[Federal Register Volume 61, Number 170 (Friday, August 30, 1996)]
[Rules and Regulations]
[Pages 46166-46328]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-22145]
[[Page 46165]]
_______________________________________________________________________
Part V
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; Final Rule
Federal Register / Vol. 61, No. 170 / Friday, August 30, 1996 / Rules
and Regulations
[[Page 46166]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, and 489
[BPD-847-F]
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: Final rule.
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SUMMARY: We are revising the Medicare hospital inpatient prospective
payment systems for operating costs and capital- related costs to
implement necessary changes arising from our continuing experience with
the systems. In addition, in the addendum to this final rule, we are
describing changes in the amounts and factors necessary to determine
prospective payment rates for Medicare hospital inpatient services for
operating costs and capital-related costs. These changes are applicable
to discharges occurring on or after October 1, 1996. We are also
setting forth rate-of-increase limits as well as policy changes for
hospitals and hospital units excluded from the prospective payment
systems.
EFFECTIVE DATE: This rule is a major rule as defined in Title 5, United
States Code, section 804(2). Pursuant to 5 U.S.C. section 801(a)(3),
this rule may not take effect until 60 days after the report required
by that section is submitted to the Congress, which is October 29,
1996. However, for purposes of the policy discussions in this document,
we have assumed that the effective date of this final rule will be
October 1, 1996, the earliest date by which this rule could take effect
under 5 U.S.C. section 801 and the Medicare statute.
ADDRESSES: 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
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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, Direct
Graduate Medical Education, 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.
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 the Provisions of the May 31, 1996 Proposed Rule
On May 31, 1996, we published a proposed rule in the Federal
Register (61 FR 27444) setting forth proposed changes to the Medicare
hospital inpatient prospective payment systems for both operating costs
and capital-related costs which would be effective for discharges
occurring on or after October 1, 1996. The following is a summary of
the major issues addressed and changes that we proposed to make:
We proposed changes for FY 1997 DRG classifications and
relative weighting factors as required by section 1886(d)(4)(c) of the
Act.
We proposed to update the wage index for FY 1997. We also
solicited comments on the possible expansion of the types of contract
labor costs included in the wage index and on possible revisions in
Puerto Rico labor market areas.
We proposed revisions to the regulations governing the
composition of the Medicare Geographic Classification Review Board
(MGCRB).
We proposed 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.
We discussed several provisions of the regulations in 42
CFR parts 412, 413, and 489 and set forth proposed changes concerning
the following:
--Sole community hospitals.
--Rural referral centers.
--Disproportionate share adjustment.
--Direct graduate medical education payments.
--Hospital distribution of ``An Important Message from Medicare.''
We discussed several provisions of the regulations in 42
CFR part 412 concerning the prospective payment system for capital-
related costs, including possible adjustments to the capital Federal
and hospital-specific rates, and set forth a proposed change concerning
the use of simplified cost accounting.
We discussed clarifications concerning the calculation of
payments to hospitals excluded from the prospective payment system.
In the addendum to the proposed rule, we set forth
proposed changes to the amounts and factors for determining
[[Page 46167]]
the FY 1997 prospective payment rates for operating costs and capital-
related costs. We also proposed new update factors for determining the
rate-of-increase limits for cost reporting periods beginning in FY 1997
for hospitals and hospital units excluded from the prospective payment
system.
In Appendix A to the proposed rule, we set forth an
analysis of the impact that the proposed changes would have on affected
entities.
In Appendix B to the proposed rule, we set forth our
technical appendix on the proposed FY 1997 capital acquisition model.
In Appendix C to the proposed rule, we set forth the data
sources used to determine the market basket relative weights and choice
of price proxies.
In Appendix D to the proposed rule, we included our 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 as required by section 1886(e)(3)(B) of the Act.
As required by sections 1886(e)(4) and (e)(5) of the Act,
in Appendix E we provided 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.
In the proposed rule, we discussed in detail the March 1,
1996 recommendations made by the Prospective Payment Assessment
Commission (ProPAC). ProPAC is directed by section 1886(e)(2)(A) of the
Act to make recommendations on the appropriate percentage change factor
to be used in updating the average standardized amounts. In addition,
section 1886(e)(2)(B) of the Act directs ProPAC to make recommendations
regarding changes in each of the Medicare payment policies under which
payments to an institution are prospectively determined. In particular,
the recommendations relating to the hospital inpatient prospective
payment systems are to include recommendations concerning the number of
DRGs used to classify 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 printed ProPAC's March 1, 1996 report, which included its
recommendations, as Appendix F to the proposed rule. The
recommendations, and the actions we proposed to take with regard to
them (when an action is recommended), were discussed in detail in the
appropriate sections of the preamble, the addendum, or the appendices
to the proposed rule.
Set forth below in this preamble, the addendum to this final rule,
and the appendices are detailed discussions of the May 31 proposed
rule, the public comments received in response to the proposed rule,
and the responses to those comments, as well as the changes we are
making. In addition, in section V.E.3 of this preamble, we address a
recent statutory amendment to the Public Health Service Act that
prohibits certain abortion-related discrimination by the Federal
Government and State and local governments. The new statutory provision
requires the Federal Government to deem accredited for certain purposes
any postgraduate physician training program that would otherwise be
accredited, except for the accrediting agency's reliance on certain
standards concerning induced abortions.
C. Public Comments Received in Response to the May 31 Proposed Rule
A total of 511 items of correspondence containing comments on the
proposed rule were received timely. We received over 300 letters on
payments for direct graduate medical education programs. The main other
areas of concern addressed by the commenters were the following:
Requests for changes in DRG classification and relative
weights.
Issues related to the wage index.
Disproportionate share adjustment.
Possible adjustments to the capital Federal and hospital-
specific rates.
II. Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on the basis of a rate per discharge that varies by the DRG to
which a beneficiary's stay is assigned. The formula used to calculate
payment for a specific case takes an individual hospital's payment rate
per case and multiplies it by the weight of the DRG to which the case
is assigned. Each DRG weight represents the average resources required
to care for cases in that particular DRG relative to the average
resources used to treat cases in all DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
annually. These adjustments are made to reflect changes in treatment
patterns, technology, and any other factors that may change the
relative use of hospital resources. The changes to the DRG
classification system and the recalibration of the DRG weights for
discharges occurring on or after October 1, 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
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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.
We proposed to make several changes to the DRG classification
system for FY 1997 and other decisions concerning DRGs. These proposed
changes and other revisions, the comments we received concerning them,
our responses to those comments, and the final DRG changes 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. 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.
Because we could not separately identify the stem cell transplant cases
from the other cases coded with 99.73 (the code previously used for
stem cell transplant) 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 MedPAR file is available for use in DRG
analysis and weight setting for FY 1997. Since the average resource use
associated with stem cell transplant is similar to that associated with
bone marrow transplant, we proposed to assign procedure code 41.04 to
DRG 481 effective with discharges occurring on or after October 1,
1996. In addition, we proposed to designate stem cell transplant as an
OR procedure. In the proposed rule, we noted that, 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).
We received five comments supporting our proposal to assign
procedure code 41.04 to DRG 481, and we will include this change in the
final DRG classifications. Two other commenters had specific questions
concerning the assignment of cases to DRG 481.
Comment: One commenter questioned the DRG assignment of cases in
which an autologous hematopoietic stem cell transplant is performed for
one of the noncovered conditions such as acute leukemia not in
remission or multiple myeloma. The commenter is unsure whether those
cases would be assigned to DRG 481 or retain their current DRG
assignment.
Response: When a stem cell transplant is performed for a noncovered
condition, the case will not be assigned to DRG 481. If the only reason
that the patient is admitted to the hospital is to receive the
noncovered procedure, then the case receives no Medicare payment
because the hospital stay is not covered. If a patient receives a
noncovered stem cell transplant during an otherwise Medicare-covered
stay, then the case is assigned to a DRG based on the patient's
principal and secondary diagnoses as well as any other covered
procedure the patient receives. The stem cell transplant will not be
considered in the DRG assignment.
Comment: One commenter was concerned about the assignment of a case
in which a kidney transplant patient receives an allogeneic bone marrow
transplant (procedure code 41.03) from the kidney donor to reduce the
incidence and magnitude of organ rejection. The commenter believes it
is inappropriate to assign such a case to DRG 481 rather than DRG 302
(Kidney Transplant) and that we should therefore revise the pre-MDC
surgical hierarchy.
Response: Allogeneic bone marrow transplants performed for purposes
of reducing rejection during a kidney transplant have not yet been
subject to a national coverage decision. Therefore, under HCFA policy,
the Medicare contractors (Part A fiscal intermediaries and Part B
carriers) determine, on a case-by-case basis, whether or not to cover
and pay for such claims. If a contractor did decide that one of these
claims should be covered, then it would be paid under DRG 481. If the
contractor determines that the bone marrow transplant is not covered,
the claim would be assigned to a DRG without considering the bone
marrow transplant. In most cases, this assignment would be DRG 302.
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Sleep apnea. As discussed in the proposed rule, 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.
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\1\ A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second 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.
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Recently, new surgical interventions to correct sleep apnea have
been introduced. The procedures most frequently performed for this
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condition are the following:
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Code 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) or to DRG
477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis),
depending on the procedure.
We proposed 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 proposed to include them in DRGs 7 and
8 (Peripheral and Cranial Nerve and Other Nervous System Procedures).
We received two comments in support of the addition of codes 27.69,
29.4 and 29.59 to DRGS 7 and 8. The commenters agree that these
procedures are frequently used as surgical interventions to correct
sleep apnea and are appropriately classified to DRGs 7 and 8. We also
received two comments that disagreed, as discussed below.
Comment: One commenter was opposed to moving the procedure codes to
DRGS 7 and 8. The commenter stated that if the patient had obstructive
sleep apnea, the more appropriate diagnosis code would be the
underlying cause of the obstruction, such as upper airway blockage
(diagnosis code 528.9, Other and Unspecified Diseases of the Oral Soft
Tissues) or diagnosis code 478.29, Other Diseases of Pharynx for
Redundant Pharyngeal Mucosa.
Response: We agree that if the medical record provides a precise
diagnosis for the obstruction, then that condition should be coded.
However, information supporting these codes is not always provided in
the medical record. Physicians frequently document obstructive sleep
apnea as the reason for the surgery. In these cases, medical record
coders are assigning code 780.57. As explained above, we believe that
it is inappropriate to continue to assign these cases to DRGS 468 and
477 and that the better policy is to assign the procedures to MDC 1.
Comment: We received one comment suggesting that obstructive sleep
apnea reported in conjunction with procedure codes 27.69, 29.4, or
29.59 would be more appropriately classified to DRGs 76 and 77 (Other
Respiratory System Procedures) in MDC 4 (Diseases of the Respiratory
System). In addition, the commenter recommended that obstructive sleep
apnea medical cases be assigned to DRGs 101 and 102 (Other Respiratory
Diagnoses).
Response: In order to properly classify each case, a diagnosis code
may be assigned to only one MDC. Diagnoses in each MDC correspond to a
single organ system or etiology and in general are associated with a
particular medical specialty. In order to classify cases of obstructive
sleep apnea to DRGs 76, 77, 101, and 102, code 780.57 would have to be
reassigned from MDC 1 to MDC 4. We believe that obstructive sleep apnea
is more appropriately classified to MDC 1; therefore, these cases
cannot be assigned to a DRG in MDC 4.
Comment: One commenter noted an error in the discussion of sleep
apnea in the proposed rule. The second time we referred to the codes to
be moved to MDC 1, we listed them as 25.59, 78.49, and 29.4 (see 61 FR
27447).
Response: In the proposed rule, we inadvertently referred to
procedures codes 25.59 and 78.49. The codes that will be added to DRGs
7 and 8 are 27.69, 29.4 and 29.59.
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).)
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 constitute approximately 20 percent of the
cases assigned to DRG 20. 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
virtually the same. Since we believe that DRG 20 is the appropriate
assignment clinically for Guillain-Barre cases, we reviewed the other
cases assigned to DRG 20 for possible change.
We found that herpes zoster of the nervous system, NOS (diagnosis
code 053.10) and herpes zoster of the nervous system, NEC (diagnosis
code 053.19) had average charges of only $7,700 and $7,100,
respectively. They also had lower average lengths of stay (6.2 and 6.1
days, respectively). (In the proposed rule, we mistakenly cited these
lengths of stay as 4.4 and 4.2, respectively (61 FR 27447).) Because
these two diagnoses 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. We proposed to reassign these
codes to DRGs 18 and 19.
Comment: We received two comments regarding our proposal to assign
diagnosis codes 053.10 and 053.19 to DRGs 18 and 19, both of which
supported the change. However, one commenter noted that even though
these cases obviously do not consume the amount of resources as other
cases assigned to DRG 20, clinically, they are more closely related to
cases in DRG 20 than those in DRGs 18 and 19. The commenter also
expressed an interest in the length of stay and charges for geniculate
herpes zoster (diagnosis code 053.11), which we did not propose to move
from DRG 20.
Response: We do not believe that reassigning these codes to DRGs 18
and 19 is clinically unsound. There are currently two other herpes
zoster diagnoses classified to those DRGs (Postherpetic trigeminal
neuralgia (code 053.12) and postherpetic polyneuropathy (code 053.13)).
Further, as the commenter noted, the charges and length of stay for
053.10 and 053.19 are very close to those for the cases assigned to
DRGs 18 and 19.
We had considered moving all three herpes diagnosis codes (035.10,
053.11, and 053.19) from DRG 20 to DRGs 18 and 19. However, the higher
charges associated with geniculate herpes zoster ($11,000) and slightly
higher length of stay (6.7 days) led us to decide instead to leave
053.11 in DRG 20 and to closely monitor these cases in upcoming years.
4. MDC 5 (Diseases and Disorders of the Circulatory System)
Effective for discharges occurring on or after October 1, 1995, we
created a
[[Page 46170]]
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).
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 September 1, 1995 final rule (60 FR 45785), we
assigned procedure code 36.06 to DRG 112 (Percutaneous Cardiovascular
Procedures), the DRG to which PTCA is assigned. 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.
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 Medicare program that
cannot be verified remains a problem. Therefore, we did not propose any
DRG assignment change for implant of coronary artery stent.
Comment: We received five comments on this issue. One commenter
agreed that the strategy of not assigning new codes into different DRGs
until Medicare data have been collected and reviewed is appropriate.
Four commenters requested that we take action this year. The commenters
suggested various options for reassigning code 36.06: assign the code
to its own DRG; move the code to a higher-weighted DRG (DRG 116, Other
Permanent Cardiac Pacemaker Implant or AICD Lead or Generator Procedure
was suggested); or increase the weight for DRG 112 to recognize that
some of these cases involve stents.
One commenter believes that if we delay action, hospitals will not
be able to provide stent therapy to Medicare beneficiaries, thereby
depriving them of state-of-the-art technology and better outcomes. The
commenter noted that although the literature has reported higher costs
(for example, cost of the device itself, increased anticoagulation
therapy, more frequent monitoring) related to this procedure, there has
also been some offset noted because of the reduction in followup
medical costs. There is also the potential that further improvement in
stent design, implantation techniques, and other anticoagulant therapy
could further increase this offset by reducing vascular complications
or length of stay.
One commenter, the manufacturer of a coronary stent device, stated
that the assignment of coronary stent implant to DRG 112 is
inappropriate in light of the higher average lengths of stay and
charges associated with this procedure compared to traditional
angioplasty. The commenter argued that, given these differences, DRG
reclassification of procedure code 36.06 would be consistent with the
statutory mandate to adjust the DRG classifications and relative
weights to ``reflect changes in treatment patterns, technology, and
other factors which may change the relative use of hospital
resources.'' (Section 1886(d)(4)(C) of the Act.)
The commenter also cited 1,200 peer-reviewed clinical publications
that demonstrate superior clinical outcomes with coronary stent
implant. Finally, the commenter stated that the variation in hospital
standardized charges for coronary stent implant cases is less than the
variation in charges for all PTCA cases without stent implant.
Response: As we stated in the proposed rule (61 FR 27447) and in
the September 1, 1995 final rule (60 FR 45785), our practice is to
assign a new code to the same DRG or DRGs as its predecessor code. One
compelling reason for this practice is our inability to move the cases
associated with the new code to a new DRG assignment as part of the DRG
reclassification and recalibration process. Because the code is new, we
cannot identify the stent cases in DRG 112 to remove the charges from
that DRG, revise the relative weight accordingly, and move those cases
to another DRG and establish the revised weight of that DRG.
We do not disagree with the commenters that the stent implant cases
are more costly, on average, than other PTCA cases. We also do not
dispute the clinical superiority of this treatment for certain
patients. However, until we can review actual Medicare data to
determine exactly what the difference in charges is, we cannot make a
reasoned decision as to whether those cases should be moved to another
DRG or be assigned to a new DRG. We believe that waiting for
appropriate data is entirely consistent with our statutory duty to
adjust DRG classifications.
Regarding the comment on the variation in charges for stent versus
nonstent PTCA cases, we note that the charges for a specific procedure
should vary less than the charges for a set of cases that vary in
severity and for which many different treatments may be performed. That
is, the homogeneity of the patients who received a stent implant should
reflect a lower degree of variation.
Finally, analysis of data provided by the stent manufacturer
convinced us that Medicare beneficiaries have access to stent implants
that is at least equal to the general population. Moreover, we note
that it is a violation of a hospital's Medicare provider agreement to
place restrictions on the number of Medicare beneficiaries it will
accept for treatment unless it places the same restrictions on all
other patients. We will carefully examine the PTCA cases with and
without stent implant in the FY 1996 claims data file as soon as it is
available. Any DRG changes we determine are supported by the data will
be addressed in the FY 1998 proposed rule.
5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
In the proposed rule, we reviewed the DRG assignment in MDC 8 of
bipolar hip replacement cases as a follow-up to a comment received last
year. The commenter believed that the procedure for partial hip
replacement (code 81.52), currently assigned to DRG 209 (Major Joint
and Limb Reattachment Procedures of Lower Extremity), 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 (Hip and Femur Procedures Except Major Joint). Further, the
commenter noted that partial hip replacement patients are more frail
individuals than the population that elects total hip replacement and
need longer hospital stays to recover.
[[Page 46171]]
After reviewing the FY 1995 MedPAR file, we concluded that the
charges and lengths of stay for partial hip replacement cases assigned
to DRG 209 were very similar to the other cases assigned to DRG 209.
However, the average charge for cases in DRG 210 was significantly less
than the partial hip replacement charges. We note that the length of
stay for partial hip replacement cases was closer to the average length
of stay for DRG 210. However, the higher charges of the partial hip
replacement cases indicate that they are more resource-intensive than
the cases in DRG 210 and similar to the cases in DRG 209. Therefore, we
proposed to retain procedure code 81.52 in DRG 209.
We received three comments, all of which supported our proposal,
and we will continue to assign partial hip replacement cases to DRG
209.
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 relative 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 procedure'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weights 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
diagnosis in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should only be considered
if no other procedure more closely related to the diagnoses in the MDC
has been performed.
A second example occurs when the difference between the average
weights for two surgical classes is very small. We have found that
small differences generally do not warrant reordering of the hierarchy
since, by virtue of the hierarchy change, the relative weights are
likely to shift such that the higher-ordered surgical class has a lower
average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we proposed to
modify the surgical hierarchy as set forth below. As 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 weights due to the
unavailability of revised GROUPER software at the time the 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.
We proposed to 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 proposed to reorder Tracheostomy
Except for Face, Mouth and Neck diagnoses (DRG 483) above Liver
Transplant (DRG 480).
In MDC 3, we proposed to 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 proposed to reorder Adrenal and Pituitary
Procedures (DRG 286) above Amputation of Lower Limb for Endocrine,
Nutritional, and Metabolic Disorders (DRG 285).
We received two comments in support of the three surgical hierarchy
changes. In addition, based on a test of the proposed changes using the
most recent MedPAR file and the revised GROUPER software, we have found
that the changes are still supported by the data and no additional
changes are indicated. Therefore, we are incorporating these changes in
this final rule.
7. Refinement of Complications and Comorbidities List
a. Addition or Deletion of CCs. 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 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.
[[Page 46172]]
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 the category of 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 proposed 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 demonstrated that their presence as a
secondary diagnosis did not significantly add to the resource use of
the case. Therefore, we did not propose 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
Based on our analysis, charges associated with those cases were
indeed comparable to the other cases assigned to DRG 121. However, when
we sought the advice of our medical specialists (physicians who work
directly for or under contract with HCFA), 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.
Our analysis of DRG 121 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 did not propose any change to DRG 121.
We received three comments supporting the addition of the remainder
of the ``family'' of codes for intestinal infection due to bacteria to
the CC list. We received one comment in support of our decision not to
add 331.0, 423.9, 348.5, 333.4, 458.0, and 458.9 to the CC list.
Comment: Two commenters requested that we reconsider our decision
not to add codes 434.xx (Occlusion of cerebral arteries) and 436
(Acute, but ill-defined, cerebrovascular disease) to the list of
conditions that are designated cardiovascular complications for
assignment to DRG 121 (Circulatory Disorders with AMI and
Cardiovascular Complications, Discharged Alive). One commenter noted
that even though these diagnoses are not cardiac in nature, they are
vascular complications. The other commenter stated that there are other
conditions assigned to DRG 121, such as acute renal failure, that are
not strictly cardiovascular conditions. The commenter supports our
decisions to completely review DRG 121, but believes diagnosis codes
434.xx and 436 should be added this year.
Response: As explained in the proposed rule (61 FR 27449), in our
initial analysis, cases assigned to DRG 121 that had these diagnoses
coded as secondary conditions contained charges that were indeed
comparable to the other cases assigned to DRG 121. However, our
analysis of DRG 121 and the list of cardiovascular conditions revealed
large variations in the charges and lengths of stay for cases within
this DRG. Because the diagnoses associated with codes 434.xx and 436
are not strictly cardiovascular in nature, we believe the better course
would be to do a comprehensive review of DRG 121, including considering
adding additional diagnosis as complicating conditions. We will address
these issues as part of our DRG analysis agenda for FY 1998.
b. CC Exclusions List. In the September 1, 1987 final notice
concerning changes to the DRG classification system (52 FR 33143), we
modified the GROUPER logic so that certain diagnoses included on the
standard list of CCs would not be considered a valid CC in combination
with a particular principal diagnosis. Thus, we created the CC
Exclusions List. We made these changes to preclude duplicative coding
or inconsistent coding from being treated as CCs, and to ensure that
cases are appropriately classified between the complicated and
uncomplicated DRGs in a pair.
In the May 19, 1987 proposed notIce concerning changes to the DRG
classification system (52 FR 18877), we explained that the excluded
secondary diagnoses were established using the following five
principles:
Chronic and acute manifestations of the same condition
should not be considered CCs for one another (as subsequently corrected
in the September 1, 1987 final notice (52 FR 33154)).
Specific and nonspecific (that is, not otherwise specified
(NOS)) diagnosis codes for a condition should not be considered CCs for
one another.
Conditions that may not co-exist, such as partial/total,
unilateral/bilateral, obstructed/unobstructed, and benign/malignant,
should not be considered CCs for one another.
The same condition in anatomically proximal sites should
not be considered CCs for one another.
Closely related conditions should not be considered CCs
for one another.
The creation of the CC Exclusions List was a major project
involving hundreds of codes. The FY 1988 revisions were intended to be
only a first step toward refinement of the CC list in that the criteria
used for eliminating certain diagnoses from consideration as CCS were
intended to identify only the most obvious diagnoses that should not be
considered complications or comorbidities of another diagnosis. For
that reason, and in light of comments and questions on the CC list, we
have continued to review the remaining CCs to identify additional
exclusions and to remove diagnoses from the master list that have been
shown not to meet the definition a CC. (See the September 30, 1988
final rule for the revisions made for the discharges occurring in FY
1989 (53 FR 38485); the September 1, 1989 final rule for the FY 1990
revisions (54 FR 36552); the September 4, 1990 final rule for the FY
1991 revisions (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
[[Page 46173]]
FY 1993 revisions (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).)
The proposed rule reflected 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 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 final
rule.
Table 6g and 6h in section V of the addendum to this final rule
contain the revisions to the CC Exclusions List that will be effective
for discharges occurring on or after October 1, 1996. Each table shows
the principal diagnoses with final 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 for 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 did
not propose 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 moved 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
[[Page 46174]]
33.27), a needle biopsy, that is significantly less resource-intensive
than the other procedures assigned to DRG 468. Therefore, we proposed
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 proposed to change the procedures from OR to
non-OR procedures. We noted that these procedures are assigned to
surgical DRGs in MDCs 2, 9, 21, 22, and 24. With this 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.
Comment: We received two comments that generally supported our
proposal to move procedure code 33.27 to the list of procedures that
result in assignment to DRG 477. However, one of the commenters was
concerned because this code also includes transbronchial lung biopsy.
The commenter believes that transbronchial lung biopsy is a high-risk
procedure and questions whether this would be considered a nonextensive
procedure.
Response: In analyzing the procedures that produce assignments to
each of DRG 468, 476, and 477 for possible reassignment, we evaluate
average charges and lengths of stay. The cases in DRG 468 with
procedure code 33.27 are significantly less resource-intensive than the
other procedures assigned to DRG 468, and more closely resemble the
average charge and length of stay for procedures classified to DRG 477.
Although transbronchial lung biopsy may be a more difficult procedure
to perform than other procedures assigned to 33.27, we do not know how
many of these cases are actually assigned to DRG 468, that is, how many
times this procedure is performed for an unrelated principal diagnosis.
It is possible that the lower charges associated with closed endoscopic
biopsy of lung cases in DRG 468 do not include many transbronchial lung
biopsy cases. We also note that in MDC 4, procedure code 33.27 is not
assigned to the major procedures DRG (DRG 75). In any case, our data
support the reclassification of these procedures to DRG 477. Therefore,
we are reassigning procedure code 33.27 from DRG 468 to DRG 477, as
proposed.
Comment: We received four comments regarding our proposal to
designate procedure code category ``other repair of eyelid'' (codes
08.81 through 08.89) as non-OR. Two commenters supported our decision,
although one of those commenters stated that even though these
procedures may not require an operating room, they may require a
specialist. One commenter requested that we consider designating these
eyelid repair codes as non-OR procedures that affect DRG assignment
when the procedure is the only one performed in connection with a
related principal diagnosis. The fourth commenter understood that our
reason for making this change had to do with our belief that many of
these injuries are sustained during hospital stays. That commenter
believes that the causes surrounding the injury are not necessarily
indicative of the nature of the services furnished or the procedures
performed and that we should not make this change unless we reviewed
the resources consumed delivering these services.
Response: Our proposal to change the OR designation for these
procedures was not based on where the injuries were incurred. Rather,
we based the decision on our analysis of claims data as part of our
annual review of procedures that result in assignment to DRGs 468, 476,
and 477, and on the clinical opinions of our physician consultants.
Cases in which 08.81 was coded as the only OR procedure, unrelated to
the principal diagnosis, were the second most frequently assigned to
DRG 477. Our evaluation of the average charges and length of stay for
these cases was the deciding factor in our proposal. Both of these
statistics were much lower for the eyelid repair cases than the average
case assigned to DRG 477. In addition, the opinion of our medical staff
was that these repairs would not normally necessitate a trip to the OR,
even if they are performed by a specialist. Because there are so many
cases of eyelid repair performed for unrelated diagnoses, we speculated
that they were the result of injuries sustained while the patient was
in the hospital.
Regarding the request to designate codes 08.81 through 08.89 as
non-OR procedures that affect DRG assignment in the MDCs to which they
were previously assigned, we analyzed the FY 1995 MedPAR file cases in
which one of these codes is assigned to DRG 40 and 41 (Extraocular
Procedures Except Orbit) in MDC 2 (Diseases and Disorders of the Eye)
and DRG 268 (Skin, Subcutaneous Tissue and Breast Plastic Procedures)
in MDC 9 (Disease and Disorders of the Skin, Subcutaneous Tissue and
Breast). In both DRGs 40 and 268 (no cases were assigned to DRG 41 in
FY 1995), there were no cases in which an eyelid repair was the only
related procedure coded. That is, in every case, there was another OR
procedure code present on the claim that would cause it to be assigned
to either DRG 40 or 268. This means that assignment of cases to these
DRGs will not be affected by changing the OR designation for the eyelid
repair codes.
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 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
[[Page 46175]]
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 field, 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 was 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 codes changes that have been approved will become
effective October 1, 1996. The new ICD-9-CM codes are listed, along
with their DRG classifications, in Tables 6a and 6b (New Diagnosis
Codes and New Procedure Codes, respectively) in section V of the
addendum to this final rule. As we stated above, the code numbers and
their titles were presented for public comment in the ICD-9-CM
Coordination and Maintenance Committee meetings. Both oral and written
comments were considered before the codes were approved.
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, and 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
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 DRG assignments for these revised codes.
Based on the comments received and our own review, we have
corrected a code title and added omitted secondary DRG assignments to
several codes in Tables 6a and 6b. The code title corrected is 995.59,
Other child abuse and neglect. The codes for which DRG changes have
been made are as follows:
In Table 6a, MDC 15 and DRG 391 were added to 752.51 and
752.52 because they are considered ``major problems'' in this DRG;
922.31, 922.32, and 922.33 were modified to add MDC 24 and DRGs 484,
485, 486, and 487; and MDC 15 and DRGs 387 and 389 were added to
998.11, 998.12, 998.13, 998.51 and 998.59 because they are considered
``major problems'' in these DRGs.
In Table 6b, DRG 303 was added to code 59.03.
Comment: One commenter supported the creation of new procedure
codes for partial cholecystectomies; however, the commenter disagreed
with their assignment to DRGs 193 and 194 (Biliary Tract Procedures
except only Cholecystectomy with or without C.D.E.). The commenter
believes that partial cholecystectomy (code 51.21) is similar to
cholecystectomy (code 51.22) and laparoscopic partial cholecystectomy
(51.23) is similar to laparoscopic cholecystectomy (51.24). Therefore,
procedure codes 51.21 and 51.23 should be assigned to the same DRGs as
51.22 and 51.24, respectively.
Response: We agree with the commenter. Partial cholecystectomies
are clinically similar to cholecystectomies and laparoscopic partial
cholecystectomies are clinically similar to laparoscopic
cholecystectomies, as well as being similar in terms of resource use.
Therefore, we have revised Table 6b to indicate that procedure code
51.21 is assigned to DRGs 195 and 196 (Cholecystectomy with C.D.E.) and
DRGs 197 and 198 (Cholecystectomy except by Laparoscope) and 51.23 is
assigned to DRGs 195 and 196 and DRGs 493 and 494 (Laparoscopic
Cholecystectomy).
Comment: We received one comment on modifications made to the ICD-
9-CM codes involving psychiatric diagnoses. The commenter had
participated in the ICD-9-CM Coordination and Maintenance Committee
meetings and had submitted written proposals for revisions. The
commenter stated that although the proposed rule listed all final code
revisions, it did not explain the final action on specific proposals or
why that action was taken. The commenter suggested that this
information be included in the final rule. The commenter also objected
to changing the title of category V61.1 from ``Marital Problems'' to
``Counseling for Marital and Partner Problems'' because it narrows the
use of the category.
Response: The National Center for Health Statistics (NCHS) has the
lead responsibility for maintaining the diagnosis part of ICD-9-CM. As
explained above, after receiving comments at the public meetings held
by the Coordination and Maintenance Committee and reviewing subsequent
written comments, NCHS proposes final revisions to ICD-9-CM diagnosis
codes. These revisions are then jointly approved by NCHS and HCFA. The
purpose of printing the final codes in the Federal Register is simply
to notify the public and solicit comment on the proposed DRG
classifications. We recommend that the commenter, or any other
interested party, contact NCHS directly to discuss the final codes. If
further revisions are sought, then these can be handled through future
meetings of the Coordination and Maintenance Committee. We will forward
the commenter's concerns on category V61.1 to NCHS for review.
Comment: One commenter supported the ICD-9-CM code revisions for
October 1, 1996, but suggested that rules relating to the sequencing of
the new code V66.7, Encounter for palliative care, should be developed
prior to its use beginning on October 1, 1996.
Response: We agree with the commenter that medical records
technicians and administrators will
[[Page 46176]]
need advice on coding this diagnosis. Specific directions in the form
of a note within the tabular section of the ICD-9-CM will direct the
coder to ``code first underlying disease'' when coding V66.7. The NCHS
has also developed an extensive set of V code guidelines that will also
clarify that V66.7 should be sequenced second. In addition, AHA
routinely includes advice on the use of new and modified codes in the
fourth quarter issue of their publication, Coding Clinic for ICD-9-CM
Coding. This year's issue will clarify that V66.7 will be used only as
a secondary diagnosis. The coding advice in Coding Clinic is a
collaborative effort among HCFA, NCHS, AHA, and AHIMA. Information on
ordering Coding Clinic can be obtained from the following: American
Hospital Association, Central Office on ICD-9-CM, One North Franklin,
Chicago, IL 60606, (312) 422-3366.
Comment: Although the Committee made no revisions to the pacemaker
codes, a commenter noted that there have been advances in pacemaker
technology that may have an effect on coding and DRG classification.
One new pacemaker device functions as a dual-chamber pacemaker
(procedure code 37.83) but has only a single lead (procedure code 37.71
or 37.73). If these pairs of codes are reported on a claim, the case is
assigned to a medical DRG rather than DRG 115 or 116 (Permanent Cardiac
Pacemaker Implant).
Response: This coding issue was addressed recently by the Editorial
Advisory Board of the Coding Clinic for ICD-9-CM. After consultation
with the manufacturer of the new pacemaker device, the Board decided
that, although this pacemaker has a single lead, it functions as dual
electrodes. Therefore, the insertion of this pacemaker should be coded
with procedure codes 37.83 and 37.72 (dual lead insertion). If a
hospital follows this coding advice, the case will be classified to DRG
115 or 116. This advice will be included in an upcoming issue of Coding
Clinic. We will monitor this situation to determine if hospitals are
following this coding advice or if a change in the DRG software is
necessary.
C. Recalibration of DRG Weights
We used 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 recalibrated the weights based on charge data for
Medicare discharges. However, we used 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 recalibrated DRG relative weights are constructed from FY 1995
MedPAR data, based on bills received by HCFA through June 1996, 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 11.1 million Medicare discharges.
The methodology used to calculate the DRG relative weights from the
FY 1995 MedPAR file is as follows:
All the claims were regrouped using the final DRG
classification revisions discussed above in section II.B of this
preamble.
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 were used in computing the current weights. That is, we
eliminated 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 cost 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 proposed to use that same case
threshold in recalibrating the DRG weights for FY 1997. For this final
rule, using the June 1996 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 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
[[Page 46177]]
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 final rule, we are making a budget neutrality adjustment to assure
that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.
III. 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
(OMB). In addition, as discussed below, we adjust the wage index to
take into account the geographic reclassification of hospitals in
accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act.
Section 1886(d)(3)(E) of the Act 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 final 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 used the same categories
of data that were used in the FY 1996 wage index. Therefore, the 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 making 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.
Although we did not propose any changes in the reporting of
hospital wage index data, we received comments regarding our current
policies. (Comments specifically related to our policy on contract
labor are addressed below in section III.D of this preamble.)
Comment: We received several comments concerning the treatment of
Medicare Part A physician salaries in the wage index calculation. One
commenter stated that we should immediately exclude all of these costs,
using Worksheet A-8-2 of the Medicare cost report to identify physician
Part A costs. Alternatively, the commenter suggested that we should
include contracted Part A physician salaries in those States where
hospitals are prohibited from employing physicians. Two other
commenters suggested we should prepare an impact analysis of the
effects of the exclusion of Part A physician salaries.
Response: As stated in the September 1, 1994 final rule (59 FR
45355), effective with cost reporting periods beginning on or after
October 1, 1994, we revised the Medicare cost report to provide for the
separate reporting of all salary costs for physicians (including
teaching physicians), interns and residents, and certified registered
nurse anesthetists. After evaluating these data, we will consider
appropriate changes in developing the FY 1999 wage index update.
In response to the suggestion that we should use Worksheet A-8-2 to
expedite our evaluation of excluding physician Part A salaries, we will
explore the technical feasibility of using the data from that
worksheet. Regarding the suggestion that we should allow contracted
Part A physician salaries to be included in the wage index calculation
in those States that do not allow hospitals to employ physicians
directly, we note that, if we were to adopt such a policy it would not
be effective until hospitals' FY 1997 cost reporting periods.
Therefore, the data would not be available until the FY 2001 wage
index. Because we are already collecting data that would allow us to
exclude all physician Part A salaries by the FY 1999 wage index, we are
not adopting this comment.
With respect to the comments that we should prepare an analysis of
the impact on the wage index of excluding Part A physician salaries,
any such analysis is, of course, contingent upon having reliable data
to analyze. At this point, we do not foresee having such data prior to
the availability of hospitals' FY 1995 cost reports.
Comment: A commenter stated that the wage index value of rural
hospitals with swing-bed programs is unfairly deflated by the inclusion
of the lower salaries related to skilled nursing level care provided to
patients in swing-beds. The commenter indicated that since hospitals
can separately identify these salaries, they should be excluded from
total salaries to be consistent with the way salaries are reported for
hospitals without a swing-bed program.
Response: Salaries related to skilled nursing level care provided
to patients in swing-beds are not reported separately on the Medicare
cost report. Salary costs for swing-beds are combined with those for
general adult and pediatric care on the cost report at line 25 of
Worksheet A. Therefore, it would not be possible under the current cost
report format to remove from the wage index calculation these costs as
we do for direct salaries associated with distinct part skilled nursing
facilities and units. Furthermore, given the nature of the swing-bed
program, we do not believe it would be appropriate to impose on
hospitals the additional recordkeeping requirements that would be
necessary to report these salaries.
1. Verification of Wage Data from the Medicare Cost Report
The data for the FY 1997 wage index were obtained from Worksheet S-
3, Part II of the Medicare cost report. The data file used to construct
the wage index includes FY 1993 data submitted to the Hospital Cost
Report Information System (HCRIS). As in past years, we performed an
intensive review of the wage data, mostly through the use of edits
designed to identify aberrant data.
In the proposed rule, we discussed in detail our review of the wage
data as well as the process that hospitals could use to verify their
wage data and submit requests for corrections if necessary (61 FR
27455). To be reflected in the final wage index, wage data corrections
had
[[Page 46178]]
to be reviewed, verified, and transmitted to HCFA through HCRIS by June
17, 1996 (any changes after this date are limited to errors related to
handling the data, as described below in section III.C of this
preamble). All data elements that failed edits have been resolved and
are reflected in this final rule.
2. Computation of the Wage Index
As noted above, we are basing the FY 1997 wage index on wage data
reported on the FY 1993 cost reports. The final wage index is based on
data from 5,231 hospitals paid under the prospective payment system and
short-term acute care hospitals in waiver States. The method used to
compute the final wage index is as follows:
Step 1--We gathered data from each of the non-Federal short-term,
acute care hospitals for which data were reported on the Worksheet S-3,
Part II of the Medicare cost report for the hospital's cost reporting
periods beginning on or after October 1, 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 wages. 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
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 wages obtained in Step 3
for all hospitals in that area to determine the total adjusted wages
for the labor market area.
Step 7--We divided the total adjusted wages 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 wages 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 $19.5533.
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.
We note that on June 28, 1996, OMB announced the designation of the
Pocatello, Idaho MSA comprising Bannock County, Idaho and the
Jonesboro, Arkansas MSA comprising Craighead County, Arkansas and the
addition of Chester County, Tennessee to the Jackson, Tennessee MSA.
These changes are reflected in the final wage index.
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
[[Page 46179]]
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 final wage index values for FY 1997 are shown in Tables 4a, 4b,
and 4c in the Addendum to this final rule. The FY 1997 wage index
values incorporate all hospital redesignations for FY 1997, withdrawals
of requests for reclassification, wage index corrections, appeals, and
the Administrator's review process. For FY 1997, 385 hospitals are
redesignated for purposes of the wage index (hospitals redesignated
under section 1886(d)(8)(B) or 1886(d)(10) of the Act). For hospitals
that are redesignated, the wage index values are shown in Table 4c. For
some areas, Table 4c shows more than one wage index value. 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. In addition, Table 3C in the addendum to this final rule
includes the adjusted average hourly wage for each hospital based on
the FY 1993 data. Hospitals should use the average hourly wage
published in this final rule in applying to the MGCRB for wage index
reclassifications that would be effective for FY 1998. 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.
C. Requests for Wage Data Corrections
In the proposed rule, we noted that we would make a diskette
available in mid-August that contained the wage data used to construct
the wage index values in this final rule. As with the diskette made
available in March 1996, HCFA made the August diskette available to
hospital associations and the public. (Please note that this data file
is also available on HCFA's World-Wide Web page, public use files
address (http://www.hcfa.gov/stats/stats.html).) This file is made
available only for the purpose of identifying any potential errors made
by HCFA or the intermediary in the handling of the final wage data that
result from the process described above, not for the initiation of new
wage data correction requests.
In addition, as noted above, Table 3C in the Addendum to this final
rule contains each hospital's adjusted average hourly wage used to
construct the 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.
As noted in the proposed rule, 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.
Requests to revisit factual determinations or policy
interpretations made by the intermediary or HCFA during the wage data
correction process.
If, after reviewing the data in the August diskette or this final
rule, 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 should outline why the hospital
believes an error exists and provide all supporting information. 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
[[Page 46180]]
the start of FY 1997 (that is, October 1, 1996). Requests sent to HCFA
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. Each request must also be
sent to the hospital's fiscal intermediary. 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.
We believe the wage data correction process described above and in
the proposed rule 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 had access to the
wage data in mid-August, they will have had 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 had 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.
Comment: One commenter commended us for making the wage data file
available on the HCFA home page. The commenter also suggested that the
file be updated frequently and include such additional information as
the MSA name where the hospital is located, the applicable inflation
adjustment factors, and the MSA to which each hospital has been
reclassified by the MGCRB, if applicable.
Response: The wage data file is currently updated twice a year, in
mid-March and mid-August, in conjunction with the issuances of the
proposed and final rules for the hospital inpatient prospective payment
systems. This effort is very labor intensive, and since hospitals are
able to submit cost reports throughout the year, it is impractical to
update the wage data file more frequently. In addition, we would point
out that the intent of making these data available is primarily to
provide hospitals the opportunity to verify the data used in the
calculation of their wage index. Updating this file more frequently is
not necessary to fulfill this primary objective.
Regarding the suggestion to include additional information on the
wage data file that we make available to the public, we note that the
suggested data elements are not necessary for the purpose of allowing
an opportunity for providers to verify the accuracy of their wage data.
We note that we publish the MSA names and inflation adjustment factors
in the proposed and final rules, and the MSAs to which hospitals are
reclassified can be found on the PPS Payment Impact Public Use File,
available shortly after publication of the proposed and final rules.
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 the proposed rule, we provided a general overview of the issues
related to including contract labor costs in the wage index calculation
and solicited comments from the public regarding further expansion of
the types of contract labor costs included in the wage index. We also
listed nine specific issues on which we were seeking public comment.
The following background material is identical to the overview included
in the proposed rule, but we believe it is useful as a reference for
responding to many of the comments we received.
1. Background
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
[[Page 46181]]
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
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 solicited
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
[[Page 46182]]
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?
2. Discussion of Comments
We received 27 individual letters addressing the issue of contract
labor in the wage index. We appreciate the time and attention of all of
the commenters. The information provided has already increased our
understanding of the issue, and we intend to include in our future
analyses an evaluation of many of the points made by commenters. The
remainder of this section discusses the comments--first by responding
to the general comments we received and some specific policy questions,
then summarizing all of the responses we received to the questions
listed above. Although we do not respond directly to these latter
comments, they will aid us in our future consideration of this issue.
Comment: One commenter who represents a national association of
health systems noted that most of the issues raised by us in the
proposed rule were addressed by a special wage index Medicare Technical
Advisory Group (MTAG) work group. The commenter stated that ``(a)fter
considering all these issues in the MTAG work group, HCFA decided to
limit the inclusion of contract labor to direct patient care services.
This was because, in general, these services are in revenue producing
cost centers that have higher personnel costs (such as nursing
services) where the treatment of contract labor in determining the wage
index would have the greatest impact on hospitals. Also, these areas
generally have had fewer problems than contract services provided in
the overhead departments where average personnel costs are lower.
Patient care contract labor is more often billed on an hourly rate, and
because these are direct patient care services, they are generally
performed by personnel working on the hospital premises and therefore
include less indirect overhead cost from the contract organization. On
the other hand, contract labor costs related to overhead departments
normally has lower average cost, often includes more indirect overhead,
and often the related hours are not available.''
Response: We appreciate this commenter's past contributions into
the development of our contract labor policies and believe that the
commenter has presented a generally correct characterization of our
rationale for our current policy on contract labor costs. However, as
noted above, we are concerned that our policy continue to accurately
measure wage costs in a rapidly changing hospital environment and,
therefore, have solicited public input into our future policy
considerations.
Comment: Several commenters, including ProPAC, supported the
principle that all contract labor costs should be included in
calculating the wage index if they would have been included had the
contract workers been employees of the hospital; but the commenters
recognized the problems of accurately collecting contract labor costs.
The Commission suggested that, in light of the increasing importance of
adjusting payments to reflect input price variations in multiple
settings with the accelerating integration of health care delivery, a
need exists for a more comprehensive strategy for obtaining geographic
input price data. Finally, ProPAC indicated it would ``be pleased to
work with HCFA staff to develop and explore feasible approaches to a
solution.''
Response: We agree that, in principle, the wage index should
measure labor costs across hospitals without regard to who employs the
workers if such costs reflect relative wage levels and can be
identified. We also agree that, as health care delivery becomes more
integrated, so do the labor costs. Of course, we have increasingly been
concerned with this issue as we have worked to develop prospective
payment systems for various provider types. Therefore, we appreciate
ProPAC's offer of cooperation in this regard and look forward to
working together to address these issues.
Comment: Several commenters disagreed with our definition of direct
patient care contract labor, specifically, the exclusion of the costs
of contracted laboratory and pharmacy services. One commenter stated
that a preferable definition would include services that are directly
identifiable and billable to individual patients. Laboratory and
pharmacy services would be included in this definition. Another
commenter called our exclusion discriminatory toward rural hospitals as
rural hospitals are more likely to contract for a pharmacist than are
urban facilities. This commenter stated that pharmacists do have direct
patient care contact, noting that they dispense drugs to patients,
provide patient education, and are required to participate on
``interdisciplinary patient care'' teams.
Response: While there may be some direct patient care contact in
providing laboratory and pharmacy services, the amount varies across
hospitals and is only a portion of the total time spent providing
service to a hospital. As we noted in the proposed rule, one of the
reasons we have limited the types of contract services included in the
wage index calculation is that hospitals reported difficulty tracking
the hours associated with off-site facilities that serve more than one
hospital. Our experience and other comments we received indicate this
is also the case for contracted laboratory and pharmacy services. For
example, it is possible that a contracted pharmacist would spend part
of an hour preparing medications for patients in more than one
hospital.
We recognize the necessity for many hospitals, particularly small
and rural hospitals, to contract for pharmacy and laboratory services,
which are likely to be relatively costly. In fact, this is one of the
issues that led us to solicit public input into how our contract labor
policy may be improved. We believe that the insight from the comments
we received, as well as continuing communication with the hospital
industry, will ultimately help to resolve these difficult issues.
Comment: Several commenters representing hospital associations
recommended that we reinstitute an MTAG to ``assist in developing the
materials and definitions needed to implement these changes in
collecting contract labor data * * *'' Other commenters recommended the
initiation of a pilot study in selected regions to determine whether
``using (contract labor) costs in the wage index methodology are worth
the collection effort.''
Response: Again, we appreciate the volume of the responses we
received. Over the next few weeks, we will review our options for
pursuing the reinstitution of an MTAG to evaluate the need to revise
our policy on contract labor. We will also contact many of the national
and State hospital associations that responded to our solicitation for
further input.
[[Page 46183]]
Comment: Several commenters pointed to the need for greater clarity
regarding our definition of contract labor. There was a call for a
``universal model and criteria'' for fiscal intermediaries to follow in
determining allowable contract labor costs. One commenter submitted an
example of what such a model could look like.
Response: We have provided more detailed cost report instructions
for reporting contract labor in periods beginning on or after October
1, 1995. We will also include these more detailed instructions in the
desk reviews of the FY 1995 cost reports. In addition, on FORM HCFA-339
(the Provider Cost Report Reimbursement Questionnaire), we require
hospitals to provide detailed information on contract labor costs
currently included in the wage index calculation. This information
consists of descriptions and aggregate costs and hours for top
management contracts and costs and hours for each type of direct
patient care contract.
We will, however, continue to pursue opportunities for policy
improvement. In that regard, we welcome the suggestions we received in
response to the proposed rule, and encourage further input from
interested parties in the future.
Below, we summarize the comments we received in response to the
specific questions listed in the proposed rule. Again, we note that
while we are not responding to these comments here, we intend to take
them into consideration in our future analysis of this issue.
To what extent do hospitals rely on the use of contract
services?
According to the comments received, hospitals, particularly those
in rural areas and smaller cities, rely on contract labor for a variety
of services. In general, hospitals have begun to reduce ongoing labor
costs by employing contract personnel in many operational areas.
Because of fluctuating patient volumes, contract labor is a more cost
effective alternative to direct hiring. Furthermore, some States
prohibit the direct hiring of certain health care personnel; thus,
these positions must be contracted. Hospitals located in areas
experiencing shortages in health care personnel such as nurses and
pharmacists also rely heavily on contract labor.
For which services are contracts typically used? Virtually
all of those who commented stated that hospitals contract for nursing
and therapy (occupational, physical, respiratory, speech) services.
Most commenters mentioned the following as services for which hospitals
contract: radiology (including mammography and ultrasound); anesthesia;
dietary (including therapeutic); psychological and social; pharmacy;
laboratory and pathology; emergency room; medical records;
housekeeping, laundry, and central supply; clerical; legal; accounting
and audit; facility and equipment maintenance; and environmental. The
following services were also mentioned by at least one commenter:
surgery (technicians); air ambulance; management (e.g., medical
director); information systems management; education; and biomedical
engineering. Based on these comments, hospitals contract for every
category of labor.
Can hospitals accurately determine hours related to
contract services?
Most commenters stated that hospitals could accurately determine
hours related to contract services, particularly for contracts billed
on an hourly basis and for services such as laboratory, pharmacy, and
management. Some commenters explained that their hospitals have
established methods for tracking hours, such as time sheets maintained
for hourly workers, or invoices that include the hours worked and the
hourly rate. Others commented that, if necessary, systems to track
hours (for example, log-in sheets) could easily be instituted. Several
others suggested that hospitals could more accurately report hours
associated with contract services if HCFA clarified the contract labor
definition, developed acceptable methods for tracking hours and
associated costs, and developed a universal model and criteria for the
fiscal intermediaries to follow in auditing contract labor costs and
hours.
A few commenters stated concerns that hospitals may not be able to
accurately report contract labor hours. One suggested there may be
difficulty in reporting hours in situations where the contractor serves
more than one client. One hospital explained that for some services, it
does not report hours, or it relies on the contractor to supply the
hours. For services such as physical therapy, this hospital pays
contractors based on a percentage of revenue generated. One hospital
association stated that hospitals may not be able to accurately
determine the hours for services such as laundry, dietary,
housekeeping, and maintenance. Another association explained that,
while hospitals in its area are required to report contract hourly
rates and hours for nonpatient care cost centers, evidence suggests
that the data for many hospitals may not be completely accurate,
reflecting the difficulty of capturing such detailed information.
Can hospitals accurately isolate labor-related costs from
nonlabor-related costs?
Several commenters stated that hospitals can accurately isolate
labor-related costs from nonlabor-related costs using invoices. One
commenter explained that for services with little or no nonlabor costs,
such as laboratory, pharmacy, and management, there is no need to
identify and isolate these costs.
On the other hand, one commenter suggested there may be difficulty
in reporting hours in situations where the contractor serves more than
one client. One hospital stated that it does not separate labor and
nonlabor costs. One association stated that contracts for services such
as laundry, dietary, housekeeping, and maintenance may include more
nonlabor costs and may be more difficult for hospitals to isolate
nonlabor costs. Another association believes that intermediaries are
inconsistent in handling nonlabor costs and that HCFA needs to develop
better guidelines.
Should the contract labor definition be expanded to
include contract services indirectly related to patient care?
The majority of the commenters support expanding the definition of
contract labor to include services indirectly related to patient care.
Two commenters stated that, in principle, all contract labor costs and
hours should be included if they would have been included had the
workers been employed by the hospital. Two commenters responded that
excluding contract labor services understates the cost of providing
patient services and puts hospitals at a disadvantage. Two others
commented that HCFA's definition of direct patient care is too
restrictive and should be revised to include services that can be
identified and billed separately and are not included in the routine
care charge. One commenter, although in support of including indirect
patient care contract services, recognized that considerable review
would be necessary to determine which labor costs should be included as
contract labor. Another commenter noted that reporting additional types
of contract labor should not be considered an unnecessary burden. Two
associations expressed concern that excluding large labor expenses, for
services such as dietary and housekeeping, may create inconsistencies
across labor market areas. Some commenters also suggested that we
include the following services (that we consider indirectly related to
patient care) in the definition of contract labor: pharmacy, dietary,
clerical,
[[Page 46184]]
housekeeping and environmental, accounting and audit, legal,
consultant, and medical director.
Some commenters, including five large hospital associations,
expressed concern over expanding the definition of contract labor to
include indirect patient care services. Two commented it would add
considerably to the complexity of tracking costs and determining which
services should be included or excluded. One commenter added that,
based on its analyses, it would be difficult to collect reliable data
and that including contracted indirect patient care costs would have
only a minor impact on the wage index. Another commented that problems
that exist with contract labor data are more prevalent in nonrevenue
producing areas.
If contract labor remains limited to direct patient care,
what categories of services, if any, in addition to those identified
above, should be included?
Commenters named the following services as those that should be
included in the direct patient care definition of contract labor:
dietary, anesthesia, social, pharmacy, laboratory, pathology, medical
records, equipment maintenance, environmental management, central
supply, and all clinical services.
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)?
Five hospitals and ProPAC commented that the wage index would more
accurately reflect relative wage levels if we did not limit contract
labor to direct patient care. One stated that failure to include all
contract labor could result in major biases in the wage index because
contract services may vary substantially among types of hospitals and
across labor market areas. Two rural hospitals argued that the current
policy discriminates against rural hospitals because they are more
likely to have to contract pharmacists and other personnel because of
employee shortages in their wage areas.
Three associations and a hospital commented that the wage index
would not more accurately reflect relative wage levels if we did not
limit contract labor to direct patient care. One explained that the
results would not be more accurate by adding or subtracting categories
of care; rather, the key to an accurate calculation is that the
components are consistent for all hospitals, not how many components
are included. Another added that, based on its analyses, including
contracted indirect patient care costs would have only a minor impact
on the wage index. A third commenter expressed concern that the time
necessary at the hospital level to obtain this information and the time
necessary for the intermediary to review such information would not be
cost effective.
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?
Commenters were unanimous in their belief that expanding the types
of contract labor that are included in the wage index would not provide
less incentive to hospitals to keep their labor costs low. Several
commenters explained that hospitals in today's environment have every
incentive to keep their costs down. Because Medicare is only one payer,
allowing labor costs to increase for improved Medicare payment would
put hospitals in an uncompetitive position as far as other payers are
concerned. Also, it would take 4 years for those costs to be reflected
in the wage index. One of them added that it is difficult to conceive
of any situation in which a hospital would benefit from paying higher
labor rates than necessary.
What other issues should be considered in revising the
policy for including contract labor in the wage index?
An association, located in a mostly rural State, suggested that
changes to expand contract labor should be made as soon as possible to
provide a more accurate and equitable wage index for all hospitals.
E. Puerto Rico Wage Index Values
For several years, hospitals in Puerto Rico have experienced large
swings in their wage index values. 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
could 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.
If we created a single labor market area for Puerto Rico, we would
do so in a budget neutral manner; therefore, the effect would be to
raise wage index values for some hospitals in Puerto Rico and to lower
the values for others. Because of the negative effect on some
hospitals, rather than propose such a change, we solicited comment on
this approach for mitigating the fluctuations in wage index values for
hospitals in Puerto Rico. We noted that the potential change would have
no impact on hospitals outside Puerto Rico. We received five comments
in response to our solicitation. These comments and our responses are
set forth below.
Comment: All of the commenters expressed grave concern regarding
the creation of a single MSA in Puerto Rico for purposes of the wage
index. Most commenters objected to the negative impact this proposal
would have on the wage index values of high wage areas. One commenter
protested the elimination of large urban status for the San Juan MSA.
Two commenters were concerned about the effect this change would have
on hospitals that are able to reclassify through the MGCRB. One
commenter noted that HCFA relies on OMB for MSA designations and OMB
has not approved this change. Finally, a commenter stated that a single
labor market area would not recognize the difference between tertiary
and secondary hospitals.
Response: We solicited comment on consolidating Puerto Rico into
one labor market area because it was one method for addressing swings
in wage index values within Puerto Rico without adversely affecting
hospitals outside Puerto Rico. Since commenters do not favor this
approach, we will not pursue the option. We note that this approach
would not have eliminated large urban status of the San Juan MSA for
standardized amount purposes. Puerto Rico would have been treated as
one labor market area solely for wage index purposes.
We have recently met with representatives of the Puerto Rico
Hospital Association to explore other solutions to the problems faced
by hospitals in the Commonwealth. In reviewing the latest Medicare cost
report data available, we find that hospitals in Puerto Rico continue
to demonstrate average Medicare operating margins comparable to all
other prospective payment hospitals.
Comment: One commenter urged an add-on adjustment of not less than
7
[[Page 46185]]
percent to the Puerto Rico standardized amounts to account for the
penalty resulting from the use of temporary cost allocation methods by
government hospitals with a noncharge structure in Puerto Rico.
Response: We do not believe it is appropriate to adjust the
standardized amounts of Puerto Rico for those government hospitals with
a noncharge structure when we have not adjusted the national
standardized amounts applicable to all other hospitals to account for
government hospitals with noncharge structures that are located in the
50 States and the District of Columbia. We believe the prospective
payment system should be fair and equitable to all hospitals, no matter
where they are located.
Comment: A commenter requested that we establish a wage index floor
for the labor market areas in Puerto Rico.
Response: The wage index measures relative wage levels across labor
market areas. Since Puerto Rico labor market areas have not increased
wages at the same average rate as all other hospitals, their wage index
values have decreased accordingly. If we were to create a floor, it
would improperly benefit labor market areas whose wages are not in line
with the national experience. The hospitals receiving the floor wage
index would receive artificially high DRG payments.
In addition, we note that, if such a change were to ever be
adopted, it would be implemented in a budget neutral manner. Thus, a
wage index floor for hospitals in Puerto Rico would result in lower
payments to other hospitals.
Comment: Two commenters suggested that we eliminate the Puerto Rico
rural area classification and classify those hospitals to the nearest
MSA.
Response: We do not believe it is appropriate to offer special
treatment to hospitals located in the rural area of Puerto Rico. While
we acknowledge certain limitations in the current geographic
classification system, we have yet to find a system that is
demonstrably better. (See the discussion on labor market area research
in the June 2, 1995 proposed rule (60 FR 29218).) Unless we decide to
adopt a new method for defining labor market areas, we will continue to
use rural areas for hospitals in counties that are not designated as
part of MSAs. We note that rural hospitals in Puerto Rico may apply for
geographic redesignation under the same criteria as all other hospitals
and that some hospitals in rural Puerto Rico have been approved for
reclassification.
Comment: One commenter suggested that OMB review the San Juan MSA
for possible redesignation of certain San Juan municipalities to other
urban areas.
Response: As acknowledged by the commenter, it is OMB that makes
the determination of which municipalities are included in a particular
MSA. We believe that OMB uses the same criteria to create the San Juan
MSA as it does for all other MSAs. We urge the commenter to forward any
suggestions directly to OMB for its consideration.
F. 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.
In the May 31, 1996 proposed rule, we proposed one change to the
MGCRB regulations. In addition, we requested 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.
In the proposed rule, in order to allow the Secretary maximum
flexibility to recruit and retain qualified Board members, we proposed
to eliminate the current requirement at Sec. 412.246(b) that a Board
member can serve for only two consecutive 3-year terms and to provide
that an appointment to the MGCRB may be for any term not to exceed 3
years.
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.
We received no comments on this proposal, and we have incorporated
it as final in this document.
2. Occupational Mix Adjustment
Section 1886(d)(10)(D)(i) of the Act requires the Secretary to
publish guidelines to be used 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,
[[Page 46186]]
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.
As noted in the proposed rule (61 FR 27459), we did not propose
collecting occupational mix data ourselves in light of past experience.
Instead, we solicited suggestions about any occupational mix data
sources that are available on a national basis. In addition, we
indicated that we were willing to consider suggestions about other
methods that would account for occupational mix in the wage index
reclassification process.
Comment: We received three comments on this issue. One commenter
believes that collection of the occupational mix data is burdensome,
that the data are unreliable, and that we should therefore eliminate
the use of such data. One commenter urged that the AHA continue to
collect the data for HCFA. The final commenter suggested that we
consider using the Geographic Reference Report to obtain occupational
mix information. That commenter noted, however, that this collection
effort would have to be expanded for our use.
Response: The AHA has notified us that it does not have enough
demand for these data to warrant continued collection. Generally, the
AHA, as well as HCFA, have found that hospitals do not want to provide
occupational breakdowns in a survey format. The Geographic Reference
Report would have to be expanded and tailored to fit our needs, which
means that it would be unavailable for at least several years as a data
source for this purpose. As there is no readily available data source
that can be used immediately to represent occupational mix data for the
purposes of reclassification applications, it appears that we will be
unable to continue to use such data as an alternative for hospital
reclassification applications. However, since the 1993 AHA data are
available for reclassification requests for FY 1998, we will not make a
final decision in this rule. If a suitable source of occupational mix
data becomes available in the next year, we will consider using it
beginning with reclassifications for FY 1999.
Comment: We received one comment from a hospital that was concerned
that it might not qualify for reclassification for purposes of using
the wage index of a proximate area because it could not meet the 108
percent qualifying criteria. This commenter noted that the hospital is
located in an area where it materially influences the average hourly
wage in its area, but it does not dominate the area. The commenter
believes that the current criteria disadvantages such a hospital,
because it can no longer meet the 108 percent threshold for
reclassification.
Response: We have addressed similar comments a number of times. The
purpose of the reclassification wage criteria is to identify situations
in which a hospital would receive more appropriate payments if it were
redesignated to another area. The 108 percent criterion in particular
is designed to identify situations in which a hospital is significantly
disadvantaged by its current geographic classification. If a hospital's
wages are less than 8 percent higher than the average hourly wage in
the hospital's labor market area, we believe the hospital is not
significantly disadvantaged by the payments it would receive and,
therefore, geographic reclassification is not appropriate.
Comment: One commenter requested confirmation of the process by
which a group of hospitals withdraw its application for
reclassification. The commenter believes that all the hospitals must be
a party to the withdrawal request.
Response: The commenter is correct. The regulations at
Sec. 412.273(b) clearly state that all hospitals that are party to the
application must request the withdrawal in writing. Therefore, a
request to withdraw an approved application by the MGCRB must be agreed
upon and requested in writing by the entire group.
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 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
[[Page 46187]]
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 moving 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 adopting a rebased and revised hospital market basket in
developing the FY 1997 update factor for the prospective payment rates.
The new market basket has been 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 the previous methodology, we relied
primarily on Medicare hospital cost report data for the rebasing. For
the rebased 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 are 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 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 1987-
1992 based
Expense categories hospital hospital
market market
basket basket
------------------------------------------------------------------------
Wages and salaries................................ 50.244 52.2
Employee benefits................................. 11.146 9.5
Nonmedical professional fees...................... 2.127 1.6
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 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). To date, the Department of Commerce has not released final 1992
cost data. Therefore, we plan to incorporate these data into the FY
1998 proposed rule.
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
[[Page 46188]]
descriptions of each category and respective price proxy are provided
in Appendix C to this final rule.
Table 2.--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*.......... 50.244 HCFA occupational wage
index.
B. Employee benefits*........... 11.146 HCFA occupational
benefits index
2. Professional fees*............... 2.127 ECI--compensation for
professional,
specialty and
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 and
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 and
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
and equipment.
(5.) Photographic supplies.. 0.399 PPI photographic
supplies
(6.) Rubber and plastics.... 4.868 PPI rubber and plastic
products.
(7.) Paper products......... 2.062 PPI converted paper and
paperboard products.
(8.) Apparel................ 0.875 PPI apparel.
(9.) Machinery and equipment 0.211 PPI machinery and
equipment.
(10.) Miscellaneous products 1.074 PPI finished goods.
B. All other services........... 8.792 .......................
(1.) Business services*..... 3.823 ECI--compensation for
private workers in
business services.
(2.) Computer services*..... 1.927 AHE computer and data
processing services.
(3.) Transportation services 0.188 CPI-U transportation.
(4.) Telephone services..... 0.531 CPI-U telephone
services.
(5.) Postage*............... 0.272 CPI-U postage.
(6.) All other: labor 1.707 ECI--compensation for
intensive*. private service
occupations.
(7.) All other: nonlabor 0.344 CPI-U all items.
intensive.
-----------
Total..................... 100.000 .......................
------------------------------------------------------------------------
* Labor-related.
Note: Due to rounding, weights may not sum to total.
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 salaries *......... 52.2 HCFA occupational wage
index.
B. Employee benefits *.......... 9.5 HCFA occupational
benefits index.
2. Professional fees *.............. 1.6 ECI--wages and salaries
for professional,
specialty and
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.
[[Page 46189]]
D. Motor gasoline............... 0.2 WPI gasoline.
E. Water and sewerage........... 0.0 CPI-U water and
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
and equipment.
(5.) Photographic supplies.. 2.6 WPI photographic
supplies.
(6.) rubber and plastics.... 2.3 WPI rubber and plastic
products.
(7.) Paper products......... 1.4 PPI converted paper and
paperboard products.
(8.) Apparel................ 1.1 WPI textile house
furnishings.
(9.) machinery and equipment 0.4 WPI machinery and
equipment.
(10.) Miscellaneous products 0.8 WPI finished goods.
B. All other services........... 11.1 .......................
(1.) Business services *.... 3.8 AHE business services.
(2.) Computer services *.... 2.0 AHE computer and data
processing services.
(3.) Transportation services 1.2 CPI-U transportation.
(4.) Telephone services..... 1.0 CPI-U telephone
services.
(5.) Blood services *....... 0.6 WPI blood and
derivatives.
(6.) Postage *.............. 0.4 CPI-U postage.
(7.) All other: labor 1.2 ECI--wages and salaries
intensive *. for private service
occupations.
(8.) All other: nonlabor 0.8 CPI-U all items.
intensive.
-----------
Total................... 100.0
------------------------------------------------------------------------
* Labor-related.4700
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 reestimated the labor-related share of the standardized amounts.
