the instructions for completing this worksheet, contract labor costs and hours were limited to labor-related payments and hours attributable to direct patient care contract services, such as nursing services. Specifically, we instructed hospitals to exclude indirect patient care contract services (for example, management and housekeeping services), nonlabor-related expenses (for example, equipment and supplies), and any contract services for which labor- related payments and hours could not be accurately determined. In the September 4, 1990 final rule (55 FR 36036), we discussed additional comments we received on the contract labor issue. Those commenters who supported the inclusion of contract labor stated that some hospitals, especially rural hospitals, are dependent on contract labor for nursing services, and it would be unfair not to include these wage data. Other commenters requested that the definition of contract [[Page 27457]] labor be expanded to include indirect patient care services. We also received several comments requesting that we continue to exclude contract labor from the wage index. These commenters stated that the contract labor data are not reliable because of the difficulty in tracking and reporting hours and the lack of consistency in the reporting of contract labor. In addition, inclusion of nonlabor contract costs would inappropriately drive up labor costs, and contract labor brought in from outside the labor market area would artificially increase or decrease the area wage index value. Finally, commenters were concerned that contract labor costs are too variable, temporary, and not reflective of true wage costs. Therefore, some suggested that contract labor should not be included in the wage index. The FY 1994 wage index, which was based on the data collected on the Worksheet S-3, Part II, was the first to include direct patient care contract labor costs. In making the decision to include these costs, we analyzed hospitals' FY 1990 data to determine if it was sufficiently complete for inclusion in the wage index calculation (see the May 26, 1993 proposed rule (58 FR 30236)). We noted that, in most labor market areas, including contract labor in the wage index computation had little effect on the average hourly wage. We further stated that, based on our analysis of the data, including direct patient care contract labor would more accurately and fairly reflect wage levels across hospitals and MSAs. In the September 1, 1993 final rule, we also responded to comments from the hospital industry expressing concern that we did not recognize the costs of certain contract management services (58 FR 46296). In particular, many rural hospitals stated they were either unable to recruit or afford top managers such as hospital administrators and must contract for these services. In the September 1, 1994 final rule (59 FR 45355), we expanded the definition of contract labor for purposes of determining the hospital wage index to include the personnel costs and hours associated with certain contract management personnel. Contract management services would be limited to individuals working in the top four positions in the hospital: the Chief Executive Officer/Hospital Administrator, Chief Operating Officer, Chief Financial Officer, and Nursing Administrator. We noted that while exact titles may vary, individuals should be performing essentially the same duties as customarily assigned these management positions. We further noted that, since the cost report did not provide at that time for the collection of management contract data, this revised definition would not be effective until cost reporting periods beginning on or after October 1, 1994 (FY 1995). Hospitals were instructed to continue to exclude all management contract costs and hours until the FY 1995 data were reported (these data will be used to compute the FY 1999 wage index). In addition, we began requiring hospitals to provide descriptions and aggregate totals for all management contracts and complete details on all direct patient care contracts on the Form HCFA-339 (the Provider Cost Report Reimbursement Questionnaire). A hospital must file this form with its corresponding cost report. We continue to receive requests that we expand our contract labor definition to include more types of contract services in the wage index. In particular, we have been asked to include the costs for pharmacy and laboratory services on the basis that these services are consistent with our definition of direct patient care (see the September 1, 1995 final rule (60 FR 45792)). Others have asked that we expand our definition to include all contracted services, both direct and indirect patient care services, in order to more appropriately calculate relative hospital wage costs. We have limited the contract services that are included in the wage index to direct patient care services and specific management services for several reasons. First, hospitals reported difficulty in accurately tracking the hours associated with contract services, especially for off-site facilities that serve more than one hospital. Second, we are concerned about the contractor's ability to separate nonlabor costs from labor costs. We believe that the generally higher costs for contract labor compared to salaried labor, due at least in part to the added costs of overhead and supplies not separately identified in most contracts, may distort the wage index. Finally, we are concerned that it is difficult to remove the costs and hours for services such as legal and accounting from total management contracts. Our goal is to ensure that our wage index policy continues to be responsive to the changing need for contract labor, allowing those hospitals that must depend on contract labor to supply needed services to reflect those costs in their wage data. At the same time, however, we wish to avoid providing an opportunity for hospitals to inflate their average hourly wage inappropriately by including nonlabor contract costs. The advantage of our approach of including only contract labor costs and hours associated with direct patient care and specific management services is that it minimizes distortions in the wage index that are due to a hospital's inability to identify and exclude nonlabor costs. While changes to the wage index values are made in a budget neutral manner and are not expected to affect aggregate payments, we strive for policies that are equitable for all hospitals. Finally, due to the 4-year time lag between the cost reporting period itself and the fiscal year when data for that period are used in calculating the wage index, it is important that we anticipate any need to change our policy on contract labor. Therefore, in order to formulate the most responsive and responsible policy, we are soliciting comments on the following issues: To what extent do hospitals rely on the use of contract services? For which services are contracts typically used? Can hospitals accurately determine hours related to contract services? Can hospitals accurately isolate labor-related costs from nonlabor-related costs? Should the contract labor definition be expanded to include contract services indirectly related to patient care? If contract labor remains limited to direct patient care, what categories of services, if any, in addition to those identified above, should be included? Would the wage index more accurately reflect relative wage levels if we did not limit contract labor to direct patient care (generally high wage) services? Would expanding the types of contract labor that are included in the wage index provide less incentive to hospitals to keep their labor costs low, as higher labor costs may result in a higher wage index value for that hospital or allow it to reclassify to a labor market with a higher wage index? What other issues should be considered in revising the policy for including contract labor in the wage index? E. Puerto Rico Wage Index Values For several years, hospitals in Puerto Rico have experienced large swings in their wage index values. In the September 1, 1995 final rule, we responded to two comments suggesting changes to the wage index for hospitals in Puerto Rico (60 FR 45796). One suggestion was to establish a floor for the wage index values of the Puerto Rico labor market areas while the other was to eliminate the rural area classification in Puerto Rico and classify the rural [[Page 27458]] hospitals to the nearest urban area. Although we did not adopt either of these suggestions, we stated that we would continue to study the issue of wage index values in Puerto Rico. To evaluate the effect that these large changes in wage index values have on hospitals in Puerto Rico, we examined the most recent Medicare cost data for these hospitals. Of the 50 hospitals contained in our data base, 64 percent had improved Medicare operating margins from 1992 to 1993. Of the 26 hospitals with data available for 1994, we found that 65 percent improved financially from 1993 to 1994. Based on this analysis, we do not believe that the wage index changes have had a detrimental effect on these hospitals as a group. However, there are individual hospitals that are not faring as well. We recognize that large shifts in the wage index values can cause shifts in the payment levels for a particular MSA. Because three of the six MSAs in Puerto Rico (Aguadilla, Arecibo, and Caguas) as well as the rural area have four or fewer hospitals, a large change in one hospital's wage data can cause a large increase or decrease in the wage index value for the entire MSA. One possible method to limit these annual swings in wage index values would be to create a single labor market area encompassing all the hospitals in Puerto Rico. That is, the six MSAs and the rural area would be combined into one area with one wage index value. A single labor market area would create a much larger set of hospitals to develop aggregate wage amounts and would mitigate situations where a change in the wage data of a single hospital has a large effect on the wage index of an MSA. Because creating one MSA for Puerto Rico would be implemented in a budget neutral manner, the effect would be to raise wage index values for some hospitals in Puerto Rico and to lower the values for others. Using the FY 1993 wage data, the following table shows the effect this change would have on the proposed wage index levels. ---------------------------------------------------------------------------------------------------------------- Number of Proposed One area Percent Area hospitals wage index wage index change ---------------------------------------------------------------------------------------------------------------- Rural....................................................... 4 0.4182 0.4555 8.92 Aguadilla................................................... 2 0.4430 0.4555 2.82 Arecibo..................................................... 2 0.4661 0.4555 -2.27 Caguas...................................................... 4 0.4638 0.4555 -1.79 Mayaguez.................................................... 5 0.4186 0.4555 8.82 Ponce....................................................... 7 0.4500 0.4555 1.22 San Juan.................................................... 29 0.4616 0.4555 -1.32 ---------------------------------------------------------------------------------------------------------------- Because of the negative effects on some hospitals, we are soliciting comment on this approach for mitigating the fluctuations in wage index values for hospitals in Puerto Rico. The potential change would have no impact on hospitals outside Puerto Rico. F. Proposed Changes to the MGCRB Composition and Criteria Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification for purposes of payment under the prospective payment system. Guidelines concerning the criteria and conditions for hospital reclassification are located at Secs. 412.230 through 412.236. The purpose of these criteria is to provide direction, to both the MGCRB and those hospitals seeking geographic reclassification, with respect to the situations that merit an exception to the rules governing the geographic classification of hospitals under the prospective payment system. The composition of the MGCRB and the procedures it follows in making reclassification determinations are set forth in Secs. 412.246 through 412.280. As discussed in detail below, we are proposing to make one change to the MGCRB regulations. In addition, we are soliciting comments on sources of data that could be used to identify the occupational mix in a given MSA. 1. MGCRB Composition (Sec. 412.246) Section 1886(d)(10)(B)(i) of the Act provides that the MGCRB is composed of five members appointed by the Secretary. This provision is implemented in regulations at Sec. 412.246(a). Two of the members must be representative of the concerns of rural hospitals and at least one member must be knowledgeable in the field of analyzing costs of providing inpatient hospital services. Under current Sec. 412.246(b), the term of office for an MGCRB member is 3 years, and appointments are limited to two consecutive 3-year terms. This section further provides that to permit staggered terms of office, initial appointments may be for shorter terms. Finally, the Secretary is permitted to terminate a member's tenure before his or her full term has expired. Since the establishment of the MGCRB 6 years ago, we have never modified the regulations that govern the MGCRB's composition, which were originally modeled after the procedural regulations of the Provider Reimbursement Review Board (PRRB). We believe that it is now appropriate to update the regulations that govern members' terms of office in light of agency experience. Appointments to the Board must comply with statutory requirements concerning rural representatives and a hospital cost expert. Since the appointment of the initial Board, the Secretary has had difficulty recruiting additional, qualified persons to serve on the MGCRB. In addition, we solicited comment in the June 2, 1995 proposed rule (60 FR 29218) on the idea of eliminating the MGCRB and transferring its functions back to HCFA. This may have caused qualified members to lose interest in becoming or remaining Board members. We no longer believe that there needs to be a limitation on the number of terms a member may serve. Deleting the term limit requirement would allow for increased flexibility in appointing and recruiting qualified Board members. Flexibility in this area will allow the Secretary to ensure that Board members are in place to meet the tight statutory deadlines associated with filing and adjudicating MGCRB applications. (Under sections 1886(d)(10)(C) (ii) and (iii) of the Act, a hospital requesting a change in geographic classification must submit its application to the Board not later than the first day of the preceding fiscal year. Once the application is received the Board must render a decision within 180 days.) Therefore, we are proposing to eliminate the current requirement at Sec. 412.246(b) that a Board member can serve for only two consecutive 3-year terms. We also considered eliminating any requirement on the length of an individual term. However, we believe that maintaining a term of office not to exceed 3 years is appropriate. If we [[Page 27459]] deleted this requirement, then the Secretary could not periodically reevaluate membership of the Board. We would, however, propose that a term of office would not be limited only to a term of exactly 3 years. Specifically, we would revise Sec. 412.246(b) to provide that an appointment to the MGCRB may be for any term not to exceed 3 years. We believe that both of these proposed changes would allow the Secretary maximum flexibility to recruit and retain qualified Board members. Under the proposed revisions, the Secretary would continue to be able to terminate a member's tenure before his or her full term has expired. This provision was modeled after the provisions of the PRRB under which the Secretary has the authority to terminate a Board member for good cause. We believe that it is appropriate for the Secretary to be able to exercise a similar termination authority over the MGCRB in case a member of the MGCRB fails to carry out his or her duties under the Act and regulations. Therefore, we would retain this provision. We note that the Secretary has not invoked this authority to date with either the PRRB or the MGCRB. 2. Occupational Mix Adjustment Section 1886(d)(10)(D)(i) of the Act requires the Secretary to publish guidelines to be utilized by the MGCRB in rendering decisions on applications submitted for geographic reclassification. Those are to include guidelines for ``comparing wages, taking into account (to the extent the Secretary determines appropriate) occupational mix, in the area in which the hospital is classified and the area in which the hospital is applying to be classified.'' Section 412.230(e) describes the criteria for hospital reclassification for purposes of the wage index. One of the criteria relates to the relationship between the hospital's wages and those of the area to which it seeks reclassification. Specifically, Sec. 412.230(e)(1)(iv) provides that the hospital must demonstrate that its wages are at least 84 percent of the average hourly wage of hospitals in the area to which it seeks reclassification, or that the hospital's average hourly wage weighted for occupational mix is at least 90 percent of the average hourly wage of hospitals in the area to which it seeks reclassification. Under Secs. 412.232(c) and 412.234(b), a group of hospitals seeking to reclassify must demonstrate that its aggregate average hourly wage is at least 85 percent of the average hourly wage of the hospitals in the area to which it seeks reclassification. These sections also provide that the threshold for occupational-mix adjusted hourly wage for hospital groups is the same as that for a single hospital, that is, 90 percent. In the September 6, 1990 interim final rule (55 FR 36760), we stated that the acceptable sources for occupational mix data were the American Hospital Association (AHA) or the Bureau of Labor Statistics. Since publication of that document, the Bureau of Labor has discontinued its hospital wage surveys. Thus, the only currently acceptable occupational mix data source is the AHA Survey Data. We have been informed by the AHA that the survey for 1993 will be the last survey to collect information on the Hospital Personnel by Occupational Category. Therefore, requests filed on or before October 1, 1996 for FY 1998 reclassification, which use FY 1993 wage data, may be the last for which we have an appropriate source of occupational mix data. As we stated in the June 4, 1991 final rule with comment period (56 FR 25458), the reclassification process requires the use of occupational mix data that are comparable across areas and can be consistently applied. We are unaware of any sources other than the AHA data that meet these criteria. We have not proposed collecting occupational mix data ourselves in light of past experience. We attempted to collect such data some time ago. In the September 30, 1988 Federal Register (53 FR 38495), we reported on our efforts to collect 1986 occupational mix data as part of the Medicare National Uniform Reporting Demonstration project, to determine the feasibility of developing a wage index that would take into account occupational mix. The majority of hospitals (more than 60 percent) failed to complete or submit the survey. A number of surveys that were submitted were not filled out completely and appeared to have numerous errors. Moreover, we believe that collecting occupational mix data from hospitals would be inappropriately burdensome to the hospitals. In the past, we have received several comments from hospitals opposing HCFA's collection of occupational mix data (56 FR 43222), citing the prohibitive cost to hospitals of furnishing occupational mix data. Finally, even if we were to decide now to begin collecting occupational mix data, it would be at least 6 years before the data would be available for use. In order to continue to allow the use of wage data weighted by occupational mix in wage index reclassification, we are seeking suggestions about any occupational mix data sources that are available on a national basis. In addition, we are willing to consider suggestions about other methods that would account for occupational mix in the wage index reclassification process. IV. Rebasing and Revising of the Hospital Market Baskets A. Operating Costs 1. Background Effective for cost reporting periods beginning on or after July 1, 1979, we developed and adopted a hospital input price index (that is, the hospital ``market basket'') for operating costs. Although ``market basket'' technically describes the mix of goods and services used to produce hospital care, this term is also commonly used to denote the input price index (that is, cost category weights and price proxies combined) derived from that market basket. Accordingly, the term ``market basket'' as used in this document refers to the hospital input price index. The percentage change in the market basket reflects the average change in the price of goods and services hospitals purchase in order to furnish inpatient care. We first used the market basket to adjust hospital cost limits by an amount that reflected the average increase in the prices of the goods and services used to furnish hospital inpatient care. This approach linked the increase in the cost limits to the efficient utilization of resources. With the inception of the hospital inpatient prospective payment system on October 1, 1983, we continued to use the hospital market basket to update each hospital's 1981 inpatient operating cost per discharge used in establishing the FY 1984 standardized payment amounts. In addition, the projected change in the hospital market basket has been the integral component of the update factor by which the prospective payment rates are updated every year. Under section 1886(b)(3)(B)(i)(XII) of the Act, the prospective payment rates will be updated in FY 1997 by the projected increase in the hospital market basket minus 0.5 percentage points. A detailed explanation of the hospital market basket used to develop the prospective payment rates was published in the Federal Register on September 3, 1986 (51 FR 31461). For additional background information on general development of hospital input price indexes, we refer the reader to the article by Freeland, Anderson, and Schendler, ``National Hospital Input Price Index,'' Health Care Financing Review, Summer 1979, pp 37-61. We also refer the reader to the September 4, 1990 Federal Register (55 FR 35990) in which we discussed the previous [[Page 27460]] rebasing of the hospital input price index. The hospital market basket is a fixed-weight, Laspeyres-type price index that is constructed in three steps. First, a base period is selected and total base period expenditures are estimated for mutually exclusive and exhaustive spending categories based upon type of expenditure. Then, the proportion of total costs that each category represents is determined. These proportions are called cost or expenditure weights. Second, each expenditure category is matched to an appropriate price/wage variable, referred to as a price proxy. These price proxies are price levels derived from a publicly available statistical series published on a consistent schedule, preferably at least on a quarterly basis. Third and finally, the price level for each spending category is multiplied by the expenditure weight for that category. The sum of these products (that is, the expenditure weights multiplied by the price levels) for all cost categories yields the composite index level in the market basket in a given year. Repeating this step for other years produces a series of market basket index levels over time. Dividing one index level by an earlier index level produces rates of growth in the input price index. The market basket is described as a fixed-weight index because it answers the question of how much it would cost, at another time, to purchase the same mix of goods and services that was purchased in the base period. The effects on total expenditures resulting from changes in the quantity or mix of goods and services purchased subsequent to the base period are not considered. For example, shifting a traditionally inpatient type of care to an outpatient setting might affect the volume of inpatient goods and services purchased by the hospital, but would not be factored into the price change measured by a fixed weight hospital market basket. We believe that it is desirable to rebase the market basket periodically so the cost weights reflect changes in the mix of goods and services that hospitals purchase (hospital inputs) in furnishing inpatient care. We last rebased the hospital market basket cost weights effective for FY 1991. This market basket, still used through FY 1996, reflected base year data from FY 1987 in the construction of the cost weights. In its April 1, 1985 report to the Secretary (Appendix C of the June 10, 1985 proposed rule (50 FR 24446)), ProPAC supported HCFA's position on periodic rebasing, stating that the market basket cost weights should be recalculated or ``rebased'' at least every 5 years, or more frequently if significant changes in the weights occur. We note that there are separate market baskets for prospective payment hospitals and hospitals and hospital units excluded from the prospective payment system. The separate, excluded hospital market basket is set forth in section IV.A.5 of this preamble. 2. Rebasing and Revising the Hospital Market Basket The terms rebasing and revising, while often used interchangeably, actually denote different activities. Rebasing means moving the base year for the structure of costs of an input price index (for example, we are proposing to move the base year cost structure from FY 1987 to FY 1992). Revising means changing data sources, cost categories, or price proxies used in the input price index. We are proposing to use a rebased and revised hospital market basket in developing the FY 1997 update factor for the prospective payment rates. The new market basket would be rebased to reflect 1992, rather than 1987, cost data. In developing the rebased and revised market basket, we reviewed hospital operating expenditure data for the market basket cost categories. In a change from previous methodology, we are relying primarily on Medicare hospital cost report data for the proposed rebasing. For the proposed market baskets, we used data on hospital expenditures for four major expense categories (wages and salaries, employee benefits, pharmaceuticals, and a residual ``all other'') from hospital cost reporting periods beginning in FY 1992 (that is, periods beginning on or after October 1, 1991 and before October 1, 1992). We refer to these as PPS-9 cost reports (the 9th year of the prospective payment system (PPS)). The market basket was previously based on 1987 expense data from the 1988 American Hospital Association (AHA) Annual Survey. Expenses for wages and salaries, employee benefits, and pharmaceuticals were determined using data from PPS-9 cost reports as reported in the Hospital Cost Report Information System (HCRIS) files. We determined total professional fees using AHA Annual Survey data. Total professional fees include medical and nonmedical professional fees. Since the medical professional fees included in the compensation of provider-based physicians is paid under Medicare Part B, we analyzed HCRIS data to determine the professional component of provider-based physician compensation and subtracted it from total professional fees to obtain an estimate of nonmedical professional fees. Malpractice insurance costs were determined using the cost share for PPS-6 (cost reporting periods beginning in FY 1989), the last year these costs had to be treated separately from all other administrative and general costs, trended forward to 1992 based on the relative importance of malpractice costs found in the previous market basket. The All Other Expenses category was calculated in two steps. First, from PPS-9 cost reports, total operating expenses were tabulated by subtracting capital-related expenses, direct medical education expenses, and the medical professional fees from total expenses. Second, we subtracted the total of the five cost category expenses already determined from total operating expenses to obtain the All Other Expenses category. After totals for these main cost categories (wages and salaries, employee benefits, professional fees, pharmaceuticals, malpractice insurance, and all other expenses) were calculated, we then determined the proportion each category represents of the total costs. These proportions represent the major rebased market basket weights. The differences between the six major categories for the proposed 1992- based index and the previous 1987-based index are summarized in Table 1 below. Table 1.--Comparison of 1992 and 1987 Prospective Payment Hospital Operating Cost Categories and Weights ------------------------------------------------------------------------ Rebased 1992 1987-based Expense categories hospital hospital market basket market basket ------------------------------------------------------------------------ Wages and Salaries...................... 50.244 52.2 Employee Benefits....................... 11.146 9.5 Nonmedical Professional Fees............ 2.127 1.6 [[Page 27461]] Malpractice Insurance................... 1.189 1.4 Pharmaceuticals......................... 4.162 3.9 All Other............................... 31.132 31.4 ------------------------------- Total............................... 100.000 100.0 ------------------------------------------------------------------------ Note: Although we rounded the weights to the tenths decimal position in the 1987-based market basket as published in the September 4, 1990 final rule, we are presenting the 1992 weights in greater specificity. Table 2 sets forth the proposed market basket cost categories, weights, and price proxies. Weights for the ``Utilities'' and the ``All Other'' cost categories, as well as the subcategories, were determined using the 1987 Department of Commerce's Bureau of Economic Analysis (BEA) Input-Output Table, from which data for the hospital industry were extracted. The BEA Input-Output database, which is updated at 5- year intervals, was most recently described in the Survey of Current Business, ``Benchmark Input-Output Accounts for the U.S. Economy, 1987'' (April 1994). We anticipate that the Department of Commerce will soon release 1992 cost data for use in determining the cost weights. If the data are released in time to be analyzed, we will use them in the final market basket for more refined estimates of cost expenditure weights. We aged the 1987 cost shares to 1992 using historical price changes between 1987 and 1992 for each category. The aged shares were normalized to be consistent with the 1992 hospital cost report data. Relative weights for the new base year were then calculated for various expenditure categories. This work resulted in the identification of 26 separate cost categories in the rebased hospital market basket, two fewer categories than were included in the 1987-based market basket. Detailed descriptions of each category and respective price proxy are provided in Appendix C to this proposed rule. Table 2.--Proposed 1992-Based Prospective Payment Hospital Operating Cost Categories, Weights, and Price Proxies ---------------------------------------------------------------------------------------------------------------- Rebased 1992 Expense categories hospital Price proxy market basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation............................. 61.390 ..................................................... A. Wages and Salaries\1\................ 50.244 HCFA Occupational Wage Index. B. Employee Benefits\1\................. 11.146 HCFA Occupational Benefits Index. 2. Professional Fees\1\..................... 2.127 ECI--Compensation for Professional, Specialty & Technical. 3. Utilities................................ 2.469 ..................................................... A. Fuel, Oil, and Gasoline.............. 0.345 PPI Refined Petroleum Products. B. Electricity.......................... 1.349 PPI Commercial Electric Power. C. Natural Gas.......................... 0.670 PPI Commercial Natural Gas. D. Water and Sewerage................... 0.106 CPI-U Water & Sewerage Maintenance. 4. Professional Liability Insurance......... 1.189 HCFA Professional Liability Insurance Premium Index. 5. All Other................................ 32.824 ..................................................... A. All Other Products................... 24.033 ..................................................... (1.) Pharmaceuticals................ 4.162 PPI Ethical (Prescription) Drugs. (2.) Food........................... 3.459 ..................................................... a. Direct Purchase.............. 2.363 PPI Processed Foods & Feeds. b. Contract Service............. 1.096 CPI-U Food Away From Home. (3.) Chemicals...................... 3.795 PPI Industrial Chemicals. (4.) Medical Instruments............ 3.128 PPI Medical Instruments & Equipment. (5.) Photographic Supplies.......... 0.399 PPI Photographic Supplies. (6.) Rubber and Plastics............ 4.868 PPI Rubber & Plastic Products. (7.) Paper Products................. 2.062 PPI Converted Paper & Paperboard Products. (8.) Apparel........................ 0.875 PPI Apparel. (9.) Machinery and Equipment........ 0.211 PPI Machinery & Equipment. (10.) Miscellaneous Products........ 1.074 PPI Finished Goods. B. All Other Services................... 8.792 ..................................................... (1.) Business Services\1\........... 3.823 ECI--Compensation for Private Workers in Business Services. (2.) Computer Services\1\........... 1.927 AHE Computer & Data Processing Services. (3.) Transportation Services........ 0.188 CPI-U Transportation. (4.) Telephone Services............. 0.531 CPI-U Telephone Services. (5.) Postage\1\..................... 0.272 CPI-U Postage. (6.) All Other: Labor Intensive*.... 1.707 ECI--Compensation for Private Service Occupations. (7.) All Other: Nonlabor Intensive.. 0.344 CPI-U All Items. -------------- Total.......................... 100.000 ---------------------------------------------------------------------------------------------------------------- \1\ Labor-related. Note: Due to rounding, weights may not sum to total. [[Page 27462]] The 1987-based market basket included a separate Blood Services cost category. In the 1992-based market basket, Blood Services is contained within the Chemicals cost category. In addition, the 1987- based cost category for Fuel Oil, Coal, etc. has been combined with the 1987-based Motor Gasoline cost category to form the 1992-based Fuel, Oil and Gasoline cost category. Both of these changes are based on revised cost categories from BEA. For comparison purposes, the 1987- based cost categories are set forth in Table 3. Table 3.--1987-Based Prospective Payment Hospital Operating Cost Categories, Weights, and Price Proxies ---------------------------------------------------------------------------------------------------------------- 1987 hospital Expense categories market Price proxy basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation............................. 61.7 ..................................................... A. Wages and Salaries1.................. 52.2 HCFA Occupational Wage Index. B. Employee Benefits1................... 9.5 HCFA Occupational Benefits Index. 2. Professional Fees1....................... 1.6 ECI--Wages & Salaries for Professional, Specialty & Technical. 3. Utilities................................ 2.4 ..................................................... A. Fuel, Oil, Coal, etc................. 0.6 WPI Light Fuel Oils. B. Electricity.......................... 1.1 WPI Industrial Power. C. Natural Gas.......................... 0.3 WPI Natural Gas. D. Motor Gasoline....................... 0.2 WPI Gasoline. E. Water and Sewerage................... 0.0 CPI-U Water & Sewerage Maintenance. 4. Professional Liability Insurance......... 1.4 HCFA Professional Liability Insurance Premiums. 5. All Other................................ 32.8 ..................................................... A. All Other Products................... 21.8 ..................................................... (1.)Pharmaceuticals................. 3.9 WPI Prescription Drugs. (2.) Food........................... 3.3 ..................................................... a. Direct Purchase.............. 2.1 WPI Processed Foods. b. Contract Service............. 1.2 CPI-U Food Away From Home. (3.) Chemicals...................... 3.1 WPI Industrial Chemicals. (4.) Medical Instruments............ 2.7 WPI Medical Instruments & Equipment. (5.) Photographic Supplies.......... 2.6 WPI Photographic Supplies. (6.) Rubber and Plastics............ 2.3 WPI Rubber & Plastic Products. (7.) Paper Products................. 1.4 PPI Converted Paper & Paperboard Products. (8.) Apparel........................ 1.1 WPI Textile House furnishings. (9.) Machinery and Equipment........ 0.4 WPI Machinery & Equipment. (10.) Miscellaneous Products........ 0.8 WPI Finished Goods. B. All Other Services................... 11.1 ..................................................... (1.) Business Services1............. 3.8 AHE Business Services. (2.) Computer Services1............. 2.0 AHE Computer & Data Processing Services. (3.)Transportation Services......... 1.2 CPI-U Transportation. (4.) Telephone Services............. 1.0 CPI-U Telephone Services. (5.) Blood Services1................ 0.6 WPI Blood & Derivatives. (6.) Postage1....................... 0.4 CPI-U Postage. (7.) All Other: Labor Intensive1.... 1.2 ECI--Wages and Salaries for Private Service Occupations. (8.) All Other: Nonlabor Intensive.. 0.8 CPI-U All Items. ------------------------------------------------------------------- Total........................... 100.0 ---------------------------------------------------------------------------------------------------------------- \1\ Labor-related. Note: Due to rounding, weights may not sum to total. In the September 4, 1990 final rule, for purposes of determining the labor-related portion of the standardized amounts, we summed the percentages of the labor-related items (that is, wages and salaries, employee benefits, professional fees, business services, computer and data processing, blood services, postage, and all other labor-intensive services) in the hospital market basket. This summation resulted in a labor-related portion of the hospital market basket of 71.4 percent and nonlabor-related portion of 28.6 percent. Under sections 1886 (d)(2)(H) and (d)(3)(E) of the Act, in making payments under the prospective payment system, the Secretary estimates from time to time the proportion of payments that are labor-related. Since October 1, 1990, then, we have considered 71.4 percent of costs to be labor-related for purposes of the prospective payment system. In connection with the rebasing of the hospital market basket, we have re-estimated the labor-related share of the standardized amounts. Based on the relative weights described in Table 2, the labor-related portion that is subject to hospital wage index adjustments (based on wages and salaries, employee benefits, professional fees, business services, computer and data processing, postage, and all other labor- intensive services) is 71.246 percent and the nonlabor-related portion is 28.754 percent. To implement this change, effective with discharges occurring on or after October 1, 1996, we are proposing to recompute the labor-related and nonlabor-related shares of the large urban and other areas' standardized amounts used to establish the prospective payment rates. The amounts in Table 4 reflect the revised labor-related and nonlabor-related portions. Due to the Bureau of Economic Analysis' reclassification of Blood Services to Chemicals, we now allocate Blood Services to a nonlabor cost category. We note that, although there are revisions of the labor and nonlabor portions, due to both weight changes and the Blood Services category change, the labor-related portions of the rates published in Table 4 have remained essentially the same. The [[Page 27463]] labor-related portion has decreased by 0.146 percentage points. Table 4.--Labor-Related Share ------------------------------------------------------------------------ Cost category Weight ------------------------------------------------------------------------ Wages and Salaries............................................ 50.244 Employee Benefits............................................. 11.146 Professional Fees............................................. 2.127 Business Services............................................. 3.823 Computer Services............................................. 1.927 Postal Services............................................... 0.272 All Other Labor Intensive..................................... 1.707 --------- Total Labor-Related....................................... 71.246 --------- Total Nonlabor Related.................................... 28.754 ------------------------------------------------------------------------ 3. Selection of Price Proxies After computing the 1992 cost weights for the rebased hospital market basket, it is necessary to select appropriate wage and price proxies to monitor the rate of increase for each expenditure category. Most of the indicators are based on Bureau of Labor Statistics (BLS) data and are grouped into one of the following BLS categories: Producer Price Indexes--Producer Price Indexes (PPIs) measure price changes for goods sold in other than retail markets. For example, we used the PPI for ethical drugs, rather than the Consumer Price Index (CPI) for prescription drugs. PPIs are preferable price proxies for goods that hospitals purchase as inputs in producing their outputs. The PPIs we used measure price change at the final stage of production. Consumer Price Indexes--Consumer Price Indexes (CPIs) measure change in the prices of final goods and services bought by the typical consumer. Because they may not represent the price faced by the producer, the consumer price indexes were used if no appropriate PPI was available, or if the expenditure was more similar to that of retail consumers in general rather than a purchase at the wholesale level. For example, the CPI for food purchased away from home was used as a proxy for contracted food services. Employment Cost Indexes--Employment Cost Indexes (ECIs) measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. They are not affected by shifts in employment mix. Average Hourly Earnings--Average Hourly Earnings (AHEs) measure the rate of change of hourly earnings for various occupations within a given industry, and, therefore, reflect a weighted occupational mix within a particular industry. The AHE series is calculated by dividing gross payrolls by total hours and measures actual earnings rather than pure wage rates. It is a current-weight series rather than a fixed-weight index and thus reflects shifts in employment mix. An AHE rather than an ECI is used when there is no corresponding ECI category that is an appropriate measure of growth for a given labor category or when the ECI does not have sufficient length of history to be useful for our purpose. Our proposed price proxies for the rebased prospective payment hospital market basket are shown in Table 2 above and are summarized in Appendix C to this proposed rule. 4. The HCFA Blended Compensation Index Compensation includes the two largest categories of the rebased hospital market basket. Wages and salaries account for 50.244 percent and employee benefits account for 11.146 percent of the total weight in the prospective payment hospital market basket. The proposed HCFA Blended Compensation Index groups hospital occupations into nine broad categories. For eight of those occupational groups, we believe that hospitals compete for labor generally with employers outside the health care sector. Accordingly, we use economy- wide employment cost indexes (ECI) as price proxies for these eight occupational groups. In the case of compensation for nurses, as well as for certain other health care technicians and professionals, the hospital labor market may be predominant. However, hospitals do compete with other industries to obtain certain skilled professional and technical staff (for example, computer programmers). Therefore, for professional and technical workers, we believe a price proxy that reflects an equal blend of internal and external compensation variables is appropriate. Similar to the methodology used for the previous rebasing, the weights for the nine cost categories in the occupational blend index were derived from the 1992 Current Population Survey (CPS) produced by BLS. Using the CPS, private hospital workers were classified into the nine occupational categories. Private hospitals better reflect the mix of occupations used to produce acute care services for the prospective payment hospital input price index. Government hospitals were excluded because their occupational mix reflects the subset of nonacute care hospitals. Once private hospital workers were sorted by occupation into one of the nine occupational groups, weights were estimated using the share of wages and salaries for each of the nine occupations. These shares formed the basis of the weights that were used for the market basket of occupational categories. An additional adjustment was made for contract labor costs. Rather than treat contract labor as a distinct noncompensation cost category, it was integrated into the occupational blend as a component of hospitals' compensation costs for purposes of the market basket index. Thus, contract labor is treated the same as other labor expenses. Contract labor was allocated to the professional and technical and service occupation categories. After adjusting the professional and technical and service workers' shares to account for contract labor, the weights for the nine occupational blend categories were renormalized to equal 100.00 percent. The weights and proxies for the nine cost categories of the HCFA Blended Wages and Salaries Index are shown in Table 5. Table 5.--HCFA Blended Wages and Salaries Index (Wages and Salaries Component of the 1992-Based Market Basket) ---------------------------------------------------------------------------------------------------------------- Cost category Weight Price proxy ---------------------------------------------------------------------------------------------------------------- Professional and Technical.............................................. 65.729 Equal blend of ECI for wages and salaries of civilian hospital workers and ECI for wages and salaries of professional, specialty and technical workers. Managers and Administrators............................................. 9.554 ECI for wages and salaries for executive, administrative and managerial workers. Sales................................................................... 0.402 ECI for wages and salaries for sales workers. Clerical Workers........................................................ 12.379 ECI for wages and salaries for administrative support including clerical workers. Craft and Kindred....................................................... 1.689 ECI for wages and salaries for precision production, craft and repair workers. [[Page 27464]] Operatives Except Transport............................................. 0.437 ECI for wages and salaries for machine operators, assemblers and inspectors. Transport Equipment Operatives.......................................... 0.122 ECI for wages and salaries for transportation and material moving workers. Nonfarm Laborers........................................................ 0.084 ECI for wages and salaries for handlers, equipment cleaners, helpers and laborers. Service Workers......................................................... 9.606 ECI for wages and salaries for service occupations. --------------------------------------- Total Wages and Salaries................................................ 100.000 Total Weight for Wages and Salaries is 50.2. ---------------------------------------------------------------------------------------------------------------- Note: Due to rounding, weights may not sum to total. 5. Separate Market Basket for Hospitals and Hospital Units Excluded From the Prospective Payment System In its March 1, 1990 report, ProPAC recommended that we establish a separate market basket for hospitals and hospital units excluded from the prospective payment system. Effective with FY 1991, HCFA adopted ProPAC's recommendation to implement separate market baskets. (See the September 4, 1990 final rule (55 FR 36044).) Prospective payment and excluded hospitals tend to have different case mixes, practice patterns, and composition of inputs. The fact that these hospitals are not included under the prospective payment system in part reflects these differences. Studies completed by HCFA, ProPAC, and the hospital industry have documented different weights for excluded hospitals and prospective payment hospitals. Table 7 compares major weights in the rebased 1992 market basket for excluded hospitals with weights in the rebased 1992 market basket for prospective payment system hospitals. Wages and salaries are 52.152 percent of total operating costs for excluded hospitals compared to 50.244 percent for prospective payment hospitals. Employee benefits are 11.569 percent for excluded hospitals compared to 11.146 percent for prospective payment hospitals. As a result, compensation costs (wages and salaries plus employee benefits) for excluded hospitals are 63.721 percent of costs compared to 61.390 percent for prospective payment hospitals. Noncompensation costs are 36.279 percent for excluded hospitals and 38.610 of costs for prospective payment hospitals. Two significant differences in the category weights occur in Pharmaceuticals and Business Services. Pharmaceuticals represent 4.162 percent of costs for prospective payment hospitals and 3.070 percent for excluded hospitals. Business services represent 3.823 percent of costs for prospective payment hospitals and 2.337 percent for excluded hospitals. The weights for the excluded hospital market basket were derived using the same data sources and methods as for the prospective payment market basket (see Appendix C to this proposed rule). Differences in weights between the proposed excluded hospital and prospective payment hospital market baskets do not necessarily lead to significant differences in the rate of price growth for the two market baskets. If the individual wages and prices move at the approximately same annual rate, both market baskets may have about the same price growth even though weights may differ substantially because both market baskets use the same wages and prices. Also, offsetting price increases for various cost components can result in similar composite price growth in both market baskets. The wage and price proxies are the same for the excluded hospital and prospective payment hospital market baskets. As discussed in section IV.A.2 of this preamble, all of the cost expenditure weights for both the prospective payment and excluded hospital market baskets are subject to refinement if the U.S. Department of Commerce data are released in time to be analyzed and incorporated in the final market basket. The excluded hospital market basket is a composite set of weights for Medicare participating psychiatric, long-term care, rehabilitation, and children's hospitals. We are proposing to use cost report data for excluded hospitals and units whose Medicare average length of stay is within 15 percent (that is, 15 percent higher or lower) of the total facility average length of stay. This is a change from the 1987-based market basket, for which data for all excluded hospitals and units were used. We believe that limiting our sample to hospitals with a Medicare average length of stay within 15 percent of the total facility average length of stay provides a more accurate reflection of the structure of costs for Medicare. We note that the proposed forecast for FY 1997 would be the same even if we had included all excluded hospitals in the calculation of weights. The forecast for both the limited and full set of excluded hospitals yields a rate of change for FY 1997 of 2.7 percent. Table 6.--Comparison of Significant Weights for 1992-Based Excluded Hospital and Prospective Payment Hospital Market Baskets ------------------------------------------------------------------------ Prospective Category Excluded payment hospitals hospitals ------------------------------------------------------------------------ Wages and Salaries............................ 52.152 50.244 Employee Benefits............................. 11.569 11.146 Professional Fees............................. 2.098 2.127 Pharmaceuticals............................... 3.070 4.162 All Other..................................... 31.111 32.321 ------------------------- Total..................................... 100.000 100.000 ------------------------------------------------------------------------ [[Page 27465]] Table 7.--Proposed 1992-Based Excluded Hospital Operating Cost Categories, Weights, and Price Proxies ---------------------------------------------------------------------------------------------------------------- Rebased 1992 excluded Expense categories hospital Price proxy market basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation............................................................ 63.721 A. Wages and Salaries.................................................. 52.152 HCFA Occupational Wage Index. B. Employee Benefits................................................... 11.569 HCFA Occupational Benefits Index. 2. Professional Fees....................................................... 2.098 ECI--Compensation for Professional, Specialty & Technical. 3. Utilities............................................................... 2.557 A. Fuel, Oil, and Gasoline............................................. 0.357 PPI Refined Petroleum Products. B. Electricity......................................................... 1.396 PPI Commercial Electric Power. C. Natural Gas......................................................... 0.694 PPI Commercial Natural Gas. D. Water and Sewerage.................................................. 0.110 CPI-U Water & Sewerage Maintenance. 4. Professional Liability Insurance........................................ 1.081 HCFA Professional Liability Insurance Premiums Index. 5. All Other............................................................... 30.543 A. All Other Products.................................................. 23.642 (1.) Pharmaceuticals............................................... 3.070 PPI Ethical (Prescription) Drugs. (2.) Food.......................................................... 3.581 a. Direct Purchase............................................. 2.446 PPI Processed Foods & Feeds. b. Contract Service............................................ 1.135 CPI-U Food Away From Home. (3.) Chemicals..................................................... 3.929 PPI Industrial Chemicals. (4.) Medical Instruments........................................... 3.238 PPI Medical Instruments & Equipment. (5.) Photographic Supplies......................................... 0.413 PPI Photographic Supplies. (6.) Rubber and Plastics........................................... 5.039 PPI Rubber & Plastic Products. (7.) Paper Products................................................ 2.134 PPI Converted Paper & Paperboard Products. (8.) Apparel....................................................... 0.906 PPI Apparel. (9.) Machinery and Equipment....................................... 0.218 PPI Machinery & Equipment. (10.) Miscellaneous Products....................................... 1.112 PPI Finished Goods. B. All Other Services.................................................. 6.901 (1.) Business Services............................................. 2.337 ECI--Compensation for Private Workers in Business Services. (2.) Computer Services............................................. 1.415 AHE Computer & Data Processing Services. (3.) Transportation Services....................................... 0.195 CPI-U Transportation. (4.) Telephone Services............................................ 0.549 CPI-U Telephone Services. (5.) Postage....................................................... 0.282 CPI-U Postage. (6.) All Other: Labor Intensive.................................... 1.767 ECI--Compensation for Private Service Occupations. (7.) All Other: Nonlabor Intensive................................. 0.356 CPI-U All Items. ----------- Total.......................................................... 100.000 ---------------------------------------------------------------------------------------------------------------- Note: Due to rounding, weights may not sum to total. Table 8, below, shows what the excluded hospital weights would be if cost data for all excluded hospitals had been used. Table 8.--1992 excluded hospital operating cost categories, weights, and proxies using data from all excluded hospitals ---------------------------------------------------------------------------------------------------------------- Rebased 1992 excluded Expense categories hospital Price proxy market basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation........................... 68.074 .................................................... A. Wages and Salaries................. 55.714 HCFA Occupational Wage Index. B. Employee Benefits.................. 12.360 HCFA Occupational Benefits Index. 2. Professional Fees...................... 2.073 ECI--Compensation for Professional, Specialty & Technical. 3. Utilities.............................. 2.191 .................................................... A. Fuel, Oil, and Gasoline............ 0.306 PPI Refined Petroleum Products. B. Electricity........................ 1.196 PPI Commercial Electric Power. C. Natural Gas........................ 0.595 PPI Commercial Natural Gas. D. Water and Sewerage................. 0.094 CPI-U Water & Sewerage Maintenance. 4. Professional Liability Insurance....... 1.081 HCFA Professional Liability Insurance Premiums Index. 5. All Other.............................. 26.582 .................................................... A. All Other Products................. 20.333 .................................................... (1.) Pharmaceuticals.............. 2.704 PPI Ethical (Prescription) Drugs. (2.) Food......................... 3.069 .................................................... a. Direct Purchase............ 2.096 PPI Processed Foods & Feeds. b. Contract Service........... 0.973 CPI-U Food Away From Home. (3.) Chemicals.................... 3.367 PPI Industrial Chemicals. (4.) Medical Instruments.......... 2.775 PPI Medical Instruments & Equipment. [[Page 27466]] (5.) Photographic Supplies........ 0.354 PPI Photographic Supplies. (6.) Rubber and Plastics.......... 4.319 PPI Rubber & Plastic Products. (7.) Paper Products............... 1.829 PPI Converted Paper & Paperboard Products. (8.) Apparel...................... 0.777 PPI Apparel. (9.) Machinery and Equipment...... 0.187 PPI Machinery & Equipment. (10.) Miscellaneous Products...... 0.953 PPI Finished Goods. B. All Other Services................. 6.248 .................................................... (1.) Business Services............ 2.337 ECI--Compensation for Private Workers in Business Services. (2.) Computer Services............ 1.213 AHE Computer & Data Processing Services. (3.) Transportation Services...... 0.167 CPI-U Transportation. (4.) Telephone Services........... 0.471 CPI-U Telephone Services. (5.) Postage...................... 0.242 CPI-U Postage. (6.) All Other: Labor Intensive... 1.514 ECI--Compensation for Private Service Occupations. (7.) All Other: Nonlabor Intensive 0.305 CPI-U All Items. --------------------------------------------------------------------- Total......................... 100.000 ---------------------------------------------------------------------------------------------------------------- The relatively small differences in weights between the proposed excluded hospital market basket data from excluded hospitals that have a Medicare length of stay within 15 percent of the total facility average length of stay and the excluded hospital market basket using data from all excluded hospitals do not lead to significant changes in the rate of price growth for these two market baskets. If all individual wages and prices move at about the same annual rate, both market baskets could have about the same price growth even if weights are somewhat different. Also, offsetting price increases for various costs components can result in the price growth being the same. To examine the sensitivity of the change to the limited set of excluded hospitals, we developed a comparison for the period 1988-1998. Using historical data and forecasts for the market baskets, we compared limited and full sets of excluded hospitals. Table 9.--A Comparison of the Proposed Excluded Hospital Market Basket and the Excluded Hospital Market Basket Rebased Using All Excluded Hospitals, Percent Change, 1988-1998 ------------------------------------------------------------------------ Proposed excluded (+/- Excluded 15%) hospital market Federal fiscal year hospital basket using Difference market all excluded basket--1992 hospitals--1992 base base ------------------------------------------------------------------------ Historical: 1988....................... 4.8 4.8 0.0 1989....................... 5.5 5.5 0.0 1990....................... 4.5 4.6 (0.1) 1991....................... 4.3 4.4 (0.1) 1992....................... 3.1 3.2 (0.1) 1993....................... 3.1 3.2 (0.1) 1994....................... 2.6 2.7 (0.1) 1995....................... 3.3 3.2 0.1 Forecasted: 1996....................... 2.6 2.6 0.0 1997....................... 2.7 2.7 0.0 1998....................... 2.9 2.9 0.0 Historical average: 1988-1995.................. 3.9 4.0 (0.1) Forecasted average: 1996-1998.................. 2.7 2.7 0.0 ------------------------------------------------------------------------ Note that the historical average rate of growth for 1988-1995 for the proposed excluded hospital market basket including only excluded hospitals with Medicare average length of stay within 15 percent of total facility average length of stay is virtually identical to that for the excluded hospital market basket with all excluded hospitals. The rates of growth using the two methodologies are identical for FY 1996, 1997, and 1998. B. Capital Costs Rebasing the Capital Input Price Index 1. Background Effective for cost reporting periods beginning on or after October 1, 1995, the Capital Input Price Index (CIPI) is used to determine the price increase associated with prospective payment hospital capital- related expenses. Capital-related expenses are defined as depreciation expenses, capital-related interest expenses, and other capital-related expenses, such as insurance and taxes. The CIPI measures the input price change of these capital-related expenses, and is included in the capital prospective payment update framework to determine a rate of increase in capital prospective payments. Like the prospective payment hospital operating input price index, the CIPI is a fixed-weight price index. A fixed-weight price index measures how much it would cost at a later date to purchase the same mix of goods and services purchased in the base period. For the prospective payment hospital operating and capital input price indexes, the base period is selected and cost category weights are determined using available data on hospitals. Next, appropriate price proxy indexes are chosen for each cost category. Then a price proxy index level for each expenditure category is multiplied by the comparable cost category weight. The sum of these products (that is, weights multiplied by price proxy index levels) for all cost categories yields the composite index level of the market basket for a given [[Page 27467]] year. Repeating the step for other years produces a time series of composite market basket index levels. Dividing an index level by a later index level produces a rate of growth in the input price index. Since the percent change is computed for the fixed mix of total capital inputs with a 1992 base, the index is called fixed-weight. Like the operating input price index, the CIPI measures the price changes associated with costs during a given year. In order to do so, the CIPI must differ from the operating input price index in one important aspect. The CIPI must reflect the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted- average of past capital purchase prices up to and including the current year. Using Medicare cost reports, AHA data, and Securities Data Corporation data, a vintage-weighted price index was developed to measure price increases associated with capital expenses. The most recent discussion on the CIPI and methodological background was published in the September 1, 1995 final rule (60 FR 45817). The following Federal Register documents describe development and revisions of the methodology involved with the construction of the CIPI: September 1, 1992 (57 FR 40016), May 26, 1993 (58 FR 30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), and September 1, 1995 (60 FR 45815). We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. Currently, both the operating input price index and the CIPI are based to FY 1987. We are proposing that the base year cost structure be updated to FY 1992, the most recent year with relatively complete data for purposes of rebasing. We explain the process of rebasing the cost structure weights for the CIPI below. 2. Rebasing the Capital Input Price Index We are proposing to use a rebased capital input price index (CIPI) in developing the FY 1997 capital update factor for capital prospective payment rates. The new CIPI would be rebased to reflect the 1992, rather than the 1987, structure of capital costs. In developing the rebased CIPI, we reviewed hospital capital expenditure data for capital cost categories (depreciation, interest, and other). Two sets of weights had to be developed in order to compute the rebased CIPI: (1) cost category weights which identify the proportion of total hospital capital expenditures attributable to each capital expenditure category, and (2) relative vintage weights for depreciation and interest which identify the proportion of capital expenditures within a cost category that are attributable to each year over the life of capital assets in that category. Because capital expense data in the Medicare Cost Reports is not available prior to 1980 for use in computing vintage weights, the two sets of weights are measured using the best data sources available as explained below and in Appendix C to this proposed rule. The computations involved with rebasing the CIPI are explained for each of these sets of weights. a. Capital Cost Category Weights. The capital cost category weights in Table 1 below were computed using a combination of the FY 1992 Medicare Cost Reports and 1992 AHA Annual Survey data. Fiscal Year 1992 marked the first year for expanded capital data available in the Medicare Cost Reports. After reviewing the data, we determined that much of the data had been reclassified into different expense categories. Therefore, we removed reports that appeared to have reclassified data, and matched the remaining reports to the corresponding reports in the AHA Annual Survey data set. These remaining 2724 reports were used to compute capital cost category weights and the expected life of capital, which is used in determining vintage weights for depreciation and interest. In reviewing the data, we determined that the Medicare Cost Reports provided accurate data for depreciation and other capital expenses, but had reclassified interest data. We determined that AHA Annual Survey data more accurately reflected interest expense, based on past trends in interest rates. Therefore, we used the AHA Annual Survey interest levels along with the Medicare Cost Report levels for depreciation and other capital expenses to develop a more robust capital cost data base. After removing depreciation, interest, and other capital expenses from total capital expenses, the remainder constitutes lease expenses. Lease expenses are not a separate cost category in the CIPI. They are distributed to the other cost categories (depreciation, interest, other), reflecting an assumption that the underlying cost structure of leases is similar to capital costs in general. We assigned 10 percent of lease expenses to the other capital expenses cost category as overhead, and the remaining lease expenses were distributed to the three cost categories based on the weights of depreciation, interest, and other capital expenses not including lease expenses. (We base this assignment of 10 percent of lease expenses to overhead on the common assumption that overhead is 10 percent of costs.) We also used the 1992 Medicare Cost Reports to determine weights for the building and fixed equipment category and the movable equipment category. Expenses for building and fixed equipment and for movable equipment were determined using the same sample of reports as was used to compute the major cost category weights. The split between building and fixed equipment and movable equipment was also used to compute the vintage weights described below. Table 10 presents a comparison of the rebased 1992 capital cost weights and the 1987 capital cost weights. We only used those hospital reports which we considered to have capital data that was not reclassified. Because we did not use all hospital reports, we were concerned that the hospitals used may not be representative of the universe. Therefore, we compared the distribution of costs for the hospitals used with the data re-weighted to reflect the characteristics of the total universe of hospitals. From this analysis we validated that the cost weights derived from the subset we used were representative of the cost weights for the entire universe of hospitals. [[Page 27468]] Table 10--Comparison of 1987 and 1992 Cost Category Weights ---------------------------------------------------------------------------------------------------------------- Rebased Expense categories FY1987 FY1992 Price proxy ---------------------------------------------------------------------------------------------------------------- Total......................................... 1.0000 1.0000 ...................................... Total depreciation............................ .6510 .6484 ...................................... 1. Building and fixed equipment .3054 .3009 Boeckh Institutional Construction depreciation. Index--vintage weighted (22 yrs) 2. Movable equipment depreciation......... .3456 .3475 PPI for Machinery and Equipment-- vintage weighted (10 yrs) Total interest................................ .3274 .3184 1. Government/Non Profit Interest......... .2783 .2706 Average Yield on Domestic Municipal Bonds (Bond Buyer 20 bonds)--vintage weighted (22 yrs) 2. For-Profit Interest.................... .0491 .0478 Average Yield on Moody's AAA Bonds-- vintage weighted (22 yrs) Other......................................... .0216 .0332 CPI (U) for Residential Rent ---------------------------------------------------------------------------------------------------------------- Source: 1992 Medicare Cost Reports, PPS year 9; 1992 AHA Annual Survey. Note: Due to rounding, weights may not sum to totals. We had planned to incorporate the 1992 data from the Department of Commerce for developing capital cost category weights. However, these data were not available when we developed this proposed rule. If the data become available in time to for us to analyze it, we plan to incorporate it as a data input for the final rule. b. Relative Vintage Weights for Prices. As we have explained in previous Federal Register documents (September 1, 1995, 60 FR 45817), the CIPI was developed to capture the vintage nature of capital; that is, because capital is acquired and consumed over time, the capital expenses in any given year are determined by past and current purchases of physical and financial capital. Therefore, a vintage-weighted CIPI was developed which used vintage weights for depreciation (physical capital) and interest (financial capital) to capture the long-term consumption of capital. These vintage weights reflect the purchase patterns of building and fixed equipment and movable equipment over time. Because depreciation and interest expenses are determined by the amount of past and current capital purchases, we use the vintage weights to compute vintage-weighted price changes associated with depreciation and interest expense, which is the purpose of the CIPI. To compute the vintage weights for depreciation and interest expenses, we used a time series of capital purchases for building and fixed equipment and movable equipment. We found no single source that provides the best time series of capital purchases by hospitals for all of the above components of capital purchases. The Medicare Cost Reports did not have sufficient capital data to meet this need. The AHA Panel Survey provides a consistent database back to 1963. While the AHA Panel Survey data does not provide annual capital purchases, it does provide a time series of depreciation and interest expenses, which can be used to infer capital purchases over time. The process of using the AHA data to estimate a time series of capital purchases, and eventually vintage weights, is explained in detail below. In order to estimate capital purchases from AHA data on depreciation and interest expenses, the expected life for building and fixed equipment, for movable equipment, and for debt instruments is needed. The expected life is used in the calculation of vintage weights for building and fixed equipment, movable equipment, and debt instruments as we explain below. We used the same sample of hospitals from FY 1992 Medicare Cost Reports and the 1992 AHA Annual Survey explained above in computing cost category weights to compute the expected life of building and fixed equipment and movable equipment. (The AHA Panel Survey is a monthly survey of a sample of hospitals, while the AHA Annual Survey is a more detailed survey of all hospitals.) The expected life of any piece of equipment can be determined by dividing the historical asset cost (excluding fully depreciated assets) by the current year depreciation amount. This calculation yields the estimated useful life of an asset if depreciation continued at current year levels, assuming straight-line depreciation, which is the only depreciation method allowed under Medicare. From the FY 1992 costs reports, the expected life of building and fixed equipment was determined to be 22 years, and the expected life of movable equipment was determined to be 10 years. By comparison, the expected life using FY 1987 data was 25 years for building and fixed equipment and 10 years for movable equipment. It was also necessary to compute the expected life of debt instruments held by hospitals. As in prior exercises, we used hospital issuances of municipal and commercial bonds from Securities Data Corporation to determine the expected life of hospital debt instruments, which is used in the estimation of vintage weights for interest expense. This data source produced a weighted average life for the two types of bonds of 22 years for FY 1992, the same expected life as was computed for the 1987-based CIPI. An annual series of total expenses and depreciation expenses was obtained from the AHA Panel Survey. For the calculation of vintage weights, this expense data was needed back to 1963. However, the depreciation expense data in the AHA Panel survey was available only back to 1976. We noticed an increasing trend in depreciation expenses as a percentage of total expenses. We performed a regression on this percentage, and used the regression equation to estimate depreciation expenses back to 1963. We then used the fixed and movable weights derived from the FY 1992 Medicare Cost Reports to partition the AHA Panel Survey depreciation expenses into annual amounts of building and fixed depreciation and movable depreciation. Multiplying the annual depreciation amounts by the expected life calculations from the FY 1992 Medicare cost reports, year-end asset costs for building and fixed equipment and movable equipment were determined. Then by subtracting the previous year asset costs from the current year asset costs, annual purchases of building and fixed equipment and movable equipment were estimated back to 1963. This capital purchase time series is then used to compute the vintage weights for building and fixed equipment, movable equipment, and debt instruments. Each of these sets of vintage weights is explained in detail below. For building and fixed equipment vintage weights, the real annual capital purchase amounts for building and fixed equipment derived from the AHA Panel Survey were used. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of the effect of price inflation. This real annual purchase amount for building and fixed equipment was produced by deflating [[Page 27469]] the nominal annual purchase amount by the building and fixed equipment price proxy, the Boeckh institutional construction index. Because building and fixed equipment has an expected life of 22 years, the vintage weights for building and fixed equipment were deemed to represent the average purchase pattern of building and fixed equipment over 22-year periods. With real building and fixed equipment purchase estimates available back to 1963, nine 22-year periods could be averaged to determine the average vintage weights for building and fixed equipment. Averaging different periods produces vintage weights that are representative of average building and fixed equipment purchase patterns over time. Vintage weights for each 22-year period are calculated by dividing the real building and fixed capital purchase amount in any given year by the total amount of purchases in the 22- year period. For example, for the 22-year period of 1964-1985, the vintage weight for year 1 is calculated by dividing the real annual capital purchase amount of building and fixed equipment in 1964 into the total amount of real annual capital purchases of building and fixed equipment over the entire 1964-1985 period. This calculation is done for each year in the 22-year period, and for each of the nine 22-year periods. An average is taken of the nine 22-year periods to determine the FY 1992 average building and fixed equipment vintage weights, presented in Table 11 with the FY 1987 vintage weights. For movable equipment vintage weights, the real annual capital purchase amounts for movable equipment derived from the AHA Panel Survey were used. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of price inflation. This real annual purchase amount for movable equipment was produced by deflating the nominal annual purchase amount by the movable equipment price proxy, the Producer Price Index for machinery and equipment. Because movable equipment has an expected life of 10 years, the vintage weights for movable equipment were deemed to represent the average purchase pattern of movable equipment over 10-year periods. With real movable equipment purchase estimates available back to 1963, 21 10-year periods could be averaged to determine the average vintage weights for movable equipment. Averaging different periods produces vintage weights which are representative of average movable equipment purchase patterns over time. Vintage weights for each 10-year period are calculated by dividing the real movable capital purchase amount for any given year by the total amount of purchases in the 10-year period. For example, for the 10-year period of 1976-1985, the vintage weight for year 1 is calculated by dividing the real annual capital purchase amount of movable equipment in 1976 into the total amount of real annual capital purchases of movable equipment over the entire 1976-1985 period. This calculation is done for each year in the 10-year period, and for each of the 21 10-year periods. The average of the 21 10-year periods is used to determine the FY 1992 average movable equipment vintage weights, presented in Table 11 with the FY 1987 vintage weights. For interest vintage weights, the nominal annual capital purchase amounts for total equipment (building and fixed, and movable) derived from the AHA Panel Survey were used. Nominal annual purchase amounts were used to capture the value of the debt instrument. Because debt instruments have an expected life of 22 years, the vintage weights for interest were deemed to represent the average purchase pattern of total equipment over 22-year periods. With nominal total equipment purchase estimates available back to 1963, nine 22-year periods could be averaged to determine the average vintage weights for interest. Averaging different periods produces vintage weights which are representative of average capital purchase patterns over time. Vintage weights for each 22-year period are calculated by dividing the nominal total capital purchase amount for any given year by the total amount of purchases in the 22-year period. For example, for the 22-year period of 1964-1985, the vintage weight for year 1 is calculated by dividing the nominal annual capital purchase amount of total equipment in 1964 into the total amount of nominal annual capital purchases of total equipment over the entire 1964-1985 period. This calculation is done for each year in the 22-year period, and for each of the nine 22-year periods. The average of the nine 22-year periods is used to determine the FY 1992 average interest vintage weights, presented in Table 11 with the FY 1987 weights. Table 11.--Vintage Weights for Capital-Related Price Proxies ---------------------------------------------------------------------------------------------------------------- Building and fixed Movable equipment Interest equipment --------------------------------------------------- -------------------------- Year Rebased FY1987 10 Rebased FY1987 22 Rebased FY1987 25 FY1992 22 yrs FY1992 10 yrs FY1992 22 yrs yrs yrs yrs ---------------------------------------------------------------------------------------------------------------- 1................................. .015 .019 .064 .069 .007 .007 2................................. .019 .020 .072 .075 .009 .008 3................................. .022 .023 .077 .083 .010 .010 4................................. .024 .026 .085 .091 .011 .012 5................................. .023 .028 .095 .097 .013 .014 6................................. .022 .030 .101 .103 .015 .016 7................................. .020 .031 .109 .109 .017 .018 8................................. .021 .032 .122 .115 .020 .021 9................................. .025 .036 .132 .124 .023 .024 10................................ .030 .039 .142 .133 .027 .029 11................................ .033 .043 ........... ........... .032 .035 12................................ .034 .047 ........... ........... .038 .041 13................................ .034 .050 ........... ........... .043 .047 14................................ .035 .052 ........... ........... .050 .052 15................................ .038 .055 ........... ........... .057 .059 16................................ .043 .059 ........... ........... .064 .067 17................................ .049 .062 ........... ........... .074 .074 18................................ .053 .065 ........... ........... .083 .081 19................................ .056 .067 ........... ........... .090 .088 [[Page 27470]] 20................................ .057 .069 ........... ........... .098 .093 21................................ .060 .072 ........... ........... .105 .099 22................................ .066 .073 ........... ........... .114 .103 23................................ .071 ........... ........... ........... ........... ........... 24................................ .075 ........... ........... ........... ........... ........... 25................................ .077 ........... ........... ........... ........... ........... ----------------------------------------------------------------------------- Total....................... 1.000 1.000 1.000 1.000 1.000 1.000 ---------------------------------------------------------------------------------------------------------------- Sources: AHA Panel Survey, 1963-1993; 1992 Medicare Cost Reports; Securities Data Corporation. 3. Selection of Price Proxies After the 1992 capital cost category weights were computed, it was necessary to select appropriate price proxies to monitor the rate of increase for each expenditure category. Our proposed price proxies for the FY 1992 based CIPI are the same as those for the FY 1987 based CIPI. The rationale for selecting the price proxies is explained in the June 2, 1995 proposed rule (60 FR 29227) and the September 1, 1995 final rule (60 FR 45817). The proposed price proxies are presented in Table 10. 4. Forecast of the CIPI for Federal Fiscal Year 1997 DRI forecasts a 1.0 percent increase in the rebased 1992 CIPI for FY 1997, as indicated in Table 12. This is the outcome of a 2.5 percent increase in projected depreciation prices (building and fixed equipment, and movable equipment) and a 2.3 percent increase in other capital expense prices in FY 1997, partially offset by a 3.0 percent decline in vintage-weighted interest rates in FY 1997. Table 12.--HCFA Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1979 to 2000 ---------------------------------------------------------------------------------------------------------------- Depreciation --------------------------------------- Fiscal Year Total Building Interest Other Total and fixed Movable equipment equipment ---------------------------------------------------------------------------------------------------------------- Weights (FY92).................... 1.0000 0.6484 0.3009 0.3475 0.3184 0.0332 ---------------------------------------------------------------------------------------------------------------- Price Changes ---------------------------------------------------------------------------------------------------------------- 1979.............................. 5.4 7.4 7.0 7.7 2.7 7.1 1980.............................. 6.9 8.0 7.3 8.5 5.4 8.6 1981.............................. 8.7 8.5 7.7 9.1 9.1 8.8 1982.............................. 9.2 8.5 8.0 9.0 10.2 8.0 1983.............................. 6.7 8.1 7.9 8.2 4.8 6.3 1984.............................. 6.3 7.3 7.6 7.1 4.9 5.0 1985.............................. 5.2 6.3 7.0 5.8 3.5 5.9 1986.............................. 3.7 5.7 6.4 5.1 0.7 6.2 1987.............................. 3.1 5.1 5.9 4.5 -0.1 4.5 1988.............................. 3.0 4.6 5.4 4.0 0.3 3.8 1989.............................. 2.6 4.4 5.2 3.7 -0.5 3.8 1990.............................. 2.3 4.0 4.9 3.2 -0.7 4.2 1991.............................. 2.0 3.6 4.6 2.7 -1.1 3.9 1992.............................. 1.5 3.2 4.4 2.1 -2.0 2.6 1993.............................. 1.1 2.9 4.1 1.8 -2.8 2.4 1994.............................. 1.1 2.7 3.9 1.7 -2.7 2.3 1995.............................. 1.3 2.6 3.8 1.6 -2.0 2.5 1996.............................. 0.9 2.5 3.7 1.5 -3.1 2.4 1997.............................. 1.0 2.5 3.5 1.5 -3.0 2.3 1998.............................. 1.0 2.5 3.4 1.5 -3.1 3.0 1999.............................. 1.0 2.4 3.4 1.5 -3.1 2.4 2000.............................. 1.1 2.4 3.4 1.5 -3.2 2.8 ---------------------------------------------------------------------------------------------------------------- Source: DRI/McGraw-Hill HCC, 1st Qtr 1996; @USSIM/TREND25YR0296 @CISSIM/CONTROL961. Released By: HCFA, OACT, Office of National Health Statistics. [[Page 27471]] 5. Comparison of Percent Changes in the FY 1992 Based CIPI and the FY 1987 Based CIPI Rebasing the CIPI from 1987 to 1992 decreased the percent change in the FY 1997 forecast by only 0.2 percentage points, from 1.2 to 1.0 as indicated in Table 4. The effect of rebasing is analyzed by comparing the 1992-based CIPI forecasted percent changes to the 1987-based CIPI forecasted percent changes using the same DRI forecast of component prices. As shown in Table 13, there is only a 0.2 percentage point difference between the percent changes in the 1992-based CIPI and the 1987-based CIPI using the first quarter 1996 forecast. The difference is caused by changes to: (1) cost category weights, (2) expected life, and (3) vintage weights. The changes to cost category weights coupled with the wide disparity in price changes between the different cost categories contributed to lowering the CIPI percent change in the FY 1997 forecast. This was the case with fixed depreciation, which has faster price growth than the other cost categories and now has a lower weight by nearly one-half of a percentage point because of rebasing to 1992. Also contributing to the 0.2 percentage point difference in FY 1997 forecast is the change in the expected life of building and fixed equipment and the change in the vintage weights for all three components: building and fixed equipment, movable equipment, and interest. The shorter expected life (22 years in 1992 versus 25 years in 1987) of building and fixed equipment slightly decreased the FY 1997 forecast CIPI percent change because years with higher price increases were not included as they had been before. The change in vintage weights also tended to decrease the FY 1997 CIPI percent change because vintage weights in all cases changed to be spread more evenly over the life of the asset, decreasing the weight of more recent years and increasing the weight of past years. In the years around FY 1997, prices for depreciation and interest are projected to increase slightly faster than prices in earlier years. Table 13.--Comparison of 1987 and 1992 Based Capital Input Price Index Using the Same DRI Forecast, Percent Change, 1979-1997 ------------------------------------------------------------------------ CIPI ------------------- Federal fiscal year Rebased 1987 1992 ------------------------------------------------------------------------ 1979................................................ 5.6 5.4 1980................................................ 7.1 6.9 1981................................................ 8.8 8.7 1982................................................ 9.3 9.2 1983................................................ 6.7 6.7 1984................................................ 6.3 6.3 1985................................................ 5.1 5.2 1986................................................ 3.7 3.7 1987................................................ 3.1 3.1 1988................................................ 3.0 3.0 1989................................................ 2.7 2.6 1990................................................ 2.4 2.3 1991................................................ 2.1 2.0 1992................................................ 1.7 1.5 1993................................................ 1.3 1.1 1994................................................ 1.3 1.1 1995................................................ 1.5 1.3 1996................................................ 1.2 0.9 1997................................................ 1.2 1.0 ------------------------------------------------------------------------ Source: DRI/McGraw-Hill HCC, 1st Qtr 1996; @USSIM/TREND25YR0296 @CISSIM/ CONTROL961. Released by: HCFA, OACT, Office of National Health Statistics. 6. Comparison of Percent Changes in the FY 1997 CIPI Forecast in the September 1, 1995 Federal Register and the current FY 1997 CIPI Forecast The previously published CIPI forecast for FY 1997 of 1.7 percent has been revised to 1.0 percent in this proposed rule. As explained above in section IV.B.5, 0.2 percentage points of the decline was the result of rebasing the CIPI from 1987 to 1992. The remaining 0.5 percentage point difference in FY 1997 between the 1992-based CIPI and the 1987-based CIPI previously published is the result of revised projections by DRI. Since making a forecast in the second quarter of 1995 for the September 1, 1995 Federal Register, DRI has revised their projections of price changes downward for every cost category in the CIPI. This revised projection accounts for 0.5 of the 0.7 difference between the 1992-based CIPI percent changes and the 1987-based CIPI percent changes previously published. V. Other Decisions and Proposed Changes to the Prospective Payment System for Inpatient Operating Costs A. Sole Community Hospital Criteria (Sec. 412.92) Under the prospective payment system, special payment protections are provided to hospitals that, by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals, are the sole source of hospital inpatient services reasonably available to Medicare beneficiaries. The criteria a hospital must meet to be classified as a sole community hospital (SCH) as well as the special payment adjustments available are set forth in the regulations at Sec. 412.92. One of the ways in which a hospital can qualify for sole community status is to be located between 25 and 35 miles from other like hospitals and prove that no more than 25 percent of residents who become inpatients or no more than 25 percent of the Medicare beneficiaries who become inpatients in the hospital's ``service area'' are admitted to other like hospitals located within a 35-mile radius of the hospital (or its service area, if larger). In the rulemaking process for FY 1989, we addressed the criteria for qualification as a sole community hospital. ProPAC had recommended that we issue guidelines before the beginning of FY 1989 to promote greater uniformity in the criteria applied by regional offices to designate sole community hospitals. In the final rule published on September 30, 1988, we stated: ``A hospital may delineate its service area by identifying the zip codes of all its inpatients for the cost reporting period ending before the date it applies for SCH status. The lowest number of zip codes accounting for at least 75 percent of its inpatients would then constitute its service area.'' (53 FR 35810-11). In March 1990, we issued a revised manual which inadvertently reflected policy prior to October 1, 1988; specifically, section 2810 A.2.c of the Medicare Provider Reimbursement Manual, Part 1 (HCFA Pub. 15-1) stated, ``A hospital may define its service area as the lowest number of contiguous zip codes from which the hospital draws at least 75 percent of its inpatients.'' (Emphasis added.) This revision does not accurately reflect the definition of ``service area'' that we set forth in the FY 1989 final rule in response to ProPAC's recommendation that we address the criteria for SCH status. It has come to our attention that, accordingly, some hospitals have raised questions about the definition of service area. In this proposed rule, we are clarifying that, consistent with the language in the September 30, 1988 final rule, our definition of ``service area'' for purposes of determining SCH status does not require contiguous zip code areas. We have applied this definition since October 1, 1988 (the effective date of the September 30, 1988 final rule). The [[Page 27472]] current manual inadvertently reflects previous policy, and does not reflect our current policy as set forth in the Federal Register and applied since October 1, 1988. We intend to revise the current manual accordingly at our earliest opportunity. B. 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 received the benefit of payment based on the other urban rather than the rural standardized amount. As of that date, the other urban and rural standardized amounts are the same. However, rural referral centers 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 may be 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 follow 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 includes all urban hospitals nationwide, and the proposed regional values are 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). These values are based on discharges occurring during FY 1995 (October 1, 1994 through September 30, 1995) and include bills posted to HCFA's records through December 1995. Therefore, in addition to meeting other criteria, we are proposing that to qualify for initial rural referral center status or to meet the triennial review standards for cost reporting periods beginning on or after October 1, 1996, a hospital's case-mix index value for FY 1995 would have to be at least-- 1.3332; 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. The median case-mix values by region are set forth in the table below: ------------------------------------------------------------------------ Case-mix Region index value ------------------------------------------------------------------------ 1. New England (CT, ME, MA, NH, RI, VT)....................... 1.2292 2. Middle Atlantic (PA, NJ, NY)............................... 1.2224 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)........ 1.3375 4. East North Central (IL, IN, MI, OH, WI).................... 1.2450 5. East South Central (AL, KY, MS, TN)........................ 1.2911 6. West North Central (IA, KS, MN, MO, NE, ND, SD)............ 1.2178 7. West South Central (AR, LA, OK, TX)........................ 1.3080 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY).................. 1.3284 9. Pacific (AK, CA, HI, OR, WA)............................... 1.3333 ------------------------------------------------------------------------ The above numbers will be revised in the final rule to the extent required to reflect the updated MedPAR file, which will contain data from additional bills received for discharges through September 30, 1995. 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 1995 case-mix index value in Table 3C in section V of the Addendum to this proposed 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 are proposing to update the regional standards. The proposed regional standards are based on discharges for urban hospitals' cost reporting periods that began during FY 1994 (that is, October 1, 1993 through September 30, 1994). That is the latest year for which we have complete discharge data available. Therefore, in addition to meeting other criteria, we are proposing that to qualify for initial rural referral center status or to meet the triennial review standards for cost reporting periods beginning on or after October 1, 1996, the number of discharges a hospital must have for its cost reporting period that began during FY 1995 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, as indicated in the table below. ------------------------------------------------------------------------ Number of Region discharges. ------------------------------------------------------------------------ 1. New England (CT, ME, MA, NH, RI, VT).................... 6812 2. Middle Atlantic (PA, NJ, NY)............................ 9067 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 6972 4. East North Central (IL, IN, MI, OH, WI)................. 6958 5. East South Central (AL, KY, MS, TN)..................... 5007 6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 4216 7. West South Central (AR, LA, OK, TX)..................... 4002 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 6992 9. Pacific (AK, CA, HI, OR, WA)............................ 5669 ------------------------------------------------------------------------ We reiterate that, to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 1996, an osteopathic hospital's number of discharges for its cost reporting period that began during FY 1995 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 [[Page 27473]] 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. 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 1997 outlined above in this section of the preamble), it will retain its status for another 3 years. 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 1997, a hospital must meet the criteria in Sec. 412.96(c) for FY 1997 or it must meet the criteria for 2 of the last 3 years as follows: ---------------------------------------------------------------------------------------------------------------- Use the discharges for the hospital's Use numerical standards as For the cost reporting period Use hospital's case- cost reporting published in the Federal beginning during FY mix index for FY period beginning Register on during FY ---------------------------------------------------------------------------------------------------------------- 1996.............................. 1994................. 1994................ September 1, 1995. 1995.............................. 1993................. 1993................ September 1, 1994. 1994.............................. 1992................. 1992................ September 1, 1993. ---------------------------------------------------------------------------------------------------------------- Example: A hospital with a cost reporting period beginning July 1 qualified as a referral center effective July 1, 1994. The hospital has fewer than 275 beds. Its 3-year status as a referral center is protected through June 30, 1997 (the end of its cost reporting period beginning July 1, 1996). 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, 1994, July 1, 1995, and July 1, 1996. The hospital must meet the criteria in effect either for its cost reporting period beginning July 1, 1997, 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, 1995, the hospital's case-mix index value during FY 1993 must have equaled or exceeded the lower of the national or the appropriate regional standard as published in the September 1, 1994 final rule with comment period. The hospital's total number of discharges during its cost reporting year beginning July 1, 1993, must have equaled or exceeded 5,000 or the regional standard as published in the September 1, 1994 final rule with comment period. 