Based on the relative weights of the 1992-based prospective payment
hospital market basket, as 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 recomputed 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 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
------------------------------------------------------------------------
Comment: Several commenters noted that because the prospective
payment system hospital input price index directly measures changes in
the price of labor for the overall economy as well as the changes in
the prices of goods and services purchased by hospitals, if legislation
is passed increasing the minimum wage in the United States the market
basket update should be revised to reflect this change.
Response: The commenters are correct in asserting that an increase
in the minimum wage should be appropriately reflected in the
prospective payment system hospital input price index. The structure of
the prospective payment
[[Page 46190]]
system hospital input price index is designed to track the historical
increases in compensation for workers comparable to those employed in
the hospital sector (as well as the prices of goods and services
comparable to those purchased by hospitals). The blend of occupational
data represents a composite of the types of labor that hospitals employ
in the production of their services. The proxies selected by HCFA to
represent these inputs are Employment Cost Indexes (ECIs) compiled by
the Bureau of Labor Statistics for the relevant occupational
categories. When the historical data for the period of the minimum wage
increase becomes available, the ECIs automatically reflect the impacts
of increases in the minimum wage. These proxies will therefore reflect
any increases in wages and benefits associated with the legislated
increase in the minimum wage.
The second quarter 1996 DRI/McGraw-Hill forecast of the prospective
payment system hospital input price index, which is included in this
final rule, reflects an anticipated increase in the minimum wage.
In the first quarter of 1996, HCFA commissioned DRI/McGraw-Hill to
consider the effects of an increase in the minimum wage on the HCFA
input price indexes. In its analysis, DRI/McGraw-Hill stated that the
critical factor in determining the relative impact on each of HCFA's
input price indexes in comparison with the economy-wide impact is the
distribution of minimum wage workers associated with the occupational
mix within each health sector. Data from the 1990, 5-percent Public Use
Micro Data Survey (scaled for consistency with the nonfarm aggregate
from the 1994 Current Population Survey) indicate that the share of all
hourly workers at or below the minimum wage is approximately 3.3
percent for the health sector as a whole, versus an economy wide share
of 3.6 percent. There is a wide variation in the importance of minimum
wage workers across health industry sectors as well, ranging from a low
of 2.0 percent for the workforce in hospitals, to a high of 9.3 percent
for nursing-care related facilities. For the key wage proxies in the
prospective payment system hospital input price index (ECI Civilian
Hospital workers and the ECI for Professional-Technical workers) the
share of minimum wage workers is negligible. The expected increase in
minimum wage will likely affect the annual rates of increase in the
prospective payment system hospital input price index in the range of
about 0.1 percent.
Comment: One commenter noted that there are few who can afford to
spend the time necessary to study the proposal to rebase and revise the
hospital market baskets in its present form or hire an economist for an
interpretation. The commenter suggests that HCFA could save valuable
resources and, at the same time, simplify a process that is extremely
complicated by using the overall cost data from the cost reports as a
means of simplifying and arriving at an accurate market basket.
Response: The Medicare cost report is designed to track hospitals'
costs for services that are covered by Medicare. Expenditures or costs
are determined by the price of inputs for a particular good or service
times the quantity of that input good or service that is used. An
increase in costs could result from input price growth (inflation) or
growth in the quantity of services used. It is essential to
understanding the growth in Medicare program costs to have a rigorous
framework for distinguishing the effects of input price growth from the
effects of increases in the quantity of inputs. A measure based upon
overall cost data from the cost reports, while appearing to simplify
the process, would not separate input price changes from changes in the
quantity of inputs and consequently would not serve the needs of
government or industry.
We do appropriately use Medicare cost report data in developing
weights for the Medicare input price indexes. The 1992 base year
weights for the four core operating categories (wages and salaries,
employee benefits, pharmaceuticals, and all other) were derived from
Medicare cost report data on hospitals' relative shares of costs in
these four categories in 1992. By holding the weights constant at their
1992 relative values, and applying proxies to measure price change over
time, it is possible to estimate the effect of pure input price
inflation while holding quantity and quality of inputs constant. This
is the purpose of the prospective payment system hospital input price
index.
Comment: A commenter stated that, in rebasing the market basket,
HCFA has chosen to put malpractice costs into a separate category. In
doing so, this cost was taken from 1989 cost reports and ``trended''
forward. The commenter suggested that, because this cost cannot be
taken from cost reports in future years, it would be better to
consolidate malpractice cost within an ``all other'' category.
Response: Malpractice has appropriately been a separate cost
category since the inception of the prospective payment system hospital
input price index. We are modifying the Medicare cost report to again
include relevant malpractice cost questions, so that we will not have
to estimate the malpractice share of costs.
3. Selection of Price Proxies
After computing the 1992 cost weights for the rebased hospital
market basket, it was 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
[[Page 46191]]
given labor category or when the ECI does not have sufficient length of
history to be useful for our purpose.
Our price proxies for the rebased prospective payment hospital
market basket are shown in Table 2 above and are summarized in Appendix
C to this final rule.
Comment: One commenter believes that the most recent available
Medicare cost report and other data should be used to establish the
cost weights, particularly because the hospital industry and its cost
structure are changing so rapidly.
Response: The prospective payment system hospital input price index
was designed to be rebased at 5-year intervals, consistent with the
scheduled release of the Commerce Department data on detailed cost
structure by industrial sector of the U.S. economy. The Gross Domestic
Product (GDP) and other related government statistics are on the same
schedule of 5-year intervals between updates. Therefore, when planning
for rebasing, HCFA adopted a base year that was 5 years from the most
recent previous base year, 1987. We note that the Department of
Commerce has not yet made its planned release of the 1992 detailed data
on cost structure by industrial sector of the U.S. economy. However, in
the proposed rule for FY 1998, we intend to modify the input price
indexes for both the prospective payment system and excluded hospitals
by incorporating the 1992 detailed cost structure data.
Comment: One commenter requested that we provide a more complete
rationale in the final rule concerning the proposed price-proxy
changes.
Response: The following discussion is offered to further explain
our rationale for the price proxy changes we are adopting.
a. Nonmedical professional fees: The ECI for Compensation for
Professional and Technical Workers replaced the ECI for Wages and
Salaries for Professional and Technical Workers. The new index measures
the growth in input prices associated with employee benefits as well as
wages and salaries. Since the nonmedical professional fees category
represents the hospital costs associated with obtaining these services,
a price measure that accounts for aggregate compensation costs is
preferable to one that measures only the wages and salaries component.
When the ECI was first collected, it measured only growth in wages and
salaries (not employee benefits). We changed the price proxy to reflect
the improved data from the Bureau of Labor Statistics (BLS).
b. In an effort to improve the general accuracy and validity of the
index's measurement of price growth, we made four minor producer price
index changes:
Fuel Oil and Gasoline: In the 1992-based index, the Fuel
Oil and Gasoline category represents a combination of the Fuel Oil and
Coal category and the Motor Gasoline category from the 1987-based
index. The weight for motor gasoline was too small to keep it as a
separate category. The price proxy used for the combined group in the
1992-based index, the Producer Price Index for Refined Petroleum
Products, encompasses both PPIs used in the 1987-based index.
Electricity: The PPI for Industrial Power was replaced
with the PPI for Commercial Electrical Power to reflect information
from the hospital industry and utility industry that commercial rates
of change for utility costs are generally more appropriate than
industrial rates.
Paper Products: The 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 was replaced by the PPI for converted paper and
paperboard products to better reflect the composition of costs in
hospitals.
Apparel: The PPI for textile house furnishings was
replaced by the PPI for Apparel to better reflect the composition of
costs in hospitals.
c. Business Services: The Average Hourly Earnings (AHE) for
Business Services (AHE73NS) was replaced by the ECI for Compensation
for Business Services. Compensation, which reflects both fringe
benefits and wages, more appropriately measures the cost of business
services. In addition, the ECI measurement holds the skill mix
constant, measuring just the change in the cost of compensation,
whereas a change in the AHE for Business Services can reflect a change
in skill mix as well as a change in earnings. At the time of
publication of the 1987-based index, the ECI for Business Services was
not available.
d. All Other Services, Labor Intensive: The ECI Wages and Salaries
for Private Service workers was replaced by the ECI Compensation for
Private Service workers. A compensation price proxy reflects both a
change in the price of benefits as well as a change in the price of
wages and salaries.
4. The HCFA Blended Compensation Index
Compensation includes the two largest categories of the rebased
market basket: wages and salaries, and employee benefits. 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 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 system 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
[[Page 46192]]
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.
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.
Comment: One commenter suggested that the manner in which hospital-
specific wages and benefits price proxies are incorporated into the
market basket should be changed, so that the internal hospital industry
wage and benefit price proxies represent more of the compensation
weights in the market basket. The ECI for hospital workers should be
blended 50-50 for all labor cost categories, not just the professional
and technical worker cost group. Although nonprofessional and technical
workers may be employed in other settings, many of these workers have
skills that are specific to the hospital industry.
Response: The blended compensation index of nine broad occupational
groups with the ECI for Hospital Workers that is included in the
prospective payment system hospital input price index reflects HCFA's
judgment that, except for the professional and technical occupational
category, hospitals compete primarily in the economy-wide labor market.
Accordingly, HCFA uses Employment Cost Indexes (ECIs) for the private
sector of the economy for eight of the nine occupation groups. For one
broad occupational group, professional and technical workers, HCFA has
recognized that certain subcategory occupations, such as registered
nurses and physical therapists, are so specialized that hospitals are
the predominant employers. Other types of professional and technical
workers such as computer programers and biological researchers are
distributed more evenly throughout the private sector economy.
Therefore, a blend of the ECI for ``Private Professional Specialty and
Technical Workers'' and the ECI for Civilian Hospital workers is used
to measure growth in compensation prices for professional and
technical. Since none of the other eight occupational categories are
likely to use substantial proportions of hospital specific occupations,
extending the blend to other labor categories is not appropriate.
As a practical matter, there is virtually no difference in the
overall hospital input price index that results from using only a 50-50
blend of the ECI for Professional-Technical Workers and the ECI for
Hospital Workers versus using a 50-50 blend for each of the nine ECI
occupation groups with the ECI for Civilian Hospital Workers. The
following table illustrates this point:
Difference in the Rate of Increase in the Hospital Index 50-50 Blend of
Professional-Technical Workers Versus 50-50 Blend of All Occupations
Federal Fiscal Year Percent Change
------------------------------------------------------------------------
1997 1998 1999
------------------------------------------------------------------------
50-50 blend of ECI P&T and ECI civilian hospital
workers........................................ 2.5 2.9 3.1
50-50 blend of all nine occupations and ECI
civilian hospital workers...................... 2.5 2.8 3.1
------------------------------------------------------------------------
The latest forecast of the rate of increase in the hospital input
price index indicates that there is no difference for the FY 1997
update. For FY 1998, the current forecasts have a 0.1 percent
difference. For FY 1999, the forecasts are identical. We will continue
to monitor the effect on the hospital input price index that results
from the alternative construction of the compensation sub-index. If a
material difference develops between the two versions, we will
reevaluate our position on the construction of the compensation sub-
index.
Comment: One commenter, noting Table 5, ``HCFA Blended Wages and
Salaries Index (Wages and Salaries Component of the 1992-Based Market
Basket) (61 FR 27463), which lists the nine occupational categories,
stated that HCFA is of the opinion that hospitals compete with the
general labor market with the first category entitled ``Professional
and Technical.'' The commenter questioned how HCFA arrives at this
conclusion. The commenter recommended that, unless there is evidence
that ``Professional and Technical'' workers provide an accurate proxy
for wages in the hospital industry, the ``blend'' be dropped and be
replaced by a hospital industry measure.
Response: The professional and technical workers category includes
computer programmers, computer systems analysts, social workers,
accountants, scientists, and lawyers. To varying degrees, hospitals
employ each of these types of personnel. As noted in the previous
comment and response, these occupations are also in significant demand
outside the hospital industry, and hospitals must compete with
employers in other industries as well as with other hospitals. For
these types of occupations, competitive market forces that affect the
compensation levels paid to workers in the nonhospital sector directly
influence the compensation that prudent buyer hospitals pay. In order
to account for this, it is appropriate to use the ECI Compensation for
Private Professional-Technical Workers.
Hospitals are also major employers of other types of workers such
as physical therapists, respiratory therapists, and registered nurses.
Because hospitals demand substantial proportions of these types of
workers, it is appropriate to reflect, at least in part, hospital
industry-specific compensation.
[[Page 46193]]
The blend of professional-technical workers with the hospital
industry specific compensation ECI is also used mitigate the effect of
potential labor market imperfections in the hospital industry.
Licensure requirements and the existence of third party insurance are
believed by some to have enabled certain occupations to command
compensation premiums that are above what can be explained by
traditional predictors such as education, skill, experience, and
location. Because certain professional and technical workers tend to
have licensure restrictions that are more limiting than other
occupations in the health care industry, there is some reason to
believe that workers with the strictest licensure requirements are most
able to realize a compensation premium. A blend provides a reasonable
way to recognize that hospital compensation of professional and
technical workers is influenced by both economy-wide and hospital
sector-specific forces and that licensure requirements may influence
compensation in ways different from a competitive market.
The advent of managed care may have diminished the ability of
certain health sector labor occupations to achieve compensation
premiums. This is suggested by the fact that recently the rate of
increase in the ECI for Hospital workers has declined relative to the
ECI for economy-wide professional-technical workers while in earlier
periods the reverse held. Since FY 1992, the ECI for Hospital Workers
has grown at a slower rate than the ECI for Private Professional and
Technical workers. We will continue to monitor the ECIs and other data
to detect changes in the market dynamics for the types of workers that
hospitals employ.
Employment Cost Index Hospital Industry Workers Versus Economywide
Professional and Technical Occupations
Federal Fiscal Year Percent Change
------------------------------------------------------------------------
1992 1993 1994 1995
------------------------------------------------------------------------
ECI civilian hospital industry workers.. 4.3 3.7 3.1 2.5
ECI private P&T occupations............. 4.5 4.0 3.2 2.6
------------------------------------------------------------------------
Comment: One commenter believed that the hospital industry does not
compete with the general labor market for the cost category entitled
``Managers and Administrators.'' Therefore, the price proxy for this
category should be the ECI for hospital workers, a hospital sector-
specific proxy.
Response: Occupations in this category require a knowledge of and
the capability to put into effect management principles, practices and
techniques. The skills that these personnel possess are in demand in
the overall economy as well as the hospital sector.
Since FY 1994, the ECI Compensation for Hospital Workers has grown
at a slower rate than the ECI Compensation for Private Executive
Administrative and Managerial Workers. Recent projections of these
price proxies by DRI/McGraw-Hill suggest that this trend will continue.
Comment: One commenter suggested that, as an alternative to using
the ECI for Hospital Industry Workers as a price proxy for all nine
occupational categories, HCFA could use the data base it has developed
over the last few years dealing with hospital wages.
Response: We assume that the commenter's reference to the data base
that HCFA has developed over the last few years refers to the Hospital
Area Wage Index. This index was developed pursuant to a statutory
requirement that the Secretary adjust the standardized amounts for area
differences in hospital wage levels. This index is designed to measure
geographic differences in wage levels, not changes in wages over time.
Also, because the area wage index is computed using total adjusted
compensation divided by the sum total hours worked in a labor market
(see section III of this preamble), it does not hold constant the
skill-mix of employees from year to year. Therefore, any year-to-year
index based upon the area wage index would include both price and
quantity effects. The hospital input price index is appropriately
designed to measure pure price inflation.
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 final rule).
Differences in weights between the 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 when the U.S. Department of Commerce 1992
data are released, analyzed by HCFA, and incorporated in
[[Page 46194]]
the PPS and exempt final market baskets.
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 using cost report data for excluded
hospitals and units whose average length of stay for Medicare patients
is within 15 percent (that is, 15 percent higher or lower) of the
facility average length of stay for all patients. 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 forecast for FY
1997 differs by only 0.1 percent when we included all excluded
hospitals in the calculation of weights. The forecast for the limited
index was 2.5 percent, while the forecast for the full set of excluded
hospitals was 2.6 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
------------------------------------------------------------------------
Table 7.--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 and
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 and
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 and
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
and equipment.
(5.) Photographic supplies.. 0.413 PPI photographic
supplies.
(6.) Rubber and plastics.... 5.039 PPI rubber and plastic
products.
(7.) Paper products......... 2.134 PPI converted paper and
paperboard products.
(8.) Apparel................ 0.906 PPI apparel.
(9.) Machinery and equipment 0.218 PPI machinery and
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 and 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 1.767 ECI--compensation for
intensive. private service
occupations.
(7.) All other: nonlabor 0.356 CPI-U all items.
intensive.
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.
[[Page 46195]]
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 and
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 and
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 and
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
and equipment.
(5.) Photographic supplies.. 0.354 PPI photographic
supplies.
(6.) Rubber and plastics.... 4.319 PPI rubber and plastic
products.
(7.) Paper products......... 1.829 PPI converted paper and
paperboard products.
(8.) Apparel................ 0.777 PPI apparel.
(9.) Machinery and equipment 0.187 PPI machinery and
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 and 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 1.514 ECI--compensation for
Intensive. private service
occupations.
(7.) All Other: Nonlabor 0.305 CPI-U all items.
Intensive.
Total..................... 100.000 .......................
------------------------------------------------------------------------
The relatively small differences in weights between the 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 Excluded Hospital Market Basket and the
Excluded Hospital Market Basket Rebased Using All Excluded Hospitals,
Percent Change, 1988-1998
------------------------------------------------------------------------
Excluded (+/- Excluded
15%) hospital market
hospital basket using
Federal fiscal year market all excluded Difference
basket--1992 hospitals--1992
base base
------------------------------------------------------------------------
Historical: 1988............. 4.9 4.8 0.1
1989......................... 5.6 5.5 0.1
1990......................... 4.6 4.7 (0.1)
1991......................... 4.3 4.4 (0.1)
[[Page 46196]]
1992......................... 3.0 3.2 (0.2)
1993......................... 3.1 3.1 (0.0)
1994......................... 2.6 2.7 (0.1)
1995......................... 3.3 3.2 0.1
Forecasted: 1996............. 2.5 2.7 (0.2)
1997......................... 2.5 2.6 (0.1)
1998......................... 2.8 2.9 (0.1)
Historical average: 1988-1995 3.9 4.0 (0.1)
Forecasted average: 1996-1998 2.6 2.7 (0.1)
------------------------------------------------------------------------
Note that the historical average rate of growth from 1988 to 1995
for the 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 within 0.1 percent
for FY 1996, 1997, and 1998.
Comment: A commenter requested a more detailed explanation about
the rationale for dropping from the calculation of the excluded
facility market basket those excluded hospitals and units with Medicare
average lengths of stay that vary by more than 15 percent from the
facility's overall average length of stay. The commenter stated that
there is no description of the hospitals being dropped or their
characteristics (e.g., if these facilities have low Medicare shares, it
may be appropriate to exclude them). More information is needed before
the appropriateness of the 15-percent screen can be assessed.
Response: To the extent possible, we used total reimbursable
facility costs to determine the weights for Medicare costs. If the
patterns of practice for Medicare patients differ significantly from
the overall patient population, we believe that total facility costs
for facilities with high shares of Medicare patients are more
representative of the Medicare population. We chose to compare the
average length of stay for all patients to that of Medicare
beneficiaries as the test of the similarity of the practice patterns
for non-Medicare patients versus Medicare patients. Our method results
in retaining hospitals that had a share of patient days attributable to
Medicare that was approximately three times that of hospitals that were
excluded. Our goal is to measure cost shares that are reflective of
case mix and practice patterns associated with providing services to
Medicare beneficiaries.
Comment: A commenter questioned whether there will be a need for a
separate market basket for each type of excluded hospital once
prospective payment systems are developed for psychiatric and
rehabilitation hospitals and units. The commenter recommended that HCFA
consider whether it would be beneficial to begin identifying a separate
market basket for each type of excluded hospital.
Response: We agree with the commenter that HCFA will have to
consider whether to use separate market baskets for each type of
excluded hospital once prospective payment systems are developed for
psychiatric and rehabilitation hospitals. However, until those systems
are designed we believe it is premature to develop separate market
baskets.
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 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).
[[Page 46197]]
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.
Comment: A commenter suggested that HCFA's model is overly
complicated and relies excessively on assumptions given that capital
costs make up approximately 10 percent of total hospital costs. The
commenter recommended that HCFA adopt a simpler approach to update the
Federal rate for capital-related costs for hospital inpatient services.
Response: Capital payments for prospective payment hospitals are
expected to be about $8.6 billion in FY 1997, a significant amount that
warrants an appropriate input price index. It would not be appropriate
to use a simpler index if it does not accurately reflect the price
increases associated with capital costs. Capital costs are inherently
complicated and are determined by complex capital purchasing decisions
over time, which are based on such factors as interest rates and debt
financing decisions. Also, capital is depreciated over periods of time
instead of being consumed in the same period it is purchased. The CIPI
accurately reflects the annual price increases associated with capital
costs, and is a useful simplification of the actual capital
accumulation process. By appropriately accounting for the vintage
nature of capital in the CIPI, HCFA is able to provide an accurate,
stable annual measure of price increases. Annual, non-vintage price
changes for capital are highly unstable due to the volatility of
interest rate changes. These unstable annual price changes do not
reflect the actual annual price changes for Medicare capital-related
costs. The HCFA CIPI reflects the underlying stability of the capital
acquisition process and provides hospitals with the ability to plan for
changes in capital payments.
The most recent discussion on the CIPI and methodological
background was published in the May 31, 1996 proposed rule (61 FR
27466). 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. Previously, both the operating input
price index and the CIPI are based to FY 1987. We are updating the base
year cost structure 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 using a rebased capital input price index (CIPI) in
developing the FY 1997 capital update factor for capital prospective
payment rates. The new CIPI is 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 final 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 10 below were computed using a combination of the FY 1992
Medicare Cost Reports and 1992 AHA Annual Survey data. FY 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 prospective payment hospital 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 prospective payment hospital 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 prospective payment
hospital 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
[[Page 46198]]
representative of the cost weights for the entire universe of
hospitals.
Table 10.--Comparison of 1987 and 1992 Cost Category Weights
------------------------------------------------------------------------
Rebased
Expense categories FY 1987 FY 1992 Price proxy
------------------------------------------------------------------------
1. Building and fixed equipment 0.3054 0.3009 Boeckh
depreciation. Institutional
Construction
Index--vintage
weighted (22 yrs)
2. Movable equipment 0.3456 0.3475 PPI for machinery
depreciation. and equipment--
vintage weighted
(10 yrs)
Total interest.............. 0.3274 0.3184
1. Government/nonprofit interest 0.2783 0.2706 Average yield on
domestic
municipal bonds
(bond buyer 20
bonds)--vintage
weighted (22 yrs)
2. For-profit interest.......... 0.0491 0.0478 Average yield on
Moody's Aaa
Bonds--vintage
weighted (22 yrs)
Other........................... 0.0216 0.0332 CPI(U) for
residential rent
Total....................... 1.0000 1.0000
Total depreciation........ 0.6510 0.6484
------------------------------------------------------------------------
Source: 1992 Medicare Cost Reports, PPS year 9; 1992 AHA Annual Survey.
Note: Due to rounding, weights may not sum to totals.
Comment: The price proxy for ``for-profit interest'' was listed in
Table 10 of the May 31, 1996 Federal Register (61 FR 27468) as the
Average Yield on Moody's AAA Corporate Bonds. A commenter pointed out
that Moody's highest ratings is Aaa instead of AAA.
Response: As the commenter pointed out, the correct Moody's rating
is Aaa. While publications other than Moody's may not be as precise in
their presentation of Moody's ratings, HCFA will use the more precise
definition of Aaa and refer to the price proxy for for-profit interest
as the Average Yield on Moody's Aaa Corporate Bonds throughout this
final rule.
We had planned to incorporate the 1992 data from the Department of
Commerce for developing capital cost category weights. However, these
data are not available for inclusion in this final rule.
b. Relative Vintage Weights for Prices. As we have explained in
previous Federal Register documents (most recently the September 1,
1995 final rule at 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 prospective payment 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
[[Page 46199]]
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 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.
[[Page 46200]]
Table 11.--Vintage Weights for Capital-Related Price Proxies
----------------------------------------------------------------------------------------------------------------
Building and fixed Movable equipment Interest
equipment ---------------------------------------------------
--------------------------
Year Rebased Fiscal Year Rebased Fiscal Year Rebased
Fiscal Year Fiscal Year 1987 10 Fiscal Year 1987 22 Fiscal Year
1987 25 1992 22 yrs 1992 10 yrs 1992 22
yrs yrs yrs yrs
----------------------------------------------------------------------------------------------------------------
1................................. 0.015 0.019 0.064 0.069 0.007 0.007
2................................. 0.019 0.020 0.072 0.075 0.009 0.008
3................................. 0.022 0.023 0.077 0.083 0.010 0.010
4................................. 0.024 0.026 0.085 0.091 0.011 0.012
5................................. 0.023 0.028 0.095 0.097 0.013 0.014
6................................. 0.022 0.030 0.101 0.103 0.015 0.016
7................................. 0.020 0.031 0.109 0.109 0.017 0.018
8................................. 0.021 0.032 0.122 0.115 0.020 0.021
9................................. 0.025 0.036 0.132 0.124 0.023 0.024
10................................ 0.030 0.039 0.142 0.133 0.027 0.029
11................................ 0.033 0.043 ........... ........... 0.032 0.035
12................................ 0.034 0.047 ........... ........... 0.038 0.041
13................................ 0.034 0.050 ........... ........... 0.043 0.047
14................................ 0.035 0.052 ........... ........... 0.050 0.052
15................................ 0.038 0.055 ........... ........... 0.057 0.059
16................................ 0.043 0.059 ........... ........... 0.064 0.067
17................................ 0.049 0.062 ........... ........... 0.074 0.074
18................................ 0.053 0.065 ........... ........... 0.083 0.081
19................................ 0.056 0.067 ........... ........... 0.090 0.088
20................................ 0.057 0.069 ........... ........... 0.098 0.093
21................................ 0.060 0.072 ........... ........... 0.105 0.099
22................................ 0.066 0.073 ........... ........... 0.114 0.103
23................................ 0.071 ........... ........... ........... ........... ...........
24................................ 0.075 ........... ........... ........... ........... ...........
25................................ 0.077 ........... ........... ........... ........... ...........
-----------------------------------------------------------------------------
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.
[[Page 46201]]
Comment: ProPAC again commented that HCFA's capital update
framework could be improved, and that ProPAC's capital update framework
is similar to the operating update framework. The ProPAC framework also
includes a discretionary financing policy adjustment for use in
extended periods of unusually high or low interest rates.
Response: The HCFA CIPI measures the annual price increase
associated with vintage-weighted capital expenses, making it consistent
with the HCFA operating input price index, which measures the annual
price increase associated with operating expenses. The ProPAC market
basket reflects the price increase of capital purchases from one year
to the next, and does not capture the vintage nature of capital that is
captured by the HCFA CIPI. Therefore, we believe the HCFA CIPI
accurately measures annual price increases in capital expenses, as we
stated before in the May 26, 1993 (58 FR 30451), September 1, 1993 (58
FR 46492), May 27, 1994 (59 FR 27889), September 1, 1994 (59 FR 45521),
June 2, 1995 (60 FR 29233), and the September 1, 1995 (60 FR 45823)
Federal Registers. ProPAC has presented no criteria (objective or
subjective) for determining when a discretionary financing policy
adjustment would be appropriate. HCFA believes that interest rates are
intrinsic to a technically sound and fair measure of price increases in
capital expenses (which are defined as depreciation, interest, and
lease expenses, and insurance and taxes), just as all expense
components are appropriately included in the HCFA operating input price
index.
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 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 price proxies are presented in Table 10.
Comment: A commenter contended the average yield on bonds rated Aaa
is not representative of the bond rating the for-profit hospital
industry is obtaining. The commenter examined the bond rating of some
of its member companies and found them to range from A3 (highest) to B1
(lowest). The commenter recommended the selection of a price proxy that
better reflects interest costs of taxpaying hospitals.
Response: The commenter is correct that the average yield on lower-
rated corporate bonds is different from the average yield on higher-
rated corporate bonds, and that some for-profit hospitals have lower
ratings than Aaa. However, the interest component for for-profit
hospitals in the HCFA CIPI is based on percent changes in yields and
not the yields themselves. We analyzed the percent change in the yield
for two bond ratings: Aaa and Baa. Despite the yields for the two bond
ratings being significantly different for the 15 years between 1981-
1995, the percent changes in the yields for the two bond ratings were
nearly identical. We used the percent changes in both yields to
calculate the CIPI and determined the impact of the different yields on
the overall CIPI was essentially zero. Because our analysis did not
reveal any significant difference in the percent change in yields for
corporate bonds with different ratings, we believe the average yield
for Moody's Aaa corporate bonds is an appropriate price proxy for for-
profit interest expense.
4. Forecast of the CIPI for Federal Fiscal Year 1997
DRI forecasts a 1.3 percent increase in the rebased 1992 CIPI for
FY 1997, as indicated in Table 12. This is the outcome of a 2.4 percent
increase in projected depreciation prices (building and fixed
equipment, and movable equipment) and a 2.2 percent increase in other
capital expense prices in FY 1997, partially offset by a 1.8 percent
decline in vintage-weighted interest rates in FY 1997.
[[Page 46202]]
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 (fiscal year 1992)........ 1.0000 0.6484 0.3009 0.3475 0.3184 0.0332
----------------------------------------------------------------------------------------------------------------
VINTAGE-WEIGHTED 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.............................. 1.1 2.5 3.6 1.5 -2.4 2.4
1997.............................. 1.3 2.4 3.5 1.5 -1.8 2.2
1998.............................. 1.2 2.4 3.3 1.5 -2.2 3.1
1999.............................. 1.2 2.4 3.3 1.5 -2.2 2.2
2000.............................. 1.3 2.4 3.3 1.5 -2.3 3.1
----------------------------------------------------------------------------------------------------------------
[[Page 46203]]
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 1.5 to 1.3 as
indicated in Table 13. 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 second quarter 1996 forecast. The difference
reflects 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.............................................. 1.4 1.1
1997.............................................. 1.5 1.3
------------------------------------------------------------------------
V. Other Decisions and 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 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).
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.) As discussed in the
proposed rule, some hospitals have raised questions about the
definition of service area. Therefore, we clarified that 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). We also indicated that we intended to revise the current
manual accordingly at our earliest opportunity.
Comment: Two commenters responded to our clarification on the use
of zip codes to determine a hospital's service area for SCH purposes.
One commenter did not object to the policy clarification, but requested
that we also clarify whether use of zip codes and use of a statewide
health planning agency are the only two methods of defining a service
area. The other commenter believes our current policy may lead to
unfair results for some hospitals in sparsely populated areas. The
commenter requested that we permit a hospital to use either the lowest
number of zip codes or the lowest number of contiguous zip codes to
determine its service area.
Response: We discussed the definition of a hospital's service area
for SCH purposes at some length in the preamble of the September 30,
1988 final rule (53 FR 38511). In that document, we stated that a
hospital's service area is the area from which it draws at least 75
percent of its inpatients for the 12-month cost reporting period ending
before it applies for SCH classification.
We noted that not all States have Statewide health planning
commissions that identify hospitals' service areas and we offered the
zip code methodology as one alternative. We also noted that ``(t)he
important consideration is that a hospital be able to define its
service area as the area from which it draws 75 percent of its
inpatient admissions, as stated in the regulations text at
Sec. 412.92(c)(3).''
We have not restricted a hospital's source of data for defining its
service area to the use of zip codes or to Statewide planning
commissions. These are merely the two most common methods and, thus,
are the two we have
[[Page 46204]]
discussed in detail. There have been instances where a State hospital
association has been the source of data used to define the hospital's
service area. If a hospital does not wish to use the zip code
methodology to define its service area, we will review data from any
independent source that can supply documented data to identify the
hospital's service area. The important consideration is that we must be
able to verify supportable evidence that a hospital drew at least 75
percent of its inpatients from the defined service area.
In regard to the commenter who requested that a hospital be
permitted to define its service area using either the lowest number of
zip codes or the lowest number of contiguous zip codes, we do not
agree. Since October 1, 1988, any hospital choosing to define its
service area using the zip code methodology has been required to use
the lowest number of zip codes from which it drew at least 75 percent
of its inpatients during its most recently completed cost reporting
period.
We have not permitted any hospital to define its service area using
the lowest number of contiguous zip codes because we do not believe
this method presents as accurate a picture of a hospital's true service
area as does the actual lowest number of zip codes. Although the
commenter presented an elaborate example of how a hospital might meet
the market share test if its service area is based on contiguous zip
codes, but not meet the market share test when service area is defined
strictly as the lowest number of zip codes, we do not believe such a
scenario is likely to occur with any frequency. And, as noted above, a
hospital is not required to use the zip code methodology to define its
service area. If a hospital does not qualify using the lowest number of
zip codes, it can look to other sources such as a State hospital
association, Statewide planning commission, or any other independent
body that can present documentable data to verify that at least 75
percent of its inpatients came from the identified area.
Comment: One commenter was concerned about the interim payments
that sole community hospitals receive during the year. Specifically,
the commenter was troubled by the method we use to account for outlier
payments. Because our pricing methodology assumes that all sole
community hospitals will receive ``average ''outlier payments, the
aggregate interim payments for a hospital with few outliers are less
than the amount ultimately due the hospital. Although the difference is
paid to the hospital during its cost report settlement, the commenter
claimed that the delay in receiving the money due the hospital has
caused dire financial consequences.
Response: One of the difficulties in making interim payments during
the year for sole community hospitals is not knowing precisely the
amount of outlier payments the hospital is going to receive. Currently,
we simply use the overall national expected rate of approximately 5.1
percent to adjust the Federal payment rate. That is, we take the
hospital's Federal payment rate, already adjusted for the wage index,
indirect medical education factor, and disproportionate share factor,
and further adjust the rate by assuming that the hospital's outlier
payments will be 5.1 percent of its total DRG payments. Then, we
compare this amount to the hospital-specific amount and, if the
hospital-specific amount is higher, we make the difference an add-on to
the Federal payment rate in making interim payments.
Some sole community hospitals, however, actually receive much less
in outlier payments than the national average of 5.1 percent. This
causes our estimate of their outlier-adjusted Federal payments to be
higher than is really the case. Therefore, the hospital does not
receive all of its add-on payments during the year, because the
difference between the hospital-specific rate and the estimated
adjusted Federal payment rate is understated. The effect is a
potentially large payment to the hospital at the time of settlement. We
note that for sole community hospitals with higher than average outlier
payments, the opposite problem results. That is, the hospitals are
overpaid during the year and must repay monies to the Federal
Government at cost report settlement.
We believe an assumption based on the expected percentage of
overall national outlier payments is reasonable, but we will explore
this problem in more detail during the next year and try to determine
if use of a hospital-specific outlier adjustment factor for this
limited purpose would be more appropriate, as well as feasible.
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 included all urban hospitals nationwide, and the proposed
regional values were the median values of urban hospitals within each
census region, excluding those with approved teaching programs (that
is, those hospitals receiving indirect medical education payments as
provided in Sec. 412.105).
The values in the proposed rule were based on discharges occurring
during FY 1995 (October 1, 1994 through September 30, 1995) and
included bills posted to HCFA's records through December 1995.
Therefore, in addition to meeting other criteria, we proposed 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,
[[Page 46205]]
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. (See the table set forth in the May 31,
1996 proposed rule at 61 FR 27472.)
Based on the latest data available (FY 1995 bills received through
June 1996), the final national case-mix value is 1.3347 and 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).................... 1.2249
2. Middle Atlantic (PA, NJ, NY)............................ 1.2230
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 1.3396
4. East North Central (IL, IN, MI, OH, WI)................. 1.2471
5. East South Central (AL, KY, MS, TN)..................... 1.2933
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 1.2125
7. West South Central (AR, LA, OK, TX)..................... 1.3116
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 1.3339
9. Pacific (AK, CA, HI, OR, WA)............................ 1.3303
------------------------------------------------------------------------
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 final rule. In
keeping with our policy on discharges, these case-mix index values are
computed based on all Medicare patient discharges subject to DRG-based
payment.
2. Discharges
Section 412.96(c)(2)(i) provides that HCFA will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, we
proposed to update the regional standards. The proposed regional
standards were based on discharges for urban hospitals' cost reporting
periods that began during FY 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 proposed 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. (See
the table set forth in the June 2, 1996 proposed rule at 61 FR 27472.)
Based on the latest discharge data available, the final median
numbers of discharges for urban hospitals by census regions are as
follows:
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................... 6771
2. Middle Atlantic (PA, NJ, NY)............................ 8486
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 7504
4. East North Central (IL, IN, MI, OH, WI)................. 7384
5. East South Central (AL, KY, MS, TN)..................... 6386
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 5794
7. West South Central (AR, LA, OK, TX)..................... 4806
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 7553
9. Pacific (AK, CA, HI, OR, WA)............................ 5617
------------------------------------------------------------------------
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 must be at least 3,000.
3. Retention of Referral Center Status
Section 412.96(f) states that each hospital receiving the referral
center adjustment is reviewed every 3 years to determine if the
hospital continues to meet the criteria for referral center status. To
retain status as a referral center, a hospital must meet the criteria
for classification as a referral center specified in Sec. 412.96 (b)(1)
or (b)(2) or (c) for 2 of the last 3 years, or for the current year. A
hospital may meet any one of the three sets of criteria for individual
years during the 3-year period or the current year. For example, a
hospital may meet the two mandatory requirements in Sec. 412.96 (c)(1)
(case-mix index) and (c)(2) (number of discharges) and the optional
criterion in paragraph (c)(3) (medical staff) during the first year.
During the second or third year, the hospital may meet the criteria
under Sec. 412.96(b)(1) (rural location and appropriate bed size).
A hospital must meet all of the criteria within any one of these
three sections of the regulations in order to meet the retention
requirement for a given year. That is, it will have to meet all 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:
------------------------------------------------------------------------
For the cost Use the discharges Use numerical
reporting Use hospital's for the hospital's standards as
period case-mix index for cost reporting published in the
beginning FY period beginning Federal Register
during FY during FY on
------------------------------------------------------------------------
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
[[Page 46206]]
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. We received no comments on the rural
referral center criteria.
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 generally
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. There is also a limited exception
providing for disproportionate share adjustments for large urban
hospitals that receive substantial state and local revenues for
indigent (non-Medicare, non-Medicaid) care.
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 the
present measure. Therefore, in the proposed rule, we solicited comments
from the industry on better and more direct measures of indigent care
than the present measure that relies on SSI and Medicaid data. We also
discussed ProPAC's recommendations concerning DSH payments (61 FR
27474).
Comment: A large number of commenters responded to our request for
input on the Medicare disproportionate share adjustment calculation and
the SSI and Medicaid data that go into its development. Some commenters
believe that the current method of identifying disproportionate share
hospitals is acceptable. Other commenters stated that we should
implement a revised formula only if it captures the current base of
eligible hospitals as well as additional facilities. Finally, several
commenters believe that the current calculation is flawed beyond repair
and that we should reevaluate the current base of hospitals that are
eligible for payments under the disproportionate share adjustment and
revise the formula dramatically. The suggestions we received follow:
Use the current formula, but expand Medicaid days to
include all days that a person eligible for Title XIX spends in the
hospital, whether or not Medicaid paid. Further, in the case of States
that have replaced traditional Medicaid programs with alternate health
care programs for their low-income population, include all days that a
person who is covered by the State's program spends in the hospital,
whether or not that person would have been eligible for Title XIX
benefits.
Use the current formula and include outpatient data as
well as inpatient data.
Use data from the Department of Commerce based on income
levels and zip code information to determine median income levels
within designated service areas. These data can then be compared to
Federal poverty guidelines to establish the appropriate level of
disbursement of disproportionate share payments.
Combine charity care and bad debts as reported on the
hospital's financial statements and multiply by the hospital's overall
cost-to-charge ratio. Then, divide these costs by the hospital's net
patient revenue excluding Medicare, Medicaid, Medicare health
maintenance organization (HMO), and Medicaid (HMO) data. This method is
similar to the current qualifying criteria for an exception under the
disproportionate share adjustment calculation set forth at
Sec. 412.106(c)(2).
Use the low-income utilization rate that is currently used
in the administration of Medicaid disproportionate share adjustments.
This is a combination of a hospital's Medicaid revenues and its State
and local subsidies divided by its total revenues and its inpatient
charity care charges minus its State and local inpatient subsidies
divided by total charges.
Some of the commenters referred to the decisions in court cases in
the 6th and the 8th Circuits that require the inclusion of days that
would have been paid by Medicaid but for a State day limitation in the
disproportionate share calculation. These commenters encouraged HCFA to
implement the Court's ruling at the national level. Other commenters
were concerned
[[Page 46207]]
about the inclusion of HMO and other managed care utilization data in
the calculation. Many of these commenters suggested that HCFA should
require States to more accurately identify the Medicaid enrollees who
receive services under a waiver program, possibly by providing these
enrollees with encrypted insurance cards to reflect Title XIX
eligibility.
Several commenters believe that the adjusted average per capita
cost (AAPCC) payment rate for Medicare managed care plans should be
revised to exclude any adjustment for disproportionate share and that
those payments should be made directly to the eligible hospitals.
Several commenters offered to work with HCFA on this issue.
Response: We appreciate the responses that we received on the
disproportionate share adjustment issue. Members of the hospital
industry and its representatives carefully considered the question of
data sources, targeted hospitals, and the indigent population. In
general, commenters believe that compensation for hospitals that treat
a disproportionate share of the indigent population is valid. However,
as noted above, there are conflicting ideas about how to target that
set of hospitals.
Although many of these comments will require further analysis, we
will address some suggestions here. First, in the current formula, we
believe that Medicaid covered days is the correct measure and the
correct interpretation of Congressional intent as we have outlined on
numerous previous occasions, most notably in the September 1, 1986
final rule (54 FR 31460-31461). Given the current statute, we believe
it is not reasonable to include days that a person spent in the
hospital while that person was not eligible for Medicaid under any
circumstances. The statute clearly states that title XIX eligibility is
a requirement under any circumstances. If a State chooses to adopt some
sort of a waiver program and elects to cover people who would not have
otherwise been eligible for care, those persons will not be included as
Medicaid days in the current formula. Further, inpatient data are used
in the Medicare disproportionate share adjustment calculation because
the payment add-on is applied to the Medicare inpatient payment. It is
not designed to reflect either Medicaid shortfalls or outpatient data,
since there is a separate Medicaid disproportionate share adjustment,
and payment for outpatient services is not made through a prospective
payment system.
Data from the Department of Commerce based on the U.S. Census are
collected only during decennial census periods. Thus, while the data
look promising on first analysis, they become increasingly
unrepresentative of the population's income trends as they relate to
geographic areas as the years pass from the base year for which the
data are collected. We also have a problem with any data that may be
reported on a hospital's financial statements but that are not reported
on its annual Medicare cost report. The Medicare cost report data are
collected annually and subject to a settlement process. The financial
statements of hospitals vary from facility to facility, are audited on
an erratic schedule, and are not currently collected by Medicare for
evaluation.
Finally, we would not want to duplicate the procedure by which the
Medicaid disproportionate share adjustment is determined since the
Medicaid program already pays hospitals an adjustment under Medicaid
based on these criteria.
Regarding commenters' concerns on HMO days, currently we collect
data on HMO utilization for use in the disproportionate share
adjustment calculation. However, it is up to the hospital, in securing
the contract with the HMO, to obtain an agreement from the HMO that
allows the hospital to be able to distinguish those Medicare and
Medicaid patients that are utilizing services so that it may report
those days to the fiscal intermediary. We note that the President's FY
1997 budget includes a provision that would mandate the removal of
disproportionate share payments from the AAPCC calculation and allow
these payments to be made directly to the eligible hospital.
While there appears to be no easy or quick solution to improving
the disproportionate share payment adjustment, we appreciate the
comments that the hospital industry provided on this issue. Our concern
is that Medicaid data will continue to vary more and more from State to
State and SSI data will continue to be protected from the hospital
industry's examination by the Privacy Act. Therefore, we will continue
to examine the inconsistencies in the current Medicare disproportionate
share adjustment calculation and ways to improve the data and the
calculation to better target those hospitals that treat a
disproportionate share of the indigent population.
D. Direct Graduate Medical Education (Sec. 413.86)
1. Initial Residency Period Limitations
As discussed in the proposed rule, 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.
The table of initial residency periods published in the proposed
rule (61 FR 27475) did not constitute a proposal in the usual
rulemaking sense because we were simply updating the tables in
accordance with current policy. Nevertheless, we received many comments
that reflected a misunderstanding of the meaning of ``initial residency
period'' in general. The initial residency period, as that term is used
in section 1886(h)(5) (F) and (G) of the Act and in Sec. 413.86 refers
to the minimum number of years necessary to satisfy the requirements
for initial board eligibility in a specialty. During the initial
residency period, each full-time resident is weighted at 1.0 full-time
equivalent (FTE) for purposes of determining GME payments. Once the
resident has worked the minimum number of years required for board
eligibility in a specialty, any subsequent training in an approved
program is weighted at 0.5 FTE.
The comments on the updated listing also brought to our attention
information that has resulted in changes in the table of initial
residency periods. We have added allopathic allergy and immunology with
an initial residency period of 3 years, osteopathic preventive
medicine/aerospace medicine with an initial residency of 4 years, and
osteopathic combined programs in internal medicine/emergency medicine
and internal medicine/pediatrics with
[[Page 46208]]
an initial residency period of 4 years. We have also modified the table
by listing pathology/anatomic and pathology/clinical with respective
initial residency periods of 3 years and pathology/anatomic and
clinical with an initial residency period of 4 years. Finally, in the
proposed rule, emergency medicine was listed with an initial residency
period of 3/4 years due to our understanding that these programs have
been approved for both 3 and 4 years. However, since the Accreditation
Council for Graduate Medical Education (ACGME) has approved 3-year
programs, the minimum number of years of training to become board
eligible in emergency medicine is actually 3 years. Accordingly, we are
including the appropriate initial residency period limitation of 3
years in the table in this final rule.
Initial Residency Period Limitations
------------------------------------------------------------------------
Initial residency
Residency type period limitation
(No. of years)
------------------------------------------------------------------------
ALLOPATHY
ALLERGY AND IMMUNOLOGY............................... 3
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
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
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.................................. 3
PATHOLOGY, CLINICAL.................................. 3
PATHOLOGY, ANATOMIC AND CLINICAL..................... 4
Blood Banking/Transfusion Medicine............... 4
Chemical Pathology............................... 4
[[Page 46209]]
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............................. 5
RADIOLOGY, DIAGNOSTIC................................ 4
Neuroradiology................................... 4
Nuclear Radiology................................ 4
Pediatric Radiology.............................. 4
Vascular and Interventional Radiology............ 4
Radiation Oncology............................... 4
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
[[Page 46210]]
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
Pediatric Hematology/Oncology.................... 3
Pediatric Infectious Diseases.................... 3
Pediatric Intensive Care......................... 3
Pediatric Nephrology............................. 3
Pediatric Pulmonology............................ 3
Pediatric Sports Medicine........................ 3
PREVENTIVE MEDICINE.................................. 4
PREVENTIVE/AEROSPACE 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
[[Page 46211]]
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(5)........ 5
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
OSTEOPATHY COMBINED PROGRAMS*
INTERNAL MEDICINE/EMERGENCY MEDICINE................. 4
INTERNAL MEDICINE/PEDIATRICS......................... 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
As discussed in the proposed rule, when we updated the listing of
the Initial Residency Period Limitations for GME, we noted many new
programs that 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-year program, with
eligibility for certification in both specialties.
Currently, we are aware of 13 allopathic and 2 osteopathic 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 proposed
to clarify how the definition of initial residency period applies in
such cases. As discussed in detail in the proposed rule (61 FR 27477),
we proposed to clarify the definition of the initial residency period
for combined programs 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
Sec. 413.86(g)(3). We received numerous comments on this policy, and
the issues raised by the commenters are discussed below.
Comment: Many commenters disagreed with our clarification
concerning initial residency periods for combined programs. These
commenters stated that residents in combined programs are not board
eligible in either specialty until they have completed the entire
combined program. Some commenters asserted that we did not understand
that training in combined programs does not occur sequentially. One
commenter noted that the Graduate Medical Education Directory states
that ``applicants may not appear for certifying examinations until all
training has been completed.'' Many commenters stated that the law
states that a resident is to be counted as a 1.0 FTE during the
resident's initial residency period, which is defined as the ``period
of board eligibility'' in section 1886(h)(5)(F) of the Act. These
commenters do not believe we have the authority to establish an initial
residency period that is shorter than the length of the combined
program, because Medicare will not be paying for residents at 1.0 FTE
for the period of initial board eligibility.
Several commenters noted that a resident enrolled in a combined
program is enrolling in one program and receives a single certificate
upon completion. One commenter stated that the directors of combined
programs have not sought to independently certify their graduates with
a single examination administered by a single
[[Page 46212]]
board. This commenter added that similar to family practice, combined
programs are not a composite of separate specialties and should be
recognized as a single discipline. Other commenters noted that training
in combined internal medicine/pediatrics programs is more intensive
than family practice and the initial residency period should recognize
this superior training in adult and pediatric medicine. Some commenters
believe our proposal implies that training in a second specialty is
``superfluous, nonessential or less important.''
Response: We have always recognized that the training in combined
programs does not occur sequentially, and we acknowledge that residents
participating in combined programs are not board eligible in either
specialty until they have completed all of their training requirements.
We agree that combined training is more intensive than training in each
specialty taken separately, and we never stated or meant to imply that
training in a second specialty is unimportant or superfluous. Our
intent is simply to establish a reasonable policy, consistent with the
statute, that provides for full Medicare payment for training in one
speciality.
We believe our policy is consistent with section 1886(h)(5)(F) of
the Act, which defines ``initial residency period'' as ``the period of
board eligibility.'' Section 1886(h)(5)(G) defines the ``period of
board eligibility'' as ``the minimum number of years of formal training
necessary to satisfy the requirements for initial board eligibility in
the particular specialty for which the resident is training.''
(Emphasis added.)
The statute does not address how to count the initial residency
period in combined programs, perhaps because such programs were not
contemplated at the time the statute was enacted. We believe the
statutory scheme indicates congressional intent to allow ``full''
Medicare payment only for the minimum period required to train in one
specialty. Contrary to the suggestion of the commenters, it is clear
that the statute does not require Medicare to apply a weighting factor
of 1.0 for a resident until the resident actually becomes board
eligible. Rather, the statute requires a weighting factor of 1.0 only
for the ``minimum number of years necessary to satisfy the requirements
for initial board eligibility''; for time beyond the ``minimum''
period, the statute provides that the weighting factor is 0.5. Thus,
the statute contemplates Medicare payments for the costs of graduate
medical education, but it does not impose an open-ended obligation for
Medicare to pay full costs until a resident becomes board eligible.
The statute defines the initial residency period as the ``minimum
number of years'' necessary to satisfy the requirements for the
``particular specialty'' for which the resident is training. Based on
the public comments we received, we are not persuaded that combined
residency programs are ``particular specialties'' in and of themselves.
As we understand it, graduates of these combined residency programs are
not certified by a single examination by a single board. Rather, they
must take each board's examination separately. Thus, these residents
can become board eligible for each distinct specialty (for example,
Internal Medicine and Pediatrics). It appears that combined programs
simply combine training in separate specialties (whose requirements may
overlap). As always, we are willing to consider further information on
this issue.
We believe our policy on combined programs is reasonable. Residents
in combined programs complete all of the training requirements for two
specialties, but the minimum number of years required to become board
eligible in either specialty is less than the length of the combined
program. We believe it is reasonable to define the initial residency
period for combined programs as the longer of the initial residency
periods for the two specialties. Our policy is consistent with the
manner in which Medicare payment would be made if the resident trained
in two specialties in a sequential manner. In such cases, the resident
would be counted as a full 1.0 FTE during the training for the first
specialty, and as 0.5 FTE for later years.
Comment: Many commenters stated that Congress established the
initial residency period limitation with the intent of discouraging
subspecialty training and increasing the primary care work force. These
commenters do not believe that Congress intended to limit training in
combined programs consisting of two primary care specialties.
Similarly, other commenters noted that graduates of combined programs
are more likely to enter primary care practice in rural and medically
underserved areas than are graduates of other programs. These
commenters said that our proposal conflicts with Congress' goal to
provide medical care to rural and medically underserved areas.
Response: The initial residency period limitation on full Medicare
payment applies to all types of programs, both primary care and non-
primary care, and is not intended to discourage primary care practice.
We agree with these commenters that in general Federal policy should
encourage more training in primary care and that programs designed to
encourage practice in rural and medically underserved areas should
continue to be an important component of Federal health policy.
However, we believe that these concerns are more properly addressed in
other contexts. We note that section 1886(h)(2)(D) of the Act provides
updates to the per resident amounts for primary care residents, but the
statute does not distinguish between primary and non-primary care
specialties for purposes of determining the initial residency period.
Comment: Some commenters were concerned that our policy
clarification would lead to the dismantling of combined residency
programs.
Response: As we have stated, we believe this policy clarification
is necessary to avoid full Medicare payments, beyond the time required
to train in one specialty. We note that hospitals will continue to be
paid for residents in combined programs beyond their initial residency
period, with the residents weighted at 0.5 FTE.
Comment: Several commenters were concerned that HCFA developed this
policy, in part, to control Medicare's graduate medical education
payments. These commenters noted that there are few of these programs
in existence with only a small number of graduates who will be
affected. Accordingly, Medicare savings resulting from this policy
clarification will be small.
Response: This policy clarification is based on considerations
concerning the appropriate application of the statute and does not
arise solely from a goal of limiting payments. However, we acknowledge
that Medicare's payment liabilities will be less under this policy than
if hospitals were allowed to weight residents as 1.0 FTE throughout the
entire training period in the combined program. We believe that
combined training programs may have grown in recent years as physicians
seek additional qualifications in a competitive job market. Our
understanding is that there are more than 1,400 students in combined
programs. Given that only a portion of these students are beyond the
initial residency period under this clarification, we agree that any
budgetary impact is small relative to the total number of residents
participating in approved programs.
Comment: One commenter noted that osteopathic residency programs
allow 4 years for internal medicine but that allopathic residency
programs allow 3
[[Page 46213]]
years. This commenter suggested that if we modified the initial
residency periods so that both were of the same duration, the 4-year
combined residency could be accommodated.
Response: Allopathic and osteopathic specialty boards set different
requirements for board certification. The first year of postgraduate
osteopathic training consists of a rotating internship which is
followed by subsequent specialty training. Most allopathic training
programs do not require similar training. In the September 29, 1989 GME
regulation published in the Federal Register (54 FR 40293), we stated
that the osteopathic rotating internship, like the transitional year
required by some allopathic medical residency programs, would not count
as an additional year beyond initial board eligibility.
Comment: One commenter questioned the limitation on the number of
years noted on the table for geriatric psychiatry. The listing of the
initial residency periods permits an additional year for training in
geriatric medicine as a subspecialty of internal medicine and family
practice but not as a subspecialty of psychiatry. This commenter noted
that there is a minimum requirement of 4 years of training in
psychiatry and requested that the initial residency period be extended
to 5 years for training in geriatric psychiatry. Another commenter
noted that section 1886(h)(5)(F) of the Act provides that a 2-year
geriatric residency or fellowship program is treated as part of the
initial residency period, ``but shall not be counted against any
limitation on the initial residency period.'' This commenter stated
that the law clearly provides that geriatric psychiatry programs should
be eligible for full funding under the special geriatric medical
education provision described in the law. Other commenters noted that
the Accreditation Council for Graduate Medical Education (ACGME) only
accredited geriatric subspecialty programs in family and internal
medicine when the 1989 regulations were published but now recognizes
geriatric subspecialty programs in psychiatry.
Response: We agree that the initial residency period for geriatric
psychiatry programs should be revised. When the September 29, 1989
regulation (54 FR 40286) was published, the ACGME was in the process of
approving training programs in geriatrics as a subspecialty of internal
medicine and family practice. At that time, we proposed to consider
expanding the exception to the initial residency period limitation to
fellowships in other programs when the appropriate national
organizations establish criteria for approving these programs.
Subsequently, the ACGME established criteria for accrediting 12-month
programs in geriatric psychiatry, and the American Board of Psychiatry
and Neurology recognizes applicants with the required training for
certification in geriatric psychiatry. Accordingly, we are including
geriatric psychiatry in the table above with an initial residency
period of 5 years, which includes a 1-year exception to the 4-year
initial residency period for psychiatry. We are also modifying the
definition of ``approved geriatric program'' in Sec. 413.86(b) to
reflect that the ACGME is accrediting, and boards are recognizing,
training in geriatric medicine in specialties other than internal
medicine and family practice.
3. Statutory Provision Regarding Prohibition on Abortion-Related
Discrimination in Training and Licensing of Physicians
(Secs. 412.105(g) and 413.86(b))
Congress recently enacted a statutory provision that prohibits
certain abortion-related discrimination by the Federal Government and
State and local governments. In section 515 of the Departments of
Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act of 1996 (see section 101(d) of the Omnibus
Consolidated Rescissions and Appropriations Act of 1996, Pub. L. No.
104-134), enacted April 26, 1996, Congress added a new section 245 to
the Public Health Service Act to provide that:
``The Federal Government, and any State or local government that
receives Federal financial assistance, may not subject any health
care entity to discrimination on the basis that--
(1) the entity refuses to undergo training in the performance of
induced abortions, to require or provide such training, to perform
such abortions, or to provide referrals for such training or such
abortions;
(2) the entity refuses to make arrangements for any of the
activities specified in paragraph (1); or
(3) the entity attends (or attended) a post-graduate physician
training program, or any other program of training in the health
professions, that does not (or did not) perform induced abortions or
require, provide or refer for training in the performance of induced
abortions, or make arrangements for the provision of such
training.''
For purposes of section 245, the statute defines ``financial
assistance'' to include ``governmental payments provided as
reimbursement for carrying out health-related activities,'' and defines
``health care entity'' to include individual physicians, postgraduate
physician training programs (which includes residency training
programs), and participants in a program of training in the health
professions.
The new section also addresses accreditation of postgraduate
physician training programs. Specifically, the statute provides that:
``In determining whether to grant a legal status to a health
care entity (including a license or certificate) or to provide such
entity with financial assistance, services or other benefits, the
Federal government, or any State or local government that receives
Federal financial assistance, shall deem accredited any postgraduate
physician training program that would be accredited but for the
accrediting agency's reliance upon an accreditation standard that
requires an entity to perform an induced abortion or require,
provide, or refer for training in the performance of induced
abortions, or make arrangements for such training, regardless of
whether such accreditation standard provides exceptions or
exemptions.''
The statute further requires that the government involved ``shall
formulate such regulations or other mechanisms, or enter into such
agreements with accrediting agencies, as are necessary to comply with
this subsection.''
Under the terms of the statute, the provisions of section 245 shall
not ``prevent any health care entity from voluntarily electing to be
trained, to train, or to arrange for training in the performance of, to
perform, or to make referrals for induced abortions.'' Similarly, the
provisions of section 245 shall not ``prevent an accrediting agency or
a Federal, State or local government from establishing standards of
medical competency applicable only to those individuals who have
voluntarily elected to perform abortions.''
In this document, we are making conforming changes to the
regulations at Sec. 412.105(g) and Sec. 413.86(b) to reflect the
accreditation provisions of section 245. These technical changes merely
conform the regulations text to the express requirements of the
statute, and do not involve an exercise of discretion by the agency.
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
[[Page 46214]]
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 ntermediaries, 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 proposed 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 proposed 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.
We received only one comment on this proposal.
Comment: One commenter agreed with the proposal to permit hospitals
to provide timely notice during the course of the hospital stay.
However, the commenter stated that the ``Important Message'' is
currently ineffective in meeting its intended purpose, regardless of
the timing, because people are too sick and frightened to comprehend
the information at the point of hospitalization. The commenter
suggested instead using mass mailings to Medicare beneficiaries when
they are healthy and have no immediate plans to be hospitalized.
Response: While we agree that making this information available to
the Medicare beneficiary prior to hospitalization may enhance
comprehension, we believe that the ``Important Message'' may be ignored
during a mass mailing because the information would not be considered
needed at the time. Moreover, it is a statutory requirement that the
``Important Message'' be provided during an individual's
hospitalization; therefore, we cannot accept the commenter's
suggestion. Furthermore, in our proposal, while we did not intend to
address the effectiveness or the content of the ``Important Message''
in this regulation, we recognize the need to review its contents.
Therefore, an internal HCFA workgroup has begun the process to revise
the ``Important Message,'' including further consideration of the
recommendations for revision made by the Beneficiary Protection and
Documentation Issues Task Force of the Medicare Technical Advisory
Group (M-TAG). The goals of the Workgroup are to improve clarity for
increased comprehension and to improve efficiency of its distribution
to Medicare beneficiaries. Comments on the revision will be solicited
from selected outside parties in the near future.
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) 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.
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.
The election of the simplified method cannot be used to shift costs
inappropriately. Furthermore, a hospital that elects the simplified
methodology must continue to use it for at least 3 years, unless a
change of ownership occurs. In the proposed rule (61 FR 27478), we
proposed to add a new paragraph (d)(4) to Sec. 412.302, to provide that
hospitals may elect to adopt the simplified cost allocation
[[Page 46215]]
methodology, as will be provided in the instructions for HCFA Form
2552-96.
Comment: One commenter agreed with our proposal to revise
Sec. 412.302(d)(4) to allow for a simplified cost allocation
methodology, but suggested that we make a technical change to existing
Sec. 412.302(d)(1) to reflect the availability of the simplified
methodology option.
Response: We are adopting the commenter's recommended change to the
regulations. Section 412.302(d)(1) will now read: ``For cost reporting
periods beginning on or after October 1, 1991 and before October 1,
2001, the hospital must follow consistent cost finding methods for
classifying and allocating capital-related costs, except as otherwise
provided in paragraph (d)(4) of this section.''
Comment: In response to our proposal on the simplified cost
allocation methodology, one commenter argued that the general capital
consistency rule is flawed. The commenter stated that a provider should
be able to request that the fiscal intermediary reassign capital costs
from the acute care hospital portion of a facility to exempt areas of
the facility if the provider is using the space differently than it was
used during the capital base year, such as using the space as a skilled
nursing facility or a rehabilitation unit.
Response: This comment concerns the underlying intent of the
capital consistency rule itself rather than the subject of our May 31,
1995 proposed rule. In the August 30, 1991 final rule that implemented
the capital prospective payment system (56 FR 43396), we explained the
rationale for the capital consistency rule. We explained that the
capital consistency rule is necessary: (1) to prevent cost shifting to
outpatient departments through changes in cost finding methods, and (2)
to provide consistency with the determination of the hospital-specific
rate used in the base year. For these reasons, it is important that the
hospital continue the same bases of cost allocation for old capital
throughout the transition.
Throughout the transition to a fully prospective payment system for
capital, the provider must continue to allocate any space that was part
of the acute care hospital in the base year in the same way. However,
if the provider opens a new section of the facility as a skilled
nursing facility or excluded unit, capital costs in those areas could
be allocated directly to those areas.
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 27.5 percent in FY 1996 relative to FY 1995, and
that payments will exceed capital costs by 8.8 percent in FY 1996.
Under current law and regulations, we estimate that aggregate payments
will further increase by 6.8 percent in FY 1997, for an increase of
36.1 percent over 2 years. We also estimate that payments will exceed
capital costs by 7.5 percent in FY 1997.
In the May 31, 1996 proposed rule, we stated that we continue to
believe that such large increases in capital payments are neither
necessary nor warranted. We identified several possible approaches for
establishing a more appropriate level for the rates and discussed the
options we considered in developing the proposed rule (61 FR 27479).
These options included freezing the inflation updates for the rates in
FY 1997 or making downward adjustments in the base rates, as discussed
below:
Reduce the standard Federal rate by 7.38 percent and the
hospital-specific rates by 9.48 percent to reflect revised data on base
year costs used to determine the rates.
Implement the provision contained in the Administration's
budget plan to reduce the base Federal and hospital-specific rates by
15.7 percent.
As discussed in detail in the proposed rule, the rationale for
reducing 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.
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. 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. We now have extensive cost report data for FY 1992
that shows an audit-adjusted FY 1992 Medicare inpatient capital cost
per discharge that is an additional 7.38 percent lower that the
estimate on which the Federal rate is currently based. Accordingly, the
rate could be reduced to reflect accurate FY 1992 capital cost per
discharge data.
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. In order to adjust the hospital-specific rate to reflect
actual FY 1992 data, the rates must be reduced by 9.48 percent.
The reduction reflected in the President's budget plan is based on
a different consideration. That 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). Our last analysis (60 FR 45826-45829) suggested that the
estimated 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. This unaccounted for
difference
[[Page 46216]]
in the rates justifies a 15.7 percent reduction to the rates.
We seriously considered proposing one of these options in the
proposed rule, and we invited public comment on their merits and on the
advisability of implementing one or the other in the final rule, in the
absence of legislative action.
We received many comments on our discussion of possible adjustments
to the capital Federal rate, and these comments and our responses are
presented below. Although we continue to believe that any of these
options is justified on the basis of current data and analysis, we are
not implementing any freeze or reduction to the capital Federal rates
in this final rule. The President's budget bill includes numerous
proposals to reform the Medicare program, including a reduction to the
capital prospective payment rate. At this time, we believe it would be
more appropriate to adopt a change to the rate in the context of more
global changes to the Medicare program than to implement this one
specific provision of the President's budget through regulation.
Therefore, we are not implementing any of the possible reductions to
the capital Federal rate that were discussed in the proposed rule but
instead are updating the capital rates in accordance with the capital
update framework, as discussed in section III of the addendum to this
final rule.
In general, commenters opposed freezing or reducing the capital
Federal rate as suggested in the proposed rule. Commenters cited
various reasons why the suggested changes were inappropriate or
unnecessary. One commenter, ProPAC, agreed that continued significant
increases in capital payments are unjustified and supported reductions
to the capital rate. ProPAC suggested several options for our
consideration, such as using the FY 1995 rates as the base for future
years, or rebasing the FY 1992 capital payment rates and updating them
to the current year using an analytic framework. As explained earlier,
although we agree with ProPAC that a reduction in the rates is
warranted, we have decided not to proceed with reducing the rates by
regulation at this time. We discuss the comments on the possible
changes in more detail below.
Comment: Some commenters contended that it would be illegal for
HCFA to implement any of the identified reductions to the rates
(including an efficiency adjustment) because HCFA does not have the
authority to rebase the capital payment rate. Two commenters
characterized the rate reduction options as thinly disguised attempts
to rebase hospitals' base year capital costs, and asserted that
Congress has not given the Secretary of Health and Human Services the
authority to rebase hospital capital costs. One commenter stated that
the rate revisions discussed in the proposed rule would violate a
fundamental principle of prospective payment: that the system provide
certain and predictable payment rates. Another commenter opposed any
reduction in the capital Federal rate undertaken without legislative
direction.
Finally, one commenter noted that when Congress specified the 7.4
percent reduction in the Federal rate as part of OBRA 93, Congress
referenced the capital Federal rate ``as described in
Sec. 412.308(c).'' That regulation describes the methodology for
defining the Federal rate. The commenter believes that the regulation
does not contemplate the substitution of actual cost data for periods
in which estimated data were used initially. The commenter believes
that because Congress cited this section of the regulations, it
implicitly approved the continued use of estimated data for setting the
rates rather than the use of actual data.