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. C. Disproportionate Share Adjustment (Sec. 412.106) Section 1886(d)(5)(F) of the Act provides for additional payments for hospitals that serve a disproportionate share of low income patients. The disproportionate share adjustment, which was added to the prospective payment system by section 9105 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99-272), was intended to address the higher Medicare costs associated with treating a large number of low-income patients. Under this provision, patients who are eligible for Medicaid and Supplemental Security Income (SSI) benefits were used as a proxy measure of the proportion of low-income patients. A hospital's disproportionate share adjustment is determined by calculating the sum of two patient percentages (Medicare Part A/ Supplemental Security Income (SSI) covered days to total Medicare Part A covered days, and Medicaid but not Medicare Part A covered days to total inpatient hospital days). Based on the location and size of the hospital, a formula determines if the hospital's patient percentage qualifies the hospital for an adjustment and how much that adjustment will be. With respect to the Medicare-SSI calculation, hospitals have expressed dissatisfaction with these proxy measures, and have challenged HCFA's implementation of them in recent litigation. Since SSI beneficiary information is confidential, hospitals do not have access to lists of patients who are eligible for both Medicare Part A and SSI benefits. Hospitals are increasingly frustrated by their inability to monitor these data. With respect to the Medicaid fraction, hospitals have complained that, because of Medicaid coverage restrictions, Medicaid covered days may not be a consistent measure of indigent care across States. Medicaid reforms under consideration by the President and Congress may further interfere with the utility of Medicaid covered days as a measure of the proportion of low-income patients. Because of these concerns, we have been examining alternative measures of indigent care. Some of the measures we have explored using are estimates of patient income in a hospital's service area, hospital levels of bad debt, and proportion of emergency room admissions in a hospital. Because of data and other limitations, however, we have yet to find an alternative that appears promising as a replacement to [[Page 27474]] the present measure. We are, therefore, soliciting comments from the industry on better and more direct measures of indigent care than the present measure that relies on SSI and Medicaid data. Our preference would be to use data that are already available. We would, however, be open to considering measures that require new data collection if we were convinced that the result would be beneficial to hospitals and HCFA. We note that since HCFA is bound by the current statutory provisions, we cannot revise the disproportionate share adjustment without legislative action. We note that ProPAC is also concerned with these issues. In its March 1, 1996 report, ProPAC recommended that the structure of the disproportionate share adjustment be reviewed to make certain that available funds are distributed equitably among the hospitals most in need of assistance. (Recommendation 18.) The Commission believes that Medicaid utilization has never been an optimal measure of service to low-income patients and is also concerned with the impact of possible reform in the structure of Medicaid. Thus, ProPAC recommends that a comprehensive review of the disproportionate share adjustment be undertaken, including assessment of the objectives of this payment and defining the population and scope of care to be covered. Alternative measures of low-income patient care could then be considered, including any data collection necessary. As discussed above, we agree with ProPAC that new measures should be explored. We believe that this is a first step in reforming the payment formula for the disproportionate share adjustment. We also recognize that the development of a better measure of the services hospitals provide to indigent patients may require the collection of new data. In addition, ProPAC is concerned about the potential impact of reductions in the disproportionate share payments. (Recommendation 17.) The Commission believes that hospitals that treat a large number of the uninsured could be particularly vulnerable because of recent changes in the health care environment. ProPAC cautions against large reductions in disproportionate share payments that would threaten the continued ability of many hospitals to serve populations who depend on them for access to care. We note that the President's FY 1997 budget does not include any reduction in payment for disproportionate share hospitals. D. Direct Graduate Medical Education (Sec. 413.86) 1. Initial Residency Period Limitations We are updating the Initial Residency Period Limitations for direct graduate medical education (GME), originally published in the Federal Register on September 29, 1989 (54 FR 40286). The regulations in Sec. 413.86(g)(1) state that, ``[e]ffective July 1, 1995, an initial residency period is defined as the minimum number of years required for board eligibility.'' The update reflects the following: Effective July 1, 1995, section 1886(h)(5)(F) of the Act, as amended by Public Law 103-66, defines an initial residency period as the minimum number of years required for initial board eligibility. Previously, this period had been defined as minimum number of years ``plus one.'' The prior listing had included the additional year, not to exceed five years. Changes in curriculum requirements regarding the number of years needed for board eligibility for previously approved programs. Addition of newly approved graduate medical education programs. Initial Residency Period Limitations ------------------------------------------------------------------------ Initial Residency Residency type Period Limitation (No. of years) ------------------------------------------------------------------------ Allopathy ANESTHESIOLOGY.......................................... 4 Critical Care Medicine.............................. 4 Pain Management..................................... 4 COLON AND RECTAL SURGERY................................ 5 DERMATOLOGY............................................. 4 Dermatopathology.................................... 4 Clinical & Laboratory Dermatological Immunology..... 4 EMERGENCY MEDICINE...................................... 3/4 Sports Medicine..................................... 3 FAMILY PRACTICE......................................... 3 Geriatric Medicine.................................. 5 Sports Medicine..................................... 3 INTERNAL MEDICINE....................................... 3 Adolescent Medicine................................. 3 Cardiovascular Disease.............................. 3 Clinical Cardiac Electrophysiology.................. 3 Clinic & Laboratory Immunology...................... 3 Critical Care Medicine.............................. 3 Endocrinology, Diabetes, and Metabolism............. 3 Gastroenterology.................................... 3 Geriatric Medicine.................................. 5 Hematology.......................................... 3 Hematology and Oncology............................. 3 Infectious Disease.................................. 3 Medical Oncology.................................... 3 Nephrology.......................................... 3 Pulmonary Disease................................... 3 Pulmonary Disease and Critical Care Medicine........ 3 Rheumatology........................................ 3 Sports Medicine..................................... 3 MEDICAL GENETICS........................................ 4 [[Page 27475]] NEUROLOGICAL SURGERY.................................... 5 Pediatric Neurological Surgery...................... 5 NEUROLOGY............................................... 4 Child Neurology..................................... 4 Clinical Neurophysiology............................ 4 NUCLEAR MEDICINE........................................ 3 OBSTETRICS AND GYNECOLOGY............................... 4 Critical Care Medicine.............................. 4 Gynecological Oncology.............................. 4 Maternal and Fetal Medicine......................... 4 Reproductive Endocrinology.......................... 4 OPHTHALMOLOGY........................................... 4 ORTHOPAEDIC SURGERY..................................... 5 Adult Reconstructive Orthopaedics................... 5 Foot and Ankle Orthopaedics......................... 5 Hand Surgery........................................ 5 Musculoskeletal Oncology............................ 5 Pediatric Orthopaedics.............................. 5 Spinal Cord Injury.................................. 5 Sports Medicine..................................... 5 OTOLARYNGOLOGY.......................................... 5 Neurotology/Otolaryngology.......................... 5 Pediatric Otolaryngology............................ 5 PATHOLOGY, ANATOMIC AND CLINICAL........................ 4 Blood Banking/Transfusion Medicine.................. 4 Chemical Pathology.................................. 4 Cytopathology....................................... 4 Dermatopathology.................................... 4 Forensic Pathology.................................. 4 Hematology.......................................... 4 Immunopathology..................................... 4 Medical Microbiology................................ 4 Neuropathology...................................... 4 Pediatric Pathology................................. 4 PEDIATRICS.............................................. 3 Adolescent Medicine................................. 3 Clinical and Laboratory Immunology.................. 3 Neonatal-Perinatal Medicine......................... 3 Pediatric Cardiology................................ 3 Pediatric Critical Care Medicine.................... 3 Pediatric Emergency Medicine........................ 3 Pediatric Endocrinology............................. 3 Pediatric Gastroenterology.......................... 3 Pediatric Hematology/Oncology....................... 3 Pediatric Infectious Disease........................ 3 Pediatric Nephrology................................ 3 Pediatric Opthamology............................... 3 Pediatric Pulmonology............................... 3 Pediatric Rheumatology.............................. 3 Pediatric Sports Medicine........................... 3 PHYSICAL MEDICINE AND REHABILITATION.................... 4 PLASTIC SURGERY......................................... 5 Hand Surgery........................................ 5 PREVENTIVE MEDICINE..................................... 3 Aerospace Medicine.................................. 3 Medical Toxicology.................................. 3 Occupational Medicine............................... 3 Public Health & General Preventive Medicine......... 3 PSYCHIATRY.............................................. 4 Addiction Medicine.................................. 4 Child & Adolescent Psychiatry....................... 4 Forensic Psychiatry................................. 4 Geriatric Psychiatry................................ 4 RADIOLOGY, DIAGNOSTIC................................... 4 Neuroradiology...................................... 4 Nuclear Radiology................................... 4 Pediatric Radiology................................. 4 Vascular and Interventional Radiology............... 4 Radiation Oncology.................................. 4 [[Page 27476]] SURGERY, GENERAL........................................ 5 Critical Care Medicine.............................. 5 Hand Surgery........................................ 5 Pediatric Surgery................................... 5 Thoracic Surgery.................................... 5 Vascular Surgery.................................... 5 UROLOGY................................................. 5 Pediatric Urology................................... 5 Osteopathy ANESTHESIOLOGY.......................................... 4 Critical Care Medicine.............................. 4 DERMATOLOGY............................................. 4 Dermatopathology.................................... 4 MOHS Micrographic Surgery........................... 4 EMERGENCY MEDICINE...................................... 4 Sports Medicine..................................... 4 FAMILY PRACTICE......................................... 3 Adolescent and Young Adult Medicine................. 3 Geriatrics.......................................... 5 Sports Medicine..................................... 3 INTERNAL MEDICINE....................................... 4 Clinical Allergy and Immunology..................... 4 Cardiology.......................................... 4 Endocrinology....................................... 4 Gastroenterology.................................... 4 Hematology.......................................... 4 Infectious Diseases................................. 4 Nephrology.......................................... 4 Oncology............................................ 4 Pulmonary Diseases.................................. 4 Rheumatology........................................ 4 Clinical Cardiac Electrophysiology.................. 4 Critical Care Medicine.............................. 4 Geriatrics.......................................... 6 Sports Medicine..................................... 4 NUCLEAR MEDICINE........................................ 4 In-Vivo and In-Vitro Nuclear Medicine............... 4 Nuclear Cardiology.................................. 4 Nuclear Imaging and Therapy......................... 4 NEUROLOGY............................................... 4 Child Neurology..................................... 4 PSYCHIATRY.............................................. 4 Child Psychiatry.................................... 4 OBSTETRICS/GYNECOLOGY................................... 5 Maternal and Fetal Medicine......................... 5 Gynecological Oncology.............................. 5 Reproductive Endocrinology.......................... 5 FACIAL PLASTIC SURGERY.................................. 5 OPHTHALMOLOGY........................................... 4 OTORHINO/FACIAL PLASTIC SURGERY......................... 5 OTORHINOLARYNGOLOGY..................................... 5 ORTHOPEDIC SURGERY...................................... 5 PATHOLOGY, ANATOMIC..................................... 4 PATHOLOGY, ANATOMIC/LABORATORY MEDICINE................. 5 PATHOLOGY, LABORATORY MEDICINE.......................... 4 Forensic Pathology.................................. 5 Blood Banking/Transfusion Medicine.................. 5 Chemical Pathology.................................. 5 Cytopathology....................................... 5 Dermatopathology.................................... 5 Hematology.......................................... 5 Immunopathology..................................... 5 Medical Microbiology................................ 5 Neuropathology...................................... 5 PEDIATRICS.............................................. 3 Adolescent and Young Adult Medicine................. 3 Neonatal Medicine................................... 3 Pediatric Allergy/Immunology........................ 3 Pediatric Cardiology................................ 3 [[Page 27477]] Pediatric Hematology/Oncology....................... 3 Pediatric Infectious Diseases....................... 3 Pediatric Intensive Care............................ 3 Pediatric Nephrology................................ 3 Pediatric Pulmonology............................... 3 Pediatric Sports Medicine........................... 3 PREVENTATIVE MEDICINE................................... 4 PROCTOLOGY.............................................. 3 RADIATION ONCOLOGY...................................... 4 RADIOLOGY, DIAGNOSTIC................................... 5 Angiography and Interventional Radiology............ 5 Diagnostic Ultrasound............................... 5 Neuroradiology...................................... 5 Nuclear Radiology................................... 5 Radiological Imaging................................ 5 Pediatric Radiology................................. 5 REHABILITATION MEDICINE................................. 4 Sports Medicine..................................... 4 GENERAL SURGERY......................................... 5 NEUROSURGERY............................................ 5 PLASTIC AND RECONSTRUCTIVE SURGERY...................... 5 THORACIC CARDIOVASCULAR SURGERY......................... 5 UROLOGICAL SURGERY...................................... 5 GENERAL VASCULAR SURGERY................................ 5 CRITICAL CARE SURGERY................................... 5 OSTEOPATHIC MANIPULATIVE MEDICINE....................... 3 Podiatry ROTATING PODIATRIC RESIDENCY (PRIMARY CARE)............. 2 PODIATRIC ORTHOPEDIC RESIDENCY.......................... 2 PODIATRIC SURGICAL RESIDENCY............................ 2 Dentistry DENTAL PUBLIC HEALTH.................................... 1 ENDODONTICS............................................. 2 ORAL PATHOLOGY.......................................... 3 ORAL AND MAXILLOFACIAL SURGERY.......................... 4 ORTHODONTICS............................................ 2 PEDIATRIC DENTISTRY..................................... 2 PERIODONTICS............................................ 3 PROSTHODONTICS.......................................... 3 PROSTHODONTICS/MAXILLOFACIAL............................ 3 GENERAL DENTISTRY....................................... 1 ADVANCED GENERAL DENTISTRY.............................. 2 Allopathy Combined Programs * FAMILY PRACTICE(3) AND PSYCHIATRY(4).................... 4 INTERNAL MEDICINE(3) & EMERGENCY MEDICINE(3)............ 3 INTERNAL MEDICINE(3) & FAMILY PRACTICE(3)............... 3 INTERNAL MEDICINE(3) & NEUROLOGY(4)..................... 4 INTERNAL MEDICINE(3) & PEDIATRICS(3).................... 3 INTERNAL MED(3) & PHYS MED & REHABILITATION(4).......... 4 INTERNAL MEDICINE(3) & PREVENTIVE MEDICINE(3)........... 3 INTERNAL MEDICINE(3) & PSYCHIATRY(4).................... 4 NEUROLOGY(4) & PHYS MEDICINE AND REHAB(4)............... 4 PEDIATRICS(3) & EMERGENCY MEDICINE(3)................... 3 PEDIATRICS(3) & PHYSICAL MEDICINE AND REHAB(4).......... 4 PEDIATRICS(3)/PSYCHIATRY(4)/CHILD & ADOL PSYCH(4)....... 4 PSYCHIATRY(4) AND NEUROLOGY(4).......................... 4 ------------------------------------------------------------------------ * For residents participating in combined programs, Medicare limits the initial residency period to the time required for individual certification in the longer of the two programs. 2. Combined Residency Programs While updating the listing of the Initial Residency Period Limitations for GME, we noted many new programs were combined specialty residency programs. The combined programs run concurrently for a period of time that is longer than the required time for certification in either specialty, but shorter than would be required if the programs were taken sequentially. Residents completing these programs are eligible for board certification in both specialties. We use the Internal Medicine and Pediatrics combined program as an example: Taken individually, Internal Medicine is a 3-year program and Pediatrics is also a 3-year program. However, taken as a combined program, Internal Medicine and Pediatrics is a 4- [[Page 27478]] year program, with certification in both specialties. Currently, we are aware of 13 combined programs, including Internal Medicine/Pediatrics, Pediatrics/Emergency Medicine, Family Practice/ Psychiatry, and Neurology/Physical Medicine and Rehabilitation. Due to the increasing prevalence of combined residency programs since our September 29, 1989 final rule, we propose to clarify how the definition of initial residency period applies in such cases. While the combined programs may have advantages from an educational standpoint, the statutory limitation on payment for GME still applies. In the initial legislation for a per resident payment to hospitals for GME, Congress limited Medicare's liability for those payments to residents in their initial residency period plus one year. The plus-one-year provision allowed for payment for an additional year as a full FTE for residents who continued on in a second approved program after completing their initial certification. However, regardless of the number of additional years the second program required for certification, at most only the first year could be paid as a full FTE. All subsequent years are paid at a 0.5 FTE rate. When Congress revised section 1886(h) of the Act to remove the plus-one-year provision, Congress further restricted payment to allow payment as a full FTE for the first residency program only. All years of a subsequent program are now limited to the 0.5 FTE rate. Congress clearly wanted to further limit Medicare's payment obligations. Accordingly, we believe that the initial residency period limitation is designed to allow full Medicare payment only for the period required to train in one specialty. For residents enrolled in combined programs, we are therefore proposing to define the initial residency period as the time required for individual certification in the longer of the two programs. Continuing to use Internal Medicine and Pediatrics as an example, we would define the initial residency for Internal Medicine and Pediatrics as 3 years. The remaining year of the combined program would be treated as 0.5 FTE, in accordance with the regulations at Sec. 413.86(g)(3). E. Distribution of an ``Important Message from Medicare'' (Sec. 489.27) Under Sec. 489.27 of our provider agreement regulations, all hospitals that participate in Medicare (including those not paid under the prospective payment system) must agree to furnish each Medicare beneficiary with a notice, at or about the time of admission, that explains the patient's discharge rights. This statement, entitled ``An Important Message from Medicare,'' advises a beneficiary of his or her rights to be fully informed about decisions affecting Medicare coverage or payment and about his or her appeal rights in response to any hospital's notice to the effect that Medicare will no longer cover the patient's care. The ``Important Message'' also advises the patient of what to do when he or she receives such a hospital statement and how to elicit more information. In November 1993, the Medicare Technical Advisory Group (M-TAG) established the Beneficiary Protection and Documentation Issues Task Force. The task force consists of HCFA staff as well as representatives from health care industry organizations, beneficiary advocate groups, fiscal intermediaries, and peer review organizations (PROs). The task force was charged with reviewing various issues that impact beneficiaries and the health care community, including how to improve the effectiveness of ``An Important Message from Medicare.'' We are proposing to adopt a recommendation of this task force that would respond to numerous requests for clarification on the timing of the written notice of discharge rights that must be given to hospital inpatients. As noted above, existing Sec. 489.27 specifies that a hospital must distribute the statement ``at or about the time of admission.'' We understand that for monitoring purposes some PROs have interpreted this requirement to mean ``within 24 hours preceding or following the admission.'' However, we agree with the task force's determination that the PRO's interpretation is unnecessarily narrow. We believe that during the first 24 hours of a patient's admission, the hospital is primarily concerned with ensuring appropriate treatment of the patient's illness or injury. Therefore, we are proposing to change Sec. 489.27 to specify that the hospital must provide timely notice during the course of the hospital stay. For purposes of this requirement, we would consider the course of the hospital stay to begin when the hospital provides the individual with a package of information regarding scheduled preadmission testing and registration for a planned hospital admission. This would give hospitals more flexibility in meeting the requirement, as well as encourage the distribution of the ``Important Message'' at a time when the beneficiary is better able to receive and more likely to understand its contents. In complying with the requirement to provide timely notice during the course of the patient's hospital stay, the hospital must give the patient the ``Important Message'' far enough in advance of the hospital's written notice regarding continued stay to provide the beneficiary time to appeal the hospital's decision. Finally, ``timely notice'' would also include adherence to any State requirements on the provision of patient rights notices. The current version of the ``Important Message'' has been in use since 1988. As part of our effort to improve communication with Medicare beneficiaries, we will continue to evaluate the effectiveness of the ``Important Message'' and welcome suggestions for its improvement. VI. Changes and Clarifications to the Prospective Payment System for Capital-Related Costs A. Consistent Cost Finding During the Capital Transition Period (Sec. 412.302(d)) Section 412.302(d) of the regulations requires that, during the transition period to full prospective payment for capital-related costs, a hospital must follow consistent cost-finding methods for classifying and allocating capital-related costs. Specifically, the regulation requires that unless there is a change of ownership, a hospital must continue the same cost-finding methods for old capital costs, including its practices for direct assignment of costs and its cost-allocation bases, that were in effect in the hospital's last cost- reporting period before becoming subject to payment under the capital prospective payment transition system. A hospital may request a change in its cost-finding methods for new capital, provided that the request is made in a timely fashion as provided in the regulation, the hospital provides justification for the change, and the intermediary determines that the justification is reasonable. It is important to note that, while the regulation does permit changes in cost-finding methods for new capital, such changes are only permitted where they do not involve any changes in cost-finding for old capital. In practice, this means that if a hospital claims any old capital, the intermediary cannot permit a change in any of the allocation bases on Worksheet B-1 of the cost report from the bases used in the last cost reporting period prior to the capital prospective payment system transition period. Otherwise, the consistency rule governing old capital cost-finding would be violated. As we discussed in the preamble to the August 30, 1991 final rule for the capital prospective payment system (56 [[Page 27479]] FR 43396), our primary reason for establishing this consistency rule was to prevent hospitals from using changes in cost-finding methodologies to shift costs to areas where payment continues to be made on a reasonable cost basis. Allowing changes in cost-finding methodologies to accomplish such cost-shifting would obviously defeat the purpose of adopting a prospective payment system. In response to concerns expressed by the hospital industry about the costs of the recordkeeping required under the cost-reporting rules, HCFA has developed new cost reporting instructions, which will be released later this year, that permit hospitals to voluntarily adopt a simplified cost allocation methodology. This methodology reduces the number of statistical bases that a hospital is required to maintain. Under the new instructions for HCFA Form 2552-96 (the cost report instructions for FY 1996 cost reporting periods), hospitals may request the simplified cost allocation methodology. However, hospitals that elect this methodology must employ a prescribed list of statistical bases with no deviations. Hospitals may not pick and choose among the prescribed statistics for the combination that is most advantageous. Furthermore, a hospital that elects the simplified methodology must continue to use it for at least 3 years, unless a change of ownership occurs. We expect that, while election of the simplified method will always result in reduced recordkeeping costs for the hospital, it will also result frequently in reduced Medicare payment for the hospital. In fact, the instructions for HCFA Form 2552-96 will caution hospitals to compare the reduced costs of program compliance with the reduced costs of the simplified recordkeeping before electing the simplified method. We believe this proposal to permit election of the simplified cost allocation methodology, as provided in the instructions for HCFA Form 2552-96, reasonably reconciles concerns about recordkeeping costs with the requirement of consistent cost-finding during the transition. Specifically, we propose to add a new paragraph (d)(4) to Sec. 412.302, to provide that, hospitals may elect to adopt the simplified cost allocation methodology, as will be provided in the instructions for HCFA Form 2552-96. B. Possible Adjustments to the Capital Prospective Payment System Federal Rate and Hospital-Specific Rates (Secs. 412.308(b) and 412.328) In the proposed and final rules for FY 1996 (60 FR 29238-29239 and 60 FR 45830-45831), we discussed the effects of the expiration of the statutory budget neutrality provision on rates and aggregate payments under the capital prospective payment system. Under the budget neutrality provision, we set the capital-prospective payment system rates during FY 1992 through FY 1995 so that payments were projected to equal 90 percent of Medicare payments that would have been made on a reasonable cost basis for each fiscal year. As a result of the provision's expiration in FY 1996, the capital-prospective payment system rates and payments under the transition system increased significantly. The FY 1996 Federal rate is 22.59 percent higher than the FY 1995 Federal rate. We now estimate that aggregate capital payments will increase 27.7 percent in FY 1996 relative to FY 1995, and that payments will exceed capital costs by 9.6 percent in FY 1996. Under current law and regulations, we estimate that aggregate payments will further increase by 7.3 percent in FY 1997, for an increase of 37.0 percent over 2 years. We do not believe that such large increases in capital payments are necessary or warranted. During the FY 1996 rulemaking process, we solicited comments on possible revisions to the capital prospective payment rates that would have moderated these substantial increases in payments. At that time, we noted that section 1886(g) of the Act gives the Secretary broad discretion in the determination of the appropriate level of rates and payments. However, we decided not to implement any reduction to the capital rates at that time, in the expectation that Congress would be considering revisions to rates and payments under the capital prospective payment system within more comprehensive legislation dealing with Medicare and the Federal budget. In its March 1, 1996 Report to Congress, the Prospective Payment Assessment Commission (ProPAC) observed that the base capital rate was reduced during the first 4 years of the transition to full prospective payment for capital to meet the statutory budget neutrality requirement. In the light of the large increase in rates and payments as a result of that provision's expiration in FY 1996, ProPAC recommends (Recommendation 11) that the capital payment rates should be set by developing an appropriate base payment rate and applying an annual update. The Commission notes that there are several ways to determine an appropriate base capital payment rate. We agree with ProPAC that the large increase in rates and payments caused by the expiration of the statutory budget neutrality provision raises an issue concerning the proper level for future rates and payments. We also agree that there are several possible approaches to establishing an appropriate level for the rates. We considered a range of options in developing this proposed rule. For example, we considered proposing to freeze the inflation updates for the rates in FY 1997, on the grounds that such an update was unnecessary and unwarranted in light of the large increase in the rates for FY 1996. Alternatively, we considered proposing actual reductions in the base rates. For example, we considered proposing to implement the provision contained in the Administration's budget plan. The Administration's FY 1997 budget includes a provision to reduce the base Federal and hospital-specific rates by 15.7 percent. Such a reduction would build the budget neutrality adjustment for FY 1995 (0.8432, or -15.68 percent) permanently into the base rates, effectively using the FY 1995 base payment rate as the base for future years. The actual payment rates for future years would then be determined by applying the analytical update framework that we adopted in the final rule for FY 1996 (60 FR 45815- 45829). We also considered proposing to implement a part of the Administration's proposal, that is, to reduce the standard Federal rate by 7.38 percent and the hospital-specific rates by 9.48 percent. The rationale for each of these options to reduce the base rate derives from an analysis of current data compared to data on which the rate was originally based. Under Sec. 412.308, HCFA determined the standard Federal rate, which is used to determine the Federal rate for each fiscal year, on the basis of an estimate of the FY 1992 national average Medicare capital cost per discharge. The FY 1992 national average Medicare capital cost per discharge was estimated by updating the FY 1989 national average Medicare capital cost per discharge by the estimated increase in Medicare inpatient capital cost per discharge. As we discussed in the preamble to the August 30, 1991 capital prospective payment system final rule (56 FR 43366-43384), HCFA used the July 1991 update of HCRIS data to estimate an FY 1989 national average Medicare cost per case of $527.22. [[Page 27480]] HCFA then updated that amount to FY 1992 by using an actuarial projection of a 31.3 percent increase in Medicare capital cost per discharge from FY 1989 to FY 1992. The standard Federal rate was thus based on an estimated FY 1992 national average Medicare capital cost per discharge of $692.24 (before the application of a transfer adjustment and a payment parameter adjustment). Section 13501(a)(3) of Public Law 103-66 amended section 1886(g)(1)(A) of the Social Security Act to require that, for discharges occurring after September 30, 1993, the unadjusted standard Federal rate be reduced by 7.4 percent. As we discussed in the September 1, 1993 final rule for FY 1994 (58 FR 46316ff.), the purpose of that reduction was to reflect revised inflation estimates, as of May 1993, for the increases in Medicare capital costs per discharge during FY 1989 through FY 1992. By that time, the estimate of increases in Medicare inpatient capital costs per discharge from FY 1989 through FY 1992 had declined from 31.3 percent to 21.57 percent. The 7.4 percent reduction to the Federal rate was calculated to account for these revised estimates (1.2157/1.313=0.926, a 7.4 percent decrease). That provision of Public Law 103-66 also required that, for cost reporting periods beginning on or after October 1, 1993, the Secretary redetermine which hospital payment methodology should be applied under the capital prospective payment system transition rules to take into account the 7.4 percent reduction to the Federal rate. As a result of the reduction required by Public Law 103-66, the standard Federal rate is now based on an estimated FY 1992 Medicare inpatient capital cost per case of $641.01 ($692.24 x 0.926). At the time of the Public Law 103-66 reduction to the Federal rate, actual cost report data on the FY 1992 Medicare capital cost per discharge were not yet available. The reduction was based on cost report data for FY 1990 and FY 1991, and a revised projection of the rate of increase in Medicare capital costs per discharge during FY 1992. We now have extensive cost report data for FY 1992. The March 1996 update of HCRIS data shows an audit-adjusted FY 1992 Medicare inpatient capital cost per discharge of $593.72, or an additional 7.38 percent lower than the estimate on which the Federal rate is currently based. Under Sec. 412.328, HCFA determined the FY 1992 hospital-specific rate by using a process similar to the process for determining the FY 1992 Federal rate. The intermediary determined each hospital's allowable Medicare inpatient capital cost per discharge for the hospital's latest cost reporting period ending on or before December 31, 1990. The intermediary then updated each hospital's FY 1990 allowable Medicare capital cost per discharge to FY 1992 based on the estimated increase in Medicare inpatient capital cost per case. As with the Federal rate updates, current data demonstrate that the estimates used to update the hospital specific rates from FY 1990 to FY 1992 were overstated. Specifically, the hospital-specific rates are 9.48 percent higher than they would have been if the rates of increase had reflected actual data. Thus, revising the Federal and the hospital-specific rates only for the known overestimations in the actual costs on which rates were based would call for reductions of 7.38 percent and 9.48 percent, respectively. The proposal in the Administration's budget to reduce the rates 15.7 percent reflects the preceding factors, as well as analysis of capital cost increases before the implementation of the prospective payment system for capital-related costs. That analysis suggests that the Federal and hospital-specific rates may reflect levels of cost in excess of what can be accounted for by the rate of 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 markets. To examine this issue, in our June 2, 1995 proposed rule (60 FR 29237) we analyzed the change in actual Medicare capital cost per case for FY 1986 through FY 1992 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 actual 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. Our last analysis (60 FR 45826-45829) suggested that the FY 1992 capital costs used to set the Federal and hospital-specific capital rates exceeded by approximately 28 percent the level that could be accounted for by known factors. We seriously considered proposing one of these options--reducing the standard (base) Federal rate either 7.38 percent to address overstated inflation estimates or 15.7 percent, as reflected in the Administration's budget proposal--in this proposed rule. We believe that either of these options is well justified on the basis of current data and analysis. As ProPAC has observed, hospitals do not seem to have been adversely affected by the level of the rates during the years in which the statutory budget neutrality provision was in effect. However, we still believe that Congress and the Administration may be able to reach an agreement on budget issues, including Medicare savings, in the near future. Therefore, as discussed in section III of the Addendum to this proposed rule, at this time we are proposing to update the capital rates in accordance with the capital update framework, without implementing any of the reductions discussed above. Our hope is that the legislative process will produce an appropriate adjustment to the rate level in time for implementation in the final rule. In the event that no such agreement is reached before the final rule for FY 1997, we may implement one of the above-described options at that time. We invite public comment on the merits of these options, and on the advisability of implementing one or the other in the final rule, in the absence of legislative action. We will reconsider all the options in the light of public comments. C. Possible Adjustment to Capital Prospective Payment System Minimum Payment Levels Section 412.348(b) of the regulations provides that, during the capital prospective payment system transition period, any hospital may receive an additional payment under an exceptions process if its total inpatient capital-related payments under its payment methodology (i.e., fully prospective or hold-harmless) are less than a minimum percentage of its allowable Medicare inpatient capital-related costs. The minimum payment levels are established by class of hospitals under Sec. 412.348(c). The minimum payment [[Page 27481]] levels for portions of cost reporting periods occurring in FY 1996 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 for previous cost reporting periods exceed its cumulative minimum payment is deducted from the additional payment that would otherwise be payable for a cost reporting period. Section 412.348(h) further provides that total estimated exceptions payments under the exceptions 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. In the final rule implementing the prospective payment system for capital- related costs we stated that the minimum payment levels in subsequent transition years would be revised, if necessary, to keep the projected percentage of payments under the exceptions process at no more than 10 percent of capital prospective payments. In section III of the Addendum to this proposed rule, we discuss the factors and adjustments used to develop the FY 1997 Federal and hospital-specific rates. In particular, we discuss the FY 1997 exceptions payment reduction factor. This factor adjusts the annual payment rates for the estimated amount of additional payments for exceptions in FY 1997. In this proposed rule, we estimate that exceptions will equal 6.07 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We will develop a new estimate of the level of exceptions payments in FY 1997, and revise the exceptions payment adjustment factor accordingly, on the basis of the data that becomes available to us in time for developing the final rule for FY 1997. While it is not necessary at this time to propose reductions in the minimum payment levels, it is possible that it will be necessary to implement adjustments to the minimum payment levels in the final rule. Our current projections show that it will almost certainly be necessary to adjust the minimum payment levels for FY 1998. We are therefore providing public notification that adjustments to the minimum payment levels are possible in the final rule, and almost certain for FY 1998. When it does become necessary to adjust the minimum payment levels in accordance with Sec. 412.348(h), our current intent is to adjust each of the existing levels (i.e., 90 percent for sole community hospitals, 80 percent for large urban DSH hospitals, and 70 percent for all other hospitals) by 5 percentage point increments until estimated exceptions payments are within the 10 percent limit. For example, we would set minimum payment levels at 85 percent for sole community hospitals, 75 percent for large urban DSH hospitals, and 65 percent for all other hospitals, provided that aggregate exceptions payments at those minimum payment levels were projected to be no more than 10 percent of total rate-based payments. If aggregate exceptions payments at those minimum payment levels still exceeded 10 percent of total rate-based payments, we would continue to reduce the minimum payment levels by 5 percentage point increments each until the requirement of Sec. 412.348(h) was satisfied. We are providing notification of our current thinking on this issue in order to allow opportunity for public comment on the appropriate method for adjusting the minimum payment levels. We invite public comment on this matter, and will consider those comments fully whenever it becomes necessary to adjust the minimum payment levels in accordance with Sec. 412.348(h). VII. Proposed Changes for Hospitals and Units Excluded From the Prospective Payment Systems Application of Ceiling in Calculating Payment for Hospital Inpatient Operating Costs (Sec. 413.40 (d) and (g)) Section 1886(b)(1)(B) of the Act provides for an additional payment to a hospital excluded from the prospective payment system when the hospital's reasonable operating costs exceed its target amount. The additional payment is based on the lesser of 50 percent of the amount by which the operating costs exceed the target amount, or 10 percent of the target amount. The Medicare statute further provides that this comparison is made ``after any exceptions or adjustments are made to such target amount for any cost reporting period.'' The regulations, at 42 CFR Sec. 413.40(d)(3), state that the total payment to the hospital for inpatient operating costs (including the additional payment described above) is based on the lesser of the following: the ``ceiling'' (target amount multiplied by the number of Medicare discharges) plus 50 percent of the allowable net inpatient operating costs in excess of the ceiling, or 110 percent of the ceiling. However, the regulations do not explicitly include the additional statutory requirement regarding the effect of exceptions or adjustments. It is our understanding that there are questions about the calculation of the additional payment under the regulations, which require comparison of two amounts: the ``ceiling'' plus 50 percent of the difference between allowable costs and the ceiling, and 110 percent of the ``ceiling.'' Specifically, where a hospital has received an adjustment to the target amount under Sec. 413.40(g), there has been confusion as to whether the ``ceiling'' used for purposes of calculating the additional payment under Sec. 413.40(d) is the unadjusted ceiling (the amount determined without consideration of any adjustments granted to the hospital) or the adjusted ceiling. We believe that the amount of the additional payment should be determined using the adjusted ceiling when hospitals receive adjustments to the ceiling. That is, the calculation of the amounts compared--50 percent of the allowable net inpatient operating costs in excess of the ceiling, or 10 percent of the ceiling--should reflect the adjusted target amount (and adjusted ceiling). To address any confusion about these issues, we propose to revise Sec. 413.40(d)(3) to specifically indicate that calculation of payments for hospital inpatient operating costs under that provision reflects the adjusted ceiling amount (the amount determined after an adjustment under Sec. 413.40(g)). This would apply to all adjustments, including adjustments based on a longer average length of stay in the hospital's rate year as compared to the base year and adjustments for increased routine services. We note that an adjusted ceiling is not used to adjust permanently the hospital's target amount or ceiling on the hospital's cost report. Instead, it is used only for purposes of calculating payments for the year the adjustment is granted. We also note that, depending on the specifics of the data in a particular case, use of an adjusted ceiling can result in either an increase or decrease in the additional payment to a hospital relative to use of an unadjusted ceiling. If the additional payment to a hospital is 50 percent of [[Page 27482]] the allowable net inpatient operating costs in excess of the ceiling, the additional payment would be lower using an adjusted ceiling (as under proposed Sec. 413.40(d)(3)) than an unadjusted ceiling. This would occur because an adjusted ceiling reduces the difference between the hospital's costs and the ceiling. However, if the additional payment to the hospital is 10 percent of the ceiling, the additional payment would be higher using an adjusted ceiling than an unadjusted ceiling. VIII. ProPAC Recommendations We have reviewed the March 1, 1996 report submitted by ProPAC to Congress and have given its recommendations careful consideration in conjunction with the proposals set forth in this document. Recommendations 10 and 12, concerning the update factors for inpatient operating costs, and the update factor for hospitals excluded from the prospective payment system and distinct-part units, are discussed in Appendix F to this proposed rule. Recommendation 11, on the setting of capital payment rates, is discussed in section VI of this proposed rule. Recommendations 17 and 18, concerning disproportionate share hospitals, are discussed in section V of this proposed rule. The remaining recommendations are discussed below. A. Slowing the Rise in Medicare Spending (Recommendation 1) Recommendation: The Commission supports the efforts of the Congress and the President to reduce the growth in Medicare expenditures. Over time, spending for services furnished to Medicare enrollees should increase at rates comparable to those in a cost- and quality-conscious private sector. Response: We agree with ProPAC about the importance of slowing the growth in Medicare spending. We support ProPAC's assertion that the experience in the private sector with market forces that encourage cost containment represents a useful factor in considering appropriate growth in Medicare. We also agree with those factors upon which ProPAC urges this comparison: spending growth on a per-person basis and recognizing the health care needs of an aged and disabled Medicare population. We caution, however, that while it may be appropriate to compare growth service by service, aggregate comparisons would not be meaningful due to differences in the mix of services. Medicare and private health insurance provide a different array of services. Medicare covers more long-term care services, such as home health visits and skilled nursing facility (SNF) stays, than private insurance. Although their share of total Medicare spending is small, SNF and home health services are growing more quickly than other services within Medicare, and therefore spending for these services has been growing at a much faster rate than for other services. Data from 1992 and 1993 indicate that payments increased for SNF and home health services by 40.6 percent and 35.2 percent, respectively, whereas the growth in physician and hospital payments were only 4.5 percent and 8.3 percent, respectively. In order for Medicare and private health insurance to grow, in aggregate, at the same rate, spending for hospital and physician services would have to be growing more slowly in Medicare than in private health insurance to offset differences in long-term care growth. Due to these differences in mix of services, meaningful comparisons between Medicare and the private sector can only be made on a service-by-service basis. B. The Failsafe Budget Mechanism (Recommendation 2) Recommendation: Any failsafe budget mechanism should include a more effective risk adjustment factor to ensure payment equity between the Medicare capitation and traditional fee-for-service programs. In addition, changes in inflation that differ substantially from Congressional Budget Office (CBO) forecasts could require modifications to the Medicare benefit budget over time. Revisions to the proposed fee-for-service sector budget allocations could also be needed as medical practices change. Response: We believe that using a failsafe budget mechanism (that is, an arbitrary cap on spending) to achieve targeted spending levels would be bad public policy. A failsafe mechanism would fundamentally change the nature of the Medicare program by breaking the link between benefits and payments. To meet the cap, benefits might have to be reduced, beneficiaries might have to pay more, and payments to providers might have to be reduced, all of which would impede access. A failsafe mechanism would encourage cost shifting to beneficiaries and other payers in order to achieve the targeted goal in government spending. These arbitrary reductions in payments would make government an unreliable business partner. As Medicare moves toward a more market- oriented approach to setting payments, arbitrary reductions imposed by the government, after providers have negotiated in good faith, would sour relations and threaten the market pricing process. The failsafe mechanism is a substitute for policy choices to achieve the desired level of spending. This arbitrary Medicare budget cap could potentially have adverse effects on the Medicare program. We note that, while ProPAC recommends using a more effective risk adjustment factor to ensure payment equity between Medicare capitated and fee-for-service programs, no adequate case-mix measure currently exists that could serve this purpose. C. Expanding Medicare's Capitation Program (Recommendation 3) Recommendation: The Commission supports reforming the Medicare capitation program to control spending while expanding beneficiary choice. Response: HCFA agrees with this recommendation and has specifically developed legislation to allow for Preferred Provider Organizations (PPOs) and Provider Sponsored Organizations (PSOs) to contract with the Medicare program. Furthermore, in October 1995, HCFA issued guidelines that notified HMOS that they were permitted to develop Point of Service (POS) Programs, which allow beneficiaries to go out of network for services. HCFA is currently conducting the Choices Demonstration, through which it is soliciting applications for the above types of provider arrangements. D. Setting and Updating the Capitation Rates (Recommendation 4) Recommendation: Geographic variation in the capitation rates and the volatility of the rates from year to year should be reduced. The Secretary should develop and test alternative payment methods that would allow the payment rates to reflect changes in local market conditions. Response: We agree that geographic variations in HCFA's payment rates should be reduced. Some of the current legislative proposals would reduce the degree of variation over time. We have been looking at ways to reduce these variations. Several demonstrations that should provide information needed to develop alternative payment methods are either currently being run or in the process of getting started. We have developed and are conducting several research and demonstration projects to review additional risk adjustors, which would modify current payment rates to reflect the health status of the members of managed care organizations. Another project would pay, from a separate pool of funds being shared by several [[Page 27483]] organizations in an area, for enrollees who have high Medicare costs. Also, HCFA is in the process of starting another project that would incorporate the payment principles associated with competitive bidding. E. Improving Risk Adjustment Methods (Recommendation 5) Recommendation: The risk adjustment methods used to set Medicare capitation payments should better reflect variation in the likely use of services. Even as research on the development of new methods continues, the Secretary should implement interim improvements as soon as possible. Response: We plan to test health status risk adjusters, such as Diagnostic Cost Groups or Ambulatory Care Groups, as part of the Choices Demonstration. Furthermore, in this demonstration, we will test reinsurance and partial capitation arrangements. We are also considering demonstrations which use health status measures as part of the Adjusted Community Rate Determination, as well as part of the payment formula. F. Medical Savings Accounts (MSAs) (Recommendation 6) Recommendation: The Congress' high deductible/MSA option would provide an additional choice for Medicare enrollees. However, ProPAC is concerned that the current Medicare risk adjustment method is not sufficient to protect the program from adverse selection and resulting excess spending. The likelihood that rates would better reflect risk would be enhanced if Medicare enrollees were required to remain in the MSA option at least for several years. Response: As ProPAC states, the Congressional Budget Office estimated that the MSA option would cost the Medicare program $4.6 billion over 7 years, in part because of the current state-of-the-art in risk adjustment methods (discussed in recommendation 5, above). The CBO estimate of the cost of the MSA option is consistent with the cost estimates of other reputable organizations. We fail to see the rationale for including an option that provides no new benefits but is expected to result in increased costs, particularly at a time when the public and Congress are concerned about the long-term financial viability of the Medicare program. G. The Medicare Plus Fee-for-Service Option (Recommendation 7) Recommendation: Enrollees choosing the fee-for-service option under the proposed Medicare Plus program could be responsible for substantially higher fees than what their plans would pay. The Secretary should monitor the impact of this option on beneficiary liability and on possible reductions in physician and other provider participation in traditional Medicare. Response: We agree with ProPAC that beneficiaries could be responsible for substantially higher fees. We also agree that, as suggested in this recommendation, allowing physicians and other providers to elect to serve Medicare beneficiaries through private fee- for-service plans that place no limits on extra-billing amounts may well result in (1) increases in beneficiary liability and (2) reductions in physicians and other providers participating in traditional Medicare. Further, as the payment methods contained in pending legislation described in H.R. 2491 are structured, the payment increases for MedicarePlus plans, relative to those in fee-for-service Medicare, mean that MedicarePlus plans would be able to pay physicians and other providers more than fee-for-service Medicare. These higher payments would create additional incentives for physicians and other providers to cease participation in traditional Medicare. Finally, while managed care plans potentially provide value added because their organizational structure facilitates coordination of care, it is not clear what, if any, value is added by creating a private fee-for- service plan option, under which the private plans receive higher payments relative to fee-for-service Medicare and physicians and providers are permitted to charge unlimited extra-billing amounts. H. Information for Beneficiary Health Plan Choices (Recommendation 8) Recommendation: Medicare should make available to beneficiaries information about the performance of plans and local providers. The Secretary should identify the information beneficiaries need to make appropriate choices and develop innovative ways to improve access to it. Response: Current HCFA initiatives to improve beneficiary information about health insurance options, which are summarized below, are consistent with ProPAC's recommendation. Development of Prototype Materials and Strategies We are currently engaged in two projects that will develop prototype beneficiary information strategies related to health insurance options. The first project, which focuses mostly on managed care issues, is examining through Medicare and Medicaid beneficiary focus groups, the types of information and dissemination media that beneficiaries would find most useful in selecting health insurance plans. Based on this information, and case studies, the project will produce and test a range of prototype beneficiary information materials, including beneficiary health plan comparison booklets and charts, and informational videos. Draft prototype materials (for Medicare, pre- Medicare and Medicaid beneficiaries) are nearing completion and are scheduled for beneficiary testing in Spring 1996. The second project will design beneficiary information and education materials and dissemination strategies to support the Medicare Open Enrollment/Competitive Pricing demonstration. This project will develop printed materials that explain the experimental open enrollment process; printed general informational materials on Medicare health insurance options; and booklets outlining the specific Medicare fee-for-service and managed care options available to beneficiaries in their area. A plan comparison chart template, which would include information on specific benefits and premiums, will also be developed, as will other information and educational approaches (including educational seminars, public service announcements (PSAs), informational videos, and a toll-free counseling phone line, all sponsored by HCFA). In addition, a dissemination strategy for HCFA and its partners in the demonstration sites will be developed (for example, Insurance Counseling and Assistance (ICA) programs and beneficiary advocacy groups). Draft materials and strategies were tested on Medicare beneficiaries in April 1996. Final products should be available for adaptation to specific demonstration sites by Summer 1996. Medicare Program Activities We have currently outlined a strategy to produce and disseminate a managed care plan comparison chart to Medicare beneficiaries, initially through the HCFA Regional Offices and HCFA-sponsored ICA programs. We will use comparison chart prototypes developed (under both of the projects discussed above) as models for the comparison chart. Prototypes will be available by Spring 1996. We plan to begin dissemination of the basic comparability charts in 1996. We may also choose to adapt some of the prototype materials for application to the Medicare program, depending on feedback and evaluations from [[Page 27484]] beneficiaries in the Open Enrollment Demonstration. These new materials could ultimately supplement or replace current materials, such as the Medicare Handbook. New prototype materials could also be provided and adapted individually by the State ICA programs. We have contributed recommendations during the development of these projects and will continue to do so. Many of the Regional Offices have developed area specific informational materials related to Medicare managed care. The Regional Offices typically use these materials to assist in their responsibilities as the local HCFA contact for beneficiaries. Related Major Initiatives While current activities have centered on efforts to provide better information on health insurance options (such as focusing on comparisons of benefits, premiums, and locations), the next major steps in improving information and educational strategies will likely be in the area of quality or performance indicators. The prototypes discussed above will include templates for eventual dissemination of quality/performance indicators for health plans. In addition, strategies for introducing the concept of indicators to Medicare and Medicaid beneficiaries will be produced. One project, short Medicare and Medicaid focused video tapes describing quality indicators using a ``grocery shopping'' analogy, has already been completed. A final version of a set of Medicaid-specific National Committee on Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) quality indicators is nearly completed. We are currently sponsoring the revision (with NCQA) of HEDIS version 3.0 to include Medicare- specific measures. Once both Medicare- and Medicaid-specific measures are available, HCFA will have available the basic tools necessary to report comparative quality indicators to beneficiaries. A specific dissemination strategy will then be determined. We are currently in the developmental stages of a proposed plan- specific Medicare beneficiary satisfaction survey. When completed, we would have comparative satisfaction information on all Medicare managed care plans, which could then be disseminated to beneficiaries as a companion to plan benefit/premium comparison charts. Based on these initiatives, HCFA should be well prepared to expand and improve both the level and types of health insurance information resources available to Medicare beneficiaries. I. Health Plan Accountability (Recommendation 9) Recommendation: Medicare must hold health plans accountable for the appropriate use of Medicare funds. In addition, standards must be developed and enforced to ensure that Medicare beneficiaries will receive services of appropriate quality. Response: We agree with these recommendations and have several plans for implementing them. First, we are working with the National Committee for Quality Assurance to develop HEDIS 3.0 for the Medicare program. Second, we plan to conduct beneficiary satisfaction surveys for a significant sample of beneficiaries from each health plan participating in the Medicare HMO program. Third, we are working with the Foundation of Accountability to develop condition-specific outcome measures. Finally, we are working with Peer Review Organizations to develop several condition-specific outcome measures that will be risk adjusted. J. Broadening Financial Support to Teaching Hospitals (Recommendation 13) Recommendation: Explicit financial support for graduate medical education activities should not be limited to the Medicare program. Mechanisms to broaden financial support for teaching-related activities in hospitals and other locations should be developed. Response: The Commission is concerned that Medicare is the only payer that provides explicit financial support for teaching activities. Even though private payers provide implicit support through higher prices for patient care services, funding is unrelated to the amount of actual teaching activity. While we would agree that all payers should contribute their fair share toward physician training and particularly for the patient care services that are provided in the course of this training, we wish to emphasize that Medicare's support for graduate medical education is limited only to Medicare's share of the total cost of graduate medical education. That is, although we believe the current level of the indirect medical education adjustment is higher than necessary to compensate for the indirect costs associated with residents' involvement in patient care, it is set at a level that at one time was thought to equal those costs. Furthermore, because this adjustment is made only for Medicare prospective payment system discharges, it is inherently only associated with Medicare's share of the indirect costs of graduate medical education. In addition, the direct graduate medical education payment is calculated based on Medicare's inpatient utilization rate, thereby ensuring that it, too, reflects only Medicare's share of direct graduate medical education. In that vein, we would support a mechanism to broaden support for physician training that did not result in Medicare contributing more than its fair share, relative to the Medicare utilization rate. We note also that some Medicaid programs explicitly pay hospitals for the indirect and direct costs of graduate medical education similar to Medicare. In addition, some States (for example, New York, through its Prospective Hospital Reimbursement Methodology) provide explicit support for teaching hospitals through private payers. Nevertheless, we join ProPAC in calling for more uniform support across all payers. We would note that although the President's health care reform bill attempted to involve private insurers in directly supporting medical education, we do not currently have a proposal to broaden support for teaching hospitals beyond that currently provided by Medicare. We have, however, proposed to broaden financial support for teaching hospitals by changing the way Medicare funds medical education through its managed care programs. Currently, Medicare payments to HMOs are based on the average cost of providing services to Medicare patients in the fee for service part of Medicare. These payments to HMOs include Medicare's costs for medical education. The President's FY 1997 budget would revise Medicare's payments to HMOs so as not to include the portion associated with medical education and paying these funds directly to teaching hospitals and to managed care plans with teaching programs. This change would benefit teaching hospitals, as well as more appropriately target Medicare funds designated for medical education. K. Medicare Payments for Graduate Medical Education Costs (Recommendation 14) Recommendation: ProPAC supports changes in Medicare teaching payments that would encourage an appropriate distribution of residents across specialties and discourage inappropriate growth in the total number of residents. Response: The Commission states that both the proposals of Congress and the President's budgets would move Medicare direct graduate medical education payments in the direction of [[Page 27485]] encouraging appropriate distribution of residents across specialties and discourage inappropriate growth in the total number of residents. The Administration is very concerned with the issue of Medicare payments to hospitals for graduate medical education. Consistent with numerous reports that the nation has an excess of specialty physicians, and that the growth of managed care is increasing the demand for primary care physicians relative to other specialties, the focus of the President's graduate medical education proposal is to encourage greater hospital participation in primary care residencies and less in specialty residencies. In addition, a significant amount of training of residents in primary care is more appropriately done in non-hospital settings. Accordingly, the President's budget includes a cap on the total number of residents and on the number of nonprimary care residents for whom Medicare will make graduate medical education payments. We would also encourage ambulatory training by including residents who rotate to non-hospital settings in the hospital's FTE count for IME purposes. We would further encourage ambulatory training by providing direct medical education payments to facilities that are not hospitals (for example, federally qualified health centers) for residents, when the residents' salaries are not paid by hospitals. The Administration has also proposed to create a Commission on Medical Education and Workforce Priorities within HHS to develop and recommend policies to address the preservation of academic health centers' research and educational capacity and the supply of the future health care workforce. This commission would also make recommendations regarding the most effective allocation of training resources to ensure that the numbers and competencies of health care professionals are responsive to national needs. L. Medicare Indirect Medical Education Payments (Recommendation 15) Recommendation: The Medicare indirect medical education adjustment should be reduced from its current 7.7 percent level to 7.0 percent. Response: As we've said in response to similar ProPAC recommendations in previous years, we agree with ProPAC that the current level of payment for the indirect costs of medical education is too high. The President's FY 1997 budget would reduce the adjustment over 3 years to a final level of 6.0 percent effective for FY 1999. In addition, residents working in nonhospital settings could be counted in a hospital's resident count for indirect medical education purposes if the hospital incurs all, or substantially all, of the costs for the training program in that setting. Finally, the President's budget would cap the number of residents that could be included in the count, with an exception provided for primary care residents and those in the specialties of obstetrics or gynecology. The Commission also supported the provision in the President's FY 1996 budget that would apply the direct graduate medical education resident count and weighting rules to the indirect medical education count. However, ProPAC recommended proceeding with caution as additional analysis would be needed to examine the effect of this policy on individual teaching hospitals. We note that this provision is not contained in the FY 1997 budget proposal. Therefore, residents would continue to be counted for IME as long as they are enrolled in an approved program. M. Distributing Additional Teaching-Related Payments (Recommendation 16) Recommendation: Funds that provide broader financial support for graduate medical education should be distributed in a way that corresponds to the additional costs incurred by teaching facilities. Providers that treat enrollees in capitation plans should receive teaching-related payments for those patients as well as for the other patients they serve. Response: This recommendation is related to Congress' proposal to create new trust funds to provide broader support for educational activities. Congress would create new trust funds that include accounts for general direct medical education, general indirect medical education, and a Medicare Plus Incentive Account financed by new appropriations. This funding would be in addition to payments currently being made by Medicare for direct and indirect medical education. The Commission is concerned that the new funding would be distributed based on previous Medicare payment levels even though general revenues will fund the newly established trust funds. With regard to the Medicare Plus Incentive Account, ProPAC is concerned that payments should give Medicare's managed care participants an incentive to use teaching hospitals and pay providers appropriately for serving patients in capitation plans. Like the Commission, we are concerned about appropriating general revenues to finance medical education, particularly given our concern that the indirect medical education adjustment already overcompensates hospitals and Medicare already pays its share of costs of direct medical education. The President's original proposal was to create an all payer fund to finance graduate medical education. However, this proposal was made in the context of overall health care reform. We continue to remain concerned that medical education should be supported to a greater extent by payers other than Medicare but have reservations about financing of medical education with additional Federal money. As we explained above in Recommendation 13, under the President's FY 1997 budget, we would revise payments made through our managed care programs to ensure that teaching programs are supported more appropriately by existing Medicare resources designated for medical education. Under the President's FY 1997 budget, payments for medical education would be eliminated from HMO rates and redistributed to teaching hospitals and managed care plans with teaching programs. N. Discharges from Hospitals to Other Facilities (Recommendation 19) Recommendation: Medicare payments should be modified to account for the shift in services from acute to postacute settings. Broadening the definition of transfer cases, however, is not an appropriate approach. Response: In both the September 1, 1994 and September 1, 1995 final rules, we expressed our concern that the current trend of declining average lengths of stay as hospitals discharge Medicare patients into alternative health care settings (other than acute care prospective payment hospitals) in less time may result in a misalignment of payments and costs under our existing payment systems (59 FR 45362; 60 FR 29221). In particular, we expressed concern over the potential for hospitals paid under the prospective payment system to shift costs (for which they are compensated through the DRG payments) to alternative settings, which are in turn paid on a cost basis. Although we solicited comments on possible solutions to this problem, we did not propose any change in policy. The President's FY 1997 budget includes a proposal to redefine discharges from acute care hospitals to excluded hospitals and units and skilled nursing facilities as transfers for payment purposes. Currently, for cases transferred from one acute care hospital paid under the prospective payment system to another like hospital, the sending hospital is paid a per diem rate [[Page 27486]] instead of the full DRG amount. For cases transferred to an excluded hospital or unit or to a skilled nursing facility (as well as cases discharged home or home with home health care), hospitals receive the full DRG payment amount, regardless of the length of stay in the hospital. Under the per diem transfer payment methodology, hospitals receive a per diem amount (doubled for the first day of the stay) until the full DRG amount is reached. Therefore, under the President's budget proposal, hospitals transferring patients to excluded facilities or skilled nursing facilities prior to the geometric mean length of stay for the DRG, minus one day (to account for the double per diem on the first day), would receive less than the full DRG amount for that case. The basis for ProPAC's opposition to this proposal is that it ``* * * thinks this policy would discourage the use of postacute providers. Moreover, it could result in longer inpatient stays, which may not be desirable or cost effective in the long run.'' We acknowledge that the change in the definition of a transfer is not the ultimate solution to this health care trend. In response to immediate concerns about overpaying hospitals for the reduced services they are providing and the rate of increase in expenditures for postacute care services, however, we believe this is an appropriate interim measure while we continue to explore long-term policy alternatives that will better integrate our payment systems for care provided to Medicare beneficiaries across the acute and postacute care settings. O. Prospective Payment for PostAcute Care (Recommendation 20) Recommendation: Prospective payment systems should be implemented for all postacute services. The payment method for each service should be consistent across delivery sites. The Secretary should explore methods to control volume of postacute service use, such as bundling services for a single payment. Response: We agree that HCFA should develop prospective payment systems for all postacute services, and we have made significant progress in this area. As we discuss in our responses to Recommendations 22 and 23, we have developed detailed implementation plans for interim prospective payment systems for skilled nursing facilities (SNFs) and home health agencies (HHAs) that do not require patient classification systems. Execution of these plans will, of course, require legislative action. Beyond our interim plan, we have developed a strategy for developing a full-fledged prospective payment system for SNFs. In the absence of legislation, we have been pursuing data that could be used to support a case-mix prospective payment system through our Multi- State Case Mix Demonstration Project. This demonstration project, now in its operational phase, is collecting data on patient case mix using a modified version of the minimum data set, the assessment tool SNFs use in developing patient care plans. Through the course of the demonstration, we hope to gather data on the full range of SNF resources needed for each resource utilization group. We are proceeding to require by regulation that all facilities provide resident assessment data. Consolidated billing of SNF services (that is, requiring SNFs to bill for all services furnished to their patients) and uniform coding of SNF services are also prerequisites for a SNF prospective payment system. Consolidated billing and uniform coding are needed to determine the appropriate payment for the ancillary services component of SNF services and to provide useful data on the range of services SNFs furnish. We have also been working on a strategy to develop a full-fledged prospective payment system for HHAs. We have funded a project to develop outcome measures for home care that can be used for an outcome- based quality improvement system. These measures will be based largely on a core standard assessment data set that includes items measuring sociodemographic, environmental, support system, health status, functional status, and health service utilization characteristics of patients. Many of these data items included in the core standard assessment data set are not only essential for assessing patient outcomes but are also critical for designing an adequate case-mix system for payment purposes. To test and refine Medicare's approach to outcome based quality improvement for home health care, HCFA is currently sponsoring the Medicare Quality Assurance and Improvement Demonstration, which uses this instrument. We plan to publish regulations identifying the required data elements and addressing the collection of information from the core standard assessment data set. We also plan to sponsor additional research that would lead to an appropriate case-mix adjuster that can be used in a national prospective payment system. In addition to the developmental work underway on SNF and HHA prospective payment systems, we have begun work on the preliminary steps necessary for the development of a prospective payment system for hospital inpatient rehabilitation services. The biggest obstacle we have faced in this effort is the lack of appropriate patient classification systems for the types of patients treated by rehabilitation hospitals. We have recently contracted with the Rand Corporation to evaluate a rehabilitation coding system known as the Functional Impairment Measure (FIM), which is a scoring system that measures the degree of functional independence of rehabilitation patients. These researchers will also evaluate the patient classification system known as functional related groups (FRGs), which are based on FIM, as a possible basis for a Medicare prospective payment system for rehabilitation services. If the research confirms functional status measures can be used to develop an appropriate patient classification system, we will begin the additional work necessary to put a prospective payment system into place. This would require collecting patient assessment data from Medicare rehabilitation hospitals and units and developing all the necessary components of the new payment system. It will take at least 3 years to design and implement such a system. To facilitate implementation, we are considering initiating collection of patient assessment data in advance of legislation establishing a prospective payment system. We will be seeking public input on whether to proceed with a requirement for patient assessment data in the absence of legislation and what data elements should be included in a core data set that could be used not only as the basis for a patient classification system but also to assess outcomes. We recognize that there are advantages to a coordinated approach in developing prospective payment systems for postacute services and we will be evaluating how to make them as consistent as possible. We also recognize that the demand for implementation of prospective payment systems for post-acute services is sufficiently immediate so that there may not be time for the broad study, data collection, and research needed to develop a ``unified'' system using similar resource grouping principles. Most of the current legislative proposals, including the Administration's proposals, would require implementation dates within the next several years. It may not be feasible to develop a ``unified'' system within the time frames contemplated by the current legislative proposals. Trade-offs may be required between continuation of the interim payment systems versus [[Page 27487]] the full-blown prospective payment systems on one hand, and the separate versus ``unified'' prospective payment systems on the other hand. P. Case-Mix Measures for PostAcute Services (Recommendation 21) Recommendation: Reliable case-mix measurement is important in prospective payment systems to account for resource use and to analyze treatment patterns and costs across sites. The Secretary should coordinate case-mix research across postacute care settings, using consistent methods for measuring patient acuity and resource use. Response: We are attempting to coordinate our work on case-mix adjustment for home health care, long-term and SNF care, and rehabilitative services. To develop a case-mix adjustment system for SNF care, time studies were conducted in order to measure resource utilization. Similarly, as noted above in response to Recommendation 20, we plan to fund research to identify a home health case-mix adjuster. In addition, in the case-mix work to date for both home health care and SNF care, dependence in activities of daily living is the biggest predictor of resource utilization. Some of the other predictors differ across SNF care and home health care due to differences in the treatment settings and the availability of information for a classification system. As also noted above in the preceding response, researchers at the University of Pennsylvania have developed a classification system based on FIMs called Function Related Groups (FIM-FRGs). This system appears promising for use in a case-mix adjusted prospective payment system for rehabilitation and long-term care facilities, and we are working with the Rand Corporation on a research project to evaluate the suitability of FIM-FRGs for this purpose. We agree that a compatible cross-provider measure of resource use would be the best multiplier in any universal postacute system. We also believe that such measures do not now exist and to produce them would require the program to incur significant costs and impose significant data reporting and collection requirements on providers. We would prefer to obtain explicit legislative direction before we incur these costs and impose these burdens. Even so, we believe several years would be required to gather the data and develop the case-mix measures. For these reasons, we believe that interim prospective payment systems of the types contained in the President's FY 1997 budget should be put in place. Q. Interim Fee-for-Service Payment Method for Skilled Nursing Facility Services (Recommendation 22) Recommendation: An interim payment method should be implemented to control the growth in Medicare payments for SNF services until a comprehensive prospective payment system is established. A system based on historical data and facility-specific limits, however, may not allow facilities to respond appropriately to changes in a dynamic environment. Response: We agree with ProPAC's recommendation that an interim payment system should be developed until a permanent system is established. Both the interim and permanent payment systems could better promote the goals of quality care, maximum access to care, and cost containment. A payment system that incorporates these goals is essential as the nursing home industry evolves toward a more eclectic mix of care levels and delivery models. In addition, the need exists for a payment system that is simpler to administer for both providers and HCFA. In order to maximize these goals, a permanent prospective payment system for SNFs should include payment for all costs (that is, routine operating, ancillary, and capital costs) and take into account actual facility case mix. However, thecase-mix and ancillary cost data necessary to accomplish this goal are not yet available. In the interim, based on current data resources, a prospective payment system could be implemented. It would apply solely to routine costs (including routine capital costs) and utilize facility-specific payment rates subject to cost limits. We are studying various cost limit designs, such as regional limits versus national limits, to account for geographical cost differences. In addition, methodologies to ease the transition from the current payment system would be incorporated into an interim prospective payment system. While there is agreement that a need exists to implement an interim prospective payment system for SNFs, the Commission believes that a system based on historical data and facility-specific limits may not allow facilities to respond appropriately to changes in a dynamic environment. However, we believe that a facility-specific interim prospective payment system would provide a number of advantages over the current system, and could be constructed to accommodate changes in a facility's case mix. The system would provide for greater cost containment and administrative simplicity, through predetermined pricing. In addition, the potential to earn a profit under the interim system, by holding down costs, would provide an incentive for nursing homes to participate in Medicare, or certify more beds if already participating. This would provide greater access for beneficiaries. This same incentive would produce greater efficiency in nursing home operations and would support the provision of quality care. When compared to a flat rate system, a facility-specific system would maintain an appropriate distribution of payments, since the basis of payments under the system is the nursing homes' own cost history. As a nursing home case-mix classification system is finalized and tested, and further analysis is completed on ancillary payment, these elements would be incorporated into the payment system. In addition, we are analyzing some features of an interim system that would result in savings for the Medicare program. Specifically, in developing providers' facility-specific payment rates for routine services, the system would incorporate one set of cost limits based on freestanding costs only. The current system provides for separate (higher) limits for hospital-based facilities. Consequently, savings would result from holding down payments to these hospital-based SNFs. In addition, savings would result through the elimination of routine cost limit exemptions granted to new providers of skilled nursing services. The current system of cost limit exceptions for ``atypical nursing services'' would be eliminated as well. Finally, the Medicare Part B carrier fee schedules could be utilized for Part A SNF services as a limit on the reasonable costs of certain ancillary services. Currently, there are no limits or reasonable cost guidelines for many of these services. We support the ProPAC view that a per-episode payment system be developed. We have noted above, however, that there are great obstacles to developing both (1) prospective payment systems that are consistent across provider types with respect to the method of measuring resource use, and (2) classifications systems for episodes of postacute care (either by provider type or in general) that account for a sufficient degree of the variability among different types of patients. Thus, our inclination would be to pursue our current plans for the prospective payment systems with the thought that [[Page 27488]] further refinements could be made when data are available. R. Interim Fee-for-Service Payment Method for Home Health Care (Recommendation 23) Recommendation: Until a fully prospective payment system for home health care is developed, the Commission supports adopting episode- based payment limits. In addition, beneficiary copayments, subject to an annual limit, should be introduced. Response: There is agreement between ProPAC and HCFA that an interim cost control mechanism should be established prior to implementing a prospective payment system for home health care. We would like to highlight significant differences between the prospective payment systems proposed by the Congress and the Administration. The congressional proposal would limit payment to 120 days of service with certain exceptions for up to 165 days of care. This provision has the potential of serious financial impact on some agencies, as well as reduced access to services for some patients with the greatest needs. The proposal also assumes the availability of data and systems to categorize and assign patients to one of the 18 ``case- mix categories'' established in Phase II of HCFA's HHA prospective payment system demonstration. Neither the data nor the systems are currently in existence, and the implementation of such a system would entail a major increase in the reporting burden on agencies. Were we able to implement such a system, we estimate that the system would be able to explain less than 10 percent of the variation in cost per episode, at best. The Administration's interim proposal entails no increased reporting burden, as it uses data currently reported by agencies. Although that budget proposal does not provide for per-episode payments, its aggregate payment caps effectively create a per-episode cap on costs. Given the uncertainty about the resource composition of individual types of episodes, the use of an aggregate cap gives agencies an incentive to provide services in a cost effective manner by sharing savings with agencies whose costs are below their per beneficiary limitation. We note that ProPAC was also concerned that the interim proposal utilizes regional cost experience, which the Commission feels may not be appropriate. The President's FY 1997 budget includes a provision to use average national or regional cost experience in constructing the per beneficiary limitation. We agree with ProPAC that, should we find unjustified differences in regional cost experience, we would support a move to national cost experience as the basis for the per beneficiary limit. It may be necessary to use regional rates to move individual HHAs toward a national norm over time. This would avoid major displacements. We are considering both regional and national blending. We do not agree with the ProPAC recommendation that beneficiary copayments be introduced. Our proposed interim system of limits should adequately control the growth in service use. We do not agree with shifting costs to beneficiaries, however limited, as a method of controlling the growth in utilization. As HCFA moves forward in designing a prospective payment system for home health care, we will consider ProPAC's recommendations to look at more uniformly defined units of services. S. Update to the Composite Rate for Dialysis Services (Recommendation 24) Recommendation: The Secretary should develop methods to control total Medicare per capita expenditures for end stage renal disease (ESRD) beneficiaries. In the meantime, the composite rate should be updated by 2.7 percent for hospital-based dialysis facilities and by 2.0 percent for freestanding facilities for fiscal year 1997. The Secretary should also develop reliable measures of patient severity and outcomes to analyze the relationships among treatment processes, patient outcomes, and costs. These factors should be considered in evaluating the need for and the level of future payment updates. Response: One of ProPAC's suggestions is that HCFA consider opening enrollment for ESRD beneficiaries to participate in Medicare risk programs. The reason for this recommendation is the rapid growth in total Medicare spending for ESRD beneficiaries. A large part of this increase is attributable to the expanding ESRD population, especially older patients who require more services. These beneficiaries are using more acute inpatient, skilled nursing and other dialysis-related services than ever before. ProPAC suggests that to control these expenditures, Medicare examine the possibility of adopting a capitation payment system for ESRD services, since capitation rates have been successful in controlling expenditure growth for other populations. At a minimum, they are recommending that utilization review or other managed care techniques be used to control the total volume of services provided to ESRD beneficiaries across all sites of care. Section 1876(d) of the Act currently prevents an individual with ESRD from enrolling in an HMO or a competitive medical plan. However, an individual who is enrolled in a prepaid health plan when he or she is determined to have ESRD may continue enrollment in that plan. A prepaid health plan may only disenroll a beneficiary as provided by regulations at 417.460. Congress addressed the issue of paying for ESRD services in a capitation setting in legislation. Section 13567(b) of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) (August 10, 1993) amended section 2355 of Public Law 98-369 by requiring the Secretary to include the integration of acute and chronic care management for patients with ESRD through expanded community care case management services in a social health maintenance organization (SHMO). Initial legislation required the Secretary to grant demonstration waivers for SHMOs that provide for the integration of health and social services at a fixed annual prepaid capitation rate. In the January 26, 1996 Federal Register, we published a notice informing interested parties of the opportunity to apply for funds for a cooperative agreement to operate an ESRD Managed Care Demonstration (61 FR 2516). Two of the demonstration's purposes would be to test whether ESRD beneficiaries can and should be given access to HMOs during open enrollment and whether the statewide capitation rate can and should be adjusted. The demonstration would adjust rates for treatment status (such as dialysis, transplant, or a functioning graft), age groups and the cause of renal failure (for example, diabetes). As the legislation requires, rates would be based on 100 percent of the adjusted average per capita costs (AAPCC); additional non-Medicare-covered benefits would be offered by the provider to justify the additional 5 percent beyond the 95 percent of the AAPCC paid to Medicare risk-contracting HMOs on behalf of ESRD enrollees. Based on the results of this demonstration, we would make recommendations to Congress concerning the appropriateness of paying for dialysis services in a capitation setting. To improve the quality of care ESRD patients are receiving, we are in the process of developing proposed rules for ESRD conditions for coverage. The essence of the regulation is patient-centered and outcome-oriented. The proposed conditions for coverage will focus on facilities achieving an optimal [[Page 27489]] level of health and well-being for all dialysis patients. The proposed rules will be published in Spring 1996 with expected implementation in late fiscal year 1997. While we share ProPAC's concern that payment rates be sufficient to assure quality care for ESRD patients, we do not believe there is sufficient evidence at this point to conclude that more money is needed to provide appropriate care. Currently, the University of Michigan, as part of a National Institute of Health grant, is examining the relationship between facilities' costs and the level of KT/V. Also the National Institute of Diabetes and Digestive and Kidney Diseases is sponsoring a study on the impact of increasing dialysis as measured by KT/V and the use of high-flux-dialysis on ESRD patients. The results of these studies should help us analyze the relationship between patient outcomes and costs, and thus provide us with a basis for recommending an appropriate payment rate increase. While we acknowledge that an increase in the composite rate may be appropriate in the next few years, we believe that any rate increase should be linked to implementation of the revised conditions for coverage. Moreover, any ESRD rate increase must be considered within the context of Medicare budgetary concerns and should have a direct link to improved patient outcomes. We will continue to monitor ESRD facility costs, and, if appropriate, we may recommend an update to the ESRD composite rate for FY 1998. We note that ProPAC's recommendation provides for an across-the- board rate increase for all renal facilities. However, data show that high volume independent facilities (over 6,000 treatments per year) account for about 85 percent of independent dialysis treatments. These high volume facilities report margins between Medicare payments and costs that are higher than average. Therefore, in proposing a future rate increase, we would want to examine the need to adjust payment increases for volume. In addition, we believe that any update to the composite rate should include an update to the wage index currently used to adjust the labor portion of the rate. We are currently using an outdated wage index which is a blend of 1980 Bureau of Labor Statistics (BLS) and 1984 prospective payment system wage data and does not reflect the MSA revisions resulting from the 1990 census. The Commission's final recommendation is that the Secretary closely monitor treatment patterns and patient outcomes to ensure that facilities use the payment increase to improve quality of care. The proposed ESRD conditions for coverage should address this issue. We expect the proposed rule to be published in the Federal Register before Summer 1996. Between the publication of the proposed and final rules, HCFA is planning to meet with the renal community to develop complete clinical data sets to monitor patient outcomes and medical conditions. These data will then be used to evaluate the quality of dialysis services furnished by individual facilities. Of course, this is a long- term project. In the short term, we are exploring the possibility of collecting limited patient outcome data such as KT/V and URR. T. Prospective Payment for Hospital Outpatient Services (Recommendation 25) Recommendation: A comprehensive prospective payment system should be developed for hospital outpatient services. Such a system should include a strategy for controlling the volume of ambulatory services. Response: We agree with the need to implement a comprehensive prospective payment system for outpatient services. While we await legislative authority, we continue to develop and refine the Medicare- specific factors of the Ambulatory Patient Group (APG) system that we recommend using. We plan to analyze the payments that would be made across sites, for example in Ambulatory Surgical Centers (ASCs) or physician radiology practices, to ensure that we have not created unwarranted incentives to perform procedures in a given setting for financial reasons. We are concerned as well about the potential for increases in the volume of services provided, both in outpatient departments and in other settings. We are examining approaches to volume measurement and control, including the level of packaging for ancillary services and monitoring of patterns of care. For example, we could track whether Medicare beneficiaries received more clinic visits per patient under APGs than they did under cost-based reimbursement. If so, we could take corrective action either systemically or on a hospital-specific basis. This issue clearly requires study. We welcome suggestions in this area. U. Beneficiary Liability for Hospital Outpatient Services (Recommendation 26) Recommendation: The growing financial burden for Medicare enrollees who receive services in hospital outpatient departments should be alleviated immediately. Beneficiary coinsurance for these 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, the Secretary should establish a new method for determining beneficiary copayments based on estimated allowed payments since they cannot be calculated precisely when services are delivered. Response: We agree that the issue of beneficiary coinsurance should be addressed. In the context of the monies available to the Medicare program, we doubt that Congress would authorize that Medicare immediately assume the full cost of paying 80 percent of the cost of outpatient services. Among the approaches that could be used are: (1) Applying the savings achieved by eliminating the formula-driven overpayment to offset the beneficiaries' responsibility; (2) requiring copayments in other areas of the program, such as for home health services or laboratory services; and/or (3) moving gradually to reduce the ratio of copayments to total payments. One issue that must be considered at the same time is the rise in the Part B premium that would accompany any significant increase in program payments. This would have the effect of distributing costs over the entire range of beneficiaries, rather than having it focused only on those patients who actually use outpatient services, as it is now. We are eager to have this issue addressed and resolved, but know that it must be examined in light of broader budget decisions. IX. Other Required Information A. Paperwork Reduction Act The Paperwork Reduction Act of 1995 provides for notice and comment when a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: Whether the information collection is necessary and useful to carry out the proper functions of the agency; The accuracy of the agency's estimate of the information collection burden; The quality, utility, and clarity of the information to be collected; and Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. [[Page 27490]] Therefore, we are soliciting public comment on each of these issues for the information collection requirement discussed below. The only information collection or paperwork burden item contained in this proposed rule involves the requirement under Sec. 489.27 that a hospital furnish each Medicare beneficiary with a notice of discharge rights supplied by HCFA, that is, `An Important Message from Medicare.' As discussed in section V.F of this preamble, we are revising the current requirement that a hospital must distribute the `Important Message' to each Medicare beneficiary at or about the time of admission. In order to permit hospitals more flexibility, but still ensure that benficiaries are aware of their discharge rights, we are proposing to revise Sec. 489.27 to specify that a hospital must provide the notice of discharge rights `during the course of the hospital stay.' We estimate that the paperwork burden associated with the requirement that hospital personnel distribute the `Important Message' to each Medicare beneficiary is approximately 1 minute per admission. Based on our most recent available data (1995 Data Compendium, HCFA Pub. No. 03364), there are roughly 11 million Medicare beneficiaries admitted to hospitals each year, resulting in an annual burden of approximately 183,000 hours. This paperwork burden is not effective until it has been approved by OMB. A notice will be published in the Federal Register when approval is obtained. Organizations and individuals desiring to comment on this paperwork burden requirement should submit comments by July 30, 1996 to the Office of Management and Budget, Human Resources and Housing Branch, Room 10235, New Executive Office Building, Washington, D.C., 20503, Attention: Allison Herron Eydt, HCFA Desk Officer. 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, and on the internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. Data files are listed below with the cost of each. Anyone wishing to purchase data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to HCFA-PUF) to cover the cost, to the following address: Health Care Financing Administration, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, Maryland 21207-0520, (410) 786-3691. Files on the internet may be downloaded without charge. 1. Expanded Modified MEDPAR-Hospital (National) The Medicare Provider Analysis and Review (MEDPAR) file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in the United States. (The file is a Federal fiscal year file which means discharges occurring October 1 through September 30.)The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the 6- position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the Federal Register on December 24, 1984 (49 FR 49941), and amended by the July 2, 1985 notice (50 FR 27361). The national file consists of approximately 11 million records. Under the requirements of these notices, a data release agreement must be signed by the purchaser before release of these data. For all files requiring a signed data release agreement, please write or call to obtain a blank agreement form before placing an order. Two versions of this file are created each year. They support the following: Notice of Proposed Rulemaking (NPRM) published in the Federal Register, usually available by the end of May. This file is derived from the MedPAR file with a cutoff of 3 months after the end of the fiscal year (December file). Final Rule published in the Federal Register, usually available by the first week of September. This file is derived from the MedPAR file with a cutoff of 9 months after the end of the fiscal year (June file). Media: Tape/Cartridge File Cost: $3,415.00 per fiscal year Periods Available: FY 1988 through FY 1995 2. Expanded Modified MedPAR-Hospital (State) The State MedPAR file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in a particular State. The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the 6- position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the December 24, 1984 Federal Register notice, and amended by the July 2, 1985 notice. This file is a subset of the Expanded Modified MedPAR-Hospital (National) as described above. Under the requirements of these notices, a data release must be signed by the purchaser before release of these data. Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually available by the end of May. This file is derived from the MedPAR file with a cutoff of 3 months after the end of the fiscal year (December file). Final Rule published in the Federal Register, usually available by the first week of September. This file is derived from the MedPAR file with a cutoff of 9 months after the end of the fiscal year (June file). Media: Tape/Cartridge File Cost: $1,050.00 per State per year Periods Available: FY 1988 through FY 1995 3. HCFA Hospital Wage Index Data File This file is composed of four separate diskettes. Included are: (1) The hospital hours and salaries for FY 1993 used to create the proposed FY 1997 prospective payment system wage indexes; (2) a history of all wage indexes used since October 1, 1983; (3) a list of State and county codes used by SSA and FIPS (Federal Information Processing Standards), county name, and Metropolitan Statistical Area (MSA); and (4) a file of hospitals that were reclassified for the purpose of the FY 1997 wage index. Two versions of these files are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final Rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet File Cost: $500.00 Periods Available: FY 1997 PPS Update We note that the files also are available individually as indicated below. (1) HCFA Hospital Wage Index Survey Only (usually available by the end of March for the NPRM and the middle of August for the final rule.) (2) Urban and Rural Wage Indices Only (3) PPS SSA/FIPS MSA State and County Crosswalk Only (usually available by the end of March) [[Page 27491]] (4) Reclassified Hospitals by Provider Only Media: Diskette/Internet File cost: $145.00 per file 4. PPS-IV to PPS-XII Minimum Data Sets The Minimum Data Set contains cost, statistical, financial, and other information from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare participating hospital by the Medicare Fiscal Intermediary to HCFA. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge ------------------------------------------------------------------------ Periods beginning on and before or after ------------------------------------------------------------------------ PPS IV.................................. 10/01/86 10/01/87 PPS V................................... 10/01/87 10/01/88 PPS VI.................................. 10/01/88 10/01/89 PPS VII................................. 10/01/89 10/01/90 PPS VIII................................ 10/01/90 10/01/91 PPS IX.................................. 10/01/91 10/01/92 PPS X................................... 10/01/92 10/01/93 PPS XI.................................. 10/01/93 10/01/94 PPS XII................................. 10/01/94 10/01/95 ------------------------------------------------------------------------ (Note: The PPS XII Minimum Data Set covering 1995 will not be available until July 31, 1996.) File Cost: $715.00 per year 5. PPS-IX to PPS-XII Capital Data Set The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare certified hospital by the Medicare fiscal intermediary to HCFA. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge ------------------------------------------------------------------------ Periods beginning on and before or after ------------------------------------------------------------------------ PPS IX.................................. 10/01/91 10/01/92 PPS X................................... 10/01/92 10/01/93 PPS XI.................................. 10/01/93 10/01/94 PPS XII................................. 10/01/94 10/01/95 ------------------------------------------------------------------------ (Note: The PPS XII Capital Data Set covering 1994 will not be available until July 31, 1996.) File Cost: $715.00 per year 6. Provider-Specific File This file is a component of the PRICER program used in the fiscal intermediary's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements. Media: Tape/Cartridge File Cost: $500.00 per file Periods Available: FY 1987 through FY 1996 (December updates) Media: Diskette/Internet File Cost: $265.00 Periods Available: FY 1996 PPS Update 7. HCFA Medicare Case-Mix Index File This file contains the Medicare case-mix index by provider number as published in each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet Price: $145.00 per year Periods Available: FY 1985 through FY 1995 (Internet--FY 1995) 8. Table 5 DRG File This file contains a listing of DRGs, DRG narrative description, relative weight, geometric mean, length of stay, and day outlier trim points as published in the Federal Register. The hardcopy image has been copied to diskette. There are two versions of this file as published in the Federal Register: a. NPRM, usually published by the end of May. b. Final rule, usually published by the first week of September. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1997 PPS Update 9. PPS Payment Impact File This file contains data used to estimate payments under Medicare's hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the Federal Register. This file is available for release 1 month after the proposed and final rules are published in the Federal Register. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1997 PPS Update 10. AOR/BOR Tables This file contains data used to develop the DRG relative weights. It contains mean, maximum, minimum, standard deviation and coefficient of variation statistics by DRG for length of stay and standardized charges. The BOR tables are ``Before Outliers Removed'' and the AOR is ``After Outliers Removed.'' (Outliers refers to statistical outliers, not payment outliers.) Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1997 PPS Update 11. HCFA FY 1992 Capital-Related Tax File This file contains data used to develop a special property tax adjustment to the capital prospective payment system for capital- related costs. The data set includes a preliminary hospital-specific add-on amount for all PPS hospitals. The data set also contains the information used to propose an adjustment to the Federal rate so that the tax add-on is budget neutral. The proposed property tax adjustment provides special treatment to qualified hospitals who pay capital- related property taxes. The add-on was 10. determined using base year tax costs per discharge attributable to Medicare. The data are taken from the FY 1992 Medicare hospital cost report and a special request for validation by the fiscal intermediaries. Media: Diskette File cost: $145.00 Period available: FY 1992 For further information concerning these data tapes, contact Mary R. White at (410) 786-0168. Commenters interested in obtaining or discussing any other data used in constructing this rule should contact Stephen Phillips at (410) 786-4548. [[Page 27492]] C. Public Comments Because of the large number of items of correspondence we normally receive on a proposed rule, we are not able to acknowledge or respond to them individually. However, in preparing the final rule, we will consider all comments concerning the provisions of this proposed rule that we receive by the date and time specified in the ``Dates'' section of this preamble and respond to those comments in the preamble to that rule. We emphasize that, given the statutory requirement under section 1886(e)(5) of the Act that our final rule for FY 1997 be published by September 1, 1996, we will consider only those comments that deal specifically with the matters discussed in this proposed rule. 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 489 Health facilities, Medicare. 42 CFR chapter IV would be amended as set forth below: A. Part 412 would be 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 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart D--Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs 2. In Sec. 412.63(s)(1), a new sentence is added at the end to read as follows: Sec. 412.63 Federal rates for inpatient operating costs for fiscal years after Federal fiscal year 1984. * * * * * (s) * * * (1) * * * The wage index is updated annually. * * * * * Subpart L--The Medicare Geographic Classification Review Board 3. In 412.246, paragraph (b) is revised to read as follows: Sec. 412.246 MGCRB members. * * * * * (b) Term of office. The term of office for an MGCRB member may not exceed 3 years. A member may serve more than one term. The Secretary may terminate a member's tenure prior to its full term. Subpart M--Prospective Payment System for Inpatient Hospital Capital Costs 4. In Sec. 412.302, a new paragraph (d)(4) is added to read as follows: Sec. 412.302 Introduction to capital costs. * * * * * (d) * * * (4) Hospitals may elect the simplified cost allocation methodology under the terms and conditions provided in the instructions for HCFA Form 2552. B. Part 413 would be amended as follows: PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES 1. The authority citation for part 413 continues to read as follows: Authority: Secs. 1102, 1861(v)(1)(A), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh). Subpart C--Limits on Cost Reimbursement 2. In Sec. 413.40, paragraph (d)(3) is revised to read as follows: Sec. 413.40 Ceiling on the rate of increase in hospital inpatient costs. * * * * * (d) * * * (3) Net inpatient operating costs are greater than the ceiling. For cost reporting periods beginning on or after October 1, 1991, if a hospital's allowable net inpatient operating costs exceed the hospital's ceiling (or the adjusted ceiling, if applicable), payment will be based on the lower of the-- (i) Ceiling (or the adjusted ceiling, if applicable) plus 50 percent of the allowable net inpatient operating costs in excess of the ceiling (or the adjusted ceiling, if applicable); or (ii) One hundred-ten percent of the ceiling (or the adjusted ceiling, if applicable). * * * * * Subpart F--Specific Categories of Costs 3. In Sec. 413.86, a new sentence is added at the end of paragraph (g)(1) introductory text to read as follows: Sec. 413.86 Direct graduate medical education payments. * * * * * (g) * * * (1) * * * For combined residency programs, an inital residency period is defined as the time required for individual certification in the longer of the two programs. * * * * * C. Part 489 would be amended as follows: PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 1. The authority citation for part 489 continues to read as follows: Authority: Secs. 1102, and 1871 of the Social Security Act (42 U.S.C. 1302, and 1395hh). Subpart B--Essentials of Provider Agreements 2. Section 489.27 is revised to read as follows: Sec. 489.27 Beneficiary notice of discharge rights. A hospital that participates in the Medicare program must furnish each Medicare beneficiary, or an individual acting on his or her behalf, the notice of discharge rights HCFA supplies to the hospital to implement section 1886(a)(1)(M) of the Act. The hospital must provide timely notice during the course of the hospital stay. For purposes of this paragraph, the course of the hospital stay may begin with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission. The hospital must be able to demonstrate compliance with this requirement. (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) [[Page 27493]] Dated: May 13, 1996. Bruce C. Vladeck, Administrator, Health Care Financing Administration. Dated: May 24, 1996. Donna E. Shalala, Secretary. [Editorial Note: The following addendum and appendixes will not appear in the Code of Federal Regulations.] Addendum--Proposed Schedule of Standardized Amounts Effective With Discharges on or After October 1, 1996 and Update Factors and Rate- of-Increase Percentages Effective With Cost Reporting Periods Beginning on or After October 1, 1996 I. Summary and Background In this addendum, we are setting forth the proposed amounts and factors for determining prospective payment rates for Medicare inpatient operating costs and Medicare inpatient capital-related costs. We are also setting forth proposed 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, 1996, except for sole community hospitals and hospitals located in Puerto Rico, each hospital's payment per discharge under the prospective payment system will be 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. For hospitals in Puerto Rico, the payment per discharge is based on the sum of 75 percent of a Puerto Rico rate and 25 percent of a national rate (section 1886(d)(9)(A) of the Act). As discussed below in section II, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs. The changes, to be applied prospectively, would affect the calculation of the Federal rates. In section III, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs. Section IV sets forth our proposed 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 proposed rule are presented at the end of this addendum in section V. II. Proposed Changes to Prospective Payment rates For Inpatient Operating Costs for FY 1997 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. Below, we discuss the manner in which we are changing some of the factors used for determining the prospective payment rates. The Federal and Puerto Rico rate changes, once issued as final, will be effective with discharges occurring on or after October 1, 1996. As required by section 1886(d)(4)(C) of the Act, we must also adjust the DRG classifications and weighting factors for discharges in FY 1997. In summary, the proposed standardized amounts set forth in Tables 1a and 1c of section V of this addendum reflect-- Updates of 2.2 percent for all areas (that is, the market basket percentage increase of 2.7 percent minus 0.5 percentage points); 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 large 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 1996 budget neutrality factor and applying a revised factor; and An adjustment to apply the revised outlier offset by removing the FY 1996 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 1997 were made. That is, the standardization adjustments reflected in the FY 1997 standardized amounts are the same as those reflected in the FY 1996 standardized amounts. Under sections 1886 (d)(2)(H) and (d)(3)(E) of the Act, in making payments under the prospective payment system, the Secretary estimates from time to time the proportion of costs that are wages and wage- related costs. Since October 1, 1990, when the market basket was last rebased, we have considered 71.4 percent of costs to be labor-related for purposes of the prospective payment system. As discussed in section IV of the preamble, we are proposing to use a rebased market basket effective for FY 1997. Based on the proposed rebased market basket, we are revising the labor and nonlabor proportions of the standardized amounts. Effective with discharges occurring on or after October 1, 1996, we are proposing a labor-related proportion of 71.2 percent and a nonlabor-related proportion of 28.8 percent. The standardized amounts in Table 1a of section V of this addendum have been recomputed to reflect the revised labor-related and nonlabor-related proportions. (We are revising the Puerto Rico standardized amounts by the average labor share in Puerto Rico of 82.8 percent. We are revising the discharged- weighted national [[Page 27494]] standardized amount to reflect the proportion of discharges in large urban and other areas from the FY 1995 MedPAR file.) 2. Computing Large Urban and Other Averages Within Geographic Areas 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 sections 1886(d)(9) (B)(iii) and (C)(i) of the Act, the average standardized amount per discharge must be determined for hospitals located in 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 ``urban areas'' as those areas within a Metropolitan Statistical Area (MSA). A ``large urban area'' is defined 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 1995 population estimates published by the Bureau of the Census, 56 areas meet the criteria to be defined as large urban areas for FY 1997. These areas are identified by an asterisk in Table 4a. Table 1a contains the two national standardized amounts that we are proposing be applicable to all hospitals, except for sole community hospitals and hospitals in Puerto Rico. For a number of years, Table 1b had been used to set forth the 18 regional standardized amounts applicable for hospitals located in census areas subject to the regional floor. However, as provided in section 1886(d)(1)(A)(iii)(II) of the Act, the regional floor expires effective with discharges occurring on or after October 1, 1996. Therefore, all hospitals (except sole community hospitals and hospitals in Puerto Rico) will be paid solely on the basis of the national standardized amounts. 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 standardized amount (as set forth in Table 1a). The national average standardized amount for Puerto Rico is now set forth in Table 1b. This table also includes the two standardized amounts that would be applicable to most hospitals in Puerto Rico. 3. Updating the Average Standardized Amounts In accordance with section 1886(d)(3)(A)(iv) of the Act, we are proposing to update the large urban and the other areas average standardized amounts for FY 1997 using the applicable percentage increases specified in section 1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XII) of the Act specifies that, for hospitals in all areas, the update factor for the standardized amounts for FY 1997 is the market basket percentage increase minus 0.5 percentage points. 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 forecast of the proposed rebased hospital market basket increase for FY 1997 is 2.7 percent. For FY 1997, this yields an update to the average standardized amounts of 2.2 percent (2.7 percent minus 0.5 percent). (See section IV of this preamble of this proposed rule for a discussion of the market basket rebasing.) As in the past, we are adjusting the FY 1996 standardized amounts to remove the effects of the FY 1996 geographic reclassifications and outlier payments before applying the FY 1997 updates. That is, we are increasing the standardized amounts to restore the reductions that were made for the effects of geographic reclassification and outliers. After including offsets to the standardized amounts for outliers and geographic reclassification, we estimate that there will be an actual increase of 2.3 percent to the large urban and other area standardized amounts. Although the update factor for FY 1997 is set by law, we are required by section 1886(e)(3)(B) of the Act to report to Congress on our initial recommendation of update factors for FY 1997 for both prospective payment hospitals and hospitals excluded from the prospective payment system. For general information purposes, we have included the report to Congress as Appendix D to this proposed rule. Our proposed recommendation on the update factors (which is required by sections 1886 (e)(4)(A) and (e)(5)(A) of the Act), as well as our responses to ProPAC's recommendation concerning the update factor, are set forth as Appendix E to this proposed 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 ensures 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. Section 1886(d)(3)(E) of the Act specifies that the hospital wage index must be updated 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 ensures 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 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 budget neutral, we compared aggregate payments using the FY 1996 relative weights and wage index to aggregate payments using the proposed FY 1997 relative weights and wage index. The same methodology was used for the FY 1996 budget neutrality adjustment. (See the discussion in the September 1, 1992 final rule (57 FR 39832).) Based on this comparison, we computed a budget neutrality adjustment factor equal to 0.998509. This budget neutrality adjustment factor is applied to the standardized amounts without removing the effects of the FY 1996 budget neutrality adjustment. We do not remove the prior budget neutrality adjustment because estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we [[Page 27495]] removed the prior year adjustment, we would not satisfy this condition. In addition, we are proposing to continue to apply the same FY 1997 adjustment factor to the hospital-specific rates that are effective for cost reporting periods beginning on or after October 1, 1996, 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 FY 1997 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. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the 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 are equal to the aggregate prospective payments that would have been made absent these provisions. To calculate this budget neutrality factor, we used historical discharge data to simulate payments, and compared total prospective payments (including IME and DSH payments) prior to any reclassifications to total prospective payments after reclassifications. We are applying an adjustment factor of 0.994059 to ensure that the effects of reclassification are budget neutral. The adjustment factor is applied to the standardized amounts after removing the effects of the FY 1996 budget neutrality adjustment factor. We note that the proposed FY 1997 adjustment reflects wage index and standardized amount reclassifications approved by the MGCRB or the Administrator as of March 14, 1996. The effects of any additional reclassification changes resulting from appeals and reviews of the MGCRB decisions for FY 1997 or from a hospital's request for the withdrawal of a reclassification request will be reflected in the final budget neutrality adjustment required under section 1886(d)(8)(D) of the Act and published in the final rule for FY 1997. c. Outliers. Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases, cases involving extraordinarily high costs (cost outliers) or long lengths of stay (day outliers). Section 1886(d)(3)(B) of the Act requires the Secretary to adjust both the large urban and other area national standardized amounts by the same factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to adjust the large urban and other standardized amounts applicable to hospitals in Puerto Rico by the same factor to account for the estimated proportion of total DRG payments made to outlier cases. Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year must be projected to be not less than 5 percent nor more than 6 percent of total payments based on DRG prospective payment rates. Beginning with FY 1995, section 1886(d)(5)(A) of the Act requires the Secretary to phase out payments for day outliers (correspondingly, payments for cost outliers would increase). Under the requirements of section 1886(d)(5)(A)(v), the proportion of day outlier payments to total outlier payments is reduced from FY 1994 levels as follows: 75 percent of FY 1994 levels in FY 1995, 50 percent of FY 1994 levels in FY 1996, and 25 percent of FY 1994 levels in FY 1997. We estimated the FY 1994 proportion of day outlier payments to total outlier payments at 31.3 percent in our September 1, 1993 final rule (58 FR 46348). Thus, the proportion of day outlier payments to total outlier payments in FY 1997 will be approximately 8 percent (25 percent of 31.3 percent). For discharges occurring after September 30, 1997, the Secretary will no longer pay for day outliers under the provisions of section 1886(d)(5)(A)(i) of the Act. i. Proposed FY 1997 Outlier Payment Policies, Including Outlier Thresholds. For FY 1996, 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 (the percent of Medicare's average per diem payment paid for each outlier day) is 44 percent for FY 1996. The fixed loss cost outlier threshold is equal to the prospective payment for the DRG plus $15,150 ($13,800 for hospitals that have not yet entered the prospective payment system for capital-related costs). The marginal cost factor for cost outliers (the percent of costs paid after costs for the case exceed the threshold) is 80 percent. We applied an outlier adjustment to the FY 1996 standardized amounts of 0.949054 for the large urban and other areas rates and 0.9526 for the capital Federal rate. For FY 1997, we propose to set the day outlier threshold at the geometric mean length of stay for each DRG plus the lesser of 24 days or 3.0 standard deviations. Section 1886(d)(5)(A)(iii) of the Act, as amended by section 13501(c)(3) of Public Law 103-66, provides that additional payments for day outlier cases may be reduced below the marginal cost of care to meet the requirements of section 1886(d)(5)(A)(v) of the Act. We are proposing to reduce the marginal cost factor for each outlier day from 44 percent to 35 percent in FY 1997. We estimate that our proposed policies will reduce the proportion of outlier payments paid as day outliers in FY 1997 to approximately 8 percent, in accordance with section 1886(d)(5)(A) of the Act. We are also proposing a fixed loss cost outlier threshold in FY 1997 equal to the prospective payment rate for the DRG plus $11,050 ($10,075 for hospitals that have not yet entered the prospective payment system for capital-related costs). In addition, we are proposing to maintain the marginal cost factor for cost outliers at 80 percent. In accordance with section 1886(d)(5)(A)(iv) of the Act, we calculated proposed outlier thresholds so that outlier payments are projected to equal 5.1 percent of total payments based on DRG prospective payment rates. In accordance with section 1886(d)(3)(E), we reduced the proposed FY 1997 standardized amounts by the same percentage to account for the projected proportion of payments paid to outliers. As stated in the September 1, 1993 final rule (58 FR 46348), we establish outlier thresholds that are applicable to both inpatient operating costs and inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a higher percentage of outlier payments for capital-related costs than for operating costs. We project that the proposed thresholds for FY 1997 will result in outlier payments equal to 5.1 percent of operating DRG payments and 5.2 percent of capital payments based on the Federal rate. Thus, the proposed outlier adjustment factors applied to the standardized amounts and the capital Federal rate for FY 1997 are as follows: [[Page 27496]] ------------------------------------------------------------------------ Capital Operating Standardized Amounts Federal Rate ------------------------------------------------------------------------ 0.948968..................................................... 0.9476 ------------------------------------------------------------------------ We would apply the proposed outlier adjustment factors after removing the effects of the FY 1996 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 would replace the ratios published in the September 1, 1995 final rule (60 FR 45922), effective October 1, 1996. Table 8b contains comparable Statewide average capital cost-to-charge ratios. These average ratios would be used to calculate cost outlier payments for those hospitals for which the intermediary computes operating cost- to-charge ratios lower than 0.24345 or greater than 1.30392 and capital cost-to-charge ratios lower than 0.013297 or greater than 0.19968. 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. We note that the cost-to-charge ratios in Tables 8a and 8b would be used for all cost reports settled during FY 1997 (regardless of the actual cost reporting period) when hospital-specific cost-to-charge ratios are either not available or outside the three standard deviations range. iii. FY 1995 and FY 1996 Outlier Payments. In the September 1, 1995 final rule (59 FR 45408), we stated that, based on available data, we estimated that actual FY 1995 outlier payments would be approximately 4.0 percent of actual total DRG payments. This percentage was computed by simulating payments using actual FY 1994 bill data available at the time. That is, the estimate of actual outlier payments did not reflect actual FY 1995 bills but instead reflected the application of FY 1995 rates and policies to available FY 1994 bills. Our current estimate, using available FY 1995 bills, is that actual outlier payments for FY 1995 were approximately 3.7 percent of actual total DRG payments (lower than the 5.1 percent we projected in setting outlier policies for FY 1995). We note that the MedPAR file for FY 1995 discharges continues to be updated. We currently estimate that actual outlier payments for FY 1996 will be approximately 4.2 percent of actual total DRG payments (lower than the 5.1 percent we projected in setting outlier policies for FY 1996). This estimate is based on simulations using the December 1995 update of the provider-specific file and the December 1995 update of the FY 1995 MedPAR file (discharge data for FY 1995 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 1996 by applying FY 1996 rates and policies to available FY 1995 bills. The following discussion addresses the methodology we use to set outlier thresholds for an upcoming fiscal year and also addresses possible explanations for the difference between projected and actual outlier payment percentages in recent years. iv. Methodology for Setting Outlier Thresholds. In previous rulemaking documents, we have discussed the methodology for setting outlier thresholds as well as our periodic refinements to that methodology. In this document, we once again describe our methodology and analyze it to suggest some possible explanations for the recent differences between projected and actual outlier percentages. We invite comments and suggestions for further refinements to the methodology. In General. In accordance with section 1886(d)(5)(A)(iv) of the Act, we set outlier thresholds so that outlier payments are expected (projected) to equal 5.1 percent of total payments based on DRG prospective payment rates. The databases used to calculate thresholds for an upcoming fiscal year include data on discharges from a previous fiscal year as well as hospital-specific data. We update the data every year. In setting the proposed FY 1997 outlier thresholds, we used the December 1995 update of the FY 1995 MedPAR file, which contains data on FY 1995 hospital inpatient discharges, and the December 1995 update of the provider-specific file, which contains information on hospital- specific payment parameters (such as cost-to-charge ratios). The methodology for setting outlier thresholds for an upcoming fiscal year involves analyzing the set of hospital inpatient cases in the MedPAR file and simulating payments for those cases by using the payment rates and policies that would apply in the upcoming fiscal year. For example, in calculating the proposed thresholds for FY 1997, we used the proposed payment rates and policies for FY 1997 and simulated payments for the set of cases in the FY 1995 MedPAR file. The computer simulation calculates ``payments''--outlier payments and total payments--for all discharges for a given set of outlier thresholds. In order to achieve established objectives (for example, the projected percentage of outlier payments relative to total DRG payments is 5.1 percent, and the projected percentage of outlier payments attributable to day outliers is 8 percent for FY 1997), the methodology involves an iterative process, that is, numerous successive simulations using alternative sets of outlier thresholds. In short, then, the outlier estimation methodology involves analyzing historical discharge data, simulating payments for the discharges in the database by using the payment rates that would apply in the upcoming fiscal year, and testing alternative sets of outlier thresholds until the simulations are consistent with established objectives. Cost Inflation Factors. In setting outlier thresholds for an upcoming fiscal year, we need to calculate the ``costs'' for each case in our database. In the payment simulations, this ``cost'' for each case is used to determine, for a given cost outlier threshold, whether a case qualifies for additional outlier payments and the amount of any such payments. (As explained above, we test alternative sets of thresholds.) The MedPAR file includes data on billed charges, and as part of the estimation methodology, we make adjustments to convert the charges to costs, including adjusting the data for inflation. In setting the proposed outlier thresholds for FY 1997, we analyzed data for FY 1995 discharges. As we explained in the September 1, 1993 final rule (58 FR 46347), prior to FY 1994, we used a charge inflation factor to adjust charges to costs; for example, in setting outlier thresholds for FY 1993, we adjusted the FY 1991 MedPAR file charge data by a charge inflation factor for 2 years in order to estimate FY 1993 charges and then applied the applicable cost-to-charge [[Page 27497]] ratio. Beginning with FY 1994, we have used a cost inflation factor to estimate ``costs''; that is, we adjust the charges by the cost-to- charge ratio and then adjust the resulting costs for 2 years of cost inflation. This adjustment automatically accounts for any changes in the cost-to-charge ratios that may occur, since the relevant variable is the estimated ``costs'' for a given case. In setting the final outlier thresholds for recent years immediately prior to FY 1995, we determined cost inflation factors by analyzing cost report information to calculate moving averages of cost inflation for prior periods. (For example, in setting the FY 1994 outlier thresholds, we analyzed cost reports for cost reporting periods beginning in FY 1988 through FY 1991 to calculate a cost inflation factor, that is, the average annual increase in cost per case, of 8.3 percent.) In doing so, we made an audit adjustment for any cost report that had not been settled, based on the average ratio of submitted to final cost report data. In setting the final outlier thresholds for FYs 1995 and 1996, we determined cost inflation factors by analyzing cost report information and calculating the change in cost per case for one year, rather than the average change in cost per case over more than one year. In setting the proposed FY 1997 outlier thresholds, we used a cost inflation factor of 0.0 percent, because it is unclear whether FY 1997 ``costs'' will be higher or lower than costs reflected in the FY 1995 MedPAR file. Analysis of recent cost report information shows that cost per case increased slightly for cost reporting periods beginning in FY 1993 relative to those beginning in FY 1992, but decreased slightly in the following year (that is, for cost reporting periods beginning in FY 1994 relative to those beginning in FY 1993). We will reevaluate this factor when we develop the final rule for FY 1997. At that time, more recent data should be available for analysis, specifically, cost report data for cost reporting periods beginning in FY 1995. Differences Between Projected and Actual Outlier Percentages. As explained above, the cost inflation factor is an important aspect of the methodology for setting outlier thresholds, and we believe the cost inflation factor is a major reason that in recent years the actual outlier percentages (the proportion of actual outlier payments to actual total DRG payments) have been lower than projected. In determining the cost inflation factor, we analyze historical hospital cost report information, and there is necessarily a time lag of 2 to 3 years between the cost reporting period itself and the time when data for that cost reporting period become available. For example, in setting the FY 1994 outlier thresholds, we used a cost inflation factor of 8.3 percent, derived from cost reports for cost reporting periods beginning in FY 1988 through FY 1991. We adjusted the charges from the FY 1992 MedPAR bills by the cost-to-charge ratio and then adjusted the resulting FY 1992 costs for 2 years of cost inflation (costs multiplied by 1.083 multiplied by 1.083) to estimate ``FY 1994 costs.'' However, analysis of more recent cost report information shows that cost per case increased at a much lower rate of 0.97 percent in cost reporting periods between FY 1992 and FY 1993 and actually decreased 1.77 percent in cost reporting periods between FY 1993 and FY 1994. In effect, we ``overestimated'' costs by approximately 15.4 percent. Since costs did not increase at nearly the rate we expected, actual costs in FY 1994 proved to be lower than those reflected in the simulations used to set the thresholds for FY 1994; accordingly, the proportion of outlier payments was lower than expected. Another aspect of the outlier methodology that may have contributed to the difference between projected and actual outlier percentages concerns the payment adjustments for indirect medical education (IME) and disproportionate share hospitals (DSH). As indicated in previous rulemaking documents, for purposes of determining outlier payments, we standardize a hospital's costs for IME and DSH adjustments; that is, we reduce the hospital's costs for a given discharge to account for IME and DSH payments. The ``standardized'' cost for a discharge is calculated by taking total costs for the discharge and dividing it by the sum of one plus the hospital's DSH factor plus the hospital's IME factor. Therefore, the higher the IME and DSH factors, the more costs are reduced by standardization. The factors used for purposes of setting thresholds are taken from the most recent provider-specific file. In setting the proposed FY 1997 outlier thresholds, we used information from the December 1995 update of the provider-specific file. We standardized the costs for each discharge in our database to account for IME and DSH adjustments. The proposed outlier thresholds reflect these standardized costs. While we use the latest, most up-to-date sources of information, the ``projected'' IME and DSH factors (the factors used to set thresholds for a fiscal year) may differ from the actual IME and DSH factors used to make payments in that fiscal year. If the ``projected'' factors used to standardize costs for a given discharge are ``too low,'' then standardization does not ``sufficiently'' reduce the costs for that discharge and the resulting standardized cost is ``too high.'' If the standardized costs for the discharges analyzed to set outlier thresholds are generally ``too high,'' then in turn the thresholds would be too high; consequently, this might result in a lower than expected proportion of outlier payments. Analysis shows that, for FY 1994 for example, the ``projected'' IME and DSH factors were on average lower than the actual factors. Conclusion. As we have done since the inception of the prospective payment system, we determine outlier thresholds based on estimates before the beginning of each fiscal year. The methodology we use involves analysis of the best data available at the time thresholds are established; however, by their nature, projections are imprecise and may differ from actual payment data for any number of reasons. We discussed above some of the numerous factors that affect payment and why these particular factors may have contributed to the difference between projected and actual outlier payments in recent years. (See also, for example, the discussion in the September 1, 1995 final rule (60 FR 45855).) We note that any difference between projected and actual outlier payment percentages in a given year does not affect standardized amounts in future years. We continue to explore refinements to the methodology for setting outlier thresholds. We welcome comments and suggestions regarding these issues. B. Adjustments for Area Wage Levels and Cost of Living The adjusted standardized amounts are divided into labor and nonlabor portions. Tables 1a 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. This section addresses two types of adjustments to the standardized amounts that are made in determining the prospective payment rates as described in this addendum. 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 [[Page 27498]] adjustment is made 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 1997, we propose to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor portion of the standardized amounts by the appropriate adjustment factor contained in the table below. If the Office of Personnel Management releases revised cost-of-living adjustment factors before August 1, 1996, we will publish them in the final rule and use them in determining FY 1997 payments. 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............................................... 1.20 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 classification system for all hospital discharges, assigning them into DRGs, and have developed relative weights for each DRG that reflect the resource utilization of cases in each DRG relative to Medicare cases in other DRGs. Table 5 of section V of this addendum contains the relative weights that we propose to use for discharges occurring in FY 1997. These factors have been recalibrated as explained in section II of the preamble. D. Calculation of Prospective Payment Rates for FY 1997 General Formula for Calculation of Prospective Payment Rates for FY 1997 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 updated FY 1982 hospital-specific rate, or 100 percent of the updated 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 national large urban standardized amount and the national other standardized amount. 1. Federal Rate For discharges occurring on or after October 1, 1996 and before October 1, 1997, except for sole community hospitals and hospitals in Puerto Rico, the hospital's payment is based exclusively on the Federal national rate. Section 1866(d)(1)(A)(iii) of the Act provides that the Federal rate is comprised of 100 percent of the Federal national rate. The payment amount is determined as follows: Step 1--Select the appropriate national standardized amount considering the type of hospital and designation of the hospital as large urban or other (see Tables 1a, 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 1997. We are proposing to increase the hospital-specific rates by 2.2 percent (the hospital market basket percentage increase minus 0.5 percentage points) for sole community hospitals located in all areas in FY 1997. Section 1886(b)(3)(C)(ii) of the Act provides that the update factor applicable to the hospital-specific rates for sole community hospitals equals the update factor provided under section 1886(b)(3)(B)(ii) of the Act, which, for FY 1997, is the market basket rate of increase minus 0.5 percentage points. b. Calculation of Hospital-Specific Rate. For sole community hospitals, the applicable FY 1997 hospital-specific rate would be calculated by multiplying a hospital's hospital-specific rate for the preceding fiscal year by the applicable update factor (2.2 percent), which is the same as the update for all prospective payment hospitals. In addition, the hospital-specific rate would be adjusted by the budget neutrality adjustment factor (that is, 0.998509) as discussed in section II.A.4.a of this Addendum. This resulting rate would be used in determining under which rate a sole community hospital is paid for its discharges beginning on or after October 1, 1996, 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, 1996 and Before October 1, 1997. 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 1b, 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). [[Page 27499]] 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 1b, 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. Proposed Changes to Payment Rates for Inpatient Capital-Related Costs for FY 1997 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 a hospital's historical costs for capital. The basic methodology for determining Federal capital prospective rates is set forth at Secs. 412.308 through 412.352. Below we discuss the factors that we used to determine the proposed Federal rate and the hospital-specific rates for FY 1997. The rates will be effective for discharges occurring on or after October 1, 1996. 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 update the standard Federal rate, as provided in Sec. 412.308(c)(1), to account for capital input price increases and other factors. Also, Sec. 412.308(c)(2) provides that the Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the Federal rate to total capital payments under the Federal rate. Section 412.308(c)(3) further requires that the Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments 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 required that the Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. 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. For FY 1992 through FY 1995, the hospital-specific rate was also adjusted by a 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. With the expiration of the budget neutrality provision, the model is still used to estimate the exceptions payment adjustment and other factors. 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 for operating costs 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 1996, the Federal rate is $461.96. With the changes we are proposing to the factors used to establish the Federal rate, the proposed FY 1997 Federal rate is $441.84. In the discussion that follows, we explain the factors that were used to determine the proposed FY 1997 Federal rate. In particular, we explain why the FY 1997 Federal rate has decreased 4.36 percent compared to the FY 1996 Federal rate. Nevertheless, as explained in section VII of Appendix A, capital payments per case are estimated to increase 4.45 percent. Taking into account the effects of increases in projected discharges, we also estimate that aggregate capital payments will increase 7.28 percent. The major factor contributing to the decrease in the proposed FY 1997 rate in comparison to the FY 1996 rate is the change in the exceptions reduction factor. We have expected the number and amount of exceptions payments generally to increase throughout the transition period. Total payments to hospitals under the prospective payment system are relatively insensitive to changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1 percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital prospective payment transition system are estimated to increase in FY 1997 compared to FY 1996. Specifically, we estimate that aggregate payments in FY 1997 will be 7.28 percent higher than they were in FY 1996. Changes in aggregate payments include changes in capital payments per discharge and changes in the number of discharges. Under the prospective payment system for capital-related costs, payments per discharge (or case) are estimated to increase 4.45 percent in FY 1997 compared to FY 1996. 1. Standard Federal Rate Update Section 412.308(c)(1) has provided that the standard Federal rate is updated on the basis of an analytical framework [[Page 27500]] that takes into account changes in a capital input price index and other factors. The update framework consists of a capital input price index (CIPI) and several policy adjustment factors. Specifically, we have adjusted the projected CIPI rate of increase as appropriate each year for case-mix index related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 1997 under that framework is 1.0 percent. This proposal is based on a projected 1.0 percent increase in the CIPI, and on policy adjustment factors of zero. We explain the basis for the FY 1997 CIPI projection in section IV.B of the preamble to this proposed rule. Here we describe the policy adjustments that have been applied. 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''). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher-weighted DRGs but do not reflect higher resource requirements. 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 have adopted this CMI adjustment in the capital update framework as well. For FY 1997, we are projecting a 1.6 percent increase in the case- mix index. We estimate that real case-mix increase will equal projected case-mix increase in FY 1997. We do not anticipate any changes in coding behavior in our projected case-mix change. We explain the basis for this determination in Appendix D to this proposed rule. The proposed net adjustment for case-mix change in FY 1997 is therefore 0.0 percentage points. We estimate that DRG reclassification and recalibration resulted in a 0.0 percent change in the case mix when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. 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 upcoming year. In any given year there may be unanticipated price fluctuations that may result in differences between the actual increase in prices faced by hospitals and the forecast used in calculating the update factors. In setting a prospective payment rate under the proposed framework, we 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. Because we only introduced this analytical framework in FY 1996, FY 1998 is the first year in which a forecast error adjustment could be required. Under the capital prospective payment system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data as in the framework for the operating prospective payment system. 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 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 have therefore incorporated the 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 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 thus provides 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. For FY 1997, we have developed a Medicare-specific intensity measure based on a five-year average using FY 1991-1995. In determining case-mix constant intensity, we found that observed case-mix increase was 2.8 percent in FY 1991, 1.8 percent in FY 1992, 0.9 percent in FY 1993, 0.8 percent in FY 1994, and 1.6 percent in FY 1995. For FY 1991 and FY 1992, we estimate that real case-mix increase was 1.0 to 1.4 percent each year. The estimate for those years is supported by past studies of case-mix change by the RAND Corporation. The most recent study was ``Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988'' by G.M. Carter, J.P. Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991). The study suggested that real case- mix change was not dependent on total change, but was rather a fairly steady 1.0 to 1.5 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. Following that study, we consider up to 1.4 percent of observed case-mix change as real for FY 1991 through FY 1994. As discussed above, we have determined that all of the observed case-mix increase for FY 1995 is real. Given estimates of real case-mix increase of 1.0 percent for FY 1991 and FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and 1.6 percent for FY 1995, we estimate that case-mix constant intensity declined by an [[Page 27501]] average 1.1 percent during FY 1991 through FY 1995, for a cumulative decrease of 5.6 percent. If we assume that real case-mix increase was 1.4 percent for FY 1991 and FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and 1.6 percent for FY 1995, we estimate that case-mix constant intensity declined by an average 1.2 percent during FY 1991 through FY 1995, for a cumulative decrease of 5.9 percent. Since we estimate that intensity has declined during that period, we are recommending a 0.0 percent intensity adjustment for FY 1997. 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, 60 percent for cost reporting periods beginning in FY 1997 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 proportion of outlier payments under the Federal rate to total inpatient capital-related payments under the Federal rate. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments. The inpatient capital- related outlier reduction factor reflects the 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, 1995 final rule, we estimated that outlier payments for capital in FY 1996 would equal 4.64 percent of inpatient capital-related payments based on the Federal rate. Accordingly, we applied an outlier adjustment factor of 0.9536 to the Federal rate. Based on the thresholds as set forth in section II.A.4.d of this Addendum, we estimate that outlier payments for capital will equal 5.24 percent of inpatient capital-related payments based on the Federal rate in FY 1997. We are, therefore, proposing an outlier adjustment factor of 0.9476 to the Federal rate. Thus, estimated capital outlier payments for FY 1997 represent a higher percentage of total capital standard payments than in FY 1996. 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 proposed net change in the outlier adjustment to the Federal rate for FY 1997 is 0.9937 (0.9476/0.9536). Thus, the outlier adjustment decreases the FY 1997 Federal rate by 0.63 percent (0.9937 - 1) compared with the FY 1996 outlier adjustment. 3. Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the Geographic Adjustment Factor Section 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that aggregate payments for the fiscal year based on the Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the geographic adjustment factor are projected to equal aggregate payments that would have been made on the basis of the Federal rate without such changes. We use 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 use 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 use these figures to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the geographic adjustment factor. For FY 1996, we calculated a GAF/DRG budget neutrality factor of 0.9994. For FY 1997, we are proposing a GAF/DRG budget neutrality factor of 0.9992. 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 estimated aggregate payments each year be no more than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the geographic adjustment factor. The proposed incremental change in the adjustment from FY 1996 to FY 1997 is 0.9992. The proposed cumulative change in the rate due to this adjustment is 1.0017 (the product of the incremental factors for FY 1993, FY 1994, FY 1995, FY 1996 and the proposed incremental factor for FY 1997: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9992 = 1.0017). This factor accounts for DRG reclassifications and recalibration and for changes in the geographic adjustment factor. It also incorporates the effects on the geographic adjustment factor of FY 1997 geographic reclassification decisions made by the MGCRB compared to FY 1996 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. 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 proportion of additional payments for exceptions under Sec. 412.348 relative to total payments under the hospital- specific rate and Federal rate. We use the model originally developed for determining the budget neutrality adjustment factor to determine the exceptions payment adjustment factor. We describe that model in Appendix B to this proposed rule. For FY 1996, we estimated that exceptions payments would equal 1.51 percent of aggregate payments based on the Federal rate and the hospital-specific rate. Therefore, we applied an exceptions reduction factor of 0.9849 (1-0.0151) in determining the Federal rate. For this proposed rule, we estimate that exceptions payments for FY 1997 will equal 6.07 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We are, therefore, proposing an exceptions payment reduction factor of 0.9393 to the Federal rate for FY 1997. The proposed exceptions reduction factor for FY 1997 is thus 4.63 percent lower than the factor for FY 1996. We have expected the number and amount of exceptions payments generally to increase throughout the transition period. The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the Federal rate. Therefore, the proposed net adjustment to the FY 1997 Federal rate is 0.9393/0.9849, or 0.9537. 5. Standard Capital Federal Rate for FY 1997 For FY 1996, the capital Federal rate was $461.96. With the changes we are proposing to the factors used to establish the Federal rate, the FY 1997 [[Page 27502]] Federal rate would be $441.84. The proposed Federal rate for FY 1997 was calculated as follows: The proposed FY 1997 update factor is 1.0100, that is, the proposed update is 1.00 percent. The proposed FY 1997 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 0.9992. The proposed FY 1997 outlier adjustment factor is 0.9476. The proposed FY 1997 exceptions payments adjustment factor is 0.9393. 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 factor for changes in the DRG relative weights and the geographic adjustment factor. We are providing a chart that shows how each of the factors and adjustments for FY 1997 affected the computation of the proposed FY 1997 Federal rate in comparison to the FY 1996 Federal rate. The proposed FY 1997 update factor has the effect of increasing the Federal rate by 1.00 percent compared to the rate in FY 1996, while the proposed geographic and DRG budget neutrality factor has the effect of decreasing the Federal rate by 0.08 percent. The proposed FY 1997 outlier adjustment factor has the effect of decreasing the Federal rate by 0.63 percent compared to FY 1996. The proposed FY 1997 exceptions reduction factor has the effect of decreasing the Federal rate by 4.63 percent compared to the exceptions reduction for FY 1996. The combined effect of all the proposed changes is to decrease the proposed Federal rate by 4.36 percent compared to the Federal rate for FY 1996. Comparison of Factors and Adjustments: FY 1996 Federal Rate and Proposed FY 1997 Federal Rate ---------------------------------------------------------------------------------------------------------------- Percent Change change ---------------------------------------------------------------------------------------------------------------- Update factor: \1\ FY 1996.................................................................... 1.0120 ......... ......... Proposed FY 1997........................................................... 1.0100 1.0100 1.00 GAF/DRG adjustment factor \1\ ......... FY 1996.................................................................... 0.9994 ......... ......... Proposed FY 1997........................................................... 0.9992 0.9992 -0.08 Outlier adjustment factor: \2\ FY 1996.................................................................... 0.9536 ......... ......... Proposed FY 1997........................................................... 0.9476 0.9937 -0.63 Exceptions adjustment factor: \2\ FY 1996.................................................................... 0.9849 ......... ......... Proposed FY 1997........................................................... 0.9393 0.9537 -4.63 Federal Rate: FY 1996.................................................................... $461.96 ......... ......... Proposed FY 1997........................................................... $441.84 0.9564 -4.36 ---------------------------------------------------------------------------------------------------------------- \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 1996 to FY 1997 resulting from the application of the 0.9992 GAF/DRG budget neutrality factor for FY 1997 is 0.9992. \2\ The outlier reduction factor and the exceptions reduction factor 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 1997 exceptions reduction factor is 0.9393/0.9849, or 0.9537. 6. Special Rate for Puerto Rico Hospitals For FY 1996, the special rate for Puerto Rico hospitals was $355.35. With the changes we are proposing to the factors used to determine the rate, the proposed FY 1997 special rate for Puerto Rico would be $339.87. B. Determination of Hospital-Specific Rate Update Section 412.328(e) of the regulations provides that the hospital- specific rate for FY 1997 be determined by adjusting the FY 1996 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 1997, we are proposing that the hospital- specific rate be updated by a factor of 1.0100. 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 1997, we estimate that exceptions payments will be 6.07 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We therefore propose that the updated hospital-specific rate be reduced by a factor of 0.9393. The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the hospital-specific rate. Therefore, the proposed net adjustment to the FY 1997 hospital-specific rate is 0.9393/0.9849, or 0.9537. 3. Net Change to Hospital-Specific Rate We are providing a chart to show the net change to the hospital- specific rate. The chart shows the factors for FY 1996 and FY 1997 and the net adjustment for each factor. It also shows that the proposed cumulative net adjustment from FY 1996 to FY 1997 is 0.9632, which represents a proposed decrease of 3.68 percent to the hospital-specific rate. The proposed FY 1997 hospital-specific rate for each hospital is determined by multiplying the FY 1996 hospital-specific rate by the cumulative net adjustment of 0.9632. [[Page 27503]] Proposed FY 1997 Update and Adjustments to Hospital-Specific Rates ---------------------------------------------------------------------------------------------------------------- Net Percent adjustment change ---------------------------------------------------------------------------------------------------------------- Update factor: FY 1996................................................................... 1.0120 .......... ......... Proposed FY 1997.......................................................... 1.0100 1.0100 1.00 Exceptions payment adjustment factor: FY 1996................................................................... 0.9849 .......... ......... Proposed FY 1997.......................................................... 0.9393 0.9537 -4.63 Cumulative adjustments: FY 1996................................................................... 0.9967 .......... ......... Proposed FY 1997.......................................................... 0.9601 0.9632 -3.68 ---------------------------------------------------------------------------------------------------------------- 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 1996 to FY 1997 is 1.0100. In contrast, the exceptions payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the exceptions reduction factor from FY 1996 to FY 1997 is 0.9393/0.9849, or 0.9537. C. Calculation of Inpatient Capital-Related Prospective Payments for FY 1997 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 making adjustments as follows: 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 of 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 1997 are 60 percent of the adjusted Federal rate and 40 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 60 percent of the Federal rate for discharges occurring in cost reporting periods beginning during FY 1997. Thus, a fully prospective hospital will receive 60 percent of the capital-related outlier payment calculated for the case for discharges occurring in cost reporting periods beginning in FY 1997. 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 proposed outlier thresholds for FY 1997 are published in section II.A.4.c of this Addendum. For FY 1997, 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 $11,050. A case qualifies as a day outlier for FY 1997 if the length of stay is greater than the geometric mean length of stay for the DRG plus the lesser of 24 days or three standard deviations of the length of stay. During the capital prospective payment system transition period, a hospital may also receive an additional payment under an exceptions process if its total inpatient capital-related [[Page 27504]] 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 proposed minimum payment levels for portions of cost reporting periods occurring in FY 1997 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. V. Tables This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. For purposes of this proposed 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, 1c, 1d, 3C, 4a, 4b, 4c, 4d, 4e, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, and 8B are presented below. The tables presented below are as follows: Table 1a--National 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 1995 and Hospital Average Hourly Wage for Federal Fiscal Year 1997 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--Invalid Procedure Codes Table 6E--Revised Diagnosis Code Titles Table 6F--Revised Procedure Code Titles Table 6G--Additions to the CC Exclusions List Table 6H--Deletions to the CC Exclusions List Table 7A--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 95 MEDPAR Update 12/95 GROUPER V13.0 Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 95 MEDPAR Update 12/95 GROUPER V14.0 Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) April 1996 Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) April 1996 Table 1a.--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor ------------------------------------------------------------------------ Large urban areas Other areas ------------------------------------------------------------------------ Non-labor Non-labor Labor-related related Labor-related related ------------------------------------------------------------------------ 2796.66.......... 1131.23 2752.39 1113.33 ------------------------------------------------------------------------ Table 1c.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor ---------------------------------------------------------------------------------------------------------------- Large urban areas Other areas --------------------------------------------------- Labor- Non-labor Labor- Non-labor related related related related ---------------------------------------------------------------------------------------------------------------- National.................................................... $2772.89 $1121.62 $2772.89 $1121.62 Puerto Rico................................................. 2501.07 521.22 2461.47 512.97 ---------------------------------------------------------------------------------------------------------------- Table 1d.--Capital Standard Federal Payment Rate ------------------------------------------------------------------------ Rate ------------------------------------------------------------------------ National..................................................... $441.84 Puerto Rico.................................................. 339.87 ------------------------------------------------------------------------ [[Page 27505]] Table 3c.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1995 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....................... 01.4400 14.82 010095.......... 00.9230 11.25 030004......... 00.9824 13.49 040004......... 01.4485 14.83 040107......... 01.1923 14.95 010004....................... 00.9600 11.10 010097.......... 00.9405 15.20 030006......... 01.5576 17.52 040005......... 01.0380 11.59 040109......... 01.1692 12.69 010005....................... 01.1609 15.40 010098.......... 01.1941 11.02 030007......... 01.3158 16.41 040007......... 01.8761 18.12 040114......... 01.8513 16.64 010006....................... 01.4752 15.23 010099.......... 01.1210 15.49 030008......... 02.1095 20.42 040008......... 01.0325 10.77 040116......... 01.3895 19.25 010007....................... 01.0986 13.12 010100.......... 01.1688 14.77 030009......... 01.2993 15.58 040010......... 01.2298 13.78 040118......... 01.1313 14.29 010008....................... 01.1366 09.54 010101.......... 01.1127 14.21 030010......... 01.4160 17.75 040011......... 00.9298 10.75 040119......... 01.0914 14.34 010009....................... 01.1377 14.82 010102.......... 00.9529 13.63 030011......... 01.4747 17.66 040014......... 01.1929 16.07 040124......... 01.2238 14.30 010010....................... 01.1330 14.33 010103.......... 01.7534 17.01 030012......... 01.2246 15.81 040015......... 01.1944 12.12 040126......... 00.9617 11.74 010011....................... 01.6185 18.94 010104.......... 01.6892 17.87 030013......... 01.2459 18.99 040016......... 01.7330 16.43 050002......... 01.5554 25.91 010012....................... 01.2666 16.27 010108.......... 01.1189 13.68 030014......... 01.4394 17.86 040017......... 01.2569 11.68 050006......... 01.3983 19.15 010015....................... 01.0512 15.63 010109.......... 01.0527 11.48 030016......... 01.2462 17.09 040018......... 01.1686 16.66 050007......... 01.5848 25.29 010016....................... 01.2643 16.76 010110.......... 01.0168 13.44 030017......... 01.4929 18.98 040019......... 01.1618 13.52 050008......... 01.4998 25.48 010018....................... 00.9017 16.19 010112.......... 01.1253 14.09 030018......... 01.7989 19.57 040020......... 01.5987 14.08 050009......... 01.7211 31.63 010019....................... 01.2868 14.99 010113.......... 01.6374 13.69 030019......... 01.1962 19.31 040021......... 01.2277 14.69 050013......... 01.8099 22.05 010021....................... 01.2388 12.20 010114.......... 01.3174 15.37 030022......... 01.5055 17.41 040022......... 01.6951 14.73 050014......... 01.1741 22.55 010022....................... 01.0109 16.89 010115.......... 00.8385 11.98 030023......... 01.2640 17.64 040024......... 01.1709 12.16 050015......... 01.3882 22.18 010023....................... 01.4760 14.71 010117.......... 00.7880 13.54 030024......... 01.7809 21.04 040025......... 00.9214 11.81 050016......... 01.1598 18.51 010024....................... 01.4014 15.62 010118.......... 01.2475 15.07 030025......... 01.1633 12.76 040026......... 01.5547 16.35 050017......... 02.0618 24.39 010025....................... 01.4390 13.16 010119.......... 01.5429 16.36 030027......... 01.0875 14.69 040027......... 01.2889 12.56 050018......... 01.3434 18.49 010027....................... 00.8352 13.55 010120.......... 00.9668 14.32 030030......... 01.6651 18.19 040028......... 01.0903 11.40 050021......... 01.4146 23.75 010029....................... 01.4957 14.84 010121.......... 01.2269 12.92 030033......... 01.2475 16.40 040029......... 01.2557 14.12 050022......... 01.4601 22.63 010031....................... 01.1808 14.58 010123.......... 01.2421 17.47 030034......... 01.0430 15.89 040030......... 00.8925 11.09 050024......... 01.3952 21.31 010032....................... 00.9478 12.45 010124.......... 01.2927 16.15 030035......... 01.3403 20.77 040032......... 01.0056 11.18 050025......... 01.8000 22.00 010033....................... 01.9143 17.61 010125.......... 01.0247 12.86 030036......... 01.1393 18.23 040035......... 01.0240 10.24 050026......... 01.4525 21.79 010034....................... 01.0751 13.48 010126.......... 01.1770 13.13 030037......... 02.0161 19.60 040036......... 01.4976 16.45 050028......... 01.4395 15.33 010035....................... 01.2397 15.13 010127.......... 01.2999 16.29 030038......... 01.6125 18.82 040037......... 01.1101 11.55 050029......... 01.3830 25.55 010036....................... 01.1252 15.34 010128.......... 00.9565 12.34 030040......... 01.1885 15.88 040039......... 01.2411 12.23 050030......... 01.3324 19.24 010038....................... 01.3397 16.48 010129.......... 01.0795 13.29 030041......... 00.9963 13.68 040040......... 00.9953 15.73 050032......... 01.2735 22.76 010039....................... 01.7029 16.14 010130.......... 01.0352 15.28 030043......... 01.1937 18.25 040041......... 01.3946 13.95 050033......... 01.4136 25.47 010040....................... 01.5335 18.21 010131.......... 01.3636 17.75 030044......... 01.0291 13.19 040042......... 01.2978 12.03 050036......... 01.6162 18.61 010043....................... 01.1036 10.35 010134.......... 00.9206 13.36 030046......... 00.9134 16.38 040044......... 00.9622 10.04 050038......... 01.4553 29.05 010044....................... 01.0919 11.01 010137.......... 01.2516 16.36 030047......... 00.9471 19.91 040045......... 01.0301 14.28 050039......... 01.6127 21.04 010045....................... 01.2121 10.79 010138.......... 00.9485 09.85 030049......... 00.9741 17.30 040047......... 01.0939 14.78 050040......... 01.0842 22.92 010046....................... 01.5291 15.51 010139.......... 01.6592 19.67 030054......... 00.8723 12.63 040048......... 01.2149 13.48 050041......... 02.8656 22.21 010047....................... 01.0243 10.05 010143.......... 01.1921 15.83 030055......... 01.2014 16.85 040050......... 01.1013 11.66 050042......... 01.3081 20.20 010049....................... 01.1121 15.66 010144.......... 01.3104 18.42 030059......... 01.2776 19.95 040051......... 01.0923 12.64 050043......... 01.5723 30.15 010050....................... 01.0635 13.48 010145.......... 01.3376 14.59 030060......... 01.2095 13.90 040053......... 01.1093 11.67 050045......... 01.2649 17.11 010051....................... 00.8549 10.24 010146.......... 01.1772 15.59 030061......... 01.6462 16.75 040054......... 01.0301 12.44 050046......... 01.1888 23.81 010052....................... 00.9858 12.78 010148.......... 00.9969 12.83 030062......... 01.2267 15.56 040055......... 01.4506 14.51 050047......... 01.6388 29.15 010053....................... 01.0653 12.67 010149.......... 01.3527 17.75 030064......... 01.6191 16.92 040058......... 01.0617 13.61 050051......... 01.1104 16.63 010054....................... 01.1726 16.17 010150.......... 01.0473 16.29 030065......... 01.6407 18.87 040060......... 00.9896 09.85 050054......... 01.1961 20.55 010055....................... 01.4846 16.35 010152.......... 01.4762 16.29 030067......... 01.0515 15.92 040062......... 01.6181 16.66 050055......... 01.3742 27.54 010056....................... 01.3970 17.99 010155.......... 00.9996 09.42 030068......... 00.9514 14.04 040063......... 01.4673 15.67 050056......... 01.3374 25.23 010058....................... 01.0881 12.96 020001.......... 01.4712 25.53 030069......... 01.3354 19.11 040064......... 01.0523 10.49 050057......... 01.4835 20.22 010059....................... 01.0165 14.17 020002.......... 01.0281 24.16 030071......... 00.9488 ....... 040066......... 01.1537 14.63 050058......... 01.4664 22.78 010061....................... 01.0127 14.70 020004.......... 01.1028 25.46 030072......... 00.9090 ....... 040067......... 01.0801 11.34 050060......... 01.5897 24.25 010062....................... 01.0042 13.45 020005.......... 00.9029 28.36 030073......... 00.9752 ....... 040069......... 01.1090 14.90 050061......... 01.4258 22.12 010064....................... 01.7890 17.85 020006.......... 01.1418 23.19 030074......... 00.8587 ....... 040070......... 00.9433 14.98 050063......... 01.4029 21.44 010065....................... 01.3668 14.30 020007.......... 00.8909 21.82 030075......... 00.8660 ....... 040071......... 01.5932 15.42 050065......... 01.6064 22.37 010066....................... 00.9789 10.87 020008.......... 01.1006 26.45 030076......... 00.9802 ....... 040072......... 01.0871 13.40 050066......... 01.2689 24.33 010068....................... 01.2370 18.82 020009.......... 00.9255 21.29 030077......... 00.8761 ....... 040074......... 01.2566 14.51 050067......... 01.3777 21.09 010069....................... 01.1589 13.06 020010.......... 00.9141 22.13 030078......... 01.1027 ....... 040075......... 01.0668 11.57 050068......... 01.0839 19.05 010072....................... 01.2161 12.72 020011.......... 01.0488 22.27 030079......... 00.7787 ....... 040076......... 01.0273 14.71 050069......... 01.6183 23.15 010073....................... 00.9701 09.66 020012.......... 01.3062 23.99 030080......... 01.6564 20.82 040077......... 00.9196 10.72 050070......... 01.2901 30.80 010078....................... 01.1795 15.04 020013.......... 01.0055 24.03 030083......... 01.3106 21.70 040078......... 01.4945 17.29 050071......... 01.3159 30.70 010079....................... 01.2807 12.53 020014.......... 01.0769 24.52 030084......... 00.9358 ....... 040080......... 01.0752 15.45 050072......... 01.3053 31.00 010080....................... 01.0389 12.99 020017.......... 01.5181 26.83 030085......... 01.5045 20.21 040081......... 00.9285 09.91 050073......... 01.3239 31.41 010081....................... 01.9832 16.16 020018.......... 00.8963 ....... 030086......... 01.3209 18.76 040082......... 01.2156 13.69 050074......... 01.2314 32.96 010083....................... 01.0377 13.25 020019.......... 00.8718 ....... 030087......... 01.6153 18.77 040084......... 01.0963 14.83 050075......... 01.4037 30.72 010084....................... 01.4816 16.61 020020.......... 00.8398 ....... 030088......... 01.3513 19.90 040085......... 01.2493 15.18 050076......... 01.7756 29.65 010085....................... 01.3233 17.11 020021.......... 00.8478 ....... 030089......... 01.5736 18.66 040088......... 01.3091 13.73 050077......... 01.6152 22.83 010086....................... 01.0507 13.54 020024.......... 01.0693 22.64 030092......... 01.5590 20.62 040090......... 00.8983 13.78 050078......... 01.3591 24.44 010087....................... 01.6243 16.88 020025.......... 01.0046 24.44 030093......... 01.3791 18.08 040091......... 01.2930 18.25 050079......... 01.5938 28.30 010089....................... 01.1934 14.91 020026.......... 01.3340 ....... 030094......... 01.2494 18.57 040093......... 00.9598 10.98 050080......... 01.2183 22.05 010090....................... 01.5725 16.40 020027.......... 00.9975 ....... 030095......... 01.2183 13.09 040095......... 00.9069 10.56 050081......... 01.6564 24.01 010091....................... 00.9195 13.43 030001.......... 01.3076 19.28 040001......... 01.1308 12.37 040100......... 01.2465 12.81 050082......... 01.4989 21.34 010092....................... 01.4209 15.17 030002.......... 01.7918 20.25 040002......... 01.1644 13.07 040105......... 01.0068 11.90 050084......... 01.5611 22.33 010094....................... 01.1410 16.76 030003.......... 01.8923 21.05 040003......... 01.0704 13.19 040106......... 01.2448 12.84 050088......... 01.1538 21.94 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27506]] Page 2 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 050089....................... 01.3485 19.92 050189.......... 00.9777 21.50 050296......... 01.2071 22.69 050420......... 01.4424 25.15 050545......... 00.8420 20.39 050090....................... 01.2755 21.75 050191.......... 01.5032 20.64 050298......... 01.3081 20.18 050421......... 01.4112 24.62 050546......... 00.7212 21.10 050091....................... 01.1984 24.42 050192.......... 01.1071 18.74 050299......... 01.3607 22.49 050423......... 00.9821 19.25 050547......... 00.9602 20.65 050092....................... 00.8504 16.19 050193.......... 01.3631 22.56 050300......... 01.3100 18.87 050424......... 01.8316 22.16 050549......... 01.7182 25.86 050093....................... 01.5917 22.35 050194.......... 01.2409 25.03 050301......... 01.3825 21.54 050425......... 01.2719 30.41 050550......... 02.3168 23.34 050096....................... 01.1244 12.95 050195.......... 01.5876 31.29 050302......... 01.4049 24.31 050426......... 01.3055 23.89 050551......... 01.3473 24.20 050097....................... 01.5025 18.40 050196.......... 01.4205 16.40 050305......... 01.5824 29.82 050430......... 00.9919 15.94 050552......... 01.1633 22.44 050099....................... 01.4660 22.91 050197.......... 01.8278 29.07 050307......... 01.4439 20.51 050431......... 01.0836 22.58 050557......... 01.4928 21.08 050100....................... 01.6910 29.38 050199.......... 00.8980 19.48 050308......... 01.5797 29.77 050432......... 01.5774 23.69 050559......... 01.3672 24.18 050101....................... 01.3999 25.12 050204.......... 01.4910 23.12 050309......... 01.3306 23.63 050433......... 01.0327 17.37 050560......... 01.1894 ...... 050102....................... 01.4714 22.34 050205.......... 01.3876 19.99 050310......... 01.2239 22.24 050434......... 01.1491 18.08 050561......... 01.2110 30.34 050103....................... 01.6097 26.74 050207.......... 01.2860 20.58 050312......... 01.9820 23.66 050435......... 01.2411 18.98 050564......... 01.2109 24.02 050104....................... 01.3906 21.73 050208.......... 00.9572 27.63 050313......... 01.1891 20.90 050436......... 01.0099 15.77 050565......... 01.1456 21.26 050107....................... 01.4355 22.92 050211.......... 01.3142 29.60 050315......... 01.1826 20.75 050438......... 01.6261 23.33 050566......... 00.8791 19.75 050108....................... 01.5819 22.78 050213.......... 01.3924 21.12 050317......... 01.3583 20.90 050440......... 01.4107 19.93 050567......... 01.6543 23.01 050109....................... 02.3436 24.68 050214.......... 01.4409 21.76 050320......... 01.3185 27.27 050441......... 01.9214 28.10 050568......... 01.4314 18.28 050110....................... 01.2436 18.72 050215.......... 01.5216 27.75 050324......... 01.8339 25.93 050443......... 00.9533 15.95 050569......... 01.3545 22.93 050111....................... 01.3786 18.81 050217.......... 01.3730 18.44 050325......... 01.2554 20.87 050444......... 01.3479 22.19 050570......... 01.7026 24.91 050112....................... 01.5234 22.15 050219.......... 01.3115 20.37 050327......... 01.5839 21.00 050446......... 00.8936 17.25 050571......... 01.4016 22.37 050113....................... 01.2749 28.23 050222.......... 01.5916 24.56 050328......... 01.4584 32.92 050447......... 01.0883 18.59 050573......... 01.6412 23.66 050114....................... 01.3978 21.65 050224.......... 01.5471 22.17 050329......... 01.3142 20.34 050448......... 01.1113 19.82 050575......... 01.2303 ...... 050115....................... 01.6146 21.11 050225.......... 01.3284 20.67 050331......... 01.4090 27.22 050449......... 01.3527 21.99 050577......... 01.3652 20.32 050116....................... 01.4542 22.73 050226.......... 01.3349 22.58 050333......... 00.9767 18.66 050454......... 01.8309 26.10 050578......... 01.1731 23.70 050117....................... 01.2871 20.93 050228.......... 01.3665 29.90 050334......... 01.7683 28.22 050455......... 01.9292 22.89 050579......... 01.5656 26.94 050118....................... 01.2840 23.24 050230.......... 01.2972 26.22 050335......... 01.2505 19.62 050456......... 01.1314 20.24 050580......... 01.3595 23.47 050121....................... 01.4060 19.96 050231.......... 01.6364 24.14 050336......... 01.3398 21.04 050457......... 01.9435 28.66 050581......... 01.4162 24.63 050122....................... 01.7066 22.90 050232.......... 01.7628 24.17 050337......... 01.1726 23.87 050459......... 01.1929 28.20 050583......... 01.5880 23.08 050124....................... 01.2730 19.72 050233.......... 01.2974 30.88 050342......... 01.3686 17.55 050464......... 01.8776 22.62 050584......... 01.2006 22.39 050125....................... 01.3140 25.98 050234.......... 01.3251 22.00 050343......... 01.0325 18.56 050468......... 01.4046 16.26 050585......... 01.2357 23.70 050126....................... 01.4704 23.23 050235.......... 01.5105 25.00 050348......... 01.6030 22.83 050469......... 01.0879 17.33 050586......... 01.3647 21.76 050127....................... 01.2952 22.89 050236.......... 01.6626 24.28 050349......... 00.8988 14.28 050470......... 01.1148 21.29 050588......... 01.3703 26.55 050128....................... 01.5405 20.97 050238.......... 01.4959 22.95 050350......... 01.3856 22.68 050471......... 01.7202 24.07 050589......... 01.3124 25.37 050129....................... 01.5583 22.11 050239.......... 01.5085 21.24 050351......... 01.4774 24.81 050476......... 01.3437 19.12 050590......... 01.4086 23.00 050131....................... 01.2652 27.83 050240.......... 01.3951 22.82 050352......... 01.2941 23.35 050477......... 01.5136 24.50 050591......... 01.2861 27.01 050132....................... 01.4397 24.55 050241.......... 01.2374 25.78 050353......... 01.5622 21.45 050478......... 00.9225 21.73 050592......... 01.3408 20.34 050133....................... 01.3513 20.16 050242.......... 01.4698 27.10 050355......... 00.9696 15.53 050481......... 01.4166 24.85 050593......... 01.5583 24.40 050135....................... 01.3794 26.86 050243.......... 01.5323 21.58 050357......... 01.7247 23.17 050482......... 00.9451 14.55 050594......... 02.0151 23.81 050136....................... 01.3772 22.75 050245.......... 01.3837 21.74 050359......... 01.2172 18.78 050483......... 01.1666 23.89 050597......... 01.2786 21.91 050137....................... 01.3802 31.46 050248.......... 01.2124 24.50 050360......... 01.4656 30.15 050485......... 01.6275 22.34 050598......... 01.3940 26.87 050138....................... 01.8728 32.07 050251.......... 01.0753 17.68 050366......... 01.3174 20.47 050486......... 01.4180 24.94 050599......... 01.6829 22.70 050139....................... 01.3396 31.14 050253.......... 00.7232 18.87 050367......... 01.2881 27.02 050488......... 01.3879 30.41 050601......... 01.3075 29.03 050140....................... 01.4139 30.76 050254.......... 01.1940 22.13 050369......... 01.3323 23.30 050489......... 00.9718 27.10 050603......... 01.4252 23.50 050144....................... 01.5835 26.03 050256.......... 01.7700 19.70 050373......... 01.3964 23.83 050491......... 01.2797 23.76 050604......... 01.5933 29.56 050145....................... 01.3571 27.67 050257.......... 01.0715 20.65 050376......... 01.3932 25.86 050492......... 01.2458 23.05 050607......... 01.3006 21.79 050146....................... 01.3245 ....... 050260.......... 01.0965 21.96 050377......... 00.9012 15.01 050494......... 01.1674 24.95 050608......... 01.3067 15.23 050147....................... 00.6896 20.55 050261.......... 01.1927 17.91 050378......... 01.0814 22.45 050496......... 01.7959 31.60 050609......... 01.4365 31.39 050148....................... 01.1273 19.62 050262.......... 01.9179 26.89 050379......... 01.0921 19.04 050497......... 00.7948 ....... 050613......... 01.1496 22.70 050149....................... 01.4339 19.87 050263.......... 01.2879 24.24 050380......... 01.6703 28.31 050498......... 01.2636 22.42 050615......... 01.6939 23.31 050150....................... 01.2565 23.23 050264.......... 01.3732 26.01 050382......... 01.4511 20.97 050502......... 01.6551 23.61 050616......... 01.2953 20.68 050152....................... 01.4301 24.60 050267.......... 01.5239 24.88 050385......... 01.3960 24.83 050503......... 01.2916 23.01 050618......... 01.0619 19.36 050153....................... 01.6384 30.53 050270.......... 01.2432 23.60 050388......... 00.9028 14.19 050506......... 01.4122 25.57 050623......... 01.1349 24.40 050155....................... 01.1043 23.60 050272.......... 01.3296 19.69 050390......... 01.2211 20.80 050510......... 01.3632 30.59 050624......... 01.3670 25.95 050158....................... 01.6805 27.88 050274.......... 00.9624 18.36 050391......... 01.2785 21.61 050512......... 01.4686 31.38 050625......... 01.6096 24.00 050159....................... 01.2651 22.01 050276.......... 01.2223 26.99 050392......... 00.9426 17.56 050515......... 01.3589 30.78 050630......... 01.3621 21.26 050167....................... 01.4551 21.67 050277.......... 01.3817 21.30 050393......... 01.4157 21.56 050516......... 01.6670 24.33 050633......... 01.2959 21.76 050168....................... 01.6003 24.83 050278.......... 01.5174 23.01 050394......... 01.5428 20.71 050517......... 01.2879 19.15 050635......... 01.4145 31.17 050169....................... 01.5891 24.53 050279.......... 01.2461 20.58 050396......... 01.6157 21.89 050522......... 01.3128 30.40 050636......... 01.4311 20.28 050170....................... 01.5175 21.58 050280.......... 01.6551 22.80 050397......... 01.0118 19.97 050523......... 01.2703 27.65 050638......... 01.1002 24.28 050172....................... 01.2609 19.96 050281.......... 01.4519 22.74 050401......... 01.1174 19.09 050526......... 01.3687 24.28 050641......... 01.2473 12.26 050173....................... 01.2203 23.70 050282.......... 01.3433 21.42 050404......... 01.1443 16.51 050528......... 01.3542 16.46 050643......... 00.7832 ...... 050174....................... 01.6873 27.89 050283.......... 01.1267 27.59 050406......... 01.1263 15.29 050531......... 01.3012 23.60 050644......... 00.9053 26.86 050175....................... 01.3926 21.97 050286.......... 01.0350 17.99 050407......... 01.3254 27.06 050534......... 01.3853 23.83 050660......... 01.3428 ...... 050177....................... 01.2994 18.76 050289.......... 01.7845 27.38 050410......... 01.0706 17.45 050535......... 01.3827 22.46 050661......... 00.8831 20.21 050179....................... 01.2600 17.29 050290.......... 01.6330 32.31 050411......... 01.4042 29.35 050537......... 01.2622 21.30 050662......... 00.8549 21.17 050180....................... 01.5539 30.12 050291.......... 01.2553 24.46 050414......... 01.2846 24.32 050539......... 01.2184 21.90 050663......... 01.0604 23.51 050183....................... 01.1940 19.09 050292.......... 01.0963 21.20 050417......... 01.3037 19.65 050541......... 01.5870 31.06 050666......... 00.7423 23.76 050186....................... 01.2694 24.12 050293.......... 01.1312 19.93 050418......... 01.4191 24.24 050542......... 01.2270 13.79 050667......... 01.0672 24.88 050188....................... 01.3467 25.25 050295.......... 01.4144 20.86 050419......... 01.3136 18.88 050543......... 00.9214 21.68 050668......... 01.1532 28.20 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27507]] Page 3 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 050670....................... 00.7582 20.12 060046.......... 01.1205 16.56 080005......... 01.3363 16.82 100071......... 01.3024 16.98 100167......... 01.3944 20.55 050672....................... 00.6267 23.77 060047.......... 00.9606 11.40 080006......... 01.3822 20.49 100072......... 01.2515 17.24 100168......... 01.3799 19.35 050674....................... 01.2111 29.18 060049.......... 01.3511 17.47 080007......... 01.3620 17.99 100073......... 01.7938 20.61 100169......... 01.8590 18.29 050675....................... 01.7056 16.32 060050.......... 01.1719 14.62 090001......... 01.4216 19.65 100075......... 01.6403 17.85 100170......... 01.4917 16.50 050676....................... 00.9864 13.83 060052.......... 01.0999 18.38 090002......... 01.3022 20.51 100076......... 01.3869 17.15 100172......... 01.3694 13.38 050677....................... 01.4253 32.99 060053.......... 00.9988 13.73 090003......... 01.3041 24.74 100077......... 01.3153 16.78 100173......... 01.6691 16.33 050678....................... 01.0713 24.07 060054.......... 01.3361 16.74 090004......... 01.7168 23.49 100078......... 01.1683 15.14 100174......... 01.5295 18.20 050680....................... 01.2114 26.13 060056.......... 00.9577 13.37 090005......... 01.3431 27.07 100079......... 01.7501 16.01 100175......... 01.2130 16.18 050682....................... 00.8558 14.98 060057.......... 01.0356 21.11 090006......... 01.3749 19.52 100080......... 01.6306 19.40 100176......... 02.0431 21.95 050684....................... 01.2074 21.30 060058.......... 00.9237 12.54 090007......... 01.3832 19.58 100081......... 01.1202 13.33 100177......... 01.3403 18.55 050685....................... 01.2219 26.94 060060.......... 00.9651 12.21 090008......... 01.5276 24.06 100082......... 01.5459 17.93 100179......... 01.6520 19.03 050686....................... 01.3503 30.96 060062.......... 00.9518 15.85 090010......... 01.0013 21.70 100083......... 01.3240 17.30 100180......... 01.4188 17.49 050688....................... 01.2730 27.89 060063.......... 01.0264 11.12 090011......... 01.9804 24.77 100084......... 01.5314 16.53 100181......... 01.2846 17.59 050689....................... 01.3988 29.12 060064.......... 01.4325 20.21 090015......... 01.3306 ....... 100085......... 01.4349 19.50 100183......... 01.3710 19.18 050690....................... 01.4363 30.39 060065.......... 01.3463 19.98 100001......... 01.5247 18.83 100086......... 01.3328 21.32 100186......... 01.4758 16.70 050693....................... 01.9152 28.80 060066.......... 00.9950 13.10 100002......... 01.4789 19.71 100087......... 01.8071 20.71 100187......... 01.4501 18.35 050694....................... 01.3678 21.20 060068.......... 01.2760 14.00 100004......... 01.0274 11.81 100088......... 01.6730 17.32 100189......... 01.3707 23.13 050695....................... 01.1808 24.30 060070.......... 01.0357 14.99 100005......... 01.0178 16.26 100090......... 01.4256 16.07 100191......... 01.3315 19.19 050696....................... 02.0076 27.85 060071.......... 01.2259 14.69 100006......... 01.5531 18.99 100092......... 01.4411 16.20 100199......... 01.4473 21.29 050697....................... 01.1093 17.93 060073.......... 01.0017 14.32 100007......... 01.8477 19.61 100093......... 01.5156 14.28 100200......... 01.3972 21.35 050698....................... 01.1189 22.83 060075.......... 01.3472 20.27 100008......... 01.7361 19.80 100098......... 01.1482 17.43 100203......... 01.2603 19.34 050699....................... 00.5855 23.13 060076.......... 01.3675 15.97 100009......... 01.5641 17.89 100099......... 01.2518 13.09 100204......... 01.6232 19.95 050700....................... 01.4412 32.46 060085.......... 00.9819 10.94 100010......... 01.5475 20.58 100102......... 01.1033 16.44 100206......... 01.3458 19.47 050701....................... 01.3170 27.13 060087.......... 01.6558 18.67 100012......... 01.6776 16.91 100103......... 01.1730 14.46 100207......... 01.4710 19.86 050702....................... 00.8637 16.98 060088.......... 01.0388 15.38 100014......... 01.4272 18.57 100105......... 01.4697 18.08 100208......... 01.6409 21.14 050704....................... 01.2140 20.48 060090.......... 00.9518 14.23 100015......... 01.2444 17.60 100106......... 01.0395 15.46 100209......... 01.6671 ...... 050706....................... 00.9234 16.16 060096.......... 00.9724 21.69 100017......... 01.6489 17.18 100107......... 01.4676 18.26 100210......... 01.6647 16.51 050707....................... 01.2237 25.62 060100.......... 01.4045 20.95 100018......... 01.2869 19.94 100108......... 01.1017 15.45 100211......... 01.3441 19.17 050708....................... 00.9493 15.13 060103.......... 01.2269 21.10 100019......... 01.4930 18.81 100109......... 01.3522 16.81 100212......... 01.6646 18.54 050709....................... 01.3030 ....... 060104.......... 01.3213 20.32 100020......... 01.3365 18.31 100110......... 01.4128 18.91 100213......... 01.5438 20.00 050710....................... 01.4014 ....... 070001.......... 01.7582 24.78 100022......... 01.8009 23.05 100112......... 00.9738 10.84 100217......... 01.3055 17.06 050711....................... 02.3868 ....... 070002.......... 01.8728 24.78 100023......... 01.3489 15.88 100113......... 02.0848 18.19 100220......... 01.9563 19.66 050712....................... 02.1147 ....... 070003.......... 01.1239 24.50 100024......... 01.3583 19.54 100114......... 01.4930 17.73 100221......... 01.5644 20.68 060001....................... 01.5550 18.95 070004.......... 01.1696 23.70 100025......... 01.8825 16.22 100117......... 01.3334 18.18 100222......... 01.3723 18.80 060003....................... 01.2961 15.85 070005.......... 01.3792 25.45 100026......... 01.6477 15.52 100118......... 01.2737 16.03 100223......... 01.4892 18.53 060004....................... 01.2624 19.46 070006.......... 01.3529 26.73 100027......... 00.9736 11.53 100121......... 01.3068 15.44 100224......... 01.4648 19.77 060006....................... 01.1955 16.19 070007.......... 01.3475 24.08 100028......... 01.2678 16.38 100122......... 01.4565 16.39 100225......... 01.3368 19.52 060007....................... 01.1900 13.06 070008.......... 01.3124 23.47 100029......... 01.4029 18.94 100124......... 01.3643 19.41 100226......... 01.3383 16.58 060008....................... 01.0198 14.31 070009.......... 01.2830 25.01 100030......... 01.2690 18.25 100125......... 01.1630 17.77 100228......... 01.2947 21.09 060009....................... 01.4621 19.88 070010.......... 01.5535 22.46 100032......... 01.9188 17.39 100126......... 01.4954 18.74 100229......... 01.3211 16.27 060010....................... 01.5276 21.10 070011.......... 01.3259 22.80 100034......... 01.7338 18.34 100127......... 01.6870 17.42 100230......... 01.5471 18.97 060011....................... 01.3023 20.75 070012.......... 01.2576 23.38 100035......... 01.6138 16.46 100128......... 02.2417 20.13 100231......... 01.6613 17.46 060012....................... 01.3852 15.79 070013.......... 01.2822 24.01 100038......... 01.5951 21.18 100129......... 01.2509 17.45 100232......... 01.2675 17.64 060013....................... 01.2654 18.83 070015.......... 01.3569 23.82 100039......... 01.7158 21.15 100130......... 01.2008 17.45 100234......... 01.5324 19.03 060014....................... 01.6915 20.52 070016.......... 01.3194 25.46 100040......... 01.6731 16.31 100131......... 01.3922 18.44 100235......... 01.4827 17.51 060015....................... 01.5657 19.33 070017.......... 01.3781 23.54 100043......... 01.4570 17.78 100132......... 01.4189 15.67 100236......... 01.4442 13.79 060016....................... 01.0954 11.42 070018.......... 01.3719 27.83 100044......... 01.5045 19.01 100134......... 01.0741 14.50 100237......... 02.1446 22.65 060018....................... 01.2199 16.36 070019.......... 01.2169 24.04 100045......... 01.4032 17.12 100135......... 01.5224 16.11 100238......... 01.4858 18.68 060020....................... 01.5176 16.73 070020.......... 01.3709 24.32 100046......... 01.5110 18.53 100137......... 01.3279 18.42 100239......... 01.4622 19.34 060022....................... 01.6695 17.89 070021.......... 01.2987 25.47 100047......... 01.9163 18.62 100138......... 00.9478 13.00 100240......... 00.8437 15.06 060023....................... 01.6463 16.65 070022.......... 01.7641 24.30 100048......... 