Response: Section 1886(g) of the Act states that ``the Secretary
shall, for hospital cost reporting periods beginning on or after
October 1, 1991, provide for payments for [capital-related] costs in
accordance with a prospective payment system established by the
Secretary.'' The statute gives the Secretary wide discretion in
determining the particular features of the prospective payment system
for capital-related costs, including the appropriate level of payment
rates.
We believe that, consistent with this broad authority, it is
appropriate to make prospective adjustments to the capital rates. We
believe that any rate revision implemented prospectively would satisfy
the principle of certainty and predictability under a prospective
system. We have never contemplated a retroactive adjustment to payment
rates used in prior years.
The provision of OBRA 93 cited by the commenter does not indicate
that we cannot make other adjustments to the capital Federal rate in
future years. Section 412.308(c) describes the process for determining
the Federal rate by adjusting the standard Federal rate by an update
factor each year. We believe that Congress cited this section solely to
identify the rate to which we applied the 7.4 percent reduction.
Since the inception of the capital prospective payment system,
rates have been set on the basis of FY 1992 capital costs. Since we set
initially set rates before FY 1992 started, we necessarily had to
project capital costs for FY 1992. We used FY 1989 costs as the basis
for projecting FY 1992 costs because they were the latest cost report
data available at that time. (Even the FY 1989 data required an
estimated adjustment for the effect of audits not yet performed.) We
applied estimated adjustment factors to the FY 1989 data to derive
estimated FY 1992 capital costs. We used this estimated FY 1992 cost
level to set rates beginning in FY 1992.
When Congress legislated that the unadjusted standard Federal rate
be reduced by 7.4 percent in 1993, the size of the adjustment was based
on more recent data on FY 1992 costs available at that time. The latest
available data now indicate an additional 7.36 percent reduction is
appropriate. Again, although we are not implementing this adjustment,
we believe that we have the authority to do so and that it would
represent a logical extension of our policy of basing the capital
Federal rate on FY 1992 capital costs.
Comment: Several commenters stated that the discussion in the
proposed rule of the possibility of implementing reductions to the
capital Federal rate through the final rule did not constitute
sufficient notice to the public of proposed regulatory changes. The
commenters asserted that before implementing a reduction in the capital
payment rates, HCFA was obligated to provide ``formal'' public notice
and time for the public to respond.
Response: As noted above, we do not intend to implement any
reduction to the capital Federal rate at this time. However, we believe
that the discussion in the proposed rule would have satisfied the
requirements of the Administrative Procedure Act by (1) describing in
some detail three potential options for cutting the capital rate, (2)
informing the public that we might implement one of these options if
Congress and the Administration did not act to cut the rate, and (3)
soliciting public comment on the possible options. We stated that it
was our intention to consider all of the options in light of the
comments received. Moreover, in the FY 1996 proposed rule (60 FR
29238), we discussed in some detail and invited comments on two options
for adjusting the Federal and hospital specific rate, to account for
the overestimation of the FY 1992 Medicare inpatient capital cost per
discharge, and to compensate for the effects of the expiration of
budget neutrality. Finally, since FY 1992 we have printed seven
discussions of the efficiency issue, and providers have long known that
we
[[Page 46217]]
might make an adjustment in the rate to account for possible
inefficiency.
Comment: Some commenters stated that we should not adjust the
Federal rate to reflect the actual level of FY 1992 capital spending
because the FY 1992 level is lower than was projected. The commenters
asserted that FY 1992 capital cost levels are lower than projected
because hospitals responded in FY 1992 to the incentives of the
prospective payment system and modified their capital spending
behavior. Some commenters argued that hospitals responded to the
possible implementation of a capital prospective payment system even
prior to FY 1992. These commenters asserted that in order to get a true
sense of the impact of the capital prospective payment system on
hospital capital expenditure behavior, one must look further back to
when hospitals believed implementation of such a system was imminent.
One commenter explained that one reason actual increases in capital
costs in FY 1992 were less than projected was because lengthy
certificate of need (CON) approval processes prevented hospitals from
beginning building projects as planned. The commenter also stated that
if rates were reduced, hospitals in States with strict CON processes
should not be subjected to the same rate reductions as hospitals in
States without such processes. The commenter asserted that facilities
in the commenter's State are undercapitalized relative to facilities in
the rest of the country.
Finally, some commenters believe that the overestimation of FY 1992
capital costs (discussed above) stems not from a forecast error in the
FY 1992 capital cost per case but from a change in the treatment of
allowable interest that was implemented in the first capital
prospective payment system final rule published on August 30, 1991.
Thus, they believe the overestimation resulted from a change in the
rules regarding capital and that the proposed reduction based on a
revised FY 1992 capital cost data is not justified.
Response: Since the inception of the capital prospective payment
system, we have based capital rates on FY 1992 cost levels. We believe
it is appropriate for the rate to reflect actual FY 1992 capital
spending, even if hospitals had modified capital spending behavior
before the current system was implemented.
We agree that the prospective payment system provides an incentive
for hospitals to modify their capital spending behavior, and that it is
likely that hospitals have done so. However, we do not believe that the
magnitude of the difference between the projection for FY 1992 capital
costs and the latest measurement of FY 1992 capital costs can be
completely explained by changes in capital spending behavior caused by
the incentives of the prospective payment system. First, most of the
capital costs in FY 1992 would be attributable to capital acquired
before FY 1992 that was still being depreciated. Second, most capital
acquired in FY 1992 would have been planned and committed prior to FY
1992. Thus, only a small proportion of FY 1992 capital spending would
have been impacted by the implementation of the capital prospective
payment system. Consequently, the implementation of the prospective
payment system would have had little, if any, effect on capital growth
in FY 1992. Moreover, the anticipated onset of the prospective payment
system for capital-related costs may have encouraged some hospitals to
limit spending, but we are aware of several situations in which
hospitals actually hastened building projects in order to qualify for
possible old capital protections.
We recognize that CON processes may well delay hospital building
projects. However, the commenter does not explain why these effects
would have been greater in FY 1992 than in previous years. Our data on
the cumulative percentage change in capital-related cost per case,
which we presented in the September 1, 1995 final rule (60 FR 45828),
demonstrate that the growth of capital costs has slowed considerably in
recent years, from a high of 19.9 percent per year in 1986 to a low of
2.9 percent per year in 1992. The most recent FY 1992 HCRIS data
available show that hospitals' actual FY 1992 capital costs per
discharge are an additional 7.36 percent lower than the estimate on
which the capital Federal rate is currently based (taking into
consideration the adjustment mandated by Public Law 103-66). We believe
it is appropriate for the rate to reflect actual costs.
In designing the prospective payment system for capital costs, we
recognized the unique position of hospitals in States with CON programs
by developing special rules with regard to obligated capital. Those
special rules (see Sec. 412.302(c)(2), ``Lengthy certificate-of-need
process'') are designed to ensure that hospitals in States with CON
programs receive equitable treatment in terms of recognition ``old
capital costs.'' Essentially, this provision permits certain obligated
capital costs in CON States to be treated in the same manner as actual
capital expenditures in non-CON States. We believe these provisions
adequately address the concerns of hospitals in states with CON
processes.
Finally, we do not agree that the August 30, 1991 final rule
implemented any change in the treatment of allowable interest. Section
412.302(b)(2)(v), which defines old capital costs for purposes of the
prospective payment system for capital-related costs, states that
``Investment income, excluding income from funded depreciation
accounts, is used to reduce old capital interest expense based on the
ratio of total old capital interest expense to total allowable interest
expense in each cost reporting period. ''(Emphasis added.) The
commenter apparently believes that this statement reflects a change in
the treatment of allowable interest because Sec. 413.130(g)(2), which
defines capital-related interest expense net of investment income
(under our reasonable cost reimbursement rules), provides that in
determining the proportion of investment income to be offset, the ratio
is to be based on capital-related interest to total interest. However,
Sec. 413.130(g) derives from Sec. 413.130(a)(7), and Sec. 413.130(a)(7)
addresses only ``allowable interest expense'' (that is, interest
expense as determined under Sec. 413.153), so the ratio expressed in
Sec. 413.130(g) is reasonably interpreted to refer to ``total allowable
interest expense.''
Comment: Commenters also addressed the possible adjustment based in
part on an efficiency analysis. A few commenters stated that higher
than expected capital costs per case for FY 1992 were not the result of
inefficient use of capital resources, but rather a reaction to pent-up
demand in States that had restrictive certificate of need (CON)
policies. Another commenter argued that no overexpansion of health
facilities has occurred in the commenter's State, because it is highly
regulated, and that the average age of hospitals' physical plants in
the State is among the oldest in the country. This commenter too
believes that it is inappropriate to apply a rate reduction equally in
all States.
Some commenters agreed with our statement that economic theory
would suggest incentives for the overuse of capital during a period in
which capital was paid on a cost basis while operating costs were paid
on the basis of a prospective rate. However, the commenters contended
that economic theory would also suggest that, if hospitals over
purchased capital, they conversely had to under employ operating
inputs. Thus, the commenters believe that reductions to the capital
Federal rate to account for the
[[Page 46218]]
inefficient overuse of capital should be matched by increases in the
operating rates to account for inefficient underutilization of
operating inputs.
Finally, one commenter suggested that we obtain an independent
evaluation of HCFA's capital model and the factors that account for the
known increase in costs per case, such as the inflation in capital
input prices, quality enhancing intensity increases, and real case-mix
growth, as well as the factors that may be responsible for the
unexplained growth in capital costs per case.
Response: As noted in our September 1, 1995 final rule in response
to a similar comment (60 FR 45829), we agree that the conjunction of
rate-based payment for operating costs and cost-based payment for
capital costs encouraged hospitals to substitute capital inputs for
labor and other operating inputs. However, we do not agree that an
inefficiently high level of capital inputs under those conditions
necessarily implies an inefficiently low level of operating inputs.
Rather, the conjunction of rate-based payment for operating costs and
cost-based payment for capital could also lead to the substitution of
inefficient capital inputs for inefficient operating inputs. Indeed,
our previous analysis of efficient operating costs for hospitals during
FY 1985 through FY 1991 (57 FR 40014) indicates that operating
prospective payments during that period were sufficient for the
efficient and cost-effective delivery of quality care. In conjunction
with the analysis of capital spending during FY 1985 to FY 1992, these
results suggest that hospitals may indeed have responded to the
existing incentives by substituting an inefficiently high level of
capital inputs for inefficient operating inputs. Under these
circumstances, it would not be appropriate to increase operating rates
in conjunction with a decrease in capital rates. Decreased capital
rates, along with the existing level of operating rates, would provide
the appropriate incentives for hospitals to achieve efficient levels of
both capital and operating inputs.
As we stated in our September 1, 1995 final rule in response to a
similar comment (60 FR 45828), our analysis suggests a significant
measure of inefficiency in capital costs, and was based on national
figures. Therefore, since we are evaluating an efficiency adjustment in
the national Federal rate, our analysis does not consider regional
differences, such as the existence of CON requirements in some States.
The national Federal rate is based on an average; thus, we recognize
that some States will have higher costs than the average and other
States will have lower costs. We note, however, that although we did
not make adjustments for CON policies for purposes of this particular
analysis, Sec. 412.302(c)(2) does provide for differential treatment of
hospitals in CON States in terms of the recognition of obligated
capital (as discussed in more detail above).
In response to the commenter's suggestion that a group of
independent economists should evaluate the capital model and our theory
about the possible cause of the unexplained growth in capital costs per
case, we note that ProPAC has also analyzed the current capital rate
and has discussed possible reductions to the capital rate, implicitly
endorsing a reduction to the capital rate in the order of magnitude
that we discussed in the proposed rule.
Comment: A number of commenters contended that the reductions
discussed in the proposed rule would jeopardize the ability of many
hospitals to meet current obligations and reduce their ability to meet
future capital needs.
Response: Our data indicate that there is ample room to cut the
capital rate without a major adverse affect on facilities in any
region. Before the implementation of the prospective payment system for
capital-related costs, facilities were paid only 85 percent of their
capital costs. In the proposed rule, we estimated that payments would
exceed capital costs by 9.6 percent in FY 1996 (61 FR 27479). We now
estimate that capital payments will exceed capital costs by 8.8 percent
in FY 1996 and 7.5 percent in FY 1997.
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, a hospital may
receive an additional payment under an exceptions process if its total
inpatient capital-related payments under its payment methodology (that
is, 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 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 the proposed rule (61 FR 27499),
we discussed the factors and adjustments used to develop the FY 1997
Federal and hospital-specific rates. In particular, we discussed the FY
1997 exceptions payment reduction factor. This factor adjusts the
annual payment rates for the estimated percentage of additional
payments for exceptions in FY 1997. In the proposed rule, we estimated
that exceptions would equal 6.07 percent of aggregate payments based on
the Federal rate and the hospital-specific rate. We indicated that it
might be necessary to implement adjustments to the minimum payment
levels in the final rule and that it will almost certainly be necessary
to adjust the minimum payment levels for FY 1998. We therefore provided
public notification that adjustments to the minimum payment levels were
imminent, discussed our ideas on the most appropriate method for
adjusting the minimum payment levels, and solicited public comment.
We stated that, when it does become necessary to adjust the minimum
payment levels, we intended to adjust each of the existing levels (that
is, 90 percent for sole community hospitals, 80 percent for large urban
DSH hospitals, and 70 percent for all other
[[Page 46219]]
hospitals) by 5 percentage point increments until estimated exceptions
payments are within the 10 percent limit.
Current estimates indicate that we will not reach the 10 percent
exception limit in FY 1997. Therefore, we are not making adjustments to
the minimum payment levels at this time; the minimum payment levels for
exception payments will remain at the current levels.
We received several comments regarding the necessity and
methodology of adjustments to the minimum payment levels.
Comment: Some commenters objected to the proposed method for
handling necessary reductions to the minimum payment levels. One
commenter suggested that we develop a more sophisticated methodology
that would allow more refined adjustment of the minimum payment levels.
Another commenter suggested a 1 or 2 percent reduction increment,
rather than the proposed 5 percent increment.
Response: As stated above, in this final rule the minimum payment
levels for exception payments will remain at the current levels, since
our current forecasts indicate that we will not reach the 10 percent
limit in FY 1997. All comments received on this issue will be taken
under advisement and considered at such time as it becomes necessary to
make such an adjustment.
Comment: Some commenters believe that HCFA's capital acquisition
model (see appendix B to this final rule for a detailed discussion)
projects excessive growth in exception payments. These commenters
objected to any reduction in the capital minimum payment levels based
on projected rapid growth in exceptions and requested further
explanation. The commenters further stated that they could not
understand why exception payments would be so large when average
payments exceed costs.
Response: Since payments under the capital prospective payment
system are based on averages, not on an individual hospital's costs,
some hospitals may receive payments exceeding their costs, while other
hospitals may receive payments less than their costs. Even if aggregate
payments exceed aggregate costs, some hospitals may have costs so much
higher than payments that they qualify for large exceptions payments.
It is these large exceptions payments that are driving the
aggregate exception payments toward the 10 percent ceiling on exception
payments. We have reviewed the cost reports for the first 3 years under
the capital prospective payment system. The number of hospitals
receiving exceptions payments and the aggregate amount paid for
exceptions have increased each year. We expect this trend to continue
throughout the transition period, as some hospitals' payments deviate
even more from their actual costs. Our model is consistent with these
findings. The model projects, as expected, that exceptions payments
will continue to grow.
``Low cost'' hospitals are paid a blend of their hospital-specific
rate, and a higher Federal rate. ``High cost'' hospitals are paid 85
percent of their old capital plus their ratio of new capital to total
capital applied to the Federal rate. In both cases, the capital the
hospitals had at the time the capital prospective payment system was
implemented is addressed by the standard payments.
Capital prospective payment rates for FY 1992 were designed to
adequately address capital costs that existed at the time the
prospective payment system began. Since then, hospitals have acquired
additional capital, with some hospitals acquiring more than others.
With each passing year, more additional capital is accumulated. In some
cases, this additional capital is large, and the affected hospitals'
capital costs greatly exceed their standard payments. Exceptions
payments mitigate the financial impact on these hospitals.
High cost hospitals are more likely to qualify for exceptions
payments. Their old capital costs are encompassed in the hold harmless
payments, while their new capital costs are reimbursed at a fraction of
the Federal rate. If their new capital costs are high, these high cost
hospitals will need the full benefit of the exceptions process. Since
high cost hospitals will acquire more additional capital over time,
more hospitals will qualify for exceptions payments. In fact, high cost
hospitals showed rapid growth in exceptions in the first three years
under the capital prospective payment system. We expect this rapid
growth to continue.
Comment: Regarding minimum payment levels, one commenter suggested
we reconcile exceptions payments retrospectively and recoup any
overpayments on a pro rata basis by reducing future payments to
hospitals. The commenter recommends reductions in subsequent Medicare
payments to hospitals.
Response: Section 412.348(d) states that ``Total estimated 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.'' (Emphasis added.)
We believe reconciling actual exceptions payments with estimated
exceptions payments on a retroactive basis would fundamentally
undermine the prospectivity of the system. Moreover, recouping
``overpayments'' on a retroactive basis may be potentially unfair to
individual hospitals. An individual hospital that qualifies for an
exception payment in one year may not also qualify for an exception in
the later year in which a ``retroactive'' exception payment is to be
made. Hospitals would not be able to predict the effects of retroactive
adjustments to supposedly prospective payment rates.
VII. 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.
As discussed in the proposed rule (61 FR 27481), we understand 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
[[Page 46220]]
any adjustments granted to the hospital) or the adjusted ceiling.
To address any confusion about these issues, we proposed to revise
Sec. 413.40(d)(3) to indicate specifically 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 received only two comments on this proposal. Both commenters
supported the proposal, and we will adopt as final the proposed changes
to the regulations at Sec. 413.40(d)(3).
VIII. ProPAC Recommendations
As required by law, we reviewed the March 1, 1996 report submitted
by ProPAC to Congress and gave its recommendations careful
consideration in conjunction with the proposals set forth in the
proposed rule. We also responded to the individual recommendations in
the proposed rule (61 FR 27482). The comments we received on the
treatment of the ProPAC recommendations are set forth below along with
our responses to those comments. However, if we received no comments
from the public concerning a ProPAC recommendation, we have not
repeated the recommendation and response in the discussion below. The
update factors for inpatient operating costs and the update factor for
hospitals excluded from the prospective payment system and distinct-
part units (ProPAC recommendations 10 and 12, respectively) are
discussed in Appendix E to this final rule. Capital payment rates
(recommendation 11) are discussed in section VI of this final rule.
Disproportionate share hospitals (recommendations 17 and 18) are
discussed in section V of this final rule. The remaining
recommendations on which we received comments are discussed below.
A. 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 the Proposed Rule: 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 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.
Comment: We received several comments on this response. ProPAC
repeated its concern that redefining transfers may not be the right
approach, indicating that ``(m)ore needs to be known about the
relationships among these services before implementing a policy that
assumes that hospitals are being overpaid for cases who use post-acute
care.'' Two other commenters expressed their objections to the
redefinition of transfers from acute care hospitals. Generally, both of
these commenters agreed with ProPAC's assessment that this would lead
to longer inpatient stays and discourage the use of postacute care.
Also, both commenters objected to ProPAC's suggestion that HCFA bundle
acute and postacute care payments. Finally, one commenter recommended
that ``the total Medicare funding for hospitals be reduced to recognize
the shift of patient days away from the hospital setting.''
Response: We agree with ProPAC that a better understanding of this
phenomenon is needed, and we are well aware of the improved efficiency
claims made by those who advocate even greater use of postacute care.
However, while we continue to explore potential refinements to reflect
the shift in services from acute to postacute settings, we believe it
is appropriate to concurrently explore interim measures for responding
to the undisputed trends showing continuing declining lengths of
hospital inpatient stays and increasing postacute care utilization,
particularly for certain DRGs. The present overlaps between our acute
and postacute payment methodologies demand immediate attention, given
our responsibility for preserving the Medicare Trust Fund.
We also understand the commenters' concerns about the transfer
redefinition. In evaluating any such interim measures two fundamental
questions need to be answered: Will this approach protect
beneficiaries' access to quality, effective health care and will it
adequately compensate the providers of that care for their costs? To
the extent that increasing utilization of postacute care allows
hospitals to release patients earlier, redefining transfers would
better match payments with costs, as well as eliminate some of the
potential incentive for premature discharges.
With regard to the comments we received about ProPAC's suggestion
that bundling might be a potential alternative, we intend to continue
to evaluate all potential payment approaches. For example, implementing
an offset to the hospital inpatient standardized amounts to reflect
cost
[[Page 46221]]
shifting is another approach under examination.
B. 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 in the Proposed Rule: 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 the 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 Independence 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 function related groups (FRGs), which
are based on the 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 postacute 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 the prospective payment systems on one
hand, and the separate versus ``unified'' prospective payment systems
on the other hand.
Comment: One commenter strongly supported adoption of a prospective
payment system for inpatient rehabilitation and believes that the RAND
research project will likely produce such a system. The commenter noted
that we are considering initiating the collection of patient assessment
data in advance of legislation establishing a prospective payment
system and urged us to begin collecting the data at the earliest
possible date. The commenter believes that imposition of a reporting
requirement based on the FIM should not be a great burden on the
industry since rehabilitation hospitals and units are already using the
FIM or similar patient evaluation measures. Systematizing collection of
such data would expedite introduction of a prospective payment system
based on FRGs and would considerably reduce the 3-year minimum
implementation period suggested in HCFA's response in the proposed
rule. The commenter also urged, as a means toward developing a payment
system that is consistent across payment sites based on patient
characteristics, that HCFA expand the RAND research project to
determine the feasibility of using an FRG-based payment system for
rehabilitation patients in skilled nursing facilities.
[[Page 46222]]
Response: Since the collection of patient assessment data in
advance of legislation establishing a prospective payment system would
expedite implementation of the system, we are exploring whether we can
initiate the collection of data from rehabilitation facilities without
legislative action. Our estimate of 3 years to design and implement a
payment system includes beginning data collection at the earliest
possible time and continuing the collection over a period sufficient to
ensure the validity and stability of the components of a payment
system, such as payment rates, relative weights of patient groups,
outlier payments, and facility payment adjustments, in addition to
ensuring the validity of coding within and across hospitals.
We agree with the commenter that, as a step toward developing a
payment system that is consistent across delivery sites, it would be
desirable to explore the usefulness of FRGs in a payment system for
rehabilitation services in skilled nursing facilities. We will,
therefore, evaluate our ability to expand the RAND project given the
limits of available resources. We note that we are also engaged in
research on other case-mix measures for SNF and home health services
and we will investigate the suitability of these measures for
rehabilitation hospital services.
C. 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 in the Proposed Rule: 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 have funded a new home health case-mix study.
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 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.
Comment: One commenter agreed with ProPAC's recommendation to
develop a unified case-mix prospective payment system for postacute
care, but expressed concern that such a prospective payment system
based on ICD-9-CM codes will require the development of uniform coding
guidelines that do not currently exist.
Response: We have not yet decided whether it would be appropriate
to use ICD-9-CM codes in connection with a postacute prospective
payment system. We will keep the overall concern of uniform coding
guidelines in mind as we progress in our evaluation of postacute
prospective payment.
D. 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 in the Proposed Rule: 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 Sec. 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 (Pub. L. 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
[[Page 46223]]
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 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.
Comment: One commenter and the Commission reiterated that ProPAC's
recommended update framework was appropriate. According to ProPAC, its
analysis suggests that input costs are rising and large productivity
gains may no longer be possible. Consequently, renal facilities may be
unable to continue to provide quality dialysis without some payment
increase.
Response: As discussed above, we recognize that an increase in the
composite payment rate may be appropriate in the future, but we believe
that any rate increase should be linked to implementation of the
revised conditions for coverage for ESRD facilities. Until such
implementation, we will continue to monitor facility costs and other
factors to determine if it is appropriate to recommend a payment rate
increase. At this time, the composite payment rate is set by statute.
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.
Therefore, in the proposed rule, we solicited public comment on each of
these issues for the information collection requirement discussed
below.
The only information collection or paperwork burden item contained
in the FY 1997 proposed or final rules 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 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 beneficiaries are aware of their discharge rights, we are
revising Sec. 489.27 to specify that a hospital must provide the notice
of discharge rights ``during the course of the hospital stay.'' We
estimated 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 approximately 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.
[[Page 46224]]
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. In our May 31,
1996 proposed rule, we published a list of data sets that are available
for purchase (61 FR 27490).
C. Waiver of Notice of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking for a rule to
provide a period for public comment. However, we may waive that
procedure if we find good cause that prior notice and comment are
impracticable, unnecessary, or contrary to public interest.
Most provisions of this final rule were directly addressed in the
May 31, 1996 proposed rule (61 FR 27444) or were made in response to
comments on that proposed rule. The only issue raised in this final
rule for which we have not provided an opportunity for notice and
comment concerns a recently enacted statutory provision. On April 26,
1996, Congress enacted the Omnibus Consolidated Rescissions and
Appropriations Act of 1996. Among other things, the new statute
requires that, for certain purposes, the Federal Government ``shall
deem accredited any postgraduate physician training program that would
be accredited but for the accrediting agency's reliance upon an
accreditation standard that requires an entity to perform an induced
abortion or require, provide, or refer for training in the performance
of induced abortions, or make arrangements for such training,
regardless of whether such standard provides exceptions or
exemptions.''
In this final rule, we are revising the regulations at Sec. 412.105
and Sec. 413.86 to conform the regulations to the new statutory
provision. We find good cause to waive the procedure for notice and
comment with respect to these conforming changes. We find that the
procedure for notice and comment is unnecessary because these technical
changes merely conform the regulations text to the express requirements
of the statute and do not involve an exercise of agency discretion;
moreover, delaying these technical changes would be contrary to the
public interest because any perceived discrepancy between the
regulations and the statute might cause confusion.
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 is amended as set forth below:
A. Part 412 is amended as follows:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102 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 G--Special Treatment of Certain Facilities Under the
Prospective Payment System for Inpatient Operating Costs
3. In Sec. 412.105, the introductory text of both paragraph (g)(1)
and paragraph (g)(1)(i) is republished and a new paragraph (g)(1)(i)(D)
is added to read as follows:
Sec. 412.105 Special treatment: Hospitals that incur indirect costs for
graduate medical education programs.
* * * * *
(g) Determining the total number of full-time equivalent residents
for cost reporting periods beginning on or after July 1, 1991.
(1) For cost reporting periods beginning on or after July 1, 1991,
the count of full-time equivalent residents for the purpose of
determining the indirect medical education adjustment is determined as
follows:
(i) The resident must be enrolled in an approved teaching program.
An approved teaching program is one that meets one of the following
requirements:
* * * * *
(D) Is a program that would be accredited except for the
accrediting agency's reliance upon an accreditation standard that
requires an entity to perform an induced abortion or require, provide,
or refer for training in the performance of induced abortions, or make
arrangements for such training, regardless of whether the standard
provides exceptions or exemptions.
* * * * *
Subpart L--The Medicare Geographic Classification Review Board
4. In Sec. 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
5. In Sec. 412.302, paragraph (d)(1) is revised and a new paragraph
(d)(4) is added to read as follows:
Sec. 412.302 Introduction to capital costs.
* * * * *
(d) Consistency in cost reporting--(1) General rule. For cost
reporting periods beginning on or after October 1, 1991, and before
October 1, 2001, the hospital must follow consistent cost finding
methods for classifying and allocating capital-related costs, except as
otherwise provided in paragraph (d)(4) of this section.
* * * * *
(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 is amended as follows:
[[Page 46225]]
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, under paragraph (b), the definition of
``Approved geriatric program'' is revised and a new paragraph (4) is
added to the definition of ``Approved medical residency program'' and 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.
* * * * *
(b) Definitions.
* * * * *
Approved geriatric program means a fellowship program of one or
more years in length that is approved by the Accreditation Council for
Graduate Medical Education (ACGME) under the ACGME's criteria for
geriatric fellowship programs.
Approved medical residency program * * *
(4) Is a program that would be accredited except for the
accrediting agency's reliance upon an accreditation standard that
requires an entity to perform an induced abortion or require, provide,
or refer for training in the performance of induced abortions, or make
arrangements for such training, regardless of whether the standard
provides exceptions or exemptions.
* * * * *
(g) * * *
(1) * * * For combined residency programs, an initial residency
period is defined as the time required for individual certification in
the longer of the 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)
Dated: August 23, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: August 23, 1996.
Donna E. Shalala,
Secretary.
[Note: The following addendum and appendixes will not appear in the
Code of Federal Regulations.]
Addendum--Schedule of Standardized Amounts Effective With
Discharges On or After October 1, 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 amounts and factors for
determining prospective payment rates for Medicare inpatient operating
costs and Medicare inpatient capital-related costs. We are also setting
forth 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 making changes in the
determination of the prospective payment rates for Medicare inpatient
operating costs. The changes, to be applied prospectively, will affect
the calculation of the Federal rates. In section III, we discuss
changes we are making in determining the prospective payment rates for
Medicare inpatient capital-related costs. Section IV sets forth our
changes for determining the rate-of-increase limits for hospitals
excluded from the prospective payment system. The tables to which we
refer in the preamble to this final rule are presented at the end of
this addendum in section V.
II. Changes to Prospective Payment Rates for Inpatient Operating
Costs for FY 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
[[Page 46226]]
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 are 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 standardized amounts set forth in Tables 1a and 1c
of section V of this addendum reflect--
Updates of 2.0 percent for all areas (that is, the market
basket percentage increase of 2.5 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 using a rebased market basket effective for
FY 1997. Based on the 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 establishing 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 also revising the discharged-weighted
national 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 are
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
[[Page 46227]]
other standardized amount (as set forth in Table 1a). The national
average standardized amount for Puerto Rico is set forth in Table 1c.
This table also includes the two standardized amounts that will be
applicable to most hospitals in Puerto Rico.
We note that on June 28, 1996, the Office of Management and Budget
announced the designation of the Pocatello, Idaho MSA and the
Jonesboro, Arkansas MSA. In addition, Chester County was added to the
Jackson, Tennessee MSA. We have incorporated these changes in this
final rule.
3. Updating the Average Standardized Amounts
In accordance with section 1886(d)(3)(A)(iv) of the Act, we are
updating 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 rebased
hospital market basket increase for FY 1997 is 2.5 percent. For FY
1997, this yields an update to the average standardized amounts of 2.0
percent (2.5 percent minus 0.5 percent). (See section IV of the
preamble to this final 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 the FY 1997 offsets to the standardized amounts for outliers
and geographic reclassification, we estimate that there will be an
actual increase of 1.8 percent to the large urban and other area
standardized amounts.
We note that the FY 1996 standardized amounts reflected a budget
neutrality factor of 0.997575 to account for the change in transfer
payment policy implemented in FY 1996. See 60 FR 45854. In the proposed
rule we stated that ``there will be no need for a further budget
neutrality adjustment'' (61 FR 27573), but we incorrectly suggested
that the FY 1996 budget neutrality adjustment for transfers should be
removed in setting the FY 1997 rates. The budget neutrality adjustment
for the transfer policy is built permanently into the unadjusted rates.
Although the update factor for FY 1997 is set by law, we were
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
published the report to Congress as Appendix D to the proposed rule.
That recommendation was based on an earlier forecast of the market
basket increase. Our final recommendation on the update factors (which
is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set
forth as Appendix D to this final rule.
4. Other Adjustments to the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index--Budget
Neutrality Adjustment.--Section 1886(d)(4)(C)(iii) of the Act specifies
that beginning in FY 1991, the annual DRG reclassification and
recalibration of the relative weights must be made in a manner that
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 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 proposed budget
neutrality adjustment factor equal to 0.998509. Based on the final FY
1997 relative weights and wage index, the final budget neutrality
adjustment factor is 0.998703. 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 removed the
prior year adjustment, we would not satisfy this condition.
In addition, we will 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 indirect medical
education and disproportionate share payments) prior to any
reclassifications to total prospective payments after
reclassifications. In the proposed rule, we applied an adjustment
factor of 0.994059 to ensure that the effects of reclassification are
budget neutral. The
[[Page 46228]]
final budget neutrality adjustment factor is 0.993514.
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 reflected wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of March 14, 1996. The final budget neutrality
adjustment factor reflects the effects of all 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.
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. 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 proposed 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 also proposed to reduce the marginal
cost factor for each outlier day from 44 percent to 35 percent in FY
1997. The thresholds that we are establishing in this final rule will
be the geometric mean length of stay for each DRG plus the lesser of 24
days or 3.0 standard deviations. Based on updated simulations, we are
establishing in this final rule a marginal cost factor of 33 percent
for each outlier day in FY 1997. We estimate that these policies will
reduce the proportion of outlier payments paid to day outliers to
approximately 8 percent, in accordance with section 1886(d)(5)(A) of
the Act.
In the proposed rule, we proposed to maintain the marginal cost
factor for cost outliers at 80 percent and proposed 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 this
final rule, based on simulations using updated data and a revised cost
inflation factor (discussed below), we are establishing a fixed loss
cost outlier threshold in FY 1997 equal to the prospective payment rate
for the DRG plus $9,700 ($8,850 for hospitals that have not yet entered
the prospective payment system for capital-related costs). We are also
establishing a marginal cost factor for cost outliers of 80 percent, as
proposed. We note that the FY 1997 cost outlier calculations are to be
completed using the revised labor/nonlabor shares discussed above in
section II.A.1 in this Addendum.
The final FY 1997 cost outlier threshold reflects a revised cost
inflation factor. As explained in the proposed rule, in setting the
proposed FY 1997 cost outlier threshold, we used a cost inflation
factor of 0.0 percent to simulate payments using FY 1995 hospital bills
(61 FR 27497). That is, to determine when a case should qualify for
cost outlier payments in FY 1997, we calculated FY 1997 ``costs'' for
each bill in the FY 1995 MedPAR file by applying a cost inflation
factor of 0.0 percent. We indicated that we would reevaluate this
factor in developing the final rule.
The latest available Medicare cost reports indicate that hospital
cost per case decreased from FY 1993 to FY 1994 as well as from FY 1994
to FY 1995. Cost report data for 4,600 hospitals for cost reporting
periods beginning in FYs 1993 and 1994 show that cost per case
decreased 1.906 percent from FY 1993 to FY 1994. Preliminary data for
cost reports beginning in FY 1995, which were unavailable when we
developed the proposed rule, show that cost per case decreased 2.392
percent from FY 1994 to FY 1995. The latter figure is preliminary to
the extent that it reflects only 1,800 hospitals and also reflects ``as
submitted'' cost reports. Nevertheless, it suggests a continued trend
in cost deflation. Accordingly, based on the more complete data for
hospital cost reporting periods beginning in FYs 1993 and 1994, we have
decided to use a cost inflation factor of minus 1.906 percent (a cost
per case decrease of 1.906 percent) for purposes of setting the final
FY 1997 outlier thresholds (as compared with our proposed FY 1997 cost
inflation factor of 0.0 percent). We note that this is the first time
we have deflated costs in making the outlier projection.
The use of a negative cost inflation factor results in lower FY
1997 ``costs'' for the set of cases analyzed. For example, if a bill in
the FY 1995 MedPAR file reflects FY 1995 ``costs'' of $1,000, the FY
1997 ``costs'' will be
$1,000 x (1-0.01906) x (1-0.01906)
(reflecting 2 years of cost deflation), or $962.24. These lower costs,
in turn, result in a lower cost outlier threshold relative to a
methodology using a positive or zero cost inflation factor (other
things being equal). As stated above, the final FY 1997 cost outlier
threshold is the DRG amount plus $9,700, rather than $11,050 as
indicated in the proposed rule.
[[Page 46229]]
In accordance with section 1886(d)(5)(A)(iv) of the Act, we
calculated 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 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 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.
The proposed outlier adjustment factors applied to the standardized
amounts and the capital Federal rate for FY 1997 were as follows:
------------------------------------------------------------------------
Operating standardized amounts Capital Federal rate
------------------------------------------------------------------------
0.948968.................................. 0.9476
------------------------------------------------------------------------
The final outlier adjustment factors applied to the standardized
amounts and the capital Federal rate for FY 1997 are as follows:
------------------------------------------------------------------------
Operating standardized amounts Capital Federal rate
------------------------------------------------------------------------
0.948766.................................. 0.9481
------------------------------------------------------------------------
As in the proposed rule, we apply the final 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 will 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 will be used to calculate cost outlier payments
for those hospitals for which the intermediary computes operating cost-
to-charge ratios lower than 0.24265 or greater than 1.28879 and capital
cost-to-charge ratios lower than 0.013243 or greater than 0.19730. 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 will 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 proposed rule, we estimated 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). This percentage was computed by simulating payments using
actual FY 1995 bill data available at the time of the proposed rule.
Our current estimate is that actual outlier payments for FY 1995 were
approximately 3.8 percent of actual total DRG payments. These estimates
are based on simulations using the July 1996 update of the provider-
specific file and the June 1996 update of the FY 1995 MedPAR file.
In the proposed rule, we estimated that actual outlier payments for
FY 1996 would 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). We currently estimate that FY 1996 outlier payments will
approximate 4.0 percent of total DRG payments. This current estimate is
based on simulations using the July 1996 update of the provider-
specific file and the June 1996 update of the FY 1995 MedPAR file. We
used these data to calculate an estimate of the actual outlier
percentage for FY 1996 by applying FY 1996 rates and policies to the FY
1995 bills.
In the proposed rule, we discussed in detail our methodology for
setting outlier thresholds, our periodic refinements to that
methodology, and some possible explanations for the recent differences
between projected and actual outlier percentages (61 FR 27496). We
invited comments and suggestions for further refinements to the
methodology. The comments on our outlier policies and methodology and
our responses are set forth below.
Comment: A number of commenters are concerned that the percentages
of actual outlier payments for FYs 1995 and 1996 are lower than we
projected when we set the respective thresholds for those years. Some
commenters requested that we monitor outlier payments during a fiscal
year, so that we can change the thresholds in the middle of the year in
the event that projected actual outlier payments are not between 5 and
6 percent of projected actual total DRG payments. Other commenters
requested that any difference between outlier payments and the amount
set aside be used to offset the amount required in the next year. One
commenter argued that it is fundamentally inequitable, even assuming
that it is not illegal, not to make additional outlier payments after
the end of the fiscal year to assure that we meet our 5.1 percent goal.
The commenter cited historical figures on outlier payments from a
pending court case in the United States District Court for the District
of Columbia, County of Los Angeles v. Shalala, C.A. No. 93-0146 SSH
(D.D.C).
Response: We have responded to similar comments a number of times,
including the final rules for FY 1993 (57 FR 39784), FY 1994 (58 FR
46347), FY 1995 (59 FR 45408), and FY 1996 (60 FR 45856). As we have
explained before and as explained below, we believe our outlier
policies are consistent with the statute and the goals of the
prospective payment system and are not inequitable.
In accordance with section 1886(d)(5)(A)(iv) of the Act, we set
outlier thresholds before a fiscal year so that outlier payments for
the fiscal year are projected to be 5.1 percent of total DRG payments.
In doing so, we use the best available Medicare discharge data and
hospital-specific data.
Many of the factors used to set prospective payment amounts for a
given fiscal year are based on estimates. These factors include not
only the outlier thresholds, but also the market basket rate of
increase used to establish
[[Page 46230]]
the update factors, the recalibration of the DRG weights, and the
various required budget neutrality provisions. We do not believe that
Congress intended for us to revise these factors in midyear. Similarly,
we do not believe that Congress intended that the standardized amounts
for a given fiscal year should be adjusted (upward or downward) to
reflect any difference between projected and actual outlier payments
for a past fiscal year. Payments for a given discharge in a given
fiscal year are generally intended to reflect or address the average
costs of that discharge in that year; that goal would be undermined if
we adjusted prospective payment system payments to account for
``underpayments'' or ``overpayments'' in other years.
Moreover, the midyear or retroactive adjustments contemplated by
the commenters would be extremely difficult or impracticable (if not
impossible) to administer. Hospital bill data with respect to a given
fiscal year continues to be added to the MedPAR file for some time
after the end of the fiscal year. (We update the MedPAR file for 2 full
years after the end of the respective fiscal year.) Therefore, precise
figures on actual outlier payments for a given fiscal year cannot be
determined until well after that fiscal year ends. We do publish
estimates of ``actual'' outlier payments for recent fiscal years, but
those estimates are based on available bills (and sometimes based on
simulations using bills for a previous year, adjusted for estimates of
inflation).
In short, we believe our outlier policies are consistent with the
statute and the goals of the prospective payment system. In a recent
court decision, the United States District Court for the Central
District of California upheld the agency's interpretation of the
statute as reasonable, writing in part that ``[a]ny retroactive
adjustment would be inconsistent with [prospective payment system]
because the incentives for cost reduction and efficiency would be
eliminated.'' Alvarado Community Hospital v. Shalala, Case No. CV 94-
0972 RMT (Ex) (C.D. Cal May 6, 1996), appeal filed, No. 96-55967 (9th
Cir.). (There is pending litigation on the same issues in the U.S.
District Court for the District of Columbia.)
Finally, we do not agree that our outlier policies are
fundamentally inequitable. As we discussed in the proposed rule, we
believe that one reason outlier payments have been lower than expected
is that hospital costs are not increasing at the rate we expected, and
costs may even be decreasing. Available data show that, beginning in FY
1994, for the first time since the inception of the prospective payment
system, hospitals are experiencing actual decreases in cost per case
from one year to the next. This information is confirmed by ProPAC in
its June 1996 Report to Congress ``Medicare and the American Health
Care System'' (Table 3-3, Annual Change in PPS Operating Costs and
Payments, First 11 Years of PPS, p. 65). These actual decreases in cost
per case follow a period of several years in which the rate of increase
in operating cost per case declined from one year to the next.
The thresholds for a given fiscal year reflect a certain level of
costs, so if hospitals are generally holding costs down, then fewer
cases qualify for outlier payments and outlier payments are lower than
expected. But if lower hospital costs result in lower than expected
outlier payments, it also results in higher than expected ``profits''
(at least with respect to nonoutlier cases). Hospital, Medicare profit
margins have rebounded to levels not seen since the middle of the
1980s. In the June 1996 report, ProPAC found the aggregate prospective
payment system operating margin to be 6.0 percent for FY 1994 (Figure
3-2, Aggregate PPS Operating Margin, First 13 Years of PPS p. 68).
ProPAC believes that aggregate prospective payment system margins are
even higher for FYs 1995 and 1996.
Therefore, we believe that ``underpayments'' for outliers are not
fundamentally inequitable because one factor contributing to this
result--lower hospital costs--results in ``overpayments'' with respect
to the standard DRG payments. We do not make retroactive adjustments to
the standard DRG payments to account for the effect of actual costs
being lower than expected; similarly, we do not make retroactive
adjustments to outlier payments.
As we have stated previously, we believe the more appropriate
action for addressing outlier payments is to continue to examine the
outlier policy and try to refine our estimation methodology.
Comment: Two commenters stated that, after modeling the outlier
payments, they were able to replicate HCFA's result of 5.1 percent for
operating outlier payments, but that their analysis yielded only 4.8
percent for capital outlier payments as compared with HCFA's result of
5.2 percent.
Response: We have determined that the methodology used by the
commenters contained several technical errors.
Comment: Two commenters requested that we develop an econometric
hospital cost model to help us predict the cost inflation factors used
for purposes of setting outlier thresholds.
Response: Currently, we calculate the cost inflation factor used to
set outlier thresholds by analyzing hospital cost report data on cost
per case for recent cost reporting periods. The nature of the
econometric cost model contemplated by the commenters is not entirely
clear to us, but we are interested in exploring such an approach and
welcome specific suggestions for developing an econometric model. We
believe such an approach might be helpful if the model could analyze
data that are more recent than the data available in hospital cost
reports.
We did not receive any specific suggestions for refinements to our
outlier estimation methodology. We note that one commenter believes
that the 0.0 percent cost inflation factor reflected in the proposed
rule is warranted. As explained above, in this final rule, we are using
a cost inflation factor of minus 1.906 percent to further reflect the
decreases in cost per case.
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 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.
[[Page 46231]]
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 are adjusting 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.
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 will 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 increasing the hospital-specific rates by 2.0 percent
(the hospital market basket percentage increase of 2.5 percent 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 will be
calculated by multiplying a hospital's hospital-specific rate for the
preceding fiscal year by the applicable update factor (2.0 percent),
which is the same as the update for all prospective payment hospitals.
In addition, the hospital-specific rate will be adjusted by the budget
neutrality adjustment factor (that is, 0.998703) as discussed in
section II.A.4.a of this addendum. This resulting rate will 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 1c, section V of the addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate wage index (see Tables 4a and 4b, section V
of the addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount.
Step 4--Multiply the result in Step 3 by 75 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
b. National Rate.--The national prospective payment rate is
determined as follows:
Step 1--Multiply the labor-related portion of the national average
standardized amount (see Table 1c, section V of the addendum) by the
appropriate wage index.
[[Page 46232]]
Step 2--Add the amount from Step 1 and the nonlabor-related portion
of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 25 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Changes to Payment Rates for Inpatient Capital-Related Costs
for FY 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 based on an increasing
proportion of the capital prospective payment system Federal rate and a
decreasing proportion of the 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 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
additional payments under the Federal rate for outlier cases,
determined as a proportion of 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 additional
payments made for exceptions under Sec. 412.348, and
Sec. 412.308(c)(4)(ii) requires that the Federal rate be adjusted so
that the annual DRG reclassification and the recalibration of DRG
weights and changes in the geographic adjustment factor are budget
neutral. For FY 1992 through FY 1995, Sec. 412.352 required that the
Federal rate also be adjusted by a budget neutrality factor so that
estimated aggregate payments for inpatient hospital capital costs were
projected to equal 90 percent of the estimated payments that would have
been made for capital-related costs on a reasonable cost basis during
the fiscal year. 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 consists
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 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 was $461.96. In the proposed rule, we
stated that the proposed FY 1997 Federal rate was $441.84. In this
final rule, we are establishing an FY 1997 Federal rate of $438.92.
In the discussion that follows, we explain the factors that were
used to determine the FY 1997 Federal rate. In particular, we explain
why the FY 1997 Federal rate has decreased 4.99 percent compared to the
FY 1996 Federal rate. We also explain that capital payments per case
are estimated to increase by 3.92 percent. Taking into account the
effects of increases in projected discharges, we estimate that
aggregate capital payments will increase 6.77 percent.
The major factor contributing to the decrease in the FY 1997 rate
in comparison to FY 1996 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 are 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 6.77 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 3.92
percent in FY 1997 compared to FY 1996.
1. Standard Federal Rate Update
Section 412.308(c)(1)(ii) has provided that the standard Federal
rate is updated based on an analytical framework that takes into
account changes in a capital input price index and other factors. The
update framework consists of a capital input price index and several
policy adjustment factors. Specifically, we have adjusted the projected
CIPI rate of increase as appropriate each year for
[[Page 46233]]
case-mix index related changes, for intensity, and for errors in
previous CIPI forecasts. The proposed rule reflected an update factor
of 1.0 percent, based on the data available at the time. The final
update factor for FY 1997 under that framework is 0.7 percent. This
update factor is based on a projected 1.3 percent increase in the CIPI,
and on policy adjustment factors of -0.6 percent. We explain the basis
for the FY 1997 CIPI projection in section IV.B of the preamble to this
final 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 now estimate that real case-mix increase will be 1.0
percent in FY 1997. In previous years, we have assumed that real case
mix will increase at about 1.0 percent per year. We expect this pattern
to continue. The final net adjustment for case-mix change in FY 1997 is
therefore 0.6 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. Without 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 5-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,
FY 1992 and FY 1995, 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 1995.
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
1.0 percent for FY 1995, we estimate that case-mix constant intensity
declined by an average 1.1 percent during FY 1991 through FY 1995, for
a cumulative decrease of 5.3 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 1.4 percent for FY 1995, we estimate
that case-mix constant intensity declined by an average 1.2 percent
during FY 1991 through FY
[[Page 46234]]
1995, for a cumulative decrease of 5.8 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 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
additional payments under the Federal rate for outlier cases,
determined as a proportion of inpatient capital-related payments under
the Federal rate. The outlier thresholds are set so that estimated
outlier payments are 5.1 percent of estimated total DRG payments. The
inpatient capital-related outlier reduction factor is then set
according to the estimated inpatient capital-related outlier payments
that would be made if all hospitals were paid according to 100 percent
of the Federal rate. For purposes of calculating the outlier thresholds
and the outlier reduction factor, we model all hospitals as if paid 100
percent of the Federal rate because, as explained above, outlier
payments are made only on the portion of the Federal rate that is
included in the hospital's inpatient capital-related payments.
In the September 1, 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 the
addendum, we estimate that outlier payments will equal 5.19 percent of
inpatient capital-related payments based on the Federal rate in FY
1997. We are, therefore, applying an outlier adjustment factor of
0.9481 to the Federal rate. Thus, estimated capital outlier payments
for FY 1997 represent a higher percentage of total capital 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 net change in the outlier adjustment to
the Federal rate for FY 1997 is 0.9942 (.9481/.9536). Thus, the outlier
adjustment decreases the FY 1997 Federal rate by 0.58 percent (1-
0.9942) 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 estimated 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 equal estimated aggregate payments that would have
been made based on 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. In the proposed rule for FY 1997, we proposed a GAF/DRG budget
neutrality factor of 0.9992. In this final rule, based on calculations
using updated data, we are applying a factor of 0.9987 to meet this
requirement. The GAF/DRG budget neutrality factors are built
permanently into the rates; that is, they are applied cumulatively in
determining the Federal rate. This follows from the requirement that
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
incremental change in the adjustment from FY 1996 to FY 1997 is 0.9987.
The cumulative change in the rate due to this adjustment is 1.0012 (the
product of the incremental factors for FY 1993, FY 1994, FY 1995, FY
1996, and FY 1997: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9987 =
1.0012).
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 additional payments for exceptions under
Sec. 412.348 determined as a proportion of total payments under the
hospital-specific rate and Federal rate. We use the model originally
developed for determining the budget neutrality adjustment factor to
estimate payments under the exceptions payment process and to determine
the exceptions payment adjustment factor. We describe that model in
Appendix B to this final 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-.0151) in determining the Federal rate. For FY
1997, we estimated in the May 31, 1996, proposed rule that exceptions
payments would equal 6.07 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. Therefore, we proposed to
apply an exceptions reduction factor of 0.9393 (1-0.0607) to determine
the FY 1997 Federal rate. For this final rule, we estimate that
exceptions payments for FY 1997 will equal 6.42 percent of aggregate
payments based on the Federal rate and the hospital-specific rate. We
are, therefore, applying an exceptions payment reduction factor of
0.9358 to the Federal rate for FY 1997.
The final exceptions reduction factor for FY 1997 is thus 4.99
percent lower than the factor for FY 1996, and 0.37 percent lower than
the factor in the FY 1997 proposed rule. As we have stated before, 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 net adjustment to the FY 1997 Federal
rate is 0.9358/0.9849, or 0.9501.
[[Page 46235]]
5. Standard Capital Federal Rate for FY 1997
For FY 1996, the capital Federal rate was $461.96. With the changes
we proposed to the factors used to establish the Federal rate, we
proposed that the FY 1997 Federal rate would be $441.84. In this final
rule, we are establishing an FY 1997 Federal rate of $438.92. The final
Federal rate for FY 1997 was calculated as follows:
The FY 1997 update factor is 1.0070, that is, the update
is 0.70 percent.
The FY 1997 outlier adjustment factor is 0.9481.
The FY 1997 budget neutrality adjustment factor applied to
the standard Federal payment rate for changes in the DRG relative
weights and in the geographic adjustment factor is 0.9987.
The FY 1997 exceptions payments adjustment factor is
0.9358.
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 are making 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 final FY 1997
Federal rate in comparison to the FY 1996 Federal rate. The final FY
1997 update factor increases the Federal rate 0.70 percent compared to
the rate in FY 1996, while the final geographic and DRG budget
neutrality factor decreases the Federal rate by 0.13 percent. The final
FY 1997 outlier adjustment factor decreases the Federal rate by 0.58
percent compared to FY 1996. The final FY 1997 exceptions reduction
factor decreases the Federal rate by 4.99 percent compared to the
exceptions reduction for FY 1996. The combined effect of all the
changes is to decrease the Federal rate by 4.99 percent compared to the
Federal rate for FY 1996.
Comparison of Factors and Adjustments: FY 1996 Federal Rate and FY 1997 Federal Rate
----------------------------------------------------------------------------------------------------------------
Change Percent change
----------------------------------------------------------------------------------------------------------------
Update factor \1\:
FY 1996............................................ 1.0120 ................. .................
FY 1997............................................ 1.0070 1.0070 0.70
GAF/DRG adjustment factor \1\:
FY 1996............................................ 0.9994 ................. .................
FY 1997............................................ 0.9987 0.9987 -0.13
Outlier adjustment factor \2\:
FY 1996............................................ 0.9536 ................. .................
FY 1997............................................ 0.9481 0.9942 -0.58
Exceptions adjustment factor \2\:
FY 1996............................................ 0.9849 ................. .................
FY 1997............................................ 0.9358 0.9501 -4.99
Federal Rate:
FY 1996............................................ $461.96 ................. .................
FY 1997............................................ $438.92 0.9501 -4.99
----------------------------------------------------------------------------------------------------------------
\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 0.9987 GAF/DRG
budget neutrality factor for FY 1997 is 0.9987.
\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 0.9358/0.9849, or 0.9501.
We are also providing a chart that shows how the final FY 1997
Federal rate differs from the proposed FY 1997 Federal rate.
This chart shows the factors that contributed to the 0.66 percent
decrease in the rate since the proposed rule. The update factor
decreased 0.30 percent since the proposed rule. Another change since
the proposed rule is seen in the exceptions reduction factor,
decreasing 0.37 percent from the earlier estimate. The GAF/DRG
reduction factor decreased only 0.05 percent since the proposed rule
and the outlier reduction factor increased 0.05 percent since the
proposed estimate.
Comparison of Factors and Adjustments: Proposed FY 1997 Federal Rate and Final FY 1997 Federal Rate
----------------------------------------------------------------------------------------------------------------
Net adjustment Percent change
----------------------------------------------------------------------------------------------------------------
Update factor:
Proposed FY 1997................................... 1.0100 ................. .................
Final FY 1997...................................... 1.0070 0.9970 -0.30
Outlier reduction factor:
Proposed FY 1997................................... 0.9476 ................. .................
Final FY 1997...................................... 0.9481 1.0005 0.05
GAF/DRG reduction factor:
Proposed FY 1997................................... 0.9992 ................. .................
Final FY 1997...................................... 0.9987 0.9995 -0.05
Exceptions reduction factor:
Proposed FY 1997................................... 0.9393 ................. .................
Final FY 1997...................................... 0.9358 0.9963 -0.37
Federal rate:
Proposed FY 1997................................... $441.84 ................. .................
Final FY 1997...................................... $438.92 0.9934 -0.66
----------------------------------------------------------------------------------------------------------------
[[Page 46236]]
6. Special Rate for Puerto Rico Hospitals
For FY 1996, the special rate for Puerto Rico hospitals was
$355.35. With the changes we proposed to the factors used to determine
the rate, the proposed FY 1997 special rate for Puerto Rico was
$339.87. In this final rule, the FY 1997 capital rate for Puerto Rico
is $337.63.
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, the hospital-specific rate will be
updated by a factor of 1.0070.
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 estimated in the proposed
rule that exceptions payments would be 6.07 percent of aggregate
payments based on the Federal rate and the hospital-specific rate. We
therefore proposed that the updated hospital-specific rate be reduced
by a factor of 0.9393. In this final rule, we estimate that exceptions
payments will be 6.42 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. We are therefore applying
an exceptions reduction factor of 0.9358 to the hospital-specific rate.
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 net adjustment to the FY
1997 hospital-specific rate is 0.9358/0.9849, or 0.9501.
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 cumulative
net adjustment from FY 1996 to FY 1997 is 0.9568, which represents a
decrease of 4.32 percent to the hospital-specific rate. The FY 1997
hospital-specific rate for each hospital is determined by multiplying
the FY 1996 hospital-specific rate by the cumulative net adjustment of
0.9568.
FY 1997 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
Net adjustment Percent change
----------------------------------------------------------------------------------------------------------------
Update factor:
FY 1996............................................ 1.0100 ................. .................
FY 1997............................................ 1.0070 1.0070 0.70
Exceptions payment adjustment factor:
FY 1996............................................ 0.9849 ................. .................
FY 1997............................................ 0.9358 0.9501 -4.99
Cumulative adjustments:
FY 1996............................................ 0.9947 ................. .................
FY 1997............................................ 0.9518 0.9568 -4.32
----------------------------------------------------------------------------------------------------------------
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 1.0070. In contrast, the exceptions
payment adjustment factor and the budget neutrality factor are not applied cumulatively. Thus, for example,
the incremental increase in the exceptions reduction factor from FY 1996 to FY 1997 is 0.9358/0.9849, or
0.9501.
C. Calculation of Inpatient Capital-Related Prospective Payments for FY
1997
During the capital prospective payment system transition period, a
hospital is paid for 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 is determined by adjusting:
For outliers by dividing the standard Federal rate by the
outlier reduction factor for that fiscal year; and,
For the payment adjustment factors applicable to the
hospital (that is, the hospital's geographic adjustment factor, the
disproportionate share adjustment factor, and the indirect medical
education adjustment factor, when appropriate).
If the hospital-specific rate is above the applicable Federal rate,
the hospital is paid under the hold-harmless methodology. If the
hospital-specific rate is below the applicable Federal rate, the
hospital is paid under the fully prospective methodology.
For purposes of calculating payments for each discharge under both
the hold-harmless payment methodology and the fully prospective payment
methodology, the standard Federal rate is adjusted as follows:
(Standard Federal Rate) x (DRG weight) x (Geographic Adjustment
Factor) x (Large Urban Add-on, if applicable) x (COLA adjustment
for hospitals located in Alaska and Hawaii) x (1 + Disproportionate
Share Adjustment Factor + Indirect Medical Education Adjustment Factor,
if applicable).
The result is termed the adjusted Federal rate.
Payments under the hold-harmless methodology are determined under
one 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
[[Page 46237]]
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
hospital's inpatient capital-related payments that is based on the
Federal rate. For fully prospective hospitals, that portion is 60
percent 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 based on 100 percent of the Federal rate, 100
percent of the Federal rate is included in the hospital's outlier
payments.
The outlier thresholds for FY 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 $9,700. 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 3 standard deviations of the length of stay or 24 days.
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 payments are less than a
minimum percentage of its allowable Medicare inpatient capital-related
costs. The minimum payment level is established by class of hospital
under Sec. 412.348. The minimum payment levels for portions of cost
reporting periods occurring in FY 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.
IV. Changes to Payment Rates for Excluded Hospitals and Hospital
Units
A. Rate-of-Increase Percentages for Excluded Hospitals and Hospital
Units
The inpatient operating costs of hospitals and hospital units
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of
the Act, which is implemented in Sec. 413.40 of the regulations. Under
these limits, an annual target amount (expressed in terms of the
inpatient operating cost per discharge) is set for each hospital, based
on the hospital's own historical cost experience trended forward by the
applicable rate-of-increase percentages (update factors). The target
amount is multiplied by the number of Medicare discharges in a
hospital's cost reporting period, yielding the ceiling on aggregate
Medicare inpatient operating costs for the cost reporting period.
Effective with cost reporting periods beginning on or after October
1, 1991, a hospital that has Medicare inpatient operating costs in
excess of its ceiling is paid its ceiling plus 50 percent of its costs
in excess of the ceiling. Total payment may not exceed 110 percent of
the ceiling. A hospital that has inpatient operating costs less than
its ceiling is paid its costs plus the lower of--
Fifty percent of the difference between the allowable
inpatient operating costs and the ceiling; or
Five percent of the ceiling.
Each hospital's target amount is adjusted annually, at the
beginning of its cost reporting period, by an applicable rate-of-
increase percentage. Section 1886(b)(3)(B) of the Act provides that for
cost reporting periods beginning on or after October 1, 1993 and before
October 1, 1994, the applicable rate-of-increase percentage is the
market basket percentage increase minus the lesser of 1 percentage
point or the percentage point difference between 10 percent and the
hospital's ``update adjustment percentage'' except for hospitals with
an ``update adjustment percentage'' of at least 10 percent. The rate-
of-increase percentage for hospitals in the latter case is the market
basket percentage increase. The ``update adjustment percentage'' is the
percentage by which a hospital's allowable inpatient operating costs
exceeds the hospital's ceiling for the cost reporting period beginning
in FY 1990. For cost reporting periods beginning on or after October 1,
1994 and before October 1, 1997, the update adjustment percentage is
the update adjustment percentage from the previous year plus the
previous year's
[[Page 46238]]
applicable reduction. The applicable reduction and applicable rate of
increase percentage are then determined in the same manner as for FY
1994. The most recent forecast of the market basket increase for FY
1997 for hospitals and hospital units excluded from the prospective
payment system is 2.5 percent.
B. Wage Index Exceptions for Excluded Hospitals and Units
In the August 30, 1991 final rule (56 FR 43232), we set forth our
policy for target amount adjustments for significant wage increases.
Effective with cost reporting periods beginning on or after April 1,
1990, significant increases in wages since the base period are
recognized as a basis for an adjustment in the target amount under
Sec. 413.40(g).
To qualify for an adjustment, the excluded hospital or hospital
unit must be located in a labor market area for which the average
hourly wage increased significantly more than the national average
hourly wage between the hospital's base period and the period subject
to the ceiling. We use the hospital wage index for prospective payment
hospitals to determine the rate of increase in the average hourly wage
in the labor market area. For a hospital to qualify for an adjustment,
the wage index value for the cost reporting period subject to the
ceiling must be at least 8 percent higher than the wage index based on
wage survey data collected for the base year cost reporting period. If
survey data are not available for one (or both) of the cost reporting
periods used in the comparison, the wage index based on the latest
available survey data collected before that cost reporting period will
be used. For example, to make the comparison between a 1983 base period
and a hospital's cost reporting period beginning in FY 1994, we would
use the rate of increase between the wage index based on 1982 wage data
and the wage index based on the FY 1993 data, since the FY 1993 data
are the most recent data currently available. Further, the comparison
is made without regard to geographic reclassifications made by the
MGCRB under sections 1886(d) (8) and (10) of the Act. Therefore, the
comparison is made based on the wage index value of the labor market
area in which the hospital is actually located.
We determine the amount of the adjustment for wage increases by
considering three factors for the time between the base period and the
period for which an adjustment is requested: the rate of increase in
the hospital's average hourly wage; the rate of increase in the average
hourly wage in the labor market area in which the hospital is located;
and, the rate of increase in the national average hourly wage for
hospital workers. The adjustment is limited to the amount by which the
lower of the hospital's or the labor market area's rate of increase in
average hourly wages significantly exceeds the national increase (that
is, exceeds the national rate of increase by more than 8 percent). For
purposes of computing the adjustment, the relative rate of increase in
the average hourly wage for the labor market area is assumed to have
been the same over each of the intervening years between the wage
surveys.
To determine the rate of increase in the national average hourly
wage, we use the average hourly earnings (AHE) component of the wages
and salaries portion of the market basket. This measure is derived from
the 1982-based market basket since the 1987-based market basket uses
the employment cost index (ECI) for hospital workers as the price proxy
for this component. Unlike the AHE, the ECI for hospital workers can be
measured historically only back to 1986. In addition, the ECI does not
adjust for skill-mix shifts and, therefore, measures only the change in
wage rates per hour.
The average hourly earnings for hospital workers as measured by the
market basket show the following increases:
1992 = 4.8 percent
1993 = 3.6 percent
1994 = 2.7 percent
1995 = 3.3 percent
1996 = 3.3 percent
1997 = 3.2 percent
We note that this section merely provides updated information with
respect to areas that would qualify for the wage index adjustment under
Sec. 413.30(g). This information was calculated in accordance with
established policy and does not reflect any change in that policy. The
geographic areas in which the percentage difference in wage indexes was
sufficient to qualify for a wage index adjustment are listed in Table
10 of section V of the addendum to this final rule. The table is
constructed with old MSAs instead of the revised MSAs effective October
1, 1993 because current adjustment requests are for years prior to FY
1995.