01.0025 11.69 100139......... 01.0496 14.54 100241......... 00.9433 12.47 060024....................... 01.8181 22.01 070024.......... 01.3541 23.81 100049......... 01.3263 18.03 100140......... 01.2518 16.87 100242......... 01.4135 16.29 060026....................... 01.4223 19.44 070025.......... 01.7842 24.06 100050......... 01.2227 15.06 100142......... 01.2004 16.68 100243......... 01.4119 18.82 060027....................... 01.6577 19.01 070026.......... 01.2223 23.07 100051......... 01.1532 16.60 100144......... 01.1466 13.65 100244......... 01.4339 17.32 060028....................... 01.4947 21.29 070027.......... 01.2599 24.31 100052......... 01.3772 15.60 100145......... 01.3481 14.87 100246......... 01.3465 20.92 060029....................... 00.9485 13.93 070028.......... 01.4783 24.67 100053......... 01.2886 17.36 100146......... 01.2770 14.27 100248......... 01.6989 17.88 060030....................... 01.3165 20.36 070029.......... 01.3524 21.65 100054......... 01.2923 17.44 100147......... 01.0996 13.43 100249......... 01.3543 18.87 060031....................... 01.6115 18.95 070030.......... 01.2990 24.71 100055......... 01.3679 17.47 100150......... 01.3759 18.64 100252......... 01.2419 19.21 060032....................... 01.5777 19.35 070031.......... 01.2706 22.24 100056......... 01.4655 19.83 100151......... 01.8572 18.63 100253......... 01.4755 20.60 060033....................... 01.1561 11.96 070033.......... 01.2881 28.25 100057......... 01.3455 16.78 100154......... 01.5689 17.95 100254......... 01.5854 17.50 060034....................... 01.4958 16.90 070034.......... 01.3752 24.74 100060......... 01.8491 17.71 100156......... 01.2204 18.65 100255......... 01.3322 19.00 060036....................... 01.1712 14.37 070035.......... 01.3469 24.31 100061......... 01.5100 20.88 100157......... 01.6134 19.31 100256......... 01.8955 19.32 060037....................... 01.0382 13.22 070036.......... 01.4320 26.98 100062......... 01.7185 16.94 100159......... 00.9856 12.76 100258......... 01.6509 21.12 060038....................... 01.0192 12.25 070039.......... 00.9213 ....... 100063......... 01.3423 16.12 100160......... 01.1059 18.07 100259......... 01.4493 16.36 060041....................... 00.9203 16.53 080001.......... 01.6101 23.66 100067......... 01.4267 16.38 100161......... 01.5194 19.76 100260......... 01.4016 20.44 060042....................... 01.0532 18.49 080002.......... 01.1904 17.32 100068......... 01.3880 17.42 100162......... 01.3924 14.53 100262......... 01.4109 19.32 060043....................... 00.9506 11.78 080003.......... 01.3137 19.32 100069......... 01.3653 17.29 100165......... 01.2958 13.45 100263......... 01.3896 15.44 060044....................... 01.2631 17.32 080004.......... 01.2871 17.59 100070......... 01.4420 17.56 100166......... 01.4618 20.31 100264......... 01.3958 18.24 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27508]] Page 4 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 100265....................... 01.3686 17.47 110063.......... 01.0768 11.44 110156......... 01.0003 12.68 130011......... 01.2386 16.74 140045......... 01.0555 14.21 100266....................... 01.2337 15.64 110064.......... 01.2883 15.87 110161......... 01.3328 20.79 130012......... 01.0233 18.53 140046......... 01.3023 14.83 100267....................... 01.3092 16.39 110065.......... 01.0143 12.00 110162......... 00.8588 ....... 130013......... 01.2416 17.21 140047......... 01.1406 13.20 100268....................... 01.1990 22.00 110066.......... 01.4374 16.30 110163......... 01.4549 18.52 130014......... 01.3094 16.43 140048......... 01.2744 21.50 100269....................... 01.3605 19.07 110069.......... 01.1706 15.22 110164......... 01.4190 19.63 130015......... 00.8608 12.43 140049......... 01.5796 19.35 100270....................... 00.8185 12.95 110070.......... 01.1733 11.37 110165......... 01.3107 17.47 130016......... 00.9300 16.18 140051......... 01.4912 19.14 100271....................... 01.6614 19.27 110071.......... 01.0308 10.29 110166......... 01.4995 16.67 130017......... 01.3710 13.03 140052......... 01.3150 16.77 100273....................... 00.5356 19.72 110072.......... 01.0243 11.53 110168......... 01.6538 19.22 130018......... 01.7015 17.60 140053......... 01.8914 17.88 100275....................... 01.4206 21.96 110073.......... 01.2050 12.67 110169......... 00.7308 19.70 130019......... 01.1172 13.74 140054......... 01.3616 26.25 100276....................... 01.3027 21.94 110074.......... 01.4803 18.11 110171......... 01.4451 21.21 130021......... 01.0324 11.96 140055......... 00.9382 13.00 100277....................... 01.0093 12.71 110075.......... 01.2149 15.29 110172......... 01.3290 22.83 130022......... 01.1917 15.44 140058......... 01.2318 15.26 100279....................... 01.3786 18.35 110076.......... 01.3902 18.01 110174......... 01.0473 17.57 130024......... 01.0580 15.25 140059......... 01.1334 13.52 100280....................... 01.3831 16.93 110078.......... 01.6637 20.46 110176......... 01.1251 19.42 130025......... 01.1537 15.21 140061......... 01.0878 13.80 100281....................... 01.2517 20.85 110079.......... 01.3869 21.08 110177......... 01.4857 19.21 130026......... 01.1747 17.89 140062......... 01.2451 23.10 100282....................... 01.0482 16.99 110080.......... 01.1544 16.86 110178......... 01.3702 16.78 130027......... 00.9528 17.18 140063......... 01.3960 22.48 100283....................... 01.5478 ....... 110082.......... 02.0163 20.36 110179......... 01.2381 21.56 130028......... 01.2515 16.08 140064......... 01.2951 16.15 110001....................... 01.2914 17.40 110083.......... 01.7255 20.66 110181......... 00.9860 12.59 130029......... 01.0268 17.07 140065......... 01.4926 23.68 110002....................... 01.2397 14.83 110086.......... 01.2253 13.74 110183......... 01.3704 19.70 130030......... 01.0243 16.20 140066......... 01.3711 13.39 110003....................... 01.3129 15.41 110087.......... 01.3386 19.17 110184......... 01.1715 17.58 130031......... 01.0201 13.26 140067......... 01.8194 18.24 110004....................... 01.3118 16.17 110088.......... 00.9740 11.17 110185......... 01.0833 12.23 130034......... 01.0393 16.38 140068......... 01.3583 19.00 110005....................... 01.1872 21.40 110089.......... 01.2146 15.37 110186......... 01.3060 15.97 130035......... 01.0736 15.37 140069......... 01.0029 14.23 110006....................... 01.3597 18.00 110091.......... 01.3449 19.15 110187......... 01.2469 17.19 130036......... 01.2609 12.50 140070......... 01.2830 16.18 110007....................... 01.4425 15.69 110092.......... 01.1821 12.55 110188......... 01.4186 18.00 130037......... 01.2616 14.58 140074......... 00.9704 14.60 110008....................... 01.2405 15.47 110093.......... 01.0096 09.81 110189......... 01.1327 19.78 130043......... 00.9469 14.61 140075......... 01.4685 21.53 110009....................... 01.0377 15.71 110094.......... 00.9542 12.06 110190......... 01.0859 14.41 130044......... 01.1660 12.37 140077......... 01.1503 17.05 110010....................... 02.1503 21.39 110095.......... 01.2750 13.86 110191......... 01.3482 18.06 130045......... 01.0284 12.15 140079......... 01.2410 20.90 110011....................... 01.2868 16.01 110096.......... 01.1414 14.30 110192......... 01.3977 22.17 130048......... 01.0663 11.90 140080......... 01.5779 19.60 110013....................... 01.1312 14.36 110097.......... 01.0166 15.58 110193......... 01.2300 16.16 130049......... 01.2960 17.55 140081......... 01.0821 13.92 110014....................... 01.0340 14.48 110098.......... 01.0881 11.76 110194......... 00.9644 11.77 130054......... 00.9683 17.12 140082......... 01.5059 22.10 110015....................... 01.3622 16.52 110100.......... 01.0968 12.27 110195......... 01.0844 10.50 130056......... 00.8652 09.45 140083......... 01.2600 16.51 110016....................... 01.2991 14.21 110101.......... 01.1035 09.24 110198......... 01.3316 22.58 130058......... 01.0150 12.87 140084......... 01.2248 17.94 110017....................... 00.8897 11.01 110103.......... 00.9630 10.35 110200......... 01.9437 15.79 130060......... 01.1458 18.38 140086......... 01.1464 13.93 110018....................... 01.1357 17.20 110104.......... 01.1073 13.28 110201......... 01.4531 16.13 130061......... 00.9513 ....... 140087......... 01.3852 17.10 110020....................... 01.2352 17.30 110105.......... 01.1304 15.17 110203......... 00.9692 14.94 140001......... 01.2958 14.63 140088......... 01.6480 23.33 110023....................... 01.2361 17.53 110107.......... 01.8146 17.59 110204......... 00.7960 13.48 140002......... 01.2776 17.04 140089......... 01.2253 15.85 110024....................... 01.4802 18.74 110108.......... 00.9720 11.27 110205......... 01.1080 11.84 140003......... 01.0184 13.14 140090......... 01.5101 23.62 110025....................... 01.4157 16.85 110109.......... 01.1115 12.14 110207......... 01.1008 15.59 140004......... 01.0799 13.75 140091......... 01.8655 17.70 110026....................... 01.1891 13.87 110111.......... 01.1934 14.70 110208......... 00.9734 14.94 140005......... 00.9511 09.98 140093......... 01.1961 17.17 110027....................... 01.1013 14.56 110112.......... 01.1522 15.06 110209......... 00.8222 ....... 140007......... 01.4675 20.56 140094......... 01.2905 18.81 110028....................... 01.5984 17.75 110113.......... 01.1384 12.86 120001......... 01.7331 24.22 140008......... 01.4859 20.57 140095......... 01.3991 ...... 110029....................... 01.3374 17.71 110114.......... 01.0749 13.75 120002......... 01.1971 21.46 140010......... 01.3888 22.14 140097......... 00.9102 14.15 110030....................... 01.2807 16.60 110115.......... 01.6188 21.82 120003......... 01.1450 21.82 140011......... 01.1465 15.31 140100......... 01.2229 17.62 110031....................... 01.3367 19.58 110118.......... 01.0422 13.18 120004......... 01.2653 20.56 140012......... 01.2840 17.59 140101......... 01.2108 18.04 110032....................... 01.2298 15.31 110120.......... 01.0800 13.35 120005......... 01.2656 18.34 140013......... 01.6579 16.49 140102......... 01.0422 14.09 110033....................... 01.5204 20.32 110121.......... 01.1802 11.84 120006......... 01.2116 22.75 140014......... 01.0745 16.31 140103......... 01.3357 16.66 110034....................... 01.5019 16.64 110122.......... 01.3550 16.03 120007......... 01.6278 20.27 140015......... 01.2937 13.45 140105......... 01.3085 18.25 110035....................... 01.3991 18.53 110124.......... 01.0703 15.32 120009......... 01.0061 18.05 140016......... 00.9317 11.59 140107......... 01.0869 11.63 110036....................... 01.6840 22.81 110125.......... 01.2217 15.97 120010......... 01.8369 22.11 140018......... 01.4564 18.85 140108......... 01.3663 20.00 110037....................... 01.0904 10.18 110127.......... 00.9066 14.43 120011......... 01.2382 30.31 140019......... 00.9926 11.80 140109......... 01.1410 12.95 110038....................... 01.4674 15.04 110128.......... 01.1920 17.54 120012......... 01.0209 20.30 140024......... 01.0178 13.59 140110......... 01.2359 14.51 110039....................... 01.3709 17.93 110129.......... 01.6749 13.01 120014......... 01.3556 21.25 140025......... 01.0795 15.88 140112......... 01.0953 13.55 110040....................... 01.0270 16.26 110130.......... 01.0721 10.57 120015......... 00.8375 21.01 140026......... 01.1409 15.58 140113......... 01.4647 19.21 110041....................... 01.2250 16.43 110132.......... 01.1433 12.87 120016......... 00.8558 21.94 140027......... 01.3182 15.96 140114......... 01.3202 18.95 110042....................... 01.2103 14.63 110134.......... 00.8944 11.65 120018......... 01.0071 21.16 140029......... 01.3782 19.62 140115......... 01.2339 19.32 110043....................... 01.7167 15.17 110135.......... 01.1981 13.83 120019......... 01.1834 19.48 140030......... 01.6711 21.46 140116......... 01.2862 19.68 110044....................... 01.0960 14.31 110136.......... 01.1213 13.57 120021......... 00.9888 19.68 140031......... 01.1749 13.02 140117......... 01.4895 17.63 110045....................... 01.2388 22.04 110140.......... 00.8182 15.03 120022......... 01.7240 17.83 140032......... 01.2531 16.44 140118......... 01.6767 22.66 110046....................... 01.1993 15.07 110141.......... 00.9067 11.65 120026......... 01.2802 22.30 140033......... 01.2640 19.10 140119......... 01.6872 19.58 110048....................... 01.3128 12.97 110142.......... 00.9806 11.15 120027......... 01.5395 21.16 140034......... 01.1800 16.74 140120......... 01.5073 14.72 110049....................... 01.0704 13.71 110143.......... 01.3994 20.07 130001......... 01.0424 17.21 140035......... 01.0305 10.70 140121......... 01.5215 10.91 110050....................... 01.0669 14.00 110144.......... 01.1678 16.44 130002......... 01.3774 14.66 140036......... 01.2388 15.03 140122......... 01.5566 21.02 110051....................... 00.9865 16.35 110146.......... 01.0299 09.43 130003......... 01.3112 18.11 140037......... 00.9794 12.24 140124......... 01.1139 23.06 110052....................... 00.9774 09.11 110149.......... 01.1319 12.17 130005......... 01.4396 18.19 140038......... 01.1510 15.00 140125......... 01.3450 15.60 110054....................... 01.2816 16.57 110150.......... 01.3658 16.56 130006......... 01.8983 18.19 140039......... 00.9224 11.51 140127......... 01.3522 16.83 110056....................... 00.9765 12.61 110152.......... 01.1295 13.06 130007......... 01.6434 18.60 140040......... 01.3093 14.34 140128......... 01.0595 16.10 110059....................... 01.2900 14.39 110153.......... 01.0212 15.33 130008......... 00.9857 10.28 140041......... 01.2320 15.01 140129......... 01.0555 13.18 110061....................... 01.0143 10.61 110154.......... 00.8337 12.68 130009......... 00.9627 14.78 140042......... 01.0524 13.30 140130......... 01.2738 21.67 110062....................... 00.9181 09.73 110155.......... 01.2376 12.27 130010......... 00.9403 15.04 140043......... 01.1790 16.37 140132......... 01.4146 18.58 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27509]] Page 5 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 140133....................... 01.3730 19.77 140230.......... 00.9439 15.48 150043......... 01.0625 16.58 150127......... 01.0419 14.34 160069......... 01.4042 16.05 140135....................... 01.3146 14.29 140231.......... 01.6272 19.79 150044......... 01.2634 17.63 150128......... 01.2340 18.59 160070......... 01.0255 13.84 140137....................... 01.0354 13.61 140233.......... 01.7471 16.57 150045......... 01.0913 15.00 150129......... 01.1915 20.35 160072......... 01.0688 12.08 140138....................... 00.9661 12.15 140234.......... 01.1838 15.82 150046......... 01.5896 16.06 150130......... 01.1496 15.90 160073......... 01.0070 11.50 140139....................... 01.0792 13.46 140236.......... 01.0311 12.82 150047......... 01.6212 17.74 150132......... 01.3365 19.17 160074......... 01.1069 12.89 140140....................... 01.1317 13.05 140239.......... 01.5856 18.81 150048......... 01.1679 16.18 150133......... 01.2095 14.96 160075......... 01.1112 13.84 140141....................... 00.8984 13.30 140240.......... 01.5048 20.90 150049......... 01.0776 13.72 150134......... 01.2828 16.61 160076......... 01.0692 16.28 140143....................... 01.0643 15.85 140242.......... 01.5726 22.51 150050......... 01.1998 14.50 150136......... 00.9472 18.69 160077......... 01.1216 10.97 140144....................... 00.9856 16.57 140245.......... 01.1273 13.55 150051......... 01.3841 16.82 150138......... 01.1623 ....... 160079......... 01.4245 15.22 140145....................... 01.2030 14.31 140246.......... 01.0570 12.03 150052......... 01.0743 12.93 150139......... 01.4806 ....... 160080......... 01.2082 15.41 140146....................... 00.9666 14.85 140250.......... 01.3165 21.35 150053......... 01.0618 16.69 150141......... 01.0859 ....... 160081......... 01.0672 14.36 140147....................... 01.1866 13.37 140251.......... 01.3066 18.25 150054......... 01.1376 12.39 150142......... 02.4300 ....... 160082......... 01.7545 17.09 140148....................... 01.8018 16.51 140252.......... 01.4201 21.25 150056......... 01.6228 21.59 150897......... 04.9892 ....... 160083......... 01.5789 17.49 140150....................... 01.5561 26.00 140253.......... 01.4456 ....... 150057......... 02.3179 15.06 160001......... 01.2719 16.39 160085......... 01.0916 12.79 140151....................... 01.1119 17.61 140258.......... 01.5345 21.07 150058......... 01.6930 18.64 160002......... 01.1888 13.13 160086......... 01.0283 12.56 140152....................... 01.0750 22.48 140271.......... 01.0260 13.54 150059......... 01.3218 18.91 160003......... 01.0221 11.87 160088......... 01.0017 13.10 140155....................... 01.1854 16.91 140275.......... 01.2294 18.20 150060......... 01.1281 12.79 160005......... 01.1072 12.93 160089......... 01.1591 14.12 140158....................... 01.2597 21.41 140276.......... 01.9589 20.48 150061......... 01.2957 15.86 160007......... 01.0085 12.02 160090......... 01.0066 13.98 140160....................... 01.2326 15.34 140280.......... 01.2769 16.16 150062......... 01.0670 15.20 160008......... 01.1043 13.93 160091......... 01.0987 10.56 140161....................... 01.1373 17.05 140281.......... 01.6388 20.19 150063......... 01.0538 18.88 160009......... 01.1577 13.54 160092......... 00.9736 12.93 140162....................... 01.7778 18.38 140285.......... 01.2063 14.75 150064......... 01.2100 16.48 160012......... 01.0588 14.05 160093......... 01.1351 15.20 140164....................... 01.2855 16.01 140286.......... 01.1491 17.59 150065......... 01.1505 15.94 160013......... 01.2189 16.64 160094......... 01.2168 14.79 140165....................... 01.1085 13.06 140288.......... 01.7781 22.47 150066......... 01.0021 13.75 160014......... 01.0459 12.72 160095......... 01.0266 12.30 140166....................... 01.2889 16.62 140289.......... 01.3089 15.67 150067......... 01.1221 14.35 160016......... 01.2911 15.68 160097......... 01.0785 13.47 140167....................... 01.1636 14.64 140290.......... 01.3385 19.21 150069......... 01.2347 16.53 160018......... 00.9429 13.19 160098......... 01.0760 13.90 140168....................... 01.1840 15.02 140291.......... 01.2645 22.64 150070......... 01.0350 16.16 160020......... 01.0963 12.11 160099......... 00.9737 12.80 140170....................... 01.1280 12.39 140292.......... 01.1678 19.04 150071......... 01.1562 12.69 160021......... 01.0439 13.85 160101......... 01.1220 17.71 140171....................... 00.9149 12.53 140294.......... 01.1864 16.10 150072......... 01.1914 15.32 160023......... 01.1458 13.66 160102......... 01.3668 14.31 140172....................... 01.5065 18.29 140297.......... 01.2589 21.42 150073......... 01.0044 15.49 160024......... 01.5710 17.39 160103......... 01.0113 12.95 140173....................... 00.9721 13.11 140300.......... 01.6785 25.11 150074......... 01.5934 19.00 160026......... 01.0986 15.21 160104......... 01.2335 19.21 140174....................... 01.4333 18.89 150001.......... 01.0846 16.95 150075......... 01.2247 13.82 160027......... 01.1671 13.22 160106......... 01.0829 14.18 140176....................... 01.2617 18.83 150002.......... 01.4319 19.23 150076......... 01.1512 19.89 160028......... 01.3407 17.78 160107......... 01.1437 13.78 140177....................... 01.2945 16.44 150003.......... 01.7075 18.32 150077......... 01.2659 16.21 160029......... 01.4962 17.46 160108......... 01.1602 14.09 140179....................... 01.3297 19.51 150004.......... 01.4226 19.99 150078......... 01.0834 17.20 160030......... 01.2338 16.67 160109......... 01.1631 12.01 140180....................... 01.5189 20.22 150005.......... 01.1932 17.16 150079......... 01.1390 13.01 160031......... 01.1797 13.26 160110......... 01.4994 17.76 140181....................... 01.3046 18.82 150006.......... 01.2074 16.72 150082......... 01.4965 18.33 160032......... 01.1573 14.66 160111......... 01.1019 10.75 140182....................... 01.3248 19.11 150007.......... 01.2302 17.95 150084......... 01.8737 21.80 160033......... 01.7246 15.82 160112......... 01.4123 14.45 140184....................... 01.1967 14.20 150008.......... 01.3398 18.38 150086......... 01.3006 15.72 160034......... 01.0681 13.81 160113......... 00.9561 11.39 140185....................... 01.4505 16.35 150009.......... 01.3365 16.97 150088......... 01.1917 16.71 160035......... 00.9375 11.91 160114......... 01.0697 14.13 140186....................... 01.3274 18.01 150010.......... 01.2041 16.10 150089......... 01.3985 18.99 160036......... 01.0756 12.83 160115......... 01.0280 13.87 140187....................... 01.4861 16.33 150011.......... 01.2190 16.76 150090......... 01.2596 19.34 160037......... 01.1621 14.80 160116......... 01.1691 15.46 140188....................... 00.9575 10.54 150012.......... 01.6875 20.57 150091......... 01.0611 15.60 160039......... 01.0670 15.23 160117......... 01.3337 15.63 140189....................... 01.1712 15.74 150013.......... 01.1675 13.09 150092......... 01.0673 12.44 160040......... 01.3537 16.04 160118......... 01.0360 12.42 140190....................... 01.1195 13.36 150014.......... 01.4216 18.85 150094......... 01.0035 16.65 160041......... 01.0646 12.88 160120......... 01.0091 09.94 140191....................... 01.3775 23.16 150015.......... 01.2264 17.85 150095......... 01.1144 15.78 160043......... 01.0338 13.38 160122......... 01.1669 14.96 140192....................... 01.1869 16.51 150017.......... 01.8448 17.26 150096......... 01.0971 17.15 160044......... 01.1574 13.36 160123......... 01.1780 12.18 140193....................... 01.0112 12.24 150018.......... 01.2919 17.47 150097......... 01.1277 16.53 160045......... 01.6987 17.48 160124......... 01.2526 15.35 140197....................... 01.2709 16.05 150019.......... 01.1266 13.09 150098......... 01.1300 11.81 160046......... 01.0369 11.92 160126......... 01.1504 13.82 140199....................... 01.0139 15.13 150020.......... 01.1554 13.19 150099......... 01.3115 17.10 160047......... 01.3602 15.87 160129......... 01.0228 13.07 140200....................... 01.4295 20.12 150021.......... 01.6718 18.22 150100......... 01.6839 18.15 160048......... 01.0179 11.76 160130......... 01.1652 13.04 140202....................... 01.3141 20.09 150022.......... 01.1381 17.62 150101......... 01.0868 14.46 160049......... 00.9842 12.04 160131......... 01.1087 12.63 140203....................... 01.1570 19.02 150023.......... 01.4914 17.81 150102......... 01.0903 14.61 160050......... 01.0246 14.12 160134......... 00.9843 11.37 140205....................... 00.9221 13.88 150024.......... 01.4448 16.96 150103......... 01.0416 17.63 160051......... 00.9907 12.90 160135......... 01.0019 13.24 140206....................... 01.0864 19.58 150025.......... 01.4616 16.32 150104......... 01.1413 15.09 160052......... 01.0589 14.80 160138......... 01.0588 13.48 140207....................... 01.3743 26.85 150026.......... 01.1878 16.69 150105......... 01.4085 16.61 160054......... 01.0231 10.82 160140......... 01.0939 14.86 140208....................... 01.6111 23.73 150027.......... 01.0647 16.04 150106......... 01.1373 15.58 160055......... 01.0477 11.48 160142......... 01.0237 13.60 140209....................... 01.7011 17.46 150029.......... 01.2733 20.57 150109......... 01.4583 16.04 160056......... 01.0409 13.16 160143......... 01.1324 13.03 140210....................... 01.0690 12.87 150030.......... 01.1956 16.20 150110......... 00.9896 14.72 160057......... 01.3309 15.92 160145......... 01.0880 13.74 140211....................... 01.2233 20.44 150031.......... 01.0590 15.93 150111......... 01.2056 12.88 160058......... 01.6642 18.42 160146......... 01.4124 15.32 140212....................... 01.3189 22.65 150032.......... 01.7894 18.85 150112......... 01.2207 16.78 160060......... 01.0892 13.82 160147......... 01.2670 15.41 140213....................... 01.2806 20.44 150033.......... 01.6083 20.07 150113......... 01.1860 16.78 160061......... 01.0020 14.19 160151......... 01.0767 12.75 140215....................... 01.1642 13.22 150034.......... 01.3961 18.15 150114......... 01.0330 13.44 160062......... 00.9619 11.95 160152......... 01.0085 13.30 140217....................... 01.2322 20.90 150035.......... 01.4087 17.90 150115......... 01.3933 17.31 160063......... 01.2910 14.24 160153......... 01.7014 17.05 140218....................... 01.0541 13.64 150036.......... 01.0486 17.35 150122......... 01.1412 15.83 160064......... 01.6406 16.37 170001......... 01.2028 15.90 140220....................... 01.1056 14.22 150037.......... 01.2673 17.06 150123......... 01.1642 12.81 160065......... 01.0735 14.51 170004......... 01.0851 13.18 140223....................... 01.5438 ....... 150038.......... 01.2744 16.27 150124......... 01.1229 15.00 160066......... 01.1266 14.06 170006......... 01.2031 13.48 140224....................... 01.3604 22.10 150039.......... 01.0121 14.51 150125......... 01.4243 18.09 160067......... 01.3705 16.70 170008......... 00.9823 13.35 140228....................... 01.7003 17.36 150042.......... 01.2850 15.47 150126......... 01.5058 19.24 160068......... 01.1116 13.30 170009......... 01.1211 16.81 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27510]] Page 6 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 170010....................... 01.2608 16.38 170090.......... 01.1085 09.58 180012......... 01.3389 17.14 180104......... 01.5043 16.55 190064......... 01.5583 17.46 170011....................... 01.4071 14.59 170092.......... 00.8754 11.45 180013......... 01.4998 17.38 180105......... 00.9304 12.23 190065......... 01.4754 15.75 170012....................... 01.4843 15.48 170093.......... 00.9342 11.58 180014......... 01.6064 18.86 180106......... 00.9106 12.65 190071......... 00.8641 11.38 170013....................... 01.3169 13.27 170094.......... 01.0452 12.81 180015......... 01.2489 14.91 180108......... 00.8486 12.49 190077......... 00.9246 13.41 170014....................... 01.0405 15.18 170095.......... 01.0812 13.80 180016......... 01.3171 14.91 180115......... 01.0261 13.72 190078......... 01.1324 11.21 170015....................... 00.9820 13.74 170097.......... 01.0300 13.42 180017......... 01.2806 13.52 180116......... 01.3689 14.92 190079......... 01.2666 14.76 170016....................... 01.6627 21.80 170098.......... 01.0817 16.21 180018......... 01.2192 15.73 180117......... 01.1619 16.14 190081......... 00.8838 09.89 170017....................... 01.1657 14.73 170099.......... 01.3324 11.00 180019......... 01.3403 17.22 180118......... 01.0536 11.72 190083......... 00.9429 12.45 170018....................... 01.0727 12.23 170100.......... 01.0203 14.63 180020......... 01.0315 15.37 180120......... 01.0378 12.49 190086......... 01.3598 14.02 170019....................... 01.1696 15.13 170101.......... 00.9101 14.13 180021......... 01.1795 13.25 180121......... 01.2234 13.09 190088......... 01.1892 16.01 170020....................... 01.3199 14.54 170102.......... 01.0187 12.78 180023......... 00.8295 11.27 180122......... 01.0373 14.67 190089......... 01.1201 09.60 170022....................... 01.1704 14.15 170103.......... 01.2458 15.28 180024......... 01.3845 15.69 180123......... 01.4607 19.39 190090......... 01.0660 15.75 170023....................... 01.4044 15.57 170104.......... 01.4205 19.52 180025......... 01.1284 16.18 180124......... 01.4836 16.00 190092......... 01.3355 20.14 170024....................... 01.1640 12.71 170105.......... 01.0303 14.45 180026......... 01.1086 13.66 180125......... 00.9440 16.23 190095......... 00.9950 14.04 170025....................... 01.1596 18.37 170106.......... 00.8419 12.54 180027......... 01.2742 14.17 180126......... 01.1707 11.90 190098......... 01.5272 17.56 170026....................... 01.0181 16.38 170108.......... 00.9468 10.88 180028......... 01.0014 16.19 180127......... 01.2444 16.63 190099......... 01.1506 17.31 170027....................... 01.3677 15.02 170109.......... 01.0506 14.67 180029......... 01.2273 15.99 180128......... 01.1902 15.40 190102......... 01.5823 16.15 170030....................... 01.0391 13.61 170110.......... 01.0039 13.62 180030......... 01.1759 12.89 180129......... 01.0293 13.93 190103......... 00.8416 09.66 170031....................... 00.9148 12.36 170112.......... 00.9127 13.44 180031......... 01.0226 12.38 180130......... 01.4291 17.87 190106......... 01.1367 17.27 170032....................... 01.1156 14.18 170113.......... 01.1547 13.43 180032......... 00.9954 15.30 180132......... 01.2480 15.19 190109......... 01.2092 13.68 170033....................... 01.3483 14.08 170114.......... 00.9562 12.96 180033......... 01.1235 12.57 180133......... 01.2433 20.73 190110......... 00.9491 11.96 170034....................... 00.9541 13.74 170115.......... 00.9903 11.01 180034......... 01.0753 13.61 180134......... 01.0116 13.71 190111......... 01.5215 17.24 170035....................... 00.9390 12.37 170116.......... 01.0372 13.94 180035......... 01.5699 18.26 180136......... 01.5878 16.63 190112......... 01.5163 20.35 170036....................... 00.8720 12.31 170117.......... 01.0112 12.63 180036......... 01.2440 17.36 180137......... 01.6535 16.82 190113......... 01.3665 17.85 170037....................... 01.1255 15.02 170119.......... 00.9561 11.32 180037......... 01.2889 20.29 180138......... 01.2129 17.02 190114......... 01.0055 11.51 170038....................... 00.9185 10.94 170120.......... 01.2849 14.66 180038......... 01.4243 14.73 180139......... 01.0726 16.41 190115......... 01.2502 16.88 170039....................... 01.1367 11.69 170122.......... 01.8944 19.69 180040......... 02.0334 19.04 180140......... 01.0095 ....... 190116......... 01.3017 14.97 170040....................... 01.5625 18.21 170123.......... 01.7747 17.69 180041......... 01.0945 13.03 190001......... 00.9375 16.35 190118......... 01.0495 11.87 170041....................... 00.9823 11.41 170124.......... 00.9503 11.92 180042......... 01.1163 13.43 190002......... 01.6513 16.28 190120......... 00.9247 12.89 170043....................... 00.9081 13.41 170126.......... 00.9191 11.07 180043......... 01.0156 15.31 190003......... 01.4519 17.16 190122......... 01.2572 13.85 170044....................... 01.1101 14.73 170128.......... 01.0769 14.31 180044......... 01.0359 14.68 190004......... 01.3759 14.75 190124......... 01.5739 18.80 170045....................... 01.0299 10.95 170131.......... 01.0980 10.54 180045......... 01.2057 16.78 190005......... 01.6645 14.94 190125......... 01.5811 16.74 170049....................... 01.3313 18.05 170133.......... 01.1443 14.09 180046......... 01.2012 16.81 190006......... 01.2072 14.50 190128......... 01.2060 17.04 170050....................... 00.8380 09.63 170134.......... 00.9114 12.10 180047......... 01.0191 13.79 190007......... 01.0078 12.79 190130......... 00.9913 11.74 170051....................... 00.9598 13.31 170137.......... 01.1842 16.81 180048......... 01.1403 15.53 190008......... 01.6528 17.79 190131......... 01.2797 17.33 170052....................... 01.0682 13.31 170139.......... 00.9877 11.66 180049......... 01.3563 14.47 190009......... 01.2058 13.40 190133......... 01.0482 15.09 170053....................... 01.0069 13.09 170140.......... 01.0533 11.17 180050......... 01.2697 15.58 190010......... 01.0884 14.69 190134......... 00.9967 12.16 170054....................... 01.0848 12.86 170142.......... 01.2641 16.10 180051......... 01.4187 14.35 190011......... 01.1233 14.08 190135......... 01.4063 21.99 170055....................... 01.0698 17.05 170143.......... 01.1251 12.53 180053......... 01.1091 14.22 190013......... 01.4220 15.27 190136......... 01.1262 10.66 170056....................... 00.9402 10.99 170144.......... 01.6112 18.74 180054......... 01.1611 14.02 190014......... 01.0578 15.36 190138......... 00.6897 15.62 170057....................... 01.0566 13.75 170145.......... 01.1694 17.02 180055......... 01.0370 13.61 190015......... 01.2421 16.38 190140......... 00.9431 11.60 170058....................... 01.1738 17.54 170146.......... 01.4168 17.58 180056......... 01.1099 16.68 190017......... 01.3736 17.22 190142......... 00.9421 12.20 170060....................... 01.1313 12.73 170147.......... 01.2245 18.33 180058......... 01.0090 12.85 190018......... 01.1816 13.78 190144......... 01.2097 18.82 170061....................... 01.1593 12.59 170148.......... 01.4763 18.35 180059......... 00.9670 11.98 190019......... 01.5042 17.57 190145......... 00.9824 13.77 170062....................... 00.9501 10.45 170150.......... 01.0726 13.13 180060......... 00.7427 13.48 190020......... 01.2002 15.83 190146......... 01.5901 18.99 170063....................... 00.8965 09.30 170151.......... 01.0012 11.69 180063......... 00.9649 10.28 190025......... 01.2859 12.36 190147......... 00.9911 13.30 170064....................... 00.9513 11.38 170152.......... 00.9801 13.27 180064......... 01.2906 14.40 190026......... 01.4470 15.65 190148......... 00.8975 11.81 170066....................... 00.9908 12.26 170160.......... 01.0468 11.25 180065......... 00.9809 09.05 190027......... 01.4852 15.62 190149......... 00.9959 11.02 170067....................... 01.0357 11.05 170164.......... 01.0426 13.87 180066......... 01.2068 16.87 190029......... 01.1320 14.09 190151......... 01.1518 12.30 170068....................... 01.3949 14.01 170166.......... 01.1504 13.49 180067......... 01.8783 15.96 190033......... 00.9721 09.64 190152......... 01.4522 20.50 170069....................... 01.1769 13.20 170168.......... 00.9486 09.97 180069......... 01.0397 16.08 190034......... 01.2434 14.93 190155......... 00.9203 10.54 170070....................... 01.0225 11.83 170171.......... 01.0889 11.15 180070......... 01.0977 14.86 190035......... 01.4128 20.27 190156......... 00.8945 11.89 170072....................... 00.9565 11.53 170172.......... 00.9841 11.07 180072......... 01.0513 13.80 190036......... 01.6475 18.96 190158......... 01.2308 20.36 170073....................... 01.0984 12.66 170174.......... 01.0890 11.58 180075......... 00.9736 13.08 190037......... 00.9653 11.05 190160......... 01.2187 15.56 170074....................... 01.1552 12.86 170175.......... 01.2928 16.30 180078......... 01.1230 17.35 190039......... 01.4080 16.41 190161......... 01.0441 12.98 170075....................... 00.8720 10.55 170176.......... 01.5021 18.40 180079......... 01.2486 13.22 190040......... 01.3863 19.03 190162......... 01.1806 21.04 170076....................... 01.0770 11.15 170181.......... 01.1668 ....... 180080......... 01.0636 15.16 190041......... 01.4973 19.72 190164......... 01.2246 16.86 170077....................... 00.9689 11.12 170182.......... 00.8647 ....... 180085......... 01.2892 17.49 190043......... 01.1348 12.38 190166......... 01.0758 14.81 170079....................... 01.0810 11.81 170183.......... 02.1585 ....... 180087......... 01.0887 13.72 190044......... 01.1634 18.27 190167......... 01.2058 16.09 170080....................... 00.9459 11.05 180001.......... 01.2246 16.18 180088......... 01.5722 19.42 190045......... 01.3672 19.09 190170......... 00.9592 12.34 170081....................... 00.9294 10.42 180002.......... 01.0070 17.16 180092......... 01.0482 14.43 190046......... 01.4814 17.16 190173......... 01.4578 19.47 170082....................... 01.0577 10.60 180004.......... 01.0888 13.51 180093......... 01.3617 14.72 190048......... 01.0669 14.55 190175......... 01.2835 ...... 170084....................... 00.9862 11.06 180005.......... 01.0390 17.40 180094......... 01.0163 11.93 190049......... 00.9644 14.74 190176......... 01.7028 18.06 170085....................... 00.9109 12.01 180006.......... 00.9063 08.63 180095......... 01.1664 12.78 190050......... 01.0420 13.90 190177......... 01.6125 22.02 170086....................... 01.7190 18.04 180007.......... 01.5485 14.17 180099......... 01.1988 11.72 190053......... 01.0567 11.98 190178......... 00.9868 11.20 170087....................... 01.4582 18.87 180009.......... 01.3310 17.70 180101......... 01.3486 18.84 190054......... 01.4052 13.67 190182......... 01.1720 20.12 170088....................... 00.9139 10.59 180010.......... 01.8382 16.91 180102......... 01.5215 15.95 190059......... 00.9447 13.58 190183......... 01.1294 13.43 170089....................... 01.0037 14.21 180011.......... 01.1737 15.71 180103......... 02.0850 18.62 190060......... 01.4907 16.51 190184......... 01.0550 12.13 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27511]] Page 7 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 190185....................... 01.3116 19.03 210004.......... 01.3245 20.30 220030......... 01.0852 16.42 220171......... 01.6972 22.55 230103......... 01.0124 17.37 190186....................... 00.9539 11.69 210005.......... 01.2407 17.70 220031......... 01.8518 27.21 220897......... 04.8084 ....... 230104......... 01.6163 20.32 190187....................... 00.7801 14.05 210006.......... 01.1291 16.84 220033......... 01.3898 19.40 230001......... 01.2015 15.98 230105......... 01.6088 19.46 190189....................... 00.9445 14.54 210007.......... 01.6215 18.82 220035......... 01.2698 19.72 230002......... 01.2238 19.28 230106......... 01.1784 18.07 190190....................... 00.9291 18.74 210008.......... 01.3146 21.21 220036......... 01.6218 23.26 230003......... 01.0945 18.07 230107......... 00.8964 12.56 190191....................... 01.3068 18.47 210009.......... 01.7134 18.57 220038......... 01.2841 21.85 230004......... 01.6105 20.95 230108......... 01.2432 16.64 190194....................... 01.1471 19.16 210010.......... 01.1960 17.00 220041......... 01.2492 20.87 230005......... 01.2825 18.02 230110......... 01.3309 17.10 190196....................... 00.9097 16.46 210011.......... 01.2110 20.12 220042......... 01.2078 24.10 230006......... 01.1303 16.19 230111......... 00.9772 15.13 190197....................... 01.2655 18.80 210012.......... 01.4840 21.27 220046......... 01.3942 21.48 230007......... 01.0869 16.51 230113......... 00.9511 17.66 190199....................... 01.3623 ....... 210013.......... 01.2780 20.65 220049......... 01.2664 21.58 230013......... 01.2659 20.70 230114......... 00.6368 23.27 190200....................... 01.5241 21.33 210015.......... 01.2720 18.48 220050......... 01.0888 17.45 230015......... 01.1338 18.01 230115......... 01.0164 15.14 190201....................... 01.2315 18.24 210016.......... 01.7279 20.37 220051......... 01.2702 19.70 230017......... 01.5125 20.40 230116......... 00.9155 15.58 190202....................... 01.4459 18.34 210017.......... 01.1256 15.35 220052......... 01.2994 22.76 230019......... 01.5077 20.50 230117......... 01.9674 23.81 190203....................... 01.6074 19.50 210018.......... 01.2414 20.93 220053......... 01.2564 18.86 230020......... 01.7180 21.17 230118......... 01.2419 17.25 190204....................... 01.5314 20.12 210019.......... 01.4011 17.42 220055......... 01.3486 20.61 230021......... 01.6010 17.25 230119......... 01.3145 21.13 190205....................... 01.8790 17.63 210022.......... 01.4536 20.07 220057......... 01.4381 20.91 230022......... 01.2422 17.62 230120......... 01.2315 19.00 190206....................... 01.4995 21.17 210023.......... 01.2956 20.31 220058......... 01.0650 17.55 230024......... 01.4216 21.79 230121......... 01.2320 19.67 190207....................... 01.1825 19.43 210024.......... 01.5336 18.06 220060......... 01.2565 24.78 230027......... 01.0587 16.25 230122......... 01.3296 18.32 190208....................... 00.8198 10.36 210025.......... 01.3227 17.84 220062......... 00.6021 19.30 230029......... 01.5998 20.91 230124......... 01.1555 16.49 190218....................... 01.1389 15.05 210026.......... 01.3187 24.54 220063......... 01.2909 18.42 230030......... 01.2415 16.55 230125......... 01.3676 12.83 190223....................... 00.5039 09.72 210027.......... 01.2046 17.10 220064......... 01.2167 20.66 230031......... 01.4660 18.32 230128......... 01.3700 19.33 190227....................... 00.8050 30.01 210028.......... 01.2256 16.66 220065......... 01.2182 20.00 230032......... 01.7444 18.97 230129......... 01.8923 19.07 190230....................... 00.8737 ....... 210029.......... 01.3064 20.04 220066......... 01.2760 19.39 230034......... 01.1948 16.64 230130......... 01.6884 22.37 190231....................... 01.2825 ....... 210030.......... 01.0993 15.77 220067......... 01.2944 22.82 230035......... 01.1377 15.84 230132......... 01.5373 22.92 190232....................... 01.6623 ....... 210031.......... 01.6370 16.97 220068......... 00.5244 15.95 230036......... 01.2807 19.78 230133......... 01.2350 14.06 190233....................... 01.0997 ....... 210032.......... 01.2096 18.42 220070......... 01.2635 17.77 230037......... 01.1606 16.96 230134......... 01.1081 15.87 200001....................... 01.2712 15.74 210033.......... 01.1818 17.38 220071......... 01.8550 24.38 230038......... 01.6451 21.18 230135......... 01.1885 19.88 200002....................... 01.0212 16.15 210034.......... 01.3996 20.29 220073......... 01.3882 25.34 230040......... 01.1976 18.35 230137......... 01.1691 17.78 200003....................... 01.1264 15.90 210035.......... 01.1952 17.25 220074......... 01.2614 21.18 230041......... 01.2085 18.20 230141......... 01.6883 20.84 200006....................... 01.0731 14.95 210037.......... 01.2887 16.14 220075......... 01.3228 20.09 230042......... 01.1542 19.03 230142......... 01.2092 18.71 200007....................... 01.0066 15.63 210038.......... 01.3413 19.90 220076......... 01.1851 22.47 230046......... 01.8239 24.65 230143......... 01.1481 15.23 200008....................... 01.2497 18.34 210039.......... 01.1613 15.25 220077......... 01.7122 22.32 230047......... 01.3070 19.61 230144......... 01.1092 21.06 200009....................... 01.7602 19.84 210040.......... 01.2993 20.32 220079......... 01.1880 21.28 230053......... 01.5387 23.82 230145......... 01.1742 15.41 200012....................... 01.1641 16.11 210043.......... 01.2569 20.04 220080......... 01.2773 17.77 230054......... 01.8228 19.74 230146......... 01.2845 19.49 200013....................... 01.1401 15.32 210044.......... 01.2000 20.28 220081......... 00.9446 23.55 230055......... 01.1760 17.36 230147......... 01.4742 19.34 200015....................... 01.2358 17.15 210045.......... 01.0148 11.73 220082......... 01.2902 19.28 230056......... 00.9776 14.17 230149......... 01.2419 14.92 200016....................... 01.0350 16.10 210046.......... 01.1079 12.34 220083......... 01.1831 19.80 230058......... 01.0786 17.42 230151......... 01.3631 21.32 200017....................... 01.2447 16.86 210048.......... 01.1746 22.47 220084......... 01.2425 22.24 230059......... 01.4842 19.00 230153......... 01.1118 15.61 200018....................... 01.1602 14.27 210049.......... 01.1517 16.57 220086......... 01.5483 24.60 230060......... 01.2882 16.90 230154......... 00.9493 12.09 200019....................... 01.2486 18.01 210051.......... 01.4541 13.94 220088......... 01.5778 21.76 230062......... 01.0291 10.93 230155......... 00.9752 13.80 200020....................... 01.1930 19.86 210054.......... 01.2790 20.17 220089......... 01.3304 22.99 230063......... 01.3106 18.41 230156......... 01.6989 21.57 200021....................... 01.1723 17.66 210055.......... 01.2914 22.48 220090......... 01.2260 20.78 230065......... 01.4805 18.63 230157......... 01.2084 19.67 200023....................... 00.8814 14.61 210056.......... 01.4132 16.51 220092......... 01.2533 20.86 230066......... 01.3629 17.55 230159......... 01.3614 18.93 200024....................... 01.2940 19.16 210057.......... 01.3587 ....... 220094......... 01.2679 19.76 230068......... 01.4269 22.29 230162......... 00.9841 13.73 200025....................... 01.2732 18.81 210058.......... 01.6842 18.09 220095......... 01.2234 17.77 230069......... 01.1751 18.86 230165......... 01.8763 20.92 200026....................... 01.0896 15.20 210059.......... 01.2581 21.91 220098......... 01.2884 19.81 230070......... 01.4926 19.30 230167......... 01.3662 19.18 200027....................... 01.1423 16.51 210060.......... 01.1731 25.28 220099......... 01.1644 15.97 230071......... 01.1363 20.78 230169......... 01.4366 21.16 200028....................... 00.9339 14.83 210061.......... 01.0980 14.25 220100......... 01.2619 23.48 230072......... 01.2879 18.87 230171......... 00.9849 14.18 200031....................... 01.2965 14.96 220001.......... 01.1636 20.98 220101......... 01.5059 22.58 230075......... 01.5257 19.29 230172......... 01.3176 17.85 200032....................... 01.3588 17.72 220002.......... 01.5368 21.62 220104......... 01.2419 23.12 230076......... 01.3128 21.53 230174......... 01.3016 19.11 200033....................... 01.7105 19.57 220003.......... 01.0806 16.92 220105......... 01.2111 21.97 230077......... 01.9772 18.44 230176......... 01.2388 20.89 200034....................... 01.1962 17.19 220004.......... 01.1812 18.85 220106......... 01.2458 21.83 230078......... 01.0869 14.76 230178......... 01.0320 16.02 200037....................... 01.2193 15.53 220006.......... 01.4332 21.79 220107......... 01.1742 18.46 230080......... 01.1933 20.41 230180......... 01.0676 15.03 200038....................... 01.1145 17.66 220008.......... 01.2523 19.26 220108......... 01.1503 20.96 230081......... 01.2191 16.55 230184......... 01.2246 16.99 200039....................... 01.2494 18.06 220010.......... 01.2949 20.94 220110......... 01.9520 30.07 230082......... 01.1643 14.88 230186......... 01.3835 15.81 200040....................... 01.0969 16.12 220011.......... 01.1570 27.95 220111......... 01.2612 21.21 230085......... 01.1115 17.10 230188......... 01.1787 15.49 200041....................... 01.2255 17.37 220012.......... 01.3654 27.84 220116......... 01.9484 23.95 230086......... 00.9885 14.03 230189......... 00.8927 14.50 200043....................... 00.5362 16.96 220015.......... 01.1767 20.35 220118......... 02.0446 26.47 230087......... 01.0641 13.65 230190......... 01.0483 22.66 200050....................... 01.2051 16.71 220016.......... 01.3547 20.16 220119......... 01.3255 24.40 230089......... 01.3379 21.55 230191......... 00.8947 14.99 200051....................... 00.9656 17.70 220017.......... 01.4233 23.78 220123......... 01.0371 23.85 230092......... 01.3295 17.77 230193......... 01.2340 16.03 200052....................... 00.9605 13.07 220019.......... 01.1716 17.06 220126......... 01.3077 19.39 230093......... 01.2320 17.37 230194......... 01.2090 14.37 200055....................... 01.1609 14.56 220020.......... 01.2174 18.47 220128......... 01.1494 20.85 230095......... 01.2251 15.53 230195......... 01.2803 19.80 200062....................... 00.9155 14.64 220021.......... 01.3823 23.21 220133......... 00.8435 30.53 230096......... 01.1954 19.85 230197......... 01.2564 22.00 200063....................... 01.1630 16.63 220023.......... 01.1522 19.37 220135......... 01.2581 23.97 230097......... 01.5433 17.75 230199......... 01.1386 17.72 200066....................... 01.1762 14.34 220024.......... 01.1696 20.14 220153......... 01.0459 19.74 230099......... 01.2223 19.06 230201......... 01.2166 14.02 210001....................... 01.4081 17.94 220025.......... 01.1948 18.87 220154......... 00.8972 18.96 230100......... 01.1604 15.19 230204......... 01.3584 19.78 210002....................... 01.9534 16.84 220028.......... 01.4680 22.20 220162......... 01.0891 ....... 230101......... 01.0566 16.79 230205......... 01.0607 14.54 210003....................... 01.5503 22.97 220029.......... 01.1933 22.25 220163......... 02.0719 24.73 230102......... 01.1047 ....... 230207......... 01.2544 19.85 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27512]] Page 8 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 230208....................... 01.1783 16.10 240047.......... 01.5215 18.27 240132......... 01.2422 20.49 250034......... 01.5418 12.99 250138......... 01.3553 16.91 230211....................... 00.9786 13.86 240048.......... 01.2786 20.43 240133......... 01.1715 16.16 250035......... 00.9041 11.82 250140......... 00.9213 09.37 230212....................... 01.0964 21.13 240049.......... 01.7763 20.33 240135......... 00.8386 11.38 250036......... 00.9863 11.34 250141......... 01.2142 15.50 230213....................... 01.0251 12.69 240050.......... 01.1234 19.89 240137......... 01.2521 15.40 250037......... 00.8717 09.53 250144......... 00.9383 11.18 230216....................... 01.5363 17.91 240051.......... 00.9749 15.97 240138......... 00.8953 13.09 250038......... 00.9909 12.52 250145......... 00.9362 ...... 230217....................... 01.2142 18.06 240052.......... 01.2480 17.21 240139......... 00.9551 14.24 250039......... 01.0004 11.71 250146......... 01.0020 12.89 230219....................... 01.0153 15.18 240053.......... 01.5190 19.67 240141......... 01.0836 19.12 250040......... 01.2911 15.65 250148......... 01.1589 ...... 230221....................... 01.1831 18.15 240056.......... 01.2490 20.13 240142......... 01.1491 15.16 250042......... 01.1491 13.78 250149......... 00.9157 ...... 230222....................... 01.3602 18.98 240057.......... 01.7418 22.04 240143......... 01.0673 12.48 250043......... 01.0303 10.49 260001......... 01.6548 15.06 230223....................... 01.3164 19.85 240058.......... 00.9730 09.64 240144......... 00.9419 13.39 250044......... 00.9825 13.98 260002......... 01.4785 20.05 230227....................... 01.5246 22.00 240059.......... 01.1011 17.98 240145......... 00.9681 12.37 250045......... 01.1454 17.17 260003......... 00.9487 12.45 230228....................... 01.2133 17.29 240061.......... 01.7409 20.93 240146......... 00.9270 17.20 250047......... 00.9527 09.12 260004......... 01.0315 11.86 230230....................... 01.5449 20.38 240063.......... 01.4559 20.88 240148......... 00.9433 11.34 250048......... 01.4527 13.51 260005......... 01.6121 19.68 230232....................... 01.0330 15.87 240064.......... 01.2630 18.13 240150......... 00.8874 11.72 250049......... 00.9058 09.93 260006......... 01.5286 16.72 230235....................... 01.1141 14.65 240065.......... 01.1480 11.14 240152......... 01.0177 17.85 250050......... 01.2448 12.30 260007......... 01.4659 16.03 230236....................... 01.3372 21.07 240066.......... 01.3895 19.08 240153......... 01.0210 14.30 250051......... 00.8585 09.44 260008......... 01.2051 13.88 230239....................... 01.1697 16.07 240069.......... 01.1596 18.31 240154......... 01.0138 13.15 250057......... 01.1766 14.06 260009......... 01.2372 15.63 230241....................... 01.1519 17.08 240071.......... 01.1245 18.05 240155......... 00.9817 14.39 250058......... 01.1385 13.65 260011......... 01.6786 16.21 230244....................... 01.3177 20.14 240072.......... 01.0272 16.08 240157......... 01.1265 13.92 250059......... 01.0322 12.16 260012......... 01.0505 11.96 230253....................... 01.0740 17.39 240073.......... 00.9172 15.13 240160......... 00.9997 14.65 250060......... 00.8084 12.19 260013......... 01.1491 12.68 230254....................... 01.2799 22.64 240075.......... 01.2180 18.79 240161......... 00.9389 14.56 250061......... 00.8634 10.75 260014......... 01.7751 17.84 230257....................... 01.1068 19.01 240076.......... 01.1373 19.69 240162......... 00.9645 15.28 250063......... 00.8596 12.68 260015......... 01.2666 13.16 230259....................... 01.1982 19.06 240077.......... 01.0463 14.15 240163......... 00.9330 14.10 250065......... 00.8907 11.72 260017......... 01.2286 13.94 230264....................... 00.9438 16.74 240078.......... 01.4536 21.46 240166......... 01.1669 14.67 250066......... 00.9404 12.17 260018......... 00.9652 09.56 230269....................... 01.3034 21.71 240079.......... 01.0176 12.57 240169......... 00.9534 15.25 250067......... 01.1253 14.14 260019......... 00.9816 12.63 230270....................... 01.2162 20.08 240080.......... 01.3774 20.87 240170......... 01.1564 14.42 250068......... 00.8556 11.19 260020......... 01.7259 18.73 230273....................... 01.6607 22.11 240082.......... 01.1194 14.55 240171......... 00.9950 14.02 250069......... 01.1870 13.42 260021......... 01.5153 17.51 230275....................... 00.5787 16.53 240083.......... 01.3925 16.60 240172......... 01.0869 14.50 250071......... 00.9541 08.06 260022......... 01.3501 18.69 230276....................... 00.8129 16.23 240084.......... 01.3436 17.20 240173......... 00.9599 14.82 250072......... 01.2914 16.67 260023......... 01.2567 15.57 230277....................... 01.2425 21.76 240085.......... 00.9247 14.90 240179......... 01.0022 14.30 250076......... 00.9579 10.32 260024......... 01.0210 12.28 230278....................... 02.0914 19.50 240086.......... 01.0520 15.23 240180......... 01.0157 10.51 250077......... 00.9505 11.08 260025......... 01.3121 13.61 230279....................... 00.6989 ....... 240087.......... 01.0824 15.69 240184......... 01.0424 11.31 250078......... 01.4419 14.21 260027......... 01.5941 18.92 230280....................... 01.0281 ....... 240088.......... 01.4444 18.10 240187......... 01.2617 16.56 250079......... 00.8562 15.12 260029......... 01.1264 15.76 230281....................... 01.7080 ....... 240089.......... 01.0010 15.23 240193......... 01.0582 14.73 250081......... 01.3034 15.19 260030......... 01.0891 09.73 240001....................... 01.5708 21.24 240090.......... 01.0970 13.57 240196......... 00.6132 22.50 250082......... 01.2857 12.30 260031......... 01.4989 18.67 240002....................... 01.6938 19.40 240093.......... 01.3186 16.49 240200......... 00.8962 13.34 250083......... 01.0251 11.01 260032......... 01.5795 17.59 240004....................... 01.4661 20.16 240094.......... 01.0543 17.26 240205......... 00.9014 ....... 250084......... 01.0930 13.92 260034......... 00.9785 14.22 240005....................... 00.9960 13.49 240096.......... 01.0160 14.12 240206......... 00.8472 ....... 250085......... 01.0093 11.42 260035......... 01.0729 11.44 240006....................... 01.1385 19.75 240097.......... 01.1270 17.05 240207......... 01.2326 21.47 250088......... 00.9591 15.56 260036......... 01.0628 15.72 240007....................... 01.1171 15.15 240098.......... 00.9677 16.41 240210......... 01.2588 21.44 250089......... 01.0276 11.77 260037......... 01.4003 15.17 240008....................... 01.0569 15.22 240099.......... 01.1143 11.00 240211......... 00.9532 11.18 250093......... 01.1064 12.17 260039......... 01.1432 11.17 240009....................... 00.9895 14.18 240100.......... 01.3089 19.58 240212......... 01.9942 ....... 250094......... 01.2377 14.41 260040......... 01.6075 14.92 240010....................... 01.9742 20.17 240101.......... 01.1581 17.32 250001......... 01.6688 15.91 250095......... 00.9795 13.57 260042......... 01.4257 15.65 240011....................... 01.1400 15.69 240102.......... 00.8915 12.27 250002......... 00.7926 13.34 250096......... 01.2945 16.48 260044......... 01.0361 14.29 240013....................... 01.3150 15.90 240103.......... 01.0772 14.10 250003......... 01.0305 14.13 250097......... 01.1910 13.83 260047......... 01.3634 14.19 240014....................... 01.0820 17.79 240104.......... 01.2345 21.68 250004......... 01.4613 15.12 250098......... 00.8668 13.73 260048......... 01.2847 18.05 240016....................... 01.3076 15.46 240105.......... 01.0028 12.70 250005......... 00.9643 09.15 250099......... 01.2680 12.73 260050......... 01.0968 14.71 240017....................... 01.1439 15.15 240106.......... 01.3245 23.78 250006......... 00.9651 12.27 250100......... 01.2315 14.53 260052......... 01.3337 15.95 240018....................... 01.2866 15.82 240107.......... 00.9788 15.07 250007......... 01.2618 16.88 250101......... 00.9408 09.89 260053......... 01.1331 09.46 240019....................... 01.2275 19.58 240108.......... 00.9539 11.64 250008......... 00.8996 11.36 250102......... 01.5414 14.80 260054......... 01.3206 15.14 240020....................... 01.1482 18.11 240109.......... 00.9922 13.59 250009......... 01.1809 15.04 250104......... 01.3619 15.58 260055......... 01.0378 13.67 240021....................... 00.9369 12.49 240110.......... 01.0305 15.18 250010......... 01.0381 11.07 250105......... 00.9206 13.13 260057......... 01.1548 13.85 240022....................... 01.1174 17.33 240111.......... 00.9867 13.06 250012......... 00.9568 13.77 250107......... 00.9087 14.16 260059......... 01.1275 14.17 240023....................... 01.0074 15.86 240112.......... 01.0531 13.30 250015......... 01.0942 09.75 250109......... 00.9352 11.54 260061......... 01.1793 10.87 240025....................... 01.1734 15.02 240114.......... 00.9888 11.13 250017......... 01.0107 13.77 250112......... 00.9947 14.22 260062......... 01.1602 19.89 240027....................... 01.0011 12.60 240115.......... 01.6063 22.30 250018......... 00.9603 09.81 250117......... 01.0705 13.28 260063......... 01.1913 14.82 240028....................... 01.1386 16.50 240116.......... 00.9465 12.43 250019......... 01.4259 17.43 250119......... 01.2047 10.80 260064......... 01.3295 15.38 240029....................... 01.1610 15.70 240117.......... 01.0697 16.21 250020......... 01.0082 10.70 250120......... 01.0645 12.04 260065......... 01.7778 15.31 240030....................... 01.3037 16.78 240119.......... 00.8486 16.93 250021......... 00.8579 07.74 250122......... 01.2735 15.87 260066......... 01.0927 13.19 240031....................... 00.9361 13.50 240121.......... 00.9008 16.90 250023......... 00.8647 11.22 250123......... 01.3262 17.72 260067......... 00.9820 10.43 240036....................... 01.5543 19.05 240122.......... 01.0504 16.80 250024......... 00.9894 08.25 250124......... 00.9137 10.69 260068......... 01.6715 18.49 240037....................... 01.0408 16.40 240123.......... 01.0498 13.30 250025......... 01.1455 13.58 250125......... 01.3231 18.35 260070......... 01.0862 11.09 240038....................... 01.4454 22.37 240124.......... 01.0139 15.71 250027......... 01.0256 10.40 250126......... 00.9923 10.22 260073......... 00.9681 11.58 240040....................... 01.2251 17.67 240125.......... 00.9399 10.75 250029......... 00.8872 11.87 250127......... 00.7630 ....... 260074......... 01.2427 14.81 240041....................... 01.2877 14.43 240127.......... 01.0142 12.51 250030......... 00.9688 11.39 250128......... 01.1010 12.64 260077......... 01.7271 16.15 240043....................... 01.1990 16.83 240128.......... 01.1180 14.55 250031......... 01.3157 17.20 250131......... 01.0539 09.36 260078......... 01.1782 12.39 240044....................... 01.2046 16.02 240129.......... 01.0153 12.18 250032......... 01.2551 15.70 250134......... 00.9795 12.70 260079......... 00.9824 11.78 240045....................... 01.0655 18.49 240130.......... 01.0151 14.54 250033......... 00.9921 11.57 250136......... 00.7871 16.84 260080......... 00.9654 09.77 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27513]] Page 9 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 260081....................... 01.4971 16.44 270004.......... 01.6477 16.49 280026......... 01.1254 12.80 280115......... 00.9809 13.59 310017......... 01.3295 21.95 260082....................... 01.1231 13.50 270006.......... 01.0290 18.67 280028......... 01.0559 13.64 280117......... 01.2229 14.48 310018......... 01.2194 21.06 260085....................... 01.5684 18.57 270007.......... 00.9630 12.26 280029......... 01.0506 12.62 280118......... 00.9757 13.28 310019......... 01.6403 20.84 260086....................... 01.0649 12.67 270009.......... 01.0387 14.91 280030......... 01.7392 23.13 280119......... 00.8364 ....... 310020......... 01.1974 19.66 260089....................... 00.9614 13.31 270011.......... 01.1242 ....... 280031......... 01.0575 12.48 280123......... 00.7918 ....... 310021......... 01.3472 21.15 260091....................... 01.6022 18.86 270012.......... 01.5945 17.10 280032......... 01.3182 15.11 290001......... 01.6372 22.35 310022......... 01.2384 19.38 260094....................... 01.1872 14.91 270013.......... 01.2847 16.78 280033......... 00.9766 13.62 290002......... 00.8981 17.99 310024......... 01.2566 22.60 260095....................... 01.4432 16.05 270014.......... 01.7192 15.97 280034......... 01.2078 13.41 290003......... 01.6179 21.15 310025......... 01.2260 21.92 260096....................... 01.5521 21.52 270016.......... 00.8187 11.51 280035......... 00.9433 11.75 290005......... 01.4399 19.66 310026......... 01.2647 21.91 260097....................... 01.1913 15.82 270017.......... 01.2275 18.32 280037......... 01.0146 13.55 290006......... 01.2170 16.54 310027......... 01.3646 18.17 260100....................... 00.9630 13.12 270019.......... 01.0625 13.34 280038......... 01.0763 13.39 290007......... 01.8961 25.07 310028......... 01.1530 20.46 260102....................... 01.0125 16.75 270021.......... 01.1007 15.55 280039......... 01.1970 14.24 290008......... 01.2200 17.14 310029......... 01.8925 20.69 260103....................... 01.3849 16.73 270023.......... 01.2916 18.76 280040......... 01.5940 18.30 290009......... 01.6244 21.07 310031......... 02.5990 24.14 260104....................... 01.6403 19.57 270024.......... 00.9931 11.15 280041......... 01.0014 10.95 290010......... 01.2053 19.33 310032......... 01.2921 20.00 260105....................... 01.8664 19.47 270026.......... 00.8654 11.95 280042......... 01.0880 13.22 290011......... 00.8812 14.39 310034......... 01.2545 19.14 260107....................... 01.3815 18.77 270027.......... 01.0389 12.69 280043......... 01.1268 12.75 290012......... 01.4385 19.97 310036......... 01.2092 18.44 260108....................... 01.8100 17.90 270028.......... 01.0741 14.91 280045......... 01.1401 13.48 290013......... 01.0185 14.85 310037......... 01.3076 24.97 260109....................... 00.9959 11.92 270029.......... 00.9031 14.51 280046......... 01.0732 11.09 290014......... 01.0444 16.52 310038......... 01.9146 22.82 260110....................... 01.6120 14.16 270031.......... 00.8747 09.71 280047......... 01.1620 15.70 290015......... 00.9730 15.38 310039......... 01.2871 20.51 260111....................... 00.9980 08.04 270032.......... 01.1788 16.46 280048......... 01.0800 11.17 290016......... 01.1392 18.71 310040......... 01.2688 23.12 260112....................... 01.4171 17.75 270033.......... 00.8766 11.39 280049......... 01.0408 13.82 290019......... 01.2774 17.92 310041......... 01.3218 22.90 260113....................... 01.1053 14.05 270035.......... 01.0275 15.87 280050......... 00.9290 13.11 290020......... 01.0859 17.65 310042......... 01.2459 21.74 260115....................... 01.2345 14.63 270036.......... 00.9483 10.42 280051......... 01.0735 13.72 290021......... 01.5601 19.17 310043......... 01.2080 20.60 260116....................... 01.1223 13.70 270039.......... 01.0661 11.99 280052......... 01.0491 11.85 290022......... 01.7399 22.47 310044......... 01.3055 20.16 260119....................... 01.1640 14.93 270040.......... 01.0825 17.60 280054......... 01.2628 17.92 290027......... 00.9567 14.68 310045......... 01.3849 25.76 260120....................... 01.1599 15.72 270041.......... 01.0693 11.14 280055......... 00.9347 11.63 290029......... 00.9400 ....... 310047......... 01.3410 23.05 260122....................... 01.1502 13.12 270044.......... 01.1913 13.40 280056......... 00.9886 10.99 290032......... 01.4149 18.66 310048......... 01.1852 20.69 260123....................... 01.0312 11.56 270046.......... 00.9346 13.50 280057......... 01.0055 14.48 290038......... 01.1064 ....... 310049......... 01.3294 23.54 260127....................... 00.9514 13.71 270048.......... 01.0940 13.30 280058......... 01.3123 13.75 300001......... 01.3957 20.70 310050......... 01.2677 20.88 260128....................... 00.9851 08.95 270049.......... 01.8346 18.19 280060......... 01.5884 18.35 300003......... 01.8607 20.92 310051......... 01.3207 24.26 260129....................... 01.2124 13.51 270050.......... 01.0380 15.96 280061......... 01.4628 14.76 300005......... 01.2620 18.65 310052......... 01.2545 20.53 260131....................... 01.2940 16.32 270051.......... 01.2980 17.65 280062......... 01.2187 11.92 300006......... 01.1221 16.24 310054......... 01.2880 23.19 260134....................... 01.1526 13.82 270052.......... 01.0663 18.02 280064......... 01.0759 12.61 300007......... 01.1527 16.76 310056......... 01.1826 20.11 260137....................... 01.2614 13.71 270053.......... 00.8678 09.53 280065......... 01.2879 16.22 300008......... 01.2481 16.95 310057......... 01.2933 20.10 260138....................... 01.9711 20.66 270057.......... 01.1715 17.35 280066......... 01.0191 11.38 300009......... 01.0977 17.45 310058......... 01.1025 25.35 260141....................... 01.8695 16.53 270058.......... 00.9411 11.20 280068......... 00.9659 09.31 300010......... 01.2364 17.80 310060......... 01.2116 17.55 260142....................... 01.1566 14.50 270059.......... 00.8676 19.21 280070......... 01.0724 10.75 300011......... 01.3481 21.53 310061......... 01.2085 19.85 260143....................... 00.9463 10.52 270060.......... 00.9702 11.92 280073......... 01.0386 12.78 300012......... 01.2749 21.64 310062......... 01.2936 23.90 260147....................... 01.0469 12.81 270063.......... 00.8933 12.94 280074......... 01.1165 12.87 300013......... 01.2241 16.87 310063......... 01.3528 20.78 260148....................... 00.9572 09.33 270068.......... 00.8629 12.38 280075......... 01.2096 12.90 300014......... 01.2293 18.41 310064......... 01.2956 21.35 260158....................... 01.1275 11.80 270072.......... 00.8605 14.88 280076......... 01.0719 12.54 300015......... 01.1807 17.56 310067......... 01.3198 21.14 260159....................... 01.2924 18.02 270073.......... 01.0764 11.06 280077......... 01.3635 17.36 300016......... 01.3137 17.41 310069......... 01.1292 18.19 260160....................... 01.0663 14.07 270074.......... 00.8832 ....... 280079......... 01.0636 09.40 300017......... 01.2137 20.49 310070......... 01.3977 22.16 260162....................... 01.7006 17.70 270075.......... 00.8610 ....... 280080......... 01.0860 11.34 300018......... 01.2397 18.85 310072......... 01.3053 20.74 260163....................... 01.3037 14.11 270076.......... 00.8395 ....... 280081......... 01.5614 17.24 300019......... 01.2613 18.43 310073......... 01.5567 22.31 260164....................... 01.0000 12.07 270079.......... 00.9594 13.36 280082......... 01.0967 13.03 300020......... 01.2666 19.78 310074......... 01.4153 21.08 260166....................... 01.2144 21.51 270080.......... 01.1499 14.27 280083......... 01.0671 15.64 300021......... 01.1635 15.69 310075......... 01.2965 21.67 260172....................... 01.0176 12.07 270081.......... 01.0780 09.77 280084......... 01.0314 10.92 300022......... 01.0939 17.08 310076......... 01.3883 28.16 260173....................... 00.9560 11.15 270082.......... 01.0050 16.10 280085......... 00.7201 14.72 300023......... 01.3251 20.13 310077......... 01.5000 23.09 260175....................... 01.1270 14.60 270083.......... 01.1179 10.96 280088......... 01.8180 17.33 300024......... 01.2662 16.56 310078......... 01.3399 22.70 260176....................... 01.6758 18.44 270084.......... 00.9031 12.77 280089......... 01.0614 13.79 300028......... 01.2716 15.52 310081......... 01.2643 20.80 260177....................... 01.3871 19.46 280001.......... 01.0866 14.11 280090......... 00.9838 11.70 300029......... 01.3165 21.79 310083......... 01.2405 22.20 260178....................... 01.4760 19.06 280003.......... 01.9467 18.11 280091......... 01.1320 13.17 300033......... 01.1041 13.70 310084......... 01.2611 20.43 260179....................... 01.5653 18.02 280005.......... 01.3791 16.72 280092......... 00.8959 11.63 300034......... 01.9294 21.31 310086......... 01.1743 20.89 260180....................... 01.7024 18.45 280009.......... 01.7304 16.70 280094......... 01.1287 13.55 310001......... 01.7682 24.56 310087......... 01.2357 18.95 260183....................... 01.6443 16.51 280011.......... 00.9606 11.56 280097......... 01.0459 12.56 310002......... 01.7260 25.58 310088......... 01.2439 19.57 260186....................... 01.2600 15.20 280012.......... 01.2348 14.88 280098......... 01.0110 09.68 310003......... 01.2210 23.16 310090......... 01.1901 22.86 260188....................... 01.2714 15.70 280013.......... 02.0127 19.71 280101......... 01.1114 10.92 310005......... 01.2226 19.20 310091......... 01.2170 21.35 260189....................... 00.9400 11.23 280014.......... 01.0034 10.78 280102......... 01.1187 11.77 310006......... 01.2198 19.02 310092......... 01.3046 20.52 260190....................... 01.2072 18.46 280015.......... 01.0314 13.78 280104......... 00.9608 09.88 310008......... 01.2739 21.23 310093......... 01.2163 19.52 260191....................... 01.1707 19.44 280017.......... 01.1537 13.42 280105......... 01.2920 16.46 310009......... 01.2782 21.35 310096......... 01.9004 21.19 260193....................... 01.2240 19.13 280018.......... 01.1931 12.25 280106......... 00.9402 13.23 310010......... 01.2912 21.05 310105......... 01.1999 22.41 260195....................... 01.1660 ....... 280020.......... 01.5257 18.97 280107......... 01.0294 12.36 310011......... 01.3017 21.71 310108......... 01.3824 21.08 260197....................... 01.3182 20.38 280021.......... 01.3499 14.01 280108......... 01.1461 13.26 310012......... 01.5940 23.47 310110......... 01.2143 19.69 260198....................... 01.2213 14.98 280022.......... 00.9770 11.07 280109......... 00.9501 10.61 310013......... 01.2768 19.91 310111......... 01.2557 19.70 260200....................... 01.3554 19.14 280023.......... 01.3780 13.73 280110......... 00.9942 10.88 310014......... 01.7025 23.69 310112......... 01.2426 20.58 270002....................... 01.1911 13.92 280024.......... 01.0114 13.22 280111......... 01.2372 16.06 310015......... 01.7776 24.34 310113......... 01.2089 20.70 270003....................... 01.2465 18.65 280025.......... 00.9810 11.07 280114......... 00.9353 10.26 310016......... 01.2225 22.93 310115......... 01.1943 19.78 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27514]] Page 10 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 310116....................... 01.2919 21.67 330028.......... 01.3448 23.76 330132......... 01.1620 13.74 330233......... 01.5441 29.08 330399......... 01.3239 29.65 310118....................... 01.1849 21.86 330029.......... 01.1111 17.36 330133......... 01.3428 28.31 330234......... 02.1918 24.17 340001......... 01.4951 19.39 310119....................... 01.5594 27.27 330030.......... 01.2349 14.89 330135......... 01.2563 16.25 330235......... 01.1332 17.37 340002......... 01.8825 18.53 310120....................... 01.0603 17.24 330033.......... 01.2846 13.46 330136......... 01.2637 20.45 330236......... 01.3832 26.18 340003......... 01.1188 16.56 310121....................... 01.0460 16.61 330034.......... 00.7718 36.61 330140......... 01.7132 17.19 330238......... 01.1820 14.53 340004......... 01.4966 17.21 320001....................... 01.4620 16.76 330036.......... 01.3298 21.00 330141......... 01.3504 23.17 330239......... 01.2013 15.44 340005......... 01.2221 14.57 320002....................... 01.4159 21.55 330037.......... 01.1242 15.17 330144......... 00.9758 13.17 330240......... 01.3354 26.47 340006......... 01.2338 14.56 320003....................... 01.1576 15.57 330038.......... 01.2140 14.91 330148......... 01.0784 14.39 330241......... 01.8652 20.92 340007......... 01.1848 14.81 320004....................... 01.2677 17.86 330039.......... 00.8486 13.18 330151......... 01.0421 13.73 330242......... 01.3516 18.35 340008......... 01.1458 16.48 320005....................... 01.3217 17.80 330041.......... 01.3912 27.81 330152......... 01.4273 27.77 330245......... 01.2716 17.15 340009......... 01.4043 18.58 320006....................... 01.3699 15.02 330043.......... 01.2400 25.15 330153......... 01.6522 17.44 330246......... 01.2502 22.99 340010......... 01.3129 16.41 320009....................... 01.5348 16.75 330044.......... 01.2405 16.99 330154......... 01.5884 ....... 330247......... 00.7071 26.49 340011......... 01.1134 13.98 320011....................... 00.9939 17.79 330045.......... 01.4167 24.83 330157......... 01.3091 18.41 330249......... 01.2314 15.89 340012......... 01.2605 15.82 320012....................... 01.0231 16.57 330046.......... 01.5105 28.39 330158......... 01.3668 24.33 330250......... 01.3166 16.01 340013......... 01.2719 16.58 320013....................... 01.2225 18.28 330047.......... 01.2265 16.63 330159......... 01.3291 17.35 330252......... 00.9141 15.40 340014......... 01.5921 22.15 320014....................... 01.0141 08.42 330048.......... 01.2888 16.10 330160......... 01.4618 26.09 330254......... 01.0327 15.52 340015......... 01.2388 16.44 320016....................... 01.1571 12.00 330049.......... 01.2436 17.52 330161......... 00.7163 16.00 330258......... 01.4234 25.28 340016......... 01.1961 15.18 320017....................... 01.2175 17.67 330053.......... 01.1270 14.39 330162......... 01.2602 26.18 330259......... 01.4434 21.99 340017......... 01.2581 15.69 320018....................... 01.4643 16.61 330055.......... 01.5089 29.02 330163......... 01.2099 17.75 330261......... 01.2224 24.35 340018......... 01.1212 14.78 320019....................... 01.4799 19.01 330056.......... 01.4367 28.30 330164......... 01.3999 18.96 330263......... 00.9948 17.00 340019......... 01.0453 13.69 320021....................... 01.7045 20.62 330057.......... 01.7192 15.43 330166......... 00.9641 13.96 330264......... 01.2753 20.00 340020......... 01.1711 17.33 320022....................... 01.1678 16.34 330058.......... 01.3255 15.69 330167......... 01.6419 27.45 330265......... 01.3114 15.78 340021......... 01.2221 15.08 320023....................... 01.0224 13.29 330059.......... 01.6149 29.66 330169......... 01.4285 31.70 330267......... 01.2789 22.78 340022......... 01.0451 14.56 320030....................... 00.9845 16.54 330061.......... 01.2961 23.38 330171......... 01.2758 21.15 330268......... 00.9689 15.79 340023......... 01.3842 18.44 320031....................... 00.8961 14.78 330062.......... 01.1834 14.99 330175......... 01.1250 14.28 330270......... 01.9667 30.33 340024......... 01.2260 15.05 320032....................... 01.0053 16.66 330064.......... 01.3837 28.38 330177......... 01.0204 12.46 330273......... 01.2909 21.36 340025......... 01.1908 14.15 320033....................... 01.1561 19.23 330065.......... 01.1753 17.14 330179......... 00.8644 14.09 330275......... 01.2168 18.19 340027......... 01.2025 15.46 320035....................... 01.0000 14.82 330066.......... 01.2326 17.26 330180......... 01.1942 16.09 330276......... 01.1889 16.58 340028......... 01.5288 17.48 320037....................... 01.2063 15.17 330067.......... 01.3792 19.68 330181......... 01.3113 28.32 330277......... 01.1317 16.35 340030......... 02.0064 19.06 320038....................... 01.1613 15.62 330072.......... 01.3367 26.92 330182......... 02.5604 26.92 330279......... 01.2905 17.24 340031......... 00.9382 12.56 320046....................... 01.1938 18.23 330073.......... 01.1865 14.20 330183......... 01.4402 18.88 330285......... 01.8179 21.81 340032......... 01.3951 17.87 320048....................... 01.3453 13.90 330074.......... 01.1952 16.89 330184......... 01.3357 25.83 330286......... 01.3134 22.59 340035......... 01.1716 14.97 320056....................... 00.9819 ....... 330075.......... 01.0925 16.48 330185......... 01.2303 24.23 330290......... 01.7595 28.28 340036......... 01.1656 17.04 320057....................... 01.0612 ....... 330078.......... 01.4429 16.90 330186......... 00.9205 18.79 330293......... 01.1658 13.72 340037......... 01.1731 15.50 320058....................... 00.9103 ....... 330079.......... 01.3056 16.60 330188......... 01.1826 17.75 330304......... 01.2716 25.62 340038......... 01.1099 14.52 320059....................... 00.9799 ....... 330080.......... 01.4028 24.95 330189......... 01.3836 16.20 330306......... 01.4564 26.59 340039......... 01.2731 19.18 320060....................... 00.9135 ....... 330082.......... 01.1164 16.29 330191......... 01.2642 17.14 330307......... 01.2198 18.33 340040......... 01.7730 17.75 320061....................... 01.0790 ....... 330084.......... 00.9954 15.59 330193......... 01.2990 27.34 330308......... 01.1771 28.68 340041......... 01.2428 15.99 320062....................... 00.9353 ....... 330085.......... 01.3139 18.66 330194......... 01.8175 26.07 330309......... 01.2301 24.67 340042......... 01.1875 13.80 320063....................... 01.3344 15.84 330086.......... 01.2522 24.13 330195......... 01.6251 29.02 330314......... 01.3625 21.07 340044......... 01.1061 13.26 320065....................... 01.2800 16.76 330088.......... 01.1053 24.41 330196......... 01.3279 25.53 330315......... 01.2528 24.58 340045......... 01.0396 10.95 320067....................... 00.8183 09.19 330090.......... 01.5574 16.86 330197......... 01.0999 14.43 330316......... 01.3007 26.23 340047......... 01.8881 17.90 320068....................... 00.9221 17.98 330091.......... 01.3825 17.64 330198......... 01.3312 22.17 330327......... 00.9294 15.30 340048......... 00.9055 09.39 320069....................... 01.0367 09.08 330092.......... 01.1062 13.64 330199......... 01.4730 24.90 330331......... 01.2281 27.78 340049......... 00.6394 15.10 320070....................... 01.0220 ....... 330094.......... 01.2285 15.57 330201......... 01.5327 27.38 330332......... 01.2569 24.30 340050......... 01.1927 14.69 320074....................... 01.1134 17.15 330095.......... 01.2586 16.43 330202......... 01.4667 25.07 330333......... 01.3666 22.00 340051......... 01.2724 16.23 320079....................... 01.1977 17.41 330096.......... 01.0690 14.47 330203......... 01.4028 19.16 330336......... 01.3373 27.39 340052......... 01.0387 18.62 330001....................... 01.1965 24.84 330097.......... 01.1645 14.51 330204......... 01.4276 24.90 330338......... 01.1337 22.52 340053......... 01.6979 18.94 330002....................... 01.4946 24.26 330100.......... 00.6809 25.95 330205......... 01.1548 19.46 330339......... 00.8047 18.09 340054......... 01.0903 12.68 330003....................... 01.3431 19.29 330101.......... 01.7909 33.09 330208......... 01.2046 23.16 330340......... 01.2007 23.91 340055......... 01.2066 16.69 330004....................... 01.2765 19.10 330102.......... 01.2998 16.32 330209......... 01.1899 21.17 330350......... 01.8078 27.96 340060......... 01.1317 16.38 330005....................... 01.8086 19.53 330103.......... 01.2457 15.94 330211......... 01.2056 16.31 330353......... 01.3988 27.49 340061......... 01.7130 19.20 330006....................... 01.3140 24.11 330104.......... 01.3533 25.44 330212......... 01.1780 20.25 330354......... 01.3850 ....... 340063......... 01.0618 13.01 330007....................... 01.3275 17.39 330106.......... 01.5693 33.04 330213......... 01.1258 16.19 330357......... 01.3770 32.07 340064......... 01.2274 16.89 330008....................... 01.1201 15.74 330107.......... 01.2581 24.38 330214......... 01.7374 28.82 330359......... 00.9481 23.70 340065......... 01.3093 12.82 330009....................... 01.3524 28.08 330108.......... 01.2108 15.85 330215......... 01.2093 15.65 330372......... 01.2689 22.53 340067......... 01.1980 12.84 330010....................... 01.1699 15.34 330111.......... 01.0835 14.62 330218......... 01.1561 17.16 330381......... 01.1775 26.80 340068......... 01.2347 14.09 330011....................... 01.2484 17.22 330114.......... 00.8917 15.48 330219......... 01.6451 18.39 330385......... 01.1714 29.27 340069......... 01.7147 18.31 330012....................... 01.6092 27.82 330115.......... 01.2026 14.46 330221......... 01.3287 26.57 330386......... 01.1388 20.82 340070......... 01.3855 16.89 330013....................... 02.0610 16.84 330116.......... 00.9205 13.82 330222......... 01.2641 15.28 330387......... 00.8466 23.28 340071......... 01.0722 14.30 330014....................... 01.3839 27.12 330118.......... 01.6256 18.16 330223......... 01.0773 15.10 330389......... 01.8147 29.95 340072......... 01.1441 13.86 330016....................... 01.0259 14.55 330119.......... 01.7361 29.88 330224......... 01.2693 18.85 330390......... 01.2508 28.38 340073......... 01.4620 20.47 330019....................... 01.1269 23.60 330121.......... 01.0046 14.35 330225......... 01.1710 23.34 330393......... 01.7066 25.24 340075......... 01.1488 15.98 330020....................... 01.0498 14.20 330122.......... 01.2006 20.92 330226......... 01.2690 16.53 330394......... 01.5060 17.27 340080......... 01.1232 13.55 330023....................... 01.2458 22.76 330125.......... 01.8084 19.69 330229......... 01.3174 14.90 330395......... 01.3465 30.16 340084......... 01.0577 14.51 330024....................... 01.9139 30.03 330126.......... 01.2271 20.35 330230......... 01.5132 26.44 330396......... 01.2729 26.86 340085......... 01.2634 15.46 330025....................... 01.1935 13.80 330127.......... 01.3930 25.99 330231......... 01.1306 27.57 330397......... 01.2901 23.98 340087......... 01.1402 16.80 330027....................... 01.4632 28.56 330128.......... 01.3068 25.26 330232......... 01.2194 15.46 330398......... 01.2229 26.59 340088......... 01.1242 16.32 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27515]] Page 11 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 340089....................... 00.9624 12.28 350011.......... 01.9150 17.37 360036......... 01.3220 17.27 360113......... 01.3029 18.24 360204......... 01.2911 16.96 340090....................... 01.1324 15.49 350012.......... 01.1423 12.36 360037......... 02.1403 20.14 360114......... 01.1471 16.05 360210......... 01.2281 19.23 340091....................... 01.6487 18.32 350013.......... 01.0828 14.58 360038......... 01.5899 17.85 360115......... 01.3208 18.08 360211......... 01.2341 17.25 340093....................... 01.0683 11.60 350014.......... 01.0438 14.29 360039......... 01.2504 15.38 360116......... 01.1336 16.04 360212......... 01.3982 20.25 340094....................... 01.3312 16.83 350015.......... 01.7039 14.44 360040......... 01.3208 17.72 360118......... 01.3257 17.37 360213......... 01.1677 15.77 340096....................... 01.2015 17.18 350016.......... 01.0482 10.35 360041......... 01.3759 18.25 360121......... 01.2853 16.74 360218......... 01.2994 16.21 340097....................... 01.1584 16.04 350017.......... 01.4595 14.52 360042......... 01.1088 16.74 360122......... 01.3802 17.77 360230......... 01.3282 20.27 340098....................... 01.6790 19.05 350018.......... 01.1672 10.67 360044......... 01.1425 15.79 360123......... 01.2539 17.50 360231......... 01.1364 12.45 340099....................... 01.0973 13.36 350019.......... 01.6119 18.69 360045......... 01.4898 19.25 360124......... 01.2571 17.08 360234......... 01.3614 17.90 340101....................... 01.0284 11.11 350020.......... 01.4933 17.82 360046......... 01.1375 18.60 360125......... 01.1173 16.87 360236......... 01.1885 18.56 340104....................... 00.9509 10.60 350021.......... 01.0719 10.94 360047......... 01.2246 13.85 360126......... 01.2013 18.97 360239......... 01.2445 18.70 340105....................... 01.3875 17.75 350023.......... 00.8794 15.59 360048......... 01.7427 21.00 360127......... 01.1556 16.28 360241......... 00.5303 17.69 340106....................... 01.1119 17.79 350024.......... 01.1055 13.69 360049......... 01.2627 17.36 360128......... 01.1296 13.85 360242......... 01.6927 ...... 340107....................... 01.3175 16.17 350025.......... 01.0584 12.60 360050......... 01.1772 12.43 360129......... 01.0407 14.06 360243......... 00.7499 14.35 340109....................... 01.3284 15.91 350027.......... 00.9693 12.57 360051......... 01.5377 21.83 360130......... 01.1314 15.16 360244......... 00.7183 16.77 340111....................... 01.1696 13.78 350029.......... 01.0052 12.34 360052......... 01.7099 17.88 360131......... 01.4113 16.27 360245......... 00.8026 12.10 340112....................... 01.2281 14.03 350030.......... 01.0850 16.04 360054......... 01.2577 15.55 360132......... 01.2353 20.78 360246......... 00.8761 15.05 340113....................... 01.9956 19.50 350033.......... 00.9626 13.23 360055......... 01.2369 18.92 360133......... 01.4730 17.61 360247......... 00.4357 ...... 340114....................... 01.5144 19.16 350034.......... 01.0422 13.58 360056......... 01.3471 16.92 360134......... 01.5906 18.25 370001......... 01.6940 18.41 340115....................... 01.5599 17.23 350035.......... 00.9058 10.11 360057......... 01.0323 13.04 360135......... 01.1609 17.12 370002......... 01.2409 13.60 340116....................... 01.9326 20.30 350038.......... 01.0433 13.26 360058......... 01.2713 15.35 360136......... 01.0537 14.73 370004......... 01.2787 15.30 340119....................... 01.2864 15.21 350039.......... 00.9735 13.53 360059......... 01.5326 20.00 360137......... 01.5595 18.98 370005......... 01.0310 14.12 340120....................... 01.1407 12.33 350041.......... 01.0473 13.05 360062......... 01.4664 18.40 360140......... 01.0061 15.47 370006......... 01.3098 14.88 340121....................... 01.0454 14.52 350042.......... 01.0545 12.39 360063......... 01.1442 17.19 360141......... 01.4435 19.84 370007......... 01.1454 12.80 340122....................... 00.9955 10.30 350043.......... 01.6433 16.58 360064......... 01.5484 19.65 360142......... 01.0217 14.99 370008......... 01.4101 16.02 340123....................... 01.1301 14.07 350044.......... 00.9167 10.01 360065......... 01.2285 16.97 360143......... 01.2936 17.74 370011......... 01.0535 12.51 340124....................... 01.0290 12.27 350047.......... 01.2270 16.64 360066......... 01.3888 17.16 360144......... 01.3153 20.19 370012......... 00.8431 09.22 340125....................... 01.4128 16.94 350049.......... 01.2236 10.38 360067......... 01.2739 12.11 360145......... 01.6266 16.84 370013......... 01.7649 18.61 340126....................... 01.4341 16.23 350050.......... 00.9361 10.25 360068......... 01.6561 21.91 360147......... 01.2668 15.55 370014......... 01.3220 17.14 340127....................... 01.3124 16.30 350051.......... 00.9479 14.13 360069......... 01.1403 16.38 360148......... 01.0725 16.50 370015......... 01.2733 13.84 340129....................... 01.3428 18.65 350053.......... 01.0745 09.47 360070......... 01.6756 16.57 360149......... 01.1481 20.33 370016......... 01.3805 14.25 340130....................... 01.3270 16.03 350055.......... 00.9216 11.50 360071......... 01.2663 15.42 360150......... 01.2805 17.70 370017......... 01.1032 12.14 340131....................... 01.4309 15.77 350056.......... 00.9559 12.92 360072......... 01.1415 16.29 360151......... 01.3134 16.55 370018......... 01.2603 14.06 340132....................... 01.3108 12.41 350058.......... 00.9358 12.18 360074......... 01.3554 19.15 360152......... 01.4800 17.65 370019......... 01.3065 11.91 340133....................... 01.0442 13.87 350060.......... 00.7458 07.59 360075......... 01.4959 20.80 360153......... 01.1489 13.64 370020......... 01.2921 12.53 340136....................... 00.7885 24.45 350061.......... 01.0638 13.77 360076......... 01.3053 18.84 360154......... 01.0301 12.39 370021......... 00.9804 10.01 340137....................... 01.2184 12.68 350063.......... 00.8926 ....... 360077......... 01.4743 18.59 360155......... 01.3265 18.75 370022......... 01.2770 15.09 340138....................... 01.1777 17.60 350064.......... 00.9587 ....... 360078......... 01.2792 18.97 360156......... 01.3473 16.47 370023......... 01.3268 14.95 340141....................... 01.6350 18.27 350066.......... 00.7912 ....... 360079......... 01.7583 19.31 360159......... 01.1944 18.50 370025......... 01.3983 15.37 340142....................... 01.2013 14.94 360001.......... 01.3143 17.88 360080......... 01.1127 14.39 360161......... 01.2723 18.78 370026......... 01.4214 16.08 340143....................... 01.3902 18.50 360002.......... 01.1965 15.17 360081......... 01.3567 17.92 360162......... 01.2555 17.27 370028......... 01.8667 17.67 340144....................... 01.4374 14.85 360003.......... 01.7521 19.64 360082......... 01.3134 19.81 360163......... 01.8595 19.87 370029......... 01.2233 12.79 340145....................... 01.3310 16.80 360006.......... 01.7493 19.53 360083......... 01.2570 15.49 360164......... 00.8555 13.98 370030......... 01.2426 12.05 340146....................... 01.0146 15.42 360007.......... 01.0552 15.41 360084......... 01.6203 18.16 360165......... 01.2257 14.31 370032......... 01.5278 14.28 340147....................... 01.2935 17.80 360008.......... 01.2985 16.20 360085......... 01.8174 19.63 360166......... 01.1556 15.83 370033......... 01.0835 11.23 340148....................... 01.4339 18.28 360009.......... 01.3946 17.35 360086......... 01.4601 16.75 360169......... 00.9799 16.99 370034......... 01.2667 12.80 340151....................... 01.1224 14.05 360010.......... 01.2275 15.38 360087......... 01.4074 17.32 360170......... 01.2837 16.07 370035......... 01.6190 15.21 340153....................... 01.9701 21.08 360011.......... 01.2285 17.83 360088......... 01.2127 15.48 360172......... 01.3763 16.62 370036......... 01.0290 ...... 340155....................... 01.3926 20.91 360012.......... 01.3020 17.61 360089......... 01.1680 16.92 360174......... 01.2365 19.24 370037......... 01.7236 17.83 340156....................... 00.8066 ....... 360013.......... 01.0836 16.71 360090......... 01.2316 17.90 360175......... 01.2401 17.61 370038......... 00.9187 12.01 340158....................... 01.1738 16.16 360014.......... 01.1219 17.57 360091......... 01.2648 18.90 360176......... 01.1559 15.53 370039......... 01.4573 17.22 340159....................... 01.1571 16.88 360016.......... 01.6012 17.81 360092......... 01.2659 17.85 360177......... 01.2581 16.30 370040......... 01.1051 10.89 340160....................... 01.0774 12.88 360017.......... 01.7592 19.82 360093......... 01.2188 16.66 360178......... 01.2276 15.58 370041......... 01.0285 13.52 340162....................... 01.2237 17.29 360018.......... 01.5445 18.51 360094......... 01.2950 20.27 360179......... 01.2916 19.01 370042......... 00.8575 10.56 340164....................... 01.4566 18.15 360019.......... 01.2857 18.22 360095......... 01.3340 16.68 360180......... 02.0922 22.07 370043......... 00.9719 12.91 340166....................... 01.4166 18.51 360020.......... 01.4313 20.05 360096......... 01.1097 16.20 360184......... 00.4913 17.11 370045......... 01.0983 10.20 340168....................... 00.5085 14.78 360021.......... 01.2770 18.04 360098......... 01.4006 18.00 360185......... 01.2493 17.09 370046......... 00.9827 09.22 340171....................... 01.1229 ....... 360024.......... 01.4310 17.76 360099......... 01.1130 16.91 360186......... 01.1727 15.04 370047......... 01.3245 15.40 350001....................... 01.0099 11.13 360025.......... 01.2355 17.66 360100......... 01.3239 15.63 360187......... 01.2787 16.00 370048......... 01.1876 13.46 350002....................... 01.7678 16.04 360026.......... 01.1897 15.59 360101......... 01.7334 19.71 360188......... 00.9998 14.77 370049......... 01.3566 15.60 350003....................... 01.1971 15.67 360027.......... 01.5255 19.06 360102......... 01.2713 19.68 360189......... 01.0092 15.40 370051......... 00.9627 13.31 350004....................... 01.9429 17.88 360028.......... 01.4563 15.28 360103......... 01.3290 18.70 360192......... 01.2404 19.28 370054......... 01.3878 14.79 350005....................... 01.0670 13.14 360029.......... 01.1611 16.41 360104......... 01.8950 20.28 360193......... 01.3104 16.77 370056......... 01.5609 15.41 350006....................... 01.3958 16.16 360030.......... 01.1326 14.82 360106......... 01.0509 13.89 360194......... 01.1180 16.14 370057......... 01.1711 15.05 350007....................... 00.9510 12.20 360031.......... 01.3534 18.42 360107......... 01.2373 16.98 360195......... 01.1319 17.72 370059......... 01.1178 13.53 350008....................... 01.0408 15.15 360032.......... 01.0876 16.18 360108......... 01.0371 15.08 360197......... 01.2030 16.76 370060......... 01.0787 12.88 350009....................... 01.1648 15.74 360034.......... 01.1698 13.30 360109......... 01.0970 17.43 360200......... 00.9989 13.48 370063......... 01.0947 13.12 350010....................... 01.1768 12.30 360035.......... 01.5734 19.90 360112......... 01.7594 21.61 360203......... 01.1502 15.55 370064......... 01.0006 10.14 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27516]] Page 12 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 370065....................... 01.0475 14.76 370195.......... 00.9505 ....... 390004......... 01.3767 16.70 390080......... 01.2555 18.66 390167......... 01.2691 20.71 370071....................... 01.0381 10.18 380001.......... 01.3213 19.27 390005......... 01.0865 14.82 390081......... 01.3510 20.23 390168......... 01.1971 17.49 370072....................... 00.9034 11.67 380002.......... 01.2104 22.74 390006......... 01.7405 17.39 390083......... 01.2377 20.87 390169......... 01.2059 18.63 370076....................... 01.3228 12.42 380003.......... 01.1411 18.75 390007......... 01.1827 21.33 390084......... 01.2406 15.29 390170......... 01.8512 22.43 370077....................... 01.2244 16.30 380004.......... 01.6835 22.89 390008......... 01.1329 15.08 390086......... 01.1338 16.87 390173......... 01.1970 17.08 370078....................... 01.7096 14.58 380005.......... 01.1844 19.47 390009......... 01.6076 17.97 390088......... 01.3128 18.42 390174......... 01.7084 24.17 370079....................... 00.9596 11.98 380006.......... 01.3941 18.29 390010......... 01.1788 16.58 390090......... 01.7984 19.42 390176......... 01.1554 16.79 370080....................... 00.9895 11.12 380007.......... 01.5747 22.66 390011......... 01.2486 16.49 390091......... 01.1719 17.09 390178......... 01.2863 17.63 370082....................... 00.9026 12.48 380008.......... 01.0694 18.69 390012......... 01.1879 19.15 390093......... 01.1483 15.20 390179......... 01.2723 22.80 370083....................... 00.9519 10.95 380009.......... 01.8168 22.17 390013......... 01.2292 16.77 390095......... 01.1706 13.95 390180......... 01.5471 22.83 370084....................... 01.0346 08.88 380010.......... 01.0963 24.15 390014......... 01.6409 16.42 390096......... 01.2685 16.88 390181......... 01.0604 17.80 370085....................... 00.8099 12.94 380011.......... 01.0945 14.95 390015......... 01.1953 13.06 390097......... 01.3276 20.91 390183......... 01.1832 17.16 370086....................... 01.1956 09.89 380013.......... 01.2681 21.54 390016......... 01.2237 15.58 390098......... 01.7625 20.06 390184......... 01.1052 17.69 370089....................... 01.2826 14.01 380014.......... 01.4140 18.89 390017......... 01.1682 14.20 390100......... 01.6300 19.30 390185......... 01.2228 16.12 370091....................... 01.6822 16.13 380017.......... 01.7069 21.77 390018......... 01.2273 19.41 390101......... 01.1992 15.70 390189......... 01.0395 17.78 370092....................... 01.0705 12.73 380018.......... 01.8382 19.21 390019......... 01.1151 14.53 390102......... 01.3664 20.34 390191......... 01.0524 13.91 370093....................... 01.8611 18.67 380019.......... 01.2076 18.88 390022......... 01.3923 21.81 390103......... 01.0990 17.17 390192......... 01.1238 17.15 370094....................... 01.4135 16.67 380020.......... 01.4350 20.06 390023......... 01.2514 19.71 390104......... 01.0557 15.15 390193......... 01.1950 15.39 370095....................... 00.9154 11.62 380021.......... 01.2873 19.10 390024......... 00.8646 22.54 390106......... 01.0122 14.85 390194......... 01.1560 18.97 370097....................... 01.3691 18.65 380022.......... 01.1702 19.92 390025......... 00.6443 16.64 390107......... 01.2482 18.52 390195......... 01.8265 22.08 370099....................... 01.1663 13.22 380023.......... 01.2350 17.76 390026......... 01.2687 20.58 390108......... 01.4077 19.97 390196......... 01.4066 ...... 370100....................... 01.0423 13.02 380025.......... 01.2670 21.81 390027......... 01.9708 23.48 390109......... 01.1523 14.44 390197......... 01.3091 18.40 370103....................... 00.9024 11.77 380026.......... 01.1899 16.87 390028......... 01.7871 18.54 390110......... 01.6465 17.36 390198......... 01.1942 15.21 370105....................... 02.0043 17.06 380027.......... 01.2587 20.25 390029......... 01.9395 18.73 390111......... 01.8583 26.22 390199......... 01.2016 14.89 370106....................... 01.5411 16.96 380029.......... 01.1474 17.29 390030......... 01.2365 16.29 390112......... 01.1488 12.16 390200......... 01.0147 14.67 370108....................... 01.0551 10.82 380031.......... 01.0329 15.92 390031......... 01.1587 16.93 390113......... 01.2113 16.04 390201......... 01.2666 18.75 370112....................... 01.0769 12.33 380033.......... 01.7783 22.97 390032......... 01.2498 17.80 390114......... 01.1217 21.07 390203......... 01.3102 20.45 370113....................... 01.1674 12.33 380035.......... 01.3580 18.58 390035......... 01.2774 17.24 390115......... 01.3154 21.40 390204......... 01.2596 20.05 370114....................... 01.6305 14.69 380036.......... 01.1305 17.27 390036......... 01.3337 17.63 390116......... 01.2237 19.91 390205......... 01.3479 22.42 370121....................... 01.1729 15.78 380037.......... 01.2063 18.24 390037......... 01.3426 18.07 390117......... 01.1636 15.65 390206......... 01.3349 19.91 370122....................... 01.1291 09.78 380038.......... 01.3425 21.15 390039......... 01.0948 15.60 390118......... 01.1524 16.29 390209......... 01.0438 15.48 370123....................... 01.2098 14.12 380039.......... 01.3082 18.89 390040......... 01.0024 12.71 390119......... 01.3475 17.17 390211......... 01.1929 16.47 370125....................... 01.0284 11.90 380040.......... 01.2507 19.23 390041......... 01.2475 16.82 390121......... 01.3363 18.95 390213......... 00.9476 14.55 370126....................... 00.9483 10.66 380042.......... 01.1550 18.06 390042......... 01.4374 20.74 390122......... 01.0719 16.06 390215......... 01.1565 20.69 370131....................... 01.0232 12.93 380047.......... 01.6960 19.84 390043......... 01.0988 15.65 390123......... 01.3041 20.58 390217......... 01.2781 17.92 370133....................... 01.1213 09.82 380048.......... 01.0936 13.92 390044......... 01.5993 18.80 390125......... 01.2255 15.08 390219......... 01.3149 18.57 370138....................... 01.1138 14.40 380050.......... 01.3349 16.37 390045......... 01.7321 17.35 390126......... 01.3266 20.07 390220......... 01.2126 19.33 370139....................... 01.0944 10.62 380051.......... 01.5217 19.13 390046......... 01.5446 18.49 390127......... 01.2319 20.26 390222......... 01.3083 20.42 370140....................... 01.0059 11.71 380052.......... 01.1764 16.70 390047......... 01.6845 18.24 390128......... 01.2014 17.96 390223......... 01.6376 23.15 370141....................... 01.3883 19.17 380055.......... 01.2275 23.88 390048......... 01.1857 16.26 390130......... 01.1480 16.62 390224......... 00.9314 13.04 370146....................... 01.0486 12.03 380056.......... 01.0753 15.78 390049......... 01.5514 19.82 390131......... 01.2704 16.06 390225......... 01.2124 15.42 370148....................... 01.6050 19.01 380060.......... 01.5375 21.51 390050......... 02.1389 21.60 390132......... 01.2425 20.25 390226......... 01.7861 23.22 370149....................... 01.2373 15.19 380061.......... 01.5190 22.00 390051......... 02.1828 24.98 390133......... 01.7790 20.57 390228......... 01.2071 18.67 370153....................... 01.0915 13.17 380062.......... 01.1039 15.07 390052......... 01.1846 16.68 390135......... 01.2913 19.73 390231......... 01.3122 21.89 370154....................... 01.0164 12.31 380063.......... 01.3354 21.48 390054......... 01.2245 14.56 390136......... 01.2338 15.66 390233......... 01.3268 16.71 370156....................... 01.1022 13.37 380064.......... 01.4398 18.47 390055......... 01.7751 21.82 390137......... 01.2962 17.80 390235......... 01.5635 23.94 370158....................... 01.0538 12.08 380065.......... 01.0680 19.24 390056......... 01.1222 15.73 390138......... 01.3365 17.41 390236......... 01.1643 15.90 370159....................... 01.3427 13.95 380066.......... 01.3162 17.60 390057......... 01.3263 18.94 390139......... 01.4984 23.50 390237......... 01.6149 20.17 370163....................... 00.8558 10.99 380068.......... 01.0655 19.31 390058......... 01.3239 17.46 390142......... 01.6716 22.64 390238......... 01.3009 16.12 370165....................... 01.0872 11.74 380069.......... 01.1328 17.51 390060......... 01.1432 16.68 390145......... 01.3596 18.64 390242......... 01.2772 18.69 370166....................... 01.0886 15.48 380070.......... 01.3924 21.21 390061......... 01.4426 20.47 390146......... 01.3088 16.19 390244......... 00.9339 13.32 370169....................... 01.1024 10.66 380071.......... 01.2894 18.06 390062......... 01.1400 15.76 390147......... 01.2505 19.22 390245......... 01.3465 23.15 370170....................... 00.9792 ....... 380072.......... 00.9714 14.15 390063......... 01.7324 19.20 390149......... 01.2579 19.59 390246......... 01.2349 15.91 370171....................... 01.0341 ....... 380075.......... 01.4281 20.90 390064......... 01.5561 16.25 390150......... 01.1065 17.50 390247......... 01.0497 17.22 370172....................... 00.8587 ....... 380078.......... 01.1638 16.95 390065......... 01.2903 18.85 390151......... 01.2927 18.26 390249......... 01.0291 10.81 370173....................... 01.2420 ....... 380081.......... 01.1568 17.66 390066......... 01.2933 17.15 390152......... 01.0351 17.07 390256......... 01.7792 23.51 370174....................... 00.9656 ....... 380082.......... 01.2906 20.35 390067......... 01.8083 18.03 390153......... 01.2473 21.93 390258......... 01.2502 19.78 370176....................... 01.1495 16.48 380083.......... 01.2487 18.93 390068......... 01.3245 18.13 390154......... 01.1877 13.93 390260......... 01.1823 15.95 370177....................... 00.9686 10.10 380084.......... 01.2127 20.61 390069......... 01.3242 19.23 390155......... 01.2985 20.06 390262......... 01.9798 17.25 370178....................... 01.0015 12.17 380087.......... 01.0083 12.30 390070......... 01.2898 19.49 390156......... 01.4337 22.61 390263......... 01.4331 18.66 370179....................... 00.8966 14.28 380088.......... 