V. Tables
This section contains the tables referred to throughout the
preamble to this final rule and in this Addendum. For purposes of this
final rule, and to avoid confusion, we have retained the designations
of Tables 1 through 5 that were first used in the September 1, 1983
initial prospective payment final rule (48 FR 39844). Tables 1A, 1C,
1D, 3C, 4a, 4b, 4c, 4d, 4e, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B,
8A, 8B, and 10 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 06/95 GROUPER V13.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 95 MEDPAR Update 06/95 GROUPER V14.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) August 1996
Table 8B--Statewide Average Capital Cost-to-Charge Ratios for Urban and
Rural Hospitals (Case Weighted) August 1996
[[Page 46239]]
Table 10--Percentage Difference in Wage Indexes for Areas that Qualify
for a Wage Index Exception for Excluded Hospitals and Units
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Nonlabor- Labor- Nonlabor-
Labor-related related related related
------------------------------------------------------------------------
$2,782.84........................... $1,125.64 $2,738.79 $1,107.83
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National............................ $2,759.22 $1,116.09 $2,759.22 $1,116.09
Puerto Rico......................... 2,488.70 518.65 2,449.31 510.446
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................... $438.92
Puerto Rico................................................ 337.63
------------------------------------------------------------------------
[[Page 46240]]
Table 3c.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1995
Page 1 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
010001....................... 01.4404 14.82 010095.......... 00.9193 11.25 030004......... 01.0049 13.48 040003......... 01.0725 13.23 040106......... 01.2549 12.84
010004....................... 00.9693 11.10 010097.......... 00.9352 15.20 030006......... 01.5554 17.52 040004......... 01.4587 14.83 040107......... 01.1909 14.95
010005....................... 01.1626 15.40 010098.......... 01.1820 11.02 030007......... 01.3159 16.41 040005......... 01.0378 11.59 040109......... 01.1653 12.69
010006....................... 01.4724 15.23 010099.......... 01.1144 15.49 030008......... 02.0954 20.42 040007......... 01.8743 18.12 040114......... 01.8503 16.64
010007....................... 01.1025 13.12 010100.......... 01.1699 14.77 030009......... 01.2852 15.58 040008......... 01.0326 10.77 040116......... 01.3868 19.25
010008....................... 01.1344 09.54 010101.......... 01.1120 14.21 030010......... 01.4117 17.75 040010......... 01.2297 13.78 040118......... 01.1263 14.29
010009....................... 01.1393 14.82 010102.......... 00.9570 13.63 030011......... 01.5040 17.66 040011......... 00.9313 10.75 040119......... 01.0928 14.34
010010....................... 01.1289 14.33 010103.......... 01.7657 17.15 030012......... 01.2238 15.81 040014......... 01.1951 16.07 040124......... 01.2159 14.30
010011....................... 01.6182 18.94 010104.......... 01.6869 17.90 030013......... 01.2435 18.99 040015......... 01.1979 12.12 040126......... 00.9606 11.74
010012....................... 01.2658 16.27 010108.......... 01.1476 13.68 030014......... 01.4395 17.86 040016......... 01.7360 16.43 050002......... 01.5608 25.91
010015....................... 01.0576 15.63 010109.......... 01.0643 11.48 030016......... 01.2487 17.09 040017......... 01.2593 11.68 050006......... 01.3917 19.15
010016....................... 01.2642 16.76 010110.......... 01.0158 13.44 030017......... 01.5214 18.98 040018......... 01.1718 16.66 050007......... 01.5863 25.29
010018....................... 00.9019 16.19 010112.......... 01.1218 14.09 030018......... 01.7970 19.57 040019......... 01.1544 13.52 050008......... 01.5106 25.48
010019....................... 01.2853 14.99 010113.......... 01.6345 13.69 030019......... 01.2020 19.31 040020......... 01.5961 14.08 050009......... 01.7160 31.63
010021....................... 01.2330 12.20 010114.......... 01.3192 15.37 030022......... 01.5026 17.41 040021......... 01.2317 14.69 050013......... 01.8083 22.05
010022....................... 01.0214 16.89 010115.......... 00.8472 11.98 030023......... 01.2631 17.64 040022......... 01.6987 14.73 050014......... 01.1762 22.55
010023....................... 01.4798 14.71 010117.......... 00.8122 13.54 030024......... 01.7885 21.04 040024......... 01.1694 12.16 050015......... 01.3901 22.18
010024....................... 01.4003 15.62 010118.......... 01.2505 15.07 030025......... 01.1635 12.76 040025......... 00.9192 11.81 050016......... 01.1490 18.51
010025....................... 01.4321 13.16 010119.......... 01.4921 16.36 030027......... 01.0796 14.69 040026......... 01.5567 16.35 050017......... 02.0442 24.39
010027....................... 00.8360 13.55 010120.......... 00.9671 14.32 030030......... 01.6610 18.19 040027......... 01.2885 12.56 050018......... 01.3313 18.49
010029....................... 01.4936 14.84 010121.......... 01.2282 12.92 030033......... 01.2472 16.40 040028......... 01.0910 11.40 050021......... 01.4226 23.40
010031....................... 01.1845 14.58 010123.......... 01.2531 16.95 030034......... 01.0470 15.89 040029......... 01.2512 14.12 050022......... 01.4532 22.63
010032....................... 00.9480 12.45 010124.......... 01.2853 16.15 030035......... 01.3434 20.77 040030......... 00.8948 11.09 050024......... 01.3916 21.31
010033....................... 01.9155 17.61 010125.......... 01.0231 12.86 030036......... 01.1448 18.23 040032......... 01.0009 11.18 050025......... 01.7849 21.97
010034....................... 01.0754 13.48 010126.......... 01.1654 13.13 030037......... 02.0251 19.60 040035......... 01.0269 10.24 050026......... 01.4559 21.79
010035....................... 01.2416 15.13 010127.......... 01.2974 16.29 030038......... 01.6224 18.82 040036......... 01.4885 16.45 050028......... 01.4384 15.33
010036....................... 01.1248 15.34 010128.......... 00.9619 12.34 030040......... 01.1863 15.88 040037......... 01.1075 11.55 050029......... 01.3835 25.55
010038....................... 01.3476 16.70 010129.......... 01.0826 13.29 030041......... 00.9847 13.68 040039......... 01.2413 12.23 050030......... 01.3340 19.24
010039....................... 01.7027 16.14 010130.......... 01.0405 15.28 030043......... 01.1901 18.25 040040......... 01.0021 15.73 050032......... 01.2750 22.76
010040....................... 01.5324 18.21 010131.......... 01.3555 17.75 030044......... 01.0338 13.19 040041......... 01.3902 13.95 050033......... 01.4227 25.47
010043....................... 01.1075 10.35 010134.......... 00.9077 13.36 030046......... 00.9532 16.38 040042......... 01.2961 12.03 050036......... 01.6184 18.61
010044....................... 01.0952 11.01 010137.......... 01.2701 16.36 030047......... 00.9496 19.91 040044......... 00.9581 10.04 050038......... 01.4467 29.05
010045....................... 01.2215 10.79 010138.......... 00.9454 09.85 030049......... 00.9747 17.30 040045......... 01.0339 14.28 050039......... 01.6003 21.04
010046....................... 01.5270 15.51 010139.......... 01.6545 19.67 030054......... 00.8681 12.63 040047......... 01.0992 14.78 050040......... 01.0789 22.92
010047....................... 01.0203 10.05 010143.......... 01.1818 15.83 030055......... 01.2107 16.85 040048......... 01.2128 13.48 050041......... 02.8307 22.21
010049....................... 01.1130 15.66 010144.......... 01.3065 18.42 030059......... 01.2755 19.95 040050......... 01.1009 11.66 050042......... 01.3156 20.20
010050....................... 01.0631 13.48 010145.......... 01.3277 14.59 030060......... 01.2055 13.90 040051......... 01.0953 12.64 050043......... 01.5742 30.15
010051....................... 00.8526 10.24 010146.......... 01.1731 15.59 030061......... 01.6515 16.75 040053......... 01.1051 11.67 050045......... 01.2631 17.44
010052....................... 00.9891 12.78 010148.......... 00.9991 12.83 030062......... 01.2298 15.56 040054......... 01.0313 12.44 050046......... 01.1948 23.81
010053....................... 01.0623 12.67 010149.......... 01.3548 16.86 030064......... 01.6287 17.31 040055......... 01.4492 14.51 050047......... 01.6384 29.15
010054....................... 01.1715 16.17 010150.......... 01.0458 16.29 030065......... 01.6550 18.87 040058......... 01.0595 13.61 050051......... 01.1150 16.63
010055....................... 01.4799 16.35 010152.......... 01.5001 16.29 030067......... 01.0493 15.92 040060......... 00.9905 09.85 050054......... 01.1945 20.55
010056....................... 01.3958 17.99 010155.......... 01.0155 09.42 030068......... 00.9533 14.04 040062......... 01.6183 16.66 050055......... 01.3688 27.48
010058....................... 01.0940 12.96 020001.......... 01.4893 25.53 030069......... 01.3387 19.11 040063......... 01.4690 15.67 050056......... 01.3269 25.23
010059....................... 01.0172 14.17 020002.......... 01.0275 24.16 030071......... 00.9564 ....... 040064......... 01.0568 10.49 050057......... 01.4831 20.22
010061....................... 01.0121 14.70 020004.......... 01.1018 25.46 030072......... 00.8597 ....... 040066......... 01.1450 14.63 050058......... 01.4657 22.78
010062....................... 01.0056 13.45 020005.......... 00.9023 28.36 030073......... 00.9795 ....... 040067......... 01.0823 11.34 050060......... 01.5871 24.25
010064....................... 01.8006 17.85 020006.......... 01.1404 23.19 030074......... 00.8590 ....... 040069......... 01.1002 14.90 050061......... 01.4278 22.12
010065....................... 01.3671 14.30 020007.......... 00.8988 21.82 030075......... 00.8591 ....... 040070......... 00.9422 14.98 050063......... 01.4169 21.44
010066....................... 00.9765 10.87 020008.......... 01.1004 26.45 030076......... 00.9802 ....... 040071......... 01.5971 15.42 050065......... 01.6154 22.37
010068....................... 01.2347 18.82 020009.......... 00.9164 21.29 030077......... 00.8769 ....... 040072......... 01.0869 13.39 050066......... 01.2719 24.33
010069....................... 01.1593 13.06 020010.......... 00.9035 22.13 030078......... 01.0972 ....... 040074......... 01.2491 14.51 050067......... 01.3827 21.09
010072....................... 01.2165 12.72 020011.......... 01.0329 22.27 030079......... 00.7727 ....... 040075......... 01.0588 11.57 050068......... 01.0946 19.05
010073....................... 00.9681 09.66 020012.......... 01.3114 23.99 030080......... 01.6582 20.82 040076......... 01.0307 14.71 050069......... 01.6194 23.15
010078....................... 01.1765 15.50 020013.......... 01.0331 24.03 030083......... 01.3074 21.70 040077......... 00.9164 10.72 050070......... 01.2861 30.65
010079....................... 01.2797 13.72 020014.......... 01.0795 24.52 030084......... 00.9397 ....... 040078......... 01.4848 17.29 050071......... 01.3190 30.60
010080....................... 01.0410 12.99 020017.......... 01.5155 26.83 030085......... 01.5017 20.21 040080......... 01.0736 15.45 050072......... 01.3045 30.90
010081....................... 01.9870 16.16 020018.......... 00.8963 ....... 030086......... 01.3255 18.76 040081......... 00.9292 09.91 050073......... 01.3242 31.28
010083....................... 01.0482 13.25 020019.......... 00.8718 ....... 030087......... 01.6136 18.77 040082......... 01.2135 13.69 050074......... 01.2333 33.23
010084....................... 01.4758 16.64 020020.......... 00.8462 ....... 030088......... 01.3530 19.90 040084......... 01.0970 14.83 050075......... 01.4037 30.63
010085....................... 01.3193 17.11 020021.......... 00.8338 ....... 030089......... 01.5845 18.66 040085......... 01.2469 15.18 050076......... 01.7727 29.53
010086....................... 01.0497 13.54 020024.......... 01.0892 22.64 030092......... 01.5679 20.62 040088......... 01.3050 13.73 050077......... 01.6129 22.83
010087....................... 01.6125 16.88 020025.......... 01.0122 24.44 030093......... 01.3720 18.08 040090......... 00.8995 13.78 050078......... 01.3591 24.44
010089....................... 01.1896 15.13 020026.......... 01.3245 ....... 030094......... 01.2482 18.57 040091......... 01.2939 18.25 050079......... 01.5793 28.30
010090....................... 01.5738 16.40 020027.......... 01.0132 ....... 030095......... 01.2170 13.09 040093......... 00.9710 10.98 050080......... 01.2370 16.56
010091....................... 00.9216 13.43 030001.......... 01.3125 19.28 030098......... 00.9899 ....... 040095......... 00.9117 10.56 050081......... 01.6631 24.01
010092....................... 01.4203 15.35 030002.......... 01.8022 20.25 040001......... 01.1237 12.37 040100......... 01.2420 12.81 050082......... 01.5000 21.34
010094....................... 01.1427 16.76 030003.......... 01.8995 21.05 040002......... 01.1641 13.07 040105......... 01.0034 11.90 050084......... 01.5602 22.33
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 46241]]
Page 2 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050088....................... 01.1393 21.94 050188.......... 01.3477 25.25 050295......... 01.4128 20.86 050419......... 01.3115 18.88 050542......... 01.2233 13.79
050089....................... 01.3622 19.92 050189.......... 00.9734 21.50 050296......... 01.2084 22.69 050420......... 01.4349 25.15 050543......... 00.9225 21.68
050090....................... 01.2815 21.75 050191.......... 01.5035 20.64 050298......... 01.2991 20.77 050421......... 01.4202 24.62 050545......... 00.8302 20.39
050091....................... 01.2000 24.42 050192.......... 01.1398 18.74 050299......... 01.3639 22.49 050423......... 00.9862 19.25 050546......... 00.7201 21.10
050092....................... 00.8597 16.12 050193.......... 01.3513 22.56 050300......... 01.3143 18.87 050424......... 01.8327 22.16 050547......... 00.9283 20.65
050093....................... 01.5911 22.35 050194.......... 01.2422 25.03 050301......... 01.3882 21.54 050425......... 01.2730 30.30 050549......... 01.7151 25.86
050096....................... 01.1293 12.95 050195.......... 01.5895 31.26 050302......... 01.4072 24.31 050426......... 01.3016 23.89 050550......... 02.3039 23.34
050097....................... 01.4914 18.40 050196.......... 01.4171 16.40 050305......... 01.5823 29.82 050427......... 00.9243 18.44 050551......... 01.3441 24.20
050099....................... 01.4623 22.91 050197.......... 01.8264 29.07 050307......... 01.4384 20.51 050430......... 00.9414 15.94 050552......... 01.1681 22.44
050100....................... 01.7458 29.38 050199.......... 00.8980 19.48 050308......... 01.5751 29.77 050431......... 01.0690 22.58 050557......... 01.4977 21.08
050101....................... 01.4057 25.12 050204.......... 01.5012 23.12 050309......... 01.3320 23.63 050432......... 01.5759 23.69 050559......... 01.3565 24.18
050102....................... 01.4495 22.34 050205.......... 01.4071 19.99 050310......... 01.2559 22.24 050433......... 01.0471 17.37 050560......... 01.1958 ......
050103....................... 01.6149 26.74 050207.......... 01.2968 20.58 050312......... 01.9778 23.66 050434......... 01.1429 18.08 050561......... 01.2258 30.34
050104....................... 01.3954 21.73 050208.......... 00.9598 27.60 050313......... 01.1978 20.90 050435......... 01.2450 18.98 050564......... 01.2054 24.02
050107....................... 01.4293 22.92 050211.......... 01.3146 29.60 050315......... 01.1780 20.82 050436......... 01.0070 15.77 050565......... 01.1520 21.26
050108....................... 01.5836 22.79 050213.......... 01.3874 21.12 050317......... 01.3273 20.90 050438......... 01.6314 23.33 050566......... 00.8825 19.75
050109....................... 02.3476 24.68 050214.......... 01.4375 21.76 050320......... 01.3287 27.27 050440......... 01.3954 19.93 050567......... 01.6587 23.01
050110....................... 01.2507 18.72 050215.......... 01.5190 27.75 050324......... 01.8319 25.93 050441......... 01.9149 28.55 050568......... 01.4204 18.28
050111....................... 01.3798 18.81 050217.......... 01.3643 18.44 050325......... 01.2523 20.87 050443......... 00.9587 15.95 050569......... 01.3542 22.93
050112....................... 01.5220 22.15 050219.......... 01.3321 20.37 050327......... 01.6010 21.00 050444......... 01.3523 22.19 050570......... 01.6980 24.91
050113....................... 01.2853 28.23 050222.......... 01.5922 24.56 050328......... 01.4495 32.92 050446......... 00.8940 17.25 050571......... 01.4204 22.37
050114....................... 01.3991 21.65 050224.......... 01.5653 22.17 050329......... 01.3164 20.34 050447......... 01.0844 18.59 050573......... 01.6397 23.66
050115....................... 01.5990 21.11 050225.......... 01.3294 20.67 050331......... 01.4127 27.08 050448......... 01.1051 19.82 050575......... 01.2273 ......
050116....................... 01.4567 22.73 050226.......... 01.3370 22.58 050333......... 00.9784 18.66 050449......... 01.3604 21.99 050577......... 01.3597 20.32
050117....................... 01.2834 20.93 050228.......... 01.3736 29.90 050334......... 01.7734 28.22 050454......... 01.8370 26.64 050578......... 01.1992 23.70
050118....................... 01.2808 23.24 050230.......... 01.2918 26.22 050335......... 01.2452 19.62 050455......... 01.9214 22.89 050579......... 01.5677 26.94
050121....................... 01.4021 19.96 050231.......... 01.6412 24.14 050336......... 01.3479 21.04 050456......... 01.1402 20.24 050580......... 01.3586 23.47
050122....................... 01.7000 22.90 050232.......... 01.7744 24.17 050337......... 01.1692 23.87 050457......... 01.9338 28.66 050581......... 01.4202 24.63
050124....................... 01.2720 19.72 050233.......... 01.2916 30.88 050342......... 01.3725 17.55 050459......... 01.1867 28.20 050583......... 01.5832 23.08
050125....................... 01.3165 25.98 050234.......... 01.3192 22.00 050343......... 01.0360 18.56 050464......... 01.8999 22.62 050584......... 01.2104 22.39
050126....................... 01.4674 23.23 050235.......... 01.5083 25.00 050348......... 01.5885 22.83 050468......... 01.3992 16.26 050585......... 01.2578 23.70
050127....................... 01.2913 22.89 050236.......... 01.6581 24.28 050349......... 00.9126 14.28 050469......... 01.0927 17.33 050586......... 01.3811 21.76
050128....................... 01.5432 20.97 050238.......... 01.4934 22.95 050350......... 01.3885 22.68 050470......... 01.1184 21.29 050588......... 01.3856 26.55
050129....................... 01.5533 22.11 050239.......... 01.5043 21.24 050351......... 01.4758 24.81 050471......... 01.7401 24.07 050589......... 01.3208 25.37
050131....................... 01.2667 27.78 050240.......... 01.3972 22.82 050352......... 01.2909 23.35 050476......... 01.3455 19.12 050590......... 01.4063 23.00
050132....................... 01.4398 24.55 050241.......... 01.2317 25.78 050353......... 01.5639 21.45 050477......... 01.5165 24.50 050591......... 01.2961 22.97
050133....................... 01.3529 20.16 050242.......... 01.4661 27.10 050355......... 00.9639 15.53 050478......... 00.9231 21.73 050592......... 01.3448 20.34
050135....................... 01.3822 26.86 050243.......... 01.5339 21.58 050357......... 01.7182 23.17 050481......... 01.4226 24.85 050593......... 01.5312 24.40
050136....................... 01.3787 21.89 050245.......... 01.3997 21.74 050359......... 01.2130 18.78 050482......... 00.9467 14.55 050594......... 02.0186 23.81
050137....................... 01.3809 31.46 050248.......... 01.2055 24.50 050360......... 01.4693 30.15 050483......... 01.1688 23.89 050597......... 01.2823 21.91
050138....................... 01.8792 32.07 050251.......... 01.0803 17.68 050366......... 01.3068 20.47 050485......... 01.6321 22.34 050598......... 01.4008 26.87
050139....................... 01.3410 31.14 050253.......... 00.7756 18.87 050367......... 01.2858 27.02 050486......... 01.4321 24.94 050599......... 01.6761 22.70
050140....................... 01.4209 30.76 050254.......... 01.1917 22.13 050369......... 01.3286 23.30 050488......... 01.3939 30.41 050601......... 01.3057 29.03
050144....................... 01.5867 26.03 050256.......... 01.7682 19.70 050373......... 01.4241 23.83 050489......... 00.9463 27.10 050603......... 01.4202 23.50
050145....................... 01.3536 27.67 050257.......... 01.0737 20.65 050376......... 01.3722 25.86 050491......... 01.2864 23.76 050604......... 01.5879 29.45
050146....................... 01.3368 ....... 050260.......... 01.0937 21.96 050377......... 00.9038 15.01 050492......... 01.2453 23.05 050607......... 01.2965 21.79
050147....................... 00.6982 20.55 050261.......... 01.1916 17.91 050378......... 01.1132 22.45 050494......... 01.1689 24.95 050608......... 01.3088 15.23
050148....................... 01.1363 19.62 050262.......... 01.9314 26.89 050379......... 01.0922 19.04 050496......... 01.7816 31.64 050609......... 01.4337 31.39
050149....................... 01.4384 21.97 050263.......... 01.2879 24.44 050380......... 01.6730 28.31 050497......... 00.7940 ....... 050613......... 01.1371 22.70
050150....................... 01.2549 23.23 050264.......... 01.3787 26.01 050382......... 01.4475 20.97 050498......... 01.2605 22.42 050615......... 01.7184 23.31
050152....................... 01.4365 24.60 050267.......... 01.5206 24.88 050385......... 01.3946 24.83 050502......... 01.6552 23.61 050616......... 01.3002 20.68
050153....................... 01.6526 30.53 050270.......... 01.2597 23.60 050388......... 00.9121 14.19 050503......... 01.3025 23.01 050618......... 01.0773 19.37
050155....................... 01.1138 23.60 050272.......... 01.3290 19.69 050390......... 01.2239 20.80 050506......... 01.4050 25.57 050623......... 01.1535 24.40
050158....................... 01.6868 27.88 050274.......... 00.9762 18.36 050391......... 01.2734 21.61 050510......... 01.3660 30.46 050624......... 01.3672 25.95
050159....................... 01.2594 22.01 050276.......... 01.2209 26.99 050392......... 00.9526 17.49 050512......... 01.4632 31.27 050625......... 01.5887 24.00
050167....................... 01.4435 21.67 050277.......... 01.3813 21.30 050393......... 01.4172 21.56 050515......... 01.3623 30.78 050630......... 01.3492 21.26
050168....................... 01.6111 24.83 050278.......... 01.5176 23.01 050394......... 01.5474 20.71 050516......... 01.6598 24.33 050633......... 01.2939 21.76
050169....................... 01.5874 24.53 050279.......... 01.2425 20.58 050396......... 01.6173 21.89 050517......... 01.2778 19.15 050635......... 01.4086 31.06
050170....................... 01.5243 21.58 050280.......... 01.6603 22.80 050397......... 01.0096 19.97 050522......... 01.3194 30.40 050636......... 01.4306 20.37
050172....................... 01.2559 19.96 050281.......... 01.4482 22.74 050401......... 01.1146 19.09 050523......... 01.2674 27.65 050638......... 01.0967 24.28
050173....................... 01.2322 23.70 050282.......... 01.3406 21.42 050404......... 01.1459 16.51 050526......... 01.3671 24.28 050641......... 01.2440 12.26
050174....................... 01.6918 27.89 050283.......... 01.1645 27.24 050406......... 01.1157 15.29 050528......... 01.3348 16.46 050643......... 00.7692 ......
050175....................... 01.3877 21.97 050286.......... 01.0345 17.99 050407......... 01.3194 27.06 050531......... 01.3097 23.60 050644......... 00.9068 26.86
050177....................... 01.2949 18.76 050289.......... 01.7959 27.38 050410......... 01.0758 17.45 050534......... 01.3868 23.83 050660......... 01.3466 ......
050179....................... 01.2634 17.29 050290.......... 01.6280 32.31 050411......... 01.4012 29.35 050535......... 01.3837 22.46 050661......... 00.8839 20.21
050180....................... 01.5556 30.12 050291.......... 01.2616 24.46 050414......... 01.2883 24.32 050537......... 01.2702 21.30 050662......... 00.8598 21.17
050183....................... 01.1975 19.09 050292.......... 01.0830 21.20 050417......... 01.3024 21.14 050539......... 01.2222 21.90 050663......... 01.0612 23.51
050186....................... 01.2894 24.12 050293.......... 01.0595 19.93 050418......... 01.4205 24.24 050541......... 01.5919 30.97 050666......... 00.7408 22.84
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[[Page 46242]]
Page 3 of 16
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050667....................... 01.1376 24.88 060043.......... 00.9469 11.78 080003......... 01.3117 19.32 100069......... 01.3695 17.29 100165......... 01.3116 13.45
050668....................... 01.1691 28.20 060044.......... 01.2667 17.32 080004......... 01.2876 17.59 100070......... 01.4431 17.56 100166......... 01.4649 20.31
050670....................... 00.7582 20.12 060046.......... 01.1210 16.56 080005......... 01.3302 16.82 100071......... 01.2985 16.98 100167......... 01.3941 20.54
050672....................... 00.6286 23.77 060047.......... 00.9812 11.40 080006......... 01.3946 20.49 100072......... 01.2499 17.24 100168......... 01.3762 19.35
050674....................... 01.2103 29.09 060049.......... 01.3584 17.47 080007......... 01.3608 17.99 100073......... 01.7985 20.61 100169......... 01.8614 18.29
050675....................... 01.7287 16.32 060050.......... 01.1733 13.77 090001......... 01.4141 19.64 100075......... 01.6343 17.85 100170......... 01.5053 16.56
050676....................... 01.0181 13.83 060052.......... 01.1025 12.56 090002......... 01.2979 20.51 100076......... 01.3934 17.15 100172......... 01.3679 13.38
050677....................... 01.4291 32.99 060053.......... 00.9924 13.73 090003......... 01.3037 24.74 100077......... 01.3130 17.25 100173......... 01.6821 16.33
050678....................... 01.0695 24.07 060054.......... 01.3339 16.80 090004......... 01.7183 23.49 100078......... 01.1660 15.14 100174......... 01.5414 18.20
050680....................... 01.2184 26.13 060056.......... 00.9638 13.37 090005......... 01.3403 27.07 100079......... 01.8349 16.01 100175......... 01.2188 16.18
050682....................... 00.8554 14.98 060057.......... 01.0526 21.45 090006......... 01.3699 19.52 100080......... 01.6185 19.40 100176......... 02.0480 21.95
050684....................... 01.2032 21.30 060058.......... 00.9353 12.54 090007......... 01.4082 19.58 100081......... 01.1190 13.33 100177......... 01.3381 18.55
050685....................... 01.2265 26.94 060060.......... 00.9689 12.21 090008......... 01.5337 24.06 100082......... 01.5411 17.93 100179......... 01.6547 19.03
050686....................... 01.3481 30.96 060062.......... 00.9518 15.85 090010......... 00.9987 21.70 100083......... 01.3214 17.50 100180......... 01.4234 17.67
050688....................... 01.2759 27.89 060063.......... 01.0378 11.12 090011......... 01.9774 24.77 100084......... 01.5306 16.53 100181......... 01.2716 17.59
050689....................... 01.4006 29.12 060064.......... 01.4255 20.21 090015......... 01.1679 ....... 100085......... 01.4393 19.50 100183......... 01.3672 19.33
050690....................... 01.4317 30.29 060065.......... 01.3431 19.98 100001......... 01.5420 18.86 100086......... 01.3389 21.32 100186......... 01.4766 16.70
050693....................... 01.9223 28.80 060066.......... 00.9927 13.10 100002......... 01.4781 19.71 100087......... 01.8063 20.83 100187......... 01.4519 18.35
050694....................... 01.3722 21.20 060068.......... 01.2574 14.00 100004......... 01.0281 11.81 100088......... 01.6818 17.41 100189......... 01.3788 23.13
050695....................... 01.1715 24.30 060070.......... 01.0379 14.99 100005......... 01.0125 16.26 100090......... 01.4281 16.49 100191......... 01.3328 19.19
050696....................... 02.0081 27.85 060071.......... 01.2272 14.69 100006......... 01.5475 18.99 100092......... 01.4493 16.91 100199......... 01.4386 21.91
050697....................... 01.1596 17.93 060073.......... 00.9804 14.32 100007......... 01.8482 19.61 100093......... 01.5191 14.28 100200......... 01.3968 21.35
050698....................... 01.1420 22.83 060075.......... 01.3519 20.27 100008......... 01.7482 19.80 100098......... 01.1444 17.43 100203......... 01.2655 19.34
050699....................... 00.5836 23.13 060076.......... 01.3688 15.97 100009......... 01.5619 18.17 100099......... 01.2518 13.09 100204......... 01.6212 19.95
050700....................... 01.4316 32.46 060085.......... 00.9849 10.28 100010......... 01.5539 20.58 100102......... 01.1013 16.44 100206......... 01.3436 19.47
050701....................... 01.3067 27.13 060087.......... 01.6543 18.67 100012......... 01.6867 16.73 100103......... 01.1795 14.46 100207......... 01.4708 19.86
050702....................... 00.8621 16.98 060088.......... 01.0424 15.38 100014......... 01.4263 18.57 100105......... 01.4672 18.08 100208......... 01.6280 21.86
050704....................... 01.2122 20.48 060090.......... 00.9635 14.23 100015......... 01.2474 17.60 100106......... 01.0473 15.46 100209......... 01.6581 22.39
050706....................... 00.9234 16.16 060096.......... 01.0000 21.70 100017......... 01.6490 17.18 100107......... 01.4657 18.26 100210......... 01.6673 16.51
050707....................... 01.1851 25.62 060100.......... 01.4179 20.95 100018......... 01.2838 19.94 100108......... 01.1057 15.45 100211......... 01.3452 19.17
050708....................... 00.9454 15.13 060103.......... 01.2446 21.10 100019......... 01.4953 18.81 100109......... 01.3492 16.81 100212......... 01.6712 18.54
050709....................... 01.3089 ....... 060104.......... 01.3185 20.32 100020......... 01.3391 18.31 100110......... 01.4144 18.91 100213......... 01.5487 20.00
050710....................... 01.4032 ....... 070001.......... 01.7660 24.78 100022......... 01.8412 23.05 100112......... 00.9727 10.84 100217......... 01.2995 17.06
050711....................... 02.3704 ....... 070002.......... 01.8658 24.78 100023......... 01.3492 15.88 100113......... 02.0782 18.19 100220......... 01.9605 19.66
050712....................... 02.1009 ....... 070003.......... 01.1262 24.50 100024......... 01.3428 19.54 100114......... 01.4899 17.73 100221......... 01.5710 20.68
060001....................... 01.5508 18.95 070004.......... 01.1725 23.70 100025......... 01.8824 16.22 100117......... 01.3400 18.32 100222......... 01.3999 18.80
060003....................... 01.2948 16.17 070005.......... 01.3749 25.45 100026......... 01.6407 15.52 100118......... 01.2643 16.03 100223......... 01.4871 18.53
060004....................... 01.2527 19.46 070006.......... 01.3549 26.73 100027......... 00.9771 11.53 100121......... 01.3066 15.44 100224......... 01.4719 19.83
060006....................... 01.1975 16.19 070007.......... 01.3479 24.08 100028......... 01.2652 16.38 100122......... 01.4506 16.39 100225......... 01.3254 19.52
060007....................... 01.2004 13.06 070008.......... 01.3150 23.47 100029......... 01.4199 18.94 100124......... 01.3626 19.41 100226......... 01.3465 16.58
060008....................... 01.0187 14.31 070009.......... 01.2763 25.01 100030......... 01.2742 18.25 100125......... 01.1588 17.77 100228......... 01.3104 21.73
060009....................... 01.4655 19.88 070010.......... 01.5525 22.46 100032......... 01.9211 17.39 100126......... 01.4979 18.74 100229......... 01.3245 16.27
060010....................... 01.5260 20.98 070011.......... 01.3234 22.80 100034......... 01.7396 18.34 100127......... 01.6887 17.42 100230......... 01.5387 18.97
060011....................... 01.3370 20.75 070012.......... 01.2507 23.38 100035......... 01.6148 16.60 100128......... 02.2486 20.13 100231......... 01.6719 17.53
060012....................... 01.3930 15.79 070013.......... 01.2967 24.01 100038......... 01.6027 21.18 100129......... 01.2547 17.45 100232......... 01.2671 17.95
060013....................... 01.2675 18.83 070015.......... 01.3575 23.82 100039......... 01.7141 21.15 100130......... 01.2030 17.45 100234......... 01.5302 19.03
060014....................... 01.7036 20.52 070016.......... 01.3214 25.46 100040......... 01.6660 17.04 100131......... 01.3906 20.00 100235......... 01.4767 17.51
060015....................... 01.5654 19.33 070017.......... 01.3822 23.54 100043......... 01.4572 17.78 100132......... 01.4161 15.67 100236......... 01.4469 17.14
060016....................... 01.0899 11.42 070018.......... 01.3711 27.83 100044......... 01.5020 19.01 100134......... 01.0905 14.50 100237......... 02.1542 22.65
060018....................... 01.2065 16.36 070019.......... 01.2155 24.04 100045......... 01.4043 17.12 100135......... 01.5238 16.11 100238......... 01.4815 18.68
060020....................... 01.5157 16.73 070020.......... 01.3663 24.32 100046......... 01.5110 18.53 100137......... 01.3214 18.42 100239......... 01.4625 19.34
060022....................... 01.6703 17.89 070021.......... 01.3063 25.47 100047......... 01.9063 18.62 100138......... 00.9490 13.00 100240......... 00.8493 15.06
060023....................... 01.6452 16.65 070022.......... 01.7748 24.30 100048......... 01.0049 11.69 100139......... 01.0446 14.54 100241......... 00.9419 12.47
060024....................... 01.8238 21.86 070024.......... 01.3565 23.81 100049......... 01.3205 18.04 100140......... 01.2494 16.91 100242......... 01.4130 16.29
060026....................... 01.4257 19.44 070025.......... 01.7832 24.06 100050......... 01.2217 15.06 100142......... 01.1996 16.68 100243......... 01.4202 18.82
060027....................... 01.6710 19.41 070026.......... 01.2095 23.07 100051......... 01.1641 16.60 100144......... 01.1391 13.65 100244......... 01.4365 17.32
060028....................... 01.4813 21.26 070027.......... 01.2527 24.31 100052......... 01.3742 15.60 100145......... 01.3457 14.87 100246......... 01.3480 20.92
060029....................... 00.9561 13.93 070028.......... 01.4842 24.67 100053......... 01.2969 17.36 100146......... 01.2636 14.27 100248......... 01.7029 17.88
060030....................... 01.3302 20.36 070029.......... 01.3530 21.65 100054......... 01.2845 17.74 100147......... 01.1046 13.43 100249......... 01.3523 18.87
060031....................... 01.6125 18.60 070030.......... 01.3017 24.71 100055......... 01.3733 17.47 100150......... 01.3716 18.64 100252......... 01.2487 19.21
060032....................... 01.5798 19.35 070031.......... 01.2736 22.24 100056......... 01.4638 19.83 100151......... 01.8558 18.63 100253......... 01.4795 20.60
060033....................... 01.1592 11.96 070033.......... 01.2828 28.25 100057......... 01.3486 16.78 100154......... 01.5652 17.95 100254......... 01.5994 17.50
060034....................... 01.4918 15.10 070034.......... 01.3756 24.74 100060......... 01.8574 17.64 100156......... 01.2197 18.65 100255......... 01.3326 19.11
060036....................... 01.1876 14.12 070035.......... 01.3457 24.31 100061......... 01.5097 20.88 100157......... 01.6104 19.31 100256......... 01.8928 19.32
060037....................... 01.0382 13.22 070036.......... 01.4357 26.98 100062......... 01.7312 17.34 100159......... 00.9792 12.76 100258......... 01.6487 21.12
060038....................... 01.0165 12.25 070039.......... 00.9163 ....... 100063......... 01.3440 16.12 100160......... 01.1077 18.07 100259......... 01.4550 16.36
060041....................... 00.9131 16.53 080001.......... 01.6108 23.66 100067......... 01.4273 16.38 100161......... 01.5218 19.76 100260......... 01.4008 20.44
060042....................... 01.0563 15.65 080002.......... 01.1901 17.34 100068......... 01.3898 17.42 100162......... 01.3906 14.53 100262......... 01.4078 19.32
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[[Page 46243]]
Page 4 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
100263....................... 01.3780 15.44 110061.......... 01.0125 10.61 110154......... 00.8337 12.68 130009......... 00.9607 14.78 140042......... 01.0485 13.30
100264....................... 01.3927 18.24 110062.......... 00.9133 09.73 110155......... 01.2457 12.27 130010......... 00.9378 15.04 140043......... 01.1788 16.37
100265....................... 01.3736 17.47 110063.......... 01.0733 11.44 110156......... 01.0063 12.68 130011......... 01.2462 16.74 140045......... 01.0658 14.21
100266....................... 01.2340 15.64 110064.......... 01.2886 15.87 110161......... 01.3364 20.79 130012......... 01.0306 18.53 140046......... 01.3024 14.83
100267....................... 01.3054 16.39 110065.......... 01.0226 12.00 110162......... 00.8869 ....... 130013......... 01.2406 17.21 140047......... 01.1337 13.20
100268....................... 01.1963 22.00 110066.......... 01.4492 15.93 110163......... 01.4519 18.52 130014......... 01.3064 16.43 140048......... 01.2661 21.68
100269....................... 01.3576 19.07 110069.......... 01.1724 15.22 110164......... 01.4148 19.63 130015......... 00.8651 12.43 140049......... 01.5736 19.35
100270....................... 00.8215 12.95 110070.......... 01.1711 11.37 110165......... 01.3220 17.47 130016......... 00.9236 16.18 140051......... 01.4909 19.14
100271....................... 01.6484 19.22 110071.......... 01.0312 10.29 110166......... 01.4938 16.67 130017......... 01.3329 13.03 140052......... 01.3125 17.02
100273....................... 00.5356 19.72 110072.......... 01.0247 11.53 110168......... 01.6565 19.22 130018......... 01.6907 17.60 140053......... 01.8943 17.53
100275....................... 01.4323 21.96 110073.......... 01.2039 12.67 110169......... 00.7217 19.70 130019......... 01.1299 13.74 140054......... 01.3596 ......
100276....................... 01.3023 21.94 110074.......... 01.4766 18.11 110171......... 01.4568 21.21 130021......... 01.0465 11.96 140055......... 00.9522 13.00
100277....................... 01.0092 12.71 110075.......... 01.2078 15.29 110172......... 01.3364 22.83 130022......... 01.1801 15.79 140058......... 01.2417 15.26
100279....................... 01.3749 18.35 110076.......... 01.3901 18.01 110174......... 01.0421 17.57 130024......... 01.0502 15.25 140059......... 01.1373 13.52
100280....................... 01.3702 16.93 110078.......... 01.6719 20.46 110176......... 01.1237 19.42 130025......... 01.1504 15.21 140061......... 01.0923 13.80
100281....................... 01.2549 20.85 110079.......... 01.3994 21.08 110177......... 01.4754 19.21 130026......... 01.1837 17.88 140062......... 01.2440 23.10
100282....................... 01.0458 16.99 110080.......... 01.1584 17.55 110178......... 01.3367 16.78 130027......... 00.9547 17.18 140063......... 01.4167 22.48
100283....................... 01.5652 ....... 110082.......... 02.0181 20.36 110179......... 01.2418 21.56 130028......... 01.2487 16.08 140064......... 01.3103 16.15
110001....................... 01.2981 17.40 110083.......... 01.7259 20.66 110181......... 00.9808 12.59 130029......... 01.0228 17.07 140065......... 01.4933 23.68
110002....................... 01.2392 15.22 110086.......... 01.2202 13.76 110183......... 01.3677 17.07 130030......... 01.0169 16.20 140066......... 01.3703 13.39
110003....................... 01.3058 15.41 110087.......... 01.3382 19.17 110184......... 01.1756 17.58 130031......... 01.0188 13.26 140067......... 01.8244 18.24
110004....................... 01.3077 16.17 110088.......... 00.9695 11.17 110185......... 01.0884 12.23 130034......... 01.0391 16.38 140068......... 01.3717 19.00
110005....................... 01.1844 21.40 110089.......... 01.2124 15.37 110186......... 01.3073 15.75 130035......... 01.0662 15.37 140069......... 01.0074 14.23
110006....................... 01.3576 18.87 110091.......... 01.3396 19.15 110187......... 01.2468 17.19 130036......... 01.2648 12.50 140070......... 01.2760 16.18
110007....................... 01.4531 16.31 110092.......... 01.1806 12.55 110188......... 01.4230 18.00 130037......... 01.2740 14.58 140074......... 00.9717 14.60
110008....................... 01.2394 15.47 110093.......... 01.0117 09.81 110189......... 01.1532 19.78 130043......... 00.9512 14.61 140075......... 01.4676 21.53
110009....................... 01.0428 15.71 110094.......... 00.9605 12.06 110190......... 01.0880 14.41 130044......... 01.1521 12.37 140077......... 01.1406 17.05
110010....................... 02.1537 21.39 110095.......... 01.2790 13.86 110191......... 01.3522 18.06 130045......... 01.0312 12.15 140079......... 01.2381 20.90
110011....................... 01.2831 16.01 110096.......... 01.1394 14.30 110192......... 01.3947 22.17 130048......... 01.0694 11.90 140080......... 01.5767 19.60
110013....................... 01.1303 14.36 110097.......... 01.0211 15.58 110193......... 01.2332 16.16 130049......... 01.2951 17.55 140081......... 01.0786 13.92
110014....................... 01.0358 14.48 110098.......... 01.0943 11.76 110194......... 00.9677 11.77 130054......... 00.9652 17.12 140082......... 01.5017 22.10
110015....................... 01.3568 16.52 110100.......... 01.0953 12.27 110195......... 01.0807 10.50 130056......... 00.8422 09.45 140083......... 01.2513 16.51
110016....................... 01.2935 14.21 110101.......... 01.0963 09.24 110198......... 01.3335 22.58 130058......... 00.9768 12.87 140084......... 01.2323 17.94
110017....................... 00.8913 11.01 110103.......... 00.9600 10.35 110200......... 01.9391 15.79 130060......... 01.1395 18.38 140086......... 01.1440 13.93
110018....................... 01.1312 17.20 110104.......... 01.1190 13.28 110201......... 01.4569 16.13 130061......... 00.9484 ....... 140087......... 01.3815 17.10
110020....................... 01.2347 17.30 110105.......... 01.1311 15.17 110203......... 00.9715 14.94 140001......... 01.2991 14.63 140088......... 01.6591 23.33
110023....................... 01.2424 17.53 110107.......... 01.8265 17.61 110204......... 00.8135 13.48 140002......... 01.2823 17.06 140089......... 01.2280 15.85
110024....................... 01.4719 16.51 110108.......... 00.9766 11.27 110205......... 01.1045 11.84 140003......... 01.0185 13.14 140090......... 01.5067 23.62
110025....................... 01.4105 16.85 110109.......... 01.1048 12.14 110207......... 01.0934 15.59 140004......... 01.0772 13.75 140091......... 01.8655 17.70
110026....................... 01.1893 14.02 110111.......... 01.1951 15.43 110208......... 00.9744 14.94 140005......... 00.9515 09.98 140093......... 01.1958 17.17
110027....................... 01.1003 14.56 110112.......... 01.1526 16.19 110209......... 00.8260 ....... 140007......... 01.4661 20.56 140094......... 01.2893 18.81
110028....................... 01.6029 17.75 110113.......... 01.1372 12.86 120001......... 01.7306 24.22 140008......... 01.4816 20.57 140095......... 01.4253 ......
110029....................... 01.3446 17.71 110114.......... 01.0725 13.75 120002......... 01.1982 21.46 140010......... 01.3912 22.14 140097......... 00.9264 14.15
110030....................... 01.2789 16.60 110115.......... 01.6206 21.82 120003......... 01.1664 21.82 140011......... 01.1461 15.31 140100......... 01.2257 17.62
110031....................... 01.3373 19.59 110118.......... 01.0282 13.18 120004......... 01.2809 20.56 140012......... 01.2854 17.59 140101......... 01.2060 18.04
110032....................... 01.2263 15.31 110120.......... 01.0844 13.35 120005......... 01.2640 18.34 140013......... 01.6583 16.49 140102......... 01.0399 14.09
110033....................... 01.5143 20.32 110121.......... 01.1813 11.84 120006......... 01.2131 22.75 140014......... 01.0788 16.53 140103......... 01.3225 16.66
110034....................... 01.5234 16.64 110122.......... 01.3572 16.03 120007......... 01.6283 20.27 140015......... 01.2919 13.45 140105......... 01.3087 18.25
110035....................... 01.4060 18.53 110124.......... 01.0707 15.32 120009......... 00.9840 18.05 140016......... 00.9315 11.59 140107......... 01.0822 11.63
110036....................... 01.6813 ....... 110125.......... 01.2239 15.97 120010......... 01.8462 22.11 140018......... 01.4546 18.85 140108......... 01.3622 20.00
110037....................... 01.0852 10.18 110127.......... 00.9150 14.43 120011......... 01.2509 30.31 140019......... 00.9900 11.80 140109......... 01.1367 12.95
110038....................... 01.4649 15.04 110128.......... 01.2059 17.54 120012......... 00.9944 20.30 140024......... 01.0188 13.59 140110......... 01.2343 14.51
110039....................... 01.3761 17.93 110129.......... 01.6793 14.06 120014......... 01.3609 21.25 140025......... 01.0804 15.88 140112......... 01.1043 13.55
110040....................... 01.0393 16.26 110130.......... 01.0709 10.57 120015......... 00.8375 21.01 140026......... 01.1408 15.58 140113......... 01.4630 19.21
110041....................... 01.2212 16.43 110132.......... 01.1522 12.87 120016......... 00.8646 21.94 140027......... 01.3210 15.96 140114......... 01.3392 18.95
110042....................... 01.2049 14.63 110134.......... 00.8920 11.65 120018......... 01.0071 21.16 140029......... 01.3790 19.62 140115......... 01.2253 19.32
110043....................... 01.7109 15.17 110135.......... 01.1993 13.83 120019......... 01.1783 19.48 140030......... 01.6766 21.46 140116......... 01.2899 19.68
110044....................... 01.0952 14.31 110136.......... 01.1192 13.74 120021......... 01.0173 19.68 140031......... 01.1664 13.02 140117......... 01.4908 17.63
110045....................... 01.2460 22.04 110140.......... 00.8194 15.03 120022......... 01.7340 17.83 140032......... 01.2528 16.44 140118......... 01.6836 23.01
110046....................... 01.1964 15.07 110141.......... 00.9075 11.65 120026......... 01.2870 22.30 140033......... 01.2626 19.10 140119......... 01.6901 19.58
110048....................... 01.3156 12.97 110142.......... 00.9799 11.15 120027......... 01.5254 21.16 140034......... 01.1754 16.74 140120......... 01.5071 14.72
110049....................... 01.0670 13.71 110143.......... 01.4049 18.27 130001......... 01.0518 17.21 140035......... 01.0183 10.70 140121......... 01.5259 10.91
110050....................... 01.0687 14.00 110144.......... 01.1632 16.44 130002......... 01.3744 14.66 140036......... 01.2342 15.03 140122......... 01.5567 21.02
110051....................... 00.9846 16.35 110146.......... 01.0267 09.43 130003......... 01.3166 18.11 140037......... 00.9837 12.24 140124......... 01.1235 23.06
110052....................... 00.9986 09.11 110149.......... 01.1280 12.17 130005......... 01.4466 18.49 140038......... 01.1512 15.00 140125......... 01.3444 15.60
110054....................... 01.2820 16.57 110150.......... 01.3562 16.56 130006......... 01.9033 18.19 140039......... 00.9224 11.51 140127......... 01.3521 17.11
110056....................... 00.9698 12.61 110152.......... 01.1389 13.06 130007......... 01.6435 19.45 140040......... 01.3038 14.34 140128......... 01.0617 16.10
110059....................... 01.2862 14.39 110153.......... 01.0201 15.49 130008......... 00.9993 10.28 140041......... 01.2502 15.01 140129......... 01.0511 13.18
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
140130....................... 01.2732 21.67 140224.......... 01.3678 22.10 150039......... 01.0056 14.51 150125......... 01.4257 18.17 160068......... 01.1088 13.30
140132....................... 01.4192 18.58 140228.......... 01.7080 17.36 150042......... 01.2901 15.47 150126......... 01.5188 19.24 160069......... 01.4027 16.05
140133....................... 01.3737 19.77 140230.......... 00.9428 15.48 150043......... 01.0529 16.65 150127......... 01.0449 14.34 160070......... 01.0379 13.84
140135....................... 01.3086 14.29 140231.......... 01.6699 19.79 150044......... 01.2628 17.63 150128......... 01.2306 18.59 160072......... 01.0673 12.08
140137....................... 01.0318 13.61 140233.......... 01.7418 16.57 150045......... 01.0901 15.00 150129......... 01.2088 20.35 160073......... 01.0129 11.50
140138....................... 00.9633 12.15 140234.......... 01.1961 16.03 150046......... 01.5910 16.06 150130......... 01.1433 16.23 160074......... 01.1103 12.98
140139....................... 01.0713 13.46 140236.......... 01.0474 12.82 150047......... 01.6262 17.74 150132......... 01.3406 19.17 160075......... 01.1107 13.84
140140....................... 01.1363 13.05 140239.......... 01.5891 18.81 150048......... 01.1670 16.18 150133......... 01.2048 14.96 160076......... 01.0695 16.33
140141....................... 00.9005 13.30 140240.......... 01.5057 20.90 150049......... 01.0814 13.72 150134......... 01.3003 16.53 160077......... 01.1355 10.97
140143....................... 01.0710 15.95 140242.......... 01.5840 22.51 150050......... 01.1857 14.50 150136......... 00.9384 18.69 160079......... 01.4258 15.22
140144....................... 00.9814 16.57 140245.......... 01.1287 13.55 150051......... 01.3842 16.92 150138......... 01.1552 ....... 160080......... 01.2094 15.46
140145....................... 01.1986 14.80 140246.......... 01.0547 12.03 150052......... 01.0656 12.93 150139......... 01.5412 ....... 160081......... 01.0669 14.36
140146....................... 00.9645 14.85 140250.......... 01.3128 21.35 150053......... 01.0612 16.69 150141......... 01.1063 ....... 160082......... 01.7526 17.09
140147....................... 01.1905 13.32 140251.......... 01.3100 18.25 150054......... 01.1373 12.39 150142......... 02.4300 ....... 160083......... 01.5750 17.49
140148....................... 01.7984 16.51 140252.......... 01.4282 21.53 150056......... 01.7052 21.58 160001......... 01.2713 16.39 160085......... 01.0913 12.79
140150....................... 01.5793 26.00 140253.......... 01.4398 ....... 150057......... 02.3094 15.06 160002......... 01.1942 13.14 160086......... 01.0153 12.88
140151....................... 01.1069 17.61 140258.......... 01.5311 20.98 150058......... 01.6859 18.64 160003......... 01.0183 11.87 160088......... 01.0346 13.10
140152....................... 01.0701 22.68 140271.......... 01.0187 13.54 150059......... 01.3219 18.93 160005......... 01.1028 12.93 160089......... 01.1654 14.12
140155....................... 01.1892 16.91 140275.......... 01.2297 18.20 150060......... 01.1301 12.79 160007......... 01.0097 12.02 160090......... 01.0018 13.98
140158....................... 01.2623 21.41 140276.......... 01.9808 20.48 150061......... 01.3042 15.86 160008......... 01.1070 13.93 160091......... 01.1032 10.56
140160....................... 01.2330 15.34 140280.......... 01.2730 16.16 150062......... 01.0694 15.20 160009......... 01.1682 13.54 160092......... 00.9729 12.93
140161....................... 01.1376 17.05 140281.......... 01.6371 20.19 150063......... 01.0497 18.88 160012......... 01.0622 14.05 160093......... 01.1433 15.20
140162....................... 01.7733 18.38 140285.......... 01.1995 14.75 150064......... 01.2128 16.48 160013......... 01.2233 16.64 160094......... 01.2151 14.79
140164....................... 01.2955 16.01 140286.......... 01.1484 17.59 150065......... 01.1479 15.94 160014......... 01.0356 12.21 160095......... 01.0295 12.30
140165....................... 01.1122 13.06 140288.......... 01.7729 22.68 150066......... 01.0006 12.89 160016......... 01.2891 15.68 160097......... 01.0918 13.47
140166....................... 01.2945 16.62 140289.......... 01.3068 15.73 150067......... 01.1174 14.35 160018......... 00.9441 13.19 160098......... 01.0813 13.90
140167....................... 01.1593 14.64 140290.......... 01.3353 19.21 150069......... 01.2347 16.53 160020......... 01.0854 12.11 160099......... 00.9773 12.80
140168....................... 01.1855 15.02 140291.......... 01.2791 22.84 150070......... 01.0425 16.70 160021......... 01.0514 13.85 160101......... 01.1119 17.71
140170....................... 01.1292 12.39 140292.......... 01.1677 19.04 150071......... 01.1521 12.69 160023......... 01.1553 13.66 160102......... 01.3846 15.69
140171....................... 00.9125 12.53 140294.......... 01.1871 16.10 150072......... 01.1943 15.32 160024......... 01.5685 17.39 160103......... 01.0159 12.95
140172....................... 01.5367 18.29 140297.......... 01.2576 21.42 150073......... 01.0179 15.49 160026......... 01.0997 15.21 160104......... 01.2441 19.21
140173....................... 00.9787 13.11 140300.......... 01.6558 24.90 150074......... 01.5921 18.63 160027......... 01.1632 13.22 160106......... 01.0809 14.18
140174....................... 01.4289 18.89 150001.......... 01.0902 16.95 150075......... 01.2189 13.82 160028......... 01.3375 17.78 160107......... 01.1459 13.78
140176....................... 01.2609 18.83 150002.......... 01.4428 19.23 150076......... 01.1446 19.89 160029......... 01.4982 17.46 160108......... 01.1575 14.09
140177....................... 01.2794 16.44 150003.......... 01.7127 18.32 150077......... 01.2631 16.21 160030......... 01.2329 16.67 160109......... 01.1710 12.01
140179....................... 01.3313 19.51 150004.......... 01.4240 20.15 150078......... 01.0858 17.20 160031......... 01.1857 13.26 160110......... 01.5051 17.76
140180....................... 01.5279 20.22 150005.......... 01.1897 17.17 150079......... 01.1456 13.01 160032......... 01.1518 14.66 160111......... 01.1008 10.75
140181....................... 01.3085 18.82 150006.......... 01.2020 16.72 150082......... 01.4952 18.38 160033......... 01.7266 15.82 160112......... 01.4058 14.48
140182....................... 01.3245 19.11 150007.......... 01.2261 17.95 150084......... 01.8742 21.80 160034......... 01.0638 13.81 160113......... 00.9632 11.39
140184....................... 01.1998 14.20 150008.......... 01.3450 18.38 150086......... 01.3003 15.76 160035......... 00.9589 11.91 160114......... 01.0691 14.13
140185....................... 01.4563 16.35 150009.......... 01.3279 16.97 150088......... 01.1875 16.71 160036......... 01.0735 12.83 160115......... 01.0315 13.87
140186....................... 01.3197 18.48 150010.......... 01.2026 16.10 150089......... 01.4010 18.99 160037......... 01.1648 14.80 160116......... 01.1763 15.46
140187....................... 01.4891 16.33 150011.......... 01.2227 16.76 150090......... 01.2547 19.34 160039......... 01.0629 15.23 160117......... 01.3429 15.52
140188....................... 00.9624 10.54 150012.......... 01.6885 20.57 150091......... 01.0744 15.66 160040......... 01.3465 16.04 160118......... 01.0327 12.42
140189....................... 01.1723 15.74 150013.......... 01.1612 13.09 150092......... 01.0659 12.44 160041......... 01.0613 12.88 160120......... 01.0161 09.94
140190....................... 01.1204 13.36 150014.......... 01.4250 18.85 150094......... 00.9984 16.65 160043......... 01.0335 13.38 160122......... 01.1556 14.96
140191....................... 01.3847 23.16 150015.......... 01.2351 17.85 150095......... 01.1097 15.78 160044......... 01.1566 13.36 160123......... 01.1606 12.18
140192....................... 01.1887 16.51 150017.......... 01.8496 17.26 150096......... 01.1003 17.15 160045......... 01.6893 17.48 160124......... 01.2587 15.35
140193....................... 01.0150 12.24 150018.......... 01.2888 17.47 150097......... 01.1268 16.64 160046......... 01.0357 11.92 160126......... 01.1485 13.82
140197....................... 01.2770 16.05 150019.......... 01.1204 13.82 150098......... 01.1387 11.81 160047......... 01.3555 15.87 160129......... 01.0397 13.07
140199....................... 01.0179 15.13 150020.......... 01.1507 13.19 150099......... 01.2979 17.10 160048......... 01.0230 11.76 160130......... 01.1619 13.04
140200....................... 01.4263 20.12 150021.......... 01.6805 18.22 150100......... 01.6831 18.15 160049......... 00.9816 12.04 160131......... 01.0980 12.63
140202....................... 01.3108 20.09 150022.......... 01.1445 17.62 150101......... 01.0919 14.46 160050......... 01.0242 14.12 160134......... 00.9706 11.37
140203....................... 01.1567 19.02 150023.......... 01.4993 17.81 150102......... 01.0920 14.61 160051......... 00.9990 12.90 160135......... 01.0543 13.24
140205....................... 00.9105 13.88 150024.......... 01.4398 16.96 150103......... 01.0356 17.63 160052......... 01.0599 14.80 160138......... 01.0612 13.48
140206....................... 01.0979 19.58 150025.......... 01.4540 16.32 150104......... 01.1461 15.09 160054......... 01.0268 10.82 160140......... 01.0940 14.86
140207....................... 01.3773 26.85 150026.......... 01.1855 16.69 150105......... 01.4058 16.61 160055......... 01.0383 11.48 160142......... 01.0318 13.60
140208....................... 01.6155 23.94 150027.......... 01.0681 16.04 150106......... 01.1387 15.58 160056......... 01.0434 12.84 160143......... 01.1292 13.03
140209....................... 01.7014 17.46 150029.......... 01.2766 20.57 150109......... 01.4513 16.04 160057......... 01.3212 15.92 160145......... 01.0839 13.74
140210....................... 01.0830 12.87 150030.......... 01.1946 16.20 150110......... 00.9917 14.72 160058......... 01.6811 18.42 160146......... 01.4188 15.32
140211....................... 01.2257 20.44 150031.......... 01.0622 15.93 150111......... 01.2066 12.88 160060......... 01.0858 13.82 160147......... 01.2744 15.02
140212....................... 01.2970 22.65 150032.......... 01.7930 18.85 150112......... 01.2228 16.84 160061......... 01.0104 14.19 160151......... 01.0694 12.75
140213....................... 01.2892 20.44 150033.......... 01.6075 20.07 150113......... 01.1843 16.78 160062......... 00.9605 11.95 160152......... 01.0169 13.30
140215....................... 01.1640 13.22 150034.......... 01.4013 18.15 150114......... 01.0253 13.44 160063......... 01.2810 14.24 160153......... 01.7061 17.05
140217....................... 01.2388 21.09 150035.......... 01.4004 17.90 150115......... 01.4004 17.31 160064......... 01.6369 16.41 170001......... 01.2005 15.90
140218....................... 01.0502 13.64 150036.......... 01.0404 17.35 150122......... 01.1415 17.55 160065......... 01.0755 14.51 170004......... 01.0839 13.18
140220....................... 01.1066 14.22 150037.......... 01.2647 17.06 150123......... 01.1703 12.81 160066......... 01.1226 14.06 170006......... 01.1973 13.48
140223....................... 01.5408 25.37 150038.......... 01.2712 16.65 150124......... 01.1239 15.00 160067......... 01.3756 16.70 170008......... 00.9787 13.35
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[[Page 46245]]
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
170009....................... 01.1209 16.81 170089.......... 00.9887 14.21 180011......... 01.1747 15.71 180103......... 02.0746 17.85 190060......... 01.4965 16.51
170010....................... 01.2604 16.38 170090.......... 01.0970 09.58 180012......... 01.3355 17.14 180104......... 01.5020 16.55 190064......... 01.5617 17.46
170011....................... 01.4042 14.59 170092.......... 00.8625 11.45 180013......... 01.5057 17.38 180105......... 00.9303 12.23 190065......... 01.4781 15.75
170012....................... 01.4938 15.48 170093.......... 00.9308 11.58 180014......... 01.6061 19.67 180106......... 00.9112 12.65 190071......... 00.8601 11.38
170013....................... 01.3148 13.27 170094.......... 01.0437 12.81 180015......... 01.2422 14.91 180108......... 00.8502 12.49 190077......... 00.9184 13.41
170014....................... 01.0357 15.18 170095.......... 01.0793 13.80 180016......... 01.3158 14.91 180115......... 01.0276 14.18 190078......... 01.1344 11.21
170015....................... 00.9779 13.74 170097.......... 01.0290 13.42 180017......... 01.2736 13.52 180116......... 01.3708 14.92 190079......... 01.2606 13.61
170016....................... 01.6634 21.80 170098.......... 01.0823 16.21 180018......... 01.2225 15.73 180117......... 01.1829 16.14 190081......... 00.8818 09.70
170017....................... 01.1668 16.76 170099.......... 01.3430 11.00 180019......... 01.3412 17.22 180118......... 01.0472 11.72 190083......... 00.9480 12.45
170018....................... 01.0636 12.23 170100.......... 00.9977 14.63 180020......... 01.0343 15.37 180120......... 01.0465 12.49 190086......... 01.3623 14.02
170019....................... 01.1792 15.13 170101.......... 00.9112 14.13 180021......... 01.1778 13.25 180121......... 01.2193 13.09 190088......... 01.1960 16.01
170020....................... 01.3277 14.54 170102.......... 01.0195 12.78 180023......... 00.8339 11.27 180122......... 01.0457 14.47 190089......... 01.1207 09.60
170022....................... 01.1643 14.15 170103.......... 01.2461 15.28 180024......... 01.3934 15.69 180123......... 01.4536 19.34 190090......... 01.0617 15.75
170023....................... 01.4219 15.57 170104.......... 01.4212 19.52 180025......... 01.1240 16.18 180124......... 01.4782 16.00 190092......... 01.3320 20.14
170024....................... 01.1563 12.71 170105.......... 01.0263 14.45 180026......... 01.1079 13.66 180125......... 00.9495 16.23 190095......... 00.9953 14.04
170025....................... 01.1622 18.37 170106.......... 00.8380 12.54 180027......... 01.2747 14.17 180126......... 01.1697 11.90 190098......... 01.5422 17.56
170026....................... 01.0141 16.38 170108.......... 00.9468 10.88 180028......... 00.9964 16.19 180127......... 01.2380 16.63 190099......... 01.1497 17.31
170027....................... 01.3730 15.02 170109.......... 01.0494 14.67 180029......... 01.2190 15.99 180128......... 01.1870 15.40 190102......... 01.5854 16.15
170030....................... 01.0399 13.61 170110.......... 01.0197 13.62 180030......... 01.1777 12.89 180129......... 01.0306 13.93 190103......... 00.8408 09.66
170031....................... 00.9163 12.36 170112.......... 00.9254 13.44 180031......... 01.0461 12.38 180130......... 01.4219 17.87 190106......... 01.1388 17.27
170032....................... 01.1121 14.18 170113.......... 01.1501 13.43 180032......... 00.9926 15.30 180132......... 01.2453 15.43 190109......... 01.1894 14.20
170033....................... 01.3417 14.08 170114.......... 00.9540 12.96 180033......... 01.1325 12.57 180133......... 01.2455 18.31 190110......... 00.9431 11.96
170034....................... 00.9579 13.74 170115.......... 00.9905 11.01 180034......... 01.0720 13.61 180134......... 01.0124 13.71 190111......... 01.5456 17.24
170035....................... 00.9370 12.37 170116.......... 01.0367 13.94 180035......... 01.5668 18.26 180136......... 01.5752 16.63 190112......... 01.5143 20.35
170036....................... 00.8755 12.31 170117.......... 00.9947 12.63 180036......... 01.2433 17.36 180137......... 01.6637 17.00 190113......... 01.3748 17.85
170037....................... 01.1197 15.02 170119.......... 00.9470 11.32 180037......... 01.2824 20.29 180138......... 01.2089 17.02 190114......... 01.0043 11.51
170038....................... 00.9180 10.94 170120.......... 01.2814 14.66 180038......... 01.4336 14.73 180139......... 01.0714 16.41 190115......... 01.2409 16.75
170039....................... 01.1372 11.69 170122.......... 01.9013 19.69 180040......... 02.0237 19.04 180140......... 01.0106 ....... 190116......... 01.2969 14.97
170040....................... 01.5594 18.21 170123.......... 01.7740 17.69 180041......... 01.0904 13.03 190001......... 00.9354 16.67 190118......... 01.0464 11.87
170041....................... 00.9886 11.41 170124.......... 00.9495 12.10 180042......... 01.1215 13.43 190002......... 01.6389 16.28 190120......... 00.9281 12.89
170043....................... 00.9329 13.41 170126.......... 00.9261 11.07 180043......... 01.0168 15.31 190003......... 01.4461 17.16 190122......... 01.2732 12.96
170044....................... 01.1174 14.73 170128.......... 01.0762 14.31 180044......... 01.0336 14.68 190004......... 01.3781 14.81 190124......... 01.5748 18.80
170045....................... 01.0311 13.54 170131.......... 01.0910 10.54 180045......... 01.2089 16.86 190005......... 01.6913 14.94 190125......... 01.5826 16.74
170049....................... 01.3345 18.05 170133.......... 01.1401 14.09 180046......... 01.2073 16.81 190006......... 01.2839 14.07 190128......... 01.2172 17.04
170050....................... 00.8380 09.63 170134.......... 00.9226 12.10 180047......... 01.0087 13.79 190007......... 01.0054 12.79 190130......... 00.9983 11.74
170051....................... 00.9591 13.31 170137.......... 01.1832 16.81 180048......... 01.1345 15.53 190008......... 01.6481 17.79 190131......... 01.2691 17.33
170052....................... 01.0675 13.31 170139.......... 00.9838 11.66 180049......... 01.3619 14.47 190009......... 01.1897 13.40 190133......... 01.0518 15.09
170053....................... 01.0064 13.09 170140.......... 00.9990 11.17 180050......... 01.2650 15.58 190010......... 01.1104 15.31 190134......... 00.9992 12.16
170054....................... 01.0821 12.86 170142.......... 01.2590 16.10 180051......... 01.4236 14.35 190011......... 01.1162 14.08 190135......... 01.4027 17.70
170055....................... 01.0629 17.05 170143.......... 01.1201 12.53 180053......... 01.1138 14.22 190013......... 01.4152 15.27 190136......... 01.1264 10.66
170056....................... 00.9457 10.99 170144.......... 01.6225 18.74 180054......... 01.1573 14.02 190014......... 01.0568 15.36 190138......... 00.7080 15.62
170057....................... 01.0529 13.75 170145.......... 01.1678 17.02 180055......... 01.0383 13.61 190015......... 01.2394 16.38 190140......... 00.9434 11.60
170058....................... 01.1738 17.54 170146.......... 01.4164 17.58 180056......... 01.1035 16.68 190017......... 01.3740 17.22 190142......... 00.9384 12.20
170060....................... 01.1254 12.73 170147.......... 01.2279 18.33 180058......... 01.0125 12.85 190018......... 01.1705 13.78 190144......... 01.2227 18.82
170061....................... 01.1532 12.59 170148.......... 01.4736 18.35 180059......... 00.9719 11.98 190019......... 01.5074 17.57 190145......... 00.9867 13.77
170062....................... 00.9501 10.45 170150.......... 01.0772 13.13 180060......... 00.7427 13.48 190020......... 01.1936 15.83 190146......... 01.5911 18.99
170063....................... 00.8993 09.30 170151.......... 00.9962 11.69 180063......... 00.9643 10.28 190025......... 01.2979 12.36 190147......... 00.9929 13.30
170064....................... 00.9472 11.38 170152.......... 00.9812 13.27 180064......... 01.3019 14.40 190026......... 01.4497 15.65 190148......... 00.8949 11.81
170066....................... 00.9901 12.26 170160.......... 01.0305 11.25 180065......... 00.9850 09.05 190027......... 01.4805 15.62 190149......... 00.9972 11.02
170067....................... 01.0335 11.05 170164.......... 01.0288 13.87 180066......... 01.2107 16.87 190029......... 01.1364 14.09 190151......... 01.1567 12.30
170068....................... 01.3864 14.01 170166.......... 01.1446 13.49 180067......... 01.8972 15.96 190033......... 00.9673 09.64 190152......... 01.4477 20.50
170069....................... 01.1712 13.20 170168.......... 00.9486 09.97 180069......... 01.0363 16.08 190034......... 01.2482 14.93 190155......... 00.9246 10.54
170070....................... 01.0193 11.83 170171.......... 01.0923 11.15 180070......... 01.0919 14.86 190035......... 01.4173 20.27 190156......... 00.8872 11.89
170072....................... 00.9565 11.53 170172.......... 00.9841 11.07 180072......... 01.0544 13.80 190036......... 01.6581 21.15 190158......... 01.2399 20.36
170073....................... 01.1115 12.66 170174.......... 01.0916 11.58 180075......... 00.9745 13.08 190037......... 00.9667 11.05 190160......... 01.2163 15.56
170074....................... 01.1546 12.86 170175.......... 01.2906 16.30 180078......... 01.1237 17.35 190039......... 01.4275 16.41 190161......... 01.0457 12.98
170075....................... 00.8688 10.55 170176.......... 01.5023 18.40 180079......... 01.2461 13.75 190040......... 01.3850 19.03 190162......... 01.1677 21.04
170076....................... 01.0722 11.15 170181.......... 01.0745 ....... 180080......... 01.0640 15.16 190041......... 01.4986 19.72 190164......... 01.2267 16.86
170077....................... 00.9683 11.12 170182.......... 00.8647 ....... 180085......... 01.2920 17.49 190043......... 01.1369 12.38 190166......... 01.0709 14.81
170079....................... 01.0838 11.81 170183.......... 02.1585 ....... 180087......... 01.0844 13.72 190044......... 01.1725 18.27 190167......... 01.2039 16.09
170080....................... 00.9559 11.05 180001.......... 01.2298 16.16 180088......... 01.5754 19.42 190045......... 01.3644 19.09 190170......... 00.9613 12.34
170081....................... 00.9254 10.42 180002.......... 01.0070 17.16 180092......... 01.0511 14.43 190046......... 01.4846 16.87 190173......... 01.4516 19.47
170082....................... 01.0572 10.60 180004.......... 01.0887 13.54 180093......... 01.3575 14.76 190048......... 01.0651 14.55 190175......... 01.2790 ......