01.0059 15.71 390071......... 01.1154 13.36 390157......... 01.3427 17.97 390265......... 01.3123 17.72 370180....................... 01.0716 ....... 380089.......... 01.2909 21.87 390072......... 01.1133 15.76 390158......... 01.5891 ....... 390266......... 01.2098 16.69 370183....................... 01.0864 14.00 380090.......... 01.3011 24.41 390073......... 01.6002 18.94 390160......... 01.2031 17.67 390267......... 01.2930 18.93 370186....................... 01.0206 12.72 380091.......... 01.2113 23.79 390074......... 01.2369 16.26 390161......... 01.0981 14.87 390268......... 01.3884 19.94 370189....................... 00.9754 10.13 380897.......... 04.9268 ....... 390075......... 01.2410 15.92 390162......... 01.4238 19.03 390270......... 01.3090 15.89 370190....................... 01.5480 17.49 390001.......... 01.3578 18.16 390076......... 01.3094 20.45 390163......... 01.2248 16.55 390272......... 00.4549 ...... 370192....................... 01.1656 ....... 390002.......... 01.3668 17.03 390078......... 01.0633 15.98 390164......... 01.9412 19.14 390277......... 00.5643 20.34 370194....................... 01.1343 ....... 390003.......... 01.2571 15.57 390079......... 01.7083 16.83 390166......... 01.1041 17.40 390278......... 00.7673 17.52 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27517]] Page 13 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 390279....................... 01.0726 09.45 420005.......... 01.2017 14.35 430013......... 01.2330 15.06 440029......... 01.2864 16.30 440148......... 01.1406 14.37 390281....................... 03.1739 ....... 420006.......... 01.2785 18.90 430014......... 01.2742 16.77 440030......... 01.1989 13.21 440149......... 01.1993 15.19 400001....................... 01.2170 08.68 420007.......... 01.5103 16.31 430015......... 01.1801 14.41 440031......... 00.9653 12.29 440150......... 01.2853 19.58 400002....................... 01.4586 10.39 420009.......... 01.2131 15.70 430016......... 01.8185 17.59 440032......... 01.0553 12.65 440151......... 01.3706 15.86 400003....................... 01.2378 07.14 420010.......... 01.1070 14.35 430018......... 00.9882 14.06 440033......... 01.0675 14.84 440152......... 01.5616 16.91 400004....................... 01.1516 07.34 420011.......... 01.0905 14.89 430022......... 00.9656 10.91 440034......... 01.5798 16.64 440153......... 01.2607 15.10 400005....................... 01.1122 06.10 420014.......... 01.1343 14.11 430023......... 00.9173 09.95 440035......... 01.3176 15.65 440156......... 01.5650 18.85 400006....................... 01.2005 08.16 420015.......... 01.3145 15.96 430024......... 00.9117 12.28 440039......... 01.6355 16.76 440157......... 01.0913 13.64 400007....................... 01.2599 07.55 420016.......... 01.0635 14.39 430026......... 01.0798 11.36 440040......... 00.9697 17.03 440159......... 01.2358 14.83 400009....................... 01.0253 07.68 420018.......... 01.7204 18.94 430027......... 01.8117 16.54 440041......... 01.0374 12.35 440161......... 01.6916 20.58 400010....................... 00.9067 07.94 420019.......... 01.2221 14.90 430028......... 01.0938 13.68 440046......... 01.3271 13.59 440166......... 01.4407 17.80 400011....................... 00.9999 08.65 420020.......... 01.3908 15.98 430029......... 00.9886 13.10 440047......... 00.9568 15.31 440168......... 01.0199 13.03 400012....................... 01.2156 07.09 420023.......... 01.4241 18.07 430031......... 00.9673 11.31 440048......... 01.7988 16.64 440173......... 01.5155 16.91 400013....................... 01.2969 08.96 420026.......... 01.9266 18.05 430033......... 01.0218 11.90 440049......... 01.6566 15.62 440174......... 00.9837 13.30 400014....................... 01.3613 07.51 420027.......... 01.3790 15.50 430034......... 01.0752 11.58 440050......... 01.2035 15.14 440175......... 01.2366 18.06 400015....................... 01.2211 10.88 420030.......... 01.2885 15.83 430036......... 01.0398 10.11 440051......... 00.9285 13.29 440176......... 01.2916 18.36 400016....................... 01.3614 10.48 420031.......... 00.9586 12.15 430037......... 00.9784 12.89 440052......... 01.2226 14.15 440178......... 01.1880 20.20 400017....................... 01.2405 06.27 420033.......... 01.2216 19.24 430038......... 01.0179 10.77 440053......... 01.3071 15.64 440180......... 01.1517 16.68 400018....................... 01.3516 09.35 420035.......... 00.7985 12.43 430039......... 01.0871 11.53 440054......... 01.2182 13.84 440181......... 01.0190 11.75 400019....................... 01.6737 09.48 420036.......... 01.2011 15.38 430040......... 00.9098 12.17 440056......... 01.0857 13.45 440182......... 00.9568 15.33 400021....................... 01.4421 07.62 420037.......... 01.2778 19.65 430041......... 00.9376 11.91 440057......... 01.0155 10.77 440183......... 01.5296 15.06 400022....................... 01.3098 09.79 420038.......... 01.2852 14.43 430042......... 00.9807 10.63 440058......... 01.3158 14.95 440184......... 01.3494 18.63 400024....................... 01.0265 08.62 420039.......... 01.1511 14.52 430043......... 01.1938 11.97 440059......... 01.3336 15.98 440185......... 01.1231 14.24 400026....................... 00.9430 05.90 420042.......... 01.2035 12.15 430044......... 00.9249 13.17 440060......... 01.1799 14.76 440186......... 01.1885 16.21 400027....................... 01.1317 08.32 420043.......... 01.1800 18.82 430047......... 01.1381 12.24 440061......... 01.2121 15.46 440187......... 01.1952 14.85 400028....................... 01.0328 07.14 420048.......... 01.1376 14.26 430048......... 01.2063 15.01 440063......... 01.6136 17.43 440189......... 01.4819 18.81 400029....................... 01.1287 06.64 420049.......... 01.1769 14.55 430049......... 00.9360 12.66 440064......... 01.1860 15.05 440192......... 01.1489 13.99 400031....................... 01.1446 08.00 420051.......... 01.5568 17.99 430051......... 01.0355 13.48 440065......... 01.2301 16.18 440193......... 01.2852 17.88 400032....................... 01.1257 07.75 420053.......... 01.1378 14.03 430054......... 01.0034 13.13 440067......... 01.1879 15.54 440194......... 01.4249 16.89 400044....................... 01.2430 09.09 420054.......... 01.3709 16.39 430056......... 00.8479 08.93 440068......... 01.2130 16.43 440196......... 00.9475 13.32 400048....................... 01.1320 07.91 420055.......... 01.0623 12.51 430057......... 00.9205 10.47 440069......... 01.1874 14.17 440197......... 01.4007 19.15 400061....................... 01.7050 13.68 420056.......... 01.1625 13.41 430060......... 01.1594 08.46 440070......... 01.1257 12.52 440200......... 01.1917 15.41 400079....................... 01.2488 08.95 420057.......... 01.1395 14.96 430062......... 00.8739 10.31 440071......... 01.3946 14.87 440203......... 00.9346 13.17 400087....................... 01.3761 08.90 420059.......... 00.9844 13.96 430064......... 01.1205 11.89 440072......... 01.5118 13.92 440205......... 01.0962 15.86 400094....................... 01.0405 07.41 420061.......... 01.1517 16.16 430065......... 00.9527 09.93 440073......... 01.3464 16.95 440206......... 01.0340 13.82 400098....................... 01.2435 07.17 420062.......... 01.4444 15.65 430066......... 00.9685 10.93 440078......... 01.0260 13.28 440208......... 02.0269 ...... 400102....................... 01.1413 08.65 420064.......... 01.1161 13.45 430073......... 01.0814 ....... 440081......... 01.1575 15.31 450002......... 01.4623 19.35 400103....................... 01.3671 08.80 420065.......... 01.3051 16.72 430076......... 00.9768 09.41 440082......... 01.9905 20.54 450004......... 01.1684 12.38 400104....................... 01.3703 08.97 420066.......... 00.9099 14.40 430077......... 01.5832 16.53 440083......... 01.1099 10.96 450005......... 01.1503 13.79 400105....................... 01.1725 08.37 420067.......... 01.2333 16.24 430079......... 00.9628 11.47 440084......... 01.1544 11.41 450007......... 01.2442 13.73 400106....................... 01.2084 08.12 420068.......... 01.2885 16.08 430080......... 01.1317 08.89 440087......... 00.9572 14.44 450008......... 01.3624 14.96 400109....................... 01.5298 09.13 420069.......... 01.1002 13.71 430081......... 01.0452 ....... 440090......... 00.9308 13.29 450010......... 01.3415 15.37 400110....................... 01.1119 07.87 420070.......... 01.2639 15.05 430082......... 00.8001 ....... 440091......... 01.5472 16.53 450011......... 01.5000 17.43 400111....................... 01.1553 07.98 420071.......... 01.3110 16.13 430083......... 00.8672 ....... 440100......... 01.0273 12.82 450014......... 01.0699 13.84 400112....................... 01.2298 09.26 420072.......... 01.0735 10.64 430084......... 00.9280 ....... 440102......... 01.0695 12.26 450015......... 01.5543 14.96 400113....................... 01.2400 07.57 420073.......... 01.3095 18.10 430085......... 00.8385 ....... 440103......... 01.2284 17.24 450016......... 01.6256 17.57 400114....................... 01.0377 06.50 420074.......... 00.8992 11.72 430087......... 00.9105 09.29 440104......... 01.6509 17.68 450018......... 01.6091 21.75 400115....................... 01.0054 07.56 420075.......... 00.9719 12.66 440001......... 01.1227 12.18 440105......... 01.3723 16.69 450020......... 01.0171 15.47 400117....................... 01.1773 09.23 420078.......... 01.8088 18.59 440002......... 01.5965 15.80 440109......... 01.1308 12.28 450021......... 01.8117 21.11 400118....................... 01.1900 08.14 420079.......... 01.5669 16.94 440003......... 01.0714 15.23 440110......... 00.9687 16.06 450023......... 01.4846 15.80 400120....................... 01.3084 09.14 420080.......... 01.2589 19.18 440006......... 01.6500 17.60 440111......... 01.3613 18.00 450024......... 01.3672 16.45 400121....................... 01.0121 06.51 420082.......... 01.3946 19.13 440007......... 01.0148 11.83 440114......... 01.0474 12.68 450025......... 01.5058 16.27 400122....................... 01.0009 05.88 420083.......... 01.2042 18.36 440008......... 00.9878 13.50 440115......... 01.1172 14.66 450028......... 01.6335 17.17 400123....................... 01.1728 08.05 420084.......... 00.7413 13.56 440009......... 01.1753 13.22 440120......... 01.5385 16.14 450029......... 01.3991 12.98 400124....................... 02.6604 09.27 420085.......... 01.3970 16.86 440010......... 00.9235 08.75 440125......... 01.4408 16.09 450031......... 01.5830 18.72 410001....................... 01.3246 23.02 420086.......... 01.3613 16.90 440011......... 01.2901 16.28 440130......... 01.1687 14.16 450032......... 01.2715 13.63 410004....................... 01.3655 21.15 420087.......... 01.5946 16.53 440012......... 01.4699 17.72 440131......... 01.1317 13.44 450033......... 01.6308 16.84 410005....................... 01.3492 21.90 420088.......... 01.1349 15.05 440014......... 01.0615 09.06 440132......... 01.1116 14.01 450034......... 01.6445 16.28 410006....................... 01.2670 21.40 420089.......... 01.2336 19.40 440015......... 01.6051 16.42 440133......... 01.5494 17.78 450035......... 01.4519 18.91 410007....................... 01.6550 20.96 420091.......... 01.2147 13.16 440016......... 01.0116 11.35 440135......... 01.3062 14.03 450037......... 01.6279 17.69 410008....................... 01.1691 21.05 430004.......... 01.0955 17.25 440017......... 01.6136 18.42 440137......... 00.9770 12.14 450039......... 01.3345 18.70 410009....................... 01.2968 20.66 430005.......... 01.3167 14.06 440018......... 01.4675 16.10 440141......... 01.0771 13.59 450040......... 01.5518 17.75 410010....................... 01.0160 25.40 430007.......... 01.0540 12.52 440019......... 01.6253 19.06 440142......... 01.0311 10.75 450042......... 01.6646 15.75 410011....................... 01.2110 22.25 430008.......... 01.1248 14.01 440020......... 01.2392 15.43 440143......... 01.1020 17.21 450043......... 01.4473 20.40 410012....................... 01.7208 19.51 430009.......... 01.0939 12.21 440022......... 01.2040 13.72 440144......... 01.3327 18.35 450044......... 01.6182 20.04 410013....................... 01.3105 24.63 430010.......... 01.1273 09.23 440023......... 00.9963 11.58 440145......... 01.0439 10.99 450046......... 01.3724 14.67 420002....................... 01.3794 18.80 430011.......... 01.3139 14.33 440024......... 01.3302 16.61 440146......... 01.0036 12.98 450047......... 01.1155 13.43 420004....................... 01.8612 18.35 430012.......... 01.3055 14.97 440025......... 01.1317 13.01 440147......... 01.1079 17.06 450050......... 01.0582 16.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27518]] Page 14 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 450051....................... 01.5923 18.22 450154.......... 01.2004 12.23 450296......... 01.3139 16.46 450484......... 01.4849 18.53 450651......... 01.8166 21.92 450052....................... 01.0171 13.13 450155.......... 01.0191 12.61 450297......... 01.0190 12.01 450488......... 01.2528 14.98 450652......... 00.9114 13.44 450053....................... 01.1479 13.11 450157.......... 01.0041 12.97 450299......... 01.3455 16.28 450489......... 00.9859 11.56 450653......... 01.2485 17.98 450054....................... 01.7181 21.32 450160.......... 00.9838 17.50 450303......... 00.9458 09.97 450497......... 01.1299 12.05 450654......... 01.0034 11.11 450055....................... 01.1238 12.92 450162.......... 01.1851 16.63 450306......... 01.0878 12.50 450498......... 01.2653 13.88 450656......... 01.4908 16.48 450056....................... 01.6174 18.26 450163.......... 01.0364 15.34 450307......... 00.9041 13.62 450508......... 01.5582 16.37 450658......... 00.9746 14.01 450058....................... 01.5774 14.76 450164.......... 01.0684 12.56 450309......... 01.0677 12.74 450514......... 01.2163 18.78 450659......... 01.5762 22.12 450059....................... 01.2421 13.21 450165.......... 00.9569 14.34 450315......... 01.1137 19.65 450517......... 01.0029 10.94 450660......... 01.5698 21.85 450060....................... 01.3622 22.17 450166.......... 00.9672 10.06 450320......... 01.3364 18.20 450518......... 01.5325 16.84 450661......... 01.1378 18.94 450063....................... 00.9758 11.51 450169.......... 00.9171 13.82 450321......... 00.9661 12.45 450523......... 01.5243 21.18 450662......... 01.6712 16.53 450064....................... 01.5083 15.34 450170.......... 00.9792 11.32 450322......... 00.7151 15.40 450530......... 01.4505 21.64 450665......... 00.9334 11.45 450065....................... 01.1393 14.75 450176.......... 01.2241 15.23 450324......... 01.6484 15.19 450534......... 00.9542 20.29 450666......... 01.2708 19.05 450068....................... 01.7951 20.31 450177.......... 01.0967 13.18 450325......... 01.2279 11.93 450535......... 01.2557 14.12 450668......... 01.5484 18.90 450070....................... 01.2671 15.46 450178.......... 01.0123 14.64 450327......... 00.9734 12.11 450537......... 01.3698 17.80 450669......... 01.2923 19.10 450072....................... 01.2351 18.19 450181.......... 01.0065 15.15 450330......... 01.2256 16.86 450538......... 01.3931 21.17 450670......... 01.2960 19.44 450073....................... 01.1202 12.84 450184.......... 01.5429 17.74 450334......... 01.0568 11.65 450539......... 01.2925 13.27 450672......... 01.6578 18.91 450076....................... 01.5802 ....... 450185.......... 01.1137 08.47 450337......... 01.2313 17.14 450544......... 01.4408 22.65 450673......... 01.1428 11.38 450078....................... 00.9949 11.17 450187.......... 01.2789 16.44 450340......... 01.3177 14.54 450545......... 01.2710 14.13 450674......... 01.0203 22.09 450079....................... 01.4395 19.03 450188.......... 01.0085 12.46 450341......... 01.0264 16.26 450546......... 01.8365 18.37 450675......... 01.5171 17.78 450080....................... 01.2966 15.79 450190.......... 01.1841 19.53 450346......... 01.3443 16.27 450547......... 01.1613 15.09 450677......... 01.4324 19.18 450081....................... 01.1087 12.87 450191.......... 01.0864 15.75 450347......... 01.1430 15.48 450550......... 00.9800 17.01 450678......... 01.4776 20.45 450082....................... 00.9627 12.75 450192.......... 01.2403 15.49 450348......... 00.9975 10.99 450551......... 01.1957 13.75 450681......... 03.0551 17.29 450083....................... 01.7142 17.21 450193.......... 01.8944 21.32 450351......... 01.1727 18.76 450558......... 01.7767 17.17 450683......... 01.3083 20.17 450085....................... 01.0903 14.38 450194.......... 01.2291 18.11 450352......... 01.1141 16.21 450559......... 00.9811 12.75 450684......... 01.2695 18.53 450087....................... 01.4141 19.35 450196.......... 01.5101 17.34 450353......... 01.3226 16.13 450561......... 01.6522 17.65 450686......... 01.5555 14.30 450090....................... 01.2144 12.40 450197.......... 01.0544 19.66 450355......... 01.1121 11.18 450563......... 01.2306 21.98 450688......... 01.2802 18.65 450092....................... 01.2129 13.12 450200.......... 01.3827 16.35 450358......... 02.0930 20.57 450565......... 01.2925 15.63 450690......... 01.4169 21.31 450094....................... 01.2531 19.39 450201.......... 01.0233 15.38 450362......... 01.1896 17.62 450570......... 01.0316 11.23 450691......... 01.1089 14.91 450096....................... 01.5315 19.25 450203.......... 01.1919 16.13 450369......... 01.0842 10.21 450571......... 01.4989 14.52 450694......... 01.2338 15.91 450097....................... 01.4577 18.33 450209.......... 01.5494 16.26 450370......... 01.1269 13.02 450573......... 01.0008 13.58 450696......... 01.6701 23.37 450098....................... 01.1683 13.75 450210.......... 01.1950 12.03 450371......... 01.1487 11.02 450574......... 00.9382 13.41 450697......... 01.5431 16.28 450099....................... 01.2816 17.70 450211.......... 01.3861 14.13 450372......... 01.2680 20.49 450575......... 01.0572 16.98 450698......... 00.9742 11.66 450101....................... 01.4848 15.03 450213.......... 01.5055 16.27 450373......... 01.1462 13.68 450578......... 00.9224 12.94 450700......... 00.9302 12.68 450102....................... 01.7093 21.87 450214.......... 01.3721 18.61 450374......... 00.9541 12.20 450580......... 01.1076 12.59 450702......... 01.6063 17.58 450104....................... 01.2182 13.74 450217.......... 01.0508 12.61 450376......... 01.5102 16.26 450583......... 01.0094 12.24 450703......... 01.5299 20.96 450107....................... 01.6171 18.75 450219.......... 01.1346 14.22 450378......... 01.0973 21.56 450584......... 01.2257 12.86 450704......... 01.3719 17.86 450108....................... 00.9967 14.49 450221.......... 01.0814 14.05 450379......... 01.5198 21.28 450586......... 00.9987 11.26 450705......... 01.0246 16.80 450109....................... 00.9911 15.36 450222.......... 01.6508 17.32 450381......... 01.0567 12.56 450587......... 01.2266 16.93 450706......... 01.2165 21.90 450110....................... 01.2522 19.34 450224.......... 01.3702 15.85 450388......... 01.7602 17.41 450591......... 01.1417 16.28 450709......... 01.2281 20.05 450111....................... 01.2466 18.63 450229.......... 01.5708 14.82 450389......... 01.2066 16.74 450596......... 01.3150 17.29 450711......... 01.6431 17.88 450112....................... 01.3508 13.87 450231.......... 01.5945 16.94 450393......... 01.3320 20.94 450597......... 01.0561 14.23 450712......... 00.7387 15.03 450113....................... 01.2359 16.99 450234.......... 00.9823 11.27 450395......... 01.0348 14.68 450603......... 00.8332 16.27 450713......... 01.4783 18.10 450118....................... 01.5629 20.94 450235.......... 01.0563 13.47 450399......... 00.9957 13.37 450604......... 01.3817 13.57 450715......... 01.4531 17.40 450119....................... 01.2958 16.37 450236.......... 01.0665 14.17 450400......... 01.1526 13.70 450605......... 01.4745 17.91 450716......... 01.2682 19.64 450121....................... 01.4393 18.70 450237.......... 01.5510 16.60 450403......... 01.3684 19.90 450609......... 00.8790 12.25 450717......... 01.3585 22.95 450123....................... 01.1554 17.47 450239.......... 01.1977 12.35 450411......... 00.9524 11.46 450610......... 01.4506 15.52 450718......... 01.2381 19.18 450124....................... 01.5864 19.48 450241.......... 01.0458 15.67 450417......... 01.0539 12.95 450614......... 01.0471 12.43 450723......... 01.3474 18.17 450126....................... 01.3845 11.95 450243.......... 00.8395 11.57 450418......... 01.3370 17.42 450615......... 01.0767 11.70 450724......... 01.2905 16.59 450128....................... 01.2434 14.78 450246.......... 00.9676 15.02 450419......... 01.2738 22.40 450617......... 01.2885 20.82 450725......... 00.9969 20.18 450130....................... 01.5025 15.17 450249.......... 00.9712 10.70 450422......... 00.8075 23.47 450620......... 01.0455 12.48 450726......... 00.8676 14.54 450131....................... 01.3707 19.58 450250.......... 00.9532 09.93 450423......... 01.4394 21.03 450623......... 01.1429 17.62 450727......... 00.9596 09.78 450132....................... 01.6610 16.45 450253.......... 01.3163 13.51 450424......... 01.2047 16.33 450626......... 01.0877 14.09 450728......... 00.9627 14.31 450133....................... 01.5384 16.49 450258.......... 01.0962 11.17 450429......... 01.1242 13.35 450628......... 00.9420 15.48 450730......... 01.3579 21.14 450135....................... 01.7273 21.81 450259.......... 01.2084 17.44 450431......... 01.6589 17.28 450630......... 01.6424 20.60 450733......... 01.3470 16.91 450137....................... 01.5099 24.28 450264.......... 00.8643 11.94 450438......... 01.1793 14.39 450631......... 01.7535 18.05 450735......... 00.8720 11.91 450140....................... 00.8414 16.46 450269.......... 01.1388 12.62 450446......... 00.8625 13.07 450632......... 01.0125 11.17 450742......... 01.3448 21.43 450142....................... 01.4366 19.50 450270.......... 01.1746 10.16 450447......... 01.3505 17.69 450633......... 01.5938 19.18 450743......... 01.4622 18.40 450143....................... 01.0982 12.23 450271.......... 01.2762 14.41 450450......... 01.0872 ....... 450634......... 01.6943 21.57 450746......... 01.0500 13.39 450144....................... 01.1175 16.23 450272.......... 01.2923 16.29 450451......... 01.1254 20.23 450637......... 01.3647 18.24 450747......... 01.3619 16.51 450145....................... 00.8692 12.46 450276.......... 01.0996 10.44 450457......... 01.7832 17.14 450638......... 01.5844 22.52 450749......... 01.0128 12.35 450146....................... 00.9881 16.53 450278.......... 00.8495 18.12 450460......... 01.0299 12.06 450639......... 01.4141 21.41 450750......... 01.0228 11.86 450147....................... 01.4175 17.66 450280.......... 01.5286 20.58 450462......... 01.8354 17.99 450641......... 01.0224 12.60 450751......... 01.3246 21.80 450148....................... 01.3079 19.02 450283.......... 01.0519 12.09 450464......... 00.9825 13.41 450643......... 01.2796 17.60 450754......... 00.8884 13.19 450149....................... 01.3501 19.33 450286.......... 01.0373 14.54 450465......... 01.3178 14.66 450644......... 01.4715 20.30 450755......... 01.1540 13.66 450150....................... 00.8919 13.62 450288.......... 01.2105 12.58 450467......... 00.9653 14.39 450646......... 01.6143 19.59 450757......... 00.9784 13.32 450151....................... 01.1057 13.27 450289.......... 01.4907 17.37 450469......... 01.3736 16.94 450647......... 02.0240 19.98 450758......... 01.2423 ...... 450152....................... 01.2645 16.04 450292.......... 01.2051 20.15 450473......... 01.0047 17.83 450648......... 01.0382 11.36 450760......... 01.2068 16.97 450153....................... 01.5803 17.10 450293.......... 00.9746 13.55 450475......... 01.1363 14.13 450649......... 01.0756 14.64 450761......... 01.0642 09.63 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27519]] Page 15 of 16 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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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 450763....................... 01.0163 15.68 460047.......... 01.7740 19.49 490067......... 01.2062 14.95 500029......... 00.9339 14.30 500141......... 01.3258 21.93 450766....................... 02.3234 14.24 460049.......... 01.9207 17.05 490069......... 01.3990 15.10 500030......... 01.4753 22.13 500143......... 00.7662 14.92 450769....................... 01.0378 13.28 460050.......... 01.3106 20.35 490071......... 01.4398 17.56 500031......... 01.2905 20.19 500146......... 01.0318 ...... 450770....................... 00.9496 13.59 460051.......... 01.1901 ....... 490073......... 01.3538 21.49 500033......... 01.2047 18.05 510001......... 01.7139 17.08 450771....................... 01.9690 17.01 470001.......... 01.2043 17.11 490074......... 01.3343 16.00 500036......... 01.3185 19.11 510002......... 01.2708 16.31 450774....................... 00.9708 23.99 470003.......... 01.8136 17.82 490075......... 01.3332 16.62 500037......... 01.1216 17.63 510004......... 00.9183 12.62 450775....................... 01.1940 19.26 470004.......... 01.1118 14.18 490077......... 01.1636 16.87 500039......... 01.3772 21.32 510005......... 01.0028 13.71 450776....................... 00.9251 ....... 470005.......... 01.2608 18.71 490079......... 01.3187 14.30 500041......... 01.2872 22.09 510006......... 01.2565 17.08 450777....................... 01.0014 15.01 470006.......... 01.1898 17.05 490083......... 00.6451 14.63 500042......... 01.3735 20.95 510007......... 01.4707 17.81 450779....................... 01.3450 20.59 470008.......... 01.2516 15.41 490084......... 01.2535 15.96 500043......... 01.2939 16.56 510008......... 01.1226 15.33 450780....................... 01.6140 19.78 470010.......... 01.1804 18.58 490085......... 01.2071 13.36 500044......... 01.8920 20.56 510012......... 01.0670 14.26 450781....................... 01.4783 16.23 470011.......... 01.1610 19.30 490088......... 01.2024 13.97 500045......... 01.1167 20.65 510013......... 01.1365 15.10 450785....................... 01.0516 26.08 470012.......... 01.2651 17.52 490089......... 01.0748 14.37 500048......... 00.9122 16.01 510015......... 00.9706 12.51 450788....................... 01.4208 ....... 470013.......... 01.1682 18.28 490090......... 01.1783 14.25 500049......... 01.4708 19.34 510016......... 00.9917 11.27 450792....................... 01.3306 ....... 470015.......... 01.0806 16.29 490091......... 01.2045 20.14 500050......... 01.4079 20.41 510018......... 01.1351 14.40 450793....................... 01.6623 ....... 470018.......... 01.1930 17.37 490092......... 01.2038 14.32 500051......... 01.6292 22.71 510020......... 01.0494 10.16 450794....................... 01.4602 ....... 470020.......... 00.9884 14.50 490093......... 01.2927 15.31 500052......... 01.2781 ....... 510022......... 01.7998 19.52 450795....................... 00.8520 ....... 470023.......... 01.2947 17.20 490094......... 01.0700 14.57 500053......... 01.2686 20.10 510023......... 01.1454 15.14 450797....................... 00.6382 ....... 470024.......... 01.1136 17.08 490095......... 01.4745 16.13 500054......... 01.8788 20.41 510024......... 01.4093 17.94 450798....................... 00.8871 ....... 490001.......... 01.0799 19.41 490097......... 01.1333 13.69 500055......... 01.0886 20.32 510026......... 00.9392 12.19 450799....................... 01.3895 ....... 490002.......... 01.0625 13.61 490098......... 01.3132 11.69 500057......... 01.3490 16.24 510027......... 00.9669 13.86 450800....................... 01.3919 ....... 490003.......... 00.6018 17.55 490099......... 00.9348 15.29 500058......... 01.5095 19.82 510028......... 01.0731 14.90 450801....................... 01.4818 ....... 490004.......... 01.2303 16.67 490100......... 01.3757 16.69 500059......... 01.1588 20.02 510029......... 01.2953 16.69 450802....................... 01.2487 ....... 490005.......... 01.5364 16.10 490101......... 01.1933 23.64 500060......... 01.4869 20.70 510030......... 01.0968 14.87 450803....................... 00.8537 ....... 490006.......... 01.1569 13.27 490104......... 00.9110 14.46 500061......... 00.9842 17.95 510031......... 01.3367 16.27 450804....................... 01.5293 ....... 490007.......... 02.0310 17.19 490105......... 00.7427 16.55 500062......... 01.0856 17.16 510033......... 01.2624 14.42 450805....................... 01.1693 ....... 490009.......... 01.8204 18.08 490106......... 00.9047 14.86 500064......... 01.5371 21.69 510035......... 01.1467 16.46 450807....................... 00.9104 ....... 490010.......... 01.0912 17.08 490107......... 01.3155 22.64 500065......... 01.3049 17.67 510036......... 01.0129 09.34 450809....................... 01.6570 ....... 490011.......... 01.4170 17.03 490108......... 00.8737 13.78 500068......... 01.0186 17.17 510038......... 01.1610 13.71 450897....................... 04.8548 ....... 490012.......... 01.1990 15.55 490109......... 00.9185 14.09 500069......... 01.1665 18.62 510039......... 01.3580 15.02 460001....................... 01.7866 19.82 490013.......... 01.2514 14.82 490110......... 01.3986 15.90 500071......... 01.3666 19.46 510043......... 00.9310 11.33 460003....................... 01.7210 18.38 490014.......... 01.3584 21.04 490111......... 01.2348 16.79 500072......... 01.1952 21.19 510046......... 01.2605 15.26 460004....................... 01.7712 20.68 490015.......... 01.4630 17.30 490112......... 01.7326 19.07 500073......... 01.0859 16.85 510047......... 01.2074 17.37 460005....................... 01.5499 18.80 490017.......... 01.3623 16.44 490113......... 01.3003 20.96 500074......... 01.1671 14.80 510048......... 01.0733 17.39 460006....................... 01.4322 18.21 490018.......... 01.2580 16.83 490114......... 01.0988 15.00 500075......... 03.7376 20.25 510050......... 01.4642 15.34 460007....................... 01.5450 19.27 490019.......... 01.2006 15.60 490115......... 01.2451 14.25 500077......... 01.3913 21.63 510053......... 01.0396 13.50 460008....................... 01.3609 16.02 490020.......... 01.1565 14.16 490116......... 01.2251 15.61 500079......... 01.4055 19.87 510055......... 01.2246 19.41 460009....................... 01.8852 18.11 490021.......... 01.1505 17.11 490117......... 01.1729 13.62 500080......... 00.8427 11.56 510058......... 01.2002 16.23 460010....................... 01.9161 20.15 490022.......... 01.4063 17.59 490118......... 01.7642 21.32 500084......... 01.1439 20.05 510059......... 01.2290 13.65 460011....................... 01.3884 16.16 490023.......... 01.2234 17.03 490119......... 01.3467 16.41 500085......... 01.0619 17.19 510060......... 01.1538 15.36 460013....................... 01.5056 18.54 490024.......... 01.7803 17.06 490120......... 01.3270 16.88 500086......... 01.4244 18.48 510061......... 01.0749 12.59 460014....................... 01.0358 15.38 490027.......... 01.1310 13.11 490122......... 01.5152 20.86 500088......... 01.3586 22.86 510062......... 01.1797 15.38 460015....................... 01.2592 19.75 490028.......... 01.3516 18.42 490123......... 01.1414 14.80 500089......... 00.9469 13.99 510063......... 01.0126 10.63 460016....................... 00.8970 13.58 490030.......... 01.1033 11.16 490124......... 01.1521 16.99 500090......... 01.1042 12.60 510065......... 01.0089 12.04 460017....................... 01.4549 16.52 490031.......... 01.1369 12.61 490126......... 01.3837 14.72 500092......... 01.0798 15.65 510066......... 01.1288 12.02 460018....................... 00.9760 13.59 490032.......... 01.7249 19.08 490127......... 01.0179 14.44 500094......... 00.9177 15.53 510067......... 01.2496 15.91 460019....................... 01.1515 12.90 490033.......... 01.1854 15.21 490130......... 01.3118 16.58 500096......... 01.0950 17.13 510068......... 01.1196 14.01 460020....................... 01.0589 14.21 490035.......... 01.2179 09.64 490131......... 01.0427 14.06 500097......... 01.1371 16.12 510070......... 01.2210 16.05 460021....................... 01.3873 19.20 490037.......... 01.1278 13.27 500001......... 01.3342 20.92 500098......... 00.9192 13.66 510071......... 01.2767 14.49 460022....................... 00.9374 19.41 490038.......... 01.2195 12.54 500002......... 01.4828 18.75 500101......... 01.0080 17.84 510072......... 01.0650 13.50 460023....................... 01.1831 20.75 490040.......... 01.4100 ....... 500003......... 01.4073 21.28 500102......... 00.9391 18.43 510077......... 01.1079 14.36 460024....................... 00.8662 13.51 490041.......... 01.3633 16.88 500005......... 01.8398 22.52 500104......... 01.2622 18.71 510080......... 01.1530 09.35 460025....................... 00.8105 12.63 490042.......... 01.3475 15.18 500007......... 01.4207 20.14 500106......... 00.9247 15.53 510081......... 01.0320 13.19 460026....................... 01.0881 16.98 490043.......... 01.3704 16.74 500008......... 01.8411 22.88 500107......... 01.1321 15.58 510082......... 01.0578 12.08 460027....................... 00.9430 18.61 490044.......... 01.3658 16.65 500009......... 01.2857 21.07 500108......... 01.6669 21.40 510084......... 00.9741 12.87 460029....................... 01.0255 15.71 490045.......... 01.1319 18.60 500011......... 01.3718 21.44 500110......... 01.2887 18.75 510085......... 01.2422 17.99 460030....................... 01.2141 15.78 490046.......... 01.4645 17.24 500012......... 01.5217 20.94 500118......... 01.1240 20.88 510086......... 01.0448 15.65 460032....................... 01.0120 19.00 490047.......... 01.0663 16.34 500014......... 01.5715 22.36 500119......... 01.3333 20.48 520002......... 01.2873 17.24 460033....................... 00.9450 18.22 490048.......... 01.4906 17.53 500015......... 01.3714 20.92 500122......... 01.1925 20.27 520003......... 01.1635 15.19 460035....................... 00.9610 10.93 490050.......... 01.4363 20.06 500016......... 01.4877 22.76 500123......... 00.8543 14.78 520004......... 01.1581 16.53 460036....................... 00.9397 19.41 490052.......... 01.6013 15.06 500019......... 01.3295 19.82 500124......... 01.3292 22.39 520006......... 01.0583 18.05 460037....................... 01.0502 15.92 490053.......... 01.2501 14.14 500021......... 01.5380 20.77 500125......... 00.9834 10.72 520007......... 01.2469 14.14 460039....................... 01.0976 21.08 490054.......... 01.1101 13.91 500023......... 01.1763 19.09 500129......... 01.7339 22.41 520008......... 01.5546 20.54 460041....................... 01.2179 18.29 490057.......... 01.5486 17.02 500024......... 01.6324 21.06 500132......... 01.0006 19.79 520009......... 01.5961 16.88 460042....................... 01.4657 16.14 490059.......... 01.5727 18.24 500025......... 01.8715 21.69 500134......... 00.7903 15.75 520010......... 01.1768 19.39 460043....................... 00.9888 20.44 490060.......... 01.0661 16.72 500026......... 01.4324 22.42 500137......... 00.7110 19.99 520011......... 01.2031 16.46 460044....................... 01.2018 19.41 490063.......... 01.6611 22.34 500027......... 01.5334 23.68 500138......... 03.4209 ....... 520013......... 01.2909 17.88 460046....................... 00.7432 10.23 490066.......... 01.2178 17.42 500028......... 01.0839 14.76 500139......... 01.4763 21.33 520014......... 01.2083 15.55 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 27520]] Page 16 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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 520015....................... 01.1174 16.65 520107.......... 01.2599 17.46 530026......... 01.0473 14.63 520016....................... 01.0872 12.75 520109.......... 00.9937 17.25 530027......... 00.8416 09.56 520017....................... 01.1927 16.87 520110.......... 01.1756 16.47 530029......... 00.9590 13.49 520018....................... 01.0801 15.88 520111.......... 00.9841 14.44 530031......... 00.8745 10.95 520019....................... 01.2873 16.65 520112.......... 01.0805 18.15 530032......... 01.1558 17.33 520021....................... 01.3538 19.16 520113.......... 01.1645 17.80 520024....................... 01.0377 13.33 520114.......... 01.1037 12.61 520025....................... 01.1242 15.19 520115.......... 01.3222 15.89 520026....................... 01.1051 17.48 520116.......... 01.2576 17.66 520027....................... 01.2244 19.22 520117.......... 01.0303 15.40 520028....................... 01.3261 17.60 520118.......... 00.9469 10.95 520029....................... 00.9657 16.70 520120.......... 00.8647 11.95 520030....................... 01.6772 20.19 520121.......... 00.9763 14.18 520031....................... 01.1054 16.11 520122.......... 00.9894 13.96 520032....................... 01.1683 14.56 520123.......... 01.1427 16.55 520033....................... 01.1820 15.91 520124.......... 01.1255 14.34 520034....................... 01.1271 17.17 520130.......... 01.0776 12.60 520035....................... 01.2587 14.67 520131.......... 01.0620 15.82 520037....................... 01.6518 18.23 520132.......... 01.1878 14.31 520038....................... 01.4916 17.14 520134.......... 01.0269 15.14 520039....................... 00.9998 16.24 520135.......... 00.9427 13.84 520040....................... 01.4327 20.05 520136.......... 01.4778 18.87 520041....................... 01.1487 14.54 520138.......... 01.8773 18.18 520042....................... 01.0742 16.25 520139.......... 01.2893 18.50 520044....................... 01.3803 16.09 520140.......... 01.6143 19.31 520045....................... 01.6794 17.97 520141.......... 01.1223 15.63 520047....................... 01.0211 14.50 520142.......... 00.9152 12.48 520048....................... 01.4410 17.67 520144.......... 01.0302 16.10 520049....................... 01.9925 17.97 520145.......... 00.9155 16.57 520051....................... 02.0296 19.41 520146.......... 01.0749 13.71 520053....................... 01.1007 14.78 520148.......... 01.1668 15.34 520054....................... 01.0919 16.40 520149.......... 00.9581 13.31 520056....................... 01.3164 17.77 520151.......... 01.0803 14.43 520057....................... 01.1308 16.08 520152.......... 01.1177 16.38 520058....................... 01.0511 17.87 520153.......... 00.9775 13.19 520059....................... 01.3130 18.17 520154.......... 01.1520 16.15 520060....................... 01.2970 15.15 520156.......... 01.1216 16.37 520062....................... 01.2707 16.18 520157.......... 00.9447 13.70 520063....................... 01.2571 17.61 520159.......... 00.9412 16.25 520064....................... 01.7132 18.60 520160.......... 01.7643 17.77 520066....................... 01.4169 17.73 520161.......... 01.0283 14.76 520068....................... 00.8891 15.82 520170.......... 01.2367 18.51 520069....................... 01.1915 16.75 520171.......... 00.9904 13.69 520070....................... 01.6012 16.93 520173.......... 01.1609 17.36 520071....................... 01.1175 17.71 520174.......... 01.3641 20.57 520074....................... 01.1086 14.96 520177.......... 01.6458 20.33 520075....................... 01.4753 17.44 520178.......... 01.0634 14.61 520076....................... 01.1296 14.40 520186.......... 02.5906 ....... 520077....................... 01.0286 14.50 530002.......... 01.1932 18.07 520078....................... 01.5021 17.89 530003.......... 00.9310 12.59 520082....................... 01.3454 15.25 530004.......... 01.0270 13.17 520083....................... 01.5871 21.59 530005.......... 01.1389 13.19 520084....................... 01.0883 15.73 530006.......... 01.1268 16.83 520087....................... 01.6162 17.16 530007.......... 01.0516 11.52 520088....................... 01.2469 17.56 530008.......... 01.2810 17.75 520089....................... 01.5230 18.79 530009.......... 00.9688 20.60 520090....................... 01.2710 16.16 530010.......... 01.2195 16.30 520091....................... 01.3709 17.25 530011.......... 01.0899 15.27 520092....................... 01.1124 15.11 530012.......... 01.5874 17.25 520094....................... 01.0158 16.07 530014.......... 01.3289 15.01 520095....................... 01.3510 18.56 530015.......... 01.1500 19.22 520096....................... 01.4979 17.78 530016.......... 01.2060 11.87 520097....................... 01.3308 17.90 530017.......... 01.0038 16.09 520098....................... 01.7143 19.40 530018.......... 01.0645 14.57 520100....................... 01.2350 15.91 530019.......... 00.9449 14.32 520101....................... 01.0947 15.75 530022.......... 01.1147 15.94 520102....................... 01.2141 19.00 530023.......... 00.8514 17.76 520103....................... 01.3242 17.70 530025.......... 01.3686 18.12 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Note: Case mix indexes do not include discharges from PPS-exempt units. Case mix indexes include cases received in HCFA central office through December 1995. [[Page 27521]] Table 4a.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas ------------------------------------------------------------------------ Urban area (constituent counties or county Wage equivalents) index GAF ------------------------------------------------------------------------ 0040 Abilene, TX................................... 0.8055 0.8623 Taylor, TX 0060 Aguadilla, PR................................. 0.4430 0.5726 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH..................................... 0.9875 0.9914 Portage, OH Summit, OH 0120 Albany, GA.................................... 0.8353 0.8841 Dougherty, GA Lee, GA 0160 Albany-Schenectady-Troy, NY................... 0.8510 0.8954 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM............................... 0.9390 0.9578 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA................................ 0.8213 0.8739 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA................ 1.0014 1.0160 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA................................... 0.9531 0.9676 Blair, PA 0320 Amarillo, TX.................................. 0.8557 0.8988 Potter, TX Randall, TX 0380 Anchorage, AK................................. 1.3285 1.3104 Anchorage, AK 0440 Ann Arbor, MI................................. 1.1688 1.1218 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL.................................. 0.7848 0.8471 Calhoun, AL 0460 Appleton-Oshkosh-Neenah, WI................... 0.8910 0.9240 Calumet, WI Outagamie, WI Winnebago, WI 0470 Arecibo, PR................................... 0.4631 0.5903 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC................................. 0.9365 0.9561 Buncombe, NC Madison, NC 0500 Athens, GA.................................... 0.9259 0.9771 Clarke, GA Madison, GA Oconee, GA 0520 *Atlanta, GA.................................. 1.0089 1.0363 Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, 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 0560 Atlantic-Cape May, NJ......................... 1.1102 1.0742 Atlantic, NJ Cape May, NJ 0600 Augusta-Aiken, GA-SC.......................... 0.8849 0.9197 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 Austin-San Marcos, TX......................... 0.9252 0.9482 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 Bakersfield, CA............................... 1.0202 1.0168 Kern, CA 0720 *Baltimore, MD................................ 0.9820 1.0173 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME.................................... 0.9412 0.9594 Penobscot, ME 0743 Barnstable-Yarmouth, MA....................... 1.3682 1.2395 Barnstable, MA 0760 Baton Rouge, LA............................... 0.8442 0.8905 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX...................... 0.8578 0.9003 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA................................ 1.1342 1.0901 Whatcom, WA 0870 Benton Harbor, MI............................. 0.8553 0.8985 Berrien, MI 0875 *Bergen-Passaic, NJ........................... 1.1717 1.1146 Bergen, NJ Passaic, NJ 0880 Billings, MT.................................. 0.8903 0.9235 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8573 0.8999 Hancock, MS Harrison, MS Jackson, MS 0960 Binghamton, NY................................ 0.8842 0.9192 Broome, NY Tioga, NY 1000 Birmingham, AL................................ 0.9047 0.9337 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND.................................. 0.7976 0.8565 Burleigh, ND Morton, ND 1020 Bloomington, IN............................... 0.8619 0.9303 Monroe, IN 1040 Bloomington-Normal, IL........................ 0.8921 0.9248 McLean, IL 1080 Boise City, ID................................ 0.9269 0.9493 Ada, ID Canyon, ID 1123 *Boston-Worcester-Lawrence-Lowell-Brockton, MA- NH................................................. 1.1639 1.1428 Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1125 Boulder-Longmont, CO.......................... 0.9383 0.9573 Boulder, CO 1145 Brazoria, TX.................................. 0.8865 0.9208 Brazoria, TX 1150 Bremerton, WA................................. 1.0926 1.0625 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX.......... 0.8561 0.8991 Cameron, TX 1260 Bryan-College Station, TX..................... 0.8760 0.9133 Brazos, TX 1280 *Buffalo-Niagara Falls, NY.................... 0.9123 0.9673 Erie, NY Niagara, NY 1303 Burlington, VT................................ 0.9126 0.9393 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR.................................... 0.4661 0.5929 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR [[Page 27522]] 1320 Canton-Massillon, OH.......................... 0.8667 0.9067 Carroll, OH Stark, OH 1350 Casper, WY.................................... 0.8841 0.9191 Natrona, WY 1360 Cedar Rapids, IA.............................. 0.8477 0.8930 Linn, IA 1400 Champaign-Urbana, IL.......................... 0.9413 0.9594 Champaign, IL 1440 Charleston-North Charleston, SC............... 0.8984 0.9293 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV................................ 0.9547 0.9688 Kanawha, WV Putnam, WV 1520 *Charlotte-Gastonia-Rock Hill, NC-SC.......... 0.9631 1.0038 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Union, NC York, SC 1540 Charlottesville, VA........................... 0.9175 0.9427 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA............................ 0.8867 0.9210 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 Cheyenne, WY.................................. 0.7695 0.8357 Laramie, WY 1600 *Chicago, IL.................................. 1.0756 1.0827 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 Chico-Paradise, CA............................ 1.0441 1.0300 Butte, CA 1640 *Cincinnati, OH-KY-IN......................... 0.9477 0.9928 Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 1660 Clarksville-Hopkinsville, TN-KY............... 0.7733 0.8386 Christian, KY Montgomery, TN 1680 *Cleveland-Lorain-Elyria, OH.................. 0.9908 1.0235 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 Colorado Springs, CO.......................... 0.9456 0.9624 El Paso, CO 1740 Columbia, MO.................................. 0.8919 0.9246 Boone, MO 1760 Columbia, SC.................................. 0.9178 0.9430 Lexington, SC Richland, SC 1800 Columbus, GA-AL............................... 0.7655 0.8328 Russell, AL Chattanoochee, GA Harris, GA Muscogee, GA 1840 *Columbus, OH................................. 0.9699 1.0087 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX............................ 0.8641 0.9048 Nueces, TX San Patricio, TX 1900 Cumberland, MD-WV............................. 0.8613 0.9028 Allegany, MD Mineral, WV 1920 *Dallas, TX................................... 0.9530 0.9966 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA.................................. 0.8516 0.8958 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL........... 0.8407 0.8880 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH........................ 0.9582 0.9858 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL............................. 0.8891 0.9296 Flagler, FL Volusia, FL 2030 Decatur, AL................................... 0.8403 0.8877 Lawrence, AL Morgan, AL 2040 Decatur, IL................................... 0.7866 0.8484 Macon, IL 2080 *Denver, CO................................... 1.0291 1.0504 Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA................................ 0.8772 0.9142 Dallas, IA Polk, IA Warren, IA 2160 *Detroit, MI.................................. 1.0748 1.0822 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL.................................... 0.7758 0.8404 Dale, AL Houston, AL 2190 Dover, DE..................................... 0.9017 0.9595 Kent, DE 2200 Dubuque, IA................................... 0.8149 0.8692 Dubuque, IA 2240 Duluth-Superior, MN-WI........................ 0.9437 0.9611 St. Louis, MN Douglas, WI 2281 Dutchess County, NY........................... 1.0604 1.0488 Dutchess, NY 2290 Eau Claire, WI................................ 0.8698 0.9089 Chippewa, WI Eau Claire, WI 2320 El Paso, TX................................... 0.9486 0.9645 El Paso, TX 2330 Elkhart-Goshen, IN............................ 0.8820 0.9176 Elkhart, IN 2335 Elmira, NY.................................... 0.8436 0.8901 Chemung, NY 2340 Enid, OK...................................... 0.7879 0.8494 Garfield, OK 2360 Erie, PA...................................... 0.9137 0.9401 Erie, PA 2400 Eugene-Springfield, OR........................ 1.1503 1.1006 Lane, OR 2440 Evansville-Henderson, IN-KY................... 0.8990 0.9297 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN......................... 0.9010 0.9311 [[Page 27523]] Clay, MN Cass, ND 2560 Fayetteville, NC.............................. 0.9025 0.9322 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR............ 0.7236 0.8013 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT.............................. 0.9039 0.9331 Coconino, AZ Kane, UT 2640 Flint, MI..................................... 1.1273 1.0964 Genesee, MI 2650 Florence, AL.................................. 0.8157 0.8698 Colbert, AL Lauderdale, AL 2655 Florence, SC.................................. 0.8614 0.9029 Florence, SC 2670 Fort Collins-Loveland, CO..................... 1.0628 1.0426 Larimer, CO 2680 *Ft. Lauderdale, FL........................... 1.0968 1.0973 Broward, FL 2700 Fort Myers-Cape Coral, FL..................... 0.9093 0.9370 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL................ 1.0192 1.0131 Martin, FL St. Lucie, FL 2720 Fort Smith, AR-OK............................. 0.7885 0.8498 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL......................... 0.9186 0.9435 Okaloosa, FL 2760 Fort Wayne, IN................................ 0.8819 0.9175 Adams, IN Allen, IN DeKalb, IN Huntington, IN Wells, IN Whitley, IN 2800 *Forth Worth-Arlington, TX.................... 1.0095 1.0367 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA.................................... 1.1202 1.0808 Fresno, CA Madera, CA 2880 Gadsden, AL................................... 0.8901 0.9234 Etowah, AL 2900 Gainesville, FL............................... 0.9455 0.9623 Alachua, FL 2920 Galveston-Texas City, TX...................... 1.1022 1.0796 Galveston, TX 2960 Gary, IN...................................... 0.9176 0.9428 Lake, IN Porter, IN 2975 Glens Falls, NY............................... 0.8560 0.8990 Warren, NY Washington, NY 2980 Goldsboro, NC................................. 0.8412 0.8883 Wayne, NC 2985 Grand Forks, ND-MN............................ 0.9228 0.9465 Polk, MN Grand Forks, ND 2995 Grand Junction, CO............................ 0.8847 0.9195 Mesa, CO 3000 Grand Rapids-Muskegon-Holland, MI............. 1.0088 1.0060 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT............................... 0.9007 0.9309 Cascade, MT 3060 Greeley, CO................................... 0.9712 0.9802 Weld, CO 3080 Green Bay, WI................................. 0.9387 0.9576 Brown, WI 3120 *Greensboro-Winston-Salem-High Point, NC...... 0.9327 0.9820 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC................................ 0.9098 0.9373 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC........... 0.8947 0.9266 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD................................ 0.9195 0.9441 Washington, MD 3200 Hamilton-Middletown, OH....................... 0.9515 0.9665 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA............... 1.0181 1.0124 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 *Hartford, CT................................. 1.2395 1.1931 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 Hattiesburg, MS............................... 0.7269 0.8038 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC.................. 0.7945 0.8542 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI.................................. 1.1487 1.1776 Honolulu, HI 3350 Houma, LA..................................... 0.7843 0.8518 Lafourche, LA Terrebonne, LA 3360 *Houston, TX.................................. 0.9790 1.0151 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH.................. 0.9194 0.9441 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL................................ 0.8145 0.8689 Limestone, AL Madison, AL 3480 *Indianapolis, IN............................. 0.9950 1.0265 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA................................. 0.9382 0.9573 Johnson, IA 3520 Jackson, MI................................... 0.9066 0.9351 Jackson, MI 3560 Jackson, MS................................... 0.7906 0.8514 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN................................... 0.8340 0.8831 Madison, TN 3605 Jacksonville, FL.............................. 0.9018 0.9317 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 Jacksonville, NC.............................. 0.7071 0.7887 Onslow, NC 3610 Jamestown, NY................................. 0.7679 0.8346 Chautaqua, NY 3620 Janesville-Beloit, WI......................... 0.8664 0.9065 Rock, WI 3640 Jersey City, NJ............................... 1.1408 1.1236 Hudson, NJ 3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8921 0.9248 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN [[Page 27524]] Bristol City, VA Scott, VA Washington, VA 3680 Johnstown, PA................................. 0.8417 0.8887 Cambria, PA Somerset, PA 3710 Joplin, MO.................................... 0.7409 0.8144 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI..................... 1.0565 1.0384 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL.................................. 0.8998 0.9582 Kankakee, IL 3760 *Kansas City, KS-MO........................... 0.9522 0.9960 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800 Kenosha, WI................................... 0.9166 0.9421 Kenosha, WI 3810 Killeen-Temple, TX............................ 1.0415 1.0282 Bell, TX Coryell, TX 3840 Knoxville, TN................................. 0.8520 0.8961 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN.................................... 0.8609 0.9025 Howard, IN Tipton, IN 3870 La Crosse, WI-MN.............................. 0.8638 0.9046 Houston, MN La Crosse, WI 3880 Lafayette, LA................................. 0.8183 0.8717 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN................................. 0.8824 0.9179 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA.............................. 0.8052 0.8621 Calcasieu, LA 3980 Lakeland-Winter Haven, FL..................... 0.8677 0.9074 Polk, FL 4000 Lancaster, PA................................. 0.9605 0.9786 Lancaster, PA 4040 Lansing-East Lansing, MI...................... 1.0016 1.0011 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX.................................... 0.7092 0.7903 Webb, TX 4100 Las Cruces, NM................................ 0.8516 0.8958 Dona Ana, NM 4120 *Las Vegas, NV-AZ............................. 1.0894 1.0922 Mohave, AZ Clark, NV Nye, NV 4150 Lawrence, KS.................................. 0.8616 0.9301 Douglas, KS 4200 Lawton, OK.................................... 0.8339 0.8830 Comanche, OK 4243 Lewiston-Auburn, ME........................... 0.9431 0.9607 Androscoggin, ME 4280 Lexington, KY................................. 0.8387 0.8865 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH...................................... 0.8752 0.9128 Allen, OH Auglaize, OH 4360 Lincoln, NE................................... 0.9193 0.9440 Lancaster, NE 4400 Little Rock-North Little Rock, AR............. 0.8616 0.9030 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX......................... 0.8633 0.9042 Gregg, TX Harrison, TX Upshur, TX 4480 *Los Angeles-Long Beach, CA................... 1.2396 1.1932 Los Angeles, CA 4520 Louisville, KY-IN............................. 0.9445 0.9617 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX................................... 0.8525 0.8965 Lubbock, TX 4640 Lynchburg, VA................................. 0.8036 0.8609 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA..................................... 0.8836 0.9187 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI................................... 1.0048 1.0033 Dane, WI 4800 Mansfield, OH................................. 0.8543 0.8978 Crawford, OH Richland, OH 4840 Mayaguez, PR.................................. 0.4186 0.5508 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX.................. 0.8502 0.8948 Hidalgo, TX 4890 Medford-Ashland, OR........................... 1.0213 1.0145 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL............. 0.9089 0.9507 Brevard, FL 4920 *Memphis, TN-AR-MS............................ 0.8185 0.8980 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 Merced, CA.................................... 1.0684 1.0463 Merced, CA 5000 *Miami, FL.................................... 0.9240 0.9757 Dade, FL 5015 *Middlesex-Somerset-Hunterdon, NJ............. 1.0777 1.0842 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 *Milwaukee-Waukesha, WI....................... 0.9667 1.0064 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 *Minneapolis-St. Paul, MN-WI.................. 1.0785 1.0847 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 5160 Mobile, AL.................................... 0.7999 0.8582 Baldwin, AL Mobile, AL 5170 Modesto, CA................................... 1.0135 1.0092 Stanislaus, CA 5190 *Monmouth-Ocean, NJ........................... 1.0842 1.0569 Monmouth, NJ [[Page 27525]] Ocean, NJ 5200 Monroe, LA.................................... 0.8234 0.8754 Ouachita, LA 5240 Montgomery, AL................................ 0.7949 0.8545 Autauga, AL Elmore, AL Montgomery, AL 5280 Muncie, IN.................................... 0.9736 1.0113 Delaware, IN 5330 Myrtle Beach, SC.............................. 0.7798 0.8434 Horry, SC 5345 Naples, FL.................................... 1.0222 1.0151 Collier, FL 5360 *Nashville, TN................................ 0.9065 0.9630 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 *Nassau-Suffolk, NY........................... 1.2852 1.2231 Nassau, NY Suffolk, NY 5483 *New Haven-Bridgeport-Stamford-Waterbury-..... 1.2778 1.2183 Danbury, CT Fairfield, CT New Haven, CT 5523 New London-Norwich, CT........................ 1.2345 1.1898 New London, CT 5560 *New Orleans, LA.............................. 0.9434 0.9897 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................................. 1.4041 1.2995 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 *Newark, NJ................................... 1.1057 1.1034 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA............................... 1.0829 1.0561 Orange, NY Pike, PA 5720 *Norfolk-Virginia Beach-Newport News, VA-NC... 0.8326 0.9086 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.................................. 1.5113 1.3666 Alameda, CA Contra Costa, CA 5790 Ocala, FL..................................... 0.8999 0.9303 Marion, FL 5800 Odessa-Midland, TX............................ 0.8552 0.8984 Ector, TX Midland, TX 5880 *Oklahoma City, OK............................ 0.8463 0.9188 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA................................... 1.0713 1.0483 Thurston, WA 5920 Omaha, NE-IA................................. 0.9425 0.9603 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 *Orange County, CA............................ 1.1929 1.1622 Orange, CA 5960 *Orlando, FL.................................. 0.9491 0.9938 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY................................. 0.7578 0.8270 Daviess, KY 6015 Panama City, FL............................... 0.8080 0.8642 Bay, FL 6020 Parkersburg-Marietta, WV-OH................... 0.7895 0.8506 Washington, OH Wood, WV 6080 Pensacola, FL................................. 0.8212 0.8738 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL.............................. 0.8923 0.9249 Peoria, IL Tazewell, IL Woodford, IL 6160 *Philadelphia, PA-NJ.......................... 1.1197 1.1129 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 *Phoenix-Mesa, AZ............................. 0.9832 1.0181 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR................................ 0.7904 0.8512 Jefferson, AR 6280 *Pittsburgh, PA............................... 0.9726 1.0106 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 Pittsfield, MA................................ 1.0570 1.0387 Berkshire, MA 6360 Ponce, PR..................................... 0.4500 0.5788 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME.................................. 0.9615 0.9735 Cumberland, ME Sagadahoc, ME York, ME 6440 *Portland-Vancouver, OR-WA.................... 1.1267 1.1177 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 Providence-Warwick-Pawtucket, RI.............. 1.1116 1.0751 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT................................ 1.0139 1.0095 Utah, UT 6560 Pueblo, CO.................................... 0.8302 0.8804 Pueblo, CO 6580 Punta Gorda, FL............................... 0.8284 0.8790 Charlotte, FL 6600 Racine, WI.................................... 0.8855 0.9201 Racine, WI 6640 Raleigh-Durham-Chapel Hill, NC................ 0.9740 0.9821 Chatham, NC Durham, NC Franklin, NC Johnston, NC [[Page 27526]] Orange, NC Wake, NC 6660 Rapid City, SD................................ 0.8493 0.8942 Pennington, SD 6680 Reading, PA................................... 0.9467 0.9728 Berks, PA 6690 Redding, CA................................... 1.1631 1.1090 Shasta, CA 6720 Reno, NV...................................... 1.1043 1.0703 Washoe, NV 6740 Richland-Kennewick-Pasco, WA.................. 0.9993 0.9995 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA....................... 0.9189 0.9437 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................. 1.1251 1.1166 Riverside, CA San Bernardino, CA 6800 Roanoke, VA................................... 0.8721 0.9105 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN................................. 1.0452 1.0307 Olmsted, MN 6840 *Rochester, NY................................ 0.9611 1.0024 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL.................................. 0.9015 0.9315 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC............................... 0.8951 0.9269 Edgecombe, NC Nash, NC 6920 *Sacramento, CA............................... 1.2382 1.1923 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI.................. 0.9605 0.9728 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN................................. 0.9478 0.9640 Benton, MN Stearns, MN 7000 St. Joseph, MO................................ 0.8570 0.8997 Andrews, MO Buchanan, MO 7040 *St. Louis, MO-IL............................. 0.8926 0.9529 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 7080 Salem, OR..................................... 0.9749 0.9901 Marion, OR Polk, OR 7120 Salinas, CA................................... 1.3835 1.2489 Monterey, CA 7160 *Salt Lake City-Ogden, UT..................... 0.9677 1.0071 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX................................ 0.7594 0.8282 Tom Green, TX 7240 *San Antonio, TX.............................. 0.8365 0.9115 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 *San Diego, CA................................ 1.2183 1.1791 San Diego, CA 7360 *San Francisco, CA............................ 1.4210 1.3102 Marin, CA San Francisco, CA San Mateo, CA 7400 *San Jose, CA................................. 1.4435 1.3244 Santa Clara, CA 7440 *San Juan-Bayamon, PR......................... 0.4616 0.6066 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 Morovis, PR Naguabo, 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 7460 San Luis Obispo-Atascadero-Paso Robles, CA.... 1.1587 1.1061 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.1267 1.0851 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA.................... 1.3551 1.2313 Santa Cruz, CA 7490 Santa Fe, NM.................................. 1.0847 1.0573 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA................................ 1.2558 1.1688 Sonoma, CA 7510 Sarasota-Bradenton, FL........................ 0.9770 0.9842 Manatee, FL Sarasota, FL 7520 Savannah, GA.................................. 1.0089 1.0061 Bryan, GA Chatham, GA Effingham, GA 7560 Scranton-Wilkes-Barre-Hazleton, PA............ 0.8767 0.9138 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 *Seattle-Bellevue-Everett, WA................. 1.1410 1.1274 Island, WA King, WA Snohomish, WA 7610 Sharon, PA.................................... 0.8764 0.9136 Mercer, PA 7620 Sheboygan, WI................................. 0.7782 0.8422 Sheboygan, WI 7640 Sherman-Denison, TX........................... 0.8650 0.9055 Grayson, TX 7680 Shreveport-Bossier City, LA................... 0.9379 0.9570 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE............................. 0.8331 0.8825 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD............................... 0.8606 0.9023 Lincoln, SD Minnehaha, SD 7800 South Bend, IN................................ 0.9957 0.9971 St. Joseph, IN [[Page 27527]] 7840 Spokane, WA................................... 1.0548 1.0372 Spokane, WA 7880 Springfield, IL............................... 0.8783 0.9150 Menard, IL Sangamon, IL 7920 Springfield, MO............................... 0.7840 0.8465 Christian, MO Greene, MO Webster, MO 8003 Springfield, MA............................... 1.0609 1.0552 Hampden, MA Hampshire, MA 8050 State College, PA............................. 0.8875 0.9215 Centre, PA 8080 Steubenville-Weirton, OH-WV................... 0.8244 0.9024 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA............................. 1.1417 1.0997 San Joaquin, CA 8140 Sumter, SC.................................... 0.7716 0.8373 Sumter, SC 8160 Syracuse, NY.................................. 0.9406 0.9589 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 Tacoma, WA.................................... 1.0891 1.0655 Pierce, WA 8240 Tallahassee, FL............................... 0.8332 0.8825 Gadsden, FL Leon, FL 8280 *Tampa-St. Petersburg-Clearwater, FL.......... 0.9322 0.9817 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 Terre Haute, IN............................... 0.8611 0.9027 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana, AR-Texarkana, TX................... 0.8484 0.8935 Miller, AR Bowie, TX 8400 Toledo, OH.................................... 1.0383 1.0445 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS.................................... 1.0108 1.0074 Shawnee, KS 8480 Trenton, NJ................................... 1.0572 1.0388 Mercer, NJ 8520 Tucson, AZ.................................... 0.9050 0.9339 Pima, AZ 8560 Tulsa, OK..................................... 0.8113 0.8666 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL................................ 0.7723 0.8378 Tuscaloosa, AL 8640 Tyler, TX..................................... 1.0158 1.0108 Smith, TX 8680 Utica-Rome, NY................................ 0.8421 0.8890 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA.................... 1.3483 1.2271 Napa, CA Solano, CA 8735 Ventura, CA................................... 1.1169 1.0786 Ventura, CA 8750 Victoria, TX.................................. 0.8478 0.8931 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ.............. 1.0015 1.0010 Cumberland, NJ 8780 Visalia-Tulare-Porterville, CA................ 1.0174 1.0119 Tulare, CA 8800 Waco, TX...................................... 0.7789 0.8427 McLennan, TX 8840 *Washington, DC-MD-VA-WV...................... 1.0842 1.0886 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 8920 Waterloo-Cedar Falls, IA...................... 0.8724 0.9108 Black Hawk, IA 8940 Wausau, WI.................................... 1.0347 1.0236 Marathon, WI 8960 West Palm Beach-Boca Raton, FL................ 1.0016 1.0036 Palm Beach, FL 9000 Wheeling, OH-WV............................... 0.7580 0.8313 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS................................... 0.9447 0.9618 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX............................. 0.8070 0.8634 Archer, TX Wichita, TX 9140 Williamsport, PA.............................. 0.8487 0.8937 Lycoming, PA 9160 Wilmington-Newark, DE-MD...................... 1.1341 1.1063 New Castle, DE Cecil, MD 9200 Wilmington, NC................................ 0.9072 0.9355 New Hanover, NC Brunswick, NC 9260 Yakima, WA.................................... 1.0049 1.0034 Yakima, WA 9270 Yolo, CA...................................... 1.1470 1.0985 Yolo, CA 9280 York, PA...................................... 0.9124 0.9391 York, PA 9320 Youngstown-Warren, OH......................... 0.9764 0.9838 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA................................. 1.0437 1.0297 Sutter, CA Yuba, CA 9360 Yuma, AZ...................................... 0.9518 0.9667 Yuma, AZ ------------------------------------------------------------------------ * Large Urban Area Table 4b.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas ------------------------------------------------------------------------ Wage Nonurban area index GAF ------------------------------------------------------------------------ Alabama............................................. 0.7160 0.7955 Alaska.............................................. 1.2472 1.2550 Arizona............................................. 0.7946 0.8543 Arkansas............................................ 0.7000 0.7833 California.......................................... 0.9991 1.0010 Colorado............................................ 0.8156 0.8697 Connecticut......................................... 1.2788 1.2189 Delaware............................................ 0.9464 0.9630 Florida............................................. 0.8677 0.9084 Georgia............................................. 0.7659 0.8331 Hawaii.............................................. 1.0268 1.0771 Idaho............................................... 0.8356 0.8843 Illinois............................................ 0.7567 0.8286 Indiana............................................. 0.8119 0.8718 Iowa................................................ 0.7394 0.8132 Kansas.............................................. 0.7113 0.7922 Kentucky............................................ 0.7772 0.8419 Louisiana........................................... 0.7284 0.8055 Maine............................................... 0.8335 0.8827 Maryland............................................ 0.8446 0.8908 Massachusetts....................................... 1.0794 1.0537 Michigan............................................ 0.8837 0.9188 Minnesota........................................... 0.8161 0.8704 Mississippi......................................... 0.6808 0.7685 Missouri............................................ 0.7249 0.8044 [[Page 27528]] Montana............................................. 0.8137 0.8683 Nebraska............................................ 0.7245 0.8020 Nevada.............................................. 0.8795 0.9158 New Hampshire....................................... 0.9776 0.9895 New Jersey \1\...................................... ........ ........ New Mexico.......................................... 0.7873 0.8489 New York............................................ 0.8565 0.8994 North Carolina...................................... 0.7945 0.8565 North Dakota........................................ 0.7370 0.8114 Ohio................................................ 0.8349 0.8909 Oklahoma............................................ 0.6963 0.7805 Oregon.............................................. 0.9715 0.9813 Pennsylvania........................................ 0.8480 0.8939 Puerto Rico......................................... 0.4182 0.5505 Rhode Island \1\.................................... ........ ........ South Carolina...................................... 0.7679 0.8356 South Dakota........................................ 0.7085 0.7898 Tennessee........................................... 0.7372 0.8116 Texas............................................... 0.7430 0.8166 Utah................................................ 0.8854 0.9200 Vermont............................................. 0.8941 0.9287 Virginia............................................ 0.7760 0.8422 Washington.......................................... 0.9956 0.9978 West Virginia....................................... 0.7943 0.8541 Wisconsin........................................... 0.8449 0.8914 Wyoming............................................. 0.8202 0.8731 ------------------------------------------------------------------------ \1\ All counties within the State are classified as urban. Table 4c.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That are Reclassified ------------------------------------------------------------------------ Wage Area reclassified to index GAF ------------------------------------------------------------------------ Abilene, TX......................................... 0.8055 0.8623 Albuquerque, NM..................................... 0.9390 0.9578 Alexandria, LA...................................... 0.8213 0.8739 Amarillo, TX........................................ 0.8557 0.8988 Anchorage, AK....................................... 1.3285 1.2147 Asheville, NC....................................... 0.9365 0.9561 Atlanta, GA......................................... 0.9986 0.9990 Bangor, ME.......................................... 0.9412 0.9594 Baton Rouge, LA..................................... 0.8442 0.8905 Benton Harbor, MI................................... 0.8553 0.8985 Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8837 0.9188 Billings, MT........................................ 0.8903 0.9235 Birmingham, AL...................................... 0.9047 0.9337 Bismarck, ND........................................ 0.7976 0.8565 Boise City, ID...................................... 0.9269 0.9493 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1639 1.1095 Caguas, PR.......................................... 0.4661 0.5929 Champaign-Urbana, IL................................ 0.8999 0.9303 Charleston-North Charleston, SC..................... 0.8984 0.9293 Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9631 0.9746 Charlottesville, VA................................. 0.9006 0.9308 Chattanooga, TN-GA.................................. 0.8867 0.9210 Chicago, IL......................................... 1.0653 1.0443 Cincinnati, OH-KY-IN................................ 0.9477 0.9639 Cleveland-Lorain-Elyria, OH......................... 0.9908 0.9937 Columbia, MO........................................ 0.8919 0.9246 Columbus, OH........................................ 0.9699 0.9793 Dallas, TX.......................................... 0.9530 0.9676 Davenport-Moline-Rock Island, IA-IL................. 0.8407 0.8880 Denver, CO.......................................... 1.0291 1.0198 Des Moines, IA...................................... 0.8772 0.9142 Duluth-Superior, MN-WI.............................. 0.9437 0.9611 Dutchess County, NY................................. 1.0309 1.0211 Elkhart-Goshen, IN.................................. 0.8820 0.9176 Eugene-Springfield, OR.............................. 1.1503 1.1006 Fargo-Moorhead, ND-MN............................... 0.8860 0.9205 Fayetteville, NC.................................... 0.8658 0.9060 Flagstaff, AR-UT.................................... 0.8848 0.9196 Flint, MI........................................... 1.1273 1.0855 Florence, AL........................................ 0.8157 0.8698 Florence, SC........................................ 0.8614 0.9029 Fort Lauderdale, FL................................. 1.0968 1.0653 Fort Pierce-Port St. Lucie, FL...................... 1.0049 1.0034 Fort Smith, AR-OK................................... 0.7885 0.8498 Fort Walton Beach, FL............................... 0.8978 0.9288 Fort Worth-Arlington, TX............................ 1.0095 1.0065 Gadsden, AL......................................... 0.8901 0.9234 Gary, IN............................................ 0.9176 0.9428 Grand Forks, ND-MN.................................. 0.9228 0.9465 Grand Junction, CO.................................. 0.8847 0.9195 Grand Rapids-Muskegon-Holland, MI................... 1.0088 1.0060 Great Falls, MT..................................... 0.9007 0.9309 Greeley, CO......................................... 0.9409 0.9591 Green Bay, WI....................................... 0.9387 0.9576 Greensboro-Winston-Salem-High Point, NC............. 0.9327 0.9534 Greenville-Spartanburg-Anderson, SC................. 0.8947 0.9266 Hartford, CT........................................ 1.2218 1.1470 Honolulu, HI........................................ 1.1487 1.0996 Houston, TX......................................... 0.9790 0.9856 Huntington-Ashland, WV-KY-OH........................ 0.9194 0.9441 Huntsville, AL...................................... 0.8040 0.8612 Indianapolis, IN.................................... 0.9833 0.9885 Jackson, MS......................................... 0.7906 0.8514 Jacksonville, FL.................................... 0.9018 0.9317 Johnson City-Kingsport-Bristol, TN-VA............... 0.8921 0.9248 Joplin, MO.......................................... 0.7409 0.8144 Kalamazoo-Battlecreek, MI........................... 1.0462 1.0314 Kansas City, KS-MO.................................. 0.9522 0.9670 Knoxville, TN....................................... 0.8520 0.8961 Lafayette, LA....................................... 0.8183 0.8717 Lansing-East Lansing, MI............................ 1.0016 1.0011 Las Vegas, NV-AZ.................................... 1.0894 1.0604 Lexington, KY....................................... 0.8387 0.8865 Lima, OH............................................ 0.8752 0.9128 Lincoln, NE......................................... 0.9059 0.9346 Little Rock-North Little Rock, AR................... 0.8616 0.9030 Longview-Marshall, TX............................... 0.8495 0.8943 Los Angeles-Long Beach, CA.......................... 1.2396 1.1585 Louisville, KY-IN................................... 0.9445 0.9617 Macon, GA........................................... 0.8460 0.8918 Madison, WI......................................... 1.0048 1.0033 Mansfield, OH....................................... 0.8543 0.8978 Medford-Ashland, OR................................. 1.0213 1.0145 Memphis, TN-AR-MS................................... 0.8185 0.8718 Middlesex-Somerset-Hunterdon, NJ.................... 1.0777 1.0526 Milwaukee-Waukesha, WI.............................. 0.9667 0.9771 Minneapolis-St. Paul, MN-WI......................... 1.0785 1.0531 Modesto, CA......................................... 1.0135 1.0092 Monmouth-Ocean, NJ.................................. 1.0572 1.0388 Montgomery, AL...................................... 0.7949 0.8545 Nashville, TN....................................... 0.9065 0.9350 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2778 1.1828 New London-Norwich, CT.............................. 1.2345 1.1552 New Orleans, LA..................................... 0.9434 0.9609 New York, NY........................................ 1.4041 1.2616 Newark, NJ.......................................... 1.0956 1.0645 Oakland, CA......................................... 1.5113 1.3268 Odessa-Midland, TX.................................. 0.8552 0.8984 Oklahoma City, OK................................... 0.8463 0.8920 Omaha, NE-IA........................................ 0.9425 0.9603 Orange County, CA................................... 1.1929 1.1284 Peoria-Pekin, IL.................................... 0.8923 0.9249 Philadelphia, PA-NJ................................. 1.1197 1.0805 Pittsburgh, PA...................................... 0.9564 0.9699 Portland, ME........................................ 0.9615 0.9735 Portland-Vancouver, OR-WA........................... 1.1267 1.0851 Provo-Orem, UT...................................... 1.0139 1.0095 Raleigh-Durham-Chapel Hill, NC...................... 0.9615 0.9735 Rapid City, SD...................................... 0.8493 0.8942 Roanoke, VA......................................... 0.8721 0.9105 Rochester, MN....................................... 1.0452 1.0307 Rockford, IL........................................ 0.9015 0.9315 Sacramento, CA...................................... 1.2382 1.1576 Saginaw-Bay City-Midland, MI........................ 0.9605 0.9728 St. Cloud, MN....................................... 0.9478 0.9640 St. Louis, MO-IL.................................... 0.8926 0.9251 Salt Lake City-Ogden, UT............................ 0.9677 0.9778 San Diego, CA....................................... 1.2183 1.1448 San Francisco, CA................................... 1.4210 1.2720 San Jose, CA........................................ 1.4435 1.2858 Santa Rosa, CA...................................... 1.2430 1.1606 Sarasota-Bradenton, FL.............................. 0.9770 0.9842 Seattle-Bellevue-Everett, WA........................ 1.1410 1.0945 Sharon, PA.......................................... 0.8764 0.9136 Sherman-Denison, TX................................. 0.8650 0.9055 Sioux Falls, SD..................................... 0.8606 0.9023 South Bend, IN...................................... 0.9957 0.9971 Springfield, IL..................................... 0.8783 0.9150 Springfield, MO..................................... 0.7840 0.8465 Stockton-Lodi, CA................................... 1.1417 1.0950 Syracuse, NY........................................ 0.9406 0.9589 Tacoma, WA.......................................... 1.0891 1.0602 Tampa-St. Petersburg-Clearwater, FL................. 0.9322 0.9531 [[Page 27529]] Texarkana, AR-Texarkana, TX......................... 0.8484 0.8935 Toledo, OH.......................................... 1.0383 1.0261 Topeka, KS.......................................... 0.9817 0.9874 Tucson, AZ.......................................... 0.9050 0.9339 Tulsa, OK........................................... 0.8113 0.8666 Tyler, TX........................................... 0.9717 0.9805 Victoria, TX........................................ 0.8259 0.8772 Washington, DC-MD-VA-WV............................. 1.0842 1.0569 Waterloo-Cedar Falls, IA............................ 0.8601 0.9019 Wausau, WI.......................................... 0.9720 0.9807 Wichita, KS......................................... 0.9282 0.9503 Rural Alabama....................................... 0.7160 0.7955 Rural Florida....................................... 0.8677 0.9074 Rural Kentucky...................................... 0.7772 0.8415 Rural Louisiana..................................... 0.7284 0.8049 Rural Michigan...................................... 0.8837 0.9188 Rural Minnesota..................................... 0.8161 0.8701 Rural New Hampshire................................. 0.9776 0.9846 Rural North Carolina................................ 0.7945 0.8542 Rural Virginia...................................... 0.7760 0.8406 Rural Washington.................................... 0.9956 0.9970 Rural West Virginia................................. 0.7943 0.8541 Rural Wyoming....................................... 0.8202 0.8731 ------------------------------------------------------------------------ Table 4d.--Average Hourly Wage for Urban Areas ------------------------------------------------------------------------ Average Urban area hourly wage ------------------------------------------------------------------------ Abilene, TX.................................................. 15.4795 Aguadilla, PR................................................ 8.6418 Akron, OH.................................................... 19.2662 Albany, GA................................................... 16.2968 Albany-Schenectady-Troy, NY.................................. 16.6016 Albuquerque, NM.............................................. 18.3100 Alexandria, LA............................................... 15.8746 Allentown-Bethlehem-Easton, PA............................... 19.5376 Altoona, PA.................................................. 18.5951 Amarillo, TX................................................. 16.6936 Anchorage, AK................................................ 25.8567 Ann Arbor, MI................................................ 22.8035 Anniston, AL................................................. 15.3104 Appleton-Oshkosh-Neenah, WI.................................. 17.3835 Arecibo, PR.................................................. 9.0343 Asheville, NC................................................ 18.2517 Athens, GA................................................... 18.0640 Atlanta, GA.................................................. 19.6832 Atlantic-Cape May, NJ........................................ 21.6594 Augusta-Aiken, GA-SC......................................... 17.2642 Austin-San Marcos, TX........................................ 18.0500 Bakersfield, CA.............................................. 19.9031 Baltimore, MD................................................ 19.1581 Bangor, ME................................................... 18.3630 Barnstable-Yarmouth, MA...................................... 26.6928 Baton Rouge, LA.............................................. 16.4700 Beaumont-Port Arthur, TX..................................... 16.7355 Bellingham, WA............................................... 22.1285 Benton Harbor, MI............................................ 16.5971 Bergen-Passaic, NJ........................................... 22.8591 Billings, MT................................................. 17.3702 Biloxi-Gulfport-Pascagoula, MS............................... 16.7252 Binghamton, NY............................................... 17.2505 Birmingham, AL............................................... 17.6503 Bismarck, ND................................................. 15.0933 Bloomington, IN.............................................. 16.8155 Bloomington-Normal, IL....................................... 17.4035 Boise City, ID............................................... 18.0695 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.7069 Boulder-Longmont, CO......................................... 18.3061 Brazoria, TX................................................. 17.9908 Bremerton, WA................................................ 21.3152 Brownsville-Harlingen-San Benito, TX......................... 16.7030 Bryan-College Station, TX.................................... 17.0898 Buffalo-Niagara Falls, NY.................................... 17.7977 Burlington, VT............................................... 17.8037 Caguas, PR................................................... 9.0488 Canton-Massillon, OH......................................... 16.9098 Casper, WY................................................... 17.2484 Cedar Rapids, IA............................................. 16.5386 Champaign-Urbana, IL......................................... 18.3634 Charleston-North Charleston, SC.............................. 17.5265 Charleston, WV............................................... 18.6261 Charlotte-Gastonia-Rock Hill, NC-SC.......................... 18.7900 Charlottesville, VA.......................................... 17.9005 Chattanooga, TN-GA........................................... 17.2991 Cheyenne, WY................................................. 15.0126 Chicago, IL.................................................. 20.9843 Chico-Paradise, CA........................................... 20.3689 Cincinnati, OH-KY-IN......................................... 18.4886 Clarksville-Hopkinsville, TN-KY.............................. 15.0873 Cleveland-Lorain-Elyria, OH.................................. 19.3306 Colorado Springs, CO......................................... 18.4479 Columbia, MO................................................. 17.4002 Columbia, SC................................................. 17.9066 Columbus, GA-AL.............................................. 14.9336 Columbus, OH................................................. 18.9232 Corpus Christi, TX........................................... 16.8587 Cumberland, MD-WV............................................ 16.8031 Dallas, TX................................................... 18.5928 Danville, VA................................................. 16.6152 Davenport-Moline-Rock Island, IA-IL.......................... 16.4021 Dayton-Springfield, OH....................................... 18.6930 Daytona Beach, FL............................................ 17.3459 Decatur, AL.................................................. 16.3934 Decatur, IL.................................................. 15.3452 Denver, CO................................................... 20.0780 Des Moines, IA............................................... 17.1139 Detroit, MI.................................................. 20.9694 Dothan, AL................................................... 15.1351 Dover, DE.................................................... 17.5916 Dubuque, IA.................................................. 15.8987 Duluth-Superior, MN-WI....................................... 18.4105 Dutchess County, NY.......................................... 20.6881 Eau Claire, WI............................................... 16.9692 El Paso, TX.................................................. 18.5059 Elkhart-Goshen, IN........................................... 17.2083 Elmira, NY................................................... 16.4576 Enid, OK..................................................... 15.3724 Erie, PA..................................................... 17.8263 Eugene-Springfield, OR....................................... 22.0384 Evansville, Henderson, IN-KY................................. 17.5397 Fargo-Moorhead, ND-MN........................................ 17.5775 Fayetteville, NC............................................. 17.6077 Fayetteville-Springdale-Rogers, AR........................... 14.1177 Flagstaff, AZ-UT............................................. 17.6344 Flint, MI.................................................... 21.9933 Florence, AL................................................. 15.5886 Florence, SC................................................. 16.8047 Fort Collins-Loveland, CO.................................... 20.7345 Fort Lauderdale, FL.......................................... 20.5796 Fort Myers-Cape Coral, FL.................................... 17.7400 Fort Pierce-Port St. Lucie, FL............................... 19.8836 Fort Smith, AR-OK............................................ 15.3772 Fort Walton Beach, FL........................................ 17.9217 Fort Wayne, IN............................................... 17.2046 Fort Worth-Arlington, TX..................................... 19.6953 Fresno, CA................................................... 21.8549 Gadsden, AL.................................................. 17.3656 Gainesville, FL.............................................. 18.4465 Galveston-Texas City, TX..................................... 21.5032 Gary, IN..................................................... 18.8135 Glens Falls, NY.............................................. 16.6999 Goldsboro, NC................................................ 16.4109 Grand Forks, ND-MN........................................... 17.6200 Grand Junction, CO........................................... 16.2899 Grand Rapids-Muskegon-Holland, MI............................ 19.6810 Great Falls, MT.............................................. 16.9748 Greeley, CO.................................................. 18.9481 Green Bay, WI................................................ 17.6730 Greensboro-Winston-Salem-High Point, NC...................... 18.1974 Greenville, NC............................................... 17.7503 Greenville-Spartanburg-Anderson, SC.......................... 17.4547 Hagerstown, MD............................................... 17.9394 Hamilton-Middletown, OH...................................... 18.5631 Harrisburg-Lebanon-Carlisle, PA.............................. 19.8630 Hartford, CT................................................. 24.1823 Hattiesburg, MS.............................................. 14.1809 Hickory-Morganton-Lenoir, NC................................. 16.8672 Honolulu, HI................................................. 22.4099 Houma, LA.................................................... 15.3009 Houston, TX.................................................. 19.1004 Huntington-Ashland, WV-KY-OH................................. 17.9378 Huntsville, AL............................................... 15.8903 Indianapolis, IN............................................. 19.4109 Iowa City, IA................................................ 18.3037 Jackson, MI.................................................. 17.6864 Jackson, MS.................................................. 15.3259 Jackson, TN.................................................. 16.2704 Jacksonville, FL............................................. 17.5917 Jacksonville, NC............................................. 13.7955 Jamestown, NY................................................ 14.9815 Janesville-Beloit, WI........................................ 16.9030 Jersey City, NJ.............................................. 22.2562 Johnson City-Kingsport-Bristol, TN-VA........................ 17.3717 Johnstown, PA................................................ 16.4213 Joplin, MO................................................... 14.3989 Kalamazoo-Battlecreek, MI.................................... 20.6127 Kankakee, IL................................................. 17.5542 Kansas City, KS-MO........................................... 18.5772 Kenosha, WI.................................................. 17.8819 Killeen-Temple, TX........................................... 20.3189 Knoxville, TN................................................ 16.6222 Kokomo, IN................................................... 16.7962 La Crosse, WI-MN............................................. 16.8513 Lafayette, LA................................................ 15.9607 Lafayette, IN................................................ 17.1635 Lake Charles, LA............................................. 15.7084 Lakeland-Winter Haven, FL.................................... 17.1559 Lancaster, PA................................................ 18.7384 Lansing-East Lansing, MI..................................... 19.5408 Laredo, TX................................................... 13.8360 Las Cruces, NM............................................... 16.6145 [[Page 27530]] Las Vegas, NV-AZ............................................. 21.2545 Lawrence, KS................................................. 16.8098 Lawton, OK................................................... 16.2681 Lewiston-Auburn, ME.......................................... 18.3998 Lexington, KY................................................ 16.3501 Lima, OH..................................................... 17.0746 Lincoln, NE.................................................. 17.9352 Little Rock-North Little Rock, AR............................ 16.8095 Longview-Marshall, TX........................................ 16.8433 Los Angeles-Long Beach, CA................................... 24.1067 Louisville, KY-IN............................................ 18.4271 Lubbock, TX.................................................. 16.6316 Lynchburg, VA................................................ 15.6776 Macon, GA.................................................... 17.2388 Madison, WI.................................................. 19.6027 Mansfield, OH................................................ 16.6677 Mayaguez, PR................................................. 8.1673 McAllen-Edinburg-Mission, TX................................. 16.5870 Medford-Ashland, OR.......................................... 19.6857 Melbourne-Titusville-Palm Bay, FL............................ 17.7314 Memphis, TN-AR-MS............................................ 15.9681 Merced, CA................................................... 20.8439 Miami, FL.................................................... 19.3734 Middlesex-Somerset-Hunterdon, NJ............................. 21.0732 Milwaukee-Waukesha, WI....................................... 18.8591 Minneapolis-St. Paul, MN-WI.................................. 21.0411 Mobile, AL................................................... 15.6052 Modesto, CA.................................................. 20.7262 Monmouth-Ocean, NJ........................................... 21.1523 Monroe, LA................................................... 16.0633 Montgomery, AL............................................... 15.5087 Muncie, IN................................................... 18.9936 Myrtle Beach, SC............................................. 15.2138 Naples, FL................................................... 19.9423 Nashville, TN................................................ 17.6844 Nassau-Suffolk, NY........................................... 26.4295 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 24.8405 New London-Norwich, CT....................................... 23.9754 New Orleans, LA.............................................. 18.4047 New York, NY................................................. 27.3928 Newark, NJ................................................... 22.9650 Newburgh, NY-PA.............................................. 21.1274 Norfolk-Virginia Beach-Newport News, VA-NC................... 16.2433 Oakland, CA.................................................. 29.3295 Ocala, FL.................................................... 17.5573 Odessa-Midland, TX........................................... 16.5854 Oklahoma City, OK............................................ 16.5112 Olympia, WA.................................................. 20.9003 Omaha, NE-IA................................................. 18.3867 Orange County, CA............................................ 23.3969 Orlando, FL.................................................. 18.5157 Owensboro, KY................................................ 14.7838 Panama City, FL.............................................. 15.7629 Parkersburg-Marietta, WV-OH.................................. 15.4018 Pensacola, FL................................................ 16.0203 Peoria-Pekin, IL............................................. 17.4092 Philadelphia, PA-NJ.......................................... 21.8450 Phoenix-Mesa, AZ............................................. 19.1821 Pine Bluff, AR............................................... 15.4205 Pittsburgh, PA............................................... 18.9757 Pittsfield, MA............................................... 20.6216 Ponce, PR.................................................... 8.7784 Portland, ME................................................. 18.7580 Portland-Vancouver, OR-WA.................................... 21.9821 Providence-Warwick, RI....................................... 21.6876 Provo-Orem, UT............................................... 19.7809 Pueblo, CO................................................... 16.1970 Punta Gorda, FL.............................................. 16.1612 Racine, WI................................................... 17.2751 Raleigh-Durham-Chapel Hill, NC............................... 19.0031 Rapid City, SD............................................... 16.5325 Reading, PA.................................................. 18.4690 Redding, CA.................................................. 22.6922 Reno, NV..................................................... 21.5443 Richland-Kennewick-Pasco, WA................................. 19.4956 Richmond-Petersburg, VA...................................... 17.9271 Riverside-San Bernardino, CA................................. 22.2324 Roanoke, VA.................................................. 17.0151 Rochester, MN................................................ 20.3908 Rochester, NY................................................ 18.7505 Rockford, IL................................................. 17.5872 Rocky Mount, NC.............................................. 17.4626 Sacramento, CA............................................... 24.1558 Saginaw-Bay City-Midland, MI................................. 18.5818 St. Cloud, MN................................................ 18.4907 St. Joseph, MO............................................... 16.7196 St. Louis, MO-IL............................................. 17.4144 Salem, OR.................................................... 19.0205 Salinas, CA.................................................. 26.9904 Salt Lake City-Ogden, UT..................................... 18.8799 San Angelo, TX............................................... 14.8158 San Antonio, TX.............................................. 16.3206 San Diego, CA................................................ 23.7299 San Francisco, CA............................................ 27.8220 San Jose, CA................................................. 28.2911 San Juan-Bayamon, PR......................................... 9.0059 San Luis Obispo-Atascadero-Paso Robles, CA................... 22.6053 Santa Barbara-Santa Maria-Lompoc, CA......................... 21.9816 Santa Cruz-Watsonville, CA................................... 26.4364 Santa Fe, NM................................................. 21.1622 Santa Rosa, CA............................................... 24.4999 Sarasota-Bradenton, FL....................................... 19.0607 Savannah, GA................................................. 19.6834 Scranton-Wilkes Barre-Hazleton, PA........................... 17.1047 Seattle-Bellevue-Everett, WA................................. 22.2595 Sharon, PA................................................... 17.0979 Sheboygan, WI................................................ 15.1817 Sherman-Denison, TX.......................................... 16.8423 Shreveport-Bossier City, LA.................................. 18.2987 Sioux City, IA-NE............................................ 16.2539 Sioux Falls, SD.............................................. 16.7892 South Bend, IN............................................... 19.4248 Spokane, WA.................................................. 20.5788 Springfield, IL.............................................. 17.1355 Springfield, MO.............................................. 15.2957 Springfield, MA.............................................. 20.6983 State College, PA............................................ 17.3139 Steubenville-Weirton, OH-WV.................................. 16.0839 Stockton-Lodi, CA............................................ 22.1532 Sumter, SC................................................... 15.0540 Syracuse, NY................................................. 18.3462 Tacoma, WA................................................... 21.2353 Tallahassee, FL.............................................. 16.2555 Tampa-St. Petersburg-Clearwater, FL.......................... 18.0837 Terre Haute, IN.............................................. 16.7989 Texarkana, AR-Texarkana, TX.................................. 16.5261 Toledo, OH................................................... 20.2562 Topeka, KS................................................... 19.7210 Trenton, NJ.................................................. 20.6250 Tucson, AZ................................................... 17.6383 Tulsa, OK.................................................... 15.8281 Tuscaloosa, AL............................................... 15.0679 Tyler, TX.................................................... 19.8177 Utica-Rome, NY............................................... 16.4296 Vallejo-Fairfield-Napa, CA................................... 27.2883 Ventura, CA.................................................. 22.5369 Victoria, TX................................................. 16.5405 Vineland-Millville-Bridgeton, NJ............................. 19.5394 Visalia-Tulare-Porterville, CA............................... 19.8483 Waco, TX..................................................... 15.1959 Washington, DC-MD-VA-WV...................................... 21.1518 Waterloo-Cedar Falls, IA..................................... 17.0208 Wausau, WI................................................... 20.1856 West Palm Beach-Boca Raton, FL............................... 19.9482 Wheeling, OH-WV.............................................. 14.7877 Wichita, KS.................................................. 18.4305 Wichita Falls, TX............................................ 15.7442 Williamsport, PA............................................. 16.5567 Wilmington-Newark, DE-MD..................................... 22.1249 Wilmington, NC............................................... 17.6987 Yakima, WA................................................... 19.6049 Yolo, CA..................................................... 22.3769 York, PA..................................................... 17.8006 Youngstown-Warren, OH........................................ 19.0484 Yuba City, CA................................................ 20.3622 Yuma, AZ..................................................... 18.5693 ------------------------------------------------------------------------ Table 4e.