170084....................... 00.9830 11.06 180005.......... 01.0375 17.40 180094......... 01.0158 11.93 190049......... 00.9679 14.74 190176......... 01.7076 18.06
170085....................... 00.9074 12.01 180006.......... 00.9157 08.63 180095......... 01.1597 12.78 190050......... 01.0446 13.90 190177......... 01.6056 22.02
170086....................... 01.7241 18.04 180007.......... 01.5430 14.17 180099......... 01.2008 11.72 190053......... 01.0575 11.98 190178......... 00.9842 11.20
170087....................... 01.4580 18.87 180009.......... 01.3358 17.70 180101......... 01.3403 18.84 190054......... 01.4118 13.67 190182......... 01.1627 20.12
170088....................... 00.9068 10.59 180010.......... 01.8318 16.91 180102......... 01.5134 16.31 190059......... 00.9449 13.58 190183......... 01.1310 13.81
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
190184....................... 01.0574 12.13 210002.......... 01.9575 16.84 220028......... 01.4667 22.45 220162......... 01.0805 ....... 230102......... 01.1047 ......
190185....................... 01.3141 19.03 210003.......... 01.5314 22.97 220029......... 01.1906 22.25 220163......... 02.0697 24.73 230103......... 01.0214 17.37
190186....................... 00.9515 11.69 210004.......... 01.3228 20.30 220030......... 01.0842 16.42 220171......... 01.6908 22.55 230104......... 01.6223 20.32
190187....................... 00.7862 14.05 210005.......... 01.2352 17.70 220031......... 02.0234 27.21 230001......... 01.2061 15.98 230105......... 01.6171 19.46
190189....................... 00.9439 14.54 210006.......... 01.1253 16.84 220033......... 01.3931 19.40 230002......... 01.2210 19.28 230106......... 01.1730 18.07
190190....................... 00.9294 18.74 210007.......... 01.6144 18.82 220035......... 01.2748 19.72 230003......... 01.0891 18.07 230107......... 00.8972 12.56
190191....................... 01.3146 18.47 210008.......... 01.3145 21.21 220036......... 01.6198 23.26 230004......... 01.6087 20.95 230108......... 01.2387 16.64
190194....................... 01.1471 19.16 210009.......... 01.7113 18.57 220038......... 01.2797 21.85 230005......... 01.2812 18.02 230110......... 01.3356 17.10
190196....................... 00.9064 16.46 210010.......... 01.2016 17.00 220041......... 01.2446 20.87 230006......... 01.1331 16.19 230111......... 00.9762 15.13
190197....................... 01.2631 19.05 210011.......... 01.2066 20.12 220042......... 01.2043 24.10 230007......... 01.0869 16.51 230113......... 00.9500 17.66
190199....................... 01.3557 12.82 210012.......... 01.4880 21.27 220046......... 01.3991 21.48 230013......... 01.2823 20.70 230114......... 00.6368 23.27
190200....................... 01.5122 21.33 210013.......... 01.2755 20.65 220049......... 01.2668 21.58 230015......... 01.1305 18.28 230115......... 01.0218 15.14
190201....................... 01.2417 18.24 210015.......... 01.2700 18.48 220050......... 01.0856 17.45 230017......... 01.5161 20.40 230116......... 00.9079 15.58
190202....................... 01.4412 18.34 210016.......... 01.7323 20.37 220051......... 01.2701 19.70 230019......... 01.5116 20.50 230117......... 01.9633 23.81
190203....................... 01.5963 19.50 210017.......... 01.1297 15.35 220052......... 01.2969 22.76 230020......... 01.7218 21.17 230118......... 01.2381 17.25
190204....................... 01.5211 20.12 210018.......... 01.2426 20.93 220053......... 01.2476 18.86 230021......... 01.5949 17.25 230119......... 01.3182 21.13
190205....................... 01.8559 17.63 210019.......... 01.3992 17.42 220055......... 01.3472 20.61 230022......... 01.2454 17.62 230120......... 01.2209 19.00
190206....................... 01.4848 21.17 210022.......... 01.4541 20.07 220057......... 01.4402 20.91 230024......... 01.4230 21.79 230121......... 01.2308 19.67
190207....................... 01.1759 19.43 210023.......... 01.2870 20.31 220058......... 01.0628 17.55 230027......... 01.0568 16.25 230122......... 01.3310 18.32
190208....................... 00.8210 10.20 210024.......... 01.5093 18.06 220060......... 01.2567 24.78 230029......... 01.5980 20.91 230124......... 01.1514 16.49
190218....................... 01.1418 15.05 210025.......... 01.3259 17.84 220062......... 00.6041 19.30 230030......... 01.2372 16.55 230125......... 01.3587 13.01
190223....................... 00.4998 12.04 210026.......... 01.3221 24.54 220063......... 01.2982 18.42 230031......... 01.4622 18.32 230128......... 01.3795 19.33
190227....................... 00.8050 30.01 210027.......... 01.2047 17.47 220064......... 01.2108 20.66 230032......... 01.7401 18.97 230129......... 01.8851 19.07
190230....................... 00.8511 ....... 210028.......... 01.2362 16.66 220065......... 01.2162 20.00 230034......... 01.1936 16.64 230130......... 01.6896 22.37
190231....................... 01.3052 ....... 210029.......... 01.3022 20.04 220066......... 01.2825 19.39 230035......... 01.1374 15.84 230132......... 01.5360 22.92
190232....................... 01.6623 ....... 210030.......... 01.0938 15.77 220067......... 01.2910 22.82 230036......... 01.2859 19.78 230133......... 01.2321 14.06
190233....................... 01.1753 ....... 210031.......... 01.6379 16.97 220068......... 00.5210 15.95 230037......... 01.1680 16.96 230134......... 01.1066 15.87
190234....................... 01.0977 ....... 210032.......... 01.2064 18.42 220070......... 01.2693 17.77 230038......... 01.6453 21.18 230135......... 01.2023 19.88
200001....................... 01.2668 15.74 210033.......... 01.1813 17.38 220071......... 01.8550 24.38 230040......... 01.1967 18.35 230137......... 01.1665 17.78
200002....................... 01.0219 16.15 210034.......... 01.3999 20.29 220073......... 01.3821 25.34 230041......... 01.2106 19.17 230141......... 01.6842 20.84
200003....................... 01.1282 15.90 210035.......... 01.1950 17.25 220074......... 01.2579 21.18 230042......... 01.1517 19.03 230142......... 01.2118 18.71
200006....................... 01.0627 14.95 210037.......... 01.2862 16.14 220075......... 01.3235 20.09 230046......... 01.8323 24.65 230143......... 01.1404 15.23
200007....................... 01.0052 16.86 210038.......... 01.3397 19.90 220076......... 01.1791 22.47 230047......... 01.3036 19.61 230144......... 01.1171 21.06
200008....................... 01.2463 18.34 210039.......... 01.1588 15.25 220077......... 01.7205 22.32 230053......... 01.5335 23.82 230145......... 01.1817 15.41
200009....................... 01.7644 19.84 210040.......... 01.2948 20.32 220079......... 01.1871 21.28 230054......... 01.8245 19.74 230146......... 01.2933 19.49
200012....................... 01.1610 16.11 210043.......... 01.2538 20.04 220080......... 01.2723 17.77 230055......... 01.1799 17.36 230147......... 01.4832 19.34
200013....................... 01.1360 15.32 210044.......... 01.2025 20.28 220081......... 00.9625 23.55 230056......... 00.9745 14.17 230149......... 01.2487 14.92
200015....................... 01.2341 17.15 210045.......... 01.0197 11.73 220082......... 01.2932 19.28 230058......... 01.0807 17.42 230151......... 01.3634 21.32
200016....................... 01.0283 16.10 210046.......... 01.1047 12.34 220083......... 01.1845 19.80 230059......... 01.4913 19.00 230153......... 01.1245 15.61
200017....................... 01.2444 16.86 210048.......... 01.1780 22.47 220084......... 01.2361 22.24 230060......... 01.2802 16.90 230154......... 00.9519 12.09
200018....................... 01.1671 14.27 210049.......... 01.1482 16.57 220086......... 01.5481 24.60 230062......... 01.0313 13.61 230155......... 00.9759 13.80
200019....................... 01.2445 18.01 210051.......... 01.4488 13.94 220088......... 01.5772 21.76 230063......... 01.3188 18.41 230156......... 01.7043 21.57
200020....................... 01.1821 19.86 210054.......... 01.2726 20.17 220089......... 01.3301 22.99 230065......... 01.5013 18.63 230157......... 01.2036 19.67
200021....................... 01.1844 17.66 210055.......... 01.2866 22.48 220090......... 01.2380 20.78 230066......... 01.3628 18.72 230159......... 01.3967 18.93
200023....................... 00.8848 14.61 210056.......... 01.4106 16.51 220092......... 01.2548 20.86 230068......... 01.4399 22.29 230162......... 00.9885 13.73
200024....................... 01.2892 19.16 210057.......... 01.3623 ....... 220094......... 01.2795 19.76 230069......... 01.1716 18.86 230165......... 01.8687 20.92
200025....................... 01.2698 18.81 210058.......... 01.6823 18.09 220095......... 01.2220 17.77 230070......... 01.4873 19.30 230167......... 01.3648 19.18
200026....................... 01.0913 15.20 210059.......... 01.2586 21.91 220098......... 01.2874 19.81 230071......... 01.1375 20.78 230169......... 01.4359 21.16
200027....................... 01.1419 16.51 210060.......... 01.1661 25.28 220099......... 01.1836 15.97 230072......... 01.2839 18.87 230171......... 00.9842 14.18
200028....................... 00.9343 14.83 210061.......... 01.0947 14.25 220100......... 01.2742 23.48 230075......... 01.5188 19.29 230172......... 01.3154 17.85
200031....................... 01.2955 14.96 220001.......... 01.1632 20.98 220101......... 01.5044 22.58 230076......... 01.3263 21.53 230174......... 01.2896 19.11
200032....................... 01.3528 17.72 220002.......... 01.5425 21.62 220104......... 01.2488 23.12 230077......... 01.9786 18.44 230175......... 04.1740 14.83
200033....................... 01.7115 19.57 220003.......... 01.0771 16.92 220105......... 01.2188 21.97 230078......... 01.0937 14.82 230176......... 01.2350 20.89
200034....................... 01.1951 17.19 220004.......... 01.1778 18.85 220106......... 01.2489 21.83 230080......... 01.1934 20.41 230178......... 01.0502 16.02
200037....................... 01.2200 15.53 220006.......... 01.4287 21.79 220107......... 01.1695 18.46 230081......... 01.2169 16.55 230180......... 01.0710 15.03
200038....................... 01.1115 17.66 220008.......... 01.2538 19.26 220108......... 01.1491 20.96 230082......... 01.1611 14.88 230184......... 01.2276 16.99
200039....................... 01.2513 18.06 220010.......... 01.2956 20.94 220110......... 01.9412 30.07 230085......... 01.1161 17.10 230186......... 01.3686 15.81
200040....................... 01.0917 16.48 220011.......... 01.1550 27.95 220111......... 01.2575 21.21 230086......... 00.9918 14.03 230188......... 01.1727 15.49
200041....................... 01.2221 17.37 220012.......... 01.3665 27.84 220116......... 01.9442 23.95 230087......... 01.0641 13.65 230189......... 00.8937 14.50
200043....................... 00.5614 16.96 220015.......... 01.1777 20.35 220118......... 02.0524 26.47 230089......... 01.3393 21.55 230190......... 01.0395 22.66
200050....................... 01.1978 16.71 220016.......... 01.3747 20.16 220119......... 01.3288 24.40 230092......... 01.3264 17.77 230191......... 00.8900 14.99
200051....................... 00.9723 17.70 220017.......... 01.4278 23.78 220123......... 01.0371 23.85 230093......... 01.2267 17.37 230193......... 01.2471 16.03
200052....................... 00.9716 13.07 220019.......... 01.1780 17.06 220126......... 01.3041 19.39 230095......... 01.2357 15.53 230194......... 01.2111 14.37
200055....................... 01.1557 14.56 220020.......... 01.2189 18.47 220128......... 01.1441 20.85 230096......... 01.1957 19.85 230195......... 01.2822 19.80
200062....................... 00.9198 14.64 220021.......... 01.3862 23.21 220133......... 00.8406 30.53 230097......... 01.5406 17.75 230197......... 01.2640 22.00
200063....................... 01.1662 16.63 220023.......... 01.1469 19.37 220135......... 01.2559 23.97 230099......... 01.2173 19.06 230199......... 01.1553 17.72
200066....................... 01.1689 14.34 220024.......... 01.1752 20.14 220153......... 01.0402 19.74 230100......... 01.1533 15.19 230201......... 01.2138 14.02
210001....................... 01.4102 17.94 220025.......... 01.1894 18.87 220154......... 00.9268 18.96 230101......... 01.0658 16.79 230204......... 01.3660 19.78
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[[Page 46247]]
Page 8 of 16
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
230205....................... 01.0570 14.54 240044.......... 01.2004 16.02 240129......... 01.0159 12.18 250032......... 01.2599 15.70 250134......... 00.9882 12.70
230207....................... 01.2586 19.85 240045.......... 01.0731 18.49 240130......... 01.0112 14.54 250033......... 00.9948 11.57 250136......... 00.7904 16.84
230208....................... 01.1857 16.10 240047.......... 01.5172 18.27 240132......... 01.2360 21.80 250034......... 01.5348 12.99 250138......... 01.3513 16.94
230211....................... 00.9823 13.86 240048.......... 01.2728 20.43 240133......... 01.1709 16.16 250035......... 00.9044 11.82 250140......... 00.9213 09.37
230212....................... 01.0970 21.13 240049.......... 01.7768 20.33 240135......... 00.8166 11.38 250036......... 00.9786 11.34 250141......... 01.2098 15.50
230213....................... 01.0251 12.69 240050.......... 01.1319 19.89 240137......... 01.2521 15.40 250037......... 00.8704 09.53 250144......... 00.9384 11.18
230216....................... 01.5269 17.91 240051.......... 00.9956 15.97 240138......... 00.8994 13.09 250038......... 00.9851 12.52 250145......... 00.9432 ......
230217....................... 01.2172 18.06 240052.......... 01.2612 17.21 240139......... 00.9643 14.24 250039......... 01.0021 11.71 250146......... 01.0011 13.25
230219....................... 01.0186 15.18 240053.......... 01.5152 19.67 240141......... 01.0919 19.12 250040......... 01.2981 15.65 250148......... 01.1518 ......
230221....................... 01.1845 18.15 240056.......... 01.2438 20.13 240142......... 01.1289 15.16 250042......... 01.1494 13.78 250149......... 00.9174 ......
230222....................... 01.3604 18.98 240057.......... 01.7426 22.04 240143......... 01.0597 12.48 250043......... 01.0352 10.49 260001......... 01.6549 16.08
230223....................... 01.3187 19.85 240058.......... 00.9668 09.64 240144......... 00.9459 13.39 250044......... 00.9822 13.98 260002......... 01.4877 20.05
230227....................... 01.5187 22.00 240059.......... 01.0942 17.98 240145......... 00.9654 12.37 250045......... 01.1477 17.17 260003......... 00.9457 12.45
230228....................... 01.2121 17.29 240061.......... 01.7512 20.93 240146......... 00.9209 17.20 250047......... 00.9674 09.12 260004......... 01.0314 11.86
230230....................... 01.5400 20.38 240063.......... 01.4674 20.88 240148......... 00.9490 11.34 250048......... 01.4542 13.51 260005......... 01.6146 19.68
230232....................... 01.0356 15.87 240064.......... 01.2630 18.13 240150......... 00.8906 11.72 250049......... 00.9037 09.93 260006......... 01.5247 16.72
230235....................... 01.1038 14.65 240065.......... 01.1600 11.14 240152......... 01.0128 17.85 250050......... 01.2407 12.30 260007......... 01.4679 16.03
230236....................... 01.3542 21.07 240066.......... 01.4040 19.08 240153......... 01.0199 14.30 250051......... 00.8548 09.44 260008......... 01.2220 15.65
230239....................... 01.1770 16.07 240069.......... 01.1629 18.35 240154......... 01.0158 13.15 250057......... 01.1806 14.06 260009......... 01.2407 15.63
230241....................... 01.1553 17.08 240071.......... 01.1200 18.05 240155......... 00.9827 14.39 250058......... 01.1385 13.65 260011......... 01.6765 16.87
230244....................... 01.3134 20.14 240072.......... 01.0257 16.08 240157......... 01.1226 13.92 250059......... 01.0304 12.16 260012......... 01.0472 11.96
230253....................... 01.0735 17.39 240073.......... 00.9213 15.13 240160......... 01.0116 14.65 250060......... 00.8121 12.19 260013......... 01.1520 14.02
230254....................... 01.2785 22.64 240075.......... 01.2132 18.79 240161......... 00.9351 14.56 250061......... 00.8654 10.75 260014......... 01.7769 17.84
230257....................... 01.1031 19.01 240076.......... 01.1434 19.94 240162......... 00.9629 15.28 250063......... 00.8615 12.68 260015......... 01.2698 13.16
230259....................... 01.1967 19.06 240077.......... 01.0646 14.15 240163......... 00.9381 14.10 250065......... 00.8878 11.72 260017......... 01.2272 13.94
230264....................... 00.9614 16.74 240078.......... 01.4510 21.46 240166......... 01.1661 14.67 250066......... 00.9422 12.17 260018......... 00.9658 09.56
230269....................... 01.3062 21.71 240079.......... 01.0143 12.57 240169......... 00.9528 15.25 250067......... 01.1241 14.14 260019......... 00.9862 12.63
230270....................... 01.2238 20.08 240080.......... 01.3766 20.87 240170......... 01.1518 14.42 250068......... 00.8546 11.19 260020......... 01.7312 19.29
230273....................... 01.6568 22.11 240082.......... 01.1233 14.55 240171......... 00.9973 14.02 250069......... 01.1820 13.42 260021......... 01.5117 18.47
230275....................... 00.5764 16.53 240083.......... 01.3779 16.60 240172......... 01.0856 14.50 250071......... 00.9499 08.06 260022......... 01.3423 18.69
230276....................... 00.8113 16.23 240084.......... 01.3446 17.20 240173......... 00.9609 14.82 250072......... 01.2933 17.40 260023......... 01.2569 15.58
230277....................... 01.2440 21.76 240085.......... 00.9356 14.90 240179......... 00.9990 14.30 250076......... 00.9378 10.32 260024......... 01.0179 12.28
230278....................... 02.1143 19.50 240086.......... 01.0496 15.23 240180......... 01.0157 10.51 250077......... 00.9481 11.08 260025......... 01.3240 13.61
230279....................... 00.7080 ....... 240087.......... 01.1088 15.69 240184......... 01.0352 11.31 250078......... 01.4504 14.21 260027......... 01.5963 18.92
230280....................... 01.0737 ....... 240088.......... 01.4423 18.10 240187......... 01.2576 16.56 250079......... 00.8573 15.12 260029......... 01.1241 15.76
230281....................... 01.8228 ....... 240089.......... 00.9966 15.23 240193......... 01.0505 14.73 250081......... 01.3046 15.19 260030......... 01.0922 09.73
240001....................... 01.5705 21.24 240090.......... 01.0889 13.57 240196......... 00.6134 22.50 250082......... 01.2852 12.30 260031......... 01.5029 18.49
240002....................... 01.6951 19.40 240093.......... 01.3149 16.49 240200......... 00.8945 13.34 250083......... 01.0297 11.01 260032......... 01.5899 17.59
240004....................... 01.4733 20.16 240094.......... 01.0470 17.26 240205......... 00.9066 ....... 250084......... 01.0930 13.92 260034......... 00.9820 14.22
240005....................... 00.9911 13.49 240096.......... 01.0126 14.12 240206......... 00.8405 ....... 250085......... 01.0146 11.42 260035......... 01.0725 11.44
240006....................... 01.1243 19.75 240097.......... 01.1262 17.05 240207......... 01.2516 21.47 250088......... 00.9555 15.43 260036......... 01.0697 15.72
240007....................... 01.1114 15.15 240098.......... 00.9639 16.41 240210......... 01.2558 21.44 250089......... 01.0349 11.77 260037......... 01.3946 15.17
240008....................... 01.0447 15.22 240099.......... 01.1186 11.00 240211......... 00.9295 11.18 250093......... 01.1144 12.17 260039......... 01.1393 11.17
240009....................... 00.9722 14.18 240100.......... 01.3180 19.58 240212......... 01.9942 ....... 250094......... 01.2380 14.41 260040......... 01.6081 14.92
240010....................... 01.9804 20.17 240101.......... 01.1585 17.32 250001......... 01.6860 15.91 250095......... 00.9763 13.57 260042......... 01.4179 15.65
240011....................... 01.1378 15.69 240102.......... 00.8877 12.27 250002......... 00.7948 13.34 250096......... 01.3058 16.49 260044......... 01.0453 14.29
240013....................... 01.3077 15.90 240103.......... 01.0788 14.10 250003......... 01.0260 14.13 250097......... 01.1879 13.83 260047......... 01.3608 14.19
240014....................... 01.0825 17.79 240104.......... 01.2317 21.71 250004......... 01.4695 15.12 250098......... 00.8668 13.73 260048......... 01.2801 18.05
240016....................... 01.3045 15.46 240105.......... 01.0024 12.70 250005......... 00.9707 09.15 250099......... 01.2736 12.73 260050......... 01.0896 14.71
240017....................... 01.1365 15.15 240106.......... 01.3351 23.68 250006......... 00.9603 12.27 250100......... 01.2423 14.53 260052......... 01.3429 15.95
240018....................... 01.2985 15.82 240107.......... 00.9779 15.07 250007......... 01.2699 16.88 250101......... 00.9416 09.89 260053......... 01.1239 09.46
240019....................... 01.2259 19.58 240108.......... 00.9570 11.64 250008......... 00.9041 11.36 250102......... 01.5340 14.80 260054......... 01.3205 16.08
240020....................... 01.1410 18.11 240109.......... 00.9926 13.59 250009......... 01.1772 15.04 250104......... 01.3615 15.58 260055......... 01.0344 13.67
240021....................... 00.9545 12.49 240110.......... 01.0347 15.18 250010......... 01.0374 11.07 250105......... 00.9185 13.13 260057......... 01.1563 13.85
240022....................... 01.1265 17.33 240111.......... 00.9806 13.06 250012......... 00.9543 13.77 250107......... 00.9101 14.16 260059......... 01.1218 14.17
240023....................... 01.0070 15.86 240112.......... 01.0585 13.30 250015......... 01.0921 09.75 250109......... 00.9351 11.54 260061......... 01.1737 10.87
240025....................... 01.1710 15.02 240114.......... 00.9961 11.13 250017......... 01.0049 13.77 250112......... 00.9915 14.22 260062......... 01.1677 19.89
240027....................... 00.9990 12.60 240115.......... 01.6186 22.30 250018......... 00.9576 09.81 250117......... 01.0706 13.28 260063......... 01.1867 14.82
240028....................... 01.1340 16.50 240116.......... 00.9450 12.43 250019......... 01.4239 17.43 250119......... 01.2057 10.80 260064......... 01.3241 15.40
240029....................... 01.1619 15.70 240117.......... 01.0688 16.21 250020......... 01.0024 10.78 250120......... 01.0683 12.04 260065......... 01.7807 15.31
240030....................... 01.2995 16.78 240119.......... 00.8459 16.93 250021......... 00.8612 07.74 250122......... 01.2814 15.87 260066......... 01.0907 12.78
240031....................... 00.9285 13.50 240121.......... 00.8986 17.10 250023......... 00.8655 11.22 250123......... 01.3253 17.72 260067......... 00.9812 10.43
240036....................... 01.5566 19.05 240122.......... 01.0462 16.80 250024......... 00.9845 08.25 250124......... 00.9123 10.69 260068......... 01.6696 18.49
240037....................... 01.0463 16.40 240123.......... 01.0518 13.30 250025......... 01.1440 13.58 250125......... 01.3189 18.35 260070......... 01.0868 11.09
240038....................... 01.4513 22.50 240124.......... 01.0123 15.71 250027......... 01.0290 10.40 250126......... 00.9867 10.22 260073......... 00.9754 11.58
240040....................... 01.2271 17.67 240125.......... 00.9399 10.75 250029......... 00.8857 11.87 250127......... 00.7659 ....... 260074......... 01.2444 11.49
240041....................... 01.3105 14.43 240127.......... 01.0272 12.51 250030......... 00.9703 11.39 250128......... 01.0941 12.64 260077......... 01.7237 16.30
240043....................... 01.2029 16.83 240128.......... 01.1234 14.55 250031......... 01.3147 17.20 250131......... 01.0545 09.36 260078......... 01.1752 12.39
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[[Page 46248]]
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
260079....................... 00.9808 11.78 270002.......... 01.1914 13.92 280024......... 01.0190 13.22 280111......... 01.2501 16.06 310014......... 01.7262 23.69
260080....................... 00.9748 09.77 270003.......... 01.2463 18.65 280025......... 00.9834 11.07 280114......... 00.9302 10.26 310015......... 01.7788 24.34
260081....................... 01.4994 16.44 270004.......... 01.6543 17.33 280026......... 01.1268 12.80 280115......... 00.9762 13.59 310016......... 01.2218 22.93
260082....................... 01.1249 13.50 270006.......... 01.0348 18.67 280028......... 01.0603 13.64 280117......... 01.2367 14.48 310017......... 01.3316 21.95
260085....................... 01.5653 18.92 270007.......... 00.9630 12.26 280029......... 01.0513 12.62 280118......... 00.9917 13.47 310018......... 01.2149 21.06
260086....................... 01.0538 12.67 270009.......... 01.0369 14.91 280030......... 01.7482 23.06 280119......... 00.8442 ....... 310019......... 01.6444 20.84
260089....................... 00.9595 13.31 270011.......... 01.1240 16.46 280031......... 01.0457 12.48 280123......... 00.7968 ....... 310020......... 01.1914 19.66
260091....................... 01.6036 18.96 270012.......... 01.5997 17.10 280032......... 01.3205 15.11 290001......... 01.6296 22.35 310021......... 01.3482 21.15
260094....................... 01.1818 15.98 270013.......... 01.2868 16.78 280033......... 00.9881 13.62 290002......... 00.9009 17.99 310022......... 01.2391 19.38
260095....................... 01.4416 16.05 270014.......... 01.7155 15.97 280034......... 01.2104 13.41 290003......... 01.6155 21.15 310024......... 01.2539 22.60
260096....................... 01.5553 21.52 270016.......... 00.8195 11.51 280035......... 00.9439 11.75 290005......... 01.4321 19.66 310025......... 01.2317 21.92
260097....................... 01.1803 15.82 270017.......... 01.2264 18.32 280037......... 01.0150 13.55 290006......... 01.2223 16.54 310026......... 01.2770 21.91
260100....................... 00.9672 13.12 270019.......... 01.0747 13.34 280038......... 01.0733 13.39 290007......... 01.9023 25.07 310027......... 01.3756 18.17
260102....................... 01.0113 16.75 270021.......... 01.1036 15.55 280039......... 01.1841 14.24 290008......... 01.2244 17.14 310028......... 01.1453 20.46
260103....................... 01.3826 16.73 270023.......... 01.2906 18.76 280040......... 01.5869 18.30 290009......... 01.6096 21.07 310029......... 01.8972 20.69
260104....................... 01.6337 19.57 270024.......... 00.9931 11.15 280041......... 00.9988 10.95 290010......... 01.2116 19.33 310031......... 02.6282 24.14
260105....................... 01.8722 19.18 270026.......... 00.8677 11.95 280042......... 01.0970 13.22 290011......... 00.8854 14.39 310032......... 01.2962 20.00
260107....................... 01.3844 18.55 270027.......... 01.0389 12.69 280043......... 01.1235 12.75 290012......... 01.4484 19.97 310034......... 01.2537 19.14
260108....................... 01.8056 18.26 270028.......... 01.0735 14.91 280045......... 01.1409 13.48 290013......... 01.0180 14.85 310036......... 01.2137 18.44
260109....................... 00.9922 11.92 270029.......... 00.9056 14.51 280046......... 01.0729 11.09 290014......... 01.0424 16.52 310037......... 01.3032 25.43
260110....................... 01.6069 14.16 270031.......... 00.8747 09.71 280047......... 01.1632 15.70 290015......... 00.9691 15.38 310038......... 01.9189 22.82
260111....................... 00.9994 08.04 270032.......... 01.1776 16.46 280048......... 01.0813 11.17 290016......... 01.1476 18.71 310039......... 01.2906 20.51
260112....................... 01.4123 17.47 270033.......... 00.8822 11.39 280049......... 01.0363 13.82 290019......... 01.2779 17.92 310040......... 01.2680 23.12
260113....................... 01.1111 14.05 270035.......... 01.0294 15.87 280050......... 00.9263 13.11 290020......... 01.0783 17.65 310041......... 01.3192 22.90
260115....................... 01.2400 14.92 270036.......... 00.9483 10.42 280051......... 01.0572 13.72 290021......... 01.5602 19.17 310042......... 01.2513 21.74
260116....................... 01.1317 13.70 270039.......... 01.0661 11.99 280052......... 01.0352 11.85 290022......... 01.7398 22.47 310043......... 01.2027 20.60
260119....................... 01.1592 15.01 270040.......... 01.0819 17.60 280054......... 01.2613 15.54 290027......... 00.9516 14.68 310044......... 01.2981 20.16
260120....................... 01.1606 15.72 270041.......... 01.0700 11.14 280055......... 00.9274 11.63 290029......... 00.9400 ....... 310045......... 01.3866 25.76
260122....................... 01.1407 13.12 270044.......... 01.1997 13.40 280056......... 00.9925 10.99 290032......... 01.4088 18.66 310047......... 01.3405 23.05
260123....................... 01.0309 11.17 270046.......... 00.9328 13.50 280057......... 01.0060 14.48 290036......... 01.4927 ....... 310048......... 01.1853 20.69
260127....................... 00.9517 13.71 270048.......... 01.0968 13.30 280058......... 01.3349 13.75 290038......... 01.1066 ....... 310049......... 01.3247 23.54
260128....................... 00.9877 08.95 270049.......... 01.8369 18.19 280060......... 01.5930 18.38 300001......... 01.3969 20.70 310050......... 01.2623 20.88
260129....................... 01.2126 13.51 270050.......... 01.0374 15.96 280061......... 01.4692 14.76 300003......... 01.8661 20.92 310051......... 01.3232 24.26
260131....................... 01.3183 16.32 270051.......... 01.2969 18.02 280062......... 01.2236 11.92 300005......... 01.2669 18.65 310052......... 01.2516 20.53
260134....................... 01.1485 13.87 270052.......... 01.0663 18.02 280064......... 01.0732 12.61 300006......... 01.1225 16.24 310054......... 01.2937 23.19
260137....................... 01.2635 13.71 270053.......... 00.8716 09.53 280065......... 01.2934 16.22 300007......... 01.1477 16.76 310056......... 01.1800 20.11
260138....................... 01.9683 20.66 270057.......... 01.1700 17.35 280066......... 01.0101 11.38 300008......... 01.2465 16.95 310057......... 01.2906 20.10
260141....................... 01.8935 16.53 270058.......... 00.9419 11.20 280068......... 00.9716 09.31 300009......... 01.1071 17.45 310058......... 01.1047 25.35
260142....................... 01.1604 14.50 270059.......... 00.8676 19.21 280070......... 01.0712 10.75 300010......... 01.2380 17.80 310060......... 01.2112 17.55
260143....................... 00.9437 10.52 270060.......... 00.9653 11.92 280073......... 01.0399 12.78 300011......... 01.3508 21.36 310061......... 01.2156 19.85
260147....................... 01.0490 12.81 270063.......... 00.8933 12.94 280074......... 01.0981 12.87 300012......... 01.2779 21.64 310062......... 01.2941 23.90
260148....................... 00.9639 09.33 270068.......... 00.8629 12.38 280075......... 01.2063 12.90 300013......... 01.2250 16.87 310063......... 01.3515 20.78
260158....................... 01.1355 11.80 270072.......... 00.8526 14.88 280076......... 01.0602 12.54 300014......... 01.2336 18.41 310064......... 01.2988 21.35
260159....................... 01.2962 18.17 270073.......... 01.0764 11.06 280077......... 01.3589 17.36 300015......... 01.1776 17.37 310067......... 01.3199 21.14
260160....................... 01.0683 14.07 270074.......... 00.8861 ....... 280079......... 01.0649 09.40 300016......... 01.3172 17.41 310069......... 01.1308 18.19
260162....................... 01.6912 17.70 270075.......... 00.8706 ....... 280080......... 01.0842 11.34 300017......... 01.2081 20.49 310070......... 01.3980 22.16
260163....................... 01.3188 14.11 270076.......... 00.8386 ....... 280081......... 01.5683 17.24 300018......... 01.2333 18.85 310072......... 01.2980 20.74
260164....................... 00.9955 12.07 270079.......... 00.9563 13.36 280082......... 01.1154 13.03 300019......... 01.2621 18.43 310073......... 01.5552 22.31
260166....................... 01.2126 21.51 270080.......... 01.1536 14.27 280083......... 01.0646 15.64 300020......... 01.2622 19.78 310074......... 01.4149 21.08
260172....................... 01.0128 12.07 270081.......... 01.0790 09.77 280084......... 01.0366 10.92 300021......... 01.1644 15.69 310075......... 01.2933 21.67
260173....................... 00.9588 11.15 270082.......... 01.0039 16.10 280085......... 00.7201 14.02 300022......... 01.1031 17.08 310076......... 01.3854 28.16
260175....................... 01.1310 14.60 270083.......... 01.1160 10.96 280088......... 01.8032 18.12 300023......... 01.3278 20.13 310077......... 01.5172 23.09
260176....................... 01.6716 19.26 270084.......... 00.9034 12.77 280089......... 01.0548 13.79 300024......... 01.2736 16.56 310078......... 01.3568 22.70
260177....................... 01.3854 19.46 280001.......... 01.0830 14.11 280090......... 00.9850 11.70 300028......... 01.2674 15.52 310081......... 01.2644 20.80
260178....................... 01.4707 19.06 280003.......... 01.9484 18.11 280091......... 01.1370 13.17 300029......... 01.3084 21.29 310083......... 01.2592 22.20
260179....................... 01.5633 18.48 280005.......... 01.3783 16.64 280092......... 00.8990 11.63 300033......... 01.1012 13.70 310084......... 01.2622 20.43
260180....................... 01.6919 18.45 280009.......... 01.7335 16.70 280094......... 01.1464 13.32 300034......... 01.9356 21.31 310086......... 01.1738 20.89
260183....................... 01.6448 16.51 280011.......... 00.9513 11.56 280097......... 01.0552 12.56 310001......... 01.7775 24.91 310087......... 01.2345 18.95
260186....................... 01.2538 15.20 280012.......... 01.2413 14.88 280098......... 01.0077 09.68 310002......... 01.7278 25.68 310088......... 01.2566 19.57
260188....................... 01.2759 15.70 280013.......... 02.0235 19.71 280101......... 01.1173 10.92 310003......... 01.2230 23.16 310090......... 01.1884 22.86
260189....................... 00.9409 11.23 280014.......... 00.9990 10.78 280102......... 01.1321 11.77 310005......... 01.2257 19.20 310091......... 01.2193 21.35
260190....................... 01.2003 18.46 280015.......... 01.0254 13.78 280104......... 00.9599 09.88 310006......... 01.2209 19.02 310092......... 01.3080 20.52
260191....................... 01.1725 19.44 280017.......... 01.1524 13.42 280105......... 01.2988 16.46 310008......... 01.2785 21.23 310093......... 01.2193 19.52
260193....................... 01.2262 19.13 280018.......... 01.1939 12.25 280106......... 00.9481 13.23 310009......... 01.2877 21.35 310096......... 01.9014 21.19
260195....................... 01.1678 ....... 280020.......... 01.5198 18.97 280107......... 01.0284 12.36 310010......... 01.2966 21.05 310105......... 01.1914 22.41
260197....................... 01.3273 20.38 280021.......... 01.3322 14.01 280108......... 01.1433 13.26 310011......... 01.3050 21.71 310108......... 01.3940 21.08
260198....................... 01.2292 14.98 280022.......... 00.9740 11.07 280109......... 00.9424 10.61 310012......... 01.5915 23.53 310110......... 01.2108 19.69
260200....................... 01.3542 19.14 280023.......... 01.3802 13.73 280110......... 01.0201 10.88 310013......... 01.2813 19.91 310111......... 01.2536 19.70
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[[Page 46249]]
Page 10 of 16
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
310112....................... 01.2441 20.58 330024.......... 01.9152 30.03 330126......... 01.2229 20.35 330230......... 01.5076 26.44 330396......... 01.2740 25.30
310113....................... 01.2115 20.70 330025.......... 01.1879 13.80 330127......... 01.3974 25.01 330231......... 01.1364 27.57 330397......... 01.3146 26.82
310115....................... 01.1954 19.78 330027.......... 01.4751 28.56 330128......... 01.3390 25.26 330232......... 01.2180 15.46 330398......... 01.2362 26.59
310116....................... 01.2905 21.67 330028.......... 01.3453 23.76 330132......... 01.1636 13.74 330233......... 01.5344 29.08 330399......... 01.3284 29.65
310118....................... 01.1883 21.86 330029.......... 01.1091 17.36 330133......... 01.3525 28.31 330234......... 02.1947 24.17 340001......... 01.4939 19.54
310119....................... 01.5440 27.27 330030.......... 01.2330 15.20 330135......... 01.2522 16.25 330235......... 01.1384 17.37 340002......... 01.8814 18.53
310120....................... 01.0653 17.24 330033.......... 01.2702 13.46 330136......... 01.2620 20.45 330236......... 01.3965 26.57 340003......... 01.1186 16.56
310121....................... 01.0416 16.61 330034.......... 00.7745 36.61 330140......... 01.7171 17.19 330238......... 01.1734 14.53 340004......... 01.4952 17.21
320001....................... 01.4645 16.76 330036.......... 01.3260 21.00 330141......... 01.3544 23.17 330239......... 01.2034 15.44 340005......... 01.2172 14.57
320002....................... 01.4190 21.55 330037.......... 01.1403 15.17 330144......... 00.9809 13.27 330240......... 01.3472 26.47 340006......... 01.2315 14.56
320003....................... 01.1694 15.57 330038.......... 01.2154 14.91 330148......... 01.0806 14.39 330241......... 01.8842 20.92 340007......... 01.1793 14.81
320004....................... 01.2647 17.86 330039.......... 00.8474 13.18 330151......... 01.0508 13.77 330242......... 01.3486 22.98 340008......... 01.1505 16.90
320005....................... 01.3207 17.86 330041.......... 01.3957 27.81 330152......... 01.4256 27.77 330245......... 01.2684 17.15 340009......... 01.3744 19.12
320006....................... 01.3742 15.20 330043.......... 01.2516 26.92 330153......... 01.6484 17.44 330246......... 01.2600 22.99 340010......... 01.3111 16.41
320009....................... 01.5332 16.49 330044.......... 01.2413 17.05 330154......... 01.5904 ....... 330247......... 00.7043 26.49 340011......... 01.1105 13.98
320011....................... 00.9883 17.79 330045.......... 01.4206 24.83 330157......... 01.3111 18.41 330249......... 01.2271 15.89 340012......... 01.2599 15.82
320012....................... 01.0365 16.57 330046.......... 01.5166 30.08 330158......... 01.3798 24.33 330250......... 01.3148 16.01 340013......... 01.2783 16.58
320013....................... 01.2196 18.28 330047.......... 01.2282 16.63 330159......... 01.3217 17.55 330252......... 00.9107 15.40 340014......... 01.5898 22.15
320014....................... 01.0172 13.13 330048.......... 01.3029 16.10 330160......... 01.4707 26.09 330254......... 01.0280 15.94 340015......... 01.2409 16.44
320016....................... 01.1611 12.00 330049.......... 01.2452 17.52 330161......... 00.7237 16.00 330258......... 01.4226 25.28 340016......... 01.2062 15.18
320017....................... 01.2209 17.34 330053.......... 01.1285 14.39 330162......... 01.2663 26.18 330259......... 01.4498 21.99 340017......... 01.2587 15.96
320018....................... 01.4884 16.61 330055.......... 01.5084 29.02 330163......... 01.2137 17.75 330261......... 01.2244 24.35 340018......... 01.1282 14.78
320019....................... 01.4863 19.01 330056.......... 01.4474 28.37 330164......... 01.3963 18.96 330263......... 00.9929 17.00 340019......... 01.0519 13.69
320021....................... 01.7092 20.62 330057.......... 01.7158 16.48 330166......... 00.9723 14.11 330264......... 01.2681 20.00 340020......... 01.1686 17.33
320022....................... 01.1787 16.34 330058.......... 01.3270 15.85 330167......... 01.6440 27.45 330265......... 01.3105 15.78 340021......... 01.2198 15.08
320023....................... 01.0348 13.29 330059.......... 01.6224 29.66 330169......... 01.4303 31.95 330267......... 01.2786 22.78 340022......... 01.0527 14.56
320030....................... 00.9822 16.54 330061.......... 01.2977 23.38 330171......... 01.2804 22.28 330268......... 00.9740 15.79 340023......... 01.3923 18.44
320031....................... 00.9008 14.78 330062.......... 01.1779 14.99 330175......... 01.1255 14.11 330270......... 01.9655 30.33 340024......... 01.2228 15.49
320032....................... 00.9936 16.66 330064.......... 01.3752 28.38 330177......... 01.0208 12.46 330273......... 01.2942 21.36 340025......... 01.1893 14.38
320033....................... 01.1484 19.23 330065.......... 01.1890 17.14 330179......... 00.8617 14.09 330275......... 01.2178 18.34 340027......... 01.1954 15.46
320035....................... 01.0033 14.82 330066.......... 01.2343 17.26 330180......... 01.1952 16.36 330276......... 01.1877 16.61 340028......... 01.5380 17.48
320037....................... 01.2052 15.17 330067.......... 01.3770 19.68 330181......... 01.3076 28.32 330277......... 01.1372 16.35 340030......... 02.0110 19.06
320038....................... 01.1660 15.62 330072.......... 01.3458 26.89 330182......... 02.5837 26.92 330279......... 01.2893 17.24 340031......... 00.9808 12.56
320046....................... 01.1839 18.23 330073.......... 01.1820 14.32 330183......... 01.4389 18.88 330285......... 01.8218 21.81 340032......... 01.3999 17.87
320048....................... 01.3187 13.90 330074.......... 01.1874 17.35 330184......... 01.3396 25.83 330286......... 01.3203 22.59 340035......... 01.1695 14.97
320056....................... 00.9819 ....... 330075.......... 01.0879 16.48 330185......... 01.2256 24.23 330290......... 01.7578 28.28 340036......... 01.1713 17.04
320057....................... 01.0573 ....... 330078.......... 01.4454 16.90 330186......... 00.9205 18.79 330293......... 01.1689 13.72 340037......... 01.1725 15.50
320058....................... 00.9038 ....... 330079.......... 01.3130 16.60 330188......... 01.1850 17.75 330304......... 01.2689 25.52 340038......... 01.1103 14.52
320059....................... 00.9778 ....... 330080.......... 01.4167 24.95 330189......... 01.3177 16.20 330306......... 01.4522 26.59 340039......... 01.2748 19.18
320060....................... 00.9187 ....... 330082.......... 01.1199 16.29 330191......... 01.2688 17.18 330307......... 01.2171 18.33 340040......... 01.7746 17.75
320061....................... 01.1051 ....... 330084.......... 00.9919 15.59 330193......... 01.3086 27.34 330308......... 01.1772 28.68 340041......... 01.2471 15.99
320062....................... 00.9353 ....... 330085.......... 01.3266 18.66 330194......... 01.8119 26.07 330309......... 01.2334 24.67 340042......... 01.1864 13.80
320063....................... 01.3272 15.84 330086.......... 01.2540 24.13 330195......... 01.6272 29.02 330314......... 01.3526 21.07 340044......... 01.1056 13.26
320065....................... 01.2822 16.76 330088.......... 01.1094 24.41 330196......... 01.3367 25.53 330315......... 01.2558 24.58 340045......... 01.0365 10.95
320067....................... 00.8203 09.19 330090.......... 01.5534 16.86 330197......... 01.0945 14.43 330316......... 01.3037 26.23 340047......... 01.9028 17.98
320068....................... 00.9119 17.98 330091.......... 01.3842 17.64 330198......... 01.3399 22.17 330327......... 00.9253 15.30 340048......... 00.9055 09.39
320069....................... 01.0454 09.08 330092.......... 01.1025 13.64 330199......... 01.4635 24.80 330331......... 01.2220 27.78 340049......... 00.6394 15.10
320070....................... 01.0243 ....... 330094.......... 01.2299 15.78 330201......... 01.5377 27.83 330332......... 01.2606 24.30 340050......... 01.1904 14.69
320074....................... 01.1107 17.15 330095.......... 01.2598 16.49 330202......... 01.4872 25.07 330333......... 01.3624 22.00 340051......... 01.2639 16.23
320079....................... 01.2049 17.41 330096.......... 01.0679 14.88 330203......... 01.3994 19.16 330336......... 01.3438 27.39 340052......... 01.0447 18.62
330001....................... 01.1955 24.84 330097.......... 01.1652 14.63 330204......... 01.4236 24.90 330338......... 01.1329 22.52 340053......... 01.6969 18.96
330002....................... 01.4938 24.26 330100.......... 00.6895 25.95 330205......... 01.1568 19.46 330339......... 00.8034 18.09 340054......... 01.0901 12.68
330003....................... 01.3393 19.29 330101.......... 01.8031 33.09 330208......... 01.2061 23.16 330340......... 01.2081 23.91 340055......... 01.2079 16.69
330004....................... 01.2785 19.10 330102.......... 01.3004 16.32 330209......... 01.1871 21.17 330350......... 01.8138 27.96 340060......... 01.1390 16.38
330005....................... 01.8133 19.53 330103.......... 01.2486 15.94 330211......... 01.2093 16.31 330353......... 01.3975 27.49 340061......... 01.7128 19.20
330006....................... 01.3128 24.11 330104.......... 01.3604 25.44 330212......... 01.1755 20.25 330354......... 01.3898 ....... 340063......... 01.0555 13.01
330007....................... 01.3289 17.43 330106.......... 01.5666 33.04 330213......... 01.1241 16.19 330357......... 01.3757 32.07 340064......... 01.2278 17.24
330008....................... 01.1187 15.77 330107.......... 01.2590 24.38 330214......... 01.7379 28.90 330359......... 00.9471 23.70 340065......... 01.3129 12.82
330009....................... 01.3480 28.08 330108.......... 01.2119 15.85 330215......... 01.2197 15.65 330372......... 01.2689 22.53 340067......... 01.1907 12.84
330010....................... 01.1648 15.34 330111.......... 01.0877 14.62 330218......... 01.1661 17.16 330381......... 01.1945 27.09 340068......... 01.2333 14.21
330011....................... 01.2464 17.22 330114.......... 00.8876 15.48 330219......... 01.6358 18.39 330385......... 01.1735 29.27 340069......... 01.7159 18.31
330012....................... 01.6173 27.84 330115.......... 01.2008 14.46 330221......... 01.3421 26.57 330386......... 01.1478 20.82 340070......... 01.3795 16.78
330013....................... 02.0611 16.93 330116.......... 00.9149 13.82 330222......... 01.2611 15.28 330387......... 00.8589 23.28 340071......... 01.0726 14.30
330014....................... 01.3852 27.12 330118.......... 01.6360 18.19 330223......... 01.0811 15.10 330389......... 01.8045 29.95 340072......... 01.1400 13.86
330016....................... 01.0249 14.55 330119.......... 01.7390 29.88 330224......... 01.2647 18.85 330390......... 01.2567 28.38 340073......... 01.4546 20.50
330019....................... 01.1339 23.60 330121.......... 01.0050 14.35 330225......... 01.1856 23.23 330393......... 01.7319 25.24 340075......... 01.1558 15.98
330020....................... 01.0573 14.25 330122.......... 01.2081 20.92 330226......... 01.2808 16.83 330394......... 01.5114 17.27 340080......... 01.1240 13.55
330023....................... 01.2492 22.80 330125.......... 01.8059 19.91 330229......... 01.3242 14.92 330395......... 01.3557 30.16 340084......... 01.0689 14.51
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
340085....................... 01.2597 15.46 350008.......... 01.0366 15.15 360032......... 01.0867 16.18 360108......... 01.0267 15.08 360197......... 01.2031 16.76
340087....................... 01.1439 16.80 350009.......... 01.1592 15.74 360034......... 01.1593 13.30 360109......... 01.0942 17.43 360200......... 01.0011 13.48
340088....................... 01.1199 16.46 350010.......... 01.1821 12.30 360035......... 01.5736 19.90 360112......... 01.7563 21.61 360203......... 01.1469 15.55
340089....................... 00.9632 12.28 350011.......... 01.9090 17.37 360036......... 01.3217 17.31 360113......... 01.3031 18.24 360204......... 01.2935 16.96
340090....................... 01.1321 16.30 350012.......... 01.1445 12.36 360037......... 02.1462 20.14 360114......... 01.1423 16.05 360210......... 01.2312 19.23
340091....................... 01.6457 18.32 350013.......... 01.0749 14.58 360038......... 01.5947 18.31 360115......... 01.3193 18.08 360211......... 01.2323 17.25
340093....................... 01.0600 11.60 350014.......... 01.0459 14.29 360039......... 01.2539 15.34 360116......... 01.1312 16.04 360212......... 01.3976 20.25
340094....................... 01.3349 16.83 350015.......... 01.7084 15.42 360040......... 01.3179 17.72 360118......... 01.3243 17.37 360213......... 01.1708 15.77
340096....................... 01.2029 17.18 350016.......... 01.0584 10.35 360041......... 01.3771 18.25 360121......... 01.2823 16.74 360218......... 01.2976 16.21
340097....................... 01.1577 16.04 350017.......... 01.4608 14.88 360042......... 01.1043 16.74 360122......... 01.3977 17.77 360230......... 01.3323 20.27
340098....................... 01.6813 19.05 350018.......... 01.1656 10.67 360044......... 01.1490 15.84 360123......... 01.2541 17.50 360231......... 01.1369 12.45
340099....................... 01.1020 13.36 350019.......... 01.6065 18.69 360045......... 01.4935 19.25 360124......... 01.2534 17.08 360234......... 01.3572 17.90
340101....................... 01.0289 11.11 350020.......... 01.4956 18.57 360046......... 01.1278 18.52 360125......... 01.1047 16.87 360236......... 01.1905 18.56
340104....................... 00.9432 10.60 350021.......... 01.0704 10.94 360047......... 01.2351 13.85 360126......... 01.2042 18.97 360239......... 01.2400 18.70
340105....................... 01.3861 17.75 350023.......... 00.8923 15.59 360048......... 01.7480 21.00 360127......... 01.1566 16.28 360241......... 00.5347 17.69
340106....................... 01.1062 17.79 350024.......... 01.1031 13.69 360049......... 01.2653 17.36 360128......... 01.1287 13.85 360242......... 01.7176 ......
340107....................... 01.3146 16.17 350025.......... 01.0558 12.60 360050......... 01.1666 12.43 360129......... 01.0400 14.06 360243......... 00.7473 14.35
340109....................... 01.3269 15.91 350027.......... 00.9712 12.57 360051......... 01.5445 21.82 360130......... 01.1366 15.16 360244......... 00.7208 16.77
340111....................... 01.1675 13.78 350029.......... 01.0062 12.34 360052......... 01.7086 17.88 360131......... 01.4162 16.27 360245......... 00.8023 12.10
340112....................... 01.2839 14.03 350030.......... 01.0917 15.42 360054......... 01.2621 15.55 360132......... 01.2311 20.78 360246......... 00.8798 15.05
340113....................... 02.0160 19.50 350033.......... 00.9596 13.23 360055......... 01.2391 18.92 360133......... 01.4596 17.61 360247......... 00.4357 ......
340114....................... 01.5131 19.16 350034.......... 01.0571 13.58 360056......... 01.3529 16.92 360134......... 01.5973 18.25 370001......... 01.6944 18.41
340115....................... 01.5532 17.23 350035.......... 00.9015 10.11 360057......... 01.0445 13.04 360135......... 01.1672 17.12 370002......... 01.2462 13.60
340116....................... 01.9191 20.30 350038.......... 01.0538 13.26 360058......... 01.2628 15.35 360136......... 01.0528 14.73 370004......... 01.2787 15.30
340119....................... 01.2839 15.21 350039.......... 00.9705 13.53 360059......... 01.5433 20.00 360137......... 01.5604 18.98 370005......... 01.0273 14.12
340120....................... 01.1296 12.33 350041.......... 01.0446 13.05 360062......... 01.4697 18.40 360140......... 01.0178 15.47 370006......... 01.3096 14.88
340121....................... 01.0450 14.52 350042.......... 01.0504 12.39 360063......... 01.1243 17.19 360141......... 01.4412 19.84 370007......... 01.1404 12.80
340122....................... 00.9921 10.30 350043.......... 01.6433 16.58 360064......... 01.5567 19.65 360142......... 01.0184 14.99 370008......... 01.4080 16.02
340123....................... 01.1293 14.07 350044.......... 00.9113 10.01 360065......... 01.2287 16.97 360143......... 01.2979 17.74 370011......... 01.0616 12.47
340124....................... 01.0275 12.27 350047.......... 01.2204 16.64 360066......... 01.3889 17.16 360144......... 01.3148 20.19 370012......... 00.8457 10.05
340125....................... 01.4145 16.94 350049.......... 01.2419 10.38 360067......... 01.2670 12.11 360145......... 01.6244 16.84 370013......... 01.7611 18.61
340126....................... 01.4353 16.23 350050.......... 00.9371 10.24 360068......... 01.6576 21.91 360147......... 01.2662 ....... 370014......... 01.3196 17.14
340127....................... 01.3099 16.30 350051.......... 00.9466 14.13 360069......... 01.1437 16.38 360148......... 01.0715 16.50 370015......... 01.2617 13.84
340129....................... 01.3429 18.65 350053.......... 01.0767 09.58 360070......... 01.6677 16.57 360149......... 01.1450 20.33 370016......... 01.3790 14.25
340130....................... 01.3332 16.03 350055.......... 00.9216 11.50 360071......... 01.2655 15.42 360150......... 01.2825 17.70 370017......... 01.1042 12.14
340131....................... 01.4267 16.05 350056.......... 00.9601 12.92 360072......... 01.1448 16.29 360151......... 01.3167 16.55 370018......... 01.2647 14.06
340132....................... 01.3222 12.41 350058.......... 00.9495 12.18 360074......... 01.3535 19.15 360152......... 01.4765 17.73 370019......... 01.3066 11.91
340133....................... 01.0518 13.87 350060.......... 00.7458 08.17 360075......... 01.4875 20.80 360153......... 01.1500 13.64 370020......... 01.2884 12.53
340136....................... 00.7885 24.45 350061.......... 01.0625 13.77 360076......... 01.3060 18.84 360154......... 01.0235 12.39 370021......... 00.9781 10.01
340137....................... 01.2154 12.68 350063.......... 00.8969 ....... 360077......... 01.4820 18.59 360155......... 01.3290 18.75 370022......... 01.2741 15.13
340138....................... 01.1811 17.60 350064.......... 00.9840 ....... 360078......... 01.2766 18.97 360156......... 01.3403 16.47 370023......... 01.3301 14.95
340141....................... 01.6320 18.27 350066.......... 00.7996 ....... 360079......... 01.7539 19.31 360159......... 01.1943 18.50 370025......... 01.4024 15.37
340142....................... 01.1998 14.94 360001.......... 01.3171 17.88 360080......... 01.1169 14.39 360161......... 01.2798 18.78 370026......... 01.4279 16.08
340143....................... 01.3874 18.50 360002.......... 01.2012 15.33 360081......... 01.3564 17.96 360162......... 01.2593 17.27 370028......... 01.8659 17.67
340144....................... 01.4263 14.85 360003.......... 01.7460 20.67 360082......... 01.3158 19.81 360163......... 01.8617 19.87 370029......... 01.2335 12.79
340145....................... 01.3230 16.80 360006.......... 01.7465 19.53 360083......... 01.2516 15.77 360164......... 00.8576 13.98 370030......... 01.2425 12.05
340146....................... 01.0175 15.42 360007.......... 01.0523 15.41 360084......... 01.6097 18.16 360165......... 01.2134 14.31 370032......... 01.5284 14.28
340147....................... 01.2925 17.80 360008.......... 01.2955 16.20 360085......... 01.8261 19.63 360166......... 01.1750 15.83 370033......... 01.0754 11.23
340148....................... 01.4427 18.28 360009.......... 01.3969 17.35 360086......... 01.4494 16.75 360169......... 00.9859 16.99 370034......... 01.2609 12.79
340151....................... 01.1215 14.05 360010.......... 01.2298 15.38 360087......... 01.4106 17.32 360170......... 01.2826 15.68 370035......... 01.6338 15.21
340153....................... 01.9740 21.08 360011.......... 01.2267 17.83 360088......... 01.2136 15.48 360172......... 01.3727 16.62 370036......... 01.0298 09.22
340155....................... 01.3941 20.91 360012.......... 01.2961 17.61 360089......... 01.1654 16.92 360174......... 01.2295 19.24 370037......... 01.7224 16.37
340156....................... 00.8042 ....... 360013.......... 01.0861 16.71 360090......... 01.2325 17.90 360175......... 01.2416 17.61 370038......... 00.9103 12.01
340158....................... 01.1785 15.94 360014.......... 01.1236 17.57 360091......... 01.2653 18.90 360176......... 01.1811 15.62 370039......... 01.4595 17.22
340159....................... 01.1571 16.88 360016.......... 01.5986 17.81 360092......... 01.2754 17.85 360177......... 01.2619 16.30 370040......... 01.1036 10.89
340160....................... 01.0888 12.88 360017.......... 01.7484 19.82 360093......... 01.2219 16.66 360178......... 01.2206 15.58 370041......... 01.0290 13.52
340162....................... 01.2211 17.78 360018.......... 01.5417 18.51 360094......... 01.3012 20.27 360179......... 01.2895 19.01 370042......... 00.8626 11.22
340164....................... 01.4594 18.17 360019.......... 01.2939 18.22 360095......... 01.3299 16.68 360180......... 02.0595 22.07 370043......... 00.9753 12.91
340166....................... 01.4192 18.51 360020.......... 01.4334 20.05 360096......... 01.1102 16.20 360184......... 00.4913 17.11 370045......... 01.1501 10.20
340168....................... 00.5028 14.78 360021.......... 01.2759 18.04 360098......... 01.3988 18.00 360185......... 01.2472 17.09 370046......... 00.9820 09.22
340171....................... 01.1220 ....... 360024.......... 01.4300 17.76 360099......... 01.1087 16.91 360186......... 01.1741 15.04 370047......... 01.3236 15.40
350001....................... 01.0070 11.08 360025.......... 01.2331 17.66 360100......... 01.3108 15.63 360187......... 01.2880 16.00 370048......... 01.1790 13.46
350002....................... 01.7570 16.04 360026.......... 01.1939 15.59 360101......... 01.7511 19.71 360188......... 01.0028 14.77 370049......... 01.3544 16.07
350003....................... 01.1983 15.67 360027.......... 01.5318 19.06 360102......... 01.2675 19.68 360189......... 01.0113 15.40 370051......... 00.9604 13.31
350004....................... 01.9399 17.94 360028.......... 01.4723 15.28 360103......... 01.3274 18.70 360192......... 01.2451 19.28 370054......... 01.3882 14.79
350005....................... 01.0794 13.14 360029.......... 01.1573 16.41 360104......... 01.9146 20.28 360193......... 01.3171 16.77 370056......... 01.5659 15.41
350006....................... 01.3898 16.16 360030.......... 01.1350 14.82 360106......... 01.0557 13.89 360194......... 01.1176 16.14 370057......... 01.1762 15.05
350007....................... 00.9506 12.20 360031.......... 01.3576 18.42 360107......... 01.2429 16.98 360195......... 01.1297 17.72 370059......... 01.1142 13.53
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
370060....................... 01.0828 12.88 370190.......... 01.6289 17.49 390002......... 01.3694 17.03 390078......... 01.0673 15.98 390164......... 01.9539 19.14
370063....................... 01.0959 13.12 370192.......... 01.1353 ....... 390003......... 01.2550 15.57 390079......... 01.7078 16.83 390166......... 01.1034 17.40
370064....................... 00.9954 10.14 370194.......... 02.0879 ....... 390004......... 01.3802 16.70 390080......... 01.2568 18.66 390167......... 01.2653 20.71
370065....................... 01.0424 14.76 370195.......... 02.4526 ....... 390005......... 01.0808 14.82 390081......... 01.3530 20.23 390168......... 01.2043 17.54
370071....................... 01.0343 10.18 380001.......... 01.3214 19.27 390006......... 01.7350 17.39 390083......... 01.2270 20.87 390169......... 01.2058 18.63
370072....................... 00.9116 11.67 380002.......... 01.2073 22.74 390007......... 01.1796 21.33 390084......... 01.2421 15.29 390170......... 01.8570 22.43
370076....................... 01.3116 12.42 380003.......... 01.1475 18.75 390008......... 01.1300 15.08 390086......... 01.1340 16.87 390173......... 01.1954 17.08
370077....................... 01.2139 16.30 380004.......... 01.8006 22.89 390009......... 01.6087 18.07 390088......... 01.3283 18.42 390174......... 01.7088 24.17
370078....................... 01.7084 14.58 380005.......... 01.1861 19.47 390010......... 01.1790 16.58 390090......... 01.8006 19.41 390176......... 01.1460 16.79
370079....................... 00.9678 11.98 380006.......... 01.3890 18.29 390011......... 01.2467 16.49 390091......... 01.1700 17.09 390178......... 01.2822 17.74
370080....................... 00.9908 11.12 380007.......... 01.5689 22.66 390012......... 01.1943 19.15 390093......... 01.1538 15.20 390179......... 01.2710 22.80
370082....................... 00.9103 12.48 380008.......... 01.0706 18.69 390013......... 01.2311 16.77 390095......... 01.1758 13.95 390180......... 01.5397 22.83
370083....................... 00.9505 10.95 380009.......... 01.8307 22.17 390014......... 01.6424 16.42 390096......... 01.2633 16.88 390181......... 01.0583 17.80
370084....................... 01.0351 08.88 380010.......... 01.0879 24.15 390015......... 01.2054 13.06 390097......... 01.3262 20.91 390183......... 01.1883 17.16
370085....................... 00.8092 12.94 380011.......... 01.1042 14.95 390016......... 01.2233 15.58 390098......... 01.7539 20.06 390184......... 01.1032 17.69
370086....................... 01.1831 09.89 380013.......... 01.2681 21.54 390017......... 01.1747 14.20 390100......... 01.6285 19.30 390185......... 01.2281 16.12
370089....................... 01.2759 14.01 380014.......... 01.4266 18.89 390018......... 01.2261 19.47 390101......... 01.2027 15.70 390189......... 01.0384 18.41
370091....................... 01.6816 16.13 380017.......... 01.7014 21.77 390019......... 01.1185 14.53 390102......... 01.3635 20.34 390191......... 01.0441 13.91
370092....................... 01.0706 12.73 380018.......... 01.8329 19.21 390022......... 01.3887 21.81 390103......... 01.0941 17.17 390192......... 01.1158 17.15
370093....................... 01.8716 18.67 380019.......... 01.2061 18.88 390023......... 01.2485 19.71 390104......... 01.0526 15.15 390193......... 01.1854 15.39
370094....................... 01.4235 16.67 380020.......... 01.4312 20.06 390024......... 00.8664 22.60 390106......... 01.0134 14.85 390194......... 01.1543 18.97
370095....................... 00.9189 11.62 380021.......... 01.2831 19.10 390025......... 00.6470 16.64 390107......... 01.2490 18.66 390195......... 01.8317 22.08
370097....................... 01.3652 18.99 380022.......... 01.1731 19.92 390026......... 01.2710 20.58 390108......... 01.4094 19.97 390196......... 01.3947 ......
370099....................... 01.1641 12.91 380023.......... 01.2312 17.76 390027......... 01.9535 23.48 390109......... 01.1447 14.44 390197......... 01.3094 18.40
370100....................... 01.0343 13.02 380025.......... 01.2677 21.90 390028......... 01.7850 18.54 390110......... 01.6460 17.36 390198......... 01.1948 15.21
370103....................... 00.9027 11.77 380026.......... 01.1914 16.87 390029......... 01.9570 18.73 390111......... 01.8484 26.22 390199......... 01.2026 14.89
370105....................... 02.0050 17.06 380027.......... 01.2567 20.25 390030......... 01.2446 16.29 390112......... 01.1485 12.16 390200......... 01.0202 14.67
370106....................... 01.5501 16.96 380029.......... 01.1523 17.29 390031......... 01.1536 16.93 390113......... 01.2135 16.04 390201......... 01.2674 18.75
370108....................... 01.0589 10.82 380031.......... 01.0334 15.92 390032......... 01.2594 17.80 390114......... 01.1068 21.07 390203......... 01.3159 20.45
370112....................... 01.0733 12.33 380033.......... 01.7873 22.97 390035......... 01.2733 17.28 390115......... 01.3311 21.40 390204......... 01.2627 20.05
370113....................... 01.1633 12.33 380035.......... 01.3604 18.58 390036......... 01.3360 17.63 390116......... 01.2395 19.91 390205......... 01.3650 22.42
370114....................... 01.6326 14.69 380036.......... 01.1184 17.27 390037......... 01.3511 18.49 390117......... 01.1590 15.65 390206......... 01.3418 19.91
370121....................... 01.1757 15.78 380037.......... 01.2075 18.24 390039......... 01.0973 15.60 390118......... 01.1514 16.34 390209......... 01.0388 15.48
370122....................... 01.1255 09.78 380038.......... 01.3358 21.15 390040......... 01.0015 12.71 390119......... 01.3484 17.17 390211......... 01.1864 17.10
370123....................... 01.2080 14.12 380039.......... 01.3285 18.89 390041......... 01.2556 16.82 390121......... 01.3362 18.95 390213......... 00.9413 14.55
370125....................... 01.0313 11.90 380040.......... 01.2529 19.23 390042......... 01.4303 21.35 390122......... 01.0707 16.06 390215......... 01.1567 20.69
370126....................... 00.9473 10.66 380042.......... 01.1547 18.06 390043......... 01.1059 15.65 390123......... 01.3002 20.58 390217......... 01.2820 17.92
370131....................... 01.0515 12.93 380047.......... 01.6980 19.84 390044......... 01.6035 18.80 390125......... 01.2243 15.08 390219......... 01.3126 18.57
370133....................... 01.1108 09.82 380048.......... 01.0877 13.92 390045......... 01.7250 17.35 390126......... 01.3270 20.07 390220......... 01.2051 19.33
370138....................... 01.1139 14.40 380050.......... 01.3535 16.37 390046......... 01.5479 18.49 390127......... 01.2341 20.26 390222......... 01.3047 20.42
370139....................... 01.0952 10.62 380051.......... 01.5153 19.13 390047......... 01.6934 23.83 390128......... 01.2022 17.96 390223......... 01.6436 23.15
370140....................... 00.9914 11.71 380052.......... 01.1886 16.70 390048......... 01.1867 16.26 390130......... 01.1400 16.62 390224......... 00.9380 13.04
370141....................... 01.3994 19.17 380055.......... 01.2332 23.88 390049......... 01.5481 19.82 390131......... 01.2704 16.24 390225......... 01.2136 15.42
370146....................... 01.0334 12.03 380056.......... 01.0805 15.78 390050......... 02.1410 21.21 390132......... 01.2472 20.25 390226......... 01.7849 23.22
370148....................... 01.5867 19.01 380060.......... 01.5427 21.51 390051......... 02.1789 24.98 390133......... 01.7840 20.57 390228......... 01.2097 18.67
370149....................... 01.2406 15.19 380061.......... 01.5190 21.85 390052......... 01.1942 16.68 390135......... 01.2903 19.73 390231......... 01.3073 21.89
370153....................... 01.0980 13.17 380062.......... 01.1022 15.07 390054......... 01.2238 14.56 390136......... 01.2304 15.66 390233......... 01.3224 16.71
370154....................... 01.0184 12.31 380063.......... 01.3291 19.90 390055......... 01.7758 21.82 390137......... 01.3205 17.80 390235......... 01.5737 23.94
370156....................... 01.0910 13.37 380064.......... 01.4379 18.47 390056......... 01.1158 15.73 390138......... 01.3335 17.41 390236......... 01.1730 15.90
370158....................... 01.0520 12.08 380065.......... 01.0522 19.24 390057......... 01.3213 18.94 390139......... 01.5034 23.50 390237......... 01.6110 20.17
370159....................... 01.3498 13.95 380066.......... 01.3198 17.60 390058......... 01.3256 17.46 390142......... 01.6703 22.64 390238......... 01.3009 16.12
370163....................... 00.8598 10.99 380068.......... 01.0572 19.31 390060......... 01.1441 16.68 390145......... 01.3568 18.64 390242......... 01.2706 18.69
370165....................... 01.0906 11.74 380069.......... 01.1302 17.51 390061......... 01.4388 20.47 390146......... 01.3133 16.19 390244......... 00.9314 13.32
370166....................... 01.0846 15.48 380070.......... 01.3936 21.21 390062......... 01.1400 15.76 390147......... 01.2593 19.22 390245......... 01.3505 23.15
370169....................... 01.1130 10.66 380071.......... 01.2923 18.06 390063......... 01.7390 19.30 390149......... 01.2546 19.59 390246......... 01.2343 15.91
370170....................... 00.9813 ....... 380072.......... 00.9776 14.15 390064......... 01.5536 16.30 390150......... 01.1045 17.50 390247......... 01.0532 17.11
370171....................... 01.0235 ....... 380075.......... 01.4343 20.90 390065......... 01.2840 18.85 390151......... 01.2950 18.26 390249......... 01.0339 10.81
370172....................... 00.8846 ....... 380078.......... 01.1630 16.95 390066......... 01.2949 17.15 390152......... 01.0397 17.07 390256......... 01.7863 23.51
370173....................... 01.2880 ....... 380081.......... 01.1420 17.66 390067......... 01.8124 18.03 390153......... 01.2439 21.93 390258......... 01.2630 19.78
370174....................... 00.9656 ....... 380082.......... 01.2830 20.35 390068......... 01.3206 18.13 390154......... 01.1846 13.93 390260......... 01.1752 20.02
370176....................... 01.1460 16.48 380083.......... 01.2473 18.93 390069......... 01.3149 19.23 390155......... 01.2947 20.56 390262......... 01.9683 17.25
370177....................... 00.9746 10.10 380084.......... 01.2083 20.61 390070......... 01.2872 19.49 390156......... 01.4292 22.61 390263......... 01.4329 18.66
370178....................... 01.0093 12.17 380087.......... 01.0126 12.30 390071......... 01.1143 13.36 390157......... 01.3465 17.97 390265......... 01.3177 17.72
370179....................... 00.8839 14.28 380088.......... 01.0041 15.71 390072......... 01.1098 15.76 390158......... 01.5904 ....... 390266......... 01.2130 16.69
370180....................... 01.0671 ....... 380089.......... 01.2966 21.87 390073......... 01.5899 18.94 390160......... 01.2106 17.51 390267......... 01.2925 18.93
370183....................... 01.0923 14.00 380090.......... 01.3003 24.41 390074......... 01.2338 16.26 390161......... 01.0926 14.87 390268......... 01.3885 19.94
370186....................... 01.0180 12.72 380091.......... 01.2100 23.79 390075......... 01.2463 15.92 390162......... 01.4285 19.03 390270......... 01.3067 15.89
370189....................... 00.9704 10.13 390001.......... 01.3711 18.16 390076......... 01.3156 20.45 390163......... 01.2240 16.55 390272......... 00.4528 ......
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[[Page 46252]]
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
390277....................... 00.5603 20.34 420002.......... 01.3814 18.80 430011......... 01.3374 14.33 440024......... 01.3270 16.22 440146......... 00.9338 11.08
390278....................... 00.7678 17.52 420004.......... 01.8677 18.35 430012......... 01.3054 14.99 440025......... 01.1364 13.01 440147......... 01.1985 17.06
390279....................... 01.0751 13.63 420005.......... 01.2065 14.35 430013......... 01.2411 15.06 440029......... 01.2900 16.30 440148......... 01.1378 14.37
390281....................... 03.2278 ....... 420006.......... 01.2691 18.90 430014......... 01.2803 16.77 440030......... 01.2038 13.21 440149......... 01.2007 15.19
400001....................... 01.2220 08.25 420007.......... 01.5104 16.31 430015......... 01.1797 14.41 440031......... 00.9661 12.29 440150......... 01.2814 19.58
400002....................... 01.4856 10.96 420009.......... 01.2122 15.70 430016......... 01.8135 17.59 440032......... 01.0524 12.65 440151......... 01.3711 15.86
400003....................... 01.2332 08.92 420010.......... 01.1103 14.35 430018......... 00.9842 14.06 440033......... 01.0675 14.84 440152......... 01.5691 16.91
400004....................... 01.1483 07.59 420011.......... 01.0948 14.89 430022......... 00.9711 10.91 440034......... 01.5752 16.64 440153......... 01.2623 15.10
400005....................... 01.1206 06.10 420014.......... 01.1243 14.11 430023......... 00.9247 09.95 440035......... 01.3207 15.65 440156......... 01.5611 18.85
400006....................... 01.2016 08.16 420015.......... 01.3249 15.96 430024......... 00.9133 12.28 440039......... 01.6370 16.76 440157......... 01.0908 13.64
400007....................... 01.2693 07.55 420016.......... 01.0738 14.39 430026......... 01.0802 11.36 440040......... 00.9724 17.03 440159......... 01.2247 14.83
400009....................... 01.0262 07.68 420018.......... 01.7297 18.63 430027......... 01.8126 16.64 440041......... 01.0380 12.35 440161......... 01.6915 20.63
400010....................... 00.9203 07.94 420019.......... 01.2334 14.90 430028......... 01.0919 13.68 440046......... 01.3297 13.59 440166......... 01.4435 17.80
400011....................... 00.9992 08.65 420020.......... 01.3863 15.98 430029......... 00.9945 13.10 440047......... 00.9562 15.31 440168......... 01.0268 13.03
400012....................... 01.2240 07.45 420023.......... 01.4196 18.07 430031......... 00.9633 11.31 440048......... 01.7952 16.64 440173......... 01.5203 16.91
400013....................... 01.3026 07.90 420026.......... 01.9243 18.05 430033......... 01.0190 11.90 440049......... 01.6599 15.62 440174......... 00.9800 13.30
400014....................... 01.3669 07.72 420027.......... 01.3766 15.51 430034......... 01.0691 11.58 440050......... 01.2144 16.03 440175......... 01.2313 18.06
400015....................... 01.2460 10.88 420030.......... 01.3136 15.83 430036......... 01.0403 10.11 440051......... 00.9274 13.29 440176......... 01.2943 18.36
400016....................... 01.3669 10.57 420031.......... 00.9596 12.15 430037......... 00.9746 12.89 440052......... 01.2208 14.25 440178......... 01.1828 20.20
400017....................... 01.2323 06.27 420033.......... 01.2169 19.24 430038......... 01.0102 10.77 440053......... 01.3082 15.64 440180......... 01.1590 16.68
400018....................... 01.3497 09.15 420035.......... 00.8201 12.43 430039......... 01.0851 11.53 440054......... 01.2219 12.82 440181......... 01.0247 11.75
400019....................... 01.6713 09.52 420036.......... 01.2109 15.61 430040......... 00.9125 12.17 440056......... 01.0837 13.45 440182......... 00.9496 15.33
400021....................... 01.4363 07.63 420037.......... 01.2790 19.65 430041......... 00.9368 11.91 440057......... 01.0173 10.77 440183......... 01.5317 15.06
400022....................... 01.3221 09.94 420038.......... 01.3043 14.43 430042......... 00.9807 10.63 440058......... 01.3195 14.95 440184......... 01.3454 18.63
400024....................... 01.0278 08.62 420039.......... 01.1575 14.52 430043......... 01.1884 12.02 440059......... 01.3263 15.63 440185......... 01.1231 14.24
400026....................... 00.9518 05.90 420042.......... 01.2023 12.15 430044......... 00.9113 13.17 440060......... 01.1970 14.76 440186......... 01.1936 16.21
400027....................... 01.1389 08.01 420043.......... 01.1809 18.82 430047......... 01.1401 12.24 440061......... 01.2086 15.46 440187......... 01.2024 14.85
400028....................... 01.0186 07.77 420048.......... 01.1316 14.26 430048......... 01.2003 15.01 440063......... 01.6128 17.43 440189......... 01.4803 18.81
400029....................... 01.1282 06.64 420049.......... 01.1758 14.55 430049......... 00.9292 12.66 440064......... 01.1917 15.05 440192......... 01.1477 14.18
400031....................... 01.1362 08.00 420051.......... 01.5589 17.99 430051......... 01.0196 13.48 440065......... 01.2342 16.18 440193......... 01.2835 17.88
400032....................... 01.1227 07.75 420053.......... 01.1416 14.03 430054......... 01.0137 13.13 440067......... 01.1944 15.54 440194......... 01.4255 16.89
400044....................... 01.2346 09.09 420054.......... 01.3673 16.39 430056......... 00.8553 08.93 440068......... 01.2212 16.43 440196......... 00.9505 13.32
400048....................... 01.1349 07.30 420055.......... 01.0608 12.51 430057......... 00.9283 10.47 440069......... 01.1286 14.17 440197......... 01.4034 19.15
400061....................... 01.6729 11.80 420056.......... 01.1544 13.41 430060......... 01.1566 08.46 440070......... 01.1243 12.52 440200......... 01.1971 15.41
400079....................... 01.2619 08.43 420057.......... 01.1466 14.96 430062......... 00.8743 10.31 440071......... 01.3952 14.87 440203......... 00.9399 13.17
400087....................... 01.3682 07.87 420059.......... 00.9934 13.96 430064......... 01.1303 11.89 440072......... 01.5223 13.92 440205......... 01.0953 14.15
400094....................... 01.0449 07.49 420061.......... 01.1508 16.16 430065......... 00.9479 09.93 440073......... 01.3496 16.96 440206......... 01.0265 13.82
400098....................... 01.2488 07.50 420062.......... 01.4491 15.65 430066......... 00.9678 10.93 440078......... 01.0256 13.28 440208......... 01.8205 ......
400102....................... 01.1685 08.67 420064.......... 01.1139 13.45 430073......... 01.0704 ....... 440081......... 01.1542 15.31 450002......... 01.4659 19.35
400103....................... 01.3822 08.80 420065.......... 01.3039 16.72 430076......... 00.9751 09.41 440082......... 01.9853 20.54 450004......... 01.1678 12.38
400104....................... 01.3757 08.97 420066.......... 00.9103 14.40 430077......... 01.5817 16.53 440083......... 01.1097 10.96 450005......... 01.1514 13.79
400105....................... 01.1767 08.37 420067.......... 01.2427 16.24 430079......... 00.9610 11.47 440084......... 01.1791 11.41 450007......... 01.2393 13.73
400106....................... 01.2375 08.39 420068.......... 01.2907 16.08 430080......... 01.1317 08.89 440087......... 00.9425 14.44 450008......... 01.3554 14.96
400109....................... 01.5324 09.13 420069.......... 01.1030 13.71 430081......... 01.0291 ....... 440090......... 00.9368 13.29 450010......... 01.3345 15.37
400110....................... 01.1163 07.65 420070.......... 01.2642 15.05 430082......... 00.8067 ....... 440091......... 01.5497 16.53 450011......... 01.5020 17.43
400111....................... 01.1523 07.98 420071.......... 01.3101 16.13 430083......... 00.8649 ....... 440100......... 01.0343 12.82 450014......... 01.0617 13.84
400112....................... 01.2541 06.01 420072.......... 01.0775 10.64 430084......... 00.9278 ....... 440102......... 01.0720 12.26 450015......... 01.5403 15.15
400113....................... 01.2466 08.20 420073.......... 01.3072 18.13 430085......... 00.9194 ....... 440103......... 01.2317 17.24 450016......... 01.6194 17.57
400114....................... 01.0452 06.50 420074.......... 00.9037 11.72 430087......... 00.9027 09.29 440104......... 01.6500 17.68 450018......... 01.6073 21.75
400115....................... 01.0096 07.56 420075.......... 00.9694 12.66 440001......... 01.1291 12.18 440105......... 01.3509 16.69 450020......... 01.0239 15.47
400117....................... 01.1759 09.23 420078.......... 01.8104 18.59 440002......... 01.6019 15.73 440109......... 01.1368 12.28 450021......... 01.8149 21.11
400118....................... 01.1868 08.61 420079.......... 01.5628 16.94 440003......... 01.0727 15.23 440110......... 00.9697 16.06 450023......... 01.4758 15.45
400120....................... 01.3057 09.14 420080.......... 01.2627 19.18 440006......... 01.6333 17.55 440111......... 01.3691 18.00 450024......... 01.3739 16.45
400121....................... 01.0090 05.80 420082.......... 01.3944 19.13 440007......... 01.0099 11.83 440114......... 01.0453 12.68 450025......... 01.5088 16.23
400122....................... 00.9993 05.88 420083.......... 01.1937 18.36 440008......... 00.9877 13.50 440115......... 01.1184 14.66 450028......... 01.6360 17.17
400123....................... 01.1685 08.24 420084.......... 00.7413 13.56 440009......... 01.1773 13.22 440120......... 01.5405 16.14 450029......... 01.3996 12.98
400124....................... 02.6681 09.27 420085.......... 01.3941 16.86 440010......... 00.9181 08.75 440125......... 01.4435 16.09 450031......... 01.5825 18.72
410001....................... 01.3237 23.02 420086.......... 01.3585 16.90 440011......... 01.2884 16.28 440130......... 01.1725 14.16 450032......... 01.2733 13.63
410004....................... 01.3672 21.15 420087.......... 01.5958 16.53 440012......... 01.4781 17.72 440131......... 01.1390 13.44 450033......... 01.6352 16.84
410005....................... 01.3477 21.90 420088.......... 01.1487 15.05 440014......... 01.0633 09.06 440132......... 01.1117 14.01 450034......... 01.6414 16.28
410006....................... 01.2581 21.40 420089.......... 01.2296 19.40 440015......... 01.6236 16.42 440133......... 01.5475 17.78 450035......... 01.4498 18.91
410007....................... 01.6598 20.37 420091.......... 01.2145 13.16 440016......... 01.0124 11.35 440135......... 01.3052 17.20 450037......... 01.6198 17.78
410008....................... 01.1681 21.05 430004.......... 01.0941 17.25 440017......... 01.6214 18.42 440137......... 00.9781 12.14 450039......... 01.3536 18.70
410009....................... 01.2979 20.66 430005.......... 01.3166 14.06 440018......... 01.4781 16.10 440141......... 01.0780 13.59 450040......... 01.5551 17.75
410010....................... 01.0163 25.40 430007.......... 01.0466 12.56 440019......... 01.6255 19.06 440142......... 01.0334 10.75 450042......... 01.6664 15.75
410011....................... 01.2082 22.25 430008.......... 01.1342 14.01 440020......... 01.2332 15.43 440143......... 01.1007 17.21 450043......... 01.4465 20.40
410012....................... 01.7245 19.51 430009.......... 01.0881 11.86 440022......... 01.2045 13.72 440144......... 01.3344 18.35 450044......... 01.6233 20.51
410013....................... 01.3149 24.63 430010.......... 01.1233 09.23 440023......... 01.0084 11.58 440145......... 01.0427 10.99 450046......... 01.3659 14.67
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[[Page 46253]]
Page 14 of 16
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450047....................... 01.1220 13.43 450152.......... 01.2584 16.04 450292......... 01.2041 20.69 450473......... 01.0025 17.83 450648......... 01.0330 11.36
450050....................... 01.0646 16.00 450153.......... 01.5850 17.97 450293......... 00.9718 13.55 450475......... 01.1382 14.13 450649......... 01.0760 14.64
450051....................... 01.5938 18.22 450154.......... 01.1993 12.23 450296......... 01.3113 16.46 450484......... 01.4918 18.53 450651......... 01.8202 21.97
450052....................... 01.0170 13.18 450155.......... 01.0180 12.61 450297......... 01.0190 12.01 450488......... 01.2564 15.04 450652......... 00.9227 13.44
450053....................... 01.1454 13.11 450157.......... 01.0065 12.97 450299......... 01.3347 17.02 450489......... 00.9782 11.56 450653......... 01.2431 18.84
450054....................... 01.7192 21.32 450160.......... 00.9923 17.50 450303......... 00.9406 09.97 450497......... 01.1271 12.05 450654......... 01.0022 11.11
450055....................... 01.1447 12.92 450162.......... 01.1938 16.77 450306......... 01.0853 12.50 450498......... 01.2476 13.88 450656......... 01.4892 16.48
450056....................... 01.6156 18.26 450163.......... 01.0440 15.34 450307......... 00.8981 13.62 450508......... 01.5513 16.37 450658......... 00.9782 14.01
450058....................... 01.5801 14.76 450164.......... 01.0742 12.56 450309......... 01.0640 12.74 450514......... 01.2130 18.78 450659......... 01.5709 21.98
450059....................... 01.2524 13.14 450165.......... 00.9592 14.34 450315......... 01.1187 19.65 450517......... 00.9987 10.94 450660......... 01.5676 21.85
450060....................... 01.3645 22.17 450166.......... 00.9684 10.06 450320......... 01.3390 18.20 450518......... 01.5354 16.84 450661......... 01.1458 19.26
450063....................... 00.9796 11.51 450169.......... 00.9080 13.82 450321......... 00.9595 12.45 450523......... 01.5274 21.38 450662......... 01.6776 16.53
450064....................... 01.5134 15.34 450170.......... 00.9791 11.32 450322......... 00.7151 15.40 450530......... 01.4471 21.64 450665......... 00.9352 11.45
450065....................... 01.1489 14.75 450176.......... 01.2251 15.23 450324......... 01.6544 15.19 450534......... 00.9729 20.29 450666......... 01.2706 19.71
450068....................... 01.7905 20.31 450177.......... 01.0924 13.18 450325......... 01.2253 11.93 450535......... 01.2548 14.12 450668......... 01.5402 18.90
450070....................... 01.2681 15.46 450178.......... 01.0088 14.65 450327......... 00.9860 12.11 450537......... 01.3601 17.80 450669......... 01.2864 19.10
450072....................... 01.2416 18.19 450181.......... 01.0019 15.15 450330......... 01.2227 16.86 450538......... 01.3999 21.17 450670......... 01.3009 19.44
450073....................... 01.1264 12.84 450184.......... 01.5407 23.27 450334......... 01.0534 11.65 450539......... 01.2984 13.27 450672......... 01.6541 19.75
450076....................... 01.5782 ....... 450185.......... 01.1327 08.47 450337......... 01.2371 17.14 450544......... 01.4369 22.65 450673......... 01.1436 11.38
450078....................... 00.9932 11.17 450187.......... 01.2814 16.44 450340......... 01.3187 14.54 450545......... 01.2718 14.13 450674......... 01.0111 22.09
450079....................... 01.4322 19.03 450188.......... 01.0119 12.46 450341......... 01.0248 16.26 450546......... 01.8222 18.37 450675......... 01.5087 17.94
450080....................... 01.2955 15.79 450190.......... 01.1860 19.53 450346......... 01.3451 16.27 450547......... 01.1713 15.09 450677......... 01.4313 19.18
450081....................... 01.0995 12.87 450191.......... 01.0888 15.75 450347......... 01.1474 15.48 450550......... 00.9808 17.01 450678......... 01.4822 20.45
450082....................... 00.9666 12.75 450192.......... 01.2364 16.25 450348......... 01.0026 10.99 450551......... 01.1921 13.75 450681......... 03.0551 17.29
450083....................... 01.7113 17.42 450193.......... 02.0587 21.32 450351......... 01.1755 18.65 450558......... 01.7741 17.17 450683......... 01.3220 20.22
450085....................... 01.0883 14.38 450194.......... 01.2395 18.11 450352......... 01.1091 16.21 450559......... 00.9492 12.75 450684......... 01.2741 18.53
450087....................... 01.4225 19.35 450196.......... 01.5055 17.58 450353......... 01.3200 17.98 450561......... 01.6456 17.65 450686......... 01.5540 14.30
450090....................... 01.2033 12.40 450197.......... 01.0524 19.66 450355......... 01.1377 11.18 450563......... 01.2363 21.98 450688......... 01.2881 18.65
450092....................... 01.2143 13.12 450200.......... 01.3821 16.35 450358......... 02.0797 20.57 450565......... 01.3067 15.63 450690......... 01.4332 20.17
450094....................... 01.2606 19.39 450201.......... 01.0166 15.38 450362......... 01.1880 18.62 450570......... 01.0343 11.74 450691......... 01.0990 14.91
450096....................... 01.5374 19.25 450203.......... 01.1911 16.13 450369......... 01.0899 10.21 450571......... 01.4975 14.52 450694......... 01.2392 15.91
450097....................... 01.4459 18.33 450209.......... 01.5470 16.62 450370......... 01.1322 13.02 450573......... 01.0043 13.58 450696......... 01.6532 23.37
450098....................... 01.1700 13.75 450210.......... 01.1942 12.03 450371......... 01.1439 11.02 450574......... 00.9401 13.41 450697......... 01.5296 16.28
450099....................... 01.2845 17.70 450211.......... 01.3875 15.53 450372......... 01.2685 20.49 450575......... 01.0588 16.98 450698......... 00.9741 11.66
450101....................... 01.4874 15.03 450213.......... 01.5135 16.27 450373......... 01.1458 13.68 450578......... 00.9188 12.94 450700......... 00.9361 12.68
450102....................... 01.7024 21.87 450214.......... 01.3724 18.61 450374......... 00.9606 12.20 450580......... 01.1043 12.59 450702......... 01.6116 17.58
450104....................... 01.2215 13.74 450217.......... 01.0493 12.61 450376......... 01.5130 16.26 450583......... 01.0101 12.24 450703......... 01.5347 22.71
450107....................... 01.6114 18.75 450219.......... 01.1376 14.22 450378......... 01.0872 21.56 450584......... 01.2252 12.86 450704......... 01.3685 17.86
450108....................... 00.9951 14.49 450221.......... 01.0919 14.05 450379......... 01.5119 21.28 450586......... 00.9990 11.26 450705......... 01.0325 16.80
450109....................... 00.9937 15.36 450222.......... 01.6583 17.32 450381......... 01.0501 12.56 450587......... 01.2284 16.93 450706......... 01.2203 21.90
450110....................... 01.2581 19.34 450224.......... 01.3804 16.16 450388......... 01.7618 17.41 450591......... 01.1443 16.28 450709......... 01.2258 20.05
450111....................... 01.2467 19.56 450229.......... 01.5720 15.17 450389......... 01.2091 16.74 450596......... 01.3111 17.29 450711......... 01.6445 17.90
450112....................... 01.3458 13.87 450231.......... 01.5952 18.09 450393......... 01.3286 20.94 450597......... 01.0558 14.23 450712......... 00.7326 15.03
450113....................... 01.2354 16.99 450234.......... 00.9894 11.27 450395......... 01.0373 14.68 450603......... 00.8313 16.27 450713......... 01.4795 18.10
450118....................... 01.5684 21.60 450235.......... 01.0641 13.47 450399......... 00.9972 13.37 450604......... 01.3843 13.57 450715......... 01.4608 19.89
450119....................... 01.2883 16.37 450236.......... 01.0680 14.17 450400......... 01.1529 13.70 450605......... 01.4572 17.91 450716......... 01.2763 19.64
450121....................... 01.4394 18.70 450237.......... 01.5497 16.60 450403......... 01.3695 19.91 450609......... 00.8873 12.25 450717......... 01.3876 22.95
450123....................... 01.1501 17.47 450239.......... 01.2041 12.35 450411......... 00.9528 11.46 450610......... 01.4525 16.09 450718......... 01.2410 20.52
450124....................... 01.5911 19.48 450241.......... 01.0376 15.67 450417......... 01.0520 12.95 450614......... 01.0500 12.43 450723......... 01.3595 18.17
450126....................... 01.3790 11.95 450243.......... 00.8397 11.57 450418......... 01.3231 17.42 450615......... 01.0751 11.70 450724......... 01.2949 16.59
450128....................... 01.2417 14.78 450246.......... 00.9745 15.02 450419......... 01.2764 22.40 450617......... 01.2951 20.82 450725......... 01.0238 20.88
450130....................... 01.5026 16.34 450249.......... 00.9682 10.70 450422......... 00.8069 23.47 450620......... 01.0721 12.48 450726......... 00.8634 14.54
450131....................... 01.3704 21.35 450250.......... 00.9525 09.93 450423......... 01.4345 21.03 450623......... 01.1422 17.62 450727......... 00.9554 09.78
450132....................... 01.6500 16.45 450253.......... 01.3238 13.51 450424......... 01.2052 16.33 450626......... 01.0899 14.09 450728......... 00.9742 14.31
450133....................... 01.5434 16.49 450258.......... 01.0987 11.17 450429......... 01.1218 13.35 450628......... 00.9432 15.48 450730......... 01.3596 21.14
450135....................... 01.7232 21.81 450259.......... 01.2053 17.44 450431......... 01.6621 17.30 450630......... 01.6460 20.60 450733......... 01.3642 16.91
450137....................... 01.5052 24.28 450264.......... 00.8888 11.94 450438......... 01.1814 14.39 450631......... 01.7443 18.24 450735......... 00.8814 12.70
450140....................... 00.8514 16.46 450269.......... 01.1527 12.62 450446......... 00.8552 13.07 450632......... 01.0135 11.17 450742......... 01.3392 21.43
450142....................... 01.4322 19.50 450270.......... 01.1746 10.16 450447......... 01.3578 17.69 450633......... 01.5955 19.99 450743......... 01.4512 18.56
450143....................... 01.0933 12.23 450271.......... 01.2705 14.41 450450......... 01.0892 16.43 450634......... 01.6915 21.57 450746......... 01.0348 13.39
450144....................... 01.1100 16.23 450272.......... 01.2918 16.29 450451......... 01.1189 20.23 450637......... 01.3801 18.24 450747......... 01.3596 16.51
450145....................... 00.8715 12.46 450276.......... 01.1012 10.44 450457......... 01.7888 17.14 450638......... 01.5960 22.52 450749......... 01.0066 12.35
450146....................... 01.0002 16.53 450278.......... 00.8518 18.12 450460......... 01.0391 12.06 450639......... 01.4075 21.41 450750......... 01.0207 11.86
450147....................... 01.4238 17.66 450280.......... 01.5267 20.58 450462......... 01.8388 19.89 450641......... 01.0270 12.60 450751......... 01.3180 21.80
450148....................... 01.3128 19.02 450283.......... 01.0534 12.09 450464......... 00.9829 13.41 450643......... 01.2616 17.57 450754......... 00.8914 13.19
450149....................... 01.3535 19.71 450286.......... 01.0404 14.54 450465......... 01.3156 14.66 450644......... 01.4772 20.30 450755......... 01.1576 13.66
450150....................... 00.8833 13.62 450288.......... 01.2198 12.58 450467......... 00.9614 14.39 450646......... 01.6091 19.59 450757......... 00.9791 13.32
450151....................... 01.1042 13.27 450289.......... 01.4806 17.37 450469......... 01.3754 16.94 450647......... 02.0177 20.35 450758......... 01.2161 13.21
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Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450760....................... 01.1995 16.97 460047.......... 01.7910 19.49 490067......... 01.2066 14.95 500028......... 01.0863 14.76 500139......... 01.4752 21.33
450761....................... 01.0624 09.63 460049.......... 01.9373 17.36 490069......... 01.4041 15.74 500029......... 00.9240 14.30 500141......... 01.3369 21.93
450763....................... 01.0137 16.27 460050.......... 01.3229 20.35 490071......... 01.4437 17.56 500030......... 01.4741 22.13 500143......... 00.7548 14.92
450766....................... 02.3026 21.39 460051.......... 01.1889 ....... 490073......... 01.3572 21.49 500031......... 01.2908 20.19 500146......... 01.0356 ......
450769....................... 01.0302 13.28 470001.......... 01.2042 17.11 490074......... 01.3267 16.06 500033......... 01.2023 18.05 510001......... 01.7170 17.08
450770....................... 00.9569 13.59 470003.......... 01.8185 20.22 490075......... 01.3350 16.62 500036......... 01.3243 19.11 510002......... 01.2698 16.31
450771....................... 01.9684 19.76 470004.......... 01.1082 14.18 490077......... 01.1612 16.87 500037......... 01.1182 17.63 510004......... 00.9340 12.62
450774....................... 00.9029 23.99 470005.......... 01.2621 18.71 490079......... 01.3172 14.30 500039......... 01.3816 21.32 510005......... 00.9906 13.71
450775....................... 01.2195 19.26 470006.......... 01.1890 17.05 490083......... 00.6451 14.63 500041......... 01.2847 22.09 510006......... 01.2547 17.08
450776....................... 00.9203 ....... 470008.......... 01.2515 15.41 490084......... 01.2474 15.96 500042......... 01.3841 20.95 510007......... 01.4719 17.81
450777....................... 01.0133 15.01 470010.......... 01.1785 18.58 490085......... 01.2069 13.36 500043......... 01.2790 16.56 510008......... 01.1392 15.33
450779....................... 01.3433 20.59 470011.......... 01.1576 19.30 490088......... 01.2040 13.97 500044......... 01.8929 20.56 510012......... 01.0689 14.26
450780....................... 01.6395 19.78 470012.......... 01.2641 17.52 490089......... 01.0777 14.37 500045......... 01.1206 20.65 510013......... 01.1401 15.10
450781....................... 01.5121 16.23 470013.......... 01.1730 18.38 490090......... 01.1910 14.25 500048......... 00.9121 16.01 510015......... 00.9645 12.51
450785....................... 01.0081 26.08 470015.......... 01.0821 16.29 490091......... 01.2048 20.14 500049......... 01.4662 19.34 510016......... 00.9894 11.27
450788....................... 01.4240 ....... 470018.......... 01.1960 17.37 490092......... 01.2073 14.32 500050......... 01.4048 20.41 510018......... 01.1325 14.40
450793....................... 01.6623 ....... 470020.......... 00.9790 14.50 490093......... 01.2886 15.31 500051......... 01.6400 22.71 510020......... 01.0439 10.16
450794....................... 01.4607 ....... 470023.......... 01.3025 17.20 490094......... 01.0703 14.57 500052......... 01.2844 ....... 510022......... 01.8032 19.52
450795....................... 00.8583 ....... 470024.......... 01.1065 17.08 490095......... 01.4704 16.32 500053......... 01.2764 20.10 510023......... 01.1453 15.14
450797....................... 00.6907 ....... 490001.......... 01.0855 19.41 490097......... 01.1309 13.69 500054......... 01.8765 20.41 510024......... 01.4123 17.94
450798....................... 00.8914 ....... 490002.......... 01.0634 13.61 490098......... 01.3117 11.69 500055......... 01.0919 20.32 510026......... 00.9431 12.19
450799....................... 01.4105 ....... 490003.......... 00.6013 17.55 490099......... 00.9354 15.29 500057......... 01.3473 16.24 510027......... 00.9624 13.86
450800....................... 01.3490 ....... 490004.......... 01.2275 16.67 490100......... 01.3718 16.69 500058......... 01.5008 19.82 510028......... 01.0722 14.90
450801....................... 01.4785 ....... 490005.......... 01.5365 16.10 490101......... 01.1892 23.64 500059......... 01.1568 20.02 510029......... 01.2911 16.69
450802....................... 01.0743 ....... 490006.......... 01.1550 13.27 490104......... 00.8927 14.46 500060......... 01.4852 20.70 510030......... 01.1024 14.87
450803....................... 00.8537 ....... 490007.......... 02.0173 17.19 490105......... 00.7368 16.55 500061......... 00.9874 17.95 510031......... 01.3462 16.27
450804....................... 01.5317 ....... 490009.......... 01.8300 18.08 490106......... 00.8894 14.86 500062......... 01.0881 17.16 510033......... 01.2683 14.42
450805....................... 01.1690 ....... 490010.......... 01.0896 17.08 490107......... 01.3168 22.65 500064......... 01.5317 21.69 510035......... 01.1333 16.46
450807....................... 00.9104 ....... 490011.......... 01.4141 17.03 490108......... 00.8692 13.78 500065......... 01.2988 17.67 510036......... 01.0124 09.34
450809....................... 01.6695 ....... 490012.......... 01.2074 15.55 490109......... 00.9193 14.09 500068......... 01.0249 17.17 510038......... 01.1602 13.71
460001....................... 01.7915 19.82 490013.......... 01.2459 14.82 490110......... 01.3951 15.90 500069......... 01.1604 18.62 510039......... 01.3713 15.02
460003....................... 01.7205 18.38 490014.......... 01.3674 21.04 490111......... 01.2384 16.79 500071......... 01.3704 19.46 510043......... 00.9246 11.33
460004....................... 01.7759 20.68 490015.......... 01.4613 17.30 490112......... 01.7317 19.07 500072......... 01.1955 21.19 510046......... 01.2634 15.26
460005....................... 01.5560 18.80 490017.......... 01.3610 16.58 490113......... 01.2998 20.96 500073......... 01.0893 16.85 510047......... 01.2119 17.26
460006....................... 01.4316 18.71 490018.......... 01.2531 16.88 490114......... 01.1055 15.00 500074......... 01.1764 14.80 510048......... 01.0836 17.39
460007....................... 01.5439 19.27 490019.......... 01.2029 15.60 490115......... 01.2378 14.25 500075......... 03.7376 20.25 510050......... 01.4644 15.34
460008....................... 01.3622 16.02 490020.......... 01.1532 14.16 490116......... 01.2262 15.61 500077......... 01.3928 21.63 510053......... 01.0373 13.50
460009....................... 01.8858 18.11 490021.......... 01.1440 17.12 490117......... 01.1727 13.62 500079......... 01.4051 19.87 510055......... 01.2326 19.41
460010....................... 01.9311 20.15 490022.......... 01.4164 17.59 490118......... 01.7640 21.32 500080......... 00.8347 11.56 510058......... 01.1980 16.23
460011....................... 01.3873 16.16 490023.......... 01.2222 17.03 490119......... 01.3430 16.41 500084......... 01.1384 20.05 510059......... 01.2369 13.65
460013....................... 01.5121 18.54 490024.......... 01.7777 17.06 490120......... 01.3210 16.90 500085......... 01.0600 17.19 510060......... 01.1653 15.36
460014....................... 01.0302 15.38 490027.......... 01.1366 13.11 490122......... 01.5068 20.86 500086......... 01.4233 18.48 510061......... 01.0684 12.59
460015....................... 01.2578 19.75 490028.......... 01.3505 18.42 490123......... 01.1433 14.80 500088......... 01.3681 22.86 510062......... 01.2001 15.38
460016....................... 00.8956 13.54 490030.......... 01.0966 11.16 490124......... 01.1494 16.99 500089......... 00.9699 13.99 510063......... 01.0086 10.63
460017....................... 01.4587 16.52 490031.......... 01.1399 12.61 490126......... 01.3829 14.72 500090......... 00.9942 12.60 510065......... 01.0057 12.04
460018....................... 00.9760 13.59 490032.......... 01.7447 19.08 490127......... 01.0153 14.44 500092......... 01.0866 15.65 510066......... 01.1328 12.02
460019....................... 01.1474 12.90 490033.......... 01.1930 15.58 490129......... 01.4271 17.98 500094......... 00.9216 15.53 510067......... 01.2442 15.91
460020....................... 01.0550 14.21 490035.......... 01.2134 09.64 490130......... 01.3112 16.58 500096......... 01.0818 17.13 510068......... 01.1194 14.01
460021....................... 01.3930 19.20 490037.......... 01.1236 13.27 490131......... 01.0313 14.06 500097......... 01.1361 16.12 510070......... 01.2176 16.05
460022....................... 00.9379 19.41 490038.......... 01.2160 12.54 500001......... 01.3320 20.92 500098......... 00.9259 13.66 510071......... 01.2805 14.49
460023....................... 01.1852 20.75 490040.......... 01.4126 21.19 500002......... 01.4806 18.75 500101......... 01.0231 17.84 510072......... 01.0631 13.50
460024....................... 00.8925 13.88 490041.......... 01.3528 16.82 500003......... 01.4107 21.28 500102......... 00.9438 18.43 510077......... 01.1112 14.36
460025....................... 00.8072 12.63 490042.......... 01.3424 15.18 500005......... 01.8423 22.52 500104......... 01.2581 18.71 510080......... 01.1526 09.35
460026....................... 01.0894 16.98 490043.......... 01.3567 16.74 500007......... 01.4103 20.14 500106......... 00.9357 15.53 510081......... 01.0273 13.19
460027....................... 00.9427 18.71 490044.......... 01.3652 16.65 500008......... 01.8538 22.88 500107......... 01.1326 15.58 510082......... 01.0492 12.08
460029....................... 01.0225 15.71 490045.......... 01.1326 18.60 500009......... 01.2784 21.07 500108......... 01.6728 21.40 510084......... 00.9917 13.25
460030....................... 01.2159 15.78 490046.......... 01.4684 17.24 500011......... 01.3857 21.44 500110......... 01.2764 18.75 510085......... 01.2369 17.99
460032....................... 01.0099 19.00 490047.......... 01.0719 16.34 500012......... 01.5255 20.94 500118......... 01.1356 20.88 510086......... 01.0561 15.65
460033....................... 00.9544 18.22 490048.......... 01.4849 17.53 500014......... 01.5705 22.36 500119......... 01.3328 20.48 520002......... 01.2922 17.24
460035....................... 00.9610 11.43 490050.......... 01.4304 20.06 500015......... 01.3611 20.92 500122......... 01.1907 20.27 520003......... 01.1620 15.19
460036....................... 00.9397 19.41 490052.......... 01.6110 15.34 500016......... 01.4832 22.76 500123......... 00.8533 14.78 520004......... 01.1559 16.53
460037....................... 01.0591 15.92 490053.......... 01.2500 14.14 500019......... 01.3350 19.82 500124......... 01.3275 22.39 520006......... 01.0574 18.05
460039....................... 01.0976 21.08 490054.......... 01.1202 13.91 500021......... 01.5313 20.77 500125......... 00.9883 10.72 520007......... 01.2421 14.14
460041....................... 01.2170 18.29 490057.......... 01.5395 17.05 500023......... 01.1880 19.09 500129......... 01.7287 22.41 520008......... 01.5505 20.54
460042....................... 01.4763 16.14 490059.......... 01.5677 18.24 500024......... 01.6344 21.06 500132......... 00.9951 19.79 520009......... 01.5958 16.88
460043....................... 00.9968 20.44 490060.......... 01.0692 16.72 500025......... 01.8629 21.69 500134......... 00.8092 15.75 520010......... 01.1719 19.34
460044....................... 01.2081 19.41 490063.......... 01.6593 22.34 500026......... 01.4296 22.42 500137......... 00.7050 19.99 520011......... 01.2046 16.46
460046....................... 00.7432 10.23 490066.......... 01.2205 17.58 500027......... 01.5358 23.68 500138......... 03.4209 ....... 520013......... 01.2869 17.88
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[[Page 46255]]
Page 16 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Case Avg. Case Avg. Case Avg. Case Avg. Case Avg.
Provider mix hour Provider mix hour Provider mix hour Provider mix hour Provider mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
520014....................... 01.2027 15.55 520103.......... 01.3253 17.70 530025......... 01.3617 17.99
520015....................... 01.1208 16.65 520107.......... 01.2590 17.46 530026......... 01.0549 14.63
520016....................... 01.0905 12.75 520109.......... 00.9991 17.25 530027......... 00.8298 09.56
520017....................... 01.1856 16.87 520110.......... 01.1737 16.47 530029......... 00.9607 13.49
520018....................... 01.0817 15.88 520111.......... 00.9881 14.44 530031......... 00.8790 10.95
520019....................... 01.2831 16.65 520112.......... 01.0774 18.15 530032......... 01.1497 17.34
520021....................... 01.3589 19.16 520113.......... 01.1649 17.80
520024....................... 01.0340 13.33 520114.......... 01.1065 12.61
520025....................... 01.1366 15.19 520115.......... 01.3241 15.89
520026....................... 01.0973 17.48 520116.......... 01.2614 17.66
520027....................... 01.2310 19.22 520117.......... 01.0328 15.40
520028....................... 01.3213 17.60 520118.......... 00.9426 10.95
520029....................... 00.9672 16.70 520120.......... 00.8716 11.95
520030....................... 01.6756 20.19 520121.......... 00.9752 14.18
520031....................... 01.1149 16.11 520122.......... 00.9991 13.96
520032....................... 01.1627 14.56 520123.......... 01.1304 16.55
520033....................... 01.1838 15.91 520124.......... 01.1231 14.34
520034....................... 01.1326 17.17 520130.......... 01.0848 12.60
520035....................... 01.2520 14.67 520131.......... 01.0608 15.82
520037....................... 01.6526 18.23 520132.......... 01.1759 14.31
520038....................... 01.4892 17.14 520134.......... 01.0288 15.14
520039....................... 01.0077 16.24 520135.......... 00.9463 13.84
520040....................... 01.4307 20.05 520136.......... 01.4791 18.87
520041....................... 01.1426 14.54 520138.......... 01.8806 18.18
520042....................... 01.0710 16.25 520139.......... 01.2886 18.50
520044....................... 01.3714 16.09 520140.......... 01.6140 19.31
520045....................... 01.6919 17.97 520141.......... 01.1169 15.63
520047....................... 01.0188 14.50 520142.......... 00.9147 12.48
520048....................... 01.4400 17.67 520144.......... 01.0393 16.10
520049....................... 01.9950 17.97 520145.......... 00.9143 16.57
520051....................... 02.0353 19.41 520146.......... 01.0746 13.71
520053....................... 01.0992 14.78 520148.......... 01.1623 15.34
520054....................... 01.0858 16.40 520149.......... 00.9555 13.31
520056....................... 01.3107 17.77 520151.......... 01.0897 14.43
520057....................... 01.1288 16.08 520152.......... 01.1331 16.38
520058....................... 01.0509 17.87 520153.......... 00.9798 13.19
520059....................... 01.3228 18.17 520154.......... 01.1472 16.15
520060....................... 01.2997 15.15 520156.......... 01.1203 16.37
520062....................... 01.2655 16.18 520157.......... 00.9424 13.70
520063....................... 01.2607 17.61 520159.......... 00.9388 16.25
520064....................... 01.7082 18.60 520160.......... 01.7678 17.77
520066....................... 01.4098 17.73 520161.......... 01.0250 14.76
520068....................... 00.8915 15.82 520170.......... 01.2443 18.51
520069....................... 01.1870 16.75 520171.......... 00.9943 13.69
520070....................... 01.5908 16.93 520173.......... 01.1567 17.36
520071....................... 01.1171 17.71 520174.......... 01.4333 20.57
520074....................... 01.0987 14.96 520177.......... 01.6449 20.33
520075....................... 01.4698 17.44 520178.......... 01.0559 14.61
520076....................... 01.1236 14.40 520186.......... 02.5906 .......
520077....................... 01.0257 14.50 530002.......... 01.1980 18.07
520078....................... 01.5135 17.89 530003.......... 00.9289 12.59
520082....................... 01.3440 15.25 530004.......... 01.0252 13.17
520083....................... 01.5917 21.59 530005.......... 01.1380 13.19
520084....................... 01.0815 15.73 530006.......... 01.1263 16.83
520087....................... 01.6157 17.16 530007.......... 01.0519 11.52
520088....................... 01.2441 17.56 530008.......... 01.2819 17.75
520089....................... 01.5181 18.76 530009.......... 00.9693 20.60
520090....................... 01.2798 16.16 530010.......... 01.2110 16.30
520091....................... 01.3653 17.25 530011.......... 01.0901 15.27
520092....................... 01.1109 15.11 530012.......... 01.5887 17.25
520094....................... 01.0028 16.07 530014.......... 01.3344 15.01
520095....................... 01.3845 18.56 530015.......... 01.1465 19.22
520096....................... 01.4966 17.78 530016.......... 01.2083 11.87
520097....................... 01.3301 17.90 530017.......... 00.9927 16.09
520098....................... 01.7373 19.40 530018.......... 01.0650 14.57
520100....................... 01.2315 15.91 530019.......... 00.9451 14.32
520101....................... 01.1002 15.75 530022.......... 01.1165 15.94
520102....................... 01.2175 19.00 530023.......... 00.8533 17.76
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Case mix indexes do not include discharges from PPS-exempt units. Case mix indexes include cases received in HCFA central office through June 1996.
[[Page 46256]]
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................................... 0.8147 0.8691
Taylor, TX
0060 Aguadilla, PR................................. 0.4237 0.5554
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 0.9853 0.9899
Portage, OH
Summit, OH
0120 Albany, GA.................................... 0.8597 0.9017
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY................... 0.8624 0.9036
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.9350 0.9550
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.8194 0.8725
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 0.9992 0.9995
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9510 0.9662
Blair, PA
0320 Amarillo, TX..................................
Potter, TX 0.8730 0.9112
Randall, TX
0380 Anchorage, AK................................. 1.3255 1.2128
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1662 1.1110
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8023 0.8600
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.8890 0.9226
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR................................... 0.4397 0.5697
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.9344 0.9546
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9408 0.9591
Clarke, GA
Madison, GA
Oconee, GA
0520 *Atlanta, GA.................................. 1.0033 1.0023
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......................... 1.1077 1.0726
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.......................... 0.8836 0.9187
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX......................... 0.9254 0.9483
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA............................... 1.0189 1.0129
Kern, CA
0720 *Baltimore, MD................................ 0.9798 0.9861
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9391 0.9579
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.3651 1.2375
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8433 0.8898
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8576 0.9001
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1317 1.0884
Whatcom, WA
0870 Benton Harbor, MI............................. 0.8550 0.8983
Berrien, MI
0875 *Bergen-Passaic, NJ........................... 1.1785 1.1190
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 0.9086 0.9365
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8554 0.8986
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.8822 0.9178
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.9036 0.9329
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.8074 0.8637
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.8652 0.9056
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.8990 0.9297
McLean, IL
1080 Boise City, ID................................ 0.9383 0.9573
Ada, ID
Canyon, ID
1123 *Boston-Worcester-Lawrence-Lowell-Brockton, MA-
NH................................................. 1.1613 1.1078
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.......................... 0.9522 0.9670
Boulder, CO
1145 Brazoria, TX.................................. 0.8845 0.9194
Brazoria, TX
1150 Bremerton, WA................................. 1.0901 1.0609
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.8542 0.8977
Cameron, TX
1260 Bryan-College Station, TX..................... 0.8851 0.9198
Brazos, TX
1280 *Buffalo-Niagara Falls, NY.................... 0.9107 0.9380
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 1.0068 1.0047
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4589 0.5866
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
[[Page 46257]]
1320 Canton-Massillon, OH.......................... 0.8648 0.9053
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.8821 0.9177
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.8458 0.8916
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.9391 0.9579
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8963 0.9278
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9526 0.9673
Kanawha, WV
Putnam, WV
1520 *Charlotte-Gastonia-Rock Hill, NC-SC.......... 0.9620 0.9738
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 0.9155 0.9413
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.8847 0.9195
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY.................................. 0.7678 0.8345
Laramie, WY
1600 *Chicago, IL.................................. 1.0760 1.0514
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0417 1.0284
Butte, CA
1640 *Cincinnati, OH-KY-IN......................... 0.9568 0.9702
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............... 0.7716 0.8373