--Average Hourly Wage for Rural Areas ------------------------------------------------------------------------ Average Nonurban area hourly wage ------------------------------------------------------------------------ Alabama...................................................... 13.9126 Alaska....................................................... 24.3314 Arizona...................................................... 15.5017 Arkansas..................................................... 13.6566 California................................................... 19.4927 Colorado..................................................... 15.9126 Connecticut.................................................. 24.9480 Delaware..................................................... 18.4636 Florida...................................................... 16.9290 Georgia...................................................... 14.9414 Hawaii....................................................... 20.0330 Idaho........................................................ 16.3016 Illinois..................................................... 14.7630 Indiana...................................................... 15.8402 Iowa......................................................... 14.4246 Kansas....................................................... 13.8771 Kentucky..................................................... 15.1633 Louisiana.................................................... 14.1714 Maine........................................................ 16.2618 Maryland..................................................... 16.4778 Massachusetts................................................ 21.0582 Michigan..................................................... 17.2254 Minnesota.................................................... 15.9225 Mississippi.................................................. 13.2817 Missouri..................................................... 14.1433 Montana...................................................... 15.8750 Nebraska..................................................... 14.1342 Nevada....................................................... 17.1588 New Hampshire................................................ 19.0608 New Jersey \1\............................................... ......... New Mexico................................................... 15.3596 New York..................................................... 16.7103 North Carolina............................................... 15.4962 North Dakota................................................. 14.3775 Ohio......................................................... 16.2883 [[Page 27531]] Oklahoma..................................................... 13.5853 Oregon....................................................... 18.9527 Pennsylvania................................................. 16.5230 Puerto Rico.................................................. 8.1591 Rhode Island \1\............................................. ......... South Carolina............................................... 14.9812 South Dakota................................................. 13.8219 Tennessee.................................................... 14.3822 Texas........................................................ 14.4957 Utah......................................................... 17.2737 Vermont...................................................... 17.4440 Virginia..................................................... 15.1073 Washington................................................... 19.4229 West Virginia................................................ 15.4577 Wisconsin.................................................... 16.4842 Wyoming...................................................... 16.0015 ------------------------------------------------------------------------ \1\ All counties within the State are classified as 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 3.0445 7.7 11.1 32 EXCEPT FOR TRAUMA. 2........... 01 SURG CRANIOTOMY FOR TRAUMA 3.0241 8.4 11.5 32 AGE >17. 3........... 01 SURG *CRANIOTOMY AGE 0-17... 1.9159 12.7 12.7 37 4........... 01 SURG SPINAL PROCEDURES..... 2.3330 5.9 9.1 30 5........... 01 SURG EXTRACRANIAL VASCULAR 1.5149 3.3 4.4 26 PROCEDURES. 6........... 01 SURG CARPAL TUNNEL RELEASE. .7359 2.4 3.4 25 7........... 01 SURG PERIPH & CRANIAL NERVE 2.4935 8.2 12.6 32 & OTHER NERV SYST PROC W CC. 8........... 01 SURG PERIPH & CRANIAL NERVE 1.1419 2.8 4.1 27 & OTHER NERV SYST PROC W/O CC. 9........... 01 MED SPINAL DISORDERS & 1.2522 5.4 7.7 29 INJURIES. 10.......... 01 MED NERVOUS SYSTEM 1.2209 5.7 8.1 30 NEOPLASMS W CC. 11.......... 01 MED NERVOUS SYSTEM .8020 3.5 5.0 28 NEOPLASMS W/O CC. 12.......... 01 MED DEGENERATIVE NERVOUS .9435 5.4 7.6 29 SYSTEM DISORDERS. 13.......... 01 MED MULTIPLE SCLEROSIS & .7799 5.0 6.3 29 CEREBELLAR ATAXIA. 14.......... 01 MED SPECIFIC 1.2003 5.5 7.5 30 CEREBROVASCULAR DISORDERS EXCEPT TIA. 15.......... 01 MED TRANSIENT ISCHEMIC .7232 3.5 4.4 27 ATTACK & PRECEREBRAL OCCLUSIONS. 16.......... 01 MED NONSPECIFIC 1.0390 4.9 6.6 29 CEREBROVASCULAR DISORDERS W CC. 17.......... 01 MED NONSPECIFIC .6308 3.0 4.0 26 CEREBROVASCULAR DISORDERS W/O CC. 18.......... 01 MED CRANIAL & PERIPHERAL .9345 4.8 6.4 29 NERVE DISORDERS W CC. 19.......... 01 MED CRANIAL & PERIPHERAL .6258 3.4 4.5 27 NERVE DISORDERS W/O CC. 20.......... 01 MED NERVOUS SYSTEM 2.4782 8.5 11.5 33 INFECTION EXCEPT VIRAL MENINGITIS. 21.......... 01 MED VIRAL MENINGITIS...... 1.4972 5.8 7.9 30 22.......... 01 MED HYPERTENSIVE .8356 3.8 4.9 28 ENCEPHALOPATHY. 23.......... 01 MED NONTRAUMATIC STUPOR & .8053 3.6 5.1 28 COMA. 24.......... 01 MED SEIZURE & HEADACHE AGE .9707 4.2 5.8 28 >17 W CC. 25.......... 01 MED SEIZURE & HEADACHE AGE .5791 3.0 3.9 24 >17 W/O CC. 26.......... 01 MED SEIZURE & HEADACHE AGE .7381 3.3 4.6 27 0-17. 27.......... 01 MED TRAUMATIC STUPOR & 1.3186 3.7 6.3 28 COMA, COMA >1 HR. 28.......... 01 MED TRAUMATIC STUPOR & 1.2075 4.8 7.2 29 COMA, COMA <1 HR AGE >17 W CC. 29.......... 01 MED TRAUMATIC STUPOR & .6382 3.0 4.1 27 COMA, COMA <1 HR AGE >17 W/O CC. 30.......... 01 MED *TRAUMATIC STUPOR & .3240 2.0 2.0 17 COMA, COMA <1 HR AGE 0- 17. 31.......... 01 MED CONCUSSION AGE >17 W .8367 3.7 5.4 28 CC. 32.......... 01 MED CONCUSSION AGE >17 W/O .4887 2.3 3.2 21 CC. 33.......... 01 MED *CONCUSSION AGE 0-17... .2036 1.6 1.6 9 34.......... 01 MED OTHER DISORDERS OF 1.0639 4.6 6.5 29 NERVOUS SYSTEM W CC. 35.......... 01 MED OTHER DISORDERS OF .6112 3.2 4.3 27 NERVOUS SYSTEM. W/O CC................. 36.......... 02 SURG RETINAL PROCEDURES.... .6156 1.3 1.6 6 37.......... 02 SURG ORBITAL PROCEDURES.... .9280 2.7 4.0 27 38.......... 02 SURG PRIMARY IRIS .4217 1.8 2.5 16 PROCEDURES. 39.......... 02 SURG LENS PROCEDURES WITH .5162 1.5 2.0 10 OR WITHOUT VITRECTOMY. 40.......... 02 SURG EXTRAOCULAR PROCEDURES .7094 2.2 3.4 26 EXCEPT ORBIT AGE >17. 41.......... 02 SURG *EXTRAOCULAR PROCEDURES .3298 1.6 1.6 7 EXCEPT ORBIT AGE 0-17. 42.......... 02 SURG INTRAOCULAR PROCEDURES .5821 1.6 2.2 13 EXCEPT RETINA, IRIS & LENS. 43.......... 02 MED HYPHEMA............... .4448 3.2 4.1 27 [[Page 27532]] 44.......... 02 MED ACUTE MAJOR EYE .6234 4.7 5.7 29 INFECTIONS. 45.......... 02 MED NEUROLOGICAL EYE .6514 3.1 3.8 22 DISORDERS. 46.......... 02 MED OTHER DISORDERS OF THE .7595 4.0 5.5 28 EYE AGE >17 W CC. 47.......... 02 MED OTHER DISORDERS OF THE .4703 2.8 3.8 27 EYE AGE >17 W/O CC. 48.......... 02 MED *OTHER DISORDERS OF THE .2906 2.9 2.9 27 EYE AGE 0-17. 49.......... 03 SURG MAJOR HEAD & NECK 1.7253 4.1 5.6 28 PROCEDURES. 50.......... 03 SURG SIALOADENECTOMY....... .7677 1.7 2.1 9 51.......... 03 SURG SALIVARY GLAND .7358 1.9 3.0 21 PROCEDURES EXCEPT SIALOADENECTOMY. 52.......... 03 SURG CLEFT LIP & PALATE 1.0971 2.1 3.6 26 REPAIR. 53.......... 03 SURG SINUS & MASTOID 1.0116 2.2 3.6 26 PROCEDURES AGE >17. 54.......... 03 SURG *SINUS & MASTOID .4711 3.2 3.2 22 PROCEDURES AGE 0-17. 55.......... 03 SURG MISCELLANEOUS EAR, .7844 1.9 3.0 22 NOSE, MOUTH & THROAT PROCEDURES. 56.......... 03 SURG RHINOPLASTY........... .8247 2.1 2.8 18 57.......... 03 SURG T&A PROC, EXCEPT .9413 2.7 4.1 27 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17. 58.......... 03 SURG *T&A PROC, EXCEPT .2674 1.5 1.5 4 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17. 59.......... 03 SURG TONSILLECTOMY &/OR .7521 2.3 3.7 26 ADENOIDECTOMY ONLY, AGE >17. 60.......... 03 SURG *TONSILLECTOMY &/OR .2037 1.5 1.5 4 ADENOIDECTOMY ONLY, AGE 0-17. 61.......... 03 SURG MYRINGOTOMY W TUBE 1.2155 2.7 5.3 27 INSERTION AGE >17. 62.......... 03 SURG *MYRINGOTOMY W TUBE .2884 1.3 1.3 5 INSERTION AGE 0-17. 63.......... 03 SURG OTHER EAR, NOSE, MOUTH 1.2217 3.2 4.7 27 & THROAT O.R. PROCEDURES. 64.......... 03 MED EAR, NOSE, MOUTH & 1.1699 4.7 7.5 29 THROAT MALIGNANCY. 65.......... 03 MED DYSEQUILIBRIUM........ .5192 2.7 3.4 20 66.......... 03 MED EPISTAXIS............. .5358 2.9 3.6 21 67.......... 03 MED EPIGLOTTITIS.......... .8452 3.4 4.2 24 68.......... 03 MED OTITIS MEDIA & URI AGE .7075 3.8 4.8 27 >17 W CC. 69.......... 03 MED OTITIS MEDIA & URI AGE .5244 3.1 3.8 20 >17 W/O CC. 70.......... 03 MED OTITIS MEDIA & URI AGE .3839 2.6 3.1 15 0-17. 71.......... 03 MED LARYNGOTRACHEITIS..... .7959 3.1 4.2 27 72.......... 03 MED NASAL TRAUMA & .6466 3.1 4.4 27 DEFORMITY. 73.......... 03 MED OTHER EAR, NOSE, MOUTH .7483 3.7 5.0 28 & THROAT DIAGNOSES AGE >17. 74.......... 03 MED *OTHER EAR, NOSE, MOUTH .3276 2.1 2.1 20 & THROAT DIAGNOSES AGE 0-17. 75.......... 04 SURG MAJOR CHEST PROCEDURES 3.1904 8.8 11.1 33 76.......... 04 SURG OTHER RESP SYSTEM O.R. 2.6018 9.1 12.5 33 PROCEDURES W CC. 77.......... 04 SURG OTHER RESP SYSTEM O.R. 1.1577 3.8 5.5 28 PROCEDURES W/O CC. 78.......... 04 MED PULMONARY EMBOLISM.... 1.4291 7.0 8.3 31 79.......... 04 MED RESPIRATORY INFECTIONS 1.6310 7.2 9.3 31 & INFLAMMATIONS AGE >17 W CC. 80.......... 04 MED RESPIRATORY INFECTIONS .9481 5.4 6.6 29 & INFLAMMATIONS AGE >17 W/O CC. 81.......... 04 MED *RESPIRATORY INFECTIONS .9716 6.1 6.1 30 & INFLAMMATIONS AGE 0- 17. 82.......... 04 MED RESPIRATORY NEOPLASMS. 1.3347 5.7 7.9 30 83.......... 04 MED MAJOR CHEST TRAUMA W .9738 4.9 6.4 29 CC. 84.......... 04 MED MAJOR CHEST TRAUMA W/O .5335 2.9 3.7 24 CC. 85.......... 04 MED PLEURAL EFFUSION W CC. 1.2229 5.6 7.4 30 86.......... 04 MED PLEURAL EFFUSION W/O .7175 3.4 4.5 27 CC. 87.......... 04 MED PULMONARY EDEMA & 1.3587 5.1 6.8 29 RESPIRATORY FAILURE. 88.......... 04 MED CHRONIC OBSTRUCTIVE .9831 4.9 6.1 29 PULMONARY DISEASE. 89.......... 04 MED SIMPLE PNEUMONIA & 1.1158 5.8 7.1 30 PLEURISY AGE >17 W CC. 90.......... 04 MED SIMPLE PNEUMONIA & .6995 4.3 5.1 24 PLEURISY AGE >17 W/O CC. 91.......... 04 MED SIMPLE PNEUMONIA & .7883 3.7 4.7 28 PLEURISY AGE 0-17. 92.......... 04 MED INTERSTITIAL LUNG 1.2053 5.6 7.3 30 DISEASE W CC. 93.......... 04 MED INTERSTITIAL LUNG .7551 4.0 5.0 28 DISEASE W/O CC. 94.......... 04 MED PNEUMOTHORAX W CC..... 1.1764 5.3 7.1 29 95.......... 04 MED PNEUMOTHORAX W/O CC... .6035 3.3 4.1 25 96.......... 04 MED BRONCHITIS & ASTHMA .8254 4.5 5.5 29 AGE >17 W CC. 97.......... 04 MED BRONCHITIS & ASTHMA .6013 3.6 4.3 22 AGE >17 W/O CC. 98.......... 04 MED BRONCHITIS & ASTHMA .8036 3.1 4.5 27 AGE 0-17. 99.......... 04 MED RESPIRATORY SIGNS & .6868 2.7 3.5 22 SYMPTOMS W CC. 100......... 04 MED RESPIRATORY SIGNS & .5126 2.0 2.4 12 SYMPTOMS W/O CC. 101......... 04 MED OTHER RESPIRATORY .8735 3.8 5.2 28 SYSTEM DIAGNOSES W CC. [[Page 27533]] 102......... 04 MED OTHER RESPIRATORY .5330 2.4 3.1 20 SYSTEM DIAGNOSES W/O CC. 103......... 05 SURG HEART TRANSPLANT...... 15.2952 28.1 39.4 52 104......... 05 SURG CARDIAC VALVE 7.3389 12.0 14.6 36 PROCEDURES W CARDIAC CATH. 105......... 05 SURG CARDIAC VALVE 5.6012 9.0 10.9 33 PROCEDURES W/O CARDIAC CATH. 106......... 05 SURG CORONARY BYPASS W 5.5599 10.3 11.7 34 CARDIAC CATH. 107......... 05 SURG CORONARY BYPASS W/O 4.0741 7.8 8.8 32 CARDIAC CATH. 108......... 05 SURG OTHER CARDIOTHORACIC 5.9226 9.8 12.6 34 PROCEDURES. 109......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0 110......... 05 SURG MAJOR CARDIOVASCULAR 4.1674 8.2 10.9 32 PROCEDURES W CC. 111......... 05 SURG MAJOR CARDIOVASCULAR 2.2863 5.9 6.7 30 PROCEDURES W/O CC. 112......... 05 SURG PERCUTANEOUS 2.0962 3.5 4.7 27 CARDIOVASCULAR PROCEDURES. 113......... 05 SURG AMPUTATION FOR CIRC 2.6919 10.6 14.4 35 SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE. 114......... 05 SURG UPPER LIMB & TOE 1.5122 6.8 9.5 31 AMPUTATION FOR CIRC SYSTEM DISORDERS. 115......... 05 SURG PERM CARDIAC PACEMAKER 3.6844 9.1 11.4 33 IMPLANT W AMI, HEART FAILURE OR SHOCK. 116......... 05 SURG OTH PERM CARDIAC 2.4158 3.9 5.4 28 PACEMAKER IMPLANT OR AICD LEAD OR GENERATOR PROC. 117......... 05 SURG CARDIAC PACEMAKER 1.1774 2.7 4.1 27 REVISION EXCEPT DEVICE REPLACEMENT. 118......... 05 SURG CARDIAC PACEMAKER 1.5782 2.1 3.2 25 DEVICE REPLACEMENT. 119......... 05 SURG VEIN LIGATION & 1.1378 3.3 5.5 27 STRIPPING. 120......... 05 SURG OTHER CIRCULATORY 1.9321 5.4 9.2 29 SYSTEM O.R. PROCEDURES. 121......... 05 MED CIRCULATORY DISORDERS 1.6473 6.4 7.8 30 W AMI & C.V. COMP DISCH ALIVE. 122......... 05 MED CIRCULATORY DISORDERS 1.1617 4.4 5.3 28 W AMI W/O C.V. COMP DISCH ALIVE. 123......... 05 MED CIRCULATORY DISORDERS 1.4519 2.7 4.7 27 W AMI, EXPIRED. 124......... 05 MED CIRCULATORY DISORDERS 1.3264 3.8 5.0 28 EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125......... 05 MED CIRCULATORY DISORDERS .9259 2.3 3.1 20 EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG. 126......... 05 MED ACUTE & SUBACUTE 2.5380 11.0 14.3 35 ENDOCARDITIS. 127......... 05 MED HEART FAILURE & SHOCK. 1.0268 4.8 6.2 29 128......... 05 MED DEEP VEIN .7861 5.9 6.7 27 THROMBOPHLEBITIS. 129......... 05 MED CARDIAC ARREST, 1.1239 2.0 3.4 26 UNEXPLAINED. 130......... 05 MED PERIPHERAL VASCULAR .9357 5.3 6.7 29 DISORDERS W CC. 131......... 05 MED PERIPHERAL VASCULAR .6045 4.3 5.2 28 DISORDERS W/O CC. 132......... 05 MED ATHEROSCLEROSIS W CC.. .6834 2.9 3.6 20 133......... 05 MED ATHEROSCLEROSIS W/O CC .5543 2.3 2.9 16 134......... 05 MED HYPERTENSION.......... .5799 3.0 3.9 23 135......... 05 MED CARDIAC CONGENITAL & .8797 3.7 5.0 28 VALVULAR DISORDERS AGE >17 W CC. 136......... 05 MED CARDIAC CONGENITAL & .5597 2.6 3.2 18 VALVULAR DISORDERS AGE >17 W/O CC. 137......... 05 MED *CARDIAC CONGENITAL & .7996 3.3 3.3 27 VALVULAR DISORDERS AGE 0-17. 138......... 05 MED CARDIAC ARRHYTHMIA & .8009 3.5 4.6 27 CONDUCTION DISORDERS W CC. 139......... 05 MED CARDIAC ARRHYTHMIA & .4975 2.4 2.9 16 CONDUCTION DISORDERS W/ O CC. 140......... 05 MED ANGINA PECTORIS....... .6210 2.8 3.5 20 141......... 05 MED SYNCOPE & COLLAPSE W .7129 3.4 4.5 27 CC. 142......... 05 MED SYNCOPE & COLLAPSE W/O .5289 2.5 3.2 18 CC. 143......... 05 MED CHEST PAIN............ .5233 2.1 2.6 14 144......... 05 MED OTHER CIRCULATORY 1.0850 4.1 5.7 28 SYSTEM DIAGNOSES W CC. 145......... 05 MED OTHER CIRCULATORY .6217 2.5 3.3 20 SYSTEM DIAGNOSES W/O CC. 146......... 06 SURG RECTAL RESECTION W CC. 2.6401 9.8 11.3 34 147......... 06 SURG RECTAL RESECTION W/O 1.6115 6.7 7.4 27 CC. 148......... 06 SURG MAJOR SMALL & LARGE 3.3693 11.2 13.4 35 BOWEL PROCEDURES W CC. 149......... 06 SURG MAJOR SMALL & LARGE 1.6038 7.1 7.7 25 BOWEL PROCEDURES W/O CC. 150......... 06 SURG PERITONEAL 2.6786 9.5 11.7 34 ADHESIOLYSIS W CC. 151......... 06 SURG PERITONEAL 1.2959 5.2 6.5 29 ADHESIOLYSIS W/O CC. 152......... 06 SURG MINOR SMALL & LARGE 1.9381 7.6 9.0 32 BOWEL PROCEDURES W CC. 153......... 06 SURG MINOR SMALL & LARGE 1.1550 5.6 6.2 24 BOWEL PROCEDURES W/O CC. 154......... 06 SURG STOMACH, ESOPHAGEAL & 4.1880 11.6 15.0 36 DUODENAL PROCEDURES AGE >17 W CC. [[Page 27534]] 155......... 06 SURG STOMACH, ESOPHAGEAL & 1.4070 4.6 5.9 29 DUODENAL PROCEDURES AGE >17 W/O CC. 156......... 06 SURG *STOMACH, ESOPHAGEAL & .8235 6.0 6.0 30 DUODENAL PROCEDURES AGE 0-17. 157......... 06 SURG ANAL & STOMAL 1.1331 4.2 5.8 28 PROCEDURES W CC. 158......... 06 SURG ANAL & STOMAL .6106 2.3 2.9 18 PROCEDURES W/O CC. 159......... 06 SURG HERNIA PROCEDURES 1.2263 4.0 5.3 28 EXCEPT INGUINAL & FEMORAL AGE >17 W CC. 160......... 06 SURG HERNIA PROCEDURES .7032 2.4 3.0 16 EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC. 161......... 06 SURG INGUINAL & FEMORAL 1.0089 3.0 4.4 27 HERNIA PROCEDURES AGE >17 W CC. 162......... 06 SURG INGUINAL & FEMORAL .5710 1.7 2.2 11 HERNIA PROCEDURES AGE >17 W/O CC. 163......... 06 SURG *HERNIA PROCEDURES AGE .7703 2.1 2.1 11 0-17. 164......... 06 SURG APPENDECTOMY W 2.3299 8.0 9.3 32 COMPLICATED PRINCIPAL DIAG W CC. 165......... 06 SURG APPENDECTOMY W 1.2576 5.1 5.8 25 COMPLICATED PRINCIPAL DIAG W/O CC. 166......... 06 SURG APPENDECTOMY W/O 1.4512 4.5 5.7 29 COMPLICATED PRINCIPAL DIAG W CC. 167......... 06 SURG APPENDECTOMY W/O .8496 2.8 3.2 15 COMPLICATED PRINCIPAL DIAG W/O CC. 168......... 03 SURG MOUTH PROCEDURES W CC. 1.0951 3.2 4.9 27 169......... 03 SURG MOUTH PROCEDURES W/O .6828 2.0 2.6 15 CC. 170......... 06 SURG OTHER DIGESTIVE SYSTEM 2.7448 8.5 12.5 33 O.R. PROCEDURES W CC. 171......... 06 SURG OTHER DIGESTIVE SYSTEM 1.1297 4.0 5.4 28 O.R. PROCEDURES W/O CC. 172......... 06 MED DIGESTIVE MALIGNANCY W 1.2934 5.7 8.2 30 CC. 173......... 06 MED DIGESTIVE MALIGNANCY W/ .6736 3.0 4.3 27 O CC. 174......... 06 MED G.I. HEMORRHAGE W CC.. .9962 4.4 5.6 28 175......... 06 MED G.I. HEMORRHAGE W/O CC .5492 2.9 3.5 17 176......... 06 MED COMPLICATED PEPTIC 1.0874 4.7 6.2 29 ULCER. 177......... 06 MED UNCOMPLICATED PEPTIC .8353 4.0 5.0 28 ULCER W CC. 178......... 06 MED UNCOMPLICATED PEPTIC .6122 3.0 3.6 19 ULCER W/O CC. 179......... 06 MED INFLAMMATORY BOWEL 1.1219 5.5 7.2 30 DISEASE. 180......... 06 MED G.I. OBSTRUCTION W CC. .9202 4.7 6.1 29 181......... 06 MED G.I. OBSTRUCTION W/O .5346 3.3 4.0 22 CC. 182......... 06 MED ESOPHAGITIS, GASTROENT .7791 3.8 5.0 28 & MISC DIGEST DISORDERS AGE >17 W CC. 183......... 06 MED ESOPHAGITIS, GASTROENT .5570 2.8 3.5 20 & MISC DIGEST DISORDERS AGE >17 W/O CC. 184......... 06 MED ESOPHAGITIS, GASTROENT .5366 2.7 3.8 26 & MISC DIGEST DISORDERS AGE 0-17. 185......... 03 MED DENTAL & ORAL DIS .8467 3.7 5.2 28 EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17. 186......... 03 MED *DENTAL & ORAL DIS .3139 2.9 2.9 23 EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17. 187......... 03 MED DENTAL EXTRACTIONS & .7211 3.1 4.3 27 RESTORATIONS. 188......... 06 MED OTHER DIGESTIVE SYSTEM 1.0593 4.5 6.1 28 DIAGNOSES AGE >17 W CC. 189......... 06 MED OTHER DIGESTIVE SYSTEM .5629 2.7 3.7 27 DIAGNOSES AGE >17 W/O CC. 190......... 06 MED OTHER DIGESTIVE SYSTEM .8364 3.9 4.9 28 DIAGNOSES AGE 0-17. 191......... 07 SURG PANCREAS, LIVER & 4.4227 12.0 16.2 36 SHUNT PROCEDURES W CC. 192......... 07 SURG PANCREAS, LIVER & 1.8016 6.2 8.0 30 SHUNT PROCEDURES W/O CC. 193......... 07 SURG BILIARY TRACT PROC 3.2582 11.4 13.9 35 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC. 194......... 07 SURG BILIARY TRACT PROC 1.7596 6.8 8.4 31 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195......... 07 SURG CHOLECYSTECTOMY W 2.6806 8.8 10.5 33 C.D.E. W CC. 196......... 07 SURG CHOLECYSTECTOMY W 1.6252 5.9 6.8 30 C.D.E. W/O CC. 197......... 07 SURG CHOLECYSTECTOMY EXCEPT 2.2636 7.5 9.1 31 BY LAPAROSCOPE W/O C.D.E. W CC. 198......... 07 SURG CHOLECYSTECTOMY EXCEPT 1.1769 4.3 5.0 23 BY LAPAROSCOPE W/O C.D.E. W/O CC. 199......... 07 SURG HEPATOBILIARY 2.3744 8.3 11.1 32 DIAGNOSTIC PROCEDURE FOR MALIGNANCY. 200......... 07 SURG HEPATOBILIARY 2.9783 7.6 11.9 32 DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY. [[Page 27535]] 201......... 07 SURG OTHER HEPATOBILIARY OR 3.6216 12.1 16.6 36 PANCREAS O.R. PROCEDURES. 202......... 07 MED CIRRHOSIS & ALCOHOLIC 1.3286 5.7 7.7 30 HEPATITIS. 203......... 07 MED MALIGNANCY OF 1.2511 5.5 7.7 30 HEPATOBILIARY SYSTEM OR PANCREAS. 204......... 07 MED DISORDERS OF PANCREAS 1.2003 5.1 6.7 29 EXCEPT MALIGNANCY. 205......... 07 MED DISORDERS OF LIVER 1.2099 5.3 7.3 29 EXCEPT MALIG,CIRR,ALC HEPA W CC. 206......... 07 MED DISORDERS OF LIVER .7211 3.6 4.8 28 EXCEPT MALIG,CIRR,ALC HEPA W/O CC. 207......... 07 MED DISORDERS OF THE 1.0500 4.4 5.8 28 BILIARY TRACT W CC. 208......... 07 MED DISORDERS OF THE .6053 2.6 3.5 21 BILIARY TRACT W/O CC. 209......... 08 SURG MAJOR JOINT & LIMB 2.2617 5.9 6.7 23 REATTACHMENT PROCEDURES OF LOWER EXTREMITY. 210......... 08 SURG HIP & FEMUR PROCEDURES 1.8458 7.2 8.5 31 EXCEPT MAJOR JOINT AGE >17 W CC. 211......... 08 SURG HIP & FEMUR PROCEDURES 1.2747 5.6 6.3 23 EXCEPT MAJOR JOINT AGE >17 W/O CC. 212......... 08 SURG *HIP & FEMUR PROCEDURES 1.1483 11.1 11.1 35 EXCEPT MAJOR JOINT AGE 0-17. 213......... 08 SURG AMPUTATION FOR 1.7045 7.0 9.6 31 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 214......... 08 SURG BACK & NECK PROCEDURES 1.9259 4.9 6.5 29 W CC. 215......... 08 SURG BACK & NECK PROCEDURES 1.1135 3.0 3.7 20 W/O CC. 216......... 08 SURG BIOPSIES OF 2.0775 7.9 11.1 32 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 217......... 08 SURG WND DEBRID & SKN GRFT 2.8715 10.2 15.3 34 EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS. 218......... 08 SURG LOWER EXTREM & HUMER 1.4562 4.8 6.2 29 PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W CC. 219......... 08 SURG LOWER EXTREM & HUMER .9560 3.1 3.8 19 PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W/O CC. 220......... 08 SURG *LOWER EXTREM & HUMER .5704 5.3 5.3 29 PROC EXCEPT HIP, FOOT, FEMUR AGE 0-17. 221......... 08 SURG KNEE PROCEDURES W CC.. 1.8379 5.8 8.2 30 222......... 08 SURG KNEE PROCEDURES W/O CC 1.0223 3.1 4.1 27 223......... 08 SURG MAJOR SHOULDER/ELBOW .8726 2.2 2.9 16 PROC, OR OTHER UPPER EXTREMITY PROC W CC. 224......... 08 SURG SHOULDER,ELBOW OR .7418 1.9 2.3 10 FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC. 225......... 08 SURG FOOT PROCEDURES....... 1.0019 3.3 5.0 27 226......... 08 SURG SOFT TISSUE PROCEDURES 1.3708 4.4 6.7 28 W CC. 227......... 08 SURG SOFT TISSUE PROCEDURES .7458 2.3 3.0 18 W/O CC. 228......... 08 SURG MAJOR THUMB OR JOINT .9381 2.3 3.6 26 PROC, OR OTH HAND OR WRIST PROC W CC. 229......... 08 SURG HAND OR WRIST PROC, .6495 1.8 2.4 14 EXCEPT MAJOR JOINT PROC, W/O CC. 230......... 08 SURG LOCAL EXCISION & 1.0592 3.3 5.2 27 REMOVAL OF INT FIX DEVICES OF HIP & FEMUR. 231......... 08 SURG LOCAL EXCISION & 1.2285 3.3 5.1 27 REMOVAL OF INT FIX DEVICES EXCEPT HIP & FEMUR. 232......... 08 SURG ARTHROSCOPY........... 1.0901 2.6 4.5 27 233......... 08 SURG OTHER MUSCULOSKELET 1.9951 6.4 9.0 30 SYS & CONN TISS O.R. PROC W CC. 234......... 08 SURG OTHER MUSCULOSKELET 1.0684 3.1 4.2 27 SYS & CONN TISS O.R. PROC W/O CC. 235......... 08 MED FRACTURES OF FEMUR.... .8353 4.6 6.9 29 236......... 08 MED FRACTURES OF HIP & .7613 4.7 6.4 29 PELVIS. 237......... 08 MED SPRAINS, STRAINS, & .5622 3.3 4.4 27 DISLOCATIONS OF HIP, PELVIS & THIGH. 238......... 08 MED OSTEOMYELITIS......... 1.3857 7.6 10.1 32 239......... 08 MED PATHOLOGICAL FRACTURES 1.0096 5.8 7.6 30 & MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240......... 08 MED CONNECTIVE TISSUE 1.2107 5.5 7.5 30 DISORDERS W CC. 241......... 08 MED CONNECTIVE TISSUE .6063 3.5 4.6 28 DISORDERS W/O CC. 242......... 08 MED SEPTIC ARTHRITIS...... 1.0535 5.8 7.7 30 243......... 08 MED MEDICAL BACK PROBLEMS. .7241 4.3 5.6 28 244......... 08 MED BONE DISEASES & .7221 4.3 5.8 28 SPECIFIC ARTHROPATHIES W CC. 245......... 08 MED BONE DISEASES & .4965 3.2 4.2 27 SPECIFIC ARTHROPATHIES W/O CC. [[Page 27536]] 246......... 08 MED NON-SPECIFIC .5901 3.6 4.6 28 ARTHROPATHIES. 247......... 08 MED SIGNS & SYMPTOMS OF .5539 2.9 4.0 27 MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248......... 08 MED TENDONITIS, MYOSITIS & .7363 3.9 5.3 28 BURSITIS. 249......... 08 MED AFTERCARE, .6514 2.9 4.3 27 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 250......... 08 MED FX, SPRN, STRN & DISL .6808 3.5 4.9 28 OF FOREARM, HAND, FOOT AGE >17 W CC. 251......... 08 MED FX, SPRN, STRN & DISL .4625 2.5 3.3 22 OF FOREARM, HAND, FOOT AGE >17 W/O CC. 252......... 08 MED *FX, SPRN, STRN & DISL .2478 1.8 1.8 15 OF FOREARM, HAND, FOOT AGE 0-17. 253......... 08 MED FX, SPRN, STRN & DISL .7438 4.3 5.8 28 OF UPARM, LOWLEG EX FOOT AGE >17 W CC. 254......... 08 MED FX, SPRN, STRN & DISL .4433 2.9 3.9 25 OF UPARM, LOWLEG EX FOOT AGE >17 W/O CC. 255......... 08 MED *FX, SPRN, STRN & DISL .2885 2.9 2.9 27 OF UPARM, LOWLEG EX FOOT AGE 0-17. 256......... 08 MED OTHER MUSCULOSKELETAL .7724 4.0 5.7 28 SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257......... 09 SURG TOTAL MASTECTOMY FOR .9021 2.8 3.4 17 MALIGNANCY W CC. 258......... 09 SURG TOTAL MASTECTOMY FOR .7099 2.2 2.5 10 MALIGNANCY W/O CC. 259......... 09 SURG SUBTOTAL MASTECTOMY .8673 2.3 3.5 26 FOR MALIGNANCY W CC. 260......... 09 SURG SUBTOTAL MASTECTOMY .6083 1.6 1.9 8 FOR MALIGNANCY W/O CC. 261......... 09 SURG BREAST PROC FOR NON- .8342 1.9 2.4 12 MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262......... 09 SURG BREAST BIOPSY & LOCAL .7694 2.7 3.9 27 EXCISION FOR NON- MALIGNANCY. 263......... 09 SURG SKIN GRAFT &/OR DEBRID 2.1157 9.8 13.9 34 FOR SKN ULCER OR CELLULITIS W CC. 264......... 09 SURG SKIN GRAFT &/OR DEBRID 1.1308 6.0 8.4 30 FOR SKN ULCER OR CELLULITIS W/O CC. 265......... 09 SURG SKIN GRAFT &/OR DEBRID 1.4949 4.8 7.7 29 EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266......... 09 SURG SKIN GRAFT &/OR DEBRID .7650 2.6 3.7 27 EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267......... 09 SURG PERIANAL & PILONIDAL .8086 2.7 4.1 27 PROCEDURES. 268......... 09 SURG SKIN, SUBCUTANEOUS .9935 2.5 4.0 27 TISSUE & BREAST PLASTIC PROCEDURES. 269......... 09 SURG OTHER SKIN, SUBCUT 1.6361 6.2 9.1 30 TISS & BREAST PROC W CC. 270......... 09 SURG OTHER SKIN, SUBCUT .7016 2.4 3.4 26 TISS & BREAST PROC W/O CC. 271......... 09 MED SKIN ULCERS........... 1.0791 6.6 8.5 31 272......... 09 MED MAJOR SKIN DISORDERS W 1.0212 5.6 7.5 30 CC. 273......... 09 MED MAJOR SKIN DISORDERS W/ .6358 4.1 5.5 28 O CC. 274......... 09 MED MALIGNANT BREAST 1.0713 5.3 7.8 29 DISORDERS W CC. 275......... 09 MED MALIGNANT BREAST .4984 2.5 3.6 27 DISORDERS W/O CC. 276......... 09 MED NON-MALIGANT BREAST .6443 3.9 5.1 28 DISORDERS. 277......... 09 MED CELLULITIS AGE >17 W .8532 5.5 6.7 29 CC. 278......... 09 MED CELLULITIS AGE >17 W/O .5775 4.3 5.1 25 CC. 279......... 09 MED *CELLULITIS AGE 0-17... .7187 4.2 4.2 24 280......... 09 MED TRAUMA TO THE SKIN, .6765 3.7 5.1 28 SUBCUT TISS & BREAST AGE >17 W CC. 281......... 09 MED TRAUMA TO THE SKIN, .4566 2.7 3.7 24 SUBCUT TISS & BREAST AGE >17 W/O CC. 282......... 09 MED *TRAUMA TO THE SKIN, .2508 2.2 2.2 19 SUBCUT TISS & BREAST AGE 0-17. 283......... 09 MED MINOR SKIN DISORDERS W .7034 4.1 5.5 28 CC. 284......... 09 MED MINOR SKIN DISORDERS W/ .4375 2.9 3.9 27 O CC. 285......... 10 SURG AMPUTAT OF LOWER LIMB 2.1948 9.5 13.5 34 FOR ENDOCRINE, NUTRIT, & METABOL DISORDERS. 286......... 10 SURG ADRENAL & PITUITARY 2.3858 6.6 8.7 31 PROCEDURES. 287......... 10 SURG SKIN GRAFTS & WOUND 1.9722 9.4 13.4 33 DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS. 288......... 10 SURG O.R. PROCEDURES FOR 2.0537 5.3 7.0 29 OBESITY. 289......... 10 SURG PARATHYROID PROCEDURES 1.0231 2.7 3.9 27 290......... 10 SURG THYROID PROCEDURES.... .8827 2.1 2.8 15 291......... 10 SURG THYROGLOSSAL .5221 1.4 1.8 8 PROCEDURES. 292......... 10 SURG OTHER ENDOCRINE, 2.6435 8.4 12.7 32 NUTRIT & METAB O.R. PROC W CC. [[Page 27537]] 293......... 10 SURG OTHER ENDOCRINE, 1.2415 4.4 6.4 28 NUTRIT & METAB O.R. PROC W/O CC. 294......... 10 MED DIABETES AGE >35....... .7604 4.3 5.7 28 295......... 10 MED DIABETES AGE 0-35...... .7171 3.3 4.3 27 296......... 10 MED NUTRITIONAL & MISC .8939 4.7 6.4 29 METABOLIC DISORDERS AGE >17 W CC. 297......... 10 MED NUTRITIONAL & MISC .5374 3.3 4.3 26 METABOLIC DISORDERS AGE >17 W/O CC. 298......... 10 MED NUTRITIONAL & MISC .5036 2.3 3.0 19 METABOLIC DISORDERS AGE 0-17. 299......... 10 MED INBORN ERRORS OF .8211 3.8 5.4 28 METABOLISM. 300......... 10 MED ENDOCRINE DISORDERS W 1.1005 5.5 7.3 30 CC. 301......... 10 MED ENDOCRINE DISORDERS W/O .6193 3.4 4.4 27 CC. 302......... 11 SURG KIDNEY TRANSPLANT...... 3.9210 10.4 12.3 34 303......... 11 SURG KIDNEY, URETER & MAJOR 2.6364 8.4 10.2 32 BLADDER PROCEDURES FOR NEOPLASM. 304......... 11 SURG KIDNEY, URETER & MAJOR 2.3744 7.5 10.3 31 BLADDER PROC FOR NON- NEOPL W CC. 305......... 11 SURG KIDNEY, URETER & MAJOR 1.1797 3.9 4.9 28 BLADDER PROC FOR NON- NEOPL W/O CC. 306......... 11 SURG PROSTATECTOMY W CC.... 1.2243 4.3 6.2 28 307......... 11 SURG PROSTATECTOMY W/O CC.. .6709 2.4 3.0 15 308......... 11 SURG MINOR BLADDER 1.5260 4.6 7.0 29 PROCEDURES W CC. 309......... 11 SURG MINOR BLADDER .8858 2.3 3.0 18 PROCEDURES W/O CC. 310......... 11 SURG TRANSURETHRAL 1.0013 3.1 4.6 27 PROCEDURES W CC. 311......... 11 SURG TRANSURETHRAL .5663 1.8 2.2 11 PROCEDURES W/O CC. 312......... 11 SURG URETHRAL PROCEDURES, .9118 3.1 4.8 27 AGE >17 W CC. 313......... 11 SURG URETHRAL PROCEDURES, .5211 1.7 2.3 13 AGE >17 W/O CC. 314......... 11 SURG *URETHRAL PROCEDURES, .4835 2.3 2.3 26 AGE 0-17. 315......... 11 SURG OTHER KIDNEY & URINARY 2.0606 5.3 9.3 29 TRACT O.R. PROCEDURES. 316......... 11 MED RENAL FAILURE......... 1.3066 5.4 7.6 29 317......... 11 MED ADMIT FOR RENAL .4837 2.0 2.8 19 DIALYSIS. 318......... 11 MED KIDNEY & URINARY TRACT 1.1233 5.0 7.2 29 NEOPLASMS W CC. 319......... 11 MED KIDNEY & URINARY TRACT .5801 2.3 3.2 24 NEOPLASMS W/O CC. 320......... 11 MED KIDNEY & URINARY TRACT .9052 5.1 6.4 29 INFECTIONS AGE >17 W CC. 321......... 11 MED KIDNEY & URINARY TRACT .6094 3.9 4.7 24 INFECTIONS AGE >17 W/O CC. 322......... 11 MED KIDNEY & URINARY TRACT .5265 3.6 4.4 24 INFECTIONS AGE 0-17. 323......... 11 MED URINARY STONES W CC, &/ .7490 2.7 3.6 24 OR ESW LITHOTRIPSY. 324......... 11 MED URINARY STONES W/O CC. .4161 1.7 2.1 10 325......... 11 MED KIDNEY & URINARY TRACT .6397 3.4 4.6 27 SIGNS & SYMPTOMS AGE >17 W CC. 326......... 11 MED KIDNEY & URINARY TRACT .4346 2.4 3.5 19 SIGNS & SYMPTOMS AGE >17 W/O CC. 327......... 11 MED *KIDNEY & URINARY TRACT .2340 3.1 3.1 27 SIGNS & SYMPTOMS AGE 0- 17. 328......... 11 MED URETHRAL STRICTURE AGE .6929 3.1 4.3 27 >17 W CC. 329......... 11 MED URETHRAL STRICTURE AGE .4536 2.1 2.8 16 >17 W/O CC. 330......... 11 MED *URETHRAL STRICTURE AGE .3114 1.6 1.6 9 0-17. 331......... 11 MED OTHER KIDNEY & URINARY .9926 4.6 6.2 29 TRACT DIAGNOSES AGE >17 W CC. 332......... 11 MED OTHER KIDNEY & URINARY .6170 2.8 3.9 27 TRACT DIAGNOSES AGE >17 W/O CC. 333......... 11 MED OTHER KIDNEY & URINARY .8641 4.3 5.9 28 TRACT DIAGNOSES AGE 0- 17. 334......... 12 SURG MAJOR MALE PELVIC 1.6656 5.3 6.0 23 PROCEDURES W CC. 335......... 12 SURG MAJOR MALE PELVIC 1.2596 4.1 4.6 17 PROCEDURES W/O CC. 336......... 12 SURG TRANSURETHRAL .8859 3.2 4.1 24 PROSTATECTOMY W CC. 337......... 12 SURG TRANSURETHRAL .6149 2.3 2.7 11 PROSTATECTOMY W/O CC. 338......... 12 SURG TESTES PROCEDURES, FOR 1.0534 3.5 5.3 27 MALIGNANCY. 339......... 12 SURG TESTES PROCEDURES, NON- 1.0213 3.1 4.9 27 MALIGNANCY AGE >17. 340......... 12 SURG *TESTES PROCEDURES, NON- .2768 2.4 2.4 13 MALIGNANCY AGE 0-17. 341......... 12 SURG PENIS PROCEDURES...... 1.0701 2.3 3.2 21 342......... 12 SURG CIRCUMCISION AGE >17.. .7579 2.6 4.0 27 343......... 12 SURG *CIRCUMCISION AGE 0-17. .1503 1.7 1.7 6 344......... 12 SURG OTHER MALE 1.0086 2.3 3.5 25 REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY. 345......... 12 SURG OTHER MALE .8396 2.7 4.0 27 REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. [[Page 27538]] 346......... 12 MED MALIGNANCY, MALE .9564 4.8 6.8 29 REPRODUCTIVE SYSTEM, W CC. 347......... 12 MED MALIGNANCY, MALE .5161 2.4 3.4 26 REPRODUCTIVE SYSTEM, W/ O CC. 348......... 12 MED BENIGN PROSTATIC .7102 3.5 4.9 28 HYPERTROPHY W CC. 349......... 12 MED BENIGN PROSTATIC .4048 2.2 3.0 21 HYPERTROPHY W/O CC. 350......... 12 MED INFLAMMATION OF THE .6631 3.9 4.8 24 MALE REPRODUCTIVE SYSTEM. 351......... 12 MED *STERILIZATION, MALE... .2309 1.3 1.3 5 352......... 12 MED OTHER MALE .5889 2.8 4.0 27 REPRODUCTIVE SYSTEM DIAGNOSES. 353......... 13 SURG PELVIC EVISCERATION, 1.9266 6.7 8.4 31 RADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354......... 13 SURG UTERINE, ADNEXA PROC 1.4646 5.2 6.3 28 FOR NON-OVARIAN/ ADNEXAL MALIG W CC. 355......... 13 SURG UTERINE, ADNEXA PROC .9065 3.6 3.9 11 FOR NON-OVARIAN/ ADNEXAL MALIG W/O CC. 356......... 13 SURG FEMALE REPRODUCTIVE .7377 2.6 3.0 12 SYSTEM RECONSTRUCTIVE PROCEDURES. 357......... 13 SURG UTERINE & ADNEXA PROC 2.3847 8.0 9.8 32 FOR OVARIAN OR ADNEXAL MALIGNANCY. 358......... 13 SURG UTERINE & ADNEXA PROC 1.1713 4.0 4.7 19 FOR NON-MALIGNANCY W CC. 359......... 13 SURG UTERINE & ADNEXA PROC .8289 3.0 3.3 10 FOR NON-MALIGNANCY W/O CC. 360......... 13 SURG VAGINA, CERVIX & VULVA .8470 2.9 3.5 17 PROCEDURES. 361......... 13 SURG LAPAROSCOPY & 1.1284 2.5 3.5 23 INCISIONAL TUBAL INTERRUPTION. 362......... 13 SURG *ENDOSCOPIC TUBAL .2950 1.4 1.4 5 INTERRUPTION. 363......... 13 SURG D&C, CONIZATION & .6887 2.6 3.5 20 RADIO-IMPLANT, FOR MALIGNANCY. 364......... 13 SURG D&C, CONIZATION EXCEPT .6823 2.6 3.6 27 FOR MALIGNANCY. 365......... 13 SURG OTHER FEMALE 1.7253 5.3 8.1 29 REPRODUCTIVE SYSTEM O.R. PROCEDURES. 366......... 13 MED MALIGNANCY, FEMALE 1.1948 5.3 7.7 29 REPRODUCTIVE SYSTEM W CC. 367......... 13 MED MALIGNANCY, FEMALE .5173 2.3 3.3 24 REPRODUCTIVE SYSTEM W/ O CC. 368......... 13 MED INFECTIONS, FEMALE 1.0303 5.3 6.9 29 REPRODUCTIVE SYSTEM. 369......... 13 MED MENSTRUAL & OTHER .5504 2.6 3.8 27 FEMALE REPRODUCTIVE SYSTEM DISORDERS. 370......... 14 SURG CESAREAN SECTION W CC. 1.0444 4.3 5.6 26 371......... 14 SURG CESAREAN SECTION W/O .6865 3.2 3.6 11 CC. 372......... 14 MED VAGINAL DELIVERY W .5471 2.4 3.3 19 COMPLICATING DIAGNOSES. 373......... 14 MED VAGINAL DELIVERY W/O .3584 1.6 1.9 7 COMPLICATING DIAGNOSES. 374......... 14 SURG VAGINAL DELIVERY W .6083 2.0 2.4 9 STERILIZATION &/OR D&C. 375......... 14 SURG *VAGINAL DELIVERY W .6696 4.4 4.4 28 O.R. PROC EXCEPT STERIL &/OR D&C. 376......... 14 MED POSTPARTUM & POST .5972 2.4 3.5 26 ABORTION DIAGNOSES W/O O.R. PROCEDURE. 377......... 14 SURG POSTPARTUM & POST .8078 2.0 3.2 26 ABORTION DIAGNOSES W O.R. PROCEDURE. 378......... 14 MED ECTOPIC PREGNANCY..... .8157 2.5 3.0 15 379......... 14 MED THREATENED ABORTION... .3573 2.0 2.9 20 380......... 14 MED ABORTION W/O D&C...... .4988 1.8 2.3 13 381......... 14 SURG ABORTION W D&C, .5212 1.6 2.3 14 ASPIRATION CURETTAGE OR HYSTEROTOMY. 382......... 14 MED FALSE LABOR........... .2100 1.3 1.7 7 383......... 14 MED OTHER ANTEPARTUM .4672 2.8 4.1 27 DIAGNOSES W MEDICAL COMPLICATIONS. 384......... 14 MED OTHER ANTEPARTUM .4140 1.9 3.3 24 DIAGNOSES W/O MEDICAL COMPLICATIONS. 385......... 15 ................ *NEONATES, DIED OR 1.3437 1.8 1.8 26 TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386......... 15 ................ *EXTREME IMMATURITY OR 4.4311 17.9 17.9 42 RESPIRATORY DISTRESS SYNDROME, NEONATE. 387......... 15 ................ *PREMATURITY W MAJOR 3.0264 13.3 13.3 37 PROBLEMS. 388......... 15 ................ *PREMATURITY W/O MAJOR 1.8261 8.6 8.6 33 PROBLEMS. 389......... 15 FULL TERM NEONATE W 2.2247 8.0 10.7 32 MAJOR PROBLEMS. 390......... 15 NEONATE W OTHER 1.4188 3.8 5.0 28 SIGNIFICANT PROBLEMS. 391......... 15 ................ *NORMAL NEWBORN........ .1489 3.1 3.1 11 392......... 16 SURG SPLENECTOMY AGE >17... 3.2602 8.9 11.7 33 393......... 16 SURG *SPLENECTOMY AGE 0-17.. 1.3163 9.1 9.1 33 [[Page 27539]] 394......... 16 SURG OTHER O.R. PROCEDURES 1.5902 4.5 7.9 28 OF THE BLOOD AND BLOOD FORMING ORGANS. 395......... 16 MED RED BLOOD CELL .8360 3.9 5.4 28 DISORDERS AGE >17. 396......... 16 MED RED BLOOD CELL .7226 2.8 3.9 27 DISORDERS AGE 0-17. 397......... 16 MED COAGULATION DISORDERS. 1.2574 4.4 6.1 28 398......... 16 MED RETICULOENDOTHELIAL & 1.2106 5.2 6.6 29 IMMUNITY DISORDERS W CC. 399......... 16 MED RETICULOENDOTHELIAL & .7061 3.5 4.4 27 IMMUNITY DISORDERS W/O CC. 400......... 17 SURG LYMPHOMA & LEUKEMIA W 2.5606 6.6 10.3 31 MAJOR O.R. PROCEDURE. 401......... 17 SURG LYMPHOMA & NON-ACUTE 2.4945 8.5 12.4 32 LEUKEMIA W OTHER O.R. PROC W CC. 402......... 17 SURG LYMPHOMA & NON-ACUTE 1.0299 3.1 4.7 27 LEUKEMIA W OTHER O.R. PROC W/O CC. 403......... 17 MED LYMPHOMA & NON-ACUTE 1.6925 6.5 9.3 30 LEUKEMIA W CC. 404......... 17 MED LYMPHOMA & NON-ACUTE .8070 3.7 5.1 28 LEUKEMIA W/O CC. 405......... 17 ................ *ACUTE LEUKEMIA W/O 1.8661 4.9 4.9 29 MAJOR O.R. PROCEDURE AGE 0-17. 406......... 17 SURG MYELOPROLIF DISORD OR 2.6923 8.1 11.2 32 POORLY DIFF NEOPL W MAJ O.R. PROC W CC. 407......... 17 SURG MYELOPROLIF DISORD OR 1.1822 3.8 4.9 28 POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC. 408......... 17 SURG MYELOPROLIF DISORD OR 1.7412 5.0 8.2 29 POORLY DIFF NEOPL W OTHER O.R. PROC. 409......... 17 MED RADIOTHERAPY.......... .9708 4.7 6.7 29 410......... 17 MED CHEMOTHERAPY W/O ACUTE .7524 2.6 3.4 20 LEUKEMIA AS SECONDARY DIAGNOSIS. 411......... 17 MED HISTORY OF MALIGNANCY .3780 2.1 2.6 14 W/O ENDOSCOPY. 412......... 17 MED HISTORY OF MALIGNANCY .4133 2.2 3.1 24 W ENDOSCOPY. 413......... 17 MED OTHER MYELOPROLIF DIS 1.3263 5.9 8.3 30 OR POORLY DIFF NEOPL DIAG W CC. 414......... 17 MED OTHER MYELOPROLIF DIS .7442 3.8 5.2 28 OR POORLY DIFF NEOPL DIAG W/O CC. 415......... 18 SURG O.R. PROCEDURE FOR 3.4473 11.4 15.7 35 INFECTIOUS & PARASITIC DISEASES. 416......... 18 MED SEPTICEMIA AGE >17.... 1.4862 6.2 8.2 30 417......... 18 MED SEPTICEMIA AGE 0-17... .7936 3.7 4.7 28 418......... 18 MED POSTOPERATIVE & POST- .9678 5.3 6.8 29 TRAUMATIC INFECTIONS. 419......... 18 MED FEVER OF UNKNOWN .8993 4.4 5.7 28 ORIGIN AGE >17 W CC. 420......... 18 MED FEVER OF UNKNOWN .6253 3.5 4.3 24 ORIGIN AGE >17 W/O CC. 421......... 18 MED VIRAL ILLNESS AGE >17. .7157 3.6 4.6 28 422......... 18 MED VIRAL ILLNESS & FEVER .5217 2.9 3.7 23 OF UNKNOWN ORIGIN AGE 0-17. 423......... 18 MED OTHER INFECTIOUS & 1.5864 6.3 8.7 30 PARASITIC DISEASES DIAGNOSES. 424......... 19 SURG O.R. PROCEDURE W 2.3596 10.9 17.8 35 PRINCIPAL DIAGNOSES OF MENTAL ILLNESS. 425......... 19 MED ACUTE ADJUST REACT & .7078 3.5 4.9 27 DISTURBANCES OF PSYCHOSOCIAL DYSFUNCTION. 426......... 19 MED DEPRESSIVE NEUROSES... .5715 4.0 5.5 28 427......... 19 MED NEUROSES EXCEPT .5544 3.7 5.3 28 DEPRESSIVE. 428......... 19 MED DISORDERS OF .7352 5.2 8.5 29 PERSONALITY & IMPULSE CONTROL. 429......... 19 MED ORGANIC DISTURBANCES & .9063 5.9 8.9 30 MENTAL RETARDATION. 430......... 19 MED PSYCHOSES............. .8422 6.9 9.8 31 431......... 19 MED CHILDHOOD MENTAL .6694 5.0 7.5 29 DISORDERS. 432......... 19 MED OTHER MENTAL DISORDER .7228 3.9 6.3 28 DIAGNOSES. 433......... 20 ................ ALCOHOL/DRUG ABUSE OR .3007 2.5 3.4 24 DEPENDENCE, LEFT AMA. 434......... 20 ................ ALC/DRUG ABUSE OR .7152 4.4 5.8 28 DEPEND, DETOX OR OTH SYMPT TREAT W CC. 435......... 20 ................ ALC/DRUG ABUSE OR .4178 3.8 4.8 28 DEPEND, DETOX OR OTH SYMPT TREAT W/O CC. 436......... 20 ................ ALC/DRUG DEPENDENCE W .8199 12.1 14.8 36 REHABILITATION THERAPY. 437......... 20 ................ ALC/DRUG DEPENDENCE, .7714 9.2 10.9 33 COMBINED REHAB & DETOX THERAPY. 438......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0 439......... 21 SURG SKIN GRAFTS FOR 1.6153 5.8 8.9 30 INJURIES. 440......... 21 SURG WOUND DEBRIDEMENTS FOR 1.7631 6.3 9.8 30 INJURIES. 441......... 21 SURG HAND PROCEDURES FOR .9344 2.4 4.4 26 INJURIES. 442......... 21 SURG OTHER O.R. PROCEDURES 2.1659 5.6 8.7 30 FOR INJURIES W CC. [[Page 27540]] 443......... 21 SURG OTHER O.R. PROCEDURES .8851 2.5 3.5 26 FOR INJURIES W/O CC. 444......... 21 MED TRAUMATIC INJURY AGE .7310 4.0 5.3 28 >17 W CC. 445......... 21 MED TRAUMATIC INJURY AGE .4754 2.8 3.8 24 >17 W/O CC. 446......... 21 MED *TRAUMATIC INJURY AGE 0- .2893 2.4 2.4 22 17. 447......... 21 MED ALLERGIC REACTIONS AGE .4908 2.1 2.8 17 >17. 448......... 21 MED ALLERGIC REACTIONS AGE .0759 1.0 1.0 1 0-17. 449......... 21 MED POISONING & TOXIC .7907 3.0 4.4 27 EFFECTS OF DRUGS AGE >17 W CC. 450......... 21 MED POISONING & TOXIC .4276 1.8 2.3 13 EFFECTS OF DRUGS AGE >17 W/O CC. 451......... 21 MED *POISONING & TOXIC .2569 2.1 2.1 17 EFFECTS OF DRUGS AGE 0- 17. 452......... 21 MED COMPLICATIONS OF .9448 3.8 5.4 28 TREATMENT W CC. 453......... 21 MED COMPLICATIONS OF .4853 2.4 3.2 20 TREATMENT W/O CC. 454......... 21 MED OTHER INJURY, .8536 3.4 5.1 27 POISONING & TOXIC EFFECT DIAG W CC. 455......... 21 MED OTHER INJURY, .4445 2.1 2.8 18 POISONING & TOXIC EFFECT DIAG W/O CC. 456......... 22 ................ BURNS, TRANSFERRED TO 1.8816 4.0 8.4 28 ANOTHER ACUTE CARE FACILITY. 457......... 22 MED EXTENSIVE BURNS W/O 1.4446 2.4 4.8 26 O.R. PROCEDURE. 458......... 22 SURG NON-EXTENSIVE BURNS W 3.5465 12.0 17.0 36 SKIN GRAFT. 459......... 22 SURG NON-EXTENSIVE BURNS W 1.6693 6.7 10.3 31 WOUND DEBRIDEMENT OR OTHER O.R. PROC. 460......... 22 MED NON-EXTENSIVE BURNS W/ .9554 4.6 6.6 29 O O.R. PROCEDURE. 461......... 23 SURG O.R. PROC W DIAGNOSES .9981 2.5 4.9 27 OF OTHER CONTACT W HEALTH SERVICES. 462......... 23 MED REHABILITATION........ 1.4294 11.0 14.0 35 463......... 23 MED SIGNS & SYMPTOMS W CC. .7074 3.8 5.2 28 464......... 23 MED SIGNS & SYMPTOMS W/O .5040 2.8 3.7 24 CC. 465......... 23 MED AFTERCARE W HISTORY OF .5611 2.3 3.9 26 MALIGNANCY AS SECONDARY DIAGNOSIS. 466......... 23 MED AFTERCARE W/O HISTORY .5728 2.5 4.7 27 OF MALIGNANCY AS SECONDARY DIAGNOSIS. 467......... 23 MED OTHER FACTORS .4588 2.4 4.1 26 INFLUENCING HEALTH STATUS. 468......... ....... ................ EXTENSIVE O.R. 3.5858 10.6 15.3 35 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 469......... ....... ................ **PRINCIPAL DIAGNOSIS .0000 .0 .0 0 INVALID AS DISCHARGE DIAGNOSIS. 470......... ....... ................ **UNGROUPABLE.......... .0000 .0 .0 0 471......... 08 SURG BILATERAL OR MULTIPLE 3.6043 6.8 8.0 31 MAJOR JOINT PROCS OF LOWER EXTREMITY. 472......... 22 SURG EXTENSIVE BURNS W O.R. 11.1357 17.3 30.7 41 PROCEDURE. 473......... 17 ................ ACUTE LEUKEMIA W/O 3.5669 8.5 14.7 32 MAJOR O.R. PROCEDURE AGE >17. 474......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0 475......... 04 MED RESPIRATORY SYSTEM 3.6736 8.6 12.3 33 DIAGNOSIS WITH VENTILATOR SUPPORT. 476......... ....... SURG PROSTATIC O.R. 2.2362 10.3 13.8 34 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 477......... ....... SURG NON-EXTENSIVE O.R. 1.7153 5.8 9.2 30 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 478......... 05 SURG OTHER VASCULAR 2.2890 5.6 8.3 30 PROCEDURES W CC. 479......... 05 SURG OTHER VASCULAR 1.4113 3.5 4.6 27 PROCEDURES W/O CC. 480......... ....... SURG LIVER TRANSPLANT....... 12.8388 22.5 29.7 47 481......... ....... SURG BONE MARROW TRANSPLANT. 11.2985 29.1 32.1 53 482......... ....... SURG TRACHEOSTOMY FOR FACE, 3.6598 11.4 15.0 35 MOUTH & NECK DIAGNOSES. 483......... ....... SURG TRACHEOSTOMY EXCEPT FOR 16.0114 35.9 46.2 60 FACE, MOUTH & NECK DIAGNOSES. 484......... 24 SURG CRANIOTOMY FOR 5.5711 10.4 15.5 34 MULTIPLE SIGNIFICANT TRAUMA. 485......... 24 SURG LIMB REATTACHMENT, HIP 3.1619 9.1 11.6 33 AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR. 486......... 24 SURG OTHER O.R. PROCEDURES 4.8009 9.0 13.5 33 FOR MULTIPLE SIGNIFICANT TRAUMA. 487......... 24 MED OTHER MULTIPLE 1.9999 6.1 9.0 30 SIGNIFICANT TRAUMA. 488......... 25 SURG HIV W EXTENSIVE O.R. 4.2773 12.9 17.6 37 PROCEDURE. 489......... 25 MED HIV W MAJOR RELATED 1.7436 7.0 10.4 31 CONDITION. 490......... 25 MED HIV W OR W/O OTHER 1.0106 4.4 6.6 28 RELATED CONDITION. 491......... 08 SURG MAJOR JOINT & LIMB 1.6358 3.6 4.3 19 REATTACHMENT PROCEDURES OF UPPER EXTREMITY. [[Page 27541]] 492......... 17 MED CHEMOTHERAPY W ACUTE 4.0624 11.2 17.4 35 LEUKEMIA AS SECONDARY DIAGNOSIS. 493......... 07 SURG LAPAROSCOPIC 1.7085 4.2 5.9 28 CHOLECYSTECTOMY W/O C.D.E. W CC. 494......... 07 SURG LAPAROSCOPIC .9186 1.8 2.4 15 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495......... ....... SURG LUNG TRANSPLANT........ 9.8070 18.4 23.8 42 ---------------------------------------------------------------------------------------------------------------- *Medicare data have been supplemented by data from 19 states 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 ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 079.6....... Respiratory syncytial virus N 15 387\1\, 389 \1\ (RSV). 18 421, 422 291.81...... Alcohol withdrawal.......... Y 20 434, 435, 436, 437 291.89...... Other specified alcoholic Y 20 434, 435, 436, 437 psychosis, not elsewhere classified. 293.84...... Organic anxiety syndrome.... Y 19 429 300.82...... Undifferentiated somatoform N 19 427 disorder. 315.32...... Receptive language disorder N 19 431 (mixed). 414.04...... Coronary atherosclerosis of N 5 132, 133 artery bypass graft. 414.05...... Coronary atherosclerosis of N 5 132, 133 unspecified type of bypass graft. 466.11...... Acute bronchiolitis due to N 4 96, 97, 98 respiratory syncytial virus (RSV). 466.19...... Acute bronchiolitis due to N 4 96, 97, 98 other infectious organisms. 483.1....... Pneumonia due to Chlamydia.. Y 4 89, 90, 91 15 387,\1\ 389\1\ 574.60...... Calculus of gallbladder and Y 7 207, 208 bile duct with acute cholecystitis without mention of obstruction. 574.61...... Calculus of gallbladder and Y 7 207, 208 bile duct with acute cholecystitis with obstruction. 574.70...... Calculus of gallbladder and Y 7 207, 208 bile duct with other cholecystitis without mention of obstruction. 574.71...... Calculus of gallbladder and Y 7 207, 208 bile duct with other cholecystitis with obstruction. 574.80...... Calculus of gallbladder and Y 7 207, 208 bile duct with acute and chronic cholecystitis without mention of obstruction. 574.81...... Calculus of gallbladder and Y 7 207, 208 bile duct with acute and chronic cholecystitis with obstruction. 574.90...... Calculus of gallbladder and Y 7 207, 208 bile duct without cholecystitis without mention of obstruction. 574.91...... Calculus of gallbladder and Y 7 207, 208 bile duct without cholecystitis with obstruction. 575.10...... Cholecystitis, unspecified.. N 7 207, 208 575.11...... Chronic cholecystitis....... N 7 207, 208 575.12...... Acute and chronic Y 7 207, 208 cholecystitis. 752.51...... Undescended testis.......... N 12 352 752.52...... Retractile testis........... N 12 352 752.61...... Hypospadias................. N 12 352 752.62...... Epispadias.................. N 12 352 752.63...... Congenital chordee.......... N 12 352 752.64...... Micropenis.................. N 12 352 752.65...... Hidden penis................ N 12 352 752.69...... Other penile anomalies...... N 12 352 753.20...... Unspecified obstructive N 11 331, 332, 333 defect of renal pelvis and ureter. 753.21...... Congenital obstruction of N 11 331, 332, 333 ureteropelvic junction. 753.22...... Congenital obstruction of N 11 331, 332, 333 ureterovesical junction. 753.23...... Congenital ureterocele...... N 11 331, 332, 333 753.29...... Obstructive defects of renal N 11 331, 332, 333 pelvis and ureter, not elsewhere classifed. 758.81...... Other conditions due to sex N 12 352 chromosome anomalies. 13 358, 359, 369 758.89...... Other conditions due to N 12 352 chromosome anomalies, not elsewhere classified. 13 358, 359, 369 922.31...... Back contusion.............. N 9 280, 281, 282 922.32...... Buttock contusion........... N 9 280, 281, 282 922.33...... Interscapular region N 9 280, 281, 282 contusion. 995.50...... Child abuse, unspecified.... N 21 454, 455 995.51...... Child emotional/ N 21 454, 455 psychological abuse. [[Page 27542]] 995.52...... Child neglect (nutritional). N 21 454, 455 995.53...... Child sexual abuse.......... N 21 454, 455 995.54...... Child physical abuse........ N 21 454, 455 995.55...... Shaken infant syndrome...... N 21 454, 455 995.59...... Child maltreatment syndrome, N 21 454, 455 not elsewhere classified. 995.80...... Adult maltreatment, N 21 454, 455 unspecified. 995.82...... Adult emotional/ N 21 454, 455 psychological abuse. 995.83...... Adult sexual abuse.......... N 21 454, 455 995.84...... Adult neglect (nutritional). N 21 454, 455 995.85...... Other adult abuse and N 21 454, 455 neglect. 998.11...... Hemorrhage complicating a Y 21 452, 453 procedure. 998.12...... Hematoma complicating a Y 21 452, 453 procedure. 998.13...... Seroma complicating a Y 21 452, 453 procedure. 998.51...... Infected postoperative Y 18 418 seroma. 998.59...... Other postoperative Y 18 418 infection. 998.83...... Non-healing surgical wound.. Y 21 452, 453 V15.41...... History of physical abuse... N 23 467 V15.42...... History of emotional abuse.. N 23 467 V15.49...... Psychological trauma, not N 23 467 elsewhere classified. V61.10...... Counseling for marital and N 23 467 partner problems, unspecified. V61.11...... Counseling for victim of N 23 467 spousal and partner abuse. V61.12...... Counseling for perpetrator N 23 467 of spousal and partner abuse. V61.22...... Counseling for perpetrator N 23 467 of parental child abuse. V62.83...... Counseling for perpetrator N 23 467 of physical/sexual abuse. V66.7....... Encounter for palliative N 23 467 care. ---------------------------------------------------------------------------------------------------------------- \1\ Diagnosis code is classified as a ``major problem'' in these DRGs. Table 6b.--New Procedure Codes ---------------------------------------------------------------------------------------------------------------- Procedure code Description OR MDC DRG ---------------------------------------------------------------------------------------------------------------- 36.17...... Abdominal-coronary artery Y 5 106, 107 bypass. 39.90...... Insertion of non-coronary N .......... .................................. artery stent or stents. 47.01...... Laparoscopic appendectomy.... Y 6 164, 165, 166, 167 47.09...... Other appendectomy........... Y 6 164, 165, 166, 167 47.11...... Laparoscopic incidental Y 13 365 appendectomy. 21 442, 443 24 486 47.19...... Other incidental appendectomy Y 13 365 21 442, 443 24 486 51.21...... Other partial cholecystectomy Y 7 193, 194 17 400, 406, 17 407 21 442, 443 24 486 51.24...... Laparoscopic partial Y 7 193, 194 cholecystectomy. 17 400, 406, 17 407, 21 442, 443 24 486 52.84...... Autotransplantation of cells N .......... .................................. of Islets of Langerhans. 52.85...... Allotransplantation of cells N .......... .................................. of Islets of Langerhans. 52.86...... Transplantation of cells of N .......... .................................. Islets of Langerhans, not otherwise specified. 54.51...... Laparoscopic lysis of Y 6 150, 151 peritoneal adhesions. 7 201 13 365 21 442, 443 24 486 54.59...... Other lysis of peritoneal Y 6 150, 151 adhesions. 7 201 13 365 21 442, 443 24 486 59.03...... Laparoscopic lysis of Y 11 303, 304, 305 perirenal or periureteral 12 344, 345 adhesions. 13 365 17 400 17 406, 407 [[Page 27543]] 21 442, 443 24 486 59.12...... Laparoscopic lysis of Y 11 308, 309 perivesical adhesions. 12 344, 345 13 365 17 400 17 406, 407 21 442, 443 24 486 65.01...... Laparoscopic oophorotomy..... Y 13 354, 355, 357, 358, 359 65.09...... Other oophorotomy............ Y 13 354, 355, 357, 358, 359 65.13...... Laparoscopic biopsy of ovary. Y 13 354, 355, 357, 358, 359 65.14...... Other laparoscopic diagnostic Y 13 354, 355, 357, 358, 359 procedures on ovaries. 65.23...... Laparoscopic marsupialization Y 13 354, 355, 357, 358, 359 of ovarian cyst. 65.24...... Laparoscopic wedge resection Y 10 292, 293 of ovary. 13 354, 355, 357, 358, 359 65.25...... Other laparoscopic local Y 13 354, 355, 357, 358, 359 excision or destruction of ovary. 65.31...... Laparoscopic unilateral Y 13 354, 355, 357, 358, 359 oophorectomy. 65.39...... Other unilateral oophorectomy Y 13 354, 355, 357, 358, 359 65.41...... Laparoscopic unilateral Y 13 354, 355, 357, 358, 359 salpingo-oophorectomy. 65.49...... Other unilateral salpingo- Y 13 354, 355, 357, 358, 359 oophorectomy. 65.53...... Laparoscopic removal of both Y 9 269, 270 ovaries at same operative episode. 13 354, 355, 13 357, 358, 359 65.54...... Laparoscopic removal of Y 9 269, 270 remaining ovary. 13 354, 355, 13 357, 358, 359 65.63...... Laparoscopic removal of both Y 9 269, 270 ovaries and tubes at same operative episode. 13 354, 355, 13 357, 358, 359 65.64...... Laparoscopic removal of Y 13 354, 355, 357, 358, 359 remaining ovary and tube. 65.74...... Laparoscopic simple suture of Y 13 354, 355, ovary. 13 357, 358, 21 359 24 442, 443, 486 65.75...... Laparoscopic reimplantation Y 13 354, 355, of ovary. 13 357, 358, 21 359 24 442, 443, 486 65.76...... Laparoscopic salpingo- Y 13 354, 355, oophoroplasty. 13 357, 358, 21 359 24 442, 443, 486 65.81...... Laparoscopic lysis of Y 13 354, 355, adhesions of ovary and 13 357, 358, fallopian tube. 21 359 24 442, 443, 486 65.89...... Other lysis of adhesions of Y 13 354, 355, ovary and fallopian tube. 13 357, 358, 21 359 24 442, 443, 486 68.23...... Endometrial ablation......... Y 13 354, 355, 357, 358, 359 68.51...... Laparoscopically assisted Y 13 354, 355, vaginal hysterectomy (LAVH). 13 357, 358, 14 359, 375 68.59...... Other vaginal hysterectomy... Y 13 354, 355, 13 357, 358, 14 359, 375 ---------------------------------------------------------------------------------------------------------------- [[Page 27544]] Table 6c.--Table Diagnosis Codes ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 291.8......... Other specified alcoholic Y 20 434, 435, 436, 437 psychosis. 466.1......... Acute bronchiolitis......... N 4 96, 97, 98 575.1......... Other cholecystitis......... N 7 207, 208 752.5......... Undescended testicle........ N 12 352 752.6......... Hypospadias and epispadias.. N 12 352 753.2......... Obstructive defects of renal N 11 331, 332, 333 pelvis and ureter. 758.8......... Other conditions due to sex N 12 352 chromosome anomalies. 13 358, 359, 369 922.3......... Contusion of back........... N 9 280, 281, 9 282 ................... 24 484, 486, 487 995.5......... Child maltreatment syndrome. N 21 454, 455 998.1......... Hemorrhage or hematoma Y 15 387 \1\, 389 \1\ complicating a procedure. 21 452, 453 998.5......... Postoperative infection..... Y 15 387 \1\, 389 \1\ 18 418 V15.4......... Psychological trauma........ N 23 467 V61.1......... Marital problems............ N 23 467 ---------------------------------------------------------------------------------------------------------------- \1\ Diagnosis code is classified as a ``major problem'' in these DRGs. Table 6d.--Invalid Procedure Codes ---------------------------------------------------------------------------------------------------------------- Procedure code Description OR MDC DRG ---------------------------------------------------------------------------------------------------------------- 47.0.......... Appendectomy................ Y 6 164, 165, 166, 167 47.1.......... Incidental appendectomy..... Y 13 365, 21 442, 443, 24 486 54.5.......... Lysis of peritoneal Y 6 150, 151 adhesions. 7 201 13 365 21 442, 443 24 486 59.01......... Ureterolysis with freeing or Y 11 303, 304, repositioning of ureter for retroperitoneal fibrosis. 11 305 12 344, 345 13 365 17 400, 406, 17 407 21 442, 443 24 486 65.0.......... Oophorotomy................. Y 13 354, 355, 357, 358, 359 65.3.......... Unilateral oophorectomy..... Y 13 354, 355, 357, 358, 359 65.4.......... Unilateral salpingo- Y 13 354, 355, 357, 358, 359 oophorectomy. 65.8.......... Lysis of adhesions of ovary Y 13 354, 355, and fallopian tube. 13 357, 358, 21 359 24 442, 443, 486 68.5.......... Vaginal hysterectomy........ Y 13 354, 355, 13 357, 358, 13 359 14 375 ---------------------------------------------------------------------------------------------------------------- Table 6e.--Revised Diagnosis Code Titles ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 414.00... Coronary atherosclerosis of N 5 132, 133 unspecified type of vessel, native or graft. 995.81... Adult physical abuse......... N 21 454, 455 997.60... Amputation stump N 8 256 complication, unspecified complication. 997.61... Amputation stump N 8 256 complication, neuroma of amputation stump. 997.62... Amputation stump Y 8 256 complication, infection (chronic). 997.69... Amputation stump N 8 256 complication, not elsewhere classified. [[Page 27545]] V61.20... Counseling for parent-child N 23 467 problem, unspecified. V61.21... Counseling for victim of N 23 467 child abuse. V67.4.... Follow-up examination, N 23 465, 466 following treatment of healed fracture. ---------------------------------------------------------------------------------------------------------------- Table 6f.--Revised Procedure Code Titles ---------------------------------------------------------------------------------------------------------------- Procedure code Description OR MDC DRG ---------------------------------------------------------------------------------------------------------------- 59.11...... Other lysis of perivesical Y 11 308, 309 adhesions. 12 344, 345 13 365 17 400, 406, 17 407 21 442, 443 24 486 65.51...... Other removal of both ovaries Y 9 269, 270 at same operative episode. 13 354, 355 13 357, 358, 359 65.52...... Other removal of remaining Y 9 269, 270 ovary. 13 354, 355 13 357, 358, 359 65.61...... Other removal of both ovaries Y 9 269, 270 and tubes at same operative 13 354, 355, episode. 13 357, 358, 359 65.62...... Other removal of remaining Y 13 354, 355, 357, 358, 359 ovary and tube. 65.71...... Other simple suture of ovary. Y 13 354, 355, 13 357, 358, 13 359 21 442, 443 24 486 65.72...... Other reimplantation of ovary Y 13 354, 355, 13 357, 358, 21 359 24 442, 443, 486 65.73...... Other salpingo-oophoroplasty. Y 11 308, 309, 12 344, 345 13 365 17 400, 406, 17 407 21 442, 443 24 486 ---------------------------------------------------------------------------------------------------------------- [[Page 27546]] Table 6g.--Additions to the CC Exclusions List Page 1 of 5 Pages CCs that are added to the list are in Table 6G--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. ------------------------------------------------------------------------ ------------------------------------------------------------------------ *0011 00844 *00800 00844 *0085 00844 *01133 *01182 00841 00845 00841 00845 00841 00845 4831 4831 00842 00846 00842 00846 00842 00846 *01134 *01183 00843 00847 00843 00847 00843 00847 4831 4831 00844 *0061 00844 *00841 00844 *0088 *01135 *01184 00845 00841 00845 00841 00845 00841 4831 4831 00846 00842 00846 00842 00846 00842 *01136 *01185 00847 00843 00847 00843 00847 00843 4831 4831 *0020 00844 *00801 00844 *00861 00844 *01140 *01186 00841 00845 00841 00845 00841 00845 4831 4831 00842 00846 00842 00846 00842 00846 *01141 *01190 00843 00847 00843 00847 00843 00847 4831 4831 00844 *0062 00844 *00842 00844 *0090 *01142 *01191 00845 00841 00845 00841 00845 00841 4831 4831 00846 00842 00846 00842 00846 00842 *01143 *01192 00847 00843 00847 00843 00847 00843 4831 4831 *0029 00844 *00802 00844 *00862 00844 *01144 *01193 00841 00845 00841 00845 00841 00845 4831 4831 00842 00846 00842 00846 00842 00846 *01145 *01194 00843 00847 00843 00847 00843 00847 4831 4831 00844 *0069 00844 *00843 00844 *01100 *01146 *01195 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01101 *01150 *01196 00847 00843 00847 00843 00847 4831 4831 4831 *0030 00844 *00803 00844 *00863 *01102 *01151 *01200 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01103 *01152 *01201 00843 00847 00843 00847 00843 4831 4831 4831 00844 *0071 00844 *00844 00844 *01104 *01153 *01202 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01105 *01154 *01203 00847 00843 00847 00843 00847 4831 4831 4831 *0049 00844 *00804 00844 *00864 *01106 *01155 *01204 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01110 *01156 *01205 00843 00847 00843 00847 00843 4831 4831 4831 00844 *0072 00844 *00845 00844 *01111 *01160 *01206 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01112 *01161 *01210 00847 00843 00847 00843 00847 4831 4831 4831 *0050 00844 *00809 00844 *00865 *01113 *01162 *01211 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01114 *01163 *01212 00843 00847 00843 00847 00843 4831 4831 4831 00844 *0073 00844 *00846 00844 *01115 *01164 *01213 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01116 *01165 *01214 00847 00843 00847 00843 00847 4831 4831 4831 *0051 00844 *0081 00844 *00866 *01120 *01166 *01215 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01121 *01170 *01216 00843 00847 00843 00847 00843 4831 4831 4831 00844 *0078 00844 *00847 00844 *01122 *01171 *01280 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01123 *01172 *01281 00847 00843 00847 00843 00847 4831 4831 4831 *0052 00844 *0082 00844 *00867 *01124 *01173 *01282 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01125 *01174 *01283 00843 00847 00843 00847 00843 4831 4831 4831 00844 *0079 00844 *00849 00844 *01126 *01175 *01284 00845 00841 00845 00841 00845 4831 4831 4831 00846 00842 00846 00842 00846 *01130 *01176 *01285 00847 00843 00847 00843 00847 4831 4831 4831 *0060 00844 *0083 00844 *00869 *01131 *01180 *01286 00841 00845 00841 00845 00841 4831 4831 4831 00842 00846 00842 00846 00842 *01132 *01181 *01480 00843 00847 00843 00847 00843 4831 4831 00841 ------------------------------------------------------------------------ [[Page 27547]] Page 2 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 00842 4831 29382 29284 *29212 29383 29614 29181 00843 *11285 29383 29289 29181 29384 29634 29189 00844 00841 29384 2929 29189 7105 29644 29384 00845 00842 30300 29381 29384 *29389 29654 *30420 00846 00843 30301 29382 *2922 29181 29664 29181 00847 00844 30302 29383 29181 29189 2980 29189 *01481 00845 30390 29384 29189 29384 2983 29384 00841 00846 30391 30300 29384 *2939 2984 *30421 00842 00847 30392 30301 *29281 29181 29900 29181 00843 *11505 30400 30302 29181 29189 29910 29189 00844 4831 30401 30390 29189 29384 29980 29384 00845 *11515 30402 30391 29384 *2940 29990 *30422 00846 4831 30410 30392 *29282 29181 *30300 29181 00847 *11595 30411 30400 29181 29189 29181 29189 *01482 4831 30412 30401 29189 29384 29189 29384 00841 *1221 30420 30402 29384 *2941 29384 *30423 00842 4831 30421 30410 *29283 29181 *30301 29181 00843 *129 30411 29181 29189 29181 29189 30422 00844 00841 30440 30412 29189 29384 29189 29384 00845 00842 30441 30420 29384 *2948 29384 *30430 00846 00843 30442 30421 *29284 29181 *30302 29181 00847 00844 30450 30422 29181 29189 29181 29189 *01483 00845 30451 30440 29189 29384 29189 29384 00841 00846 30452 30441 29384 *2949 29384 *30431 00842 00847 30460 30442 *29289 29181 *30303 29181 00843 *1304 30461 30450 29181 29189 29181 29189 00844 4831 30462 30451 29189 29384 29189 29384 00845 *1363 30470 30452 29384 *30082 29384 *30432 00846 4831 30471 30460 *2929 29500 *30390 29181 00847 *2910 30472 30461 29181 29501 29181 29189 *01484 29181 30480 30462 29189 29502 29189 29384 00841 29189 30481 30470 29384 29503 29384 *30433 00842 29384 30482 30471 *2930 29504 *30391 29181 00843 *2911 30490 30472 29181 29510 29181 29189 00844 29181 30491 30480 29189 29511 29189 29384 00845 29189 30492 30481 29384 29512 29384 *30440 00846 29384 30500 30482 *2931 29513 *30392 29181 00847 *2912 30501 30490 29181 29514 29181 29189 *01485 29181 30502 30491 29189 29521 29189 29384 00841 29189 30530 30492 29384 29522 29384 *30441 00842 29384 30531 30500 *29381 29523 *30393 29181 00843 *2913 30532 30501 29181 29524 29181 29189 00844 29181 30540 30502 29189 29530 29189 29384 00845 29189 30541 30530 29384 29531 29384 *30442 00846 29384 30542 30531 *29382 29532 *30400 29181 00847 *2914 30550 30532 29181 29533 29181 29189 *01486 29181 30551 30540 29189 29534 29189 29384 00841 29189 30552 30541 29384 29540 29384 *30443 00842 29384 30560 30542 *29383 29541 *30401 29181 00843 *2915 30561 30550 29181 29542 29181 29189 00844 29181 30562 30551 29189 29543 29189 29384 00845 29189 30570 30552 29384 29544 29384 *30450 00846 29384 30571 30560 *29384 29560 *30402 29181 00847 *29181 30572 30561 2910 29561 29181 29189 *01790 2910 30590 30562 2911 29562 29189 29384 4831 2911 30591 30570 2912 29563 29384 *30451 *01791 2912 30592 30571 2913 29564 *30403 29181 4831 2913 *29189 30572 2914 29570 29181 29189 *01792 2914 2910 30590 29181 29571 29189 29384 4831 29181 2911 30591 29189 29572 29384 *30452 *01793 29189 2912 30592 2919 29573 *30410 29181 4831 2919 2913 *2919 2920 29574 29181 29189 *01794 2920 2914 29181 29211 29580 29189 29384 4831 29211 29181 29189 29212 29581 29384 *30453 *01795 29212 29189 29384 2922 29582 *30411 29181 4831 2922 2919 *2920 29281 29583 29181 29189 *01796 29281 2920 29181 29282 29584 29189 29384 4831 29282 29211 29189 29283 29590 29384 *30460 *0212 29283 29212 29384 29284 29591 *30412 29181 4831 29284 2922 *29211 29289 29592 29181 29189 *0310 29289 29281 29181 2929 29593 29189 29384 4831 2929 29282 29189 29381 29594 29384 *30461 *0391 29381 29283 29384 29382 29604 *30413 29181 ------------------------------------------------------------------------ [[Page 27548]] Page 3 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 29189 29384 *30562 29532 *48239 01180 5078 4831 29384 *30520 29181 29533 4831 01181 5080 *5062 *30462 29181 29189 29534 *4824 01182 5081 4831 29181 29189 29384 29540 4831 01183 5171 *5063 29189 29384 *30563 29541 *48281 01184 *4838 4831 29384 *30521 29181 29542 4831 01185 4831 *5064 *30463 29181 29189 29543 *48282 01186 *4841 4831 29181 29189 29384 29544 4831 01190 4831 *5069 29189 29384 *30570 29560 *48283 01191 *4843 4831 29384 *30522 29181 29561 4831 01192 4831 *5070 *30470 29181 29189 29562 *48289 01193 *4845 4831 29181 29189 29384 29563 4831 01194 4831 *5071 29189 29384 *30571 29564 *4829 01195 *4846 4831 29384 *30523 29181 29570 4831 01196 4831 *5078 *30471 29181 29189 29571 *4830 01200 *4847 4831 29181 29189 29384 29572 4831 01201 4831 *5080 29189 29384 *30572 29573 *4831 01202 *4848 4831 29384 *30530 29181 29574 01100 01203 4831 *5081 *30472 29181 29189 29580 01101 01204 *485 4831 29181 29189 29384 29581 01102 01205 4831 *5088 29189 29384 *30573 29582 01103 01206 *486 4831 29384 *30531 29181 29583 01104 01210 4831 *5089 *30473 29181 29189 29584 01105 01211 *4870 4831 29181 29189 29384 29590 01106 01212 4831 *5171 29189 29384 *30580 29591 01110 01213 *4871 4831 29384 *30532 29181 29592 01111 01214 4831 *5178 *30480 29181 29189 29593 01112 01215 *4878 4831 29181 29189 29384 29594 01113 01216 00841 *51889 29189 29384 *30581 29604 01114 0310 00842 4831 29384 *30533 29181 29614 01115 11505 00843 *5198 *30481 29181 29189 29634 01116 11515 00844 4831 29181 29189 29384 29644 01120 1304 00845 *5199 29189 29384 *30582 29654 01121 1363 00846 4831 29384 *30540 29181 29664 01122 481 00847 *53081 *30482 29181 29189 2980 01123 4820 *494 99811 29181 29189 29384 2983 01124 4821 4831 99812 29189 29384 *30583 2984 01125 4822 *4950 99813 29384 *30541 29181 29900 01126 48230 4831 *53082 *30483 29181 29189 29910 01130 48231 *4951 99811 29181 29189 29384 29980 01131 48232 4831 99812 29189 29384 *30590 29990 01132 48239 *4952 99813 29384 *30542 29181 *4560 01133 4824 4831 *53083 *30490 29181 29189 99811 01134 48281 *4953 99811 29181 29189 29384 99812 01135 48282 4831 99812 29189 29384 *30591 99813 01136 48283 *4954 99813 29384 *30543 29181 *45620 01140 48289 4831 *53089 *30491 29181 29189 99811 01141 4829 *4955 99811 29181 29189 29384 99812 01142 4830 4831 99812 29189 29384 *30592 99813 01143 4831 *4956 99813 29384 *30550 29181 *4800 01144 4838 4831 *53100 *30492 29181 29189 4831 01145 4841 *4957 99811 29181 29189 29384 *4801 01146 4843 4831 99812 29189 29384 *30593 4831 01150 4845 *4958 99813 29384 *30551 29181 *4802 01151 4846 4831 *53101 *30493 29181 29189 4831 01152 4847 *4959 99811 29181 29189 29384 *4808 01153 4848 4831 99812 29189 29384 *31532 4831 01154 485 *496 99813 29384 *30552 29500 *4809 01155 486 4831 *53120 *30500 29181 29501 4831 01156 4870 *500 99811 29181 29189 29502 *481 4950 4831 99812 01160 29189 29384 29503 4831 01161 4951 *501 99813 29384 *30553 29504 *4820 01162 4952 4831 *53121 *30501 29181 29510 4831 01163 4953 *502 99811 29181 29189 29511 *4821 01164 4954 4831 99812 29189 29384 29512 4831 01165 4955 *503 99813 29384 *30560 29513 *4822 01166 4956 4831 *53140 *30502 29181 29514 4831 01170 4957 *504 99811 29181 29189 29521 *48230 01171 4958 4831 99812 29189 29384 29522 4831 01172 4959 *505 99813 29384 *30561 29523 *48231 01173 5060 4831 *53141 *30503 29181 29524 4831 01174 5061 *5060 99811 29181 29189 29530 *48232 01175 5070 4831 99812 29189 29384 29531 4831 01176 5071 *5061 99813 ------------------------------------------------------------------------ [[Page 27549]] Page 4 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ *53160 99811 00846 00843 00844 57431 57400 57400 99811 99812 00847 00844 00845 57440 57401 57401 99812 99813 *53783 00845 00846 57441 57410 57410 99813 *53401 99811 00846 00847 57450 57411 57411 *53161 99811 99812 00847 *56202 57451 57421 57421 99811 99812 99813 *5565 99811 57460 57430 57430 99812 99813 *5550 00841 99812 57461 57431 57431 99813 *53420 00841 00842 99813 57470 57440 57440 *53200 99811 00842 00843 *56203 57471 57441 57441 99811 99812 00843 00844 99811 57490 57450 57450 99812 99813 00844 00845 99812 57491 57451 57451 99813 *53421 00845 00846 99813 5750 57470 57460 *53201 99811 00846 00847 *56212 *57461 57471 57461 99811 99812 00847 *5566 99811 57400 57480 57470 99812 99813 *5551 00841 99812 57401 57481 57471 99813 *53440 00841 00842 99813 57410 57490 57480 *53220 99811 00842 00843 *56213 57411 57491 57481 99811 99812 00843 00844 99811 57421 5750 57490 99812 99813 00844 00845 99812 57430 *57490 57491 99813 *53441 00845 00846 99813 57431 57430 5750 *53221 99811 00846 00847 *5641 57440 57431 57512 99811 99812 00847 *5568 00841 57441 57440 *57512 99812 99813 *5552 00841 00842 57450 57441 57400 99813 *53460 00841 00842 00843 57451 57450 57401 *53240 99811 00842 00843 00844 57460 57451 57410 99811 99812 00843 00844 00845 57461 57470 57411 99812 99813 00844 00845 00846 57470 57471 57421 99813 *53461 00845 00846 00847 57471 57490 57430 *53241 99811 00846 00847 *5693 57490 57491 57431 99811 99812 00847 *5569 99811 57491 *57491 57440 99812 99813 *5559 00841 99812 5750 57430 57441 99813 *53501 00841 00842 99813 *57470 57431 57450 *53260 99811 00842 00843 *56985 57430 57440 57451 99811 99812 00843 00844 99811 57431 57441 57460 99812 99813 00844 00845 99812 57440 57450 57461 99813 *53511 00845 00846 99813 57441 57451 57470 *53261 99811 00846 00847 *57430 57450 57470 57471 99811 99812 00847 *5570 57470 57451 57471 57480 99812 99813 *5560 00841 57471 57470 57490 57481 99813 *53521 00841 00842 57490 57471 57491 57490 *53300 99811 00842 00843 57491 57490 *5750 57491 99811 99812 00843 00844 *57431 57491 57460 5750 99812 99813 00844 00845 57470 *57471 57461 57512 99813 *53531 00845 00846 57471 57430 57470 *5759 *53301 99811 00846 00847 57490 57431 57471 57460 99811 99812 00847 *5571 57491 57440 57480 57461 99812 99813 *5561 00841 *57440 57441 57481 57480 99813 *53541 00841 00842 57470 57450 57490 57481 *53320 99811 00842 00843 57471 57451 57491 57512 99811 99812 00843 00844 57490 57470 57512 *5768 99812 99813 00844 00845 57491 57471 *57510 57460 99813 *53551 00845 00846 *57441 57490 57400 57461 *53321 99811 00846 00847 57470 57491 57401 57470 99811 99812 00847 *5579 57471 *57480 57410 57471 99812 99813 *5562 00841 57490 57400 57411 57480 99813 *53561 00841 00842 57491 57401 57421 57481 *53340 99811 00842 00843 *57450 57410 57430 57490 99811 99812 00843 00844 57470 57411 57431 57491 99812 99813 00844 00845 57471 57421 57440 57512 99813 *5363 00845 00846 57490 57430 57441 *5769 *53341 00841 00846 00847 57491 57431 57450 57460 99811 00842 00847 *5582 *57451 57440 57451 57461 99812 00843 *5563 00841 57470 57441 57460 57470 99813 00844 00841 00842 57471 57450 57461 57471 *53360 00845 00842 00843 57490 57451 57470 57480 99811 00846 00843 00844 57491 57470 57471 57481 99812 00847 00844 00845 *57460 57471 57480 57490 99813 *5368 00845 00846 57400 57480 57481 57491 *53361 00841 00846 00847 57401 57481 57490 57512 99811 00842 00847 *5589 57410 57490 57491 *5780 99812 00843 *5564 00841 57411 57491 5750 99811 99813 00844 00841 00842 57421 5750 57512 99812 *53400 00845 00842 00843 57430 *57481 *57511 99813 ------------------------------------------------------------------------ [[Page 27550]] Page 5 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ *5781 5996 00841 99812 9971 99811 78820 00842 99813 9972 99812 78829 00843 *99813 9973 99813 *75329 00844 9585 9974 *5789 5845 00845 9954 9975 99811 5846 00846 9980 99762 99812 5847 00847 99811 99799 99813 5849 *7758 99812 9980 *74861 585 00841 99813 9982 4831 5996 00842 *99851 9983 *75261 78820 00843 99851 9984 5970 78829 00844 99859 9986 5981 *7724 00845 *99859 9987 5982 99811 00846 99851 99883 5994 99812 00847 99859 99889 *75262 99813 *7759 *99881 9989 5970 *7750 00841 99811 *99889 5981 00841 00842 99812 99811 5982 00842 00843 99813 99812 5994 00843 00844 99851 99813 *75263 00844 00845 99859 99851 5970 00845 00846 99883 99859 5981 00846 00847 *99883 99883 5982 00847 *7775 9580 *9989 5994 *7751 00841 9581 99811 *75264 00841 00842 9582 99812 5970 00842 00843 9583 99813 5981 00843 00844 9584 99851 5982 00844 00845 9585 99859 5994 00845 00846 9587 99883 *75265 00846 00847 9954 5970 00847 *7778 99600 5981 *7752 00841 99601 5982 00841 00842 99602 5994 00842 00843 99603 *75269 00843 00844 99604 5970 00844 00845 99609 5981 00845 00846 9961 5982 00846 00847 9962 5994 00847 *7903 99630 *75320 *7753 29181 99639 5845 00841 29189 9964 5846 00842 29384 99660 5847 00843 *99791 99661 5849 00844 99811 99662 585 00845 99812 99663 5996 00846 99813 99664 78820 00847 99851 99665 78829 *7754 99859 99666 *75321 00841 99883 99667 5845 00842 *99799 99669 5846 00843 99811 99670 5847 00844 99812 99671 5849 00845 99813 99672 585 00846 99851 99673 5996 00847 99859 99674 78820 *7755 99883 99675 78829 00841 *9980 99676 *75322 00842 99811 99677 5845 00843 99812 99678 5846 00844 99813 99679 5847 00845 *99811 99690 5849 00846 9585 99691 585 00847 9954 99692 5996 *7756 9980 99693 78820 00841 99811 99694 78829 00842 99812 99695 *75323 00843 99813 99696 5845 00844 *99812 99699 5846 00845 9585 99700 5847 00846 9954 99701 5849 00847 9980 99702 585 *7757 99811 99709 ------------------------------------------------------------------------ [[Page 27551]] Table 6h.--Deletions to the CC Exclusions List Page 1 of 1 Page CCs that are deleted from the list are in Table 6H--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. ------------------------------------------------------------------------ ------------------------------------------------------------------------ *2910 30502 2918 2918 2918 9981 57421 2918 30530 *30303 *30471 *30563 *53261 57430 *2911 30531 2918 2918 2918 9981 57431 2918 30532 *30390 *30472 *30570 *53300 57440 *2912 30540 2918 2918 2918 9981 57441 2918 30541 *30391 *30473 *30571 *53301 57450 *2913 30542 2918 2918 2918 9981 57451 2918 30550 *30392 *30480 *30572 *53320 5750 *2914 30551 2918 2918 2918 9981 *5780 2918 30552 *30393 *30481 *30573 *53321 9981 *2915 30560 2918 2918 2918 9981 *5781 2918 30561 *30400 *30482 *30580 *53340 9981 *2918 30562 2918 2918 2918 9981 *5789 2910 30570 *30401 *30483 *30581 *53341 9981 2911 30571 2918 2918 2918 9981 *7526 2912 30572 *30402 *30490 *30582 *53360 5970 2913 30590 2918 2918 2918 9981 5981 2914 30591 *30403 *30491 *30583 *53361 5982 2918 30592 2918 2918 2918 9981 5994 2919 *2919 *30410 *30492 *30590 *53400 *7532 2920 2918 2918 2918 2918 9981 5845 29211 *2920 *30411 *30493 *30591 *53401 5846 29212 2918 2918 2918 2918 9981 5847 2922 *29211 *30412 *30500 *30592 *53420 5849 29281 2918 2918 2918 2918 9981 585 29282 *29212 *30413 *30501 *30593 *53421 5996 29283 2918 2918 2918 2918 9981 78820 29284 *2922 *30420 *30502 *4560 *53440 78829 29289 2918 2918 2918 9981 9981 *7724 2929 *29281 *30421 *30503 *45620 *53441 9981 29381 2918 2918 2918 9981 9981 *7903 29382 *29282 *30422 *30520 *53081 *53460 2918 29383 2918 2918 2918 9981 9981 *99791 30300 *29283 *30423 *30521 *53082 *53461 9981 30301 2918 2918 2918 9981 9981 9985 30302 *29284 *30430 *30522 *53083 *53501 *99799 30390 2918 2918 2918 9981 9981 9981 30391 *29289 *30431 *30523 *53089 *53511 9985 30392 2918 2918 2918 9981 9981 *9980 30400 *2929 *30432 *30530 *53100 *53521 9981 30401 2918 2918 2918 9981 9981 *9981 30402 *2930 *30433 *30531 *53101 *53531 9585 30410 2918 2918 2918 9981 9981 9954 30411 *2931 *30440 *30532 *53120 *53541 9980 30412 2918 2918 2918 9981 9981 9981 30420 *29381 *30441 *30533 *53121 *53551 *9985 30421 2918 2918 2918 9981 9981 9985 30422 *29382 *30442 *30540 *53140 *53561 *99881 30440 2918 2918 2918 9981 9981 9981 30441 *29383 *30443 *30541 *53141 *53783 9985 30442 2918 2918 2918 9981 9981 *99889 30450 *29389 *30450 *30542 *53160 *56202 9981 30451 2918 2918 2918 9981 9981 9985 30452 *2939 *30451 *30543 *53161 *56203 *9989 30460 2918 2918 2918 9981 9981 9981 30461 *2940 *30452 *30550 *53200 *56212 9985 30462 2918 2918 2918 9981 9981 30470 *2941 30453 *30551 *53201 *56213 30471 2918 2918 2918 9981 9981 30472 *2948 *30460 *30552 *53220 *5693 30480 2918 2918 2918 9981 9981 30481 *2949 *30461 *30553 *53221 *56985 30482 2918 2918 2918 9981 9981 30490 *30300 *30462 *30560 *53240 *5751 30491 2918 2918 2918 9981 57400 30492 *30301 *30463 *30561 *53241 57401 30500 2918 2918 2918 9981 57410 30501 *30302 *30470 *30562 *53260 57411 ------------------------------------------------------------------------ [[Page 27552]] Table 7a.--Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY95 MEDPAR Update 12/95 Grouper V13.0] -------------------------------------------------------------------------------------------------------------------------------------------------------- Number Arithmetic 10th 25th 50th 75th 90th DRG discharges mean LOS percentile percentile percentile percentile percentile -------------------------------------------------------------------------------------------------------------------------------------------------------- 1....................................... 32723 11.0372 3 4 8 14 23 2....................................... 6165 11.5178 3 5 8 14 23 3....................................... 1 10.0000 10 10 10 10 10 4....................................... 5866 9.1202 2 3 6 11 20 5....................................... 95896 4.4060 2 2 3 5 9 6....................................... 444 3.3581 1 1 2 4 7 7....................................... 10526 12.5752 3 5 8 14 25 8....................................... 2248 4.1348 1 1 3 5 9 9....................................... 1655 7.5287 2 3 5 9 16 10...................................... 19194 7.9610 2 3 6 10 16 11...................................... 2866 4.9215 1 2 4 6 10 12...................................... 23355 7.5868 2 3 5 9 14 13...................................... 5969 6.2406 2 4 5 7 11 14...................................... 351205 7.4178 2 3 6 9 14 15...................................... 138882 4.4367 1 2 3 5 8 16...................................... 11877 6.5858 2 3 5 8 12 17...................................... 3217 4.0258 1 2 3 5 7 18...................................... 22783 6.3682 2 3 5 8 12 19...................................... 7433 4.5271 1 2 4 6 8 20...................................... 5990 11.2129 3 5 9 15 22 21...................................... 1114 7.8905 2 3 6 10 16 22...................................... 2585 4.8584 2 2 4 6 9 23...................................... 5720 5.0336 1 2 4 6 10 24...................................... 53620 5.8059 2 3 4 7 11 25...................................... 21830 3.8592 1 2 3 5 7 26...................................... 46 4.6087 1 2 3 6 10 27...................................... 3475 6.2774 1 1 4 7 15 28...................................... 11179 7.0945 1 3 5 9 14 29...................................... 3684 4.0581 1 2 3 5 8 31...................................... 3167 5.4436 1 2 4 6 10 32...................................... 1723 3.1573 1 1 2 4 6 34...................................... 16272 6.4700 2 3 5 8 12 35...................................... 3648 4.2928 1 2 3 5 8 36...................................... 9010 1.5970 1 1 1 2 3 37...................................... 1878 4.0213 1 1 3 5 8 38...................................... 234 2.5385 1 1 2 3 5 39...................................... 3289 1.9663 1 1 1 2 4 40...................................... 2779 3.3843 1 1 2 4 7 42...................................... 7351 2.2049 1 1 1 2 5 43...................................... 97 4.0928 1 2 3 5 8 44...................................... 1614 5.7038 2 3 5 7 10 45...................................... 2412 3.8163 1 2 3 5 7 46...................................... 2952 5.4814 1 2 4 7 10 47...................................... 1333 3.7802 1 2 3 5 7 49...................................... 2139 5.6396 1 2 4 7 11 50...................................... 3347 2.1138 1 1 2 2 3 51...................................... 308 2.9870 1 1 1 3 7 52...................................... 78 3.6282 1 1 2 3 8 53...................................... 3340 3.5548 1 1 2 4 8 54...................................... 1 1.0000 1 1 1 1 1 55...................................... 1924 2.9569 1 1 2 3 6 56...................................... 704 2.7514 1 1 2 3 6 57...................................... 637 4.0973 1 1 3 5 8 59...................................... 88 3.7045 1 1 2 4 7 60...................................... 3 1.0000 1 1 1 1 1 61...................................... 217 5.2535 1 1 2 7 14 62...................................... 1 2.0000 2 2 2 2 2 63...................................... 3996 4.6652 1 2 3 5 10 64...................................... 3351 7.5067 1 2 5 9 16 65...................................... 29525 3.4147 1 2 3 4 6 66...................................... 6479 3.5658 1 2 3 4 6 67...................................... 510 4.2039 2 2 3 5 8 68...................................... 9443 4.7605 2 3 4 6 9 69...................................... 3062 3.7606 1 2 3 5 7 70...................................... 30 3.0667 1 2 3 3 5 71...................................... 90 4.1556 1 2 3 5 8 72...................................... 561 4.3529 1 2 3 5 9 73...................................... 6017 4.9493 1 2 4 6 9 75...................................... 39401 11.1088 4 6 8 14 21 76...................................... 38785 12.4555 3 6 10 15 24 [[Page 27553]] 77...................................... 2331 5.5268 1 2 4 8 12 78...................................... 28979 8.2306 4 5 7 10 13 79...................................... 207606 9.2488 3 5 7 11 17 80...................................... 8932 6.6160 2 4 5 8 12 81...................................... 9 7.2222 1 2 6 11 12 82...................................... 68573 7.8881 2 3 6 10 16 83...................................... 6976 6.3817 2 3 5 8 12 84...................................... 1430 3.7217 1 2 3 5 7 85...................................... 18398 7.3317 2 3 6 9 14 86...................................... 1372 4.5117 1 2 4 6 9 87...................................... 58612 6.7959 1 3 6 9 13 88...................................... 345365 6.0658 2 3 5 7 11 89...................................... 415072 7.0754 3 4 6 9 12 90...................................... 40306 5.1392 2 3 4 6 9 91...................................... 50 4.5800 2 2 3 6 8 92...................................... 11849 7.2524 2 4 6 9 13 93...................................... 1262 4.9374 1 3 4 6 9 94...................................... 12531 7.0527 2 3 5 9 14 95...................................... 1365 4.1341 1 2 3 5 8 96...................................... 60887 5.5101 2 3 5 7 10 97...................................... 25835 4.2614 2 2 4 5 7 98...................................... 19 4.4737 1 1 3 6 10 99...................................... 25241 3.4914 1 2 3 4 7 100..................................... 10191 2.4244 1 1 2 3 4 101..................................... 19810 5.1725 1 2 4 7 10 102..................................... 4399 3.1298 1 1 2 4 6 103..................................... 445 39.3528 10 15 29 53 80 104..................................... 22854 14.5510 6 8 12 18 26 105..................................... 19821 10.9286 5 7 9 13 19 106..................................... 96166 11.7202 6 8 10 14 19 107..................................... 61255 8.8314 5 6 7 10 14 108..................................... 6560 12.5834 4 7 10 15 23 110..................................... 59173 10.7795 3 6 9 13 20 111..................................... 5800 6.6512 3 5 6 8 10 112..................................... 191511 4.6987 1 2 4 6 9 113..................................... 45003 14.3320 4 6 10 17 28 114..................................... 8788 9.4467 2 4 7 12 18 115..................................... 10395 11.3715 4 6 9 14 20 116..................................... 81298 5.4177 1 2 4 7 11 117..................................... 4482 4.1142 1 1 2 5 8 118..................................... 6687 3.1952 1 1 2 4 7 119..................................... 1705 5.4985 1 1 3 7 13 120..................................... 40465 9.1860 1 2 6 12 21 121..................................... 158928 7.4120 2 4 6 9 13 122..................................... 87089 5.0036 1 3 5 6 9 123..................................... 46281 4.6510 1 1 2 6 11 124..................................... 138564 4.8885 1 2 4 6 9 125..................................... 59232 3.0694 1 1 2 4 6 126..................................... 4619 13.9985 4 7 11 17 29 127..................................... 670461 6.2113 2 3 5 8 12 128..................................... 19612 6.7259 3 4 6 8 11 129..................................... 4584 3.4271 1 1 1 4 9 130..................................... 91826 6.6818 2 4 6 8 12 131..................................... 25592 5.1808 1 3 5 7 8 132..................................... 127274 3.5716 1 2 3 4 6 133..................................... 5813 2.9696 1 1 2 4 5 134..................................... 28493 3.9142 1 2 3 5 7 135..................................... 7141 4.9779 1 2 4 6 9 136..................................... 1014 3.2209 1 2 3 4 6 138..................................... 195932 4.5466 1 2 3 6 8 139..................................... 67345 2.9337 1 1 2 4 5 140..................................... 175930 3.4831 1 2 3 4 6 141..................................... 76111 4.4923 1 2 3 5 8 142..................................... 35701 3.1999 1 2 2 4 6 143..................................... 132318 2.6077 1 1 2 3 5 144..................................... 66761 5.6816 1 2 4 7 11 145..................................... 6735 3.2413 1 1 2 4 6 146..................................... 8626 11.2570 6 7 9 13 18 147..................................... 1624 7.3651 4 6 7 9 11 148..................................... 140141 13.4097 6 8 11 16 24 [[Page 27554]] 149..................................... 15769 7.7194 4 6 7 9 11 150..................................... 22516 11.6884 4 7 10 14 21 151..................................... 4518 6.4748 2 4 6 8 11 152..................................... 4469 9.0257 4 6 8 10 15 153..................................... 1710 6.1655 3 4 6 8 9 154..................................... 35661 14.9524 5 8 12 18 28 155..................................... 4557 5.8824 2 3 5 8 10 156..................................... 4 15.7500 4 4 10 22 27 157..................................... 11419 5.7824 1 2 4 7 11 158..................................... 5082 2.9124 1 1 2 4 6 159..................................... 17132 5.3155 1 2 4 7 10 160..................................... 9971 2.9553 1 1 2 4 5 161..................................... 14786 4.3655 1 2 3 5 9 162..................................... 7990 2.1914 1 1 2 3 4 163..................................... 5 2.2000 1 1 1 3 5 164..................................... 4995 9.2993 4 6 8 11 16 165..................................... 1674 5.7575 3 4 5 7 9 166..................................... 3283 5.7286 2 3 4 7 10 167..................................... 2284 3.2439 1 2 3 4 6 168..................................... 1739 4.8562 1 2 3 6 10 169..................................... 1025 2.5473 1 1 2 3 5 170..................................... 12463 12.4436 2 5 9 15 25 171..................................... 1157 5.4105 1 2 4 7 11 172..................................... 30820 8.1481 2 3 6 10 16 173..................................... 2188 4.2870 1 2 3 5 9 174..................................... 231782 5.5456 2 3 4 7 10 175..................................... 23071 3.5073 1 2 3 4 6 176..................................... 16011 6.1346 2 3 5 7 11 177..................................... 11991 4.9873 2 3 4 6 9 178..................................... 4174 3.6195 1 2 3 5 7 179..................................... 11198 7.1657 2 4 6 9 14 180..................................... 79145 6.0471 2 3 5 7 11 181..................................... 22152 3.9606 1 2 3 5 7 182..................................... 226099 4.9591 2 2 4 6 9 183..................................... 72147 3.4552 1 2 3 4 6 184..................................... 67 3.7463 1 2 2 4 6 185..................................... 3804 5.1966 1 2 4 6 10 186..................................... 1 2.0000 2 2 2 2 2 187..................................... 832 4.2524 1 2 3 6 8 188..................................... 61112 6.1262 2 3 5 8 12 189..................................... 7787 3.6773 1 1 3 5 7 190..................................... 62 4.8548 1 3 4 6 10 191..................................... 10459 16.1606 5 8 12 20 32 192..................................... 880 7.9625 2 4 7 9 14 193..................................... 8477 13.8662 5 8 11 17 25 194..................................... 805 8.4348 3 5 7 10 15 195..................................... 9196 10.4533 4 6 9 12 18 196..................................... 796 6.7651 3 4 6 8 11 197..................................... 28016 9.1380 4 5 7 11 16 198..................................... 7906 4.9586 2 3 4 6 8 199..................................... 2208 11.1005 3 5 9 14 22 200..................................... 1525 11.8413 2 4 8 14 25 201..................................... 1466 16.5750 4 7 13 21 34 202..................................... 25094 7.6794 2 3 6 9 15 203..................................... 28743 7.6566 2 3 6 10 15 204..................................... 49035 6.6942 2 3 5 8 13 205..................................... 21512 7.2152 2 3 5 9 14 206..................................... 1692 4.7305 1 2 4 6 10 207..................................... 35330 5.7193 2 3 4 7 11 208..................................... 10251 3.4474 1 2 3 4 6 209..................................... 328015 6.6569 3 4 6 7 10 210..................................... 131592 8.5557 4 5 7 10 14 211..................................... 25325 6.2610 3 4 6 7 10 212..................................... 9 5.0000 2 3 4 5 8 213..................................... 6788 9.6117 3 4 7 12 19 214..................................... 51282 6.4551 2 3 5 8 12 215..................................... 41115 3.6816 1 2 3 5 7 216..................................... 6435 11.0449 2 5 8 14 22 217..................................... 19341 15.2991 3 6 10 18 31 218..................................... 21844 6.2064 2 3 5 7 11 [[Page 27555]] 219..................................... 17973 3.7492 1 2 3 5 6 220..................................... 2 5.5000 5 5 6 6 6 221..................................... 4962 8.1475 2 4 6 10 16 222..................................... 3560 4.0573 1 2 3 5 8 223..................................... 18306 2.8650 1 1 2 3 5 224..................................... 7946 2.2699 1 1 2 3 4 225..................................... 6199 5.0045 1 2 3 6 11 226..................................... 5349 6.7080 1 2 4 8 14 227..................................... 4604 2.9622 1 1 2 4 6 228..................................... 3014 3.5551 1 1 2 4 7 229..................................... 1345 2.4007 1 1 2 3 5 230..................................... 2455 5.1548 1 2 3 6 11 231..................................... 10331 5.0624 1 2 3 6 11 232..................................... 576 4.5017 1 1 2 5 10 233..................................... 4538 8.9595 2 4 7 11 18 234..................................... 2220 4.1730 1 2 3 5 8 235..................................... 5543 6.7231 1 3 4 7 13 236..................................... 37803 6.2862 2 3 5 7 12 237..................................... 1510 4.4139 1 2 3 5 8 238..................................... 7538 10.0649 3 5 7 12 19 239..................................... 59581 7.6027 2 4 6 9 14 240..................................... 12047 7.4987 2 3 5 9 15 241..................................... 3019 4.6277 1 2 4 6 9 242..................................... 2528 7.6606 2 4 6 9 15 243..................................... 79979 5.6107 2 3 4 7 10 244..................................... 11456 5.8092 2 3 4 7 11 245..................................... 4259 4.2158 1 2 3 5 8 246..................................... 1312 4.5899 1 2 4 6 9 247..................................... 10591 3.9716 1 2 3 5 8 248..................................... 6767 5.2815 1 2 4 6 10 249..................................... 10077 4.2995 1 2 3 5 9 250..................................... 3178 4.9091 1 2 3 6 9 251..................................... 2090 3.2933 1 1 3 4 6 252..................................... 1 1.0000 1 1 1 1 1 253..................................... 17469 5.8164 2 3 4 7 11 254..................................... 9208 3.8588 1 2 3 5 7 255..................................... 1 2.0000 2 2 2 2 2 256..................................... 4600 5.7178 1 2 4 7 11 257..................................... 23640 3.4239 1 2 3 4 6 258..................................... 18784 2.4905 1 2 2 3 4 259..................................... 4010 3.5077 1 1 2 3 7 260..................................... 4868 1.8683 1 1 1 2 3 261..................................... 2334 2.3500 1 1 2 3 4 262..................................... 712 3.9284 1 1 2 5 8 263..................................... 29088 13.8669 4 6 10 16 28 264..................................... 3559 8.3442 2 4 6 10 17 265..................................... 4274 7.6467 1 2 5 9 16 266..................................... 2712 3.6855 1 1 3 5 7 267..................................... 222 4.0811 1 1 3 5 9 268..................................... 891 4.0000 1 1 2 4 9 269..................................... 10173 9.1218 2 3 7 12 18 270..................................... 3456 3.3958 1 1 2 4 8 271..................................... 21515 8.4984 3 4 7 10 15 272..................................... 5863 7.4481 2 3 6 9 14 273..................................... 1426 5.5035 2 2 4 7 11 274..................................... 2526 7.7458 2 3 5 9 15 275..................................... 250 3.5040 1 1 2 4 8 276..................................... 889 5.0472 1 2 4 6 9 277..................................... 79054 6.7240 3 4 5 8 12 278..................................... 26008 5.1420 2 3 4 6 9 279..................................... 5 4.8000 2 2 3 4 12 280..................................... 13098 5.1142 1 2 4 6 9 281..................................... 5890 3.6448 1 2 3 4 7 283..................................... 5233 5.4888 2 2 4 7 10 284..................................... 1755 3.8632 1 2 3 5 7 285..................................... 4886 13.5014 3 6 10 16 26 286..................................... 1918 8.7195 3 4 6 9 16 287..................................... 6284 13.3908 3 6 9 16 26 288..................................... 957 7.0449 2 4 5 7 11 289..................................... 4992 3.9732 1 2 2 4 8 [[Page 27556]] 290..................................... 8514 2.8404 1 1 2 3 5 291..................................... 86 1.7558 1 1 1 2 3 292..................................... 5046 12.6958 2 5 9 16 25 293..................................... 294 6.4456 1 3 5 8 14 294..................................... 86024 5.6681 2 3 4 7 10 295..................................... 3712 4.2826 1 2 3 5 8 296..................................... 218940 6.3561 2 3 5 8 12 297..................................... 31455 4.2781 1 2 3 5 8 298..................................... 95 3.0211 1 1 2 4 5 299..................................... 868 5.3652 1 2 4 7 10 300..................................... 14115 7.3032 2 3 6 9 14 301..................................... 2146 4.3877 1 2 3 6 9 302..................................... 7567 12.3190 6 7 9 14 21 303..................................... 18462 10.1938 4 6 8 12 18 304..................................... 12867 10.2970 3 5 7 13 21 305..................................... 2526 4.9097 1 3 4 6 9 306..................................... 11305 6.2204 2 2 4 8 13 307..................................... 2596 2.9819 1 2 2 3 5 308..................................... 9137 7.0113 1 2 5 9 15 309..................................... 3371 3.0009 1 1 2 4 6 310..................................... 28549 4.6077 1 2 3 6 9 311..................................... 9697 2.1734 1 1 2 3 4 312..................................... 1995 4.7895 1 2 3 6 10 313..................................... 745 2.2644 1 1 2 3 5 314..................................... 1 5.0000 5 5 5 5 5 315..................................... 27722 9.2695 1 2 6 12 20 316..................................... 69941 7.4958 2 3 6 9 15 317..................................... 779 2.8434 1 1 2 3 6 318..................................... 5981 7.1195 2 3 5 9 14 319..................................... 506 3.2174 1 1 2 4 7 320..................................... 169078 6.4297 2 3 5 8 11 321..................................... 25512 4.7020 2 3 4 6 8 322..................................... 81 4.3580 2 2 4 6 8 323..................................... 17690 3.5573 1 2 3 4 7 324..................................... 8755 2.0870 1 1 2 3 4 325..................................... 7381 4.5898 1 2 3 5 9 326..................................... 2186 3.4492 1 1 2 4 6 327..................................... 8 3.1250 1 2 2 2 4 328..................................... 817 4.2742 1 2 3 5 9 329..................................... 109 2.7523 1 1 2 3 5 330..................................... 1 1.0000 1 1 1 1 1 331..................................... 38181 6.1753 2 3 5 8 12 332..................................... 4687 3.8835 1 2 3 5 8 333..................................... 357 5.8319 1 3 4 7 13 334..................................... 19011 6.0503 3 4 5 7 9 335..................................... 9821 4.5786 2 3 4 6 7 336..................................... 60748 4.1251 1 2 3 5 8 337..................................... 38538 2.6717 1 2 2 3 4 338..................................... 4813 5.2703 1 2 3 6 11 339..................................... 2302 4.9392 1 2 3 6 10 340..................................... 2 3.0000 1 1 5 5 5 341..................................... 6427 3.2367 1 1 2 4 6 342..................................... 224 4.0089 1 1 2 5 8 344..................................... 3820 3.4652 1 1 2 4 7 345..................................... 1355 3.9734 1 2 3 4 9 346..................................... 5343 6.7477 1 3 5 8 14 347..................................... 418 3.3349 1 1 2 4 7 348..................................... 3021 4.8875 1 2 4 6 9 349..................................... 684 2.9956 1 1 2 4 6 350..................................... 6884 4.7451 2 3 4 6 8 352..................................... 576 3.9392 1 2 3 5 8 353..................................... 2621 8.3564 3 5 6 10 15 354..................................... 9693 6.3330 3 4 5 7 11 355..................................... 5607 3.8639 2 3 4 4 6 356..................................... 28647 3.0247 1 2 3 4 5 357..................................... 6526 9.8462 4 5 8 12 18 358..................................... 26797 4.7425 2 3 4 5 8 359..................................... 27392 3.2715 2 3 3 4 5 360..................................... 16717 3.5393 1 2 3 4 6 361..................................... 618 3.4644 1 1 2 4 7 [[Page 27557]] 363..................................... 4355 3.4953 1 2 2 3 6 364..................................... 1778 3.6310 1 1 2 5 8 365..................................... 2396 8.1123 2 3 5 10 18 366..................................... 4470 7.6707 2 3 5 10 16 367..................................... 544 3.3107 1 1 2 4 7 368..................................... 2285 6.9190 2 3 5 9 13 369..................................... 2409 3.7410 1 1 3 5 7 370..................................... 1083 5.5568 3 3 4 5 9 371..................................... 950 3.5874 2 3 3 4 5 372..................................... 809 3.3498 1 2 2 3 6 373..................................... 3637 1.9249 1 1 2 2 3 374..................................... 116 2.3621 1 2 2 2 3 375..................................... 5 2.2000 1 1 2 3 4 376..................................... 151 3.4834 1 1 2 4 8 377..................................... 26 3.2308 1 1 1 3 8 378..................................... 163 2.9755 1 2 3 3 5 379..................................... 309 2.9256 1 1 2 3 5 380..................................... 71 2.3239 1 1 2 3 4 381..................................... 194 2.2835 1 1 1 2 5 382..................................... 47 1.6596 1 1 1 1 3 383..................................... 1455 4.0460 1 2 3 5 8 384..................................... 123 3.3496 1 1 1 3 7 385..................................... 3 17.0000 1 1 1 49 49 389..................................... 24 10.6667 3 4 8 10 18 390..................................... 10 5.0000 1 2 3 6 9 392..................................... 2467 11.6700 4 6 8 15 24 394..................................... 1642 7.8831 1 2 5 9 16 395..................................... 65671 5.3672 1 2 4 7 10 396..................................... 18 3.9444 1 1 3 7 8 397..................................... 15421 6.0683 2 3 4 7 12 398..................................... 16602 6.5798 2 3 5 8 12 399..................................... 1424 4.4347 1 2 4 6 8 400..................................... 7470 10.3424 2 4 7 13 23 401..................................... 6368 12.3990 2 5 9 16 25 402..................................... 1542 4.6984 1 1 3 6 10 403..................................... 34812 9.2838 2 4 7 12 19 404..................................... 3946 5.0867 1 2 4 7 10 406..................................... 3264 11.1468 3 5 8 14 23 407..................................... 723 4.9267 1 2 4 6 9 408..................................... 2949 8.2035 1 2 5 10 18 409..................................... 5649 6.6516 2 3 4 6 14 410..................................... 85873 3.3544 1 2 3 4 5 411..................................... 50 2.5600 1 1 2 3 7 412..................................... 35 3.0857 1 1 2 4 8 413..................................... 8421 8.2956 2 3 6 10 17 414..................................... 797 5.2070 1 2 4 7 11 415..................................... 38804 15.6974 4 7 12 19 31 416..................................... 192133 8.2122 2 4 7 10 15 417..................................... 45 4.6222 1 2 4 7 10 418..................................... 18663 6.7433 2 3 5 8 13 419..................................... 15677 5.6580 2 3 4 7 10 420..................................... 2871 4.3006 2 2 4 5 8 421..................................... 11386 4.6473 2 2 4 6 8 422..................................... 89 3.6854 1 2 3 4 7 423..................................... 9118 8.6534 2 4 6 10 18 424..................................... 1990 17.7397 3 6 12 20 34 425..................................... 15247 4.8955 1 2 3 6 10 426..................................... 4721 5.4938 1 2 4 7 11 427..................................... 1773 5.2775 1 2 4 7 11 428..................................... 904 8.4303 1 3 5 10 18 429..................................... 38861 8.9079 2 3 6 10 17 430..................................... 53430 9.7495 2 4 7 12 19 431..................................... 190 7.4632 1 3 5 9 14 432..................................... 430 6.3395 1 2 4 6 11 433..................................... 7843 3.4051 1 1 2 4 7 434..................................... 20810 5.8148 2 3 4 7 11 435..................................... 15477 4.8166 1 3 4 6 8 436..................................... 2915 14.5413 4 8 14 21 28 437..................................... 14205 10.8943 4 6 10 14 20 439..................................... 867 8.9262 2 3 6 11 18 [[Page 27558]] 440..................................... 4751 9.7838 2 3 6 12 21 441..................................... 611 4.4386 1 1 2 4 7 442..................................... 13818 8.7372 1 3 6 11 18 443..................................... 3299 3.5335 1 1 2 5 7 444..................................... 3319 5.3203 1 3 4 6 10 445..................................... 1321 3.7858 1 2 3 5 7 446..................................... 1 1.0000 1 1 1 1 1 447..................................... 3816 2.7953 1 1 2 3 5 448..................................... 84 1.0000 1 1 1 1 1 449..................................... 28775 4.4101 1 2 3 5 9 450..................................... 6807 2.3364 1 1 2 3 5 451..................................... 7 6.1429 2 3 4 5 7 452..................................... 19382 5.4066 1 2 4 6 11 453..................................... 3636 3.1876 1 1 2 4 6 454..................................... 5132 5.1046 1 2 3 6 10 455..................................... 1092 2.8333 1 1 2 3 5 456..................................... 194 8.3711 1 1 4 9 21 457..................................... 127 4.7953 1 1 2 5 10 458..................................... 1550 16.9387 4 7 13 22 35 459..................................... 533 10.3471 2 4 7 13 22 460..................................... 2303 6.6309 1 3 5 8 13 461..................................... 3040 4.8862 1 1 2 5 12 462..................................... 9360 13.7955 5 6 12 18 26 463..................................... 11987 5.1410 1 2 4 6 10 464..................................... 3079 3.7347 1 2 3 5 7 465..................................... 197 3.9086 1 1 2 4 7 466..................................... 1838 4.6366 1 1 2 4 10 467..................................... 1722 4.1057 1 1 2 4 8 468..................................... 58649 15.1829 3 7 12 19 30 471..................................... 9111 8.0289 4 5 6 9 13 472..................................... 150 30.6667 2 9 28 41 62 473..................................... 8217 14.3113 2 4 8 21 35 475..................................... 89514 12.1394 2 5 10 16 24 476..................................... 6875 13.7876 3 7 11 17 25 477..................................... 28128 8.8453 1 3 6 11 18 478..................................... 117755 8.2916 1 3 6 10 17 479..................................... 17758 4.5591 1 2 4 6 9 480..................................... 359 29.7159 10 13 22 37 61 481..................................... 119 35.0000 21 23 30 39 59 482..................................... 6754 14.9011 5 8 11 17 28 483..................................... 36200 45.7958 15 23 37 56 84 484..................................... 327 15.3364 2 6 11 21 32 485..................................... 3165 11.5893 4 6 9 13 21 486..................................... 2045 13.3482 1 6 11 18 28 487..................................... 3765 8.8770 1 3 7 11 17 488..................................... 1593 17.5267 5 8 13 22 35 489..................................... 17612 10.3989 2 4 7 13 22 490..................................... 4999 6.5719 1 2 4 8 14 491..................................... 9441 4.2777 2 3 3 5 7 492..................................... 2029 17.3834 3 5 10 28 37 493..................................... 52260 5.8809 1 2 5 8 11 494..................................... 27127 2.4245 1 1 2 3 5 495..................................... 107 23.7944 10 13 18 29 41 ================ 10571233 -------------------------------------------------------------------------------------------------------------------------------------------------------- Table 7b.--Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY95 MEDPAR Update 12/95 Grouper V14.0] -------------------------------------------------------------------------------------------------------------------------------------------------------- Number Arithmetic 10th 25th 50th 75th 90th DRG discharges mean LOS percentile percentile percentile percentile percentile -------------------------------------------------------------------------------------------------------------------------------------------------------- 1....................................... 32723 11.0372 3 4 8 14 23 2....................................... 6165 11.5178 3 5 8 14 23 3....................................... 1 10.0000 10 10 10 10 10 4....................................... 5866 9.1202 2 3 6 11 20 5....................................... 95896 4.4060 2 2 3 5 9 6....................................... 444 3.3581 1 1 2 4 7 7....................................... 10526 12.5752 3 5 8 14 25 [[Page 27559]] 8....................................... 2248 4.1348 1 1 3 5 9 9....................................... 1655 7.5287 2 3 5 9 16 10...................................... 19194 7.9610 2 3 6 10 16 11...................................... 2866 4.9215 1 2 4 6 10 12...................................... 23355 7.5868 2 3 5 9 14 13...................................... 5969 6.2406 2 4 5 7 11 14...................................... 351205 7.4178 2 3 6 9 14 15...................................... 138882 4.4367 1 2 3 5 8 16...................................... 11877 6.5858 2 3 5 8 12 17...................................... 3217 4.0258 1 2 3 5 7 18...................................... 22783 6.3682 2 3 5 8 12 19...................................... 7433 4.5271 1 2 4 6 8 20...................................... 5990 11.2129 3 5 9 15 22 21...................................... 1114 7.8905 2 3 6 10 16 22...................................... 2585 4.8584 2 2 4 6 9 23...................................... 5720 5.0336 1 2 4 6 10 24...................................... 53620 5.8059 2 3 4 7 11 25...................................... 21830 3.8592 1 2 3 5 7 26...................................... 46 4.6087 1 2 3 6 10 27...................................... 3475 6.2774 1 1 4 7 15 28...................................... 11179 7.0945 1 3 5 9 14 29...................................... 3684 4.0581 1 2 3 5 8 31...................................... 3167 5.4436 1 2 4 6 10 32...................................... 1723 3.1573 1 1 2 4 6 34...................................... 16272 6.4700 2 3 5 8 12 35...................................... 3648 4.2928 1 2 3 5 8 36...................................... 9010 1.5970 1 1 1 2 3 37...................................... 1878 4.0213 1 1 3 5 8 38...................................... 234 2.5385 1 1 2 3 5 39...................................... 3289 1.9663 1 1 1 2 4 40...................................... 2779 3.3843 1 1 2 4 7 42...................................... 7351 2.2049 1 1 1 2 5 43...................................... 97 4.0928 1 2 3 5 8 44...................................... 1614 5.7038 2 3 5 7 10 45...................................... 2412 3.8163 1 2 3 5 7 46...................................... 2952 5.4814 1 2 4 7 10 47...................................... 1333 3.7802 1 2 3 5 7 49...................................... 2139 5.6396 1 2 4 7 11 50...................................... 3347 2.1138 1 1 2 2 3 51...................................... 308 2.9870 1 1 1 3 7 52...................................... 78 3.6282 1 1 2 3 8 53...................................... 3340 3.5548 1 1 2 4 8 54...................................... 1 1.0000 1 1 1 1 1 55...................................... 1924 2.9569 1 1 2 3 6 56...................................... 704 2.7514 1 1 2 3 6 57...................................... 637 4.0973 1 1 3 5 8 59...................................... 88 3.7045 1 1 2 4 7 60...................................... 3 1.0000 1 1 1 1 1 61...................................... 217 5.2535 1 1 2 7 14 62...................................... 1 2.0000 2 2 2 2 2 63...................................... 3996 4.6652 1 2 3 5 10 64...................................... 3351 7.5067 1 2 5 9 16 65...................................... 29525 3.4147 1 2 3 4 6 66...................................... 6479 3.5658 1 2 3 4 6 67...................................... 510 4.2039 2 2 3 5 8 68...................................... 9443 4.7605 2 3 4 6 9 69...................................... 3062 3.7606 1 2 3 5 7 70...................................... 30 3.0667 1 2 3 3 5 71...................................... 90 4.1556 1 2 3 5 8 72...................................... 561 4.3529 1 2 3 5 9 73...................................... 6017 4.9493 1 2 4 6 9 75...................................... 39401 11.1088 4 6 8 14 21 76...................................... 38785 12.4555 3 6 10 15 24 77...................................... 2331 5.5268 1 2 4 8 12 78...................................... 28979 8.2306 4 5 7 10 13 79...................................... 207606 9.2488 3 5 7 11 17 80...................................... 8932 6.6160 2 4 5 8 12 81...................................... 9 7.2222 1 2 6 11 12 82...................................... 68573 7.8881 2 3 6 10 16 83...................................... 6976 6.3817 2 3 5 8 12 [[Page 27560]] 84...................................... 1430 3.7217 1 2 3 5 7 85...................................... 18398 7.3317 2 3 6 9 14 86...................................... 1372 4.5117 1 2 4 6 9 87...................................... 58612 6.7959 1 3 6 9 13 88...................................... 345365 6.0658 2 3 5 7 11 89...................................... 415072 7.0754 3 4 6 9 12 90...................................... 40306 5.1392 2 3 4 6 9 91...................................... 50 4.5800 2 2 3 6 8 92...................................... 11849 7.2524 2 4 6 9 13 93...................................... 1262 4.9374 1 3 4 6 9 94...................................... 12531 7.0527 2 3 5 9 14 95...................................... 1365 4.1341 1 2 3 5 8 96...................................... 60887 5.5101 2 3 5 7 10 97...................................... 25835 4.2614 2 2 4 5 7 98...................................... 19 4.4737 1 1 3 6 10 99...................................... 25241 3.4914 1 2 3 4 7 100..................................... 10191 2.4244 1 1 2 3 4 101..................................... 19810 5.1725 1 2 4 7 10 102..................................... 4399 3.1298 1 1 2 4 6 103..................................... 445 39.3528 10 15 29 53 80 104..................................... 22854 14.5510 6 8 12 18 26 105..................................... 19821 10.9286 5 7 9 13 19 106..................................... 96166 11.7202 6 8 10 14 19 107..................................... 61255 8.8314 5 6 7 10 14 108..................................... 6560 12.5834 4 7 10 15 23 110..................................... 59173 10.7795 3 6 9 13 20 111..................................... 5800 6.6512 3 5 6 8 10 112..................................... 191511 4.6987 1 2 4 6 9 113..................................... 45003 14.3320 4 6 10 17 28 114..................................... 8788 9.4467 2 4 7 12 18 115..................................... 10395 11.3715 4 6 9 14 20 116..................................... 81298 5.4177 1 2 4 7 11 117..................................... 4482 4.1142 1 1 2 5 8 118..................................... 6687 3.1952 1 1 2 4 7 119..................................... 1705 5.4985 1 1 3 7 13 120..................................... 40465 9.1860 1 2 6 12 21 121..................................... 158928 7.4120 2 4 6 9 13 122..................................... 87089 5.0036 1 3 5 6 9 123..................................... 46281 4.6510 1 1 2 6 11 124..................................... 138564 4.8885 1 2 4 6 9 125..................................... 59232 3.0694 1 1 2 4 6 126..................................... 4619 13.9985 4 7 11 17 29 127..................................... 670461 6.2113 2 3 5 8 12 128..................................... 19612 6.7259 3 4 6 8 11 129..................................... 4584 3.4271 1 1 1 4 9 130..................................... 91826 6.6818 2 4 6 8 12 131..................................... 25592 5.1808 1 3 5 7 8 132..................................... 127274 3.5716 1 2 3 4 6 133..................................... 5813 2.9696 1 1 2 4 5 134..................................... 28493 3.9142 1 2 3 5 7 135..................................... 7141 4.9779 1 2 4 6 9 136..................................... 1014 3.2209 1 2 3 4 6 138..................................... 195932 4.5466 1 2 3 6 8 139..................................... 67345 2.9337 1 1 2 4 5 140..................................... 175930 3.4831 1 2 3 4 6 141..................................... 76111 4.4923 1 2 3 5 8 142..................................... 35701 3.1999 1 2 2 4 6 143..................................... 132318 2.6077 1 1 2 3 5 144..................................... 66761 5.6816 1 2 4 7 11 145..................................... 6735 3.2413 1 1 2 4 6 146..................................... 8626 11.2570 6 7 9 13 18 147..................................... 1624 7.3651 4 6 7 9 11 148..................................... 140141 13.4097 6 8 11 16 24 149..................................... 15769 7.7194 4 6 7 9 11 150..................................... 22516 11.6884 4 7 10 14 21 151..................................... 4518 6.4748 2 4 6 8 11 152..................................... 4469 9.0257 4 6 8 10 15 153..................................... 1710 6.1655 3 4 6 8 9 154..................................... 35661 14.9524 5 8 12 18 28 155..................................... 4557 5.8824 2 3 5 8 10 [[Page 27561]] 156..................................... 4 15.7500 4 4 10 22 27 157..................................... 11419 5.7824 1 2 4 7 11 158..................................... 5082 2.9124 1 1 2 4 6 159..................................... 17132 5.3155 1 2 4 7 10 160..................................... 9971 2.9553 1 1 2 4 5 161..................................... 14786 4.3655 1 2 3 5 9 162..................................... 7990 2.1914 1 1 2 3 4 163..................................... 5 2.2000 1 1 1 3 5 164..................................... 4995 9.2993 4 6 8 11 16 165..................................... 1674 5.7575 3 4 5 7 9 166..................................... 3283 5.7286 2 3 4 7 10 167..................................... 2284 3.2439 1 2 3 4 6 168..................................... 1739 4.8562 1 2 3 6 10 169..................................... 1025 2.5473 1 1 2 3 5 170..................................... 12463 12.4436 2 5 9 15 25 171..................................... 1157 5.4105 1 2 4 7 11 172..................................... 30820 8.1481 2 3 6 10 16 173..................................... 2188 4.2870 1 2 3 5 9 174..................................... 231782 5.5456 2 3 4 7 10 175..................................... 23071 3.5073 1 2 3 4 6 176..................................... 16011 6.1346 2 3 5 7 11 177..................................... 11991 4.9873 2 3 4 6 9 178..................................... 4174 3.6195 1 2 3 5 7 179..................................... 11198 7.1657 2 4 6 9 14 180..................................... 79145 6.0471 2 3 5 7 11 181..................................... 22152 3.9606 1 2 3 5 7 182..................................... 226099 4.9591 2 2 4 6 9 183..................................... 72147 3.4552 1 2 3 4 6 184..................................... 67 3.7463 1 2 2 4 6 185..................................... 3804 5.1966 1 2 4 6 10 186..................................... 1 2.0000 2 2 2 2 2 187..................................... 832 4.2524 1 2 3 6 8 188..................................... 61112 6.1262 2 3 5 8 12 189..................................... 7787 3.6773 1 1 3 5 7 190..................................... 62 4.8548 1 3 4 6 10 191..................................... 10459 16.1606 5 8 12 20 32 192..................................... 880 7.9625 2 4 7 9 14 193..................................... 8477 13.8662 5 8 11 17 25 194..................................... 805 8.4348 3 5 7 10 15 195..................................... 9196 10.4533 4 6 9 12 18 196..................................... 796 6.7651 3 4 6 8 11 197..................................... 28016 9.1380 4 5 7 11 16 198..................................... 7906 4.9586 2 3 4 6 8 199..................................... 2208 11.1005 3 5 9 14 22 200..................................... 1525 11.8413 2 4 8 14 25 201..................................... 1466 16.5750 4 7 13 21 34 202..................................... 25094 7.6794 2 3 6 9 15 203..................................... 28743 7.6566 2 3 6 10 15 204..................................... 49035 6.6942 2 3 5 8 13 205..................................... 21512 7.2152 2 3 5 9 14 206..................................... 1692 4.7305 1 2 4 6 10 207..................................... 35330 5.7193 2 3 4 7 11 208..................................... 10251 3.4474 1 2 3 4 6 209..................................... 328015 6.6569 3 4 6 7 10 210..................................... 131592 8.5557 4 5 7 10 14 211..................................... 25325 6.2610 3 4 6 7 10 212..................................... 9 5.0000 2 3 4 5 8 213..................................... 6789 9.6170 3 4 7 12 19 214..................................... 51282 6.4551 2 3 5 8 12 215..................................... 41115 3.6816 1 2 3 5 7 216..................................... 6435 11.0449 2 5 8 14 22 217..................................... 19341 15.2991 3 6 10 18 31 218..................................... 21844 6.2064 2 3 5 7 11 219..................................... 17973 3.7492 1 2 3 5 6 220..................................... 2 5.5000 5 5 6 6 6 221..................................... 4962 8.1475 2 4 6 10 16 222..................................... 3560 4.0573 1 2 3 5 8 223..................................... 18306 2.8650 1 1 2 3 5 224..................................... 7946 2.2699 1 1 2 3 4 225..................................... 6199 5.0045 1 2 3 6 11 [[Page 27562]] 226..................................... 5349 6.7080 1 2 4 8 14 227..................................... 4604 2.9622 1 1 2 4 6 228..................................... 3014 3.5551 1 1 2 4 7 229..................................... 1345 2.4007 1 1 2 3 5 230..................................... 2455 5.1548 1 2 3 6 11 231..................................... 10331 5.0624 1 2 3 6 11 232..................................... 576 4.5017 1 1 2 5 10 233..................................... 4538 8.9595 2 4 7 11 18 234..................................... 2220 4.1730 1 2 3 5 8 235..................................... 5543 6.7231 1 3 4 7 13 236..................................... 37803 6.2862 2 3 5 7 12 237..................................... 1510 4.4139 1 2 3 5 8 238..................................... 7538 10.0649 3 5 7 12 19 239..................................... 59580 7.6024 2 4 6 9 14 240..................................... 12047 7.4987 2 3 5 9 15 241..................................... 3019 4.6277 1 2 4 6 9 242..................................... 2528 7.6606 2 4 6 9 15 243..................................... 79979 5.6107 2 3 4 7 10 244..................................... 11456 5.8092 2 3 4 7 11 245..................................... 4259 4.2158 1 2 3 5 8 246..................................... 1312 4.5899 1 2 4 6 9 247..................................... 10591 3.9716 1 2 3 5 8 248..................................... 6767 5.2815 1 2 4 6 10 249..................................... 10077 4.2995 1 2 3 5 9 250..................................... 3178 4.9091 1 2 3 6 9 251..................................... 2090 3.2933 1 1 3 4 6 252..................................... 1 1.0000 1 1 1 1 1 253..................................... 17469 5.8164 2 3 4 7 11 254..................................... 9208 3.8588 1 2 3 5 7 255..................................... 1 2.0000 2 2 2 2 2 256..................................... 4600 5.7178 1 2 4 7 11 257..................................... 23640 3.4239 1 2 3 4 6 258..................................... 18784 2.4905 1 2 2 3 4 259..................................... 4010 3.5077 1 1 2 3 7 260..................................... 4868 1.8683 1 1 1 2 3 261..................................... 2334 2.3500 1 1 2 3 4 262..................................... 712 3.9284 1 1 2 5 8 263..................................... 29088 13.8669 4 6 10 16 28 264..................................... 3559 8.3442 2 4 6 10 17 265..................................... 4274 7.6467 1 2 5 9 16 266..................................... 2712 3.6855 1 1 3 5 7 267..................................... 222 4.0811 1 1 3 5 9 268..................................... 891 4.0000 1 1 2 4 9 269..................................... 10174 9.1235 2 3 7 12 18 270..................................... 3456 3.3958 1 1 2 4 8 271..................................... 21515 8.4984 3 4 7 10 15 272..................................... 5863 7.4481 2 3 6 9 14 273..................................... 1426 5.5035 2 2 4 7 11 274..................................... 2526 7.7458 2 3 5 9 15 275..................................... 250 3.5040 1 1 2 4 8 276..................................... 889 5.0472 1 2 4 6 9 277..................................... 79054 6.7240 3 4 5 8 12 278..................................... 26008 5.1420 2 3 4 6 9 279..................................... 5 4.8000 2 2 3 4 12 280..................................... 13098 5.1142 1 2 4 6 9 281..................................... 5890 3.6448 1 2 3 4 7 283..................................... 5233 5.4888 2 2 4 7 10 284..................................... 1755 3.8632 1 2 3 5 7 285..................................... 4886 13.5014 3 6 10 16 26 286..................................... 1918 8.7195 3 4 6 9 16 287..................................... 6284 13.3908 3 6 9 16 26 288..................................... 957 7.0449 2 4 5 7 11 289..................................... 4992 3.9732 1 2 2 4 8 290..................................... 8514 2.8404 1 1 2 3 5 291..................................... 86 1.7558 1 1 1 2 3 292..................................... 5046 12.6958 2 5 9 16 25 293..................................... 294 6.4456 1 3 5 8 14 294..................................... 86024 5.6681 2 3 4 7 10 295..................................... 3712 4.2826 1 2 3 5 8 296..................................... 218940 6.3561 2 3 5 8 12 [[Page 27563]] 297..................................... 31455 4.2781 1 2 3 5 8 298..................................... 95 3.0211 1 1 2 4 5 299..................................... 868 5.3652 1 2 4 7 10 300..................................... 14115 7.3032 2 3 6 9 14 301..................................... 2146 4.3877 1 2 3 6 9 302..................................... 7567 12.3190 6 7 9 14 21 303..................................... 18462 10.1938 4 6 8 12 18 304..................................... 12867 10.2970 3 5 7 13 21 305..................................... 2526 4.9097 1 3 4 6 9 306..................................... 11305 6.2204 2 2 4 8 13 307..................................... 2596 2.9819 1 2 2 3 5 308..................................... 9137 7.0113 1 2 5 9 15 309..................................... 3371 3.0009 1 1 2 4 6 310..................................... 28549 4.6077 1 2 3 6 9 311..................................... 9697 2.1734 1 1 2 3 4 312..................................... 1995 4.7895 1 2 3 6 10 313..................................... 745 2.2644 1 1 2 3 5 314..................................... 1 5.0000 5 5 5 5 5 315..................................... 27722 9.2695 1 2 6 12 20 316..................................... 69941 7.4958 2 3 6 9 15 317..................................... 779 2.8434 1 1 2 3 6 318..................................... 5981 7.1195 2 3 5 9 14 319..................................... 506 3.2174 1 1 2 4 7 320..................................... 169078 6.4297 2 3 5 8 11 321..................................... 25512 4.7020 2 3 4 6 8 322..................................... 81 4.3580 2 2 4 6 8 323..................................... 17690 3.5573 1 2 3 4 7 324..................................... 8755 2.0870 1 1 2 3 4 325..................................... 7381 4.5898 1 2 3 5 9 326..................................... 2186 3.4492 1 1 2 4 6 327..................................... 8 3.1250 1 2 2 2 4 328..................................... 817 4.2742 1 2 3 5 9 329..................................... 109 2.7523 1 1 2 3 5 330..................................... 1 1.0000 1 1 1 1 1 331..................................... 38181 6.1753 2 3 5 8 12 332..................................... 4687 3.8835 1 2 3 5 8 333..................................... 357 5.8319 1 3 4 7 13 334..................................... 19011 6.0503 3 4 5 7 9 335..................................... 9821 4.5786 2 3 4 6 7 336..................................... 60748 4.1251 1 2 3 5 8 337..................................... 38538 2.6717 1 2 2 3 4 338..................................... 4813 5.2703 1 2 3 6 11 339..................................... 2302 4.9392 1 2 3 6 10 340..................................... 2 3.0000 1 1 5 5 5 341..................................... 6427 3.2367 1 1 2 4 6 342..................................... 224 4.0089 1 1 2 5 8 344..................................... 3820 3.4652 1 1 2 4 7 345..................................... 1355 3.9734 1 2 3 4 9 346..................................... 5344 6.7500 1 3 5 8 14 347..................................... 418 3.3349 1 1 2 4 7 348..................................... 3021 4.8875 1 2 4 6 9 349..................................... 684 2.9956 1 1 2 4 6 350..................................... 6884 4.7451 2 3 4 6 8 352..................................... 576 3.9392 1 2 3 5 8 353..................................... 2621 8.3564 3 5 6 10 15 354..................................... 9693 6.3330 3 4 5 7 11 355..................................... 5607 3.8639 2 3 4 4 6 356..................................... 28647 3.0247 1 2 3 4 5 357..................................... 6526 9.8462 4 5 8 12 18 358..................................... 26797 4.7425 2 3 4 5 8 359..................................... 27392 3.2715 2 3 3 4 5 360..................................... 16717 3.5393 1 2 3 4 6 361..................................... 618 3.4644 1 1 2 4 7 363..................................... 4355 3.4953 1 2 2 3 6 364..................................... 1778 3.6310 1 1 2 5 8 365..................................... 2396 8.1123 2 3 5 10 18 366..................................... 4471 7.6741 2 3 5 10 16 367..................................... 545 3.3266 1 1 2 4 7 368..................................... 2285 6.9190 2 3 5 9 13 369..................................... 2409 3.7410 1 1 3 5 7 [[Page 27564]] 370..................................... 1083 5.5568 3 3 4 5 9 371..................................... 950 3.5874 2 3 3 4 5 372..................................... 809 3.3498 1 2 2 3 6 373..................................... 3637 1.9249 1 1 2 2 3 374..................................... 116 2.3621 1 2 2 2 3 375..................................... 5 2.2000 1 1 2 3 4 376..................................... 151 3.4834 1 1 2 4 8 377..................................... 26 3.2308 1 1 1 3 8 378..................................... 163 2.9755 1 2 3 3 5 379..................................... 309 2.9256 1 1 2 3 5 380..................................... 71 2.3239 1 1 2 3 4 381..................................... 194 2.2835 1 1 1 2 5 382..................................... 47 1.6596 1 1 1 1 3 383..................................... 1455 4.0460 1 2 3 5 8 384..................................... 123 3.3496 1 1 1 3 7 385..................................... 3 17.0000 1 1 1 49 49 389..................................... 24 10.6667 3 4 8 10 18 390..................................... 10 5.0000 1 2 3 6 9 392..................................... 2467 11.6700 4 6 8 15 24 394..................................... 1642 7.8831 1 2 5 9 16 395..................................... 65671 5.3672 1 2 4 7 10 396..................................... 18 3.9444 1 1 3 7 8 397..................................... 15421 6.0683 2 3 4 7 12 398..................................... 16601 6.5794 2 3 5 8 12 399..................................... 1424 4.4347 1 2 4 6 8 400..................................... 7468 10.3293 2 4 7 13 23 401..................................... 6365 12.3829 2 5 9 16 25 402..................................... 1542 4.6984 1 1 3 6 10 403..................................... 34765 9.2628 2 4 7 12 19 404..................................... 3944 5.0822 1 2 4 7 10 406..................................... 3264 11.1468 3 5 8 14 23 407..................................... 723 4.9267 1 2 4 6 9 408..................................... 2949 8.2035 1 2 5 10 18 409..................................... 5649 6.6516 2 3 4 6 14 410..................................... 85871 3.3540 1 2 3 4 5 411..................................... 50 2.5600 1 1 2 3 7 412..................................... 35 3.0857 1 1 2 4 8 413..................................... 8422 8.2992 2 3 6 10 17 414..................................... 797 5.2070 1 2 4 7 11 415..................................... 38804 15.6974 4 7 12 19 31 416..................................... 192133 8.2122 2 4 7 10 15 417..................................... 45 4.6222 1 2 4 7 10 418..................................... 18663 6.7433 2 3 5 8 13 419..................................... 15677 5.6580 2 3 4 7 10 420..................................... 2871 4.3006 2 2 4 5 8 421..................................... 11386 4.6473 2 2 4 6 8 422..................................... 89 3.6854 1 2 3 4 7 423..................................... 9118 8.6534 2 4 6 10 18 424..................................... 1990 17.7397 3 6 12 20 34 425..................................... 15247 4.8955 1 2 3 6 10 426..................................... 4721 5.4938 1 2 4 7 11 427..................................... 1773 5.2775 1 2 4 7 11 428..................................... 904 8.4303 1 3 5 10 18 429..................................... 38861 8.9079 2 3 6 10 17 430..................................... 53430 9.7495 2 4 7 12 19 431..................................... 190 7.4632 1 3 5 9 14 432..................................... 430 6.3395 1 2 4 6 11 433..................................... 7843 3.4051 1 1 2 4 7 434..................................... 20810 5.8148 2 3 4 7 11 435..................................... 15477 4.8166 1 3 4 6 8 436..................................... 2915 14.5413 4 8 14 21 28 437..................................... 14205 10.8943 4 6 10 14 20 439..................................... 867 8.9262 2 3 6 11 18 440..................................... 4751 9.7838 2 3 6 12 21 441..................................... 611 4.4386 1 1 2 4 7 442..................................... 13818 8.7372 1 3 6 11 18 443..................................... 3299 3.5335 1 1 2 5 7 444..................................... 3319 5.3203 1 3 4 6 10 445..................................... 1321 3.7858 1 2 3 5 7 446..................................... 1 1.0000 1 1 1 1 1 [[Page 27565]] 447..................................... 3816 2.7953 1 1 2 3 5 448..................................... 84 1.0000 1 1 1 1 1 449..................................... 28775 4.4101 1 2 3 5 9 450..................................... 6807 2.3364 1 1 2 3 5 451..................................... 7 6.1429 2 3 4 5 7 452..................................... 19382 5.4066 1 2 4 6 11 453..................................... 3636 3.1876 1 1 2 4 6 454..................................... 5132 5.1046 1 2 3 6 10 455..................................... 1092 2.8333 1 1 2 3 5 456..................................... 194 8.3711 1 1 4 9 21 457..................................... 127 4.7953 1 1 2 5 10 458..................................... 1550 16.9387 4 7 13 22 35 459..................................... 533 10.3471 2 4 7 13 22 460..................................... 2303 6.6309 1 3 5 8 13 461..................................... 3040 4.8862 1 1 2 5 12 462..................................... 9360 13.7955 5 6 12 18 26 463..................................... 11987 5.1410 1 2 4 6 10 464..................................... 3079 3.7347 1 2 3 5 7 465..................................... 197 3.9086 1 1 2 4 7 466..................................... 1838 4.6366 1 1 2 4 10 467..................................... 1722 4.1057 1 1 2 4 8 468..................................... 56350 15.2546 3 7 12 19 30 471..................................... 9111 8.0289 4 5 6 9 13 472..................................... 150 30.6667 2 9 28 41 62 473..................................... 8211 14.3041 2 4 8 21 35 475..................................... 89514 12.1394 2 5 10 16 24 476..................................... 6875 13.7876 3 7 11 17 25 477..................................... 30427 9.1915 1 3 7 12 19 478..................................... 117755 8.2916 1 3 6 10 17 479..................................... 17758 4.5591 1 2 4 6 9 480..................................... 359 29.7159 10 13 22 37 61 481..................................... 177 32.0678 19 22 28 35 52 482..................................... 6754 14.9011 5 8 11 17 28 483..................................... 36200 45.7958 15 23 37 56 84 484..................................... 327 15.3364 2 6 11 21 32 485..................................... 3165 11.5893 4 6 9 13 21 486..................................... 2045 13.3482 1 6 11 18 28 487..................................... 3765 8.8770 1 3 7 11 17 488..................................... 1593 17.5267 5 8 13 22 35 489..................................... 17612 10.3989 2 4 7 13 22 490..................................... 4999 6.5719 1 2 4 8 14 491..................................... 9441 4.2777 2 3 3 5 7 492..................................... 2029 17.3834 3 5 10 28 37 493..................................... 52260 5.8809 1 2 5 8 11 494..................................... 27127 2.4245 1 1 2 3 5 495..................................... 107 23.7944 10 13 18 29 41 ---------------- 10571233 -------------------------------------------------------------------------------------------------------------------------------------------------------- Table 8a.--Statewide Average Operating Cost-To-Charge Ratios for Urban and Rural Hospitals (Case Weighted) April 1996 ------------------------------------------------------------------------ State Urban Rural ------------------------------------------------------------------------ ALABAMA............................................... 0.421 0.476 ALASKA................................................ 0.505 0.795 ARIZONA............................................... 0.426 0.567 ARKANSAS.............................................. 0.539 0.501 CALIFORNIA............................................ 0.408 0.544 COLORADO.............................................. 0.509 0.595 CONNECTICUT........................................... 0.553 0.551 DELAWARE.............................................. 0.533 0.523 DISTRICT OF COLUMBIA.................................. 0.525 ....... FLORIDA............................................... 0.414 0.414 GEORGIA............................................... 0.527 0.532 HAWAII................................................ 0.484 0.567 IDAHO................................................. 0.563 0.639 ILLINOIS.............................................. 0.490 0.588 INDIANA............................................... 0.565 0.628 IOWA.................................................. 0.546 0.685 KANSAS................................................ 0.457 0.651 KENTUCKY.............................................. 0.507 0.562 LOUISIANA............................................. 0.478 0.538 MAINE................................................. 0.589 0.590 MARYLAND.............................................. 0.765 0.816 MASSACHUSETTS......................................... 0.579 0.600 MICHIGAN.............................................. 0.514 0.619 MINNESOTA............................................. 0.565 0.655 MISSISSIPPI........................................... 0.524 0.527 MISSOURI.............................................. 0.460 0.532 MONTANA............................................... 0.513 0.622 NEBRASKA.............................................. 0.526 0.696 NEVADA................................................ 0.322 0.550 NEW HAMPSHIRE......................................... 0.597 0.615 NEW JERSEY............................................ 0.479 ....... NEW MEXICO............................................ 0.484 0.546 NEW YORK.............................................. 0.595 0.684 NORTH CAROLINA........................................ 0.546 0.501 [[Page 27566]] NORTH DAKOTA.......................................... 0.651 0.693 OHIO.................................................. 0.567 0.606 OKLAHOMA.............................................. 0.494 0.572 OREGON................................................ 0.573 0.649 PENNSYLVANIA.......................................... 0.437 0.585 PUERTO RICO........................................... 0.495 0.642 RHODE ISLAND.......................................... 0.587 ....... SOUTH CAROLINA........................................ 0.476 0.497 SOUTH DAKOTA.......................................... 0.571 0.629 TENNESSEE............................................. 0.534 0.577 TEXAS................................................. 0.463 0.565 UTAH.................................................. 0.578 0.665 VERMONT............................................... 0.638 0.596 VIRGINIA.............................................. 0.499 0.538 WASHINGTON............................................ 0.636 0.686 WEST VIRGINIA......................................... 0.579 0.541 WISCONSIN............................................. 0.607 0.686 WYOMING............................................... 0.495 0.735 ------------------------------------------------------------------------ Table 8b.--Statewide Average Capital Cost-To-Charge Ratios (Case Weighted) April 1996 ------------------------------------------------------------------------ State Ratio ------------------------------------------------------------------------ ALABAMA........................................................ 0.055 ALASKA......................................................... 0.077 ARIZONA........................................................ 0.051 ARKANSAS....................................................... 0.055 CALIFORNIA..................................................... 0.040 COLORADO....................................................... 0.053 CONNECTICUT.................................................... 0.037 DELAWARE....................................................... 0.054 DISTRICT OF COLUMBIA........................................... 0.042 FLORIDA........................................................ 0.051 GEORGIA........................................................ 0.052 HAWAII......................................................... 0.051 IDAHO.......................................................... 0.067 ILLINOIS....................................................... 0.045 INDIANA........................................................ 0.059 IOWA........................................................... 0.062 KANSAS......................................................... 0.055 KENTUCKY....................................................... 0.056 LOUISIANA...................................................... 0.069 MAINE.......................................................... 0.045 MARYLAND....................................................... 0.013 MASSACHUSETTS.................................................. 0.060 MICHIGAN....................................................... 0.053 MINNESOTA...................................................... 0.055 MISSISSIPPI.................................................... 0.056 MISSOURI....................................................... 0.053 MONTANA........................................................ 0.064 NEBRASKA....................................................... 0.058 NEVADA......................................................... 0.034 NEW HAMPSHIRE.................................................. 0.065 NEW JERSEY..................................................... 0.045 NEW MEXICO..................................................... 0.055 NEW YORK....................................................... 0.059 NORTH CAROLINA................................................. 0.050 NORTH DAKOTA................................................... 0.074 OHIO........................................................... 0.056 OKLAHOMA....................................................... 0.058 OREGON......................................................... 0.051 PENNSYLVANIA................................................... 0.045 PUERTO RICO.................................................... 0.078 RHODE ISLAND................................................... 0.039 SOUTH CAROLINA................................................. 0.053 SOUTH DAKOTA................................................... 0.064 TENNESSEE...................................................... 0.057 TEXAS.......................................................... 0.055 UTAH........................................................... 0.055 VERMONT........................................................ 0.050 VIRGINIA....................................................... 0.058 WASHINGTON..................................................... 0.063 WEST VIRGINIA.................................................. 0.060 WISCONSIN...................................................... 0.048 WYOMING........................................................ 0.067 ------------------------------------------------------------------------ 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 proposed 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 Social Security Act (the Act) requires the Secretary to prepare a regulatory impact analysis for any proposed 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 NECMA. Thus, for purposes of the prospective payment system, we classify these hospitals as urban hospitals. It is clear that the changes being proposed in this document would 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 proposed rule, constitutes a combined regulatory impact analysis and regulatory flexibility analysis. II. Objectives The primary objective of the prospective payment system is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of deficit reduction and restraints on government spending in general. We believe the proposed changes would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are, in general, reasonable and equitable while avoiding or minimizing unintended adverse consequences. 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 proposed policy changes, as well as statutory changes effective for FY 1997, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per case while holding all other payment policies 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. As we have done in previous proposed rules, we are soliciting comments and information about the anticipated effects of these changes on hospitals, and our methodology for estimating them. 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. There were 46 Indian Health Service hospitals in our data base, which we excluded from the analysis due to the special characteristics of the prospective payment method for these hospitals. Among other short-term, acute care hospitals, only the 50 such hospitals in Maryland remain excluded from the prospective payment system under the waiver at section 1814(b)(3) of the Act. Thus, as of April 1996, we have included 5,130 hospitals in our analysis. This represents about 82 percent of all [[Page 27567]] Medicare-participating hospitals. The majority of this impact analysis focuses on this set of hospitals. The remaining 18 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 per discharge). These hospitals include psychiatric, rehabilitation, long-term care, children's, and cancer hospitals. The impacts of our proposed policy changes on these hospitals are discussed below. V. Impact on Excluded Hospitals and Units As of April 1996, there were 1,141 specialty hospitals excluded from the prospective payment system and instead paid on a reasonable cost basis subject to the rate-of-increase ceiling under Sec. 413.40. In addition, there were 2,258 psychiatric and rehabilitation units in hospitals otherwise subject to the prospective payment system. These excluded units are also paid in accordance with Sec. 413.40. In accordance with section 1886(b)(3)(B)(ii)(V) of the Act, the update factor applicable to the rate-of-increase limit for excluded hospitals and units for FY 1997 would be 1.7 percent (excluded hospital market basket minus 1.0 percentage points), adjusted to account for the relationship between the hospital's allowable operating cost per case and its target amounts. The impact on excluded hospitals and units of the proposed 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 at a level below the percentage increases in the rate-of-increase limits since their base period, 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 would have to absorb. In this context, we note that, under Sec. 413.40(d)(3), an excluded hospital or unit whose costs exceed the rate-of-increase limit is allowed 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 payment adjustments for significant, justifiable, increases in operating costs that exceed the limit. At the same time, however, by generally limiting payment increases, we continue to provide an incentive for excluded hospitals and units to restrain the growth in their spending for patient services. VI. Quantitative Impact Analysis of the Proposed Policy Changes Under the Prospective Payment System for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing policy changes and payment rate updates for the prospective payment systems for operating and capital-related costs. We have prepared separate analyses of the proposed 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 1995 MedPAR file 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 cost data, the most recently available hospital cost report data were used to create some of the variables by which hospitals are categorized. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to these proposed policy changes. Second, due to the interdependent nature of the prospective payment system, it is very difficult to precisely quantify the impact associated with each proposed 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. Using cases in the FY 1995 MedPAR file, we simulated 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 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 analyzed here. Estimated payment impacts of proposed FY 1997 changes to the capital prospective payment system are discussed below in section VII of this Appendix. The proposed changes discussed separately below are the following: The effects of the annual reclassification of diagnoses and procedures and the recalibration of the diagnosis-related group (DRG) relative weights required by section 1886(d)(4)(C) of the Act. The effects of changes in hospitals' wage index values reflecting the wage index update (FY 1993 data). The effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB) that will be effective in FY 1997. The effects of phasing out payments for extraordinarily lengthy cases (day outlier cases) with a corresponding increase in payments for extraordinarily costly cases (cost outliers), in accordance with section 1886(d)(5)(A)(v) of the Act. The total change in payments based on FY 1997 policies relative to payments based on FY 1996 policies. To illustrate the impacts of the FY 1997 proposed changes, our analysis begins with an FY 1997 baseline simulation model using: the FY 1996 GROUPER (version 13.0); the FY 1996 wage indexes; no MGCRB reclassifications; and current outlier policy (50 percent phase out of day outlier payments). Outlier payments are assumed to be 5.1 percent of total DRG payments. Each policy change is then added incrementally to this baseline model, finally arriving at an FY 1997 model incorporating all of the proposed changes. This allows us to isolate the effects of each proposed change. Our final comparison illustrates the percent change in payments per case from FY 1996 to FY 1997. Four factors not displayed in the previous five columns have significant impacts here. First is the update to the standardized amounts. In accordance with section 1886(d)(3)(A)(iv) of the Act, we are proposing to update the large urban and the other areas average standardized amounts for FY 1997 using the most recently forecasted hospital market basket increase for FY 1997 of 2.7 percent, minus 0.5 percentage points. Thus, the update to the large urban and other areas standardized amounts is 2.2 percent. Similarly, section 1886(b)(3)(C)(ii) of the Act provides that the update factor applicable to the hospital-specific rates for sole community hospitals (SCHs) and essential access community hospitals (EACHs) (which are treated as SCHs for [[Page 27568]] payment purposes) is also the market basket increase minus 0.5 percent, or 2.2 percent. A second significant factor impacting changes in hospitals' payments per case from FY 1996 to FY 1997 is a change in MGCRB reclassification status from one year to the next. That is, hospitals reclassified in FY 1996 that are no longer reclassified in FY 1997 may have a negative payment impact going from FY 1996 to FY 1997; conversely, hospitals not reclassified in FY 1996 that are reclassified in FY 1997 may have a positive impact. In some cases these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage increase in payments for the category may be below the national mean. A third significant factor is that we currently estimate that actual outlier payments during FY 1996 will be 4.2 percent of actual total DRG payments. When the FY 1996 final rule was published, we projected FY 1996 outlier payments would be 5.1 percent of total DRG payments, and the standardized amounts were reduced correspondingly. The effects of the lower than expected outlier payments during FY 1996 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 1996 payments per case to estimated FY 1997 payments per case. Finally, the regional floor provision (section 1886(d)(1)(A)(iii)(II) of the Act) expires effective with discharges occurring on or after October 1, 1996. Under this provision (applicable during FY 1996), hospitals within any census division having a regional standardized amount greater than the national standardized amount (large urban or other, depending on which amount was applicable) received a blend of 85 percent of the national amount and 15 percent of the regional amount. Hospitals in census divisions where the regional floor was applicable during FY 1996 will be negatively impacted by its expiration when comparing FY 1996 to FY 1997. 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 5,130 hospitals included in the analysis. This is 77 fewer hospitals than were included in the impact analysis in the FY 1996 final rule (60 FR 45924). Data for 107 hospitals that were included in last year's analysis were not available for analysis this year; however, data were available this year for 30 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 urban, which is further divided into large urban and other urban, or rural). There are 2,878 hospitals located in urban areas (MSAs or NECMAs) included in our analysis. Among these, there are 1,597 hospitals located in large urban areas (populations over 1 million), and 1,281 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 2,252 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 hospital groups based on hospitals' FY 1997 payment classifications, including any reclassifications under section 1886(d)(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 2,978, 1,793, 1,185, and 2,152, respectively. The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have residency programs (teaching hospitals that receive an indirect medical education (IME) adjustment), receive disproportionate share (DSH) payments, or some combination of these two adjustments. There are 4,057 nonteaching hospitals in our analysis, 841 teaching hospitals with fewer than 100 residents, and 232 teaching hospitals with 100 or more residents. In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural after MGCRB reclassifications. Hospitals in the rural DSH categories, therefore, represent hospitals that were not reclassified for purposes of the standardized amount. (They may, however, have been reclassified for purposes of the wage index.) The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next four rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, rural referral centers (RRCs), and EACHs), as well as rural hospitals not receiving a special payment designation. Rural hospitals reclassified for FY 1997 for purposes of the standardized amount are not included here. The RRCs (90), SCH/EACHs (641), and SCH/EACH and RRCs (39) shown here were not reclassified for purposes of the standardized amount. There are four EACHs included in our analysis and five EACH/RRCs. There are two RRCs and three SCHs that will be reclassified for the standardized amount in FY 1997 that, therefore, are not included in these rows. There are significantly fewer reclassifications among these groups than there were in FY 1996, owing to the new criterion under Sec. 412.230(a)(5)(ii) that a hospital may not be reclassified for purposes of the standardized amount if the area to which the hospital seeks reclassification does not have a higher standardized amount than that currently received by the hospital. (See the September 1, 1995 final rule (60 FR 45799).) Before this change (effective with reclassifications for FY 1997), some rural hospitals reclassified to other urban areas in order to qualify for urban DSH payments. For other rural hospitals that already qualified for DSH payments, the urban designation enabled them to qualify for a higher DSH adjustment than they would receive as a rural hospital. 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 primarily from the FY 1994 Medicare cost report files, if available (otherwise FY 1993 data are used). Data needed to calculate Medicare utilization percentages were unavailable for 131 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 concern the geographic reclassification status of hospitals. The first three groupings display hospitals that were reclassified by the MGCRB for either FY 1996 or FY 1997, or for both years, by urban/rural status. The next rows illustrate the overall number of FY 1997 reclassifications, as well as the numbers of reclassified hospitals grouped by urban and rural location. 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. [[Page 27569]] Table I.--Impact Analysis of Changes for FY 1997 Operating Prospective Payment System [Percent changes in payments per case] Day outlier Number of DRG New wage MGCRB policy All FY 97 hosps.\1\ recalibration data \3\ reclassification changes \5\ changes \6\ (0) (1) (2) (3) (4) (5) -------------------------------------------------------------------------------------------------------------------------------------------------------- (By Geographic Location) -------------------------------------------------------------------------------------------------------------------------------------------------------- All hospitals................................................ 5,130 0.1 -0.1 0.0 0.0 3.1 Urban hospitals.............................................. 2,878 0.1 0.0 -0.4 -0.1 3.2 Large urban.............................................. 1,597 0.1 0.0 -0.5 -0.2 3.1 Other urban.............................................. 1,281 0.1 -0.1 -0.2 0.1 3.3 Rural hospitals.............................................. 2,252 0.0 -0.1 2.3 0.1 2.7 Bed size (urban): 0-99 beds................................................ 716 0.0 -0.3 -0.5 0.2 3.0 100-199 beds............................................. 938 0.0 -0.2 -0.4 0.1 2.9 200-299 beds............................................. 577 0.1 -0.1 -0.4 0.0 3.1 300-499 beds............................................. 479 0.1 0.0 -0.4 -0.1 3.4 500 or more beds......................................... 168 0.1 0.1 -0.2 -0.4 3.4 Bed size (rural): 0-49 beds................................................ 1,173 -0.1 0.0 0.0 0.1 2.8 50-99 beds........................................... 663 -0.1 -0.1 1.1 0.2 2.8 100-149 beds......................................... 241 0.0 -0.1 3.1 0.2 2.9 150-199 beds......................................... 99 0.0 -0.1 2.8 0.1 2.8 200 or more beds..................................... 76 0.1 -0.2 4.9 0.1 2.2 Urban by census division: New England.............................................. 160 0.1 0.0 -0.1 -0.1 2.4 Middle Atlantic.......................................... 434 0.1 0.6 -0.3 -1.1 3.5 South Atlantic........................................... 419 0.1 -0.2 -0.5 0.1 3.3 East North Central....................................... 483 0.1 0.3 -0.2 0.2 2.9 East South Central....................................... 163 0.1 -0.3 -0.5 0.2 3.4 West North Central....................................... 193 0.1 -0.4 -0.5 0.3 3.4 West South Central....................................... 375 0.1 -0.4 -0.5 0.4 3.6 Mountain................................................. 125 0.2 -0.4 -0.4 0.3 3.3 Pacific.................................................. 478 0.1 -0.5 -0.4 0.2 2.9 Puerto Rico.............................................. 48 -0.1 -0.7 -0.5 0.0 2.6 Rural by census division: New England.............................................. 53 0.1 -1.0 2.0 0.3 2.1 Middle Atlantic.......................................... 85 0.1 -0.5 0.8 -0.2 1.9 South Atlantic........................................... 297 0.0 -0.5 3.1 0.1 2.6 East North Central....................................... 304 0.1 0.2 2.1 0.2 2.9 East South Central....................................... 278 -0.1 0.2 2.5 0.2 2.2 West North Central....................................... 525 0.0 -0.1 2.1 0.2 2.8 West South Central....................................... 351 -0.1 0.2 3.1 0.2 3.2 Mountain................................................. 213 0.1 -0.2 0.8 0.1 3.0 Pacific.................................................. 141 0.1 0.5 2.4 0.2 4.0 Puerto Rico.............................................. 5 -0.2 -2.1 2.7 -0.1 3.8 -------------------------------------------------------------------------------------------------------------------------------------------------------- (by payment categories) -------------------------------------------------------------------------------------------------------------------------------------------------------- Urban hospitals.............................................. 2,978 0.1 0.0 -0.3 -0.1 3.2 Large urban.............................................. 1,793 0.1 0.0 -0.2 -0.2 3.2 Other urban.............................................. 1,185 0.1 -0.1 -0.4 0.1 3.3 Rural hospitals.............................................. 2,152 0.0 -0.1 1.9 0.1 2.6 Teaching status: Non-teaching............................................. 4,057 0.0 -0.2 0.3 0.2 3.1 Less than 100 res........................................ 841 0.1 0.0 -0.4 0.0 3.2 100+ residents........................................... 232 0.1 0.2 -0.1 -0.5 3.2 Disproportionate Share Hospitals (DSH) Non-DSH.................................................. 3,200 0.1 -0.2 0.2 0.1 3.2 Urban DSH: 100 beds or more..................................... 1,410 0.0 0.0 -0.3 -0.2 3.2 Fewer than 100 beds.................................. 111 -0.3 -0.4 -0.5 0.3 2.5 Rural DSH: Sole community (SCH)................................. 146 -0.1 -0.1 0.2 0.0 3.3 Referral centers (RRC)............................... 25 0.0 -0.1 3.9 -0.1 3.7 Over 65.................................................. 1,353 0.0 -0.1 0.1 0.1 3.1 Unknown.................................................. 131 -0.1 0.9 -0.4 -1.4 3.1 -------------------------------------------------------------------------------------------------------------------------------------------------------- Hospitals Reclassified by the Medicare Geographic Review Board -------------------------------------------------------------------------------------------------------------------------------------------------------- Reclassification status during FY96 and FY97 Reclassified during both FY96 and FY97................... 381 0.1 0.1 5.9 0.0 3.1 [[Page 27570]] Urban................................................ 133 0.1 0.3 3.6 -0.2 3.4 Rural................................................ 248 0.0 -0.2 9.1 0.1 2.8 Reclassified during FY97 only............................ 103 0.1 0.3 3.5 -0.4 8.6 Urban................................................ 34 0.2 0.4 2.4 -0.5 8.0 Rural................................................ 69 0.0 -0.2 7.1 0.1 10.5 Reclassified during FY96 only 251 0.1 -0.6 -1.3 0.1 -0.5 Urban................................................ 88 0.1 -0.9 -2.0 0.0 0.8 Rural................................................ 163 0.0 -0.2 -0.4 0.2 -2.1 FY 97 Reclassifications: All reclassified hosp.................................... 484 0.1 0.1 5.3 -0.1 4.3 Stand. amount only................................... 120 0.1 0.0 1.7 0.1 3.1 Wage index only...................................... 274 0.1 -0.3 8.1 -0.1 3.9 Both................................................. 90 0.1 0.8 4.4 -0.2 5.9 Nonreclassified...................................... 4,619 0.1 -0.1 -0.6 0.0 3.0 All urban reclass........................................ 167 0.1 0.3 3.3 -0.3 4.6 Stand. amount only................................... 63 0.1 0.1 0.9 0.0 3.3 Wage index only...................................... 30 0.2 -0.6 6.7 -0.6 4.5 Both................................................. 74 0.1 0.9 3.1 -0.2 5.6 Nonreclassified...................................... 2,711 0.1 -0.1 -0.6 -0.1 3.1 All rural reclass........................................ 317 0.0 -0.2 8.8 0.1 3.8 Stand. amount only................................... 57 0.0 -0.3 4.6 0.3 2.7 Wage index only...................................... 244 0.0 -0.1 8.8 0.1 3.6 Both................................................. 16 0.1 -0.4 18.8 0.2 9.1 Nonreclassified...................................... 1,908 0.0 -0.1 -0.4 0.1 2.2 Other reclassifed: Hospitals (section 1886(d)(8)(B))........................ 27 0.1 -0.1 0.8 0.2 3.1 \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. Discharge data are from FY 1995, and hospital cost report data are from reporting periods beginning in FY 1993 and FY 1994. \2\ This column displays the payment impacts of the recalibration of the DRG weights, based on FY 1995 MedPAR data and the DRG classification changes, in accordance with section 1886(d)(4)(C) of the Act. \3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1993 cost reports. The percentage changes displayed here reflect the impacts of the wage and recalibration budget neutrality factor (0.998509). \4\ Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The effects shown here demonstrate the FY 1997 payment impacts of going from no reclassifications to the reclassifications scheduled to be in effect for FY 1997. Reclassification for prior years has no bearing on the payment impacts shown here. \5\ This column illustrates the payment impacts of changes in outlier payments, in accordance with section 1886(d)(5) of the Act. \6\ This column shows changes in payments from FY 1996 to FY 1997. It incorporates all of the changes displayed in columns 1 through 5. It also displays the impacts of the updates to the FY 1997 standardized amounts, changes in hospitals' reclassification status in FY 1997 compared to FY 1996, the expiration of the regional floor provision at section 1886(d)(1)(A)(iii)(II) of the Act, and the difference in outlier payments from FY 1996 to FY 1997. The sum of the first five columns plus these effects may be different from the percentage changes shown here due to changes in hospitals' geographic reclassification status from FY 1996 to FY 1997, rounding errors and interactive effects. B. The Impact of the Proposed Changes to the DRG Classifications and Relative Weights (Column 1) In column 1 of Table I, we present the combined effects of the DRG reclassifications and recalibration, as discussed in section II of the preamble to this proposed 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 reclassifications and recalibration on aggregate payments is required by section 1886(d)(4)(C)(iii) of the Act to be budget neutral. In addition, section 1886(d)(3)(E) specifies that any updates or adjustments to the wage index are budget neutral. As pointed out in the Addendum to this proposed rule, we compared aggregate payments using the FY 1996 DRG relative weights and the wage index effective October 1, 1995 to aggregate payments using the proposed FY 1997 DRG relative weights and wage index. Based on this comparison, we computed a wage and recalibration budget neutrality factor of 0.998509. In Table I, the combined overall impacts of the effects of both the DRG reclassifications and recalibration and the updated wage index (the All Hospitals row of columns 1 and 2) demonstrate that the net effect of these changes are budget neutral. That is, the 0.1 percent increase for all hospitals due to the DRG changes is negated by the 0.1 percent decrease for all hospitals with the new wage data. Consistent with the minor changes we are proposing for the FY 1997 GROUPER, the redistributional impacts across hospital groups are very small (an increase of 0.1 for large and other urban hospitals). Among other hospital categories, the net effects are slightly negative changes for small (up to 99 beds) rural hospitals and slightly positive changes for larger (over 200 beds) rural and urban hospitals. The largest single effect on any of the hospital categories examined is a 0.3 percent decrease in payments for smaller (100 or fewer beds) urban and rural hospitals that receive DSH payments. We note that the only other hospital category to experience a [[Page 27571]] decrease of more than 0.1 percent is rural hospitals in Puerto Rico. We attribute these negative changes to the increasing gap between the relative weights for medical, diagnostic, and less complicated surgical DRGs and the weights for the more complicated surgical DRGs. Since the cases associated with the former DRGs tend to be treated more often in smaller hospitals with fewer resources available, lowering the relative weights associated with those cases would disproportionately affect these hospitals. In general, small hospitals that serve a disproportionate share of low-income patients and hospitals in rural Puerto Rico fit this definition. We note, however, that these negative impacts are relatively minor and do not result solely from the limited DRG revisions we are proposing for FY 1997. C. The Impact of Updating the Wage Data (Column 2) 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 proposed wage index for FY 1997 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 1992 and before October 1, 1993. As with the previous column, the impact of the new data on hospital payments is isolated by holding the other payment parameters constant in the two simulations. That is, column 2 shows the percentage changes in payments when going from a model using the FY 1996 wage index before geographic reclassifications based on FY 1992 wage data to a model using the FY 1997 prereclassification wage index based on FY 1993 wage data. As noted above, to comply with the requirements that the DRG and wage index changes be implemented in a budget neutral manner, we compute a budget neutrality adjustment factor to apply to the standardized amounts. The 0.1 percent decrease for all hospitals in this column reflects the wage and recalibration budget neutrality factor of 0.998509. This decrease, combined with the 0.1 percent increase for all hospitals in column 1, demonstrates that the net effect on aggregate payments of the proposed DRG and wage index changes are budget neutral. The results indicate that the new wage data do not have a significant overall impact on hospital payments. (It should be noted that the percentage changes attributed here to the new wage data are generally reduced by 0.2 percentage points due to the budget neutrality factor.) Thus, hospitals with significant changes in their wage indexes are not concentrated within any particular hospital group. Some of the largest changes are found among both urban and rural hospitals grouped by census division. In almost all cases, payments change by less than 1 percent. Our review of the wage data (as described below) indicates that these changes were attributable to improved reporting, as well as relative changes in labor costs. In the 50 States and the District of Columbia, among the urban hospitals, the largest increase (0.6 percent) is in the Middle Atlantic census division. Significantly, New York City's wage index rises by over 1.6 percent (this also contributes to the 0.2 percent increase among major teaching hospitals and the 0.9 percent increase in the Unknown category under the Medicare Utilization rows). Last year, the Middle Atlantic experienced one of the largest decreases (0.6 percent), which contributed to the 0.4 percent decline among major teaching hospitals--New York City's wage index fell by nearly 2.0 percent in FY 1996 (60 FR 45929). The largest decrease among urban hospitals occurs in the Pacific census division, with a decline of 0.5 percent. Among the rural hospitals, the largest increase (0.5 percent) is in the Pacific census division; the largest decrease (1.0 percent) is in the New England census division. This decrease is primarily due to a 2.5 percent decrease in the wage index for rural Connecticut hospitals and a 2.4 percent decrease in the wage index for rural New Hampshire hospitals. The Pacific rural hospitals also experienced one of the greatest increases (0.6 percent) among rural hospitals last year. In Puerto Rico, payments decline by 2.1 percent for the five rural hospitals and by 0.7 percent for the urban hospitals. The average hourly wages reported in FY 1993 by two rural Puerto Rico hospitals fell from those reported in FY 1992 by 22.4 percent and 18.1 percent, leading to the 2.1 percent overall decline. Of the six urban areas in Puerto Rico, two experience increases in wage index values while four experience decreases. Among these four, three experience a decline of more than 5 percent. These MSAs have relatively few hospitals (two, five, and seven hospitals). The decreases appear to be the result of one or two hospitals in each area with a decrease of more than 5 percent in average hourly wages. The proposed FY 1997 wage index represents the fourth annual update to the wage data, and will continue to include salaries, fringe benefits, home office salaries, and certain contract labor costs. In the past, updates to the wage data have resulted in significant payment shifts among hospitals. Since the wage index is now updated annually, we expect these payment fluctuations will decrease. This expectation is borne out by comparing the proposed FY 1997 wage index (after reclassifications under sections 1886(d)(8)(B) and 1886(d)(10) of the Act) to the FY 1996 wage index. The following chart compares the shifts in wage index values (after reclassifications) for labor markets for FY 1997 with those from FY 1996. The majority of labor market areas (339) experience less than a 5 percent change. Only 25 labor market areas experience a change between 5 and 10 percent; 13 of those experience increases. Still fewer labor markets experience a change of more than 10 percent; two experience increases and two experience decreases. For FY 1996, by comparison, 10 labor market areas experienced an increase in their wage index value of more than 10 percent. 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. ------------------------------------------------------------------------ Number of labor market areas Percentage change in area wage index values ----------------- FY FY 1997 1996 ------------------------------------------------------------------------ Increase more than 10 percent......................... 2 10 Increase between 5 and 10 percent, (inclusive)........ 13 21 Increase/decrease below 5 percent..................... 339 331 Decrease between 5 and 10 percent, (inclusive)........ 12 6 Decrease more than 10 percent......................... 2 0 ------------------------------------------------------------------------ Under the proposed FY 1997 wage index, 96.2 percent of urban hospitals and 92.7 percent of rural hospitals would experience a change in their wage index of less than 5 percent. Approximately 5.9 percent (3.1 percent of urban hospitals and 2.8 percent of rural hospitals) would experience a change of between 5 and 10 percent, and 5.3 percent (0.8 percent of urban hospitals and 4.5 percent of rural hospitals) would experience a change of more than 10 percent. The following chart shows the projected impact for urban and rural hospitals. [[Page 27572]] ------------------------------------------------------------------------ Percent of hospitals (by Percentage change in area wage index values Urban/Rural) ----------------- Urban Rural ------------------------------------------------------------------------ Increase more than 10 percent......................... 0.4 2.5 Increase between 5 and 10 percent (inclusive)......... 1.5 0.9 Increase or decrease less than 5 percent.............. 96.2 2.7 Decrease between 5 and 10 percent (inclusive)......... 1.6 1.9 Decrease more than 10 percent......................... 0.4 2.0 ------------------------------------------------------------------------ ANote: The sum of the columns may not total to 100 due to rounding. D. The Impact of MGCRB Reclassifications (Column 3) Our impact analysis to this point has assumed hospitals are paid on the basis of their actual 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 3 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 1997. As noted below, these decisions affect hospitals' standardized amount and wage index area assignments. In addition, rural hospitals reclassified for purposes of the standardized amount also qualify to be treated as urban for purposes of the DSH adjustment. 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. The MGCRB may reclassify a hospital for the purpose of using the other area's standardized amount, wage index value, or both. (RRCs and SCHs are exempt from the proximity requirement.) Effective FY 1997, rural hospitals can no longer be reclassified to an other urban area for purposes of the standardized amount under section 1886(d)(10) of the Act. The proposed FY 1997 wage index values incorporate all of the MGCRB's reclassification decisions for FY 1997. The wage index values also reflect any decisions made by the HCFA Administrator through the appeals and review process for MGCRB decisions as of March 29, 1996. Additional changes that result from the Administrator's review of MGCRB decisions or a request by a hospital to withdraw its application will be reflected in the final rule for FY 1997. The overall effect of geographic reclassification is required to be budget neutral by section 1886(d)(8)(D) of the Act. Therefore, we applied an adjustment of 0.994059 to ensure that the effects of reclassification are budget neutral. (See section II.A.4 of the Addendum to this proposed rule). As a group, rural hospitals benefit from geographic reclassification. Their payments rise 2.3 percent, while payments to urban hospitals decline 0.4 percent. Large urban hospitals lose 0.5 percent because, as a group, they have the smallest percentage of hospitals that are reclassified (fewer than 3 percent of large urban hospitals are reclassified). There are enough hospitals in other urban areas that are reclassified to limit the decrease in payments to urban hospitals stemming from the budget neutrality offset to 0.2 percent. Among urban hospital groups generally (that is, bed size, census division, and special payment status), payments fall between 0.2 and 0.5 percent. A positive impact is evident among all rural hospital groups except rural hospitals with up to 49 beds, which experience a 0.0 percent impact. The smallest effect among all rural census divisions is 0.8 percent for the Middle Atlantic and Mountain divisions. These divisions have relatively fewer MGCRB reclassifications. Among urban census divisions, New England displays the smallest negative impact, 0.1 percent. Among rural hospitals designated as RRCs, 50 hospitals are reclassified for purposes of the wage index only and experience a 9.5 percent increase in payments overall. This positive impact on RRCs is also reflected in the category of rural hospitals with 200 or more beds, which have a 4.9 percent increase in payments. Rural hospitals reclassified for FY 1996 and FY 1997 experience a 9.1 percent increase in payments, the greatest of any group in the category. This may be due to the fact that these hospitals have the most to gain from reclassification and have been reclassified for a period of years. Rural hospitals reclassified for FY 1997 only experience a 7.1 percent increase in payments while rural hospitals reclassified for FY 1996 only experience a 0.4 decrease in payments. This is due to the budget neutrality adjustment, since the changes in this column reflect FY 1997 payments relative to no reclassifications, rather than to FY 1996 reclassifications. Urban hospitals reclassified for FY 1996 but not FY 1997 experience a 2.0 percent decline in payments overall. This appears to be due to the combined impacts of the budget neutrality adjustment and a number of hospitals in this category that experience a 6 percent drop in their wage index after reclassification. Urban hospitals reclassified for FY 1997 but not for FY 1996 experience a 2.4 percent increase in payments. The FY 1997 Reclassification rows of Table I show the changes in payments per case for all FY 1997 reclassified and nonreclassified hospitals in urban and rural locations for each of the three reclassification categories (standardized amount only, wage index only, or both). The table illustrates that the largest impact for reclassified rural hospitals is for those hospitals reclassified for both the standardized amount and the wage index. These hospitals receive an 18.8 percent increase in payments. The number of hospitals in this category has declined from 42 in FY 1996 to 16 in FY 1997. In addition, rural hospitals reclassified for the wage index receive an 8.8 percent payment increase. The overall impact on reclassified hospitals is to increase their payments per case by an average of 5.3 percent for FY 1997. Among the 27 rural hospitals deemed to be urban under section 1886(d)(8)(B) of the Act, payments increase 0.8 percent due to MGCRB reclassification. This is because, although these hospitals are treated as being attached to an urban area in our baseline (their redesignation is ongoing, rather than annual like the MGCRB reclassifications), they are eligible for MGCRB reclassification. For FY 1997, one hospital in this category reclassified to a large urban area, resulting in a net increase due to reclassifications of 0.8 percent. 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 are not reclassified, the overall impact of hospital reclassifications is an average decrease in payments per case of about 0.6 percent, which corresponds closely with the geographic reclassification budget neutrality factor. Rural nonreclassified hospitals decrease slightly less, experiencing a 0.4 percent decrease. This occurs because the wage index values in some rural areas increase after reclassified hospitals are excluded from the calculation of those index values. The number of reclassifications for purposes of the standardized amount, or for both the standardized amount and the wage index, has declined from 358 in FY 1996 to 210 in FY 1997. This is not surprising because of the elimination of standardized amount [[Page 27573]] reclassifications from rural to other urban areas for individual hospitals. Individual rural hospitals can continue to reclassify to large urban areas for purposes of the standardized amount. The number of wage index only reclassifications increased slightly from 260 in FY 1996 to 274 in FY 1997. The foregoing analysis was based on MGCRB and HCFA Administrator decisions made by March 29 of this year. As previously noted, there may be changes to some MGCRB decisions through the appeals, review, and applicant withdrawal process. The outcome of these cases will be reflected in the analysis presented in the final rule. E. Outlier Changes (Column 4) Medicare provides extra payment in addition to the basic DRG payment amount for extremely costly or extraordinarily lengthy cases (cost outliers and day outliers, respectively). Section 1886(d)(5)(A)(v) of the Act requires the Secretary to phase out payment for day outliers from FY 1994 day outlier levels in 25 percent increments beginning in FY 1995. Day outliers in FY 1997 should account for approximately 8 percent of total outlier payments (25 percent of FY 1994 levels). This reduction in day outlier payments will be offset by an increase in cost outlier payments. As discussed in the Addendum, for FY 1997, we are proposing a day outlier threshold equal to the geometric mean length of stay for each DRG plus the lesser of 24 days or 3.0 standard deviations. The proposed marginal cost factor for day outliers is 35 percent. For FY 1997, we are proposing that a case would receive cost outlier payments if its costs exceed the DRG amount plus $11,050. We are also proposing to maintain the marginal cost factor for cost outliers at 80 percent. The payment impacts of these changes are minimal. Hospital categories negatively affected by phasing out day outliers are consistent with the categories negatively affected in previous years: urban New England (0.1 percent decline); urban and rural Middle Atlantic census divisions (1.1 percent and 0.2 percent declines, respectively); urban hospitals with 500 or more beds (0.4 percent decline); teaching hospitals with 100 or more residents (0.5 percent decline); and hospitals for which data were unavailable to calculate Medicare utilization rates (1.4 percent decline). As noted in the wage index discussion previously, this last category contains a number of New York City hospitals. Because the changes to outlier policy result in a shift in payments from cases paid as day outliers to cases paid as cost outliers, this indicates that these categories have higher percentages of day outliers. The largest positive impact is among urban hospitals in the West South Central census division (0.4 percent increase). F. All Changes (Column 5) Column 5 compares our estimate of payments per case incorporating all of our proposed changes for FY 1997 to our estimate of payments per case in FY 1996. It also includes the effects of the 2.2 percent update to the standardized amounts and the hospital-specific rates for SCHs and EACHs, and the 0.9 percentage point difference between the percentage of projected outlier payments in FY 1997 (5.1 percent) and the current estimate of the percentage of actual outlier payments in FY 1996 (4.2 percent), as described in the introduction to this Appendix and the Addendum. We also note that column 5 includes the impacts of FY 1997 MGCRB reclassifications compared to the payment impacts of FY 1996 reclassifications. Therefore, when comparing FY 1997 payments to FY 1996, the percent changes due to FY 1997 reclassifications shown in column 3 need to be offset by the effects of reclassification on hospitals' FY 1996 payments (column 4 of Table 1, September 1, 1995 final rule; 60 FR 45926). That is, column 3 of Table 1 shows the impacts of going from no MGCRB reclassifications to the FY 1997 reclassifications. When comparing FY 1996 and FY 1997 payments, hospitals similarly reclassified during FY 1996 would not experience the full extent of the change shown in column 3. For example, the impact of MGCRB reclassifications on rural hospitals' FY 1996 payments was approximately a 2.3 percent increase, equal to the 2.3 percent increase for FY 1997. Therefore, the net increase in FY 1997 payments due to reclassification for rural hospitals is 0 percent. In addition, eliminating the regional floor provision effective for discharges occurring on or after October 1, 1996, results in approximately a 0.2 percent lower average payment in FY 1997 than would occur otherwise. Of course, this effect is attributable to particular census divisions, as discussed below. Finally, the FY 1996 standardized amounts were adjusted by a budget neutrality factor of 0.997575, in accordance with section 1886(d)(5)(I) of the Act, so that the change to the transfer payment methodology we implemented last year (doubling the per diem payment for the first day of a transfer) would not affect aggregate payments. As we indicated in last year's final rule (60 FR 45854), this adjustment was applied on a one-time basis to the FY 1996 standardized amounts. After FY 1996, there will be no need for a further budget neutrality adjustment unless or until we make further changes to the transfer payment methodology. As a result, the FY 1997 standardized amounts are relatively higher (0.2 percent). A single geographic reclassification budget neutrality factor of 0.994059 was applied to the proposed FY 1997 standardized amounts, compared to the FY 1996 factor of 0.994011. The budget neutrality adjustment factor for the updated wage index and the DRG recalibration is 0.998509, compared to the FY 1996 factor of 0.999306. Although the net effect of these changes is small, they are reflected in the payment differences shown in this column. 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 5 may not equal the sum of the previous columns plus the other impacts that we are able to identify. The overall payment increase from FY 1997 to FY 1996 for all hospitals is a 3.1 percent increase. This reflects the 0.0 percent net change in total payments due to the proposed changes for FY 1997 shown in columns 1 through 4, the 2.2 percent update for FY 1997, and the 0.9 percent higher outlier payments in FY 1997 compared to FY 1996, as discussed above. Hospitals in urban areas experience a 3.2 percent rise in payments per case over FY 1996. Similar to all hospitals nationally, this is primarily due to the factors discussed above: the 2.2 percent update; a 0.9 percent higher level of outlier payments estimated for FY 1997; and the offsetting effects of eliminating the regional floor and the FY 1996 transfer budget neutrality factor. Urban hospitals benefit 0.1 percent from DRG recalibration, while losing 0.1 percent due to the phase out of the day outlier policy. Their 0.4 negative impact in FY 1997 due to reclassification is offset by a similar impact from FY 1996 reclassifications. Hospitals in large and other urban areas experience 3.1 percent and 3.3 percent increases, respectively. The lower increase for hospitals in large urban areas appears to be attributable primarily to the 0.2 percent negative impact of the continuing phase out of day outliers. [[Page 27574]] Hospitals in rural areas experience a 2.7 percent increase. Their FY 1997 payments are estimated to be 0.6 percent higher than for FY 1996 due to higher outlier payments. Like urban hospitals, the impact of geographic reclassification in FY 1997 is offset by an identical 2.3 percent increase in FY 1996. Among urban bed size groups, column 5 shows changes in payments are higher for the largest urban hospitals compared to smaller urban 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 2. Among rural bed size groups, the impacts range from 2.8 percent to 2.9 percent, with the exception of rural hospitals with 200 or more beds. Payments per case for this group of hospitals is estimated to increase 2.2 percent during FY 1997. This below average rate of increase appears to be attributable primarily to a smaller, though still significant, impact of MGCRB reclassifications during FY 1997 compared to FY 1996. In column 3 the FY 1997 impact of reclassification is shown to be 4.9 percent. For FY 1996, however, this impact was 5.4 percent. Thus, the rate of increase is 0.5 percent less for FY 1997 due to a smaller reclassification impact. As discussed previously, effective for discharges on or after October 1, 1996, the regional floor, which benefitted certain census divisions, expires. The regional floor provided that, in those census divisions where the regional standardized amount exceeded the national standardized amount, hospitals would be paid a blend of 85 percent of the national amount and 15 percent of the regional amount. The census divisions affected by the regional floor during FY 1996 are New England and East North Central. In New England, the impacts of eliminating the regional floor are a 0.7 percent decrease for urban hospitals and a 0.6 percent decrease among rural hospitals. In the East North Central region, the impacts are a 1.0 percent reduction for urban hospitals, and a 0.7 percent reduction for rural hospitals. The negative impacts of losing the regional floor for urban hospitals in the East North Central region are largely offset by higher estimated outlier payments in FY 1997 compared to FY 1996, the 0.3 percent higher payments due to the FY 1993 wage data (column 2), and the 0.2 percent increase due to the phase-out of day outliers (column 4). On the other hand, urban New England hospitals' higher outlier payments in FY 1997 are offset entirely by the negative impacts of the expiration of the regional floor. Rural New England hospitals also see a 1.0 percent decrease in payments stemming from the FY 1993 wage data. Other census divisions below the average payment increase are urban Pacific, urban Puerto Rico, rural Middle Atlantic, rural South Atlantic, rural East South Central, and rural Mountain. With the exception of the rural Middle Atlantic and rural East South Central, the below average overall payment impacts of these census divisions are related to negative impacts of introducing the FY 1993 wage data. In the rural Middle Atlantic, the negative impact of the new wage data is combined with a smaller impact stemming from MGCRB reclassifications in FY 1997 (0.8 percent compared to 1.5 percent in FY 1996). A smaller FY 1997 reclassification impact (2.5 percent compared with 3.7 percent in FY 1996) is also the reason for the small (2.2 percent) rate of increase in the rural East South Central census division. Conversely, the urban Middle Atlantic, urban West South Central, rural Pacific, and rural Puerto Rico census divisions all have overall rates of increase at least 0.4 percent above the national average. The urban West South Central gains from the continued phase-out of day outliers, as well as higher estimated FY 1997 outlier payments compared to FY 1996. As noted previously, the urban Middle Atlantic benefits significantly from the updated wage index data. These hospitals also have higher estimated FY 1997 outlier payments, which offset their 1.1 percent decrease due to the phase-out of day outliers. Rural Pacific hospitals benefit from geographic reclassification in FY 1997, with 12 hospitals being reclassified that were not reclassified in FY 1996. The only hospital groups with negative payment impacts from FY 1996 to FY 1997 are hospitals that were reclassified for FY 1996 and are not reclassified for FY 1997. Overall, these hospitals lose 0.5 percent. The urban hospitals in this category actually experience slight payment increases over FY 1996 (0.8 percent), while the rural hospitals lose 2.1 percent. On the other hand, hospitals reclassified for FY 1997 that were not reclassified for FY 1996 would experience the greatest payment increases: 10.5 percent for 69 rural hospitals in this category and 8.0 percent for 34 urban hospitals. Reclassification appears to be a significant factor influencing the payment increases for a number of rural hospital groups with above average overall payment increases in column 5. For example, among hospital groups identified in the discussion of the impacts of MGCRB reclassifications for FY 1997 (column 3), almost all have overall increases of 3.6 percent or greater. This outcome highlights the redistributive effects of reclassification decisions upon hospital payments. This impact is illustrated even more clearly when one examines the rows categorizing hospitals by their reclassification status for FY 1997. All nonreclassified hospitals have an average payment increase of 3.0 percent. The average payment increase for all reclassified hospitals is 4.3 percent. Among SCH/EACHs, the payment increase is 2.7 percent. The primary reason for this below average increase is that there is minimal impact upon these hospitals from the higher estimated FY 1997 outlier payments. Because these hospital groups receive their hospital-specific rate if it exceeds the applicable Federal amount (including outliers), there is less of an impact due to changes in outlier payment levels, which are not applied to the hospital-specific rate. In addition, nonspecial status rural hospitals experience only a 2.1 percent increase. This is largely attributable to a much smaller reclassification impact for FY 1997 among these hospitals. [[Page 27575]] Table II.--Impact Analysis of Changes for FY 1997 Operating Prospective Payment System [Payments per case] Average FY Average FY Number of 1996 1997 hospitals payment payment All changes percase percase (1) (2) \1\ (3) \1\ (4) ---------------------------------------------------------------------------------------------------------------- (By Geographic Location) ---------------------------------------------------------------------------------------------------------------- All hospitals............................................... 5,130 6,470 6,673 3.1 Urban hospitals............................................. 2,878 7,004 7,229 3.2 Large urban areas........................................... 1,597 7,524 7,761 3.1 Other urban areas........................................... 1,281 6,317 6,524 3.3 Rural areas................................................. 2,252 4,302 4,419 2.7 Bed size (urban): 0-99 beds............................................... 716 4,721 4,862 3.0 100-199 beds............................................ 938 5,939 6,112 2.9 200-299 beds............................................ 577 6,521 6,722 3.1 300-499 beds............................................ 479 7,410 7,660 3.4 500 or more beds........................................ 168 9,150 9,457 3.4 Bed Size (rural): 0-49 beds............................................... 1,173 3,540 3,639 2.8 50-99 beds.............................................. 663 3,996 4,108 2.8 100-149 beds............................................ 241 4,462 4,593 2.9 150-199 beds............................................ 99 4,582 4,713 2.8 200 or more beds........................................ 76 5,417 5,537 2.2 Urban by Census div.: New England............................................. 160 7,508 7,686 2.4 Middle Atlantic......................................... 434 7,686 7,953 3.5 South Atlantic.......................................... 419 6,664 6,887 3.3 East North Central...................................... 483 6,742 6,940 2.9 East South Central...................................... 163 6,185 6,395 3.4 West North Central...................................... 193 6,652 6,880 3.4 West South Central...................................... 375 6,524 6,756 3.6 Mountain................................................ 125 6,774 6,996 3.3 Pacific................................................. 478 8,077 8,313 2.9 Puerto Rico............................................. 48 2,584 2,652 2.6 Rural by Census div.: New England............................................. 53 5,236 5,344 2.1 Middle Atlantic......................................... 85 4,695 4,785 1.9 South Atlantic.......................................... 297 4,476 4,591 2.6 East North Central...................................... 304 4,328 4,454 2.9 East South Central...................................... 278 3,960 4,048 2.2 West North Central...................................... 525 4,008 4,121 2.8 West South Central...................................... 351 3,876 4,001 3.2 Mountain................................................ 213 4,575 4,712 3.0 Pacific................................................. 141 5,306 5,519 4.0 Puerto Rico............................................. 5 2,042 2,118 3.8 ---------------------------------------------------------------------------------------------------------------- (By Payment Categories) ---------------------------------------------------------------------------------------------------------------- Urban hospitals............................................. 2,978 6,960 7,184 3.2 Large urban areas........................................... 1,793 7,352 7,586 3.2 Other urban areas........................................... 