Christian, KY
Montgomery, TN
1680 *Cleveland-Lorain-Elyria, OH.................. 0.9886 0.9922
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9341 0.9544
El Paso, CO
1740 Columbia, MO.................................. 0.8904 0.9236
Boone, MO
1760 Columbia, SC.................................. 0.9160 0.9417
Lexington, SC
Richland, SC
1800 Columbus, GA-AL...............................
Russell, AL 0.7779 0.8420
Chattanoochee, GA
Harris, GA
Muscogee, GA
1840 *Columbus, OH................................. 0.9681 0.9780
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8881 0.9219
Nueces, TX
San Patricio, TX
1900 Cumberland, MD-WV............................. 0.8671 0.9070
Allegany, MD
Mineral, WV
1920 *Dallas, TX................................... 0.9729 0.9814
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.8497 0.8945
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8388 0.8866
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9559 0.9696
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL............................. 0.8871 0.9212
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8384 0.8863
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.7848 0.8471
Macon, IL
2080 *Denver, CO................................... 1.0166 1.0113
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8815 0.9173
Dallas, IA
Polk, IA
Warren, IA
2160 *Detroit, MI.................................. 1.0724 1.0490
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7740 0.8391
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.8997 0.9302
Kent, DE
2200 Dubuque, IA................................... 0.8112 0.8665
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 0.9416 0.9596
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 1.0589 1.0400
Dutchess, NY
2290 Eau Claire, WI................................ 0.8678 0.9075
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.9464 0.9630
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.8801 0.9163
Elkhart, IN
2335 Elmira, NY.................................... 0.8417 0.8887
Chemung, NY
2340 Enid, OK...................................... 0.7862 0.8481
Garfield, OK
2360 Erie, PA...................................... 0.9159 0.9416
Erie, PA
2400 Eugene-Springfield, OR........................ 1.1477 1.0989
Lane, OR
2440 Evansville-Henderson, IN-KY................... 0.8983 0.9292
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.9045 0.9336
[[Page 46258]]
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.9007 0.9309
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.7220 0.8001
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 0.9019 0.9317
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1248 1.0839
Genesee, MI
2650 Florence, AL.................................. 0.8111 0.8664
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8594 0.9014
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0562 1.0382
Larimer, CO
2680 *Ft. Lauderdale, FL........................... 1.0586 1.0398
Broward, FL
2700 Fort Myers-Cape Coral, FL..................... 0.9032 0.9327
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 1.0169 1.0115
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7867 0.8485
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL......................... 0.9192 0.9439
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.8800 0.9162
Adams, IN
Allen, IN
DeKalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 *Forth Worth-Arlington, TX.................... 1.0153 1.0105
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.1177 1.0792
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8881 0.9219
Etowah, AL
2900 Gainesville, FL............................... 0.9434 0.9609
Alachua, FL
2920 Galveston-Texas City, TX...................... 1.0997 1.0672
Galveston, TX
2960 Gary, IN...................................... 0.9155 0.9413
Lake, IN
Porter, IN
2975 Glens Falls, NY............................... 0.8562 0.8991
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8393 0.8869
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.9207 0.9450
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.8825 0.9180
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI............. 1.0119 1.0081
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 0.9015 0.9315
Cascade, MT
3060 Greeley, CO................................... 0.9690 0.9787
Weld, CO
3080 Green Bay, WI................................. 0.9366 0.9561
Brown, WI
3120 *Greensboro-Winston-Salem-High Point, NC...... 0.9314 0.9525
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9078 0.9359
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.8927 0.9252
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................ 0.9175 0.9427
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.9490 0.9648
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 1.0158 1.0108
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 *Hartford, CT................................. 1.2367 1.1566
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS............................... 0.7252 0.8025
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.7953 0.8548
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1461 1.0979
Honolulu, HI
3350 Houma, LA..................................... 0.7853 0.8475
Lafourche, LA
Terrebonne, LA
3360 *Houston, TX.................................. 1.0000 1.0000
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9174 0.9427
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8206 0.8734
Limestone, AL
Madison, AL
3480 *Indianapolis, IN............................. 0.9903 0.9933
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9361 0.9558
Johnson, IA
3520 Jackson, MI................................... 0.9045 0.9336
Jackson, MI
3560 Jackson, MS................................... 0.7928 0.8530
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.8288 0.8793
Chester, TN
Madison, TN
3600 Jacksonville, FL.............................. 0.9089 0.9367
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC.............................. 0.7055 0.7875
Onslow, NC
3610 Jamestown, NY................................. 0.7670 0.8339
Chautaqua, NY
3620 Janesville-Beloit, WI......................... 0.8645 0.9051
Rock, WI
3640 Jersey City, NJ............................... 1.1382 1.0927
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8901 0.9234
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
[[Page 46259]]
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA................................. 0.8398 0.8873
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.7220 0.8001
Craighead, AR
3710 Joplin, MO.................................... 0.7659 0.8331
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.0542 1.0368
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.9115 0.9385
Kankakee, IL
3760 *Kansas City, KS-MO........................... 0.9478 0.9640
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................................... 0.9145 0.9406
Kenosha, WI
3810 Killeen-Temple, TX............................ 1.0392 1.0267
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.8502 0.8948
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.8590 0.9012
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.8618 0.9032
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8165 0.8704
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.8804 0.9165
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.8034 0.8608
Calcasieu, LA
3980 Lakeland-Winter Haven, FL..................... 0.8668 0.9067
Polk, FL
4000 Lancaster, PA................................. 0.9583 0.9713
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 1.0010 1.0007
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.7073 0.7889
Webb, TX
4100 Las Cruces, NM................................ 0.8497 0.8945
Dona Ana, NM
4120 *Las Vegas, NV-AZ............................. 1.0870 1.0588
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8597 0.9017
Douglas, KS
4200 Lawton, OK.................................... 0.8365 0.8849
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.9410 0.9592
Androscoggin, ME
4280 Lexington, KY................................. 0.8303 0.8804
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.8732 0.9113
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9161 0.9418
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8597 0.9017
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8645 0.9051
Gregg, TX
Harrison, TX
Upshur, TX
4480 *Los Angeles-Long Beach, CA................... 1.2382 1.1576
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9447 0.9618
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8510 0.8954
Lubbock, TX
4640 Lynchburg, VA................................. 0.8052 0.8621
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.8824 0.9179
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0021 1.0014
Dane, WI
4800 Mansfield, OH................................. 0.8524 0.8964
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4215 0.5534
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8485 0.8936
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0082 1.0056
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9068 0.9352
Brevard, FL
4920 *Memphis, TN-AR-MS............................ 0.8166 0.8705
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 1.0660 1.0447
Merced, CA
5000 *Miami, FL.................................... 0.9938 0.9958
Dade, FL
5015 *Middlesex-Somerset-Hunterdon, NJ............. 1.0688 1.0466
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 *Milwaukee-Waukesha, WI....................... 0.9645 0.9756
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 *Minneapolis-St. Paul, MN-WI.................. 1.0777 1.0526
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.................................... 0.7981 0.8569
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0112 1.0077
Stanislaus, CA
[[Page 46260]]
5190 *Monmouth-Ocean, NJ........................... 1.0996 1.0672
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8211 0.8737
Ouachita, LA
5240 Montgomery, AL................................ 0.7876 0.8492
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 0.9714 0.9803
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.7790 0.8428
Horry, SC
5345 Naples, FL.................................... 1.0199 1.0136
Collier, FL
5360 *Nashville, TN................................ 0.9081 0.9361
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford, TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 *Nassau-Suffolk, NY........................... 1.3547 1.2311
Nassau, NY
Suffolk, NY
5483 *New Haven-Bridgeport-Stamford-Waterbury-..... 1.2750 1.1810
Danbury, CT
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT........................ 1.2317 1.1534
New London, CT
5560 *New Orleans, LA.............................. 0.9294 0.9511
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................................. 1.4154 1.2686
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 *Newark, NJ................................... 1.1036 1.0698
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.0803 1.0543
Orange, NY
Pike, PA
5720 *Norfolk-Virginia Beach-Newport News, VA-NC... 0.8348 0.8837
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.................................. 1.5069 1.3242
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9105 0.9378
Marion, FL
5800 Odessa-Midland, TX............................ 0.8566 0.8994
Ector, TX
Midland, TX
5880 *Oklahoma City, OK............................ 0.8371 0.8854
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.0689 1.0467
Thurston, WA
5920 Omaha, NE-IA.................................. 0.9480 0.9641
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 *Orange County, CA............................ 1.1902 1.1266
Orange, CA
5960 *Orlando, FL.................................. 0.9470 0.9634
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY................................. 0.7575 0.8268
Daviess, KY
6015 Panama City, FL............................... 0.8061 0.8628
Bay, FL
6020 Parkersburg-Marietta, WV-OH................... 0.7877 0.8492
Washington, OH
Wood, WV
6080 Pensacola, FL................................. 0.8202 0.8731
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8905 0.9237
Peoria, IL
Tazewell, IL
Woodford, IL
6160 *Philadelphia, PA-NJ.......................... 1.1237 1.0831
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 *Phoenix-Mesa, AZ............................. 0.9810 0.9870
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7886 0.8499
Jefferson, AR
6280 *Pittsburgh, PA............................... 0.9701 0.9794
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA................................ 1.0552 1.0375
Berkshire, MA
6340 Pocatello, ID................................. 0.8784 0.9150
Bannock, ID
6360 Ponce, PR..................................... 0.4685 0.5950
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9619 0.9738
Cumberland, ME
Sagadahoc, ME
York, ME
6440 *Portland-Vancouver, OR-WA.................... 1.1235 1.0830
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI.............. 1.1092 1.0736
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 1.0116 1.0079
Utah, UT
6560 Pueblo, CO.................................... 0.8284 0.8790
Pueblo, CO
6580 Punta Gorda, FL............................... 0.8353 0.8841
Charlotte, FL
6600 Racine, WI.................................... 0.8835 0.9187
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC................ 0.9728 0.9813
[[Page 46261]]
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8458 0.8916
Pennington, SD
6680 Reading, PA................................... 0.9445 0.9617
Berks, PA
6690 Redding, CA................................... 1.1605 1.1073
Shasta, CA
6720 Reno, NV...................................... 1.1018 1.0686
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 0.9970 0.9979
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9194 0.9441
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................. 1.1234 1.0829
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8702 0.9092
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.0428 1.0291
Olmsted, MN
6840 *Rochester, NY................................ 0.9649 0.9758
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.8994 0.9300
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.8955 0.9272
Edgecombe, NC
Nash, NC
6920 *Sacramento, CA............................... 1.2351 1.1556
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9667 0.9771
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9457 0.9625
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.8551 0.8983
Andrews, MO
Buchanan, MO
7040 *St. Louis, MO-IL............................. 0.9022 0.9319
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..................................... 0.9728 0.9813
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.3803 1.2470
Monterey, CA
7160 *Salt Lake City-Ogden, UT..................... 0.9677 0.9778
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7577 0.8270
Tom Green, TX
7240 *San Antonio, TX.............................. 0.8390 0.8867
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 *San Diego, CA................................ 1.2154 1.1429
San Diego, CA
7360 *San Francisco, CA............................ 1.4211 1.2721
Marin, CA
San Francisco, CA
San Mateo, CA
7400 *San Jose, CA................................. 1.4455 1.2870
Santa Clara, CA
7440 *San Juan-Bayamon, PR......................... 0.4506 0.5793
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.... 1.1561 1.1044
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.1242 1.0835
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.3520 1.2294
Santa Cruz, CA
7490 Santa Fe, NM.................................. 1.0823 1.0557
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................ 1.2487 1.1643
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9789 0.9855
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.9649 0.9758
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA.......... 0.8752 0.9128
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 *Seattle-Bellevue-Everett, WA................. 1.1384 1.0928
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.................................... 0.8885 0.9222
Mercer, PA
7620 Sheboygan, WI................................. 0.7764 0.8409
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.8631 0.9041
Grayson, TX
7680 Shreveport-Bossier City, LA................... 0.9359 0.9556
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8313 0.8812
Woodbury, IA
[[Page 46262]]
Dakota, NE
7760 Sioux Falls, SD............................... 0.8620 0.9033
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9934 0.9955
St. Joseph, IN
7840 Spokane, WA................................... 1.0524 1.0356
Spokane, WA
7880 Springfield, IL............................... 0.8671 0.9070
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.7842 0.8466
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA............................... 1.0586 1.0398
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9538 0.9681
Centre, PA
8080 Steubenville-Weirton, OH-WV................... 0.8266 0.8777
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.1391 1.0933
San Joaquin, CA
8140 Sumter, SC.................................... 0.7699 0.8360
Sumter, SC
8160 Syracuse, NY.................................. 0.9396 0.9582
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.0866 1.0585
Pierce, WA
8240 Tallahassee, FL............................... 0.8313 0.8812
Gadsden, FL
Leon, FL
8280 *Tampa-St. Petersburg-Clearwater, FL.......... 0.9302 0.9517
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.8591 0.9012
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.8509 0.8953
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 1.0361 1.0246
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 1.0086 1.0059
Shawnee, KS
8480 Trenton, NJ................................... 1.0549 1.0373
Mercer, NJ
8520 Tucson, AZ.................................... 0.9075 0.9357
Pima, AZ
8560 Tulsa, OK..................................... 0.8095 0.8653
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.7784 0.8424
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.9996 0.9997
Smith, TX
8680 Utica-Rome, NY................................ 0.8413 0.8884
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.3452 1.2252
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.1052 1.0709
Ventura, CA
8750 Victoria, TX.................................. 0.8393 0.8869
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 0.9993 0.9995
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 1.0151 1.0103
Tulare, CA
8800 Waco, TX...................................... 0.7772 0.8415
McLennan, TX
8840 *Washington, DC-MD-VA-WV...................... 1.0823 1.0557
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...................... 0.8705 0.9094
Black Hawk, IA
8940 Wausau, WI.................................... 1.0323 1.0220
Marathon, WI
8960 West Palm Beach-Boca Raton, FL................ 1.0002 1.0001
Palm Beach, FL
9000 Wheeling, OH-WV............................... 0.7563 0.8259
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9369 0.9563
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.8041 0.8613
Archer, TX
Wichita, TX
9140 Williamsport, PA.............................. 0.8467 0.8923
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1315 1.0883
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9046 0.9336
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.................................... 1.0026 1.0018
Yakima, WA
9270 Yolo, CA...................................... 1.1444 1.0968
Yolo, CA
9280 York, PA...................................... 0.9104 0.9377
York, PA
9320 Youngstown-Warren, OH......................... 0.9742 0.9823
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0414 1.0282
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 0.9497 0.9653
Yuma, AZ
------------------------------------------------------------------------
*Large Urban Area
Table 4b.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7150 0.7947
Alaska.............................................. 1.2444 1.1615
Arizona............................................. 0.7928 0.8530
Arkansas............................................ 0.6954 0.7798
California.......................................... 1.0002 1.0001
Colorado............................................ 0.8092 0.8650
Connecticut......................................... 1.2759 1.1816
Delaware............................................ 0.9447 0.9618
Florida............................................. 0.8668 0.9067
Georgia............................................. 0.7653 0.8326
Hawaii.............................................. 1.0245 1.0167
Idaho............................................... 0.8277 0.8785
Illinois............................................ 0.7553 0.8252
Indiana............................................. 0.8124 0.8674
Iowa................................................ 0.7366 0.8111
Kansas.............................................. 0.7107 0.7915
Kentucky............................................ 0.7753 0.8401
Louisiana........................................... 0.7253 0.8026
Maine............................................... 0.8317 0.8814
[[Page 46263]]
Maryland............................................ 0.8427 0.8894
Massachusetts....................................... 1.0770 1.0521
Michigan............................................ 0.8836 0.9187
Minnesota........................................... 0.8144 0.8688
Mississippi......................................... 0.6793 0.7674
Missouri............................................ 0.7261 0.8032
Montana............................................. 0.8128 0.8677
Nebraska............................................ 0.7214 0.7996
Nevada.............................................. 0.8775 0.9144
New Hampshire....................................... 0.9751 0.9829
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.8000 0.8583
New York............................................ 0.8558 0.8989
North Carolina...................................... 0.7953 0.8548
North Dakota........................................ 0.7358 0.8105
Ohio................................................ 0.8332 0.8825
Oklahoma............................................ 0.6942 0.7788
Oregon.............................................. 0.9664 0.9769
Pennsylvania........................................ 0.8459 0.8917
Puerto Rico......................................... 0.4026 0.5363
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.7668 0.8337
South Dakota........................................ 0.7063 0.7881
Tennessee........................................... 0.7341 0.8092
Texas............................................... 0.7462 0.8183
Utah................................................ 0.8848 0.9196
Vermont............................................. 0.8921 0.9248
Virginia............................................ 0.7729 0.8383
Washington.......................................... 0.9933 0.9954
West Virginia....................................... 0.7923 0.8526
Wisconsin........................................... 0.8430 0.8896
Wyoming............................................. 0.8177 0.8713
------------------------------------------------------------------------
\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......................................... 0.8147 0.8691
Albuquerque, NM..................................... 0.9350 0.9550
Alexandria, LA...................................... 0.8194 0.8725
Allentown-Bethlehem-Easton, PA...................... 0.9992 0.9995
Amarillo, TX........................................ 0.8730 0.9112
Anchorage, AK....................................... 1.3255 1.2128
Asheville, NC....................................... 0.9344 0.9546
Atlanta, GA......................................... 1.0033 1.0023
Bangor, ME.......................................... 0.9391 0.9579
Baton Rouge, LA..................................... 0.8433 0.8898
Benton Harbor, MI................................... 0.8550 0.8983
Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8836 0.9187
Billings, MT........................................ 0.9086 0.9365
Birmingham, AL...................................... 0.9036 0.9329
Bismarck, ND........................................ 0.8074 0.8637
Boise City, ID...................................... 0.9383 0.9573
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1613 1.1078
Caguas, PR.......................................... 0.4589 0.5866
Champaign-Urbana, IL................................ 0.8978 0.9288
Charleston-North Charleston, SC..................... 0.8963 0.9278
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9620 0.9738
Charlottesville, VA................................. 0.8990 0.9297
Chattanooga, TN-GA.................................. 0.8847 0.9195
Chicago, IL......................................... 1.0658 1.0446
Cincinnati, OH-KY-IN................................ 0.9568 0.9702
Cleveland-Lorain-Elyria, OH......................... 0.9886 0.9922
Columbia, MO........................................ 0.8904 0.9236
Columbus, OH........................................ 0.9681 0.9780
Dallas, TX.......................................... 0.9729 0.9814
Davenport-Moline-Rock Island, IA-IL................. 0.8388 0.8866
Denver, CO.......................................... 1.0166 1.0113
Des Moines, IA...................................... 0.8714 0.9100
Duluth-Superior, MN-WI.............................. 0.9416 0.9596
Dutchess County, NY................................. 1.0291 1.0198
Elkhart-Goshen, IN.................................. 0.8801 0.9163
Eugene-Springfield, OR.............................. 1.1477 1.0989
Fargo-Moorhead, ND-MN............................... 0.8879 0.9218
Fayetteville, NC.................................... 0.8640 0.9047
Flagstaff, AR-UT.................................... 0.8828 0.9182
Flint, MI........................................... 1.1248 1.0839
Florence, AL........................................ 0.8111 0.8664
Florence, SC........................................ 0.8594 0.9014
Fort Lauderdale, FL................................. 1.0586 1.0398
Fort Pierce-Port St. Lucie, FL...................... 1.0027 1.0018
Fort Smith, AR-OK................................... 0.7867 0.8485
Fort Walton Beach, FL............................... 0.8980 0.9290
Fort Worth-Arlington, TX............................ 1.0153 1.0105
Gadsden, AL......................................... 0.8881 0.9219
Gary, IN............................................ 0.9155 0.9413
Grand Forks, ND-MN.................................. 0.9207 0.9450
Grand Junction, CO.................................. 0.8825 0.9180
Grand Rapids-Muskegon-Holland, MI................... 1.0119 1.0081
Great Falls, MT..................................... 0.9015 0.9315
Greeley, CO......................................... 0.9388 0.9577
Green Bay, WI....................................... 0.9366 0.9561
Greensboro-Winston-Salem-High Point, NC............. 0.9314 0.9525
Greenville-Spartanburg-Anderson, SC................. 0.8927 0.9252
Hartford, CT........................................ 1.2191 1.1453
Honolulu, HI........................................ 1.1461 1.0979
Houston, TX......................................... 1.0000 1.0000
Huntington-Ashland, WV-KY-OH........................ 0.9174 0.9427
Huntsville, AL...................................... 0.8081 0.8642
Indianapolis, IN.................................... 0.9796 0.9860
Jackson, MS......................................... 0.7928 0.8530
Jacksonville, FL.................................... 0.9089 0.9367
Johnson City-Kingsport-Bristol, TN-VA............... 0.8901 0.9234
Joplin, MO.......................................... 0.7659 0.8331
Kalamazoo-Battlecreek, MI........................... 1.0542 1.0368
Kansas City, KS-MO.................................. 0.9478 0.9640
Knoxville, TN....................................... 0.8502 0.8948
Lafayette, LA....................................... 0.8165 0.8704
Lansing-East Lansing, MI............................ 1.0010 1.0007
Las Vegas, NV-AZ.................................... 1.0870 1.0588
Lexington, KY....................................... 0.8303 0.8804
Lima, OH............................................ 0.8732 0.9113
Lincoln, NE......................................... 0.9030 0.9325
Little Rock-North Little Rock, AR................... 0.8597 0.9017
Longview-Marshall, TX............................... 0.8504 0.8950
Los Angeles-Long Beach, CA.......................... 1.2382 1.1576
Louisville, KY-IN................................... 0.9447 0.9618
Macon, GA........................................... 0.8468 0.8924
Madison, WI......................................... 1.0021 1.0014
Mansfield, OH....................................... 0.8524 0.8964
Medford-Ashland, OR................................. 1.0082 1.0056
Memphis, TN-AR-MS................................... 0.8166 0.8705
Middlesex-Somerset-Hunterdon, NJ.................... 1.0688 1.0466
Milwaukee-Waukesha, WI.............................. 0.9645 0.9756
Minneapolis-St. Paul, MN-WI......................... 1.0777 1.0526
Modesto, CA......................................... 1.0112 1.0077
Monmouth-Ocean, NJ.................................. 1.0764 1.0517
Montgomery, AL...................................... 0.7876 0.8492
Nashville, TN....................................... 0.9081 0.9361
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2750 1.1810
New London-Norwich, CT.............................. 1.2317 1.1534
New Orleans, LA..................................... 0.9294 0.9511
New York, NY........................................ 1.4010 1.2597
Newark, NJ.......................................... 1.1036 1.0698
Oakland, CA......................................... 1.5069 1.3242
Odessa-Midland, TX.................................. 0.8566 0.8994
Oklahoma City, OK................................... 0.8371 0.8854
Omaha, NE-IA........................................ 0.9480 0.9641
Orange County, CA................................... 1.1902 1.1266
Peoria-Pekin, IL.................................... 0.8905 0.9237
Philadelphia, PA-NJ................................. 1.1237 1.0831
Pittsburgh, PA...................................... 0.9539 0.9682
Portland, ME........................................ 0.9619 0.9738
Portland-Vancouver, OR-WA........................... 1.1235 1.0830
Provo-Orem, UT...................................... 1.0116 1.0079
Raleigh-Durham-Chapel Hill, NC...................... 0.9602 0.9726
Rapid City, SD...................................... 0.8458 0.8916
Roanoke, VA......................................... 0.8702 0.9092
Rochester, MN....................................... 1.0428 1.0291
Rockford, IL........................................ 0.8994 0.9300
Sacramento, CA...................................... 1.2351 1.1556
Saginaw-Bay City-Midland, MI........................ 0.9667 0.9771
St. Cloud, MN....................................... 0.9457 0.9625
St. Louis, MO-IL.................................... 0.9022 0.9319
Salt Lake City-Ogden, UT............................ 0.9677 0.9778
San Diego, CA....................................... 1.2154 1.1429
San Francisco, CA................................... 1.4211 1.2721
San Jose, CA........................................ 1.4455 1.2870
Santa Rosa, CA...................................... 1.2363 1.1563
Sarasota-Bradenton, FL.............................. 0.9789 0.9855
Seattle-Bellevue-Everett, WA........................ 1.1384 1.0928
Sharon, PA.......................................... 0.8885 0.9222
Sherman-Denison, TX................................. 0.8631 0.9041
[[Page 46264]]
Sioux Falls, SD..................................... 0.8620 0.9033
South Bend, IN...................................... 0.9934 0.9955
Springfield, IL..................................... 0.8671 0.9070
Springfield, MO..................................... 0.7842 0.8466
Stockton-Lodi, CA................................... 1.1391 1.0933
Syracuse, NY........................................ 0.9396 0.9582
Tacoma, WA.......................................... 1.0866 1.0585
Tampa-St. Petersburg-Clearwater, FL................. 0.9302 0.9517
Texarkana, AR-Texarkana, TX......................... 0.8509 0.8953
Toledo, OH.......................................... 1.0361 1.0246
Topeka, KS.......................................... 0.9795 0.9859
Tucson, AZ.......................................... 0.9075 0.9357
Tulsa, OK........................................... 0.8095 0.8653
Tyler, TX........................................... 0.9605 0.9728
Victoria, TX........................................ 0.8185 0.8718
Washington, DC-MD-VA-WV............................. 1.0823 1.0557
Waterloo-Cedar Falls, IA............................ 0.8591 0.9012
Wausau, WI.......................................... 0.9698 0.9792
Wichita, KS......................................... 0.9211 0.9453
Rural Alabama....................................... 0.7150 0.7947
Rural Florida....................................... 0.8668 0.9067
Rural Kentucky...................................... 0.7753 0.8401
Rural Louisiana..................................... 0.7253 0.8026
Rural Michigan...................................... 0.8836 0.9187
Rural Minnesota..................................... 0.8144 0.8688
Rural New Hampshire................................. 0.9751 0.9829
Rural North Carolina................................ 0.7953 0.8548
Rural Virginia...................................... 0.7729 0.8383
Rural Virginia (Rural Kentucky Hosp.)............... 0.7753 0.8401
Rural Washington.................................... 0.9933 0.9954
Rural West Virginia................................. 0.7923 0.8526
Rural Wyoming....................................... 0.8177 0.8713
------------------------------------------------------------------------
Table 4d.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 15.7361
Aguadilla, PR................................................ 8.2856
Akron, OH.................................................... 19.2662
Albany, GA................................................... 16.8101
Albany-Schenectady-Troy, NY.................................. 16.8634
Albuquerque, NM.............................................. 18.2712
Alexandria, LA............................................... 15.8746
Allentown-Bethlehem-Easton, PA............................... 19.5376
Altoona, PA.................................................. 18.5951
Amarillo, TX................................................. 17.0704
Anchorage, AK................................................ 25.8567
Ann Arbor, MI................................................ 22.8035
Anniston, AL................................................. 15.6871
Appleton-Oshkosh-Neenah, WI.................................. 17.3835
Arecibo, PR.................................................. 8.5979
Asheville, NC................................................ 18.2517
Athens, GA................................................... 18.3967
Atlanta, GA.................................................. 19.6186
Atlantic-Cape May, NJ........................................ 21.6594
Augusta-Aiken, GA-SC......................................... 17.2764
Austin-San Marcos, TX........................................ 18.0941
Bakersfield, CA.............................................. 19.9230
Baltimore, MD................................................ 19.1581
Bangor, ME................................................... 18.3630
Barnstable-Yarmouth, MA...................................... 26.6928
Baton Rouge, LA.............................................. 16.4888
Beaumont-Port Arthur, TX..................................... 16.7698
Bellingham, WA............................................... 22.1285
Benton Harbor, MI............................................ 16.6319
Bergen-Passaic, NJ........................................... 23.0426
Billings, MT................................................. 17.7662
Biloxi-Gulfport-Pascagoula, MS............................... 16.7252
Binghamton, NY............................................... 17.2505
Birmingham, AL............................................... 17.6684
Bismarck, ND................................................. 15.4928
Bloomington, IN.............................................. 16.9184
Bloomington-Normal, IL....................................... 17.5793
Boise City, ID............................................... 18.3461
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.7074
Boulder-Longmont, CO......................................... 18.6194
Brazoria, TX................................................. 17.9908
Bremerton, WA................................................ 21.3152
Brownsville-Harlingen-San Benito, TX......................... 16.7030
Bryan-College Station, TX.................................... 17.3076
Buffalo-Niagara Falls, NY.................................... 17.8073
Burlington, VT............................................... 19.6864
Caguas, PR................................................... 8.9423
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.......................... 18.8112
Charlottesville, VA.......................................... 17.9005
Chattanooga, TN-GA........................................... 17.2991
Cheyenne, WY................................................. 15.0126
Chicago, IL.................................................. 21.0400
Chico-Paradise, CA........................................... 20.3689
Cincinnati, OH-KY-IN......................................... 18.7085
Clarksville-Hopkinsville, TN-KY.............................. 15.0873
Cleveland-Lorain-Elyria, OH.................................. 19.3308
Colorado Springs, CO......................................... 18.2642
Columbia, MO................................................. 17.4002
Columbia, SC................................................. 17.9118
Columbus, GA-AL.............................................. 15.2114
Columbus, OH................................................. 18.9295
Corpus Christi, TX........................................... 17.3648
Cumberland, MD-WV............................................ 16.9547
Dallas, TX................................................... 19.0236
Danville, VA................................................. 16.6152
Davenport-Moline-Rock Island, IA-IL.......................... 16.4021
Dayton-Springfield, OH....................................... 18.6913
Daytona Beach, FL............................................ 17.3459
Decatur, AL.................................................. 16.3934
Decatur, IL.................................................. 15.3452
Denver, CO................................................... 19.8786
Des Moines, IA............................................... 17.2370
Detroit, MI.................................................. 20.9694
Dothan, AL................................................... 15.1351
Dover, DE.................................................... 17.5916
Dubuque, IA.................................................. 15.8624
Duluth-Superior, MN-WI....................................... 18.4105
Dutchess County, NY.......................................... 20.7053
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..................................................... 17.9082
Eugene-Springfield, OR....................................... 22.0384
Evansville, Henderson, IN-KY................................. 17.5644
Fargo-Moorhead, ND-MN........................................ 17.6861
Fayetteville, NC............................................. 17.6113
Fayetteville-Springdale-Rogers, AR........................... 14.1177
Flagstaff, AZ-UT............................................. 17.6344
Flint, MI.................................................... 21.9933
Florence, AL................................................. 15.5219
Florence, SC................................................. 16.8047
Fort Collins-Loveland, CO.................................... 20.6529
Fort Lauderdale, FL.......................................... 20.6250
Fort Myers-Cape Coral, FL.................................... 17.6607
Fort Pierce-Port St. Lucie, FL............................... 19.8836
Fort Smith, AR-OK............................................ 15.3772
Fort Walton Beach, FL........................................ 17.9727
Fort Wayne, IN............................................... 17.2067
Fort Worth-Arlington, TX..................................... 19.8533
Fresno, CA................................................... 21.8549
Gadsden, AL.................................................. 17.3656
Gainesville, FL.............................................. 18.4465
Galveston-Texas City, TX..................................... 21.5032
Gary, IN..................................................... 18.8504
Glens Falls, NY.............................................. 16.7411
Goldsboro, NC................................................ 16.4109
Grand Forks, ND-MN........................................... 17.6200
Grand Junction, CO........................................... 16.2997
Grand Rapids-Muskegon-Holland, MI............................ 19.7853
Great Falls, MT.............................................. 16.9748
Greeley, CO.................................................. 18.9481
Green Bay, WI................................................ 17.6730
Greensboro-Winston-Salem-High Point, NC...................... 18.2112
Greenville, NC............................................... 17.7503
Greenville-Spartanburg-Anderson, SC.......................... 17.4559
Hagerstown, MD............................................... 17.9394
Hamilton-Middletown, OH...................................... 18.5562
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.................................................... 15.3561
Houston, TX.................................................. 19.5534
Huntington-Ashland, WV-KY-OH................................. 17.9378
Huntsville, AL............................................... 16.0449
Indianapolis, IN............................................. 19.3630
Iowa City, IA................................................ 18.3037
Jackson, MI.................................................. 17.6864
Jackson, MS.................................................. 15.4167
Jackson, TN.................................................. 16.2068
Jacksonville, FL............................................. 17.7663
Jacksonville, NC............................................. 13.7955
Jamestown, NY................................................ 14.9979
Janesville-Beloit, WI........................................ 16.9030
Jersey City, NJ.............................................. 22.2562
Johnson City-Kingsport-Bristol, TN-VA........................ 17.3717
Johnstown, PA................................................ 16.4213
Jonesboro, AR................................................ 14.1168
Joplin, MO................................................... 14.9353
Kalamazoo-Battlecreek, MI.................................... 20.6127
Kankakee, IL................................................. 17.8236
Kansas City, KS-MO........................................... 18.5333
Kenosha, WI.................................................. 17.8819
[[Page 46265]]
Killeen-Temple, TX........................................... 20.3189
Knoxville, TN................................................ 16.6250
Kokomo, IN................................................... 16.7962
La Crosse, WI-MN............................................. 16.8513
Lafayette, LA................................................ 15.9607
Lafayette, IN................................................ 17.1690
Lake Charles, LA............................................. 15.7084
Lakeland-Winter Haven, FL.................................... 17.1559
Lancaster, PA................................................ 18.7384
Lansing-East Lansing, MI..................................... 19.5719
Laredo, TX................................................... 13.8306
Las Cruces, NM............................................... 16.6145
Las Vegas, NV-AZ............................................. 21.2545
Lawrence, KS................................................. 16.8098
Lawton, OK................................................... 16.3566
Lewiston-Auburn, ME.......................................... 18.3998
Lexington, KY................................................ 16.2159
Lima, OH..................................................... 17.0746
Lincoln, NE.................................................. 17.9136
Little Rock-North Little Rock, AR............................ 16.8095
Longview-Marshall, TX........................................ 16.9037
Los Angeles-Long Beach, CA................................... 24.1347
Louisville, KY-IN............................................ 18.4730
Lubbock, TX.................................................. 16.6400
Lynchburg, VA................................................ 15.7441
Macon, GA.................................................... 17.2534
Madison, WI.................................................. 19.5953
Mansfield, OH................................................ 16.6677
Mayaguez, PR................................................. 8.2422
McAllen-Edinburg-Mission, TX................................. 16.5901
Medford-Ashland, OR.......................................... 19.6857
Melbourne-Titusville-Palm Bay, FL............................ 17.7314
Memphis, TN-AR-MS............................................ 15.9681
Merced, CA................................................... 20.8439
Miami, FL.................................................... 19.4323
Middlesex-Somerset-Hunterdon, NJ............................. 21.2792
Milwaukee-Waukesha, WI....................................... 18.8591
Minneapolis-St. Paul, MN-WI.................................. 21.0727
Mobile, AL................................................... 15.6052
Modesto, CA.................................................. 20.7262
Monmouth-Ocean, NJ........................................... 21.1825
Monroe, LA................................................... 16.0553
Montgomery, AL............................................... 15.4009
Muncie, IN................................................... 18.9936
Myrtle Beach, SC............................................. 15.2321
Naples, FL................................................... 19.9423
Nashville, TN................................................ 17.7573
Nassau-Suffolk, NY........................................... 26.4893
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 24.8405
New London-Norwich, CT....................................... 23.9754
New Orleans, LA.............................................. 18.1738
New York, NY................................................. 27.6763
Newark, NJ................................................... 22.9987
Newburgh, NY-PA.............................................. 21.1229
Norfolk-Virginia Beach-Newport News, VA-NC................... 16.3222
Oakland, CA.................................................. 29.3127
Ocala, FL.................................................... 17.8031
Odessa-Midland, TX........................................... 16.5854
Oklahoma City, OK............................................ 16.3683
Olympia, WA.................................................. 20.9003
Omaha, NE-IA................................................. 18.5371
Orange County, CA............................................ 23.3969
Orlando, FL.................................................. 18.5164
Owensboro, KY................................................ 14.8119
Panama City, FL.............................................. 15.7629
Parkersburg-Marietta, WV-OH.................................. 15.4018
Pensacola, FL................................................ 16.0371
Peoria-Pekin, IL............................................. 17.4120
Philadelphia, PA-NJ.......................................... 21.9722
Phoenix-Mesa, AZ............................................. 19.1821
Pine Bluff, AR............................................... 15.4205
Pittsburgh, PA............................................... 18.9688
Pittsfield, MA............................................... 20.6334
Pocatello, ID................................................ 17.1752
Ponce, PR.................................................... 9.1599
Portland, ME................................................. 18.8079
Portland-Vancouver, OR-WA.................................... 21.9679
Providence-Warwick, RI....................................... 21.6876
Provo-Orem, UT............................................... 19.7809
Pueblo, CO................................................... 16.1970
Punta Gorda, FL.............................................. 16.3323
Racine, WI................................................... 17.2751
Raleigh-Durham-Chapel Hill, NC............................... 19.0221
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...................................... 17.9776
Riverside-San Bernardino, CA................................. 22.2475
Roanoke, VA.................................................. 17.0151
Rochester, MN................................................ 20.3908
Rochester, NY................................................ 18.8662
Rockford, IL................................................. 17.5872
Rocky Mount, NC.............................................. 17.5097
Sacramento, CA............................................... 24.1510
Saginaw-Bay City-Midland, MI................................. 18.7939
St. Cloud, MN................................................ 18.4907
St. Joseph, MO............................................... 16.7196
St. Louis, MO-IL............................................. 17.6400
Salem, OR.................................................... 19.0205
Salinas, CA.................................................. 26.9904
Salt Lake City-Ogden, UT..................................... 18.9211
San Angelo, TX............................................... 14.8158
San Antonio, TX.............................................. 16.4044
San Diego, CA................................................ 23.7268
San Francisco, CA............................................ 27.8836
San Jose, CA................................................. 28.3887
San Juan-Bayamon, PR......................................... 8.8111
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............................................... 24.4155
Sarasota-Bradenton, FL....................................... 19.1406
Savannah, GA................................................. 18.8663
Scranton-Wilkes Barre-Hazleton, PA........................... 17.1121
Seattle-Bellevue-Everett, WA................................. 22.2595
Sharon, PA................................................... 17.3726
Sheboygan, WI................................................ 15.1817
Sherman-Denison, TX.......................................... 16.8423
Shreveport-Bossier City, LA.................................. 18.2999
Sioux City, IA-NE............................................ 16.2539
Sioux Falls, SD.............................................. 16.8540
South Bend, IN............................................... 19.4248
Spokane, WA.................................................. 20.5788
Springfield, IL.............................................. 16.9538
Springfield, MO.............................................. 15.2957
Springfield, MA.............................................. 20.6983
State College, PA............................................ 18.6507
Steubenville-Weirton, OH-WV.................................. 16.1632
Stockton-Lodi, CA............................................ 22.1532
Sumter, SC................................................... 15.0540
Syracuse, NY................................................. 18.3703
Tacoma, WA................................................... 21.2354
Tallahassee, FL.............................................. 16.2555
Tampa-St. Petersburg-Clearwater, FL.......................... 18.0859
Terre Haute, IN.............................................. 16.7989
Texarkana, AR-Texarkana, TX.................................. 16.6266
Toledo, OH................................................... 20.2601
Topeka, KS................................................... 19.7210
Trenton, NJ.................................................. 20.6259
Tucson, AZ................................................... 17.7311
Tulsa, OK.................................................... 15.8281
Tuscaloosa, AL............................................... 15.2197
Tyler, TX.................................................... 19.5462
Utica-Rome, NY............................................... 16.4509
Vallejo-Fairfield-Napa, CA................................... 27.2708
Ventura, CA.................................................. 22.3964
Victoria, TX................................................. 16.4116
Vineland-Millville-Bridgeton, NJ............................. 19.5394
Visalia-Tulare-Porterville, CA............................... 19.8483
Waco, TX..................................................... 15.1959
Washington, DC-MD-VA-WV...................................... 21.1632
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.................................................. 18.3188
Wichita Falls, TX............................................ 15.7237
Williamsport, PA............................................. 16.5567
Wilmington-Newark, DE-MD..................................... 22.1249
Wilmington, NC............................................... 17.6887
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...................................................... 13.9255
Alaska....................................................... 24.3314
Arizona...................................................... 15.5012
Arkansas..................................................... 13.5966
California................................................... 19.5577
Colorado..................................................... 15.8231
Connecticut.................................................. 24.9480
Delaware..................................................... 18.4711
Florida...................................................... 16.9485
Georgia...................................................... 14.9642
Hawaii....................................................... 20.0330
Idaho........................................................ 16.1848
Illinois..................................................... 14.7683
Indiana...................................................... 15.8851
Iowa......................................................... 14.4039
Kansas....................................................... 13.8962
Kentucky..................................................... 15.1598
Louisiana.................................................... 14.1417
Maine........................................................ 16.2618
Maryland..................................................... 16.4777
Massachusetts................................................ 21.0582
Michigan..................................................... 17.2651
[[Page 46266]]
Minnesota.................................................... 15.9249
Mississippi.................................................. 13.2829
Missouri..................................................... 14.1978
Montana...................................................... 15.8928
Nebraska..................................................... 14.1063
Nevada....................................................... 17.1588
New Hampshire................................................ 19.0549
New Jersey \1\............................................... .........
New Mexico................................................... 15.6424
New York..................................................... 16.7329
North Carolina............................................... 15.5456
North Dakota................................................. 14.3865
Ohio......................................................... 16.2910
Oklahoma..................................................... 13.5735
Oregon....................................................... 18.8958
Pennsylvania................................................. 16.5277
Puerto Rico.................................................. 7.8716
Rhode Island \1\............................................. .........
South Carolina............................................... 14.9937
South Dakota................................................. 13.8107
Tennessee.................................................... 14.3532
Texas........................................................ 14.5903
Utah......................................................... 17.3014
Vermont...................................................... 17.4440
Virginia..................................................... 15.0809
Washington................................................... 19.4229
West Virginia................................................ 15.4544
Wisconsin.................................................... 16.4842
Wyoming...................................................... 15.9886
------------------------------------------------------------------------
\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 3.0486 7.7 11.1 32
EXCEPT FOR TRAUMA.
2........... 01 SURG CRANIOTOMY FOR TRAUMA 3.0134 8.4 11.6 32
AGE >17.
3........... 01 SURG *CRANIOTOMY AGE 0-17... 1.9167 12.7 12.7 37
4........... 01 SURG SPINAL PROCEDURES...... 2.3399 5.9 9.1 30
5........... 01 SURG EXTRACRANIAL VASCULAR 1.5143 3.4 4.4 26
PROCEDURES.
6........... 01 SURG CARPAL TUNNEL RELEASE.. .7419 2.4 3.4 26
7........... 01 SURG PERIPH & CRANIAL NERVE 2.4886 8.1 12.6 32
& OTHER NERV SYST PROC
W CC.
8........... 01 SURG PERIPH & CRANIAL NERVE 1.0962 2.6 3.9 27
& OTHER NERV SYST PROC
W/O CC.
9........... 01 MED SPINAL DISORDERS & 1.2677 5.4 7.8 29
INJURIES.
10.......... 01 MED NERVOUS SYSTEM 1.2196 5.7 8.1 30
NEOPLASMS W CC.
11.......... 01 MED NERVOUS SYSTEM .8000 3.5 5.0 28
NEOPLASMS W/O CC.
12.......... 01 MED DEGENERATIVE NERVOUS .9457 5.4 7.7 29
SYSTEM DISORDERS.
13.......... 01 MED MULTIPLE SCLEROSIS & .7770 5.0 6.2 29
CEREBELLAR ATAXIA.
14.......... 01 MED SPECIFIC 1.1999 5.5 7.5 30
CEREBROVASCULAR
DISORDERS EXCEPT TIA.
15.......... 01 MED TRANSIENT ISCHEMIC .7231 3.5 4.5 27
ATTACK & PRECEREBRAL
OCCLUSIONS.
16.......... 01 MED NONSPECIFIC 1.0371 4.9 6.6 29
CEREBROVASCULAR
DISORDERS W CC.
17.......... 01 MED NONSPECIFIC .6331 3.0 4.0 26
CEREBROVASCULAR
DISORDERS W/O CC.
18.......... 01 MED CRANIAL & PERIPHERAL .9319 4.8 6.4 29
NERVE DISORDERS W CC.
19.......... 01 MED CRANIAL & PERIPHERAL .6230 3.4 4.5 27
NERVE DISORDERS W/O CC.
20.......... 01 MED NERVOUS SYSTEM 2.4854 8.6 11.6 33
INFECTION EXCEPT VIRAL
MENINGITIS.
21.......... 01 MED VIRAL MENINGITIS....... 1.4910 5.8 7.8 30
22.......... 01 MED HYPERTENSIVE .8353 3.8 4.9 28
ENCEPHALOPATHY.
23.......... 01 MED NONTRAUMATIC STUPOR & .8089 3.6 5.1 28
COMA.
24.......... 01 MED SEIZURE & HEADACHE AGE .9694 4.2 5.8 28
>17 W CC.
25.......... 01 MED SEIZURE & HEADACHE AGE .5793 3.0 3.9 24
>17 W/O CC.
26.......... 01 MED SEIZURE & HEADACHE AGE .7387 3.3 4.6 27
0-17.
27.......... 01 MED TRAUMATIC STUPOR & 1.3060 3.6 6.3 28
COMA, COMA >1 HR.
28.......... 01 MED TRAUMATIC STUPOR & 1.2033 4.8 7.1 29
COMA, COMA <1 HR AGE
>17 W CC.
29.......... 01 MED TRAUMATIC STUPOR & .6371 3.0 4.1 27
COMA, COMA <1 HR AGE
>17 W/O CC.
30.......... 01 MED *TRAUMATIC STUPOR & .3241 2.0 2.0 17
COMA, COMA <1 HR AGE 0-
17.
31.......... 01 MED CONCUSSION AGE >17 W CC .8412 3.7 5.4 28
32.......... 01 MED CONCUSSION AGE >17 W/O .4861 2.3 3.1 20
CC.
33.......... 01 MED *CONCUSSION AGE 0-17... .2037 1.6 1.6 9
34.......... 01 MED OTHER DISORDERS OF 1.0673 4.6 6.5 29
NERVOUS SYSTEM W CC.
35.......... 01 MED OTHER DISORDERS OF .6149 3.2 4.3 27
NERVOUS SYSTEM W/O CC.
36.......... 02 SURG RETINAL PROCEDURES..... .6134 1.3 1.6 6
37.......... 02 SURG ORBITAL PROCEDURES..... .9323 2.7 4.0 27
38.......... 02 SURG PRIMARY IRIS PROCEDURES .4282 1.9 2.6 17
39.......... 02 SURG LENS PROCEDURES WITH OR .5184 1.5 2.0 10
WITHOUT VITRECTOMY.
40.......... 02 SURG EXTRAOCULAR PROCEDURES .7072 2.2 3.4 26
EXCEPT ORBIT AGE >17.
41.......... 02 SURG *EXTRAOCULAR PROCEDURES .3299 1.6 1.6 7
EXCEPT ORBIT AGE 0-17.
[[Page 46267]]
42.......... 02 SURG INTRAOCULAR PROCEDURES .5816 1.6 2.2 13
EXCEPT RETINA, IRIS &
LENS.
43.......... 02 MED HYPHEMA................ .4520 3.3 4.2 27
44.......... 02 MED ACUTE MAJOR EYE .6237 4.7 5.7 29
INFECTIONS.
45.......... 02 MED NEUROLOGICAL EYE .6525 3.1 3.8 22
DISORDERS.
46.......... 02 MED OTHER DISORDERS OF THE .7656 4.0 5.6 28
EYE AGE >17 W CC.
47.......... 02 MED OTHER DISORDERS OF THE .4664 2.8 3.8 27
EYE AGE >17 W/O CC.
48.......... 02 MED *OTHER DISORDERS OF THE .2907 2.9 2.9 27
EYE AGE 0-17.
49.......... 03 SURG MAJOR HEAD & NECK 1.7245 4.1 5.7 28
PROCEDURES.
50.......... 03 SURG SIALOADENECTOMY........ .7686 1.7 2.1 9
51.......... 03 SURG SALIVARY GLAND .7345 1.9 2.9 20
PROCEDURES EXCEPT
SIALOADENECTOMY.
52.......... 03 SURG CLEFT LIP & PALATE 1.0271 2.1 3.4 24
REPAIR.
53.......... 03 SURG SINUS & MASTOID 1.0128 2.2 3.6 26
PROCEDURES AGE >17.
54.......... 03 SURG *SINUS & MASTOID .4712 3.2 3.2 22
PROCEDURES AGE 0-17.
55.......... 03 SURG MISCELLANEOUS EAR, .7880 2.0 3.0 22
NOSE, MOUTH & THROAT
PROCEDURES.
56.......... 03 SURG RHINOPLASTY............ .8283 2.1 2.7 18
57.......... 03 SURG T&A PROC, EXCEPT .9325 2.8 4.1 27
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE >17.
58.......... 03 SURG *T&A PROC, EXCEPT .2676 1.5 1.5 4
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59.......... 03 SURG TONSILLECTOMY &/OR .7439 2.3 3.6 26
ADENOIDECTOMY ONLY,
AGE >17.
60.......... 03 SURG *TONSILLECTOMY &/OR .2038 1.5 1.5 4
ADENOIDECTOMY ONLY,
AGE 0-17.
61.......... 03 SURG MYRINGOTOMY W TUBE 1.1960 2.7 5.1 27
INSERTION AGE >17.
62.......... 03 SURG *MYRINGOTOMY W TUBE .2885 1.3 1.3 5
INSERTION AGE 0-17.
63.......... 03 SURG OTHER EAR, NOSE, MOUTH 1.2168 3.2 4.7 27
& THROAT O.R.
PROCEDURES.
64.......... 03 MED EAR, NOSE, MOUTH & 1.1737 4.8 7.6 29
THROAT MALIGNANCY.
65.......... 03 MED DYSEQUILIBRIUM......... .5195 2.7 3.4 20
66.......... 03 MED EPISTAXIS.............. .5366 2.9 3.6 21
67.......... 03 MED EPIGLOTTITIS........... .8397 3.4 4.2 24
68.......... 03 MED OTITIS MEDIA & URI AGE .7098 3.9 4.8 27
>17 W CC.
69.......... 03 MED OTITIS MEDIA & URI AGE .5239 3.1 3.8 20
>17 W/O CC.
70.......... 03 MED OTITIS MEDIA & URI AGE .3727 2.4 2.9 15
0-17.
71.......... 03 MED LARYNGOTRACHEITIS...... .7702 3.1 4.0 27
72.......... 03 MED NASAL TRAUMA & .6532 3.1 4.4 27
DEFORMITY.
73.......... 03 MED OTHER EAR, NOSE, MOUTH .7505 3.7 5.0 28
& THROAT DIAGNOSES AGE
>17.
74.......... 03 MED *OTHER EAR, NOSE, MOUTH .3278 2.1 2.1 20
& THROAT DIAGNOSES AGE
0-17.
75.......... 04 SURG MAJOR CHEST PROCEDURES. 3.1951 8.8 11.2 33
76.......... 04 SURG OTHER RESP SYSTEM O.R. 2.6036 9.1 12.5 33
PROCEDURES W CC.
77.......... 04 SURG OTHER RESP SYSTEM O.R. 1.1593 3.8 5.5 28
PROCEDURES W/O CC.
78.......... 04 MED PULMONARY EMBOLISM..... 1.4292 7.0 8.3 31
79.......... 04 MED RESPIRATORY INFECTIONS 1.6300 7.2 9.3 31
& INFLAMMATIONS AGE
>17 W CC.
80.......... 04 MED RESPIRATORY INFECTIONS .9436 5.3 6.6 29
& INFLAMMATIONS AGE
>17 W/O CC.
81.......... 04 MED RESPIRATORY INFECTIONS 1.4845 6.3 7.8 30
& INFLAMMATIONS AGE 0-
17.
82.......... 04 MED RESPIRATORY NEOPLASMS.. 1.3319 5.7 7.9 30
83.......... 04 MED MAJOR CHEST TRAUMA W CC .9782 4.9 6.4 29
84.......... 04 MED MAJOR CHEST TRAUMA W/O .5319 2.9 3.7 23
CC.
85.......... 04 MED PLEURAL EFFUSION W CC.. 1.2200 5.6 7.4 30
86.......... 04 MED PLEURAL EFFUSION W/O CC .7117 3.4 4.5 27
87.......... 04 MED PULMONARY EDEMA & 1.3615 5.1 6.9 29
RESPIRATORY FAILURE.
88.......... 04 MED CHRONIC OBSTRUCTIVE .9846 4.9 6.1 29
PULMONARY DISEASE.
89.......... 04 MED SIMPLE PNEUMONIA & 1.1156 5.8 7.1 30
PLEURISY AGE >17 W CC.
90.......... 04 MED SIMPLE PNEUMONIA & .6978 4.3 5.1 24
PLEURISY AGE >17 W/O
CC.
91.......... 04 MED SIMPLE PNEUMONIA & .7524 3.5 4.5 27
PLEURISY AGE 0-17.
92.......... 04 MED INTERSTITIAL LUNG 1.2029 5.6 7.3 30
DISEASE W CC.
93.......... 04 MED INTERSTITIAL LUNG .7498 4.0 4.9 28
DISEASE W/O CC.
94.......... 04 MED PNEUMOTHORAX W CC...... 1.1780 5.3 7.1 29
95.......... 04 MED PNEUMOTHORAX W/O CC.... .5996 3.3 4.1 25
96.......... 04 MED BRONCHITIS & ASTHMA AGE .8272 4.5 5.5 29
>17 W CC.
97.......... 04 MED BRONCHITIS & ASTHMA AGE .6035 3.6 4.3 22
>17 W/O CC.
98.......... 04 MED BRONCHITIS & ASTHMA AGE .7807 2.9 4.3 27
0-17.
[[Page 46268]]
99.......... 04 MED RESPIRATORY SIGNS & .6869 2.7 3.5 22
SYMPTOMS W CC.
100......... 04 MED RESPIRATORY SIGNS & .5113 2.0 2.4 12
SYMPTOMS W/O CC.
101......... 04 MED OTHER RESPIRATORY .8748 3.9 5.2 28
SYSTEM DIAGNOSES W CC.
102......... 04 MED OTHER RESPIRATORY .5335 2.4 3.1 20
SYSTEM DIAGNOSES W/O
CC.
103......... 05 SURG HEART TRANSPLANT....... 15.3358 28.4 40.0 52
104......... 05 SURG CARDIAC VALVE 7.3199 12.0 14.6 36
PROCEDURES W CARDIAC
CATH.
105......... 05 SURG CARDIAC VALVE 5.5998 9.0 11.0 33
PROCEDURES W/O CARDIAC
CATH.
106......... 05 SURG CORONARY BYPASS W 5.5564 10.3 11.7 34
CARDIAC CATH.
107......... 05 SURG CORONARY BYPASS W/O 4.0685 7.8 8.8 32
CARDIAC CATH.
108......... 05 SURG OTHER CARDIOTHORACIC 5.9135 9.8 12.6 34
PROCEDURES.
109......... ................ NO LONGER VALID........ .0000 .0 .0 0
110......... 05 SURG MAJOR CARDIOVASCULAR 4.1589 8.2 10.9 32
PROCEDURES W CC.
111......... 05 SURG MAJOR CARDIOVASCULAR 2.2875 5.9 6.7 30
PROCEDURES W/O CC.
112......... 05 SURG PERCUTANEOUS 2.0946 3.5 4.7 27
CARDIOVASCULAR
PROCEDURES.
113......... 05 SURG AMPUTATION FOR CIRC 2.6935 10.6 14.4 35
SYSTEM DISORDERS
EXCEPT UPPER LIMB &
TOE.
114......... 05 SURG UPPER LIMB & TOE 1.5152 6.8 9.5 31
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115......... 05 SURG PERM CARDIAC PACEMAKER 3.6827 9.1 11.5 33
IMPLANT W AMI, HEART
FAILURE OR SHOCK.
116......... 05 SURG OTH PERM CARDIAC 2.4150 3.9 5.4 28
PACEMAKER IMPLANT OR
AICD LEAD OR GENERATOR
PROC.
117......... 05 SURG CARDIAC PACEMAKER 1.1764 2.7 4.1 27
REVISION EXCEPT DEVICE
REPLACEMENT.
118......... 05 SURG CARDIAC PACEMAKER 1.5825 2.1 3.2 25
DEVICE REPLACEMENT.
119......... 05 SURG VEIN LIGATION & 1.1435 3.3 5.5 27
STRIPPING.
120......... 05 SURG OTHER CIRCULATORY 1.9318 5.4 9.2 29
SYSTEM O.R. PROCEDURES.
121......... 05 MED CIRCULATORY DISORDERS W 1.6482 6.4 7.8 30
AMI & C.V. COMP DISCH
ALIVE.
122......... 05 MED CIRCULATORY DISORDERS W 1.1617 4.4 5.3 28
AMI W/O C.V. COMP
DISCH ALIVE.
123......... 05 MED CIRCULATORY DISORDERS W 1.4555 2.7 4.7 27
AMI, EXPIRED.
124......... 05 MED CIRCULATORY DISORDERS 1.3258 3.8 5.0 28
EXCEPT AMI, W CARD
CATH & COMPLEX DIAG.
125......... 05 MED CIRCULATORY DISORDERS .9246 2.3 3.1 20
EXCEPT AMI, W CARD
CATH W/O COMPLEX DIAG.
126......... 05 MED ACUTE & SUBACUTE 2.5379 11.0 14.3 35
ENDOCARDITIS.
127......... 05 MED HEART FAILURE & SHOCK.. 1.0265 4.8 6.2 29
128......... 05 MED DEEP VEIN .7861 5.9 6.7 27
THROMBOPHLEBITIS.
129......... 05 MED CARDIAC ARREST, 1.1316 2.0 3.5 26
UNEXPLAINED.
130......... 05 MED PERIPHERAL VASCULAR .9352 5.3 6.7 29
DISORDERS W CC.
131......... 05 MED PERIPHERAL VASCULAR .6038 4.3 5.2 28
DISORDERS W/O CC.
132......... 05 MED ATHEROSCLEROSIS W CC... .6840 2.9 3.6 20
133......... 05 MED ATHEROSCLEROSIS W/O CC. .5537 2.3 2.9 16
134......... 05 MED HYPERTENSION........... .5787 3.0 3.9 23
135......... 05 MED CARDIAC CONGENITAL & .8838 3.7 5.0 28
VALVULAR DISORDERS AGE
>17 W CC.
136......... 05 MED CARDIAC CONGENITAL & .5629 2.6 3.3 18
VALVULAR DISORDERS AGE
>17 W/O CC.
137......... 05 MED *CARDIAC CONGENITAL & .7999 3.3 3.3 27
VALVULAR DISORDERS AGE
0-17.
138......... 05 MED CARDIAC ARRHYTHMIA & .8008 3.5 4.6 27
CONDUCTION DISORDERS W
CC.
139......... 05 MED CARDIAC ARRHYTHMIA & .4971 2.4 2.9 16
CONDUCTION DISORDERS W/
O CC.
140......... 05 MED ANGINA PECTORIS........ .6205 2.8 3.5 20
141......... 05 MED SYNCOPE & COLLAPSE W CC .7128 3.4 4.5 27
142......... 05 MED SYNCOPE & COLLAPSE W/O .5288 2.5 3.2 18
CC.
143......... 05 MED CHEST PAIN............. .5223 2.1 2.6 14
144......... 05 MED OTHER CIRCULATORY 1.0857 4.1 5.7 28
SYSTEM DIAGNOSES W CC.
145......... 05 MED OTHER CIRCULATORY .6208 2.5 3.2 20
SYSTEM DIAGNOSES W/O
CC.
146......... 06 SURG RECTAL RESECTION W CC.. 2.6363 9.8 11.2 34
147......... 06 SURG RECTAL RESECTION W/O CC 1.6018 6.7 7.3 27
148......... 06 SURG MAJOR SMALL & LARGE 3.3710 11.2 13.5 35
BOWEL PROCEDURES W CC.
149......... 06 SURG MAJOR SMALL & LARGE 1.5999 7.0 7.7 25
BOWEL PROCEDURES W/O
CC.
150......... 06 SURG PERITONEAL ADHESIOLYSIS 2.6828 9.5 11.7 34
W CC.
151......... 06 SURG PERITONEAL ADHESIOLYSIS 1.2910 5.2 6.5 29
W/O CC.
152......... 06 SURG MINOR SMALL & LARGE 1.9311 7.6 9.0 32
BOWEL PROCEDURES W CC.
[[Page 46269]]
153......... 06 SURG MINOR SMALL & LARGE 1.1568 5.6 6.2 24
BOWEL PROCEDURES W/O
CC.
154......... 06 SURG *STOMACH, ESOPHAGEAL & 4.1817 11.6 15.0 36
DUODENAL PROCEDURES
AGE >17 W CC.
155......... 06 SURG STOMACH, ESOPHAGEAL & 1.4059 4.5 5.9 29
DUODENAL PROCEDURES
AGE >17 W/O CC.
156......... 06 SURG *STOMACH, ESOPHAGEAL & .8238 6.0 6.0 30
DUODENAL PROCEDURES
AGE 0-17.
157......... 06 SURG ANAL & STOMAL 1.1352 4.2 5.8 28
PROCEDURES W CC.
158......... 06 SURG ANAL & STOMAL .6077 2.3 2.9 18
PROCEDURES W/O CC.
159......... 06 SURG HERNIA PROCEDURES 1.2268 4.0 5.3 28
EXCEPT INGUINAL &
FEMORAL AGE >17 W CC.
160......... 06 SURG HERNIA PROCEDURES .7026 2.4 3.0 16
EXCEPT INGUINAL &
FEMORAL AGE >17 W/O CC.
161......... 06 SURG INGUINAL & FEMORAL 1.0066 3.0 4.4 27
HERNIA PROCEDURES AGE
>17 W CC.
162......... 06 SURG INGUINAL & FEMORAL .5707 1.7 2.2 11
HERNIA PROCEDURES AGE
>17 W/O CC.
163......... 06 SURG *HERNIA PROCEDURES AGE .7706 2.1 2.1 11
0-17.
164......... 06 SURG APPENDECTOMY W 2.3386 8.0 9.4 32
COMPLICATED PRINCIPAL
DIAG W CC.
165......... 06 SURG APPENDECTOMY W 1.2582 5.1 5.8 24
COMPLICATED PRINCIPAL
DIAG W/O CC.
166......... 06 SURG APPENDECTOMY W/O 1.4497 4.5 5.7 29
COMPLICATED PRINCIPAL
DIAG W CC.
167......... 06 SURG APPENDECTOMY W/O .8431 2.8 3.2 15
COMPLICATED PRINCIPAL
DIAG W/O CC.
168......... 03 SURG MOUTH PROCEDURES W CC.. 1.0929 3.2 5.0 27
169......... 03 SURG MOUTH PROCEDURES W/O CC .6717 2.0 2.5 15
170......... 06 SURG OTHER DIGESTIVE SYSTEM 2.7453 8.5 12.5 33
O.R. PROCEDURES W CC.
171......... 06 SURG OTHER DIGESTIVE SYSTEM 1.1202 4.0 5.4 28
O.R. PROCEDURES W/O CC.
172......... 06 MED DIGESTIVE MALIGNANCY W 1.2920 5.7 8.2 30
CC.
173......... 06 MED DIGESTIVE MALIGNANCY W/ .6769 3.0 4.4 27
O CC.
174......... 06 MED G.I. HEMORRHAGE W CC... .9952 4.4 5.6 28
175......... 06 MED G.I. HEMORRHAGE W/O CC. .5485 2.9 3.5 17
176......... 06 MED COMPLICATED PEPTIC 1.0856 4.7 6.2 29
ULCER.
177......... 06 MED UNCOMPLICATED PEPTIC .8335 4.0 5.0 28
ULCER W CC.
178......... 06 MED UNCOMPLICATED PEPTIC .6091 3.0 3.6 19
ULCER W/O CC.
179......... 06 MED INFLAMMATORY BOWEL 1.1188 5.5 7.2 30
DISEASE.
180......... 06 MED G.I. OBSTRUCTION W CC.. .9194 4.7 6.1 29
181......... 06 MED G.I. OBSTRUCTION W/O CC .5338 3.3 4.0 22
182......... 06 MED ESOPHAGITIS, GASTROENT .7789 3.8 5.0 28
& MISC DIGEST
DISORDERS AGE >17 W CC.
183......... 06 MED ESOPHAGITIS, GASTROENT .5553 2.8 3.4 20
& MISC DIGEST
DISORDERS AGE >17 W/O
CC.
184......... 06 MED ESOPHAGITIS, GASTROENT .5414 2.8 3.9 27
& MISC DIGEST
DISORDERS AGE 0-17.
185......... 03 MED DENTAL & ORAL DIS .8424 3.7 5.2 28
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE >17.
186......... 03 MED *DENTAL & ORAL DIS .3140 2.9 2.9 23
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187......... 03 MED DENTAL EXTRACTIONS & .7104 3.1 4.2 27
RESTORATIONS.
188......... 06 MED OTHER DIGESTIVE SYSTEM 1.0591 4.5 6.1 28
DIAGNOSES AGE >17 W CC.
189......... 06 MED OTHER DIGESTIVE SYSTEM .5640 2.7 3.7 27
DIAGNOSES AGE >17 W/O
CC.
190......... 06 MED OTHER DIGESTIVE SYSTEM .8769 3.9 5.1 28
DIAGNOSES AGE 0-17.
191......... 07 SURG PANCREAS, LIVER & SHUNT 4.4543 12.1 16.3 36
PROCEDURES W CC.
192......... 07 SURG PANCREAS, LIVER & SHUNT 1.7889 6.2 7.9 30
PROCEDURES W/O CC.
193......... 07 SURG BILIARY TRACT PROC 3.2878 11.4 13.9 35
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W CC.
194......... 07 SURG BILIARY TRACT PROC 1.7549 6.8 8.5 31
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W/O CC.
195......... 07 SURG CHOLECYSTECTOMY W 2.6894 8.8 10.5 33
C.D.E. W CC.
196......... 07 SURG CHOLECYSTECTOMY W 1.6127 5.8 6.7 30
C.D.E. W/O CC.
197......... 07 SURG CHOLECYSTECTOMY EXCEPT 2.2679 7.5 9.2 31
BY LAPAROSCOPE W/O
C.D.E. W CC.
198......... 07 SURG CHOLECYSTECTOMY EXCEPT 1.1738 4.3 4.9 23
BY LAPAROSCOPE W/O
C.D.E. W/O CC.
[[Page 46270]]
199......... 07 SURG HEPATOBILIARY 2.3728 8.4 11.2 32
DIAGNOSTIC PROCEDURE
FOR MALIGNANCY.
200......... 07 SURG HEPATOBILIARY 3.1772 7.9 12.4 32
DIAGNOSTIC PROCEDURE
FOR NON-MALIGNANCY.
201......... 07 SURG OTHER HEPATOBILIARY OR 3.7669 12.1 16.8 36
PANCREAS O.R.
PROCEDURES.
202......... 07 MED CIRRHOSIS & ALCOHOLIC 1.3675 5.7 7.8 30
HEPATITIS.
203......... 07 MED MALIGNANCY OF 1.2486 5.5 7.7 30
HEPATOBILIARY SYSTEM
OR PANCREAS.
204......... 07 MED DISORDERS OF PANCREAS 1.2004 5.1 6.8 29
EXCEPT MALIGNANCY.
205......... 07 MED DISORDERS OF LIVER 1.2194 5.3 7.3 29
EXCEPT MALIG, CIRR,
ALC HEPA W CC.
206......... 07 MED DISORDERS OF LIVER .7159 3.6 4.7 28
EXCEPT MALIG, CIRR,
ALC HEPA W/O CC.
207......... 07 MED DISORDERS OF THE 1.0508 4.4 5.8 28
BILIARY TRACT W CC.
208......... 07 MED DISORDERS OF THE .6045 2.6 3.5 21
BILIARY TRACT W/O CC.
209......... 08 SURG MAJOR JOINT & LIMB 2.2606 5.9 6.7 23
REATTACHMENT
PROCEDURES OF LOWER
EXTREMITY.
210......... 08 SURG HIP & FEMUR PROCEDURES 1.8460 7.2 8.6 31
EXCEPT MAJOR JOINT AGE
>17 W CC.
211......... 08 SURG HIP & FEMUR PROCEDURES 1.2740 5.6 6.3 23
EXCEPT MAJOR JOINT AGE
>17 W/O CC.
212......... 08 SURG *HIP & FEMUR PROCEDURES 1.1487 11.1 11.1 35
EXCEPT MAJOR JOINT AGE
0-17.
213......... 08 SURG AMPUTATION FOR 1.7049 7.0 9.7 31
MUSCULOSKELETAL SYSTEM
& CONN TISSUE
DISORDERS.
214......... 08 SURG BACK & NECK PROCEDURES 1.9255 4.9 6.5 29
W CC.
215......... 08 SURG BACK & NECK PROCEDURES 1.1119 3.0 3.7 20
W/O CC.
216......... 08 SURG BIOPSIES OF 2.0784 7.9 11.1 32
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
217......... 08 SURG WND DEBRID & SKN GRFT 2.8812 10.2 15.4 34
EXCEPT HAND, FOR
MUSCSKELET & CONN TISS
DIS.
218......... 08 SURG LOWER EXTREM & HUMER 1.4574 4.8 6.2 29
PROC EXCEPT HIP, FOOT,
FEMUR AGE >17 W CC.
219......... 08 SURG LOWER EXTREM & HUMER .9553 3.1 3.8 19
PROC EXCEPT HIP, FOOT,
FEMUR AGE >17 W/O CC.
220......... 08 SURG *LOWER EXTREM & HUMER .5706 5.3 5.3 29
PROC EXCEPT HIP, FOOT,
FEMUR AGE 0-17.
221......... 08 SURG KNEE PROCEDURES W CC... 1.8340 5.8 8.1 30
222......... 08 SURG KNEE PROCEDURES W/O CC. 1.0177 3.1 4.0 27
223......... 08 SURG MAJOR SHOULDER/ELBOW .8720 2.2 2.9 16
PROC, OR OTHER UPPER
EXTREMITY PROC W CC.
224......... 08 SURG SHOULDER, ELBOW OR .7417 1.9 2.3 10
FOREARM PROC, EXC
MAJOR JOINT PROC, W/O
CC.
225......... 08 SURG FOOT PROCEDURES........ 1.0020 3.3 5.0 27
226......... 08 SURG SOFT TISSUE PROCEDURES 1.3831 4.4 6.7 28
W CC.
227......... 08 SURG SOFT TISSUE PROCEDURES .7449 2.3 3.0 18
W/O CC.
228......... 08 SURG MAJOR THUMB OR JOINT .9349 2.3 3.5 26
PROC, OR OTH HAND OR
WRIST PROC W CC.
229......... 08 SURG HAND OR WRIST PROC, .6512 1.8 2.4 13
EXCEPT MAJOR JOINT
PROC, W/O CC.
230......... 08 SURG LOCAL EXCISION & 1.0567 3.3 5.2 27
REMOVAL OF INT FIX
DEVICES OF HIP & FEMUR.
231......... 08 SURG LOCAL EXCISION & 1.2263 3.3 5.1 27
REMOVAL OF INT FIX
DEVICES EXCEPT HIP &
FEMUR.
232......... 08 SURG ARTHROSCOPY............ 1.0884 2.6 4.5 27
233......... 08 SURG OTHER MUSCULOSKELET SYS 2.0170 6.4 9.1 30
& CONN TISS O.R. PROC
W CC.
234......... 08 SURG OTHER MUSCULOSKELET SYS 1.0675 3.1 4.1 27
& CONN TISS O.R. PROC
W/O CC.
235......... 08 MED FRACTURES OF FEMUR..... .8395 4.7 6.9 29
236......... 08 MED FRACTURES OF HIP & .7620 4.7 6.4 29
PELVIS.
237......... 08 MED SPRAINS, STRAINS, & .5637 3.3 4.4 27
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238......... 08 MED OSTEOMYELITIS.......... 1.3796 7.6 10.1 32
239......... 08 MED PATHOLOGICAL FRACTURES 1.0115 5.8 7.6 30
& MUSCULOSKELETAL &
CONN TISS MALIGNANCY.
240......... 08 MED CONNECTIVE TISSUE 1.2112 5.5 7.5 30
DISORDERS W CC.
241......... 08 MED CONNECTIVE TISSUE .6029 3.5 4.6 28
DISORDERS W/O CC.
242......... 08 MED SEPTIC ARTHRITIS....... 1.0492 5.8 7.7 30
[[Page 46271]]
243......... 08 MED MEDICAL BACK PROBLEMS.. .7241 4.3 5.6 28
244......... 08 MED BONE DISEASES & .7279 4.3 5.8 28
SPECIFIC ARTHROPATHIES
W CC.
245......... 08 MED BONE DISEASES & .4954 3.2 4.3 27
SPECIFIC ARTHROPATHIES
W/O CC.
246......... 08 MED NON-SPECIFIC .5887 3.6 4.6 28
ARTHROPATHIES.
247......... 08 MED SIGNS & SYMPTOMS OF .5523 2.9 4.0 27
MUSCULOSKELETAL SYSTEM
& CONN TISSUE.
248......... 08 MED TENDONITIS, MYOSITIS & .7325 3.9 5.3 28
BURSITIS.
249......... 08 MED AFTERCARE, .6522 2.9 4.3 27
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
250......... 08 MED FX, SPRN, STRN & DISL .6915 3.6 5.1 28
OF FOREARM, HAND, FOOT
AGE >17 W CC.
251......... 08 MED FX, SPRN, STRN & DISL .4640 2.5 3.3 22
OF FOREARM, HAND, FOOT
AGE >17 W/O CC.
252......... 08 MED *FX, SPRN, STRN & DISL .2479 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 .4451 2.9 3.9 25
OF UPARM, LOWLEG EX
FOOT AGE >17 W/O CC.
255......... 08 MED *FX, SPRN, STRN & DISL .2886 2.9 2.9 27
OF UPARM, LOWLEG EX
FOOT AGE 0-17.
256......... 08 MED OTHER MUSCULOSKELETAL .7651 4.0 5.7 28
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
257......... 09 SURG TOTAL MASTECTOMY FOR .9015 2.8 3.4 17
MALIGNANCY W CC.
258......... 09 SURG TOTAL MASTECTOMY FOR .7087 2.2 2.5 10
MALIGNANCY W/O CC.
259......... 09 SURG SUBTOTAL MASTECTOMY FOR .8640 2.3 3.5 26
MALIGNANCY W CC.
260......... 09 SURG SUBTOTAL MASTECTOMY FOR .6083 1.6 1.9 8
MALIGNANCY W/O CC.
261......... 09 SURG BREAST PROC FOR NON- .8286 1.9 2.3 12
MALIGNANCY EXCEPT
BIOPSY & LOCAL
EXCISION.
262......... 09 SURG BREAST BIOPSY & LOCAL .7695 2.7 3.9 27
EXCISION FOR NON-
MALIGNANCY.
263......... 09 SURG SKIN GRAFT &/OR DEBRID 2.1226 9.9 13.9 34
FOR SKIN ULCER OR
CELLULITIS W CC.
264......... 09 SURG SKIN GRAFT &/OR DEBRID 1.1270 6.0 8.3 30
FOR SKIN ULCER OR
CELLULITIS W/O CC.
265......... 09 SURG SKIN GRAFT &/OR DEBRID 1.4993 4.8 7.7 29
EXCEPT FOR SKIN ULCER
OR CELLULITIS W CC.
266......... 09 SURG SKIN GRAFT &/OR DEBRID .7629 2.7 3.7 27
EXCEPT FOR SKIN ULCER
OR CELLULITIS W/O CC.
267......... 09 SURG PERIANAL & PILONIDAL .8330 2.8 4.3 27
PROCEDURES.
268......... 09 SURG SKIN, SUBCUTANEOUS .9916 2.5 4.1 27
TISSUE & BREAST
PLASTIC PROCEDURES.
269......... 09 SURG OTHER SKIN, SUBCUT TISS 1.6416 6.3 9.3 30
& BREAST PROC W CC.
270......... 09 SURG OTHER SKIN, SUBCUT TISS .7003 2.4 3.4 26
& BREAST PROC W/O CC.
271......... 09 MED SKIN ULCERS............ 1.0816 6.6 8.5 31
272......... 09 MED MAJOR SKIN DISORDERS W 1.0158 5.6 7.5 30
CC.
273......... 09 MED MAJOR SKIN DISORDERS W/ .6346 4.1 5.5 28
O CC.
274......... 09 MED MALIGNANT BREAST 1.0760 5.3 7.9 29
DISORDERS W CC.
275......... 09 MED MALIGNANT BREAST .5085 2.5 3.7 27
DISORDERS W/O CC.
276......... 09 MED NON-MALIGNANT BREAST .6374 3.9 5.0 28
DISORDERS.
277......... 09 MED CELLULITIS AGE >17 W CC .8526 5.5 6.7 29
278......... 09 MED CELLULITIS AGE >17 W/O .5774 4.3 5.2 25
CC.
279......... 09 MED *CELLULITIS AGE 0-17... .7190 4.2 4.2 24
280......... 09 MED TRAUMA TO THE SKIN, .6750 3.7 5.1 28
SUBCUT TISS & BREAST
AGE >17 W CC.
281......... 09 MED TRAUMA TO THE SKIN, .4560 2.7 3.6 24
SUBCUT TISS & BREAST
AGE >17 W/O CC.
282......... 09 MED *TRAUMA TO THE SKIN, .2509 2.2 2.2 19
SUBCUT TISS & BREAST
AGE 0-17.
283......... 09 MED MINOR SKIN DISORDERS W .6990 4.1 5.5 28
CC.
284......... 09 MED MINOR SKIN DISORDERS W/ .4340 2.9 3.8 26
O CC.
285......... 10 SURG AMPUTAT OF LOWER LIMB 2.2015 9.5 13.7 34
FOR ENDOCRINE, NUTRIT,
& METABOL DISORDERS.
286......... 10 SURG ADRENAL & PITUITARY 2.3775 6.6 8.7 31
PROCEDURES.
287......... 10 SURG SKIN GRAFTS & WOUND 1.9765 9.4 13.4 33
DEBRID FOR ENDOC,
NUTRIT & METAB
DISORDERS.
288......... 10 SURG O.R. PROCEDURES FOR 2.0104 5.2 6.9 29
OBESITY.
289......... 10 SURG PARATHYROID PROCEDURES. 1.0198 2.7 4.0 27
290......... 10 SURG THYROID PROCEDURES..... .8798 2.1 2.8 15
[[Page 46272]]
291......... 10 SURG THYROGLOSSAL PROCEDURES .5189 1.4 1.8 8
292......... 10 SURG OTHER ENDOCRINE, NUTRIT 2.6450 8.4 12.8 32
& METAB O.R. PROC W CC.
293......... 10 SURG OTHER ENDOCRINE, NUTRIT 1.2671 4.6 6.8 29
& METAB O.R. PROC W/O
CC.
294......... 10 MED DIABETES AGE >35....... .7594 4.3 5.7 28
295......... 10 MED DIABETES AGE 0-35...... .7159 3.3 4.3 27
296......... 10 MED NUTRITIONAL & MISC .8929 4.7 6.4 29
METABOLIC DISORDERS
AGE >17 W CC.
297......... 10 MED NUTRITIONAL & MISC .5364 3.3 4.3 26
METABOLIC DISORDERS
AGE >17 W/O CC.
298......... 10 MED NUTRITIONAL & MISC .5221 2.5 3.4 23
METABOLIC DISORDERS
AGE 0-17.
299......... 10 MED INBORN ERRORS OF .8330 3.9 5.4 28
METABOLISM.
300......... 10 MED ENDOCRINE DISORDERS W 1.0950 5.5 7.3 30
CC.
301......... 10 MED ENDOCRINE DISORDERS W/O .6182 3.4 4.4 27
CC.
302......... 11 SURG KIDNEY TRANSPLANT...... 3.9047 10.4 12.3 34
303......... 11 SURG KIDNEY, URETER & MAJOR 2.6409 8.4 10.2 32
BLADDER PROCEDURES FOR
NEOPLASM.
304......... 11 SURG KIDNEY, URETER & MAJOR 2.3716 7.5 10.3 31
BLADDER PROC FOR NON-
NEOPL W CC.
305......... 11 SURG KIDNEY, URETER & MAJOR 1.1776 3.9 4.9 28
BLADDER PROC FOR NON-
NEOPL W/O CC.
306......... 11 SURG PROSTATECTOMY W CC..... 1.2258 4.3 6.2 28
307......... 11 SURG PROSTATECTOMY W/O CC... .6708 2.4 3.0 15
308......... 11 SURG MINOR BLADDER 1.5252 4.7 7.0 29
PROCEDURES W CC.
309......... 11 SURG MINOR BLADDER .8860 2.3 3.0 18
PROCEDURES W/O CC.
310......... 11 SURG TRANSURETHRAL 1.0015 3.2 4.6 27
PROCEDURES W CC.
311......... 11 SURG TRANSURETHRAL .5670 1.8 2.2 11
PROCEDURES W/O CC.
312......... 11 SURG URETHRAL PROCEDURES, .9124 3.2 4.8 27
AGE >17 W CC.
313......... 11 SURG URETHRAL PROCEDURES, .5223 1.8 2.3 13
AGE >17 W/O CC.
314......... 11 SURG *URETHRAL PROCEDURES, .4836 2.3 2.3 26
AGE 0-17.
315......... 11 SURG OTHER KIDNEY & URINARY 2.0574 5.3 9.3 29
TRACT O.R. PROCEDURES.
316......... 11 MED RENAL FAILURE.......... 1.3034 5.4 7.6 29
317......... 11 MED ADMIT FOR RENAL .4845 1.9 2.9 20
DIALYSIS.
318......... 11 MED KIDNEY & URINARY TRACT 1.1296 5.0 7.2 29
NEOPLASMS W CC.
319......... 11 MED KIDNEY & URINARY TRACT .5772 2.3 3.2 24
NEOPLASMS W/O CC.
320......... 11 MED KIDNEY & URINARY TRACT .9048 5.1 6.4 29
INFECTIONS AGE >17 W
CC.
321......... 11 MED KIDNEY & URINARY TRACT .6077 3.9 4.7 24
INFECTIONS AGE >17 W/O
CC.
322......... 11 MED KIDNEY & URINARY TRACT .5133 3.6 4.4 23
INFECTIONS AGE 0-17.
323......... 11 MED URINARY STONES W CC, &/ .7496 2.7 3.6 24
OR ESW LITHOTRIPSY.
324......... 11 MED URINARY STONES W/O CC.. .4159 1.7 2.1 10
325......... 11 MED KIDNEY & URINARY TRACT .6377 3.4 4.6 27
SIGNS & SYMPTOMS AGE
>17 W CC.
326......... 11 MED KIDNEY & URINARY TRACT .4320 2.4 3.4 19
SIGNS & SYMPTOMS AGE
>17 W/O CC.
327......... 11 MED *KIDNEY & URINARY TRACT .2341 3.1 3.1 27
SIGNS & SYMPTOMS AGE 0-
17.
328......... 11 MED URETHRAL STRICTURE AGE .6886 3.1 4.3 27
>17 W CC.
329......... 11 MED URETHRAL STRICTURE AGE .4567 2.1 2.8 17
>17 W/O CC.
330......... 11 MED *URETHRAL STRICTURE AGE .3115 1.6 1.6 9
0-17.
331......... 11 MED OTHER KIDNEY & URINARY .9914 4.6 6.2 29
TRACT DIAGNOSES AGE
>17 W CC.
332......... 11 MED OTHER KIDNEY & URINARY .6070 2.8 3.9 27
TRACT DIAGNOSES AGE
>17 W/O CC.
333......... 11 MED OTHER KIDNEY & URINARY .8562 4.3 5.8 28
TRACT DIAGNOSES AGE 0-
17.
334......... 12 SURG MAJOR MALE PELVIC 1.6653 5.3 6.1 23
PROCEDURES W CC.