1,185 6,322 6,528 3.3 Rural areas................................................. 2,152 4,269 4,379 2.6 Teaching status: Non-teaching............................................ 4,057 5,293 5,458 3.1 Fewer than 100 residents................................ 841 6,900 7,118 3.2 100 or more residents................................... 232 10,565 10,901 3.2 Disproportionate Share Hospitals (DSH): Non-DSH................................................. 3,200 5,602 5,779 3.2 Urban DSH: 100 beds or more.................................... 1,410 7,595 7,835 3.2 Fewer than 100 beds................................. 111 4,811 4,929 2.5 Rural DSH: Sole community (SCH)................................ 146 4,478 4,625 3.3 Referral centers (RRC).............................. 25 5,216 5,409 3.7 Other rural DSH hosp.: 100 beds or more.................................... 89 4,235 4,280 1.1 Fewer than 100 beds................................. 149 3,412 3,497 2.5 Urban Teaching and DSH: Both teaching and DSH................................... 682 8,576 8,843 3.1 Teaching and no DSH..................................... 337 7,094 7,324 3.2 [[Page 27576]] No Teaching and DSH..................................... 839 6,093 6,292 3.3 No teaching and no DSH.................................. 1,120 5,479 5,663 3.4 Rural hospital types: Nonspecial Status Hospitals............................. 1,382 3,901 3,984 2.1 RRC..................................................... 90 5,068 5,249 3.6 SCH/Each................................................ 641 4,415 4,536 2.7 SCH/Each and RRC........................................ 39 5,200 5,345 2.8 Type of ownership: Voluntary............................................... 3,084 6,634 6,846 3.2 Proprietary............................................. 691 5,917 6,093 3.0 Government.............................................. 1,355 6,030 6,207 2.9 Medicare utilization as a percent of inpatient days 0-25.................................................... 256 8,577 8,803 2.6 25-50................................................... 1,285 7,877 8,124 3.1 50-65................................................... 2,105 5,944 6,133 3.2 Over 65................................................. 1,353 5,062 5,220 3.1 Unknown................................................. 131 7,372 7,597 3.1 ---------------------------------------------------------------------------------------------------------------- Hospitals Reclassified by the Medicare Geographic Review Board ---------------------------------------------------------------------------------------------------------------- Reclassification status during FY96 and FY97: Reclassified during both FY96 and FY97.................. 381 5,864 6,046 3.1 Urban............................................... 133 6,750 6,976 3.4 Rural............................................... 248 5,003 5,143 2.8 Reclassified during FY97 only........................... 103 6,150 6,679 8.6 Urban............................................... 34 7,091 7,658 8.0 Rural............................................... 69 4,374 4,831 10.5 Reclassified during FY96 only........................... 251 5,658 5,630 -0.5 Urban............................................... 88 7,131 7,189 0.8 Rural............................................... 163 4,515 4,421 -2.1 FY 97 Reclassifications: All reclassified hosp. 484 5,922 6,176 4.3 Stand. amt. Only.................................... 120 5,764 5,944 3.1 Wage index only..................................... 274 5,839 6,065 3.9 Both................................................ 90 6,205 6,571 5.9 Nonreclass.......................................... 4,619 6,548 6,745 3.0 All urban reclass....................................... 167 6,837 7,150 4.6 Stand. amt. only.................................... 63 6,230 6,433 3.3 Wage index only..................................... 30 9,311 9,728 4.5 Both................................................ 74 6,370 6,727 5.6 Nonreclass.......................................... 2,711 7,018 7,235 3.1 All rural reclass....................................... 317 4,909 5,096 3.8 Stand. amt. only.................................... 57 4,623 4,749 2.7 Wage index only..................................... 244 4,968 5,146 3.6 Both................................................ 16 4,898 5,345 9.1 Nonreclass.......................................... 1,908 4,063 4,152 2.2 Other reclassifed: Hospitals (section 1886(d)(8)(B))....................... 27 4,611 4,756 3.1 \1\ These payment amounts per case do not reflect any estimates of annual case-mix increases. Table II presents the projected impact of the proposed changes for FY 1997 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the projected payments per case for FY 1997 with the average estimated per case payments for FY 1996, as calculated under our models. 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 column 5 of Table I. VII. Impact of Proposed Changes in the Capital Prospective Payment System A. General Considerations We now have data that were unavailable in previous impact analyses for the capital prospective payment system. Specifically, we have cost report data for the third year of the capital prospective payment system (cost reports beginning in FY 1994) available through the March 1996 update of the Hospital Cost Report Information System (HCRIS). We also have updated information on the projected 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 [[Page 27577]] 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 individual hospitals. Moreover, our policy of recognizing certain obligated capital as old capital makes it difficult to project 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 by 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 projected aggregate obligated capital amounts. However, we still do not know when these projects will actually be put into use for patient care, the actual 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 for purposes of the FY 1997 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 1997 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 1997. In addition, we have integrated sufficient hospital-specific information into our actuarial model to project the impact of the proposed FY 1997 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 randomly generate 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. We continue to be unable to predict accurately FY 1997 capital costs for individual hospitals, but with the more recent data on the 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 1997 payment policies. B. Projected Impact Based on the Proposed FY 1997Actuarial Model 1. Assumptions In this impact analysis, we model dynamically the impact of the capital prospective payment system from FY 1996 to FY 1997 using a capital acquisition model. The FY 1997 model, described in Appendix B of this proposed rule, integrates actual data from individual hospitals with randomly generated capital cost amounts. We have capital cost data from cost reports beginning in FY 1989 through FY 1994 received through the March 1996 update of the Hospital Cost Reporting Information System (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 January 1, 1996 in the Provider-Specific file. We used this data to determine the proposed FY 1997 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 1993, and we age that capital by a formula described in Appendix B. We therefore need to randomly generate only new capital acquisitions for any year after FY 1993. All Federal rate payment parameters are assigned to the applicable hospital. For purposes of this impact analysis, the FY 1997 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 ------------------------------------------------------------------------ 1995....................................................... -1.50 1996....................................................... 5.05 1997....................................................... 5.21 ------------------------------------------------------------------------ The Medicare case-mix index will increase by 1.6 percent in FY 1996 and FY 1997. The Federal capital rate as well as the hospital-specific rate is updated in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs, and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. The proposed FY 1997 update for inflation is 1.00 percent (see Addendum, Part III). 2. Results We have used the actuarial model to estimate the change in payment for capital-related costs from FY 1996 to FY 1997. Table III shows the effect of the capital prospective payment system on low capital cost hospitals and high capital cost 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: [[Page 27578]] Capital Transition Payment Methodology ---------------------------------------------------------------------------------------------------------------- FY 1997 FY 1997 Percent of FY 1997 percent of percent of Type of hospital hospitals percent of capital capital discharges costs payments ---------------------------------------------------------------------------------------------------------------- Low Cost Hospital........................................... 66 62 53 56 High Cost Hospital.......................................... 34 38 47 44 ---------------------------------------------------------------------------------------------------------------- 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 1996 to FY 1997 using the above described actuarial model. [[Page 27579]] Table III.--Impact of Proposed Changes for FY 1997 on Payments per Discharge FY 1996 payments per discharge -------------------------------------------------------------------------------------------------------------------------------------------------------- Adjusted Average Hospital Hold Number of Discharges federal federal specific harmless Exceptions Total hospitals payment percent payment payment payment payment -------------------------------------------------------------------------------------------------------------------------------------------------------- Low Cost Hospitals...................................... 3,367 6,543,036 $413.51 55.01 $200.60 $15.30 $16.59 $646.01 Fully Prospective................................... 1,472 2,953,665 373.96 50.00 236.94 .......... 11.59 622.49 Rebase--Fully Prospective........................... 1,561 2,777,809 373.98 50.00 220.57 .......... 23.17 617.72 Rebase--100% Federal Rate........................... 237 633,924 798.96 100.00 .......... .......... 0.05 799.00 Rebase--Hold Harmless............................... 97 177,638 313.93 44.64 .......... 563.62 55.92 933.48 High Cost Hospitals..................................... 1,737 4,044,123 665.47 85.61 .......... 152.51 16.36 834.35 100% Federal Rate................................... 1,126 2,842,423 788.87 100.00 .......... .......... 2.30 791.18 Hold Harmless....................................... 611 1,201,700 373.59 49.81 .......... 513.26 49.61 936.46 Total Hospitals................................... 5,104 10,587,159 509.76 66.94 123.98 67.71 16.50 717.95 -------------------------------------------------------------------------------------------------------------------------------------------------------- FY 1997 payments per discharge -------------------------------------------------------------------------------------------------------------------------------------------------------- Adjusted Average Hospital Hold Number of Discharges federal federal specific harmless Exceptions Total Percent hospitals payment percent payment payment payment payment change -------------------------------------------------------------------------------------------------------------------------------------------------------- Low Cost Hospitals.......................... 3,367 6,720,494 $472.14 64.07 $157.08 $12.37 $38.44 $680.03 5.27 Fully Prospective....................... 1,472 3,033,773 438.87 60.00 185.55 .......... 34.06 658.48 5.78 Rebase--Fully Prospective............... 1,561 2,853,148 440.66 60.00 172.70 .......... 45.15 658.50 6.60 Rebase--100% Federal Rate............... 243 657,828 785.22 100.00 .......... .......... 0.58 785.81 -1.65 Rebase--Hold Harmless................... 91 175,744 385.79 55.77 .......... 473.19 146.68 1,005.66 7.73 High Cost Hospitals......................... 1,737 4,153,806 691.63 89.42 .......... 123.03 48.28 862.93 3.43 100% Federal Rate....................... 1,164 2,988,949 780.85 100.00 .......... .......... 11.02 791.87 0.09 Hold Harmless........................... 573 1,164,856 462.69 61.34 .......... 438.70 143.88 1,045.27 11.62 Total Hospitals....................... 5,104 10,874,300 555.98 74.04 97.08 54.64 42.20 749.90 4.45 -------------------------------------------------------------------------------------------------------------------------------------------------------- [[Page 27580]] Under section 1886(g)(1)(A) of the Act, aggregate payments under the capital prospective payment system for FY 1992 through 1995 respectively, were projected to equal 90 percent of payments that would have been payable on a reasonable cost basis in each year. With the expiration of the capital budget neutrality provision, we now estimate that there was an aggregate 27.73 percent increase in FY 1996 Medicare capital payments over the FY 1995 payments. With the proposed Federal rate, we estimate aggregate Medicare capital payments will increase by 7.28 percent in FY 1997. We project that low capital cost hospitals paid under the fully prospective payment methodology will experience an average increase in payments per case of 5.27 percent, and high capital cost hospitals will experience an average increase of 3.43 percent. For hospitals paid under the fully prospective payment methodology, the Federal rate payment percentage will increase from 50 percent to 60 percent and the hospital-specific rate payment percentage will decrease from 50 to 40 percent in FY 1997. The Federal rate payment percentage for hospitals 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 hospitals receiving a hold-harmless payment for old capital will increase from 49.81 percent to 61.34 percent. We estimate the percentage of hold-harmless hospitals paid based on 100 percent of the Federal rate will increase from 65.8 percent to 67.9 percent. We expect that the average hospital-specific rate payment per discharge will decrease from $123.98 in FY 1996 to $97.08 in FY 1997. This is partly due to the 3.68 percent decrease in the FY 1997 hospital-specific rate compared to FY 1996. We are proposing no changes in our exceptions policies for FY 1997. As a result, the minimum payment levels would be: 90 percent for sole community hospitals; 80 percent for urban hospitals with 100 or more 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 2.30 percent of total capital payments in FY 1996 to 5.63 percent of payments in FY 1997. The number and amount of exceptions payments is expected to increase throughout the transition period. The projected distribution of the payments is shown in the table below: Estimated FY 1997 Exceptions Payments ------------------------------------------------------------------------ Percent of Type of hospital Number of exceptions hospitals payments ------------------------------------------------------------------------ Low Capital Cost.............................. 450 58 High Capital Cost............................. 331 42 ------------------------- Total..................................... 781 100 ------------------------------------------------------------------------ C. Cross-Sectional Comparison of Capital Prospective Payment Methodologies Table IV 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 Number of paid hold- Percentage paid fully Hospitals harmless paid fully prospective (A) federal (B) rate ---------------------------------------------------------------------------------------------------------------- By Geographic Location: All hospitals........................................... 5,104 13.0 27.6 59.4 Large urban areas (populations over 1 million).......... 1,584 15.6 34.5 49.9 Other urban areas (populations of 1 million or fewer)... 1,271 15.1 33.4 51.5 Rural areas............................................. 2,249 10.0 19.4 70.6 Urban hospitals......................................... 2,855 15.4 34.0 50.6 0-99 beds........................................... 698 16.2 27.7 56.2 100-199 beds........................................ 933 19.3 36.8 43.9 200-299 beds........................................ 577 13.9 37.3 48.9 300-499 beds........................................ 479 11.5 32.6 55.9 500 or more beds.................................... 168 6.5 37.5 56.0 Rural hospitals......................................... 2,249 10.0 19.4 70.6 0-49 beds........................................... 1,171 7.1 14.3 78.7 50-99 beds.......................................... 662 12.8 21.9 65.3 100-149 beds........................................ 241 14.5 30.3 55.2 150-199 beds........................................ 99 16.2 22.2 61.6 200 or more beds.................................... 76 7.9 39.5 52.6 By Region: Urban by Region......................................... 2,855 15.4 34.0 50.6 New England......................................... 160 7.5 25.0 67.5 Middle Atlantic..................................... 434 9.9 30.0 60.1 South Atlantic...................................... 417 19.2 41.0 39.8 East North Central.................................. 480 11.3 28.5 60.2 East South Central.................................. 162 19.8 36.4 43.8 West North Central.................................. 190 17.4 28.4 54.2 West South Central.................................. 366 25.7 47.5 26.8 Mountain............................................ 124 15.3 42.7 41.9 Pacific............................................. 474 13.3 30.4 56.3 Puerto Rico......................................... 48 18.8 16.7 64.6 Rural by Region......................................... 2,249 10.0 19.4 70.6 [[Page 27581]] New England......................................... 53 7.5 15.1 77.4 Middle Atlantic..................................... 84 6.0 19.0 75.0 South Atlantic...................................... 297 13.1 25.3 61.6 East North Central.................................. 304 8.6 13.5 78.0 East South Central.................................. 278 10.1 30.6 59.4 West North Central.................................. 525 7.2 15.0 77.7 West South Central.................................. 349 10.0 24.1 65.9 Mountain............................................ 213 15.5 12.7 71.8 Pacific............................................. 141 11.3 15.6 73.0 Large urban areas (populations over 1 million).......... 1,780 15.3 34.3 50.4 Other urban areas (populations of 1 million or fewer)... 1,175 15.4 32.3 52.3 Rural areas............................................. 2,149 9.8 19.4 70.8 Teaching Status: Non-teaching........................................ 4,031 13.7 26.6 59.7 Fewer than 100 Residents............................ 841 11.1 32.0 57.0 100 or more Residents............................... 232 7.8 28.4 63.8 Disproportionate share hospitals (DSH): Non-DSH............................................. 3,175 12.7 23.8 63.5 Urban DSH: 100 or more beds................................ 1,410 15.0 36.2 48.8 Less than 100 beds.............................. 110 11.8 25.5 62.7 Rural DSH: Sole Community (SCH/EACH)........................... 146 9.6 20.5 69.9 Referral Center (RRC/EACH).......................... 25 8.0 32.0 60.0 Other Rural: 100 or more beds............................ 89 13.5 39.3 47.2 Less than 100 beds.......................... 149 6.7 25.5 67.8 Urban teaching and DSH: Both teaching and DSH............................... 682 9.1 32.8 58.1 Teaching and no DSH................................. 337 13.6 27.6 58.8 No teaching and DSH................................. 838 19.3 37.6 43.1 No teaching and no DSH.............................. 1,098 16.7 32.7 50.6 Rural Hospital Types: NON special status hospitals........................ 1,379 7.6 19.5 72.9 RRC/EACH............................................ 90 8.9 37.8 53.3 SCH/EACH............................................ 641 14.5 16.4 69.1 SCH, RRC and EACH................................... 39 12.8 20.5 66.7 Type of Ownership: Voluntary: Voluntary........................................... 3,058 12.8 27.7 59.5 Proprietary......................................... 691 23.6 46.2 30.2 Government.......................................... 1,355 8.1 17.9 74.0 Medicare Utilization as a Percent of Inpatient Days: 0-25................................................ 256 14.8 25.0 60.2 25-50............................................... 1,285 14.6 33.1 52.3 50-65............................................... 2,105 12.9 27.8 59.3 Over 65............................................. 1,353 10.4 22.2 67.3 ---------------------------------------------------------------------------------------------------------------- As we explain in Appendix B, we were not able to determine a hospital-specific rate for 26 of the 5,130 hospitals in our data base. Consequently, the payment methodology distribution is based on 5,104 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. The percentage of hospitals paid fully Federal (100 percent of the Federal rate) as hold-harmless hospitals is expected to increase to 27.6 percent in FY 1997. Table IV indicates that 59.4 percent of hospitals are paid under the fully prospective payment methodology. (This figure, unlike the figure of 66 percent for low cost capital hospitals in the previous section, takes account of 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 (70.8 percent and 74.0 percent, respectively by payment classification) are being paid under the fully prospective methodology. This is a reflection of their lower than average capital costs [[Page 27582]] per case. In contrast, only 30.2 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 1997 actuarial model to estimate the potential impact of our proposed changes for FY 1997 on total capital payments per case, using a universe of 5,104 hospitals. The individual hospital payment parameters are taken from the best available data, including: the January 1, 1996 update to the Provider-Specific file, cost report data, and audit information supplied by intermediaries. Table V presents estimates of payments per case under our model for FY 1996 and FY 1997 (columns 2 and 3). Column 4 shows the total percentage change in payments from FY 1996 to FY 1997. Column 5 presents the percentage change in payments that can be attributed to Federal rate changes alone. Federal rate changes represented in Column 5 include the 4.36 percent decrease in the Federal rate, a 1.6 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), and reclassifications by the Medicare Geographic Classification Review Board. Column 4 includes the effects of the Federal rate changes represented in Column 3. Column 4 also reflects the effects of all other changes, including: the change from 50 percent to 60 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, capital payments per case can be expected to increase 4.4 percent in FY 1997. The results show that the effect of the Federal rate changes alone is to decrease payments by 0.9 percent. The decrease attributable to the Federal rate changes is more than offset by a 5.3 percent increase is attributable to the effects of all other changes. Our comparison by geographic location shows that capital payments per case to urban and rural hospitals experience similar rates of increase (4.4 percent and 4.8 percent, respectively). Payments per case for urban hospitals will decrease at about the same rate as payments per case for rural hospitals (0.8 percent and 1.3 percent, respectively) from the Federal rate changes alone. Urban hospitals will gain slightly less than rural hospitals (5.2 percent compared to 6.1 percent) from the effects of all other changes. By region, there is relatively little variation compared to some previous years. All regions are estimated to receive increases in total capital payments per case, due to the increased share of payments that is based on the Federal rate (from 50 to 60 percent). Changes by region vary from a low of 2.1 percent increase (Middle Atlantic rural region) to a high of 15.6 percent increase (rural hospitals of the New England region). By type of ownership, government hospitals are projected to have the largest rate of increase (5.1 percent, -1.1 percent due to Federal rate changes and a 6.2 percent positive offset from the effects of all other changes). Payments to voluntary hospitals will increase 4.5 percent (a 0.9 percent decrease due to Federal rate changes and a 5.4 percent positive offset from the effects of all other changes) and payments to proprietary hospitals will increase 3.8 percent (a 0.7 percent decrease due to Federal rate changes and a 4.5 percent positive offset from the effects of all other changes). Section 1886(d)(10) of the Act established the Medicare Geographic Classification Review Board (MGCRB). Hospitals may apply for reclassification for purposes of the standardized amount, wage index, or both. Although the Federal capital rate is not affected, 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 1997 compared to the effects of reclassification for FY 1996, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. For FY 1997 reclassifications, we indicate 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 during FY 1997 as a whole are projected to experience a 5.3 percent increase in payments (a 0.3 percent decrease attributable to Federal rate changes and a 5.6 percent positive offset attributable to the effects of all other changes). Payments to nonreclassified hospitals will increase slightly less (4.3 percent) than reclassified hospitals (5.3 percent) overall. Payments to nonreclassified hospitals will decrease slightly more than reclassified hospitals from the Federal rate changes (1.0 percent compared to 0.3 percent), but they will gain about the same from the effects of all other changes (5.3 percent compared to 5.6 percent). Table V.--Comparison of Total Payments Per Case [FY 1996 Payments Compared to FY 1997 Payments] ---------------------------------------------------------------------------------------------------------------- Portion Number of Average FY Average FY attibutable hospitals 1996 pay- 1997 pay- All changes to federal ments/case ments/case rate change ---------------------------------------------------------------------------------------------------------------- By Geographic Location: All hospitals.............................. 5,104 718 750 4.4 -0.9 Large urban areas (populations over 1 million).................................. 1,584 823 858 4.3 -0.9 Other urban areas (populations of 1 million of fewer)................................. 1,271 714 747 4.5 -0.8 Rural areas................................ 2,249 479 503 4.8 -1.3 Urban hospitals............................ 2,855 776 810 4.4 -0.8 [[Page 27583]] 0-99 beds.............................. 698 570 594 4.3 -0.9 100-199 beds........................... 933 703 731 4.1 -1.0 200-299 beds........................... 577 744 776 4.2 -0.9 300-499 beds........................... 479 800 838 4.8 -0.8 500 or more beds....................... 168 944 984 4.3 -0.5 Rural hospitals............................ 2,249 479 503 4.8 -1.3 0-49 beds.............................. 1,171 368 389 5.8 -1.5 50-99 beds............................. 662 445 468 5.0 -1.2 100-149 beds........................... 241 512 536 4.7 -1.3 150-199 beds........................... 99 517 543 4.9 -1.0 200 or more beds....................... 76 609 633 3.9 -1.5 By Region: Urban by Region............................ 2,855 776 810 4.4 -0.8 New England............................ 160 780 818 4.9 -1.5 Middle Atlantic........................ 434 816 855 4.8 -0.8 South Atlantic......................... 417 777 809 4.2 -0.8 East North Central..................... 480 730 759 4.0 -0.7 East South Central..................... 162 707 744 5.3 -0.5 West North Central..................... 190 768 807 5.1 -0.8 West South Central..................... 366 794 825 3.8 -0.3 Mountain............................... 124 774 804 3.8 -1.1 Pacific................................ 474 856 890 4.1 -1.3 Puerto Rico............................ 48 291 313 7.5 -1.1 Rural by Region............................ 2,249 479 503 4.8 -1.3 New England............................ 53 605 699 15.6 -1.8 Middle Atlantic........................ 84 489 499 2.1 -2.4 South Atlantic......................... 297 501 518 3.4 -1.5 East North Central..................... 304 479 506 5.7 -0.9 East South Central..................... 278 453 471 4.0 -1.5 West North Central..................... 525 449 471 5.0 -1.4 West South Central..................... 349 447 467 4.4 -0.9 Mountain............................... 213 507 540 6.4 -0.5 Pacific................................ 141 549 582 6.1 -0.9 By Payment Classification: All hospitals.............................. 5,104 718 750 4.4 -0.9 Large urban areas (populations over 1 million).................................. 1,780 808 842 4.3 -0.9 Other urban areas (populations of 1 million of fewer)................................. 1,175 714 747 4.6 -0.8 Rural areas................................ 2,149 473 495 4.8 -1.4 Teaching Status: Non-teaching........................... 4,031 623 647 3.9 -1.0 Fewer than 100 Residents............... 841 756 791 4.7 -0.9 100 or more Residents.................. 232 1,039 1,096 5.5 -0.7 Urban DSH: 100 or more beds................... 1,410 814 850 4.5 -0.9 Less than 100 beds................. 110 557 587 5.4 -1.1 Rural DSH: Sole Community (SCH/EACH).......... 146 458 495 8.1 -1.9 Referral Center (RRC/EACH)......... 25 544 560 2.9 -0.2 Other Rural: 100 or more beds................... 89 501 519 3.6 -1.9 Less than 100 beds................. 149 365 385 5.5 -1.6 Urban teaching and DSH:.................... Both teaching and DSH.................. 682 879 919 4.6 -0.8 Teaching and no DSH.................... 337 786 827 5.3 -0.8 No teaching and DSH.................... 838 712 743 4.4 -0.9 No teaching and no DSH................. 1,098 672 695 3.4 -0.8 Rural Hospital Types: Non special status hospitals........... 1,379 439 458 4.3 -1.7 RRC/EACH............................... 90 559 574 2.5 -0.8 SCH/EACH............................... 641 471 506 7.4 -1.2 SCH, RRC and EACH...................... 39 577 608 5.4 -1.0 Hospitals Reclassified by the Medicare Geographic Classification Review Board: Reclassification Status During FY96 and FY97: Reclassified During Both FY96 and FY97.............................. 381 668 698 4.5 -1.1 Reclassified During FY97 Only...... 103 678 736 8.6 2.9 Reclassified During FY96 Only...... 228 631 640 1.4 -3.6 FY97 Reclassifications: All Reclassified Hospitals......... 484 670 706 5.3 -0.3 [[Page 27584]] All Nonreclassified Hospitals...... 4,593 725 756 4.3 -1.0 All Urban Reclassified Hospitals... 167 762 799 4.9 -0.3 Urban Nonreclassified Hospitals.... 2,688 777 811 4.3 -0.9 All Reclassified Rural Hospitals... 317 568 602 6.0 -0.3 Rural Nonreclassified Hospitals.... 1,905 443 463 4.3 -1.8 Other Reclassified Hospitals (Section 1886 (D)(8)(B))....................... 27 552 575 4.1 -1.3 Type of Ownership: Voluntary.............................. 3,058 732 765 4.5 -0.9 Proprietary............................ 691 748 776 3.8 -0.7 Government............................. 1,355 618 649 5.1 -1.1 Medicare Utilization as a Percent of Inpatient Days: 0-25................................... 256 793 847 6.8 -1.4 25-50.................................. 1,285 844 880 4.2 -0.8 50-65.................................. 2,105 675 706 4.6 -0.9 Over 65................................ 1,353 603 628 4.1 -1.0 ---------------------------------------------------------------------------------------------------------------- Appendix B: Technical Appendix on the Capital Acquisition Model and Required Adjustments Under section 1886(g)(1)(A) of the Act, we set capital prospective payment rates for FY 1992 through FY 1995 so that aggregate prospective payments for capital costs were projected to be 10 percent lower than the amount that would have been payable on a reasonable cost basis for capital-related costs in that year. To implement this requirement, we developed the capital acquisition model to determine the budget neutrality adjustment factor. Even though the budget neutrality requirement expires effective with FY 1996, we must continue to determine the recalibration and geographic reclassification budget neutrality adjustment factor, and the reduction in the Federal and hospital-specific rates for exceptions payments. We continue to use the capital acquisition model to determine these factors. The following data are used in the capital acquisition model for FY 1997: the March 8, 1996 update of the cost reports for PPS-IX (cost reporting periods beginning in FY 1992), PPS-X (cost reporting periods beginning in FY 1993) and PPS-XI (cost reporting periods beginning in FY 1994), the January 1, 1996 update of the provider-specific file, and the March 1994 update of the intermediary audit file. The available data still lack certain items that were required for the determination of budget neutrality, including each 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. Since hospitals under alternative payment system waivers (that is, hospitals in Maryland) are currently excluded from the capital prospective payment system, we excluded these hospitals from our model. We then developed FY 1992, FY 1993, FY 1994, FY 1995, and FY 1996 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), 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), that the FY 1995 increase in the hospital-specific rate was at least 0.05 percent (the net FY 1995 update), and that the FY 1996 increase in the hospital-specific rate was at least 21.10 percent (the net FY 1996 update). We were able to match hospitals to the files as shown in the following table. ------------------------------------------------------------------------ Number of Source hospitals ------------------------------------------------------------------------ Provider-Specific File Only................................ 101 Provider-Specific and Audit File........................... 5029 ------------ Total................................................ 5130 ------------------------------------------------------------------------ Sixty-eight of these hospitals had unusable or missing data. We were able to backfill a hospital-specific rate for 42 of these hospitals from the cost reports as shown in the following table. ------------------------------------------------------------------------ Number of Source hospitals ------------------------------------------------------------------------ PPS-VII Cost Reports....................................... 1 PPS-VIII Cost Reports...................................... 2 PPS-IX Cost Reports........................................ 3 PPS-X Cost Reports......................................... 7 PPS-XI Cost Reports........................................ 29 ------------ Total................................................ 42 ------------------------------------------------------------------------ We did not have data for 26 hospitals, and had to eliminate them from the capital analysis. These hospitals likely are new hospitals or hospitals with very few Medicare admissions. This leaves us with 5104 hospitals and should not affect the precision of the required adjustment factors. Next, we determined old and new capital amounts for FY 1992 using the PPS-IX cost reports as the first source of data. For FY 1993 amounts, we used PPS-IX and PPS-X cost reports as the first source of data, weighting each cost report by the number of days in FY 1993. For FY 1994 amounts, we used PPS-X and PPS-XI cost reports as the first source of data, weighting each cost report by the number of days in FY 1994. We were able to match 5,049 PPS-IX cost reports, 5,062 PPS-X cost reports, and 4,654 PPS-XI cost reports. In cases where cost reports could not be matched, we used the provider-specific file for old capital information. Even in cases where a cost report was available, the breakout 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 [[Page 27585]] the old capital amount from the hospital-specific rate. Finally, we used the intermediary audit file to develop obligated capital amounts. 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 does not reflect 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 costs per discharge amount. Since we must project capital amounts for each hospital, we continued to use a Monte Carlo simulation to develop these amounts. (This model is described in detail in the August 30, 1991 final rule (56 FR 43517).) 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 cost 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 0.85 (aging factor). The 0.85 aging factor is the average of changes in capital over its life due to the gradual decrease in interest payments and the retirement of fully depreciatiated capital. The aged new and old capital is subtracted from the projected capital described in the previous paragraph. The difference represents newly acquired capital. If the hospital has obligated capital, any increase in ``old'' capital up to the total amount of obligated capital in FY 1993 and FY 1994 is assigned to obligated capital. Any remaining obligated capital is assigned to FY 1995 up to the amount of the modeled increase in capital for FY 1995. Even though obligated capital must be put in use for patient care by October 1, 1994, the use of the obligated capital may have started late in FY 1994 with only part of the ``first year'' depreciation and interest realized in FY 1994. The remainder of the ``first year'' depreciation and interest would be realized in 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. Hence, no obligated capital is assigned to years FY 1996 and later. Once obligated capital is assigned, it is included with the ``old'' capital and is capitalized into future years as part of ``old'' capital. 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-IX 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 FY 1995 MedPAR file using the FY 1997 DRG relative weights published in this proposed rule. The case-mix index is increased each year after FY 1995 based on analysis of past experiences in case-mix increases. We analyzed the case-mix increases for the recent past and found that case-mix increases have decelerated to about 1.53 percent in FY 1992, 0.80 percent in FY 1993, and 0.75 percent in FY 1994. It appears that the case-mix increase for FY 1995 accelerated to around 1.6 percent. Early indications show that FY 1996 case-mix is increasing at FY 1995 level, around 1.6 percent. It appears that the deceleration of case-mix increases in FY 1993 and FY 1994 were anomalous, rather than the beginning of a trend. Therefore, in the model we are using the recent experience and have used a case-mix increase of 1.6 percent in FY 1995 and a projected case-mix increase of 1.6 percent in both FY 1996 and FY 1997. (Since we are using FY 1995 cases for our analysis, the FY 1995 increase in case mix has no effect on projected capital payments.) Changes in geographic classification and revisions to 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 1886(g)(1)(A) of the Act 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. Since budget neutrality expires effective with FY 1996, this adjustment affects the adjusted Federal rate starting in FY 1996. [[Page 27586]] 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 1996, the budget neutrality adjustment factor was 1.0025. To determine the factor for FY 1997, we first determined the portion of the Federal rate that would be paid for each hospital in FY 1997 based on its applicable payment methodology. Using our model, we then compared estimated aggregate Federal rate payments based on the FY 1996 DRG relative weights and the FY 1996 geographic adjustment factor to estimated aggregate Federal rate payments based on the FY 1997 relative weights and the FY 1997 geographic adjustment factor. In making the comparison, we held the FY 1997 Federal rate portion constant and set the other budget neutrality adjustment factor and the 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 0.9992 for FY 1997 should be applied to the previous cumulative FY 1996 adjustment of 1.0025 (the product of the FY 1993 incremental adjustment of 0.9980, the FY 1994 incremental adjustment of 1.0053, the FY 1995 incremental adjustment of 0.9998, and the FY 1996 incremental adjustment of 0.9994), yielding a cumulative adjustment of 1.0017 through FY 1997. 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 relative 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 simulate total payments under the prospective payment system. 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 the exceptions reduction factor. This exceptions reduction factor ensures that aggregate payments under the capital prospective payment system, including exceptions payments, are projected to equal the aggregate payments that would have been made 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 exceptions reduction factor must be determined through iteration. 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 FY 1992, FY 1993, FY 1994, FY 1995, FY 1996, the proposed FY 1997 factor, and the estimated factors that would be applicable through FY 2001. We caution that, except with respect to FY 1992, FY 1993, FY 1994, FY 1995 and FY 1996, these 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 1.0017 for FY 1997 and later because we do not have sufficient information to estimate the change that will occur in the factor for years after FY 1997. The projections are as follows: ---------------------------------------------------------------------------------------------------------------- Federal Update Exceptions Budget rate (after Fiscal year factor reduction neutrality outlier) factor factor reduction) ---------------------------------------------------------------------------------------------------------------- 1992........................................................ N/A 0.9813 0.9602 415.59 1993........................................................ 6.07 .9756 .9162 \1\ 417.29 1994........................................................ 3.04 .9485 .8947 \2\ 378.34 1995........................................................ 3.44 .9734 .8432 \3\ 376.83 1996........................................................ 1.20 .9849 N/A \4\ 461.96 1997........................................................ 1.00 .9393 N/A \5\ 441.84 1998........................................................ 1.00 .9161 N/A 435.23 1999........................................................ 1.00 .9228 N/A 442.80 2000........................................................ 1.10 .9155 N/A 444.13 2001........................................................ 1.10 N/A6 N/A 490.46 ---------------------------------------------------------------------------------------------------------------- \1\ Note: Includes the DRG/GAF adjustment factor of 0.9980 and the change in the outlier adjustment from 0.9497 in FY 1992 to 0.9496 in FY 1993. \2\ 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. \3\ 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. \4\ Note: Includes the the transfer adjustment of .9972. Also includes the DRG/GAF adjustment factor of 1.0025 and the change in the outlier adjustment from 0.9414 in FY 1995 to 0.9536 in FY 1996. \5\ Note: Includes the DRG/GAF adjustment factor of 1.0017 and the change in the outlier adjustment from 0.9536 in FY 1996 to 0.9476 in FY 1997. Future adjustments are, for purposes of this projection, assumed to remain at the same level. \6\ Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (Sec. 412.348(g) of the regulations) because the regular exceptions provision (Sec. 412.348(e)) expires. [[Page 27587]] Appendix C: Rebased Market Basket Data Sources I. Data Sources Used To Determine the Market Basket Relative Weights and Choice of Price Proxy Variables for the Operating Hospital Input Price Indexes As discussed in section IV of the preamble to this proposed rule, we are rebasing and revising the hospital market baskets. This appendix describes the technical features of the 1992-based indexes that we are proposing in this rule. For both the prospective payment and excluded hospital market baskets, the differences between the proposed 1992- based market basket and the previous 1987-based market basket are noted. In the September 4, 1990 final rule (55 FR 36170), we discussed in detail the 1987-based hospital market baskets. We present this description of the hospital operating market baskets in three steps: A synopsis of the structural differences between the 1987- based market baskets and the proposed 1992-based market baskets. A description of the methodology used to develop the cost category weights in the 1992-based market baskets, making note of the differences from the methodology used to develop the 1987-based market baskets. A description of the data sources used to measure price change for each component of the 1992-based market baskets, making note of the differences from the price proxies used in the 1987-based hospital market baskets. A. Synopsis of Structural Changes Adopted in the Rebased 1992 Operating Hospital Market Baskets Three major structural differences exist between the 1987-based and the proposed 1992-based operating hospital market baskets. The proposed hospital market baskets are based on more recent hospital expenditure data. The 1987-based market baskets contained skeletal cost shares that were derived from the 1987 cost data from the 1988 Annual Survey of the American Hospital Association (AHA). The 1992-based market baskets use data from the hospital cost reports for cost reporting periods beginning on or after October 1, 1991 and before October 1, 1992. Some cost categories have been combined, namely Fuel, Oil, Coal, and Other Fuel with Motor Gasoline, and Blood Services with Chemicals. These category mergers reflect the Bureau of Economic Analysis (BEA) reclassification decisions in the 1987 update of the BEA Input-Output Tables. In the proposed 1992-based market basket, the sample of excluded hospitals is restricted to more closely reflect the average Medicare length of stay in excluded hospitals. We have used cost report data for excluded hospitals from only those hospitals in which the Medicare average length of stay is within 15 percent of the total average length of stay to more accurately reflect the structure of costs for Medicare cases. This is a change from the FY 1987-based market basket, for which data from all excluded hospitals were used. B. Methodology for Developing the Cost Category Weights Cost category weights for the 1992-based market baskets were developed in four stages. First, base weights for three (Wages and Salaries, Employee Benefits, Pharmaceuticals) of the six main categories were derived from the 1992 Medicare cost reports for operating costs. Second, the weight for Nonmedical Professional Fees was developed by subtracting Medical Professional Fees reported in the Hospital Cost Report Information System (HCRIS) file from AHA Annual Survey Total Professional Fees to obtain Nonmedical Professional Fees, and the weight for Professional Liability Insurance was developed using 1989 HCRIS data trended forward to 1992, using the relative importance values in the previous market baskets. Third, the sum of Wages and Salaries, Employee Benefits, Pharmaceuticals, Nonmedical Professional Fees, and Professional Liability Insurance was subtracted from total expenses to obtain All Other Expenses. Finally, the weight for All Other Expenses was divided into subcategories using cost shares from the 1987 Input-Output Table for the hospital industry, produced by the U.S. Department of Commerce, Bureau of Economic Analysis, aged to 1992 using price changes. We will incorporate 1992 data from the U.S. Department of Commerce into the final market basket if the data are released in time to be analyzed in developing the final rule. Below, we describe the source of the six main category weights and their subcategories in the 1992-based market baskets. We make note of the differences between the methodologies used to develop the 1987- based and the 1992-based market baskets. 1. Wages and Salaries: The cost weight for the Wages and Salaries category was derived using the 1992 Medicare cost reports. Contract Labor, which is also derived from the 1992 Medicare cost reports, is split between the Wages and Salaries and Employee Benefits cost categories, using the relationship for employed workers. Examples of Contract Labor are registered nurses and workers in hospital food service or security who are employed and paid by firms that contract for their work with the hospital. The Wages and Salaries cost category was disaggregated into nine occupational subcategories (professional and technical, managers and administration, sales, clerical, craft and kindred, operatives excluding transport, transport equipment operatives, nonfarm laborers and service workers) to reflect the mix of occupational inputs used by hospitals. The Contract Labor wages and salaries component was allocated proportionally to Professional- Technical and Service occupations. The 1987-based weights were developed from the 1987 Current Population Survey, while the 1992-based weights were developed from the 1992 Current Population Survey. 2. Employee Benefits: The cost weight for the employee benefits category was derived from the 1992 cost reports. Like wages and salaries, the employee benefit weight in each 1992-based market basket is a composite of nine labor subcategories. The employee benefits categories in the 1987-based market baskets were developed from the 1987 AHA Annual Survey and used the 1987 Current Population Survey. In 1987 Contract Labor's implied fringe benefits were allocated proportionally to Professional and Technical occupations, while in 1992 they were allocated to Professional-Technical and Service occupations. 3. Nonmedical Professional Fees: The cost weight for the nonmedical professional fees category was derived from the 1992 Medicare Cost Reports and AHA Annual Survey data. Total professional fees were split into the subcategories medical and other (nonmedical) fees using AHA Total Professional Fees minus HCRIS Medical Professional Fees to equal Nonmedical Professional Fees. The 1987-based nonmedical professional fees cost category was derived from the 1987 AHA Annual Survey and American Medical Association (AMA) data. It was split into the subcategories medical and other fees using data derived from the American Medical Association. The medical professional fees category is excluded from the hospital market basket since it is paid under Medicare Part B. 4. Professional Liability Insurance: The 1987-based market baskets have weights for professional liability insurance that were derived from the June 30 and December 31, 1987 HAS/Monitrend surveys. The cost weight for [[Page 27588]] the 1992-based professional liability insurance category was derived from 1989 HCRIS cost shares trended to 1992 using the change in the relative importance factor for professional liability insurance (malpractice) from the previous 1987-based prospective payment hospital and excluded hospital market baskets. 5. Utilities: For the 1987-based market baskets, the cost weight for utilities was derived by extrapolating the 1985 AHA Annual Survey utilities cost weight forward to 1987 using the rate of growth in the HAS/Monitrend cost weight for utilities between 1985 and 1987. The 1987 Utility subcategory weights were aged from their 1982-based index subcategory weights using price changes from 1982 to 1987. The 1992- based market basket cost weights for the subcategories (fuel, oil and gasoline; electricity; natural gas; and water and sewage) were derived from the Bureau of Economic Analysis' 1987 Input-Output table for the hospital industry, aged forward to 1992 by price changes and summed to a weight for utilities. 6. All Other Goods and Services: The all other goods and services category has more subcategories than any other market basket category. Goods found in this category include: direct service food, contract service food, pharmaceuticals, chemicals, medical instruments, photo supplies, rubber and plastics, paper products, apparel, machinery and equipment and miscellaneous products. Services found in this category include: business services, computer services, transportation and shipping, telephone, postage, other labor-intensive services, and other nonlabor-intensive services. The share for pharmaceuticals was derived from the 1992 Medicare cost reports. Relative shares for the other subcategories were derived from the 1987 Bureau of Economic Analysis' Input-Output table for the hospital industry and were aged forward to 1992 using price changes. As noted above, if more recent U.S. Department of Commerce data become available for these categories and we have time to analyze these data before the publication of the final rule, they will be incorporated into the final market baskets. C. Price Proxies Used to Measure Cost Category Growth 1. Wages and Salaries: For measuring price growth in the 1992-based market basket, 10 price proxies are applied to the 9 occupational subcategories within the wages and salaries component. As in the 1987- based market basket, the professional and technical subcategory was split in half. An Employee Cost Index (ECI) for hourly wages paid to civilian hospital workers was applied to one half. An ECI of hourly wages and salaries paid to professional and technical workers in private industry was applied to the other half of the professional and technical component. The other eight occupations subcategories of the wages and salaries component were proxied using ECIs for wages and salaries for private industry workers in their respective occupational categories. 2. Employee Benefits: The 1992-based hospital market baskets use occupation-specific ECIs for employee benefits. The distribution of weights and price proxies is the same as for wages and salaries discussed above, but occupation-specific employee benefit ECIs replace occupation-specific wages and salaries ECIs. The components are summed into a composite index, just as was done for the 1987-based market basket. 3. Nonmedical Professional Fees: The ECI for compensation for professional and technical workers in private industry is applied to this category. This is a revision from the 1987-based market basket in which the ECI for wages and salaries for professional and technical workers in private industry was used. 4. Fuel, Oil, and Gasoline: The percentage change in the price of refined petroleum products as measured by the Producer Price Index (PPI) (Commodity Code #057) was applied to this component. This is a revision from the 1987-based indexes in which the PPIs for Light Fuel Oil (Commodity Code #0573) and Gasoline (Commodity Code #0571) were used. 5. Electricity: The percentage change in the price of commercial electric power as measured by the PPI (Commodity Code #0542) was applied to this component. This is a revision from the 1987-based indexes in which the PPI for industrial power (Commodity Code #0543) was used. 6. Natural Gas: The percentage change in the price of gas fuels as measured by the PPI (Commodity Code #0552) was applied to this component. This is a revision from the 1987-based indexes in which the PPI for Natural Gas (Commodity Code #0531) was used. 7. Water and Sewerage: The percentage change in the price of water and sewerage maintenance as measured by the Consumer Price Index (CPI) for all urban consumers was applied to this component. The same price measure was used in the 1987-based market baskets. 8. Professional Liability Insurance: The percentage change in the hospital professional liability insurance price as estimated by hospital industry professional liability insurance premium increase was applied to this component. The same price measure was used in the 1987- based market baskets. 9. Pharmaceuticals: The percentage change in the price of ethical preparations as measured by the PPI (Commodity Code #0635) was applied to this variable. The same price measure was used in the 1987-based market baskets. 10. Food, Direct Purchases: The percentage change in the price of processed foods and feeds as measured by the PPI (Commodity Code #02) was applied to this component. The same price measure was used in the 1987-based market baskets. 11. Food, Contract Services: The percentage change in the price of food purchased away from home as measured by the CPI for all urban consumers was applied to this component. The same price measure was used in the 1987-based market baskets. 12. Chemicals: The percentage change in the price of industrial chemical products as measured by the PPI (Commodity Code #061) was applied to this component. The same price measure was used in the 1987- based market baskets. 13. Surgical and Medical Equipment: The percentage change in the price of medical and surgical instruments as measured by the PPI (Commodity Code #1562) was applied to this component. The same price measure was used in the 1987-based market baskets. 14. Photographic Supplies: The percentage change in the price of photographic supplies as measured by the PPI (Commodity Code #1542) was applied to this component. The same price measure was used in the 1987- based market baskets. 15. Rubber and Plastics: The percentage change in the price of rubber and plastic products as measured by the PPI (Commodity Code #07) was applied to this component. The same price measure was used in the 1987-based market baskets. 16. Paper Products: The percentage change in the price of converted paper and paperboard products as measured by the PPI (Commodity Code # 0915) was used. This is a revision from the 1987-based indexes in which a weighted average of the percentage change in the price of converted paper and paperboard products and the percentage change in the price of paper excluding newsprint and packaging paper (Commodity Code #091301) was used. [[Page 27589]] 17. Apparel: The percentage change in the price of apparel as measured by the PPI (Commodity Code #381) was applied to this component. This is a revision from the 1987-based indexes in which the PPI for textile house furnishings (Commodity Code #0382) was used. 18. Minor Machinery and Equipment: The percentage change in the price of machinery and equipment as measured by the PPI (Commodity Code #11) was applied to this component. The same price measure was used in the 1987-based market baskets. 19. Miscellaneous Products: The percentage change in the price of all finished goods as measured by the PPI was applied to this component. The same price measure was used in the 1987-based market baskets. 20. Business Services: The ECI for compensation for workers in the business services industry was applied to this component. This is a revision from the 1987-based indexes in which the percentage change in the AHE for wages and salaries for production and nonsupervisory workers in the business services industry as measured by the Bureau of Labor Statistics (SIC Code 73) was used. 21. Computer and Data Processing Services: The percentage change in the AHE of production and nonsupervisory workers engaged in firms furnishing computer data processing services (SIC Code 737) was applied to this component. The same price measure was used in the 1987-based market baskets. 22. Transportation and Shipping: The percentage change in the transportation component of the CPI for all urban consumers was applied to this component. The same price measure was used in the 1987-based market baskets. 23. Telephone: The percentage change in the price of telephone services as measured by the CPI for all urban consumers was applied to this component. The same price measure was used in the 1987-based market baskets. 24. Postage: The percentage change in the price of postage as measured by the CPI for all urban consumers was applied to this component. The same price measure was used in the 1987-based market baskets. 25. All Other Services, Labor Intensive: The percentage change in the ECI for compensation paid to service workers employed in private industry was applied to this component. This is a revision from the 1987-based indexes in which the ECI for wages and salaries paid to service workers employed in private industry was used. 26. All Other Services, Nonlabor Intensive: The percentage change in the all-items component of the CPI for all urban consumers was applied to this component. The same price measure was used in the 1987- based market baskets. For further discussion of the rationale for choosing specific price proxies, we refer the reader to the September 3, 1986 final rule (51 FR 31582). II. Data Sources Used to Determine the Cost Category Weights and Vintage Weights, and Choices of Price Proxy Variables for the Hospital Capital Input Price Index In the preamble to this proposed rule, we discuss the rebasing of the capital input price index (CIPI). This appendix describes certain technical features of the 1992-based index that we are proposing in this rule, as well as differences between the proposed 1992-based CIPI and the current 1987-based CIPI. We discussed the 1987-based CIPI in the September 1, 1995 final rule (60 FR 45817.) This discussion has the following three parts: A synopsis of the differences between the 1987-based CIPI and the proposed 1992-based CIPI. A description of the methodology used to develop the cost category weights and vintage weights in the 1992-based CIPI, making note of the differences from the methodology used to develop the 1987- based CIPI. A description of the data sources used to measure price change for each component of the 1992-based CIPI, making note of the differences from the price proxies used in the 1987-based CIPI. A. Synopsis of Changes Adopted in the Rebased 1992 CIPI We made no structural changes in the 1992-based CIPI. The only major change is the use of more recent hospital capital expenditure data in the proposed 1992-based CIPI. The 1987-based CIPI contained cost category weights that were derived from 1987 Medicare cost report data and the 1987 Annual Survey of the AHA. The 1992-based CIPI uses data from the hospital Medicare cost reports for cost periods beginning between October 1, 1991 and September 30, 1992. The 1992-based CIPI also uses data from the 1992 Annual Survey of the AHA. The 1987-based CIPI contained vintage weights that were derived from 1987 Medicare cost report data, the 1963-1987 Panel Survey of the AHA, and the 1980-1989 Securities Data Corporation data on hospital bonds. The 1992-based CIPI uses data from the 1992 Medicare cost reports, the 1963-1992 Panel Survey of the AHA, and 1980-1992 Securities Data Corporation data on hospital bonds. B. Methodology for Developing Cost Category Weights and Vintage Weights for the 1992-based CIPI There are five cost categories in the CIPI: building and fixed equipment depreciation, movable equipment depreciation, capital-related interest expense from government/nonprofit debt instruments, capital- related interest expense from for-profit debt instruments, and other capital-related expenses, such as taxes and insurance. The methodology for developing each of these cost category weights is described below: 1. Building and Fixed Equipment Depreciation: The 1992-based cost weight for building and fixed equipment depreciation was derived using the 1992 Medicare cost reports. The proportion of lease expenses attributable to building and fixed equipment was included in the cost weight based on the proportion of overall capital expenses allocated to building and fixed equipment depreciation. The 1987-based weight was developed from the 1987 Medicare cost reports and the 1987 AHA Annual Survey. 2. Movable Equipment Depreciation: The 1992-based cost weight for movable equipment depreciation was derived using the 1992 Medicare Cost Reports. The proportion of lease expenses attributable to movable equipment was included in the cost weight based on the proportion of overall capital expenses allocated to movable equipment depreciation. The 1987-based weight was developed from the 1987 Medicare cost reports and the 1987 AHA Annual Survey. 3. Government/Nonprofit Interest: The 1992-based cost weight for government/nonprofit interest was derived using the 1992 AHA Annual Survey data. The government/nonprofit interest is 85 percent of total interest, reflecting the relative debts of the government/nonprofit hospital sector and the for-profit hospital sector. The proportion of lease expenses attributable to government/nonprofit interest was included in the cost weight based on the proportion of overall capital expenses allocated to government/non-profit interest expense. The 1987- based weight was developed from the 1987 AHA Annual Survey. 4. For-Profit Interest: The 1992-based cost weight of for-profit interest was [[Page 27590]] derived using the 1992 AHA Annual Survey data. The for-profit interest is 15 percent of total interest, reflecting the relative debts of the government/nonprofit hospital sector and the for-profit hospital sector. The proportion of lease expenses attributable to for-profit interest was included in the cost weight based on the proportion of overall capital expenses allocated to for-profit interest expense. The 1987-based weight was developed from the 1987 AHA Annual Survey. 5. Other Capital-Related Expenses: The 1992-based cost weight for other capital-related expenses was derived using 1992 Medicare cost reports. The proportion of lease expenses attributable to other capital-related expenses was included in the cost weight based on the proportion of overall capital expenses allocated to other capital- related expenses. The 1987-based weight was developed from the 1987 Medicare cost reports and the 1987 Capital Expenditure Survey. There are three sets of vintage weights in the CIPI: building and fixed equipment depreciation, movable equipment depreciation, and interest expense. The methodology for developing each of these vintage weights is described below. 1. Building and Fixed Equipment: The 1992-based building and fixed equipment vintage weights were derived from the 1992 Medicare cost reports and the 1963-1992 AHA Panel Survey. The 1987-based weights were developed from the 1987 Medicare cost reports and the 1963-1987 AHA Panel Survey. 2. Movable Equipment: The 1992-based movable equipment vintage weights were derived from the 1992 Medicare cost reports and the 1963- 1992 AHA Panel Survey. The 1987-based weights were developed from the 1987 Medicare cost reports and the 1963-1987 AHA Panel Survey. 3. Capital-Related Interest: The 1992-based movable equipment vintage weights were derived from the 1980-1992 Securities Data Corporation data on hospital bonds and the 1963-1992 AHA Panel Survey. The 1987-based weights were developed from the 1980-1989 Securities Data Corporation data on hospital bonds and the 1963-1987 AHA Panel Survey. C. Price Proxies Used to Measure Cost Category Growth in the CIPI 1. Building and Fixed Equipment Depreciation: The percentage change in the vintage-weighted price of building and fixed equipment depreciation as measured by the Boeckh institutional construction index was applied to this category in the 1992-based CIPI. The same price proxy was used in the 1987-based CIPI. 2. Movable Equipment Depreciation: The percentage change in the vintage-weighted price of movable equipment depreciation as measured by the Producer Price Index (PPI) for machinery and equipment was applied to this category in the 1992-based CIPI. The same price proxy was used in the 1987-based CIPI. 3. Government/Nonprofit Interest Expense: The percentage change in the vintage-weighted price of government/nonprofit interest expense as measured by the Average yield on Domestic Municipal Bonds from the Bond Buyer index of 20 bonds was applied to this category in the 1992-based CIPI. The same price proxy was used in the 1987-based CIPI. 4. For-Profit Interest Expense: The percentage change in the vintage-weighted price of for-profit interest expense as measured by the Average yield on Moody's AAA Bonds was applied to this category in the 1992-based CIPI. The same price proxy was used in the 1987-based CIPI. 5. Other Capital-Related Expenses: The percentage change in the price of other capital-related expenses as measured by the CPI for all urban consumers for residential rent was applied to this category in the 1992-based CIPI. The same price proxy was used in the 1987-based CIPI. We provided more detailed discussion of the rationale for the choice of these price proxies in the June 2, 1995 proposed rule (60 FR 29227) and in the September 1, 1995 final rule (60 FR 45815). The Honorable Albert Gore, Jr. President of the Senate Washington, D.C. 20510 Dear Mr. President: Section 1886(e)(3)(B) of the Social Security Act (the Act) requires me to report to Congress the initial estimate of the applicable percentage increase in inpatient hospital payment rates for Federal Fiscal Year (FY) 1997 that I will recommend for hospitals subject to the Medicare prospective payment system (PPS) and for hospitals and units excluded from PPS. This submission constitutes the required report. Current law mandates an update for all PPS hospitals of the market basket rate of increase minus 0.5 percentage points. The President's FY 1997 budget includes an update for PPS hospitals in both large urban areas and other areas equal to the market basket rate of increase minus 1.5 percentage points. The President's FY 1997 budget estimated the PPS market basket rate of increase for FY 1997 to be 3.6 percent. Based on this estimate, we recommend an update for hospitals in both large urban and other areas of 2.1 percent. However, recent data from ProPAC and other sources suggest that the final PPS market basket rate of increase for FY 1997 will be lower. Sole community hospitals (SCHs) are the sole source of care in their area and are afforded special payment protection to maintain access to services for Medicare beneficiaries. SCHs are paid the higher of a hospital-specific rate or the Federal PPS rate. Current law mandates an update for sole community hospitals of the market basket rate of increase minus 0.5 percentage points. Consistent with the President's FY 1997 budget, we recommend an update to hospital- specific rates equal to the increase for all PPS hospitals; that is, the market basket rate of increase of 3.6 percent minus 1.5 percentage points, or 2.1 percent. Hospitals and distinct part hospital units excluded from PPS are paid based on their reasonable costs subject to a limit under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current law mandates an update for all hospitals and distinct part hospital units excluded from PPS equal to the rate of increase in the excluded hospital market basket minus 1.0 percentage point, although the update can be higher for certain hospitals and units with costs that are greater than their target amounts. The President's FY 1997 budget incorporates an increase in the TEFRA limit equal to the rate of increase in the excluded hospital market basket (3.6 percent) minus 1.5 percentage points. Therefore, we recommend an increase in the TEFRA limit of 2.1 percent. My recommendation for the updates is based on cost projections used in the President's FY 1997 budget. A final recommendation on the appropriate percentage increases for FY 1997 will be made nearer the beginning of the new Federal Fiscal Year based on the most current market basket projection available at that time. The final recommendation will incorporate our analysis of the latest estimates of all relevant factors, including recommendations by the Prospective Payment Assessment Commission (ProPAC). We currently expect that the final estimate of the market basket rate of increase will be lower than the estimate used in the President's FY 1997 budget. Section 1886(d)(4)(C)(iv) of the Act also requires that I include in my report recommendations with respect to adjustments to the diagnosis-related group (DRG) weighting factors. At this time I do not anticipate recommending any adjustment to the DRG weighting factors for FY 1997. I am pleased to provide this recommendation to you. I am also sending a copy of this letter to the Speaker of the House of Representatives. Sincerely, Donna E. Shalala The Honorable Newt Gingrich Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: Section 1886(e)(3)(B) of the Social Security Act (the Act) requires me to report to Congress the initial estimate of the applicable percentage increase in inpatient hospital payment rates for Federal Fiscal Year (FY) 1997 that I will recommend for hospitals subject to the Medicare prospective payment system (PPS) and for hospitals and units excluded from PPS. This submission constitutes the required report. [[Page 27591]] Current law mandates an update for all PPS hospitals of the market basket rate of increase minus 0.5 percentage points. The President's FY 1997 budget includes an update for PPS hospitals in both large urban areas and other areas equal to the market basket rate of increase minus 1.5 percentage points. The President's FY 1997 budget estimated the PPS market basket rate of increase for FY 1997 to be 3.6 percent. Based on this estimate, we recommend an update for hospitals in both large urban and other areas of 2.1 percent. However, recent data from ProPAC and other sources suggest that the final PPS market basket rate of increase for FY 1997 will be lower. Sole community hospitals (SCHs) are the sole source of care in their area and are afforded special payment protection to maintain access to services for Medicare beneficiaries. SCHs are paid the higher of a hospital-specific rate or the Federal PPS rate. Current law mandates an update for sole community hospitals of the market basket rate of increase minus 0.5 percentage points. Consistent with the President's FY 1997 budget, we recommend an update to hospital- specific rates equal to the increase for all PPS hospitals; that is, the market basket rate of increase of 3.6 percent minus 1.5 percentage points, or 2.1 percent. Hospitals and distinct part hospital units excluded from PPS are paid based on their reasonable costs subject to a limit under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current law mandates an update for all hospitals and distinct part hospital units excluded from PPS equal to the rate of increase in the excluded hospital market basket minus 1.0 percentage point, although the update can be higher for certain hospitals and units with costs that are greater than their target amounts. The President's FY 1997 budget incorporates an increase in the TEFRA limit equal to the rate of increase in the excluded hospital market basket (3.6 percent) minus 1.5 percentage points. Therefore, we recommend an increase in the TEFRA limit of 2.1 percent. My recommendation for the updates is based on cost projections used in the President's FY 1997 budget. A final recommendation on the appropriate percentage increases for FY 1997 will be made nearer the beginning of the new Federal Fiscal Year based on the most current market basket projection available at that time. The final recommendation will incorporate our analysis of the latest estimates of all relevant factors, including recommendations by the Prospective Payment Assessment Commission (ProPAC). We currently expect that the final estimate of the market basket rate of increase will be lower than the estimate used in the President's FY 1997 budget. Section 1886(d)(4)(C)(iv) of the Act also requires that I include in my report recommendations with respect to adjustments to the diagnosis-related group (DRG) weighting factors. At this time I do not anticipate recommending any adjustment to the DRG weighting factors for FY 1997. I am pleased to provide this recommendation to you. I am also sending a copy of this letter to the President of the Senate. Sincerely, Donna E. Shalala Appendix E: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background Several provisions of the Social Security Act (the Act) address the setting of update factors for inpatient services furnished in FY 1997 by hospitals subject to the prospective payment system and those excluded from the prospective payment system. Section 1886(b)(3)(B)(i)(XII) of the Act sets the FY 1997 percentage increase in the operating cost standardized amounts equal to the rate of increase in the hospital market basket minus 0.5 percentage points for prospective payment hospitals in all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 1997 percentage increase in the hospital- specific rates applicable to sole community hospitals equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act, that is, the same update factor as all other hospitals subject to the prospective payment system, or the rate of increase in the market basket minus 0.5 percentage points. Section 1886(b)(3)(B)(ii) of the Act sets the FY 1997 percentage increase in the rate of increase limits for hospitals excluded from the prospective payment system equal to the rate of increase in the excluded hospital market basket minus the applicable reduction or, in the case of a hospital in a fiscal year for which the hospital's update adjustment percentage is at least 10 percent, the excluded hospital market basket percentage increase. Under section 1886(b)(3)(B)(v) of the Act, a hospital's update adjustment percentage increase for FY 1997 is the percentage increase by which the hospital's allowable operating costs of inpatient hospital services recognized under this title for the cost reporting period beginning in FY 1990 exceed the hospital's target amount for such cost reporting period, increased for each fiscal year (beginning with FY 1994) by the sum of any of the hospital's applicable reductions for previous years. The applicable reduction with respect to a hospital for FY 1997 is the lesser of 1 percentage point or the percentage point difference between 10 percent and the hospital's update adjustment percentage for FY 1997. In accordance with section 1886(d)(3)(A) of the Act, we are proposing to update the standardized amounts, the hospital-specific rates, and the rate-of-increase limits for hospitals excluded for the prospective payment system as provided in section 1886(b)(3)(B) of the Act. Based on the first quarter 1996 forecast of the FY 1997 rebased market basket increase of 2.7 percent for hospitals subject to the prospective payment system, the proposed updates in the standardized amounts are 2.2 percent for hospitals in both large urban and other areas. The proposed update in the hospital-specific rate applicable to sole community hospitals is 2.2 percent (that is, the market basket rate of increase of 2.7 percent minus 0.5 percentage points). The proposed update for hospitals excluded from the prospective payment system is based on the percentage increase in the excluded hospital market basket (currently estimated at 2.7 percent) minus the applicable reduction factor. The applicable reduction factor is the lesser of 1 percentage point or the percentage point difference between 10 percent and the hospital's update adjustment percentage. Therefore, for excluded hospitals, the hospital-specific proposed update can vary between 1.7 and 2.7 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, 1996 an update factor that takes into account changes in the market basket rate of increase 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. In its March 1, 1996 report, ProPAC recommended update factors to the standardized amounts equal to the percentage increase in the market basket minus 0.7 to 2.0 percentage points for hospitals in both large urban and other areas (Recommendation 10). Based on its market basket rate of increase estimate of 2.7 percent, ProPAC's recommended update to the standardized amounts equals 2.0 to 0.7 percent for hospitals in both large urban and other areas. (ProPAC's market basket is still using the 1987-based weights.) ProPAC did not make a separate recommendation for the hospital-specific rates applicable to sole community hospitals. The components of ProPAC's update factor recommendations are described in detail in the ProPAC report, which is published as Appendix F to this document. We discuss ProPAC's recommendations concerning the update factors and our responses to these recommendations below. Section 1886(e)(4) of the Act requires that the Secretary, taking into [[Page 27592]] consideration the recommendations of ProPAC, recommend update factors for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5) of the Act, we are required to publish the update factors recommended under section 1886(e)(4) of the Act. Accordingly, this appendix provides the recommendations of appropriate update factors, the analysis underlying our recommendations, and our responses to the ProPAC recommendations concerning the update factors. II. Secretary's Recommendations Under section 1886(e)(4) of the Act, we are recommending that the standardized amounts be increased by an amount equal to the market basket rate of increase minus 1.5 percentage points for hospitals located in large urban and other areas. We are also recommending an update of the market basket rate of increase minus 1.5 percentage points to the hospital-specific rate for sole community hospitals. These figures are consistent with the President's FY 1997 budget recommendation, which continues the reductions imposed by section 13501 of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66), that is, reductions in the hospital market basket of 2.5 percentage points for FYs 1994 and 1995 and 2.0 percentage points for FY 1996. We believe these recommended changes in the update factor would ensure that Medicare acts as a prudent purchaser and provide incentives to hospitals for increased efficiency, thereby contributing to the solvency of the Medicare Part A Trust Fund. When the President's budget was submitted, the market basket rate of increase was projected at 3.6 percent. As noted above, this proposed recommendation is based on the most recent forecast of the proposed rebased market basket. (See section IV of the preamble to this proposed rule for a detailed discussion of the market basket.) We recommend that hospitals excluded from the prospective payment system receive an update equal to the percentage increase in the proposed rebased market basket that measures input price increases for services furnished by excluded hospitals minus 1.5 percentage points. That market basket rate of increase is currently forecast at 2.7 percent. Subtracting 1.5 percentage points would result in an update for hospitals excluded from the prospective payment system of 1.2 percent. This recommendation is consistent with the President's budget, acknowledging that the market basket rate of increase for these hospitals also was forecast at 3.6 percent at the time the budget was submitted. As required by section 1886(e)(4) of the Act, we have taken into consideration the recommendations of ProPAC in setting these recommended update factors. Our responses to the ProPAC recommendations concerning the update factors are discussed below. III. ProPAC Recommendation for Updating the Prospective Payment System Standardized Amounts For FY 1997, ProPAC's update framework would support an update between 0.7 percentage points and 2.0 percentage points less than the increase in the hospital market basket index. The methodology employed by the Commission in previous years would lead to a recommendation of about market basket minus 1.5 percentage points, roughly corresponding to the midpoint of that range. In light of the significant changes occurring in health care delivery, the Commission believes that the increase in the prospective payment system rates could be held to market basket minus 2.0 percentage points for the next year or two. However, it is concerned about the potential effects of continuing updates at that level on hospitals' financial health. Low updates over an extended period of time could affect a hospital's ability to provide quality care to Medicare beneficiaries, compromise access, and impede the diffusion of quality-enhancing technological advances. Based on the market basket estimate of 2.7 percent, ProPAC recommends that hospitals in large urban and other areas receive an update between 0.7 to 2.0 percent. Response: We are recommending an update that is consistent with the Administration's budget proposal. Our recommendation is that the update for FY 1997 for prospective payment system hospitals located in large urban and other areas be equal to the market basket rate of increase forecast minus 1.5 percentage points. Based on HCFA's current forecast of the market basket rate of increase (2.7 percent), we recommend an update for FY 1997 for large urban and other hospitals equal to 1.2 percent. Our recommendation is supported by the following analyses that measure changes in hospital productivity, scientific and technological advances, practice pattern changes, and changes in case mix: Productivity: Service level productivity is defined as the ratio of total service output to full-time equivalent employees (FTEs). While we recognize that productivity is a function of many variables (for example, labor, nonlabor material, and capital inputs), we use a labor productivity measure since this update framework applies to operating payment. To recognize that we are apportioning the short run output changes to the labor input and not considering the nonlabor inputs, we weight our productivity measure for operating costs by the share of direct labor services in the market basket rate of increase to determine the expected effect on cost per case. Our recommendation for the service productivity component is based on historical trends in productivity and total output for both the hospital industry and the general economy, and projected levels of future hospital service output. ProPAC has also estimated cumulative service productivity growth to be 4.9 percent from 1985-1989, or 1.2 percent annually. At the same time, the Commission estimates total output growth at 3.4 percent annually, implying a ratio of service productivity growth to output growth of 0.35. Our Medicare Provider Analysis and Review (MedPAR) file analysis indicates total Medicare service output (charges per admission, adjusted for CPI change) increased 10.7 percent from 1987-1995, or an approximate average annual increase of 1.2 percent. Since it is not possible at this time to develop a productivity measure specific to Medicare patients, we examined productivity (output per hour) and output (gross domestic product) for the economy. Depending on the exact time period, annual changes in productivity range from 0.3 to 0.35 percent of the change in output (that is, a 1.0 percent increase in output would be correlated with an 0.3 to 0.35 percent change in output per hour). Under our framework, the recommended update is based in part on expected productivity--that is, projected service output during the year multiplied by the historical ratio of service productivity to total service output, multiplied by the share of labor in total operating inputs, as calculated in the hospital market basket rate of increase. This method estimates an expected labor productivity improvement in the same proportion to expected total service growth that has occurred in the past and assumes that, at a minimum, growth in FTEs changes proportionally to the growth in total service output. Thus, the recommendation allows for unit productivity to be smaller than the [[Page 27593]] historical averages in years that output growth is relatively low and higher in years that output growth is larger than the historical trend. Based on the above estimates from both the hospital industry and the economy, we have chosen to employ the range of ratios of productivity change to output change of 0.30 to 0.35. The expected change in total hospital service output is the product of projected growth in total admissions (adjusted for outpatient usage), projected real case-mix growth, and expected quality enhancing intensity growth, net of expected decline in intensity due to reduction of cost ineffective practice. Case-mix growth and intensity numbers for Medicare are used as proxies for those of the total hospital, since case-mix increases (used in the intensity measure as well) are unavailable for non-Medicare patients. Thus, expected output growth is simply the sum of the expected change in intensity (0.0 percent), projected admissions change (2.7 percent for FY 1997), and projected real case-mix growth (1.6 percent), or 4.3 percent. The share of direct labor services in the market basket rate of increase (consisting of wages, salaries, and employee benefits) is 61.4 percent. Multiplying the expected change in total hospital service output (4.3 percent) by the ratio of historical service productivity change to total service growth of 0.30 to 0.35 and by the direct labor share percentage (0.614) provides our productivity standard of 0.8 to 0.9 percent. ProPAC also believes hospitals should be given an incentive for additional productivity improvement. ProPAC measures productivity as the ratio of hospital admissions (adjusted for case mix and outpatient services) per FTE employee (adjusted for changes in skill mix). ProPAC includes in its productivity measurement the effect of changes in practice patterns. We treat practice pattern changes as a portion of our intensity adjustment, described below. ProPAC's latest estimate indicate that hospital productivity increased as much as 2.3 percent in 1994. Given this improvement, ProPAC believes a productivity adjustment in the range of -0.7 to -1.2 percentage points would be reasonable in fiscal year 1997. The adjustment is intended to share productivity equally between hospitals and Medicare. In the near future, ProPAC believes there may be even greater productivity improvements, as hospitals strive to stay competitive and financially viable. Intensity: We base our intensity standard on the combined effect of three separate factors: changes in the use of quality enhancing services, changes in the use of services due to shifts in within-DRG severity, and changes in the use of services due to reductions of cost-ineffective practices. For FY 1997, we recommend an adjustment of 0.0 percent. The basis of this recommendation is discussed below. We have no empirical evidence that accurately gauges the level of quality-enhancing technology changes. Typically, a specific new technology increases cost in some uses and decreases cost in other uses. Concurrently, health status is improved in some situations while in other situations it may be unaffected or even worsened using the same technology. It is difficult to separate out the relative significance of each of the cost increasing effects for individual technologies and new technologies. The quality enhancing technology component is intended to recognize the use of services that increase cost but whose value in terms of enhanced health-status is commensurate with these costs. Such services may result from technological change, or in some cases, increased use of existing technologies. The latter recognizes that as cost and medical effectiveness studies become available, some increased use of existing, as well as new, services may be warranted. The component for reduction of cost-ineffective practice recognizes that some improvements in practice patterns could be made so that the intensity of services provided is more consistent with the efficient use of limited resources. That is, improvements could be made so that the number of services provided during an inpatient stay, and their complexity, produce an improvement in health status that is consistent with the cost of care. This component of our update recommendation is intended to encourage both hospitals and physicians to more carefully consider the cost-effectiveness of medical care. This component of the framework also accounts for real within-DRG change, since that should be directly reflected in the CMI-adjusted growth in real charges per case. Following methods developed by HCFA's Office of the Actuary for deriving hospital output estimates from total hospital charges, we have developed Medicare-specific intensity measures based on a 5-year average using FY 1991-1995 MedPAR billing data. Case-mix constant intensity is calculated as the change in total Medicare charges per discharge adjusted for changes in the average charge per unit of service as measured by the Medical CPI hospital component and changes in real case mix. Thus, in order to measure changes in intensity, one must measure changes in real case mix. For FY 1991 and FY 1992, we estimate that 1.0 to 1.4 percent of observed case-mix increase was real. This estimate is supported by past studies of case-mix change by the RAND Corporation. The most recent study was Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988 by G.M. Carter, J.P. Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991). The study suggests that real case-mix change was not dependent on total change, but was rather a fairly steady 1.0 to 1.5 percent per year. In the past we have used 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. For FY 1993 and FY 1994, we assumed that all of the observed case-mix increases of 0.9 and 0.8 percent, respectively, were real. For FY 1995, we assumed that all of the observed case-mix increase of 1.6 percent was real. We note that this assumed increase in real case mix is higher than our previously assumed upper bound of 1.4 percent. Based on its analysis of the FY 1995 MedPAR data, the Office of the Actuary has concluded that the apparent shifting of some cases to the outpatient setting and activity in the cardiovascular DRGs has contributed to a higher than expected increase in real case mix. Given estimates of real case-mix increase of 1.0 percent for FY 1991-1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and 1.6 percent for FY 1995, we estimate case-mix constant intensity declined by an average 1.1 percent during FY 1991 through 1995, for a cumulative decrease of 5.6 percent. If we assume that real case-mix increase was 1.4 percent for FYs 1991 and 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and 1.6 percent for FY 1995, we estimate case-mix constant intensity declined by an average of 1.2 percent during FY 1991 through 1994, for a cumulative decrease of 5.9 percent. Since we estimate that intensity has declined during FY 1991-1995 period, we are recommending a 0.0 percent intensity adjustment for FY 1997. Quality Enhancing New Science and Technology: For FY 1997, ProPAC has computed the adjustment for scientific and technological advances to be a future-oriented policy target intended to provide additional funds for hospitals to adopt quality-enhancing, cost increasing health care innovations. [[Page 27594]] While in the past the Commission has included an adjustment ranging from 0.3 to 1.0 percentage points, the current range is lower because there is little evidence of significant new cost-increasing advances ready for implementation. Moreover, the cost-competitive environment now faced by hospitals may dampen the adoption of new technologies as they closely evaluate their relative costs and benefits. Therefore, the Commission recommends an adjustment of 0.1 to 0.6 percentage points for the increase in operating costs due to scientific and technological advances. Change in Case Mix: Our analysis takes into account projected changes in case mix, adjusted for changes attributable to improved coding practices. For our FY 1997 update recommendation, we are projecting a 1.6 percent increase in the case-mix index. We define real case-mix increase as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher-weighted DRGs but do not reflect greater resource requirements. For FY 1997, we believe that real case-mix increase is equal to our projected change in case mix. We do not see any changes in coding behavior in our projected case-mix change. Our net adjustment to case-mix change for FY 1997 is 0.0 percentage points. The -1.0 to -0.9 percent figure used in the ProPAC framework represents ProPAC's projection for observed case-mix change. ProPAC projects a 0.8 to 0.9 percentage points increase in real case-mix change across DRG's and a 0.0 to 0.2 percentage points increase in within-DRG case-complexity change. ProPAC's net adjustment for case mix is -0.2 to 0.0 percentage points. Effect of FY 1995 DRG Reclassification and Recalibration: We estimate that DRG reclassification and recalibration for FY 1995 resulted in a 0.0 percent increase in the case-mix index when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the GROUPER. ProPAC does not make an adjustment for DRG reclassification and recalibration in its update recommendation. Correction for Market Basket Forecast Error: The estimated market basket percentage increase used to update the FY 1995 payment rates was 3.6 percent. Our most recent data indicate the actual FY 1995 increase was 3.0 percent, reflecting that the actual increase in wages was lower than projected. The resulting forecast error in the FY 1995 market basket rate of increase is 0.6 percentage points. Under our update framework, we make a forecast error correction if our estimate is off by 0.25 percentage points or more. Therefore, we are recommending an adjustment of -0.6 percentage points to reflect this overestimation of the FY 1995 market basket rate of increase. The following is a summary of the update ranges supported by our analyses compared to ProPAC's framework. Table 1.--Comparison of FY 1997 Update Recommendations ---------------------------------------------------------------------------------------------------------------- HHS ProPAC ---------------------------------------------------------------------------------------------------------------- Market Basket......................................................... MB MB Difference Between HCFA & ProPAC Market Baskets....................... ................... -0.1 to 0.0 ----------------------------------------- Subtotal........................................................ MB MB to MB-0.1 ========================================= Policy Adjustment Factors Productivity.......................................................... -0.9 to -0.8 -1.2 to -0.7 Intensity: 0.0 ................... Science and Technology............................................ ................... 0.1 to 0.6 Practice Patterns................................................. ................... (\1\) Real Within DRG Change............................................ ................... (\2\) ----------------------------------------- Subtotal........................................................ -0.9 to -0.8 -1.1 to -0.1 ========================================= Case-Mix Adjustment Factors Projected Case-Mix Change......................................... -1.6 -1.0 to -0.9 Real Across DRG Change............................................ 1.6 0.8 to 0.9 Real Within DRG Change............................................ (\3\) 0.0 to 0.2 ----------------------------------------- Subtotal........................................................ 0.0 -0.2 to 0.0 ========================================= Effect of 1995 Reclassification and Recalibration................. 0.0 ................... Forecast Error Correction............................................. -0.6 -0.6 ----------------------------------------- Total Recommended Update........................................ MB-1.5 to MB-1.4 MB-2.0 to MB-0.7 ---------------------------------------------------------------------------------------------------------------- \1\ Included in ProPAC's Productivity Measure. \2\ Included in ProPAC's Case-Mix Adjustment. \3\ Included in HHS' Intensity Factor. The above analysis would support a recommendation that the update be between market basket minus 1.4 and market basket minus 1.5 percentage points. We are recommending an update of market basket minus 1.5 percentage points, consistent with President Clinton's FY 1997 budget proposal. We also recommend that the hospital-specific rates applicable to sole community hospitals be increased by the same update, market basket minus 1.5 percentage points. V. ProPAC Recommendation for Updating the Rate-of-Increase Limits for Excluded Hospitals ProPAC recommends an update factor equal to the market basket rate of increase minus 0.6 percentage points for excluded hospitals and units (Recommendation 12). The 0.6 percentage points reduction represents a [[Page 27595]] reduction of 0.6 percentage points to account for the forecast error in the FY 1995 market basket rate of increase for excluded units, no increase to reflect the different compensation price proxies used by ProPAC, and no allowance for new technology. ProPAC believes that major changes in the excluded hospitals' target amounts should not be made at this time. Rather, a prospective payment system for excluded hospitals and units should be implemented as soon as possible. Response: We recommend that hospitals 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 1.5 percentage points. The reduction is consistent with the updates provided under President Clinton's budget proposal. The market basket rate of increase for excluded hospitals is currently forecast at 2.7 percent. Subtracting 1.5 percentage points would result in an update of 1.2 percent for excluded hospitals and units. As noted by ProPAC, HCFA has contracted with the RAND Corporation to analyze a classification system for rehabilitation patients that appears to have the potential to serve as the basis for a prospective payment system for rehabilitation hospitals and units. However, even if this classification system is found to be suitable, it would be several years before we could fully implement any prospective payment system for these facilities. In addition, we have been less successful in our pursuit of a suitable classification system for the other types of excluded hospitals. Therefore, as an interim measure, the President's budget contains a proposal to rebase the target amounts for excluded hospitals and units on more recent cost data. Changes would also be made to the conditions under which facilities would receive additional payment when they exceed their limits. Incentive payments for facilities whose costs are below their target amounts would be eliminated. 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[TIFF OMITTED] TP31MY96.112 [FR Doc. 96-13613 Filed 5-30-96; 8:45 am] BILLING CODE 4120-01-C