335......... 12 SURG MAJOR MALE PELVIC 1.2610 4.2 4.6 17
PROCEDURES W/O CC.
336......... 12 SURG TRANSURETHRAL .8848 3.2 4.1 24
PROSTATECTOMY W CC.
337......... 12 SURG TRANSURETHRAL .6147 2.3 2.7 11
PROSTATECTOMY W/O CC.
338......... 12 SURG TESTES PROCEDURES, FOR 1.0499 3.5 5.3 27
MALIGNANCY.
339......... 12 SURG TESTES PROCEDURES, NON- 1.0194 3.1 5.3 27
MALIGNANCY AGE >17.
340......... 12 SURG *TESTES PROCEDURES, NON- .2769 2.4 2.4 13
MALIGNANCY AGE 0-17.
341......... 12 SURG PENIS PROCEDURES....... 1.0745 2.3 3.3 21
342......... 12 SURG CIRCUMCISION AGE >17... .7578 2.7 4.0 27
343......... 12 SURG *CIRCUMCISION AGE 0-17. .1504 1.7 1.7 6
[[Page 46273]]
344......... 12 SURG OTHER MALE REPRODUCTIVE 1.0083 2.3 3.5 25
SYSTEM O.R. PROCEDURES
FOR MALIGNANCY.
345......... 12 SURG OTHER MALE REPRODUCTIVE .8422 2.8 4.0 27
SYSTEM O.R. PROC
EXCEPT FOR MALIGNANCY.
346......... 12 MED MALIGNANCY, MALE .9559 4.8 6.8 29
REPRODUCTIVE SYSTEM, W
CC.
347......... 12 MED MALIGNANCY, MALE .5096 2.4 3.3 25
REPRODUCTIVE SYSTEM, W/
O CC.
348......... 12 MED BENIGN PROSTATIC .7107 3.6 4.9 28
HYPERTROPHY W CC.
349......... 12 MED BENIGN PROSTATIC .3974 2.2 3.0 20
HYPERTROPHY W/O CC.
350......... 12 MED INFLAMMATION OF THE .6611 3.9 4.8 24
MALE REPRODUCTIVE
SYSTEM.
351......... 12 MED *STERILIZATION, MALE... .2309 1.3 1.3 5
352......... 12 MED OTHER MALE REPRODUCTIVE .5877 2.8 3.9 27
SYSTEM DIAGNOSES.
353......... 13 SURG PELVIC EVISCERATION, 1.9174 6.7 8.3 31
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354......... 13 SURG UTERINE, ADNEXA PROC 1.4643 5.2 6.3 28
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355......... 13 SURG UTERINE, ADNEXA PROC .9056 3.6 3.9 11
FOR NON-OVARIAN/
ADNEXAL MALIG W/O CC.
356......... 13 SURG FEMALE REPRODUCTIVE .7376 2.6 3.0 12
SYSTEM RECONSTRUCTIVE
PROCEDURES.
357......... 13 SURG UTERINE & ADNEXA PROC 2.3824 8.0 9.8 32
FOR OVARIAN OR ADNEXAL
MALIGNANCY.
358......... 13 SURG UTERINE & ADNEXA PROC 1.1713 4.1 4.8 19
FOR NON-MALIGNANCY W
CC.
359......... 13 SURG UTERINE & ADNEXA PROC .8285 3.0 3.3 10
FOR NON-MALIGNANCY W/O
CC.
360......... 13 SURG VAGINA, CERVIX & VULVA .8459 2.9 3.5 17
PROCEDURES.
361......... 13 SURG LAPAROSCOPY & 1.1148 2.5 3.5 23
INCISIONAL TUBAL
INTERRUPTION.
362......... 13 SURG *ENDOSCOPIC TUBAL .2951 1.4 1.4 5
INTERRUPTION.
363......... 13 SURG D&C, CONIZATION & RADIO- .6911 2.6 3.5 21
IMPLANT, FOR
MALIGNANCY.
364......... 13 SURG D&C, CONIZATION EXCEPT .6739 2.6 3.6 27
FOR MALIGNANCY.
365......... 13 SURG OTHER FEMALE 1.7237 5.3 8.1 29
REPRODUCTIVE SYSTEM
O.R. PROCEDURES.
366......... 13 MED MALIGNANCY, FEMALE 1.1941 5.3 7.8 29
REPRODUCTIVE SYSTEM W
CC.
367......... 13 MED MALIGNANCY, FEMALE .5216 2.3 3.2 24
REPRODUCTIVE SYSTEM W/
O CC.
368......... 13 MED INFECTIONS, FEMALE 1.0230 5.3 6.9 29
REPRODUCTIVE SYSTEM.
369......... 13 MED MENSTRUAL & OTHER .5454 2.6 3.7 27
FEMALE REPRODUCTIVE
SYSTEM DISORDERS.
370......... 14 SURG CESAREAN SECTION W CC.. 1.0401 4.3 5.6 26
371......... 14 SURG CESAREAN SECTION W/O CC .6838 3.2 3.6 11
372......... 14 MED VAGINAL DELIVERY W .5439 2.4 3.4 20
COMPLICATING DIAGNOSES.
373......... 14 MED VAGINAL DELIVERY W/O .3602 1.7 1.9 7
COMPLICATING DIAGNOSES.
374......... 14 SURG VAGINAL DELIVERY W .6775 2.0 2.6 11
STERILIZATION &/OR D&C.
375......... 14 SURG *VAGINAL DELIVERY W .6698 4.4 4.4 28
O.R. PROC EXCEPT
STERIL &/OR D&C.
376......... 14 MED POSTPARTUM & POST .5638 2.3 3.4 25
ABORTION DIAGNOSES W/O
O.R. PROCEDURE.
377......... 14 SURG POSTPARTUM & POST .8188 2.1 3.3 26
ABORTION DIAGNOSES W
O.R. PROCEDURE.
378......... 14 MED ECTOPIC PREGNANCY...... .8054 2.4 2.9 15
379......... 14 MED THREATENED ABORTION.... .3591 2.0 3.0 21
380......... 14 MED ABORTION W/O D&C....... .4775 1.7 2.3 12
381......... 14 SURG ABORTION W D&C, .5151 1.7 2.3 14
ASPIRATION CURETTAGE
OR HYSTEROTOMY.
382......... 14 MED FALSE LABOR............ .2013 1.3 1.6 6
383......... 14 MED OTHER ANTEPARTUM .4655 2.8 4.1 27
DIAGNOSES W MEDICAL
COMPLICATIONS.
384......... 14 MED OTHER ANTEPARTUM .3921 1.8 3.1 22
DIAGNOSES W/O MEDICAL
COMPLICATIONS.
385......... 15 ................ *NEONATES, DIED OR 1.3443 1.8 1.8 26
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386......... 15 ................ *EXTREME IMMATURITY OR 4.4329 17.9 17.9 42
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387......... 15 ................ *PREMATURITY W MAJOR 3.0276 13.3 13.3 37
PROBLEMS.
388......... 15 ................ *PREMATURITY W/O MAJOR 1.8268 8.6 8.6 33
PROBLEMS.
389......... 15 ................ FULL TERM NEONATE W 2.2451 7.9 10.7 32
MAJOR PROBLEMS.
390......... 15 ................ NEONATE W OTHER 1.2845 3.6 4.7 28
SIGNIFICANT PROBLEMS.
[[Page 46274]]
391......... 15 ................ *NORMAL NEWBORN........ .1490 3.1 3.1 11
392......... 16 SURG SPLENECTOMY AGE >17.... 3.2443 8.9 11.7 33
393......... 16 SURG *SPLENECTOMY AGE 0-17.. 1.3168 9.1 9.1 33
394......... 16 SURG OTHER O.R. PROCEDURES 1.5994 4.5 8.0 28
OF THE BLOOD AND BLOOD
FORMING ORGANS.
395......... 16 MED RED BLOOD CELL .8362 3.9 5.4 28
DISORDERS AGE >17.
396......... 16 MED RED BLOOD CELL .6966 2.7 3.8 27
DISORDERS AGE 0-17.
397......... 16 MED COAGULATION DISORDERS.. 1.2612 4.4 6.1 28
398......... 16 MED RETICULOENDOTHELIAL & 1.2106 5.2 6.6 29
IMMUNITY DISORDERS W
CC.
399......... 16 MED RETICULOENDOTHELIAL & .7030 3.5 4.4 27
IMMUNITY DISORDERS W/O
CC.
400......... 17 SURG LYMPHOMA & LEUKEMIA W 2.5572 6.7 10.4 31
MAJOR O.R. PROCEDURE.
401......... 17 SURG LYMPHOMA & NON-ACUTE 2.4834 8.5 12.4 32
LEUKEMIA W OTHER O.R.
PROC W CC.
402......... 17 SURG LYMPHOMA & NON-ACUTE 1.0255 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 .8059 3.7 5.1 28
LEUKEMIA W/O CC.
405......... 17 ................ *ACUTE LEUKEMIA W/O 1.8669 4.9 4.9 29
MAJOR O.R. PROCEDURE
AGE 0-17.
406......... 17 SURG MYELOPROLIF DISORD OR 2.6841 8.1 11.3 32
POORLY DIFF NEOPL W
MAJ O.R. PROC W CC.
407......... 17 SURG MYELOPROLIF DISORD OR 1.1787 3.8 4.9 28
POORLY DIFF NEOPL W
MAJ O.R. PROC W/O CC.
408......... 17 SURG MYELOPROLIF DISORD OR 1.7393 5.0 8.2 29
POORLY DIFF NEOPL W
OTHER O.R. PROC.
409......... 17 MED RADIOTHERAPY........... .9763 4.7 6.7 29
410......... 17 MED CHEMOTHERAPY W/O ACUTE .7514 2.6 3.4 20
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411......... 17 MED HISTORY OF MALIGNANCY W/ .3837 2.1 2.7 16
O ENDOSCOPY.
412......... 17 MED HISTORY OF MALIGNANCY W .4080 2.1 3.0 23
ENDOSCOPY.
413......... 17 MED OTHER MYELOPROLIF DIS 1.3257 6.0 8.4 30
OR POORLY DIFF NEOPL
DIAG W CC.
414......... 17 MED OTHER MYELOPROLIF DIS .7337 3.7 5.2 28
OR POORLY DIFF NEOPL
DIAG W/O CC.
415......... 18 SURG O.R. PROCEDURE FOR 3.4430 11.4 15.8 35
INFECTIOUS & PARASITIC
DISEASES.
416......... 18 MED SEPTICEMIA AGE >17..... 1.4838 6.2 8.3 30
417......... 18 MED SEPTICEMIA AGE 0-17.... .8089 3.7 4.6 28
418......... 18 MED POSTOPERATIVE & POST- .9697 5.4 6.8 29
TRAUMATIC INFECTIONS.
419......... 18 MED FEVER OF UNKNOWN ORIGIN .8991 4.4 5.7 28
AGE >17 W CC.
420......... 18 MED FEVER OF UNKNOWN ORIGIN .6264 3.5 4.3 24
AGE >17 W/O CC.
421......... 18 MED VIRAL ILLNESS AGE >17.. .7153 3.6 4.7 28
422......... 18 MED VIRAL ILLNESS & FEVER .5347 2.9 3.8 25
OF UNKNOWN ORIGIN AGE
0-17.
423......... 18 MED OTHER INFECTIOUS & 1.5947 6.3 8.8 30
PARASITIC DISEASES
DIAGNOSES.
424......... 19 SURG O.R. PROCEDURE W 2.3637 10.9 18.0 35
PRINCIPAL DIAGNOSES OF
MENTAL ILLNESS.
425......... 19 MED ACUTE ADJUST REACT & .7051 3.5 4.9 27
DISTURBANCES OF
PSYCHOSOCIAL
DYSFUNCTION.
426......... 19 MED DEPRESSIVE NEUROSES.... .5680 3.9 5.5 28
427......... 19 MED NEUROSES EXCEPT .5495 3.7 5.2 28
DEPRESSIVE.
428......... 19 MED DISORDERS OF .7303 5.2 8.4 29
PERSONALITY & IMPULSE
CONTROL.
429......... 19 MED ORGANIC DISTURBANCES & .9075 5.9 9.0 30
MENTAL RETARDATION.
430......... 19 MED PSYCHOSES.............. .8391 6.9 9.8 31
431......... 19 MED CHILDHOOD MENTAL .6556 4.9 7.2 29
DISORDERS.
432......... 19 MED OTHER MENTAL DISORDER .7363 3.9 6.5 28
DIAGNOSES.
433......... 20 ................ ALCOHOL/DRUG ABUSE OR .2986 2.5 3.4 25
DEPENDENCE, LEFT AMA.
434......... 20 ................ ALC/DRUG ABUSE OR .7141 4.3 5.8 28
DEPEND, DETOX OR OTH
SYMPT TREAT W CC.
435......... 20 ................ ALC/DRUG ABUSE OR .4164 3.8 4.8 28
DEPEND, DETOX OR OTH
SYMPT TREAT W/O CC.
436......... 20 ................ ALC/DRUG DEPENDENCE W .8183 12.1 14.8 36
REHABILITATION THERAPY.
437......... 20 ................ ALC/DRUG DEPENDENCE, .7657 9.2 10.9 33
COMBINED REHAB & DETOX
THERAPY.
438......... NO LONGER VALID........ .0000 .0 .0 0
439......... 21 SURG SKIN GRAFTS FOR 1.6144 5.9 8.9 30
INJURIES.
[[Page 46275]]
440......... 21 SURG W/OUND DEBRIDEMENTS FOR 1.7725 6.3 9.9 30
INJURIES.
441......... 21 SURG HAND PROCEDURES FOR .9294 2.4 4.4 26
INJURIES.
442......... 21 SURG OTHER O.R. PROCEDURES 2.1653 5.6 8.7 30
FOR INJURIES W CC.
443......... 21 SURG OTHER O.R. PROCEDURES .8849 2.5 3.6 26
FOR INJURIES W/O CC.
444......... 21 MED TRAUMATIC INJURY AGE .7312 4.0 5.3 28
>17 W CC.
445......... 21 MED TRAUMATIC INJURY AGE .4845 2.9 3.9 25
>17 W/O CC.
446......... 21 MED *TRAUMATIC INJURY AGE 0- .2894 2.4 2.4 22
17.
447......... 21 MED ALLERGIC REACTIONS AGE .4918 2.1 2.8 17
>17.
448......... 21 MED ALLERGIC REACTIONS AGE .0777 1.0 1.0 1
0-17.
449......... 21 MED POISONING & TOXIC .7902 3.0 4.5 27
EFFECTS OF DRUGS AGE
>17 W CC.
450......... 21 MED POISONING & TOXIC .4274 1.8 2.3 13
EFFECTS OF DRUGS AGE
>17 W/O CC.
451......... 21 MED *POISONING & TOXIC .2570 2.1 2.1 17
EFFECTS OF DRUGS AGE 0-
17.
452......... 21 MED COMPLICATIONS OF .9473 3.8 5.4 28
TREATMENT W CC.
453......... 21 MED COMPLICATIONS OF .4822 2.4 3.2 20
TREATMENT W/O CC.
454......... 21 MED OTHER INJURY, POISONING .8575 3.4 5.1 27
& TOXIC EFFECT DIAG W
CC.
455......... 21 MED OTHER INJURY, POISONING .4467 2.1 2.8 18
& TOXIC EFFECT DIAG W/
O CC.
456......... 22 MED BURNS, TRANSFERRED TO 1.8327 4.1 8.4 28
ANOTHER ACUTE CARE
FACILITY.
457......... 22 MED EXTENSIVE BURNS W/O 1.4657 2.4 4.8 26
O.R. PROCEDURE.
458......... 22 SURG NON-EXTENSIVE BURNS W 3.4991 11.9 16.9 36
SKIN GRAFT.
459......... 22 SURG NON-EXTENSIVE BURNS W W/ 1.6538 6.7 10.3 31
OUND DEBRIDEMENT OR
OTHER O.R. PROC.
460......... 22 MED NON-EXTENSIVE BURNS W/O .9547 4.6 6.6 29
O.R. PROCEDURE.
461......... 23 SURG O.R. PROC W DIAGNOSES .9963 2.5 4.9 27
OF OTHER CONTACT W
HEALTH SERVICES.
462......... 23 MED REHABILITATION......... 1.4298 11.0 13.9 35
463......... 23 MED SIGNS & SYMPTOMS W CC.. .7101 3.8 5.2 28
464......... 23 MED SIGNS & SYMPTOMS W/O CC .5028 2.8 3.8 24
465......... 23 MED AFTERCARE W HISTORY OF .5571 2.3 3.9 26
MALIGNANCY AS
SECONDARY DIAGNOSIS.
466......... 23 MED AFTERCARE W/O HISTORY .5905 2.5 4.8 27
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
467......... 23 MED OTHER FACTORS .4588 2.4 4.1 26
INFLUENCING HEALTH
STATUS.
468......... ................ EXTENSIVE O.R. 3.6028 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 3.5980 6.8 8.1 31
MAJOR JOINT PROCS OF
LOWER EXTREMITY.
472......... 22 SURG EXTENSIVE BURNS W O.R. 10.9989 17.0 30.2 41
PROCEDURE.
473......... 17 ................ ACUTE LEUKEMIA W/O 3.5740 8.5 14.7 33
MAJOR O.R. PROCEDURE
AGE >17.
474......... ................ NO LONGER VALID........ .0000 .0 .0 0
475......... 04 MED RESPIRATORY SYSTEM 3.6765 8.6 12.3 33
DIAGNOSIS WITH
VENTILATOR SUPPORT.
476......... SURG PROSTATIC O.R. 2.2479 10.3 13.9 34
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
477......... SURG NON-EXTENSIVE O.R. 1.7266 5.9 9.3 30
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478......... 05 SURG OTHER VASCULAR 2.2883 5.6 8.3 30
PROCEDURES W CC.
479......... 05 SURG OTHER VASCULAR 1.4080 3.5 4.6 27
PROCEDURES W/O CC.
480......... SURG LIVER TRANSPLANT....... 13.9424 26.4 32.6 50
481......... SURG BONE MARROW TRANSPLANT. 11.2299 29.7 32.6 54
482......... SURG TRACHEOSTOMY FOR FACE, 3.6578 11.4 14.9 35
MOUTH & NECK DIAGNOSES.
483......... SURG TRACHEOSTOMY EXCEPT FOR 16.0413 36.0 46.4 60
FACE, MOUTH & NECK
DIAGNOSES.
484......... 24 SURG CRANIOTOMY FOR MULTIPLE 5.6821 10.6 15.9 35
SIGNIFICANT TRAUMA.
485......... 24 SURG LIMB REATTACHMENT, HIP 3.2058 9.2 11.7 33
AND FEMUR PROC FOR
MULTIPLE SIGNIFICANT
TR.
486......... 24 SURG OTHER O.R. PROCEDURES 4.7915 9.0 13.6 33
FOR MULTIPLE
SIGNIFICANT TRAUMA.
487......... 24 MED OTHER MULTIPLE 2.0305 6.2 9.1 30
SIGNIFICANT TRAUMA.
488......... 25 SURG HIV W EXTENSIVE O.R. 4.7905 14.3 20.5 38
PROCEDURE.
489......... 25 MED HIV W MAJOR RELATED 1.8141 7.2 10.7 31
CONDITION.
[[Page 46276]]
490......... 25 MED HIV W OR W/O OTHER 1.0116 4.4 6.6 28
RELATED CONDITION.
491......... 08 SURG MAJOR JOINT & LIMB 1.6308 3.6 4.3 19
REATTACHMENT
PROCEDURES OF UPPER
EXTREMITY.
492......... 17 MED CHEMOTHERAPY W ACUTE 4.0299 11.2 17.4 35
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493......... 07 SURG LAPAROSCOPIC 1.7100 4.2 5.9 28
CHOLECYSTECTOMY W/O
C.D.E. W CC.
494......... 07 SURG LAPAROSCOPIC .9169 1.8 2.4 15
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495......... SURG LUNG TRANSPLANT........ 9.2870 18.0 22.7 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 (RSV)... N 15 387,\1\ 389 \1\
18 421, 422
291.81...... Alcohol withdrawal.................. Y 20 434, 435, 436, 437
291.89...... Other specified alcoholic psychosis, Y 20 434, 435, 436, 437
not elsewhere classified.
293.84...... Organic anxiety syndrome............ Y 19 429
300.82...... Undifferentiated somatoform disorder N 19 427
315.32...... Receptive language disorder (mixed). N 19 431
414.04...... Coronary atherosclerosis of artery N 5 132, 133
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 other N 4 96, 97, 98
infectious organisms.
483.1....... Pneumonia due to Chlamydia.......... Y 4 89, 90, 91
15 387,\1\ 389 \1\
574.60...... Calculus of gallbladder and bile Y 7 207, 208
duct with acute cholecystitis
without mention of obstruction.
574.61...... Calculus of gallbladder and bile Y 7 207, 208
duct with acute cholecystitis with
obstruction.
574.70...... Calculus of gallbladder and bile Y 7 207, 208
duct with other cholecystitis
without mention of obstruction.
574.71...... Calculus of gallbladder and bile Y 7 207, 208
duct with other cholecystitis with
obstruction.
574.80...... Calculus of gallbladder and bile Y 7 207, 208
duct with acute and chronic
cholecystitis without mention of
obstruction.
574.81...... Calculus of gallbladder and bile Y 7 207, 208
duct with acute and chronic
cholecystitis with obstruction.
574.90...... Calculus of gallbladder and bile Y 7 207, 208
duct without cholecystitis without
mention of obstruction.
574.91...... Calculus of gallbladder and bile Y 7 207, 208
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 cholecystitis..... Y 7 207, 208
752.51...... Undescended testis.................. N 12 352
15 391 \1\
752.52...... Retractile testis................... N 12 352
15 391 \1\
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 defect of N 11 331, 332, 333
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 pelvis N 11 331, 332, 333
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 chromosome N 12 352
anomalies, not elsewhere classified. 13 358, 359, 369
922.31...... Back contusion...................... N 9 280, 281, 282
24 484, 485, 486, 487
[[Page 46277]]
922.32...... Buttock contusion................... N 9 280, 281, 282
24 484, 485, 486, 487
922.33...... Interscapular region contusion...... N 9 280, 281, 282
24 484, 485, 486, 487
995.50...... Child abuse, unspecified............ N 21 454, 455
995.51...... Child emotional/psychological abuse. N 21 454, 455
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...... Other child abuse and neglect....... N 21 454, 455
995.80...... Adult maltreatment, unspecified..... N 21 454, 455
995.82...... Adult emotional/psychological abuse. N 21 454, 455
995.83...... Adult sexual abuse.................. N 21 454, 455
995.84...... Adult neglect (nutritional)......... N 21 454, 455
995.85...... Other adult abuse and neglect....... N 21 454, 455
998.11...... Hemorrhage complicating a procedure. Y 15 387,\1\ 389 \1\
21 452, 453
998.12...... Hematoma complicating a procedure... Y 15 387,\1\ 389 \1\
21 452, 453
998.13...... Seroma complicating a procedure..... Y 15 387,\1\ 389 \1\
21 452, 453
998.51...... Infected postoperative seroma....... Y 15 387,\1\ 389 \1\
18 418
998.59...... Other postoperative infection....... Y 15 387,\1\ 389 \1\
18 418
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 elsewhere N 23 467
classified.
V61.10...... Counseling for marital and partner N 23 467
problems, unspecified.
V61.11...... Counseling for victim of spousal and N 23 467
partner abuse.
V61.12...... Counseling for perpetrator of N 23 467
spousal and partner abuse.
V61.22...... Counseling for perpetrator of N 23 467
parental child abuse.
V62.83...... Counseling for perpetrator of N 23 467
physical/sexual abuse.
V66.7....... Encounter for palliative care....... N 23 467
----------------------------------------------------------------------------------------------------------------
\1\ Diagnosis code is classified as a ``major problem'' in these DRGs.
Table 6b.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
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 Y 13 365
appendectomy. 21 442, 443
24 486
51.21....... Other partial Y 7 195, 196, 197, 198
cholecystectomy.
17 400, 406,
17 407
21 442, 443
24 486
51.24....... Laparoscopic partial Y 7 195, 196, 493, 494
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....... Laparoscopiclysis of Y 6 150, 151
peritoneal adhesions. 7 201
13 365
[[Page 46278]]
21 442, 443
24 486
54.59....... Otherlys is 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
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 Y 13 354, 355, 357,358, 359
diagnostic procedures on
ovaries.
65.23....... Laparoscopic Y 13 354, 355, 357, 358, 359
marsupialization 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 Y 13 354, 355, 357, 358, 359
oophorectomy.
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 13 354, 355
episode. 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 13 354, 355,
operative episode. 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 Y 13 354, 355,
of ovary. 13 357, 358,
13 359
21 442, 443
24 486
65.75....... Laparoscopic reimplantation Y 13 354, 355,
of ovary. 13 357, 358,
13 359
21 442, 443
24 486
65.76....... Laparoscopic salpingo- Y 13 354, 355,
oophoroplasty. 13 357, 358,
13 359
21 442, 443
24 486
[[Page 46279]]
65.81....... Laparoscopic lysis of Y 13 354, 355,
adhesions of ovary and 13 357, 358,
fallopian tube.
13 359
21 442, 443
24 486
65.89....... Other lysis of adhesions of Y 13 354, 355,
ovary and fallopian tube. 13 357, 358,
13 359
21 442, 443
24 486
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,
13
359
14 375
22 477
68.59....... Other vaginal hysterectomy.. Y 13 354, 355,
13 357, 358,
13 359
14 375
22 477
----------------------------------------------------------------------------------------------------------------
Table 6c.--Invalid 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, 485, 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 11 305
retroperitoneal fibrosis. 12 344, 345
13 365
17 400, 406,
[[Page 46280]]
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,
oophorectomy. 359
65.8........ Lysis of adhesions of ovary Y 13 354, 355,
and fallopian tube. 13 357, 358,
13 359
21 442, 443
24 486
68.5........ Vaginal hysterectomy........ Y 13 354, 355,
13 357, 358,
13 359
14 375
22 477
----------------------------------------------------------------------------------------------------------------
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.
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.
----------------------------------------------------------------------------------------------------------------
[[Page 46281]]
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 Y 9 269, 270
ovaries at same operative 13 354, 355
episode. 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 Y 9 269, 270
ovaries and tubes at same
operative episode.
13 354, 355,
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 Y 13 354, 355,
ovary. 13 357, 358,
13 359
21 442, 443
24 486
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 46282]]
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 46283]]
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 46284]]
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 46285]]
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 46286]]
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 46287]]
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 46288]]
Table 7a.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
[FY95 MEDPAR Update 06/96 Grouper V13.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 34442 11.0870 3 4 8 14 23
2....................................... 6577 11.5545 3 5 8 14 23
3....................................... 1 10.0000 10 10 10 10 10
4....................................... 6221 9.1249 2 3 6 11 20
5....................................... 100697 4.4155 2 2 3 5 9
6....................................... 464 3.4030 1 1 2 4 7
7....................................... 11182 12.6678 3 5 8 14 25
8....................................... 2377 4.1586 1 1 3 5 9
9....................................... 1768 7.6697 2 3 5 9 16
10...................................... 20201 7.9723 2 3 6 10 16
11...................................... 3044 4.9152 1 2 4 6 10
12...................................... 24534 7.6319 2 3 5 9 14
13...................................... 6348 6.2098 2 4 5 7 11
14...................................... 368912 7.4277 2 3 6 9 14
15...................................... 145736 4.4476 1 2 3 5 8
16...................................... 12479 6.5732 2 3 5 8 12
17...................................... 3377 4.0269 1 2 3 5 7
18...................................... 22488 6.3283 2 3 5 8 12
19...................................... 7265 4.5076 1 2 4 6 8
20...................................... 8354 10.1263 2 4 8 13 20
21...................................... 1176 7.8180 2 3 6 10 16
22...................................... 2753 4.8554 2 2 4 6 9
23...................................... 6038 5.0600 1 2 4 6 10
24...................................... 56498 5.8137 2 3 4 7 11
25...................................... 23104 3.8625 1 2 3 5 7
26...................................... 48 4.5625 1 2 3 6 10
27...................................... 3729 6.3130 1 1 4 7 14
28...................................... 11872 7.0601 1 3 5 8 14
29...................................... 3959 4.0354 1 2 3 5 8
31...................................... 3381 5.4590 1 2 4 6 10
32...................................... 1848 3.1483 1 1 2 4 6
34...................................... 17083 6.4969 2 3 5 8 13
35...................................... 3832 4.3072 1 2 3 5 8
36...................................... 9404 1.6325 1 1 1 2 3
37...................................... 1995 4.0551 1 1 3 5 8
38...................................... 246 2.6098 1 1 2 3 5
39...................................... 3436 1.9744 1 1 1 2 4
40...................................... 2958 3.3966 1 1 2 4 7
42...................................... 7697 2.2076 1 1 1 2 5
43...................................... 105 4.1524 1 2 3 5 8
44...................................... 1705 5.7238 2 3 5 7 10
45...................................... 2545 3.8310 1 2 3 5 7
46...................................... 3116 5.5209 1 2 4 7 10
47...................................... 1417 3.7890 1 1 3 5 7
49...................................... 2260 5.6518 1 2 4 7 11
50...................................... 3511 2.1191 1 1 2 2 3
51...................................... 323 2.9195 1 1 1 2 7
52...................................... 84 3.5357 1 1 2 3 8
53...................................... 3546 3.5491 1 1 2 4 8
54...................................... 2 4.0000 1 1 7 7 7
55...................................... 2035 2.9666 1 1 2 3 6
56...................................... 766 2.7454 1 1 2 3 6
57...................................... 677 4.0694 1 1 3 5 8
59...................................... 94 3.6064 1 1 2 4 7
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 226 5.1372 1 1 2 7 14
62...................................... 1 2.0000 2 2 2 2 2
63...................................... 4238 4.6487 1 2 3 5 10
64...................................... 3550 7.5346 1 2 5 9 16
65...................................... 30917 3.4293 1 2 3 4 6
66...................................... 6878 3.5650 1 2 3 4 6
67...................................... 532 4.1992 2 2 3 5 8
68...................................... 10392 4.7941 2 3 4 6 9
69...................................... 3353 3.7739 1 2 3 5 7
70...................................... 32 2.9375 1 2 3 3 5
71...................................... 96 4.0313 1 2 3 5 8
72...................................... 612 4.4167 1 2 3 5 9
73...................................... 6332 4.9588 1 2 4 6 9
75...................................... 41590 11.1419 4 6 8 14 22
76...................................... 40960 12.4911 3 6 10 15 24
[[Page 46289]]
77...................................... 2446 5.5200 1 2 4 8 12
78...................................... 30530 8.2292 4 5 7 10 13
79...................................... 220024 9.2606 3 5 7 11 17
80...................................... 9456 6.6214 2 4 5 8 12
81...................................... 10 7.4000 1 4 6 12 15
82...................................... 72211 7.8884 2 3 6 10 16
83...................................... 7541 6.3896 2 3 5 8 12
84...................................... 1582 3.6846 1 2 3 5 7
85...................................... 19391 7.3326 2 3 6 9 14
86...................................... 1444 4.5062 1 2 4 6 9
87...................................... 62143 6.8199 1 3 6 9 13
88...................................... 368008 6.0847 2 3 5 7 11
89...................................... 442736 7.0834 3 4 6 9 12
90...................................... 43190 5.1359 2 3 4 6 9
91...................................... 53 4.4151 1 2 3 6 8
92...................................... 12548 7.2620 2 4 6 9 13
93...................................... 1332 4.9234 1 3 4 6 9
94...................................... 13242 7.0497 2 3 5 9 14
95...................................... 1458 4.1221 1 2 3 5 8
96...................................... 65710 5.5228 2 3 5 7 10
97...................................... 27798 4.2826 2 2 4 5 7
98...................................... 20 4.3000 1 1 3 6 10
99...................................... 26552 3.4947 1 2 3 4 7
100..................................... 10746 2.4205 1 1 2 3 4
101..................................... 20899 5.1925 1 2 4 7 10
102..................................... 4669 3.1371 1 1 2 4 6
103..................................... 487 39.8973 10 15 29 54 82
104..................................... 24152 14.5670 6 8 12 18 26
105..................................... 20847 10.9617 5 7 9 13 19
106..................................... 101038 11.7331 6 8 10 14 19
107..................................... 64206 8.8424 5 6 7 10 14
108..................................... 6883 12.5720 4 7 10 15 23
110..................................... 62140 10.7845 3 6 9 13 20
111..................................... 6119 6.6568 3 5 7 8 10
112..................................... 201028 4.7049 1 2 4 6 9
113..................................... 47381 14.3687 4 6 10 17 28
114..................................... 9250 9.4685 2 4 7 12 18
115..................................... 11017 11.4341 4 6 9 14 20
116..................................... 85879 5.4281 1 2 4 7 11
117..................................... 4837 4.1211 1 1 2 5 8
118..................................... 7120 3.2142 1 1 2 4 7
119..................................... 1791 5.5366 1 1 3 7 13
120..................................... 42743 9.1977 1 2 6 12 21
121..................................... 167116 7.4255 2 4 6 9 13
122..................................... 91508 5.0063 1 3 5 7 9
123..................................... 48692 4.6628 1 1 2 6 11
124..................................... 145526 4.9010 1 2 4 6 9
125..................................... 62240 3.0708 1 1 2 4 6
126..................................... 4864 14.0113 4 7 11 17 29
127..................................... 705511 6.2183 2 3 5 8 12
128..................................... 20583 6.7301 3 4 6 8 11
129..................................... 4847 3.5251 1 1 1 4 8
130..................................... 96345 6.6835 2 4 6 8 12
131..................................... 26865 5.1799 1 3 5 7 8
132..................................... 133374 3.5805 1 2 3 4 6
133..................................... 6162 2.9761 1 1 2 4 5
134..................................... 30025 3.9084 1 2 3 5 7
135..................................... 7497 4.9941 1 2 4 6 9
136..................................... 1079 3.2586 1 2 3 4 6
138..................................... 205732 4.5589 1 2 3 6 9
139..................................... 70666 2.9401 1 1 2 4 5
140..................................... 184595 3.4847 1 2 3 4 6
141..................................... 80056 4.4979 1 2 3 5 8
142..................................... 37589 3.2040 1 2 3 4 6
143..................................... 138969 2.6105 1 1 2 3 5
144..................................... 70455 5.7021 1 2 4 7 11
145..................................... 7063 3.2390 1 1 2 4 6
146..................................... 9116 11.2399 6 7 9 13 18
147..................................... 1716 7.3462 4 6 7 9 11
148..................................... 147240 13.4390 6 8 11 16 24
[[Page 46290]]
149..................................... 16479 7.7172 4 6 7 9 11
150..................................... 23661 11.7462 4 7 10 14 21
151..................................... 4727 6.4637 2 4 6 8 11
152..................................... 4681 9.0305 4 6 8 10 15
153..................................... 1810 6.1663 3 4 6 8 9
154..................................... 37523 14.9701 5 8 12 18 28
155..................................... 4800 5.8863 2 3 5 8 10
156..................................... 4 15.7500 4 4 10 22 27
157..................................... 11976 5.8075 1 2 4 7 11
158..................................... 5338 2.9039 1 1 2 4 6
159..................................... 18014 5.3347 1 2 4 7 10
160..................................... 10461 2.9524 1 1 2 4 5
161..................................... 15500 4.3536 1 2 3 5 9
162..................................... 8397 2.1870 1 1 2 3 4
163..................................... 8 3.0000 1 1 3 4 5
164..................................... 5240 9.3945 4 6 8 11 16
165..................................... 1757 5.7518 3 4 5 7 9
166..................................... 3440 5.7122 2 3 4 7 10
167..................................... 2409 3.2333 1 2 3 4 6
168..................................... 1870 4.9610 1 2 3 6 10
169..................................... 1091 2.5371 1 1 2 3 5
170..................................... 13152 12.4993 2 5 9 15 25
171..................................... 1205 5.4008 1 2 4 7 11
172..................................... 32440 8.1497 2 3 6 10 16
173..................................... 2286 4.3994 1 2 3 5 9
174..................................... 243520 5.5478 2 3 4 7 10
175..................................... 24208 3.5122 1 2 3 4 6
176..................................... 16840 6.1428 2 3 5 7 11
177..................................... 12619 4.9756 2 3 4 6 9
178..................................... 4386 3.6147 1 2 3 5 7
179..................................... 11791 7.1640 2 4 6 9 14
180..................................... 82971 6.0508 2 3 5 7 11
181..................................... 23209 3.9601 1 2 3 5 7
182..................................... 237577 4.9658 2 2 4 6 9
183..................................... 75774 3.4541 1 2 3 4 6
184..................................... 77 3.8831 1 2 2 4 7
185..................................... 4037 5.1850 1 2 4 6 10
186..................................... 2 1.5000 1 1 2 2 2
187..................................... 944 4.2108 1 2 3 6 8
188..................................... 64209 6.1263 2 3 5 8 12
189..................................... 8146 3.6866 1 1 3 5 7
190..................................... 68 5.0882 1 2 4 7 10
191..................................... 11098 16.2616 5 8 12 20 32
192..................................... 930 7.9161 2 4 7 10 14
193..................................... 8975 13.9348 5 8 11 17 25
194..................................... 847 8.4652 3 5 7 10 15
195..................................... 9686 10.4650 4 6 9 12 18
196..................................... 845 6.7136 3 4 6 8 11
197..................................... 29491 9.1586 4 5 7 11 16
198..................................... 8311 4.9344 2 3 4 6 8
199..................................... 2348 11.1661 3 5 9 14 22
200..................................... 1655 12.3329 2 4 8 15 26
201..................................... 1557 16.7534 4 7 13 21 34
202..................................... 26477 7.7437 2 3 6 10 15
203..................................... 30205 7.6570 2 3 6 10 15
204..................................... 51448 6.7152 2 3 5 8 13
205..................................... 22675 7.2389 2 3 5 9 14
206..................................... 1783 4.7196 1 2 4 6 10
207..................................... 37006 5.7262 2 3 4 7 11
208..................................... 10751 3.5105 1 2 3 4 6
209..................................... 344259 6.6642 3 4 6 7 10
210..................................... 138205 8.5738 4 5 7 10 14
211..................................... 26619 6.2716 3 4 6 7 10
212..................................... 9 5.0000 2 3 4 5 8
213..................................... 7164 9.7067 3 4 7 12 19
214..................................... 53836 6.4605 2 3 5 8 12
215..................................... 43190 3.6846 1 2 3 5 7
216..................................... 6760 11.0719 2 5 8 14 22
217..................................... 20436 15.3636 3 6 10 18 31
218..................................... 23224 6.2155 2 3 5 7 11
[[Page 46291]]
219..................................... 19076 3.7567 1 2 3 5 6
220..................................... 2 5.5000 5 5 6 6 6
221..................................... 5227 8.1037 2 4 6 10 16
222..................................... 3750 4.0496 1 2 3 5 8
223..................................... 19410 2.8704 1 1 2 3 5
224..................................... 8378 2.2731 1 1 2 3 4
225..................................... 6594 5.0059 1 2 3 6 11
226..................................... 5651 6.7383 1 2 4 8 14
227..................................... 4846 2.9610 1 1 2 4 6
228..................................... 3199 3.5261 1 1 2 4 7
229..................................... 1427 2.4043 1 1 2 3 5
230..................................... 2578 5.2002 1 2 3 6 11
231..................................... 10890 5.0626 1 2 3 6 11
232..................................... 602 4.4651 1 1 2 5 10
233..................................... 4808 9.0422 2 4 7 11 18
234..................................... 2363 4.1727 1 2 3 5 8
235..................................... 5827 6.7833 1 3 4 7 13
236..................................... 39844 6.2907 2 3 5 7 12
237..................................... 1586 4.4067 1 2 3 5 8
238..................................... 7925 10.0430 3 5 7 12 19
239..................................... 62430 7.6248 2 4 6 9 14
240..................................... 12701 7.5282 2 3 5 9 15
241..................................... 3183 4.5922 1 2 4 5 9
242..................................... 2644 7.6539 2 4 6 9 15
243..................................... 84034 5.6150 2 3 4 7 10
244..................................... 12036 5.8284 2 3 4 7 11
245..................................... 4477 4.3044 1 2 3 5 8
246..................................... 1391 4.6161 1 2 4 6 9
247..................................... 11132 3.9656 1 2 3 5 8
248..................................... 7135 5.2685 1 2 4 6 10
249..................................... 10593 4.2878 1 1 3 5 9
250..................................... 3359 5.0473 1 2 4 6 9
251..................................... 2228 3.3039 1 1 3 4 6
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 18452 5.8248 2 3 4 7 11
254..................................... 9735 3.8817 1 2 3 5 7
255..................................... 1 2.0000 2 2 2 2 2
256..................................... 4819 5.6921 1 2 4 7 11
257..................................... 24829 3.4343 1 2 3 4 6
258..................................... 19718 2.4910 1 2 2 3 4
259..................................... 4225 3.5089 1 1 2 3 7
260..................................... 5083 1.8702 1 1 2 2 3
261..................................... 2489 2.3403 1 1 2 3 4
262..................................... 749 3.9439 1 1 2 5 8
263..................................... 30581 13.9228 4 6 10 16 28
264..................................... 3723 8.3503 2 4 6 10 17
265..................................... 4517 7.6810 1 3 5 9 16
266..................................... 2850 3.7140 1 1 3 5 8
267..................................... 238 4.3361 1 1 3 5 9
268..................................... 983 4.0651 1 1 2 4 9
269..................................... 10745 9.2352 2 4 7 12 19
270..................................... 3643 3.4161 1 1 2 4 8
271..................................... 22531 8.5207 3 4 7 10 15
272..................................... 6142 7.4650 2 3 6 9 14
273..................................... 1500 5.4860 2 2 4 7 11
274..................................... 2654 7.7939 2 3 5 9 16
275..................................... 258 3.6705 1 1 2 4 8
276..................................... 928 5.0151 1 2 4 6 9
277..................................... 82879 6.7243 3 4 5 8 12
278..................................... 27272 5.1610 2 3 4 6 9
279..................................... 6 4.1667 1 2 3 4 4
280..................................... 13880 5.0710 1 2 4 6 9
281..................................... 6277 3.6108 1 2 3 4 7
283..................................... 5522 5.4681 2 2 4 7 10
284..................................... 1841 3.8403 1 2 3 5 7
285..................................... 5132 13.6613 3 6 10 16 26
286..................................... 2035 8.6993 3 4 6 9 16
287..................................... 6605 13.3889 3 6 9 16 26
288..................................... 1020 6.8824 3 4 5 7 11
289..................................... 5276 3.9780 1 2 2 4 8
[[Page 46292]]
290..................................... 8909 2.8289 1 1 2 3 5
291..................................... 91 1.7692 1 1 1 2 3
292..................................... 5308 12.7491 2 5 9 16 25
293..................................... 310 6.7935 1 3 5 8 14
294..................................... 90532 5.6749 2 3 4 7 10
295..................................... 3894 4.2766 1 2 3 5 8
296..................................... 230295 6.3598 2 3 5 8 12
297..................................... 33134 4.2911 1 2 3 5 8
298..................................... 108 3.3796 1 1 2 4 6
299..................................... 927 5.4132 1 2 4 7 10
300..................................... 14815 7.2798 2 3 6 9 14
301..................................... 2247 4.3796 1 2 3 5 9
302..................................... 8314 12.3018 6 7 9 14 21
303..................................... 19404 10.2201 4 6 8 12 18
304..................................... 13543 10.2916 3 5 7 13 21
305..................................... 2681 4.9276 1 3 4 6 9
306..................................... 11853 6.2378 2 2 4 8 13
307..................................... 2696 2.9841 1 2 2 3 5
308..................................... 9573 7.0330 1 2 5 9 15
309..................................... 3563 3.0230 1 1 2 4 6
310..................................... 30025 4.6157 1 2 3 6 9
311..................................... 10221 2.1764 1 1 2 3 4
312..................................... 2120 4.8198 1 2 3 6 10
313..................................... 788 2.2855 1 1 2 3 5
314..................................... 1 5.0000 5 5 5 5 5
315..................................... 29516 9.3027 1 2 6 12 20
316..................................... 73804 7.4996 2 3 6 9 15
317..................................... 838 2.9033 1 1 2 3 6
318..................................... 6303 7.1525 2 3 5 9 14
319..................................... 522 3.2184 1 1 2 4 7
320..................................... 177322 6.4439 2 3 5 8 11
321..................................... 26732 4.7118 2 3 4 6 8
322..................................... 87 4.3333 2 2 4 5 8
323..................................... 18552 3.5564 1 2 3 4 7
324..................................... 9159 2.0887 1 1 2 3 4
325..................................... 7781 4.5729 1 2 3 5 9
326..................................... 2305 3.4265 1 1 2 4 6
327..................................... 9 3.3333 1 2 2 4 5
328..................................... 853 4.2579 1 2 3 6 8
329..................................... 113 2.7965 1 1 2 3 5
330..................................... 1 1.0000 1 1 1 1 1
331..................................... 40267 6.1796 2 3 5 8 12
332..................................... 4973 3.8520 1 2 3 5 8
333..................................... 379 5.7968 1 3 4 7 13
334..................................... 19978 6.0539 3 4 5 7 9
335..................................... 10312 4.6223 2 3 4 6 7
336..................................... 63889 4.1249 1 2 3 5 8
337..................................... 40544 2.6722 1 2 2 3 4
338..................................... 5063 5.2558 1 2 3 6 11
339..................................... 2416 5.2562 1 2 3 6 11
340..................................... 2 3.0000 1 1 5 5 5
341..................................... 6766 3.2573 1 1 2 4 6
342..................................... 231 4.0649 1 1 2 5 8
344..................................... 4022 3.4510 1 1 2 4 7
345..................................... 1428 4.0210 1 2 3 5 9
346..................................... 5626 6.7600 1 3 5 8 14
347..................................... 443 3.2889 1 1 2 4 7
348..................................... 3187 4.8892 1 2 4 6 9
349..................................... 734 2.9646 1 1 2 4 6
350..................................... 7234 4.7432 2 3 4 6 8
352..................................... 603 3.9005 1 1 3 5 8
353..................................... 2743 8.3252 3 4 6 9 15
354..................................... 10187 6.3342 3 4 5 7 11
355..................................... 5884 3.8600 2 3 4 4 6
356..................................... 30093 3.0252 1 2 3 4 5
357..................................... 6842 9.8297 4 5 8 12 18
358..................................... 28152 4.7532 2 3 4 5 8
359..................................... 28825 3.2709 2 3 3 4 5
360..................................... 17592 3.5444 1 2 3 4 6
361..................................... 655 3.4580 1 1 2 4 7
[[Page 46293]]
363..................................... 4555 3.5139 1 2 2 3 6
364..................................... 1879 3.6003 1 1 2 4 8
365..................................... 2522 8.1257 2 3 5 10 18
366..................................... 4694 7.6877 2 3 5 10 16
367..................................... 571 3.3135 1 1 2 4 7
368..................................... 2408 6.9049 2 3 5 8 13
369..................................... 2531 3.7246 1 1 3 5 7
370..................................... 1201 5.5679 3 3 4 5 9
371..................................... 1044 3.6236 2 3 3 4 5
372..................................... 872 3.3601 1 2 2 3 6
373..................................... 3961 1.9258 1 1 2 2 3
374..................................... 141 2.5957 1 2 2 3 4
375..................................... 5 2.2000 1 1 2 3 4
376..................................... 164 3.3537 1 1 2 4 7
377..................................... 27 3.2963 1 1 2 3 8
378..................................... 172 2.9186 1 2 3 3 5
379..................................... 332 3.0361 1 1 2 3 5
380..................................... 75 2.2800 1 1 2 2 4
381..................................... 209 2.2967 1 1 1 2 5
382..................................... 54 1.5741 1 1 1 1 3
383..................................... 1557 4.0873 1 2 3 5 8
384..................................... 135 3.1481 1 1 1 2 7
385..................................... 4 13.5000 1 1 1 3 49
386..................................... 1 36.0000 36 36 36 36 36
389..................................... 23 10.7391 3 4 8 10 18
390..................................... 11 4.7273 1 2 3 5 9
392..................................... 2622 11.6484 4 6 8 14 24
394..................................... 1734 7.9862 1 2 5 9 16
395..................................... 69281 5.3835 1 2 4 7 10
396..................................... 19 3.7895 1 1 3 5 8
397..................................... 16238 6.0846 2 3 5 7 12
398..................................... 17490 6.5883 2 3 5 8 12
399..................................... 1505 4.4399 1 2 4 6 8
400..................................... 7877 10.4160 2 4 7 13 23
401..................................... 6683 12.3822 2 5 9 16 25
402..................................... 1621 4.7218 1 1 3 6 10
403..................................... 36569 9.2960 2 4 7 12 19
404..................................... 4137 5.1047 1 2 4 7 10
406..................................... 3407 11.2548 3 5 8 14 23
407..................................... 761 4.9304 1 2 4 6 9
408..................................... 3100 8.1632 1 2 5 10 18
409..................................... 5931 6.7132 2 3 4 6 15
410..................................... 89997 3.3583 1 2 3 4 5
411..................................... 58 2.6724 1 1 2 3 7
412..................................... 37 2.9730 1 1 2 4 5
413..................................... 8878 8.3323 2 3 6 10 17
414..................................... 845 5.1361 1 2 4 7 11
415..................................... 40783 15.7224 4 7 12 19 31
416..................................... 201554 8.2165 2 4 7 10 15
417..................................... 54 4.5741 1 2 4 7 10
418..................................... 19614 6.7661 2 3 5 8 13
419..................................... 16484 5.6830 2 3 4 7 10
420..................................... 3023 4.3126 2 2 4 5 8
421..................................... 12216 4.6523 2 2 4 5 8
422..................................... 97 3.8041 1 2 3 4 7
423..................................... 9588 8.7110 2 4 6 10 18
424..................................... 2102 17.9139 3 6 12 20 35
425..................................... 16010 4.8731 1 2 3 6 10
426..................................... 4920 5.5150 1 2 4 7 11
427..................................... 1856 5.2333 1 2 4 6 11
428..................................... 956 8.3347 1 3 5 10 18
429..................................... 40733 8.9700 2 3 6 10 17
430..................................... 55753 9.7545 2 4 7 12 19
431..................................... 200 7.1500 1 3 5 9 13
432..................................... 457 6.5252 1 2 4 6 11
433..................................... 8283 3.4066 1 1 2 4 7
434..................................... 21933 5.8212 2 3 4 7 11
435..................................... 16378 4.8060 1 3 4 6 8
436..................................... 3128 14.3744 4 8 14 21 28
437..................................... 14927 10.8952 4 6 10 14 20
[[Page 46294]]
439..................................... 910 8.9264 2 3 6 11 18
440..................................... 5007 9.8354 2 3 6 12 21
441..................................... 648 4.4213 1 1 2 4 8
442..................................... 14653 8.7421 1 3 6 11 18
443..................................... 3469 3.5509 1 1 2 5 7
444..................................... 3543 5.2882 1 3 4 6 10
445..................................... 1415 3.9046 1 2 3 5 7
446..................................... 1 1.0000 1 1 1 1 1
447..................................... 3991 2.8013 1 1 2 3 5
448..................................... 88 1.0000 1 1 1 1 1
449..................................... 30264 4.4273 1 2 3 5 9
450..................................... 7178 2.3403 1 1 2 3 5
451..................................... 8 6.0000 2 3 4 5 7
452..................................... 20326 5.4275 1 2 4 6 11
453..................................... 3831 3.1929 1 1 2 4 6
454..................................... 5391 5.1330 1 2 3 6 10
455..................................... 1181 2.8442 1 1 2 3 5
456..................................... 213 8.3803 1 1 4 9 21
457..................................... 135 4.8222 1 1 2 5 12
458..................................... 1650 16.8358 3 7 13 22 35
459..................................... 582 10.2887 2 4 7 13 21
460..................................... 2437 6.6422 1 3 5 8 13
461..................................... 3230 4.8920 1 1 2 5 12
462..................................... 9786 13.7570 4 6 12 18 26
463..................................... 12587 5.1722 1 2 4 6 10
464..................................... 3225 3.7479 1 2 3 5 7
465..................................... 202 3.8762 1 1 2 4 7
466..................................... 1943 4.8101 1 1 2 4 10
467..................................... 1820 4.1264 1 1 2 4 8
468..................................... 62094 15.2184 3 7 12 19 30
471..................................... 9604 8.0717 4 5 6 9 14
472..................................... 159 30.1635 1 9 28 40 61
473..................................... 8650 14.3808 2 4 8 21 36
475..................................... 94974 12.1639 2 5 10 16 24
476..................................... 7275 13.8367 3 7 11 17 25
477..................................... 29790 8.9095 1 3 6 11 18
478..................................... 123960 8.3140 1 3 6 10 17
479..................................... 18606 4.5577 1 2 4 6 9
480..................................... 43 33.5581 12 16 24 39 61
481..................................... 122 36.2787 21 25 31 42 60
482..................................... 7121 14.8666 5 8 11 17 28
483..................................... 38597 45.9566 15 23 37 56 85
484..................................... 366 15.8115 2 6 12 22 32
485..................................... 3426 11.6985 4 6 9 14 22
486..................................... 2316 13.4473 1 6 11 18 28
487..................................... 4136 8.9350 1 3 7 11 18
488..................................... 1694 17.6251 5 8 13 22 35
489..................................... 18721 10.4348 2 4 7 13 22
490..................................... 5263 6.5565 1 2 4 8 14
491..................................... 9897 4.2698 2 3 3 5 7
492..................................... 2139 17.3703 3 5 10 28 37
493..................................... 54769 5.8892 1 2 5 8 11
494..................................... 28573 2.4247 1 1 2 3 5
495..................................... 131 22.7176 10 12 17 26 39
----------------
11135858
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7b.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
[FY95 MEDPAR Update 06/96 Grouper V14.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 34442 11.0870 3 4 8 14 23
2....................................... 6577 11.5545 3 5 8 14 23
3....................................... 1 10.0000 10 10 10 10 10
4....................................... 6221 9.1249 2 3 6 11 20
5....................................... 100697 4.4155 2 2 3 5 9
6....................................... 464 3.4030 1 1 2 4 7
[[Page 46295]]
7....................................... 11326 12.5507 2 5 8 14 25
8....................................... 2651 3.8989 1 1 2 5 9
9....................................... 1768 7.6697 2 3 5 9 16
10...................................... 20201 7.9723 2 3 6 10 16
11...................................... 3044 4.9152 1 2 4 6 10
12...................................... 24534 7.6319 2 3 5 9 14
13...................................... 6348 6.2098 2 4 5 7 11
14...................................... 368912 7.4277 2 3 6 9 14
15...................................... 145736 4.4476 1 2 3 5 8
16...................................... 12480 6.5737 2 3 5 8 12
17...................................... 3376 4.0243 1 2 3 5 7
18...................................... 23963 6.3732 2 3 5 8 12
19...................................... 7792 4.5249 1 2 4 6 8
20...................................... 6352 11.2835 3 5 9 15 22
21...................................... 1176 7.8180 2 3 6 10 16
22...................................... 2753 4.8554 2 2 4 6 9
23...................................... 6038 5.0600 1 2 4 6 10
24...................................... 56509 5.8142 2 3 4 7 11
25...................................... 23093 3.8603 1 2 3 5 7
26...................................... 48 4.5625 1 2 3 6 10
27...................................... 3729 6.3130 1 1 4 7 14
28...................................... 11873 7.0603 1 3 5 8 14
29...................................... 3958 4.0341 1 2 3 5 8
31...................................... 3382 5.4595 1 2 4 6 10
32...................................... 1847 3.1462 1 1 2 4 6
34...................................... 17085 6.4968 2 3 5 8 13
35...................................... 3830 4.3065 1 2 3 5 8
36...................................... 9404 1.6325 1 1 1 2 3
37...................................... 1994 4.0341 1 1 3 5 8
38...................................... 246 2.6098 1 1 2 3 5
39...................................... 3436 1.9744 1 1 1 2 4
40...................................... 2958 3.3966 1 1 2 4 7
42...................................... 7697 2.2076 1 1 1 2 5
43...................................... 105 4.1524 1 2 3 5 8
44...................................... 1705 5.7238 2 3 5 7 10
45...................................... 2545 3.8310 1 2 3 5 7
46...................................... 3117 5.5201 1 2 4 7 10
47...................................... 1416 3.7895 1 1 3 5 7
49...................................... 2260 5.6518 1 2 4 7 11
50...................................... 3511 2.1191 1 1 2 2 3
51...................................... 323 2.9195 1 1 1 2 7
52...................................... 100 3.3600 1 1 2 3 7
53...................................... 3624 3.5566 1 1 2 4 8
54...................................... 2 4.0000 1 1 7 7 7
55...................................... 2035 2.9666 1 1 2 3 6
56...................................... 766 2.7454 1 1 2 3 6
57...................................... 637 4.1334 1 1 3 5 8
59...................................... 94 3.6064 1 1 2 4 7
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 226 5.1372 1 1 2 7 14
62...................................... 1 2.0000 2 2 2 2 2
63...................................... 4238 4.6487 1 2 3 5 10
64...................................... 3550 7.5346 1 2 5 9 16
65...................................... 30917 3.4293 1 2 3 4 6
66...................................... 6878 3.5650 1 2 3 4 6
67...................................... 532 4.1992 2 2 3 5 8
68...................................... 10400 4.7953 2 3 4 6 9
69...................................... 3345 3.7677 1 2 3 5 7
70...................................... 32 2.9375 1 2 3 3 5
71...................................... 96 4.0313 1 2 3 5 8
72...................................... 612 4.4167 1 2 3 5 9
73...................................... 6332 4.9588 1 2 4 6 9
75...................................... 41590 11.1419 4 6 8 14 22
76...................................... 40962 12.4917 3 6 10 15 24
77...................................... 2444 5.5041 1 2 4 8 12
78...................................... 30530 8.2292 4 5 7 10 13
79...................................... 220099 9.2617 3 5 7 11 17
80...................................... 9381 6.5760 2 4 5 8 12
81...................................... 10 7.4000 1 4 6 12 15
82...................................... 72211 7.8884 2 3 6 10 16
[[Page 46296]]
83...................................... 7541 6.3896 2 3 5 8 12
84...................................... 1582 3.6846 1 2 3 5 7
85...................................... 19393 7.3333 2 3 6 9 14
86...................................... 1442 4.4938 1 2 4 6 9
87...................................... 62143 6.8199 1 3 6 9 13
88...................................... 368008 6.0847 2 3 5 7 11
89...................................... 442908 7.0843 3 4 6 9 12
90...................................... 43018 5.1184 2 3 4 6 9
91...................................... 53 4.4151 1 2 3 6 8
92...................................... 12552 7.2631 2 4 6 9 13
93...................................... 1328 4.9059 1 3 4 6 9
94...................................... 13243 7.0498 2 3 5 9 14
95...................................... 1457 4.1187 1 2 3 5 8
96...................................... 65750 5.5233 2 3 5 7 10
97...................................... 27758 4.2796 2 2 4 5 7
98...................................... 20 4.3000 1 1 3 6 10
99...................................... 26556 3.4948 1 2 3 4 7
100..................................... 10742 2.4197 1 1 2 3 4
101..................................... 20903 5.1927 1 2 4 7 10
102..................................... 4665 3.1346 1 1 2 4 6
103..................................... 487 39.8973 10 15 29 54 82
104..................................... 24152 14.5670 6 8 12 18 26
105..................................... 20847 10.9617 5 7 9 13 19
106..................................... 101038 11.7331 6 8 10 14 19
107..................................... 64206 8.8424 5 6 7 10 14
108..................................... 6883 12.5720 4 7 10 15 23
110..................................... 62161 10.7839 3 6 9 13 20
111..................................... 6098 6.6496 3 5 6 8 10
112..................................... 201028 4.7049 1 2 4 6 9
113..................................... 47381 14.3687 4 6 10 17 28
114..................................... 9250 9.4685 2 4 7 12 18
115..................................... 11017 11.4341 4 6 9 14 20
116..................................... 85879 5.4281 1 2 4 7 11
117..................................... 4837 4.1211 1 1 2 5 8
118..................................... 7120 3.2142 1 1 2 4 7
119..................................... 1791 5.5366 1 1 3 7 13
120..................................... 42743 9.1977 1 2 6 12 21
121..................................... 167116 7.4255 2 4 6 9 13
122..................................... 91508 5.0063 1 3 5 7 9
123..................................... 48692 4.6628 1 1 2 6 11
124..................................... 145526 4.9010 1 2 4 6 9
125..................................... 62240 3.0708 1 1 2 4 6
126..................................... 4864 14.0113 4 7 11 17 29
127..................................... 705511 6.2183 2 3 5 8 12
128..................................... 20583 6.7301 3 4 6 8 11
129..................................... 4847 3.5251 1 1 1 4 8
130..................................... 96377 6.6838 2 4 6 8 12
131..................................... 26833 5.1772 1 3 5 7 8
132..................................... 133378 3.5806 1 2 3 4 6
133..................................... 6158 2.9737 1 1 2 4 5
134..................................... 30025 3.9084 1 2 3 5 7
135..................................... 7497 4.9941 1 2 4 6 9
136..................................... 1079 3.2586 1 2 3 4 6
138..................................... 205779 4.5592 1 2 3 6 9
139..................................... 70619 2.9382 1 1 2 4 5
140..................................... 184595 3.4847 1 2 3 4 6
141..................................... 80072 4.4984 1 2 3 5 8
142..................................... 37573 3.2025 1 2 3 4 6
143..................................... 138969 2.6105 1 1 2 3 5
144..................................... 70462 5.7020 1 2 4 7 11
145..................................... 7056 3.2372 1 1 2 4 6
146..................................... 9120 11.2398 6 7 9 13 18
147..................................... 1712 7.3376 4 6 7 9 11
148..................................... 147283 13.4382 6 8 11 16 24
149..................................... 16436 7.7095 4 6 7 9 11
150..................................... 23670 11.7463 4 7 10 14 21
151..................................... 4718 6.4532 2 4 6 8 11
152..................................... 4688 9.0299 4 6 8 10 15
153..................................... 1803 6.1570 3 4 6 8 9
154..................................... 37530 14.9694 5 8 12 18 28
[[Page 46297]]
155..................................... 4793 5.8782 2 3 5 8 10
156..................................... 4 15.7500 4 4 10 22 27
157..................................... 11982 5.8109 1 2 4 7 11
158..................................... 5332 2.8931 1 1 2 4 6
159..................................... 18017 5.3350 1 2 4 7 10
160..................................... 10458 2.9512 1 1 2 4 5
161..................................... 15509 4.3541 1 2 3 5 9
162..................................... 8388 2.1838 1 1 2 3 4
163..................................... 8 3.0000 1 1 3 4 5
164..................................... 5242 9.3937 4 6 8 11 16
165..................................... 1755 5.7499 3 4 5 7 9
166..................................... 3444 5.7134 2 3 4 7 10
167..................................... 2405 3.2274 1 2 3 4 5
168..................................... 1837 4.9559 1 2 3 6 10
169..................................... 1070 2.5421 1 1 2 3 5
170..................................... 13155 12.5003 2 5 9 15 25
171..................................... 1202 5.3719 1 2 4 7 11
172..................................... 32447 8.1498 2 3 6 10 16
173..................................... 2279 4.3857 1 2 3 5 9
174..................................... 243715 5.5466 2 3 4 7 10
175..................................... 24013 3.5080 1 2 3 4 6
176..................................... 16840 6.1428 2 3 5 7 11
177..................................... 12681 4.9738 2 3 4 6 9
178..................................... 4324 3.6004 1 2 3 5 7
179..................................... 11791 7.1640 2 4 6 9 14
180..................................... 83016 6.0517 2 3 5 7 11
181..................................... 23164 3.9529 1 2 3 5 7
182..................................... 237845 4.9666 2 2 4 6 9
183..................................... 75506 3.4460 1 2 3 4 6
184..................................... 77 3.8831 1 2 2 4 7
185..................................... 4037 5.1850 1 2 4 6 10
186..................................... 2 1.5000 1 1 2 2 2
187..................................... 944 4.2108 1 2 3 6 8
188..................................... 64238 6.1261 2 3 5 8 12
189..................................... 8117 3.6789 1 1 3 5 7
190..................................... 68 5.0882 1 2 4 7 10
191..................................... 11104 16.2586 5 8 12 20 32
192..................................... 924 7.8983 2 4 7 9 14
193..................................... 8979 13.9328 5 8 11 17 25
194..................................... 843 8.4603 3 5 7 10 15
195..................................... 9690 10.4638 4 6 9 12 18
196..................................... 841 6.7099 3 4 6 8 11
197..................................... 29506 9.1575 4 5 7 11 16
198..................................... 8296 4.9306 2 3 4 6 8
199..................................... 2348 11.1661 3 5 9 14 22
200..................................... 1655 12.3329 2 4 8 15 26
201..................................... 1557 16.7534 4 7 13 21 34
202..................................... 26477 7.7437 2 3 6 10 15
203..................................... 30205 7.6570 2 3 6 10 15
204..................................... 51448 6.7152 2 3 5 8 13
205..................................... 22678 7.2389 2 3 5 9 14
206..................................... 1780 4.7163 1 2 4 6 10
207..................................... 37033 5.7267 2 3 4 7 11
208..................................... 10724 3.5030 1 2 3 4 6
209..................................... 344259 6.6642 3 4 6 7 10
210..................................... 138220 8.5746 4 5 7 10 14
211..................................... 26604 6.2664 3 4 6 7 10
212..................................... 9 5.0000 2 3 4 5 8
213..................................... 7164 9.7067 3 4 7 12 19
214..................................... 53845 6.4613 2 3 5 8 12
215..................................... 43181 3.6830 1 2 3 5 7
216..................................... 6760 11.0719 2 5 8 14 22
217..................................... 20436 15.3636 3 6 10 18 31
218..................................... 23230 6.2178 2 3 5 7 11
219..................................... 19070 3.7531 1 2 3 5 6
220..................................... 2 5.5000 5 5 6 6 6
221..................................... 5230 8.1076 2 4 6 10 16
222..................................... 3747 4.0408 1 2 3 5 8
223..................................... 19412 2.8709 1 1 2 3 5
224..................................... 8377 2.2724 1 1 2 3 4
[[Page 46298]]
225..................................... 6594 5.0059 1 2 3 6 11
226..................................... 5654 6.7386 1 2 4 8 14
227..................................... 4843 2.9583 1 1 2 4 6
228..................................... 3200 3.5291 1 1 2 4 7
229..................................... 1426 2.3969 1 1 2 3 5
230..................................... 2578 5.2002 1 2 3 6 11
231..................................... 10890 5.0626 1 2 3 6 11
232..................................... 601 4.4609 1 1 2 4 10
233..................................... 4811 9.0518 2 4 7 11 18
234..................................... 2360 4.1470 1 2 3 5 8
235..................................... 5827 6.7833 1 3 4 7 13
236..................................... 39844 6.2907 2 3 5 7 12
237..................................... 1586 4.4067 1 2 3 5 8
238..................................... 7925 10.0430 3 5 7 12 19
239..................................... 62429 7.6246 2 4 6 9 14
240..................................... 12705 7.5277 2 3 5 9 15
241..................................... 3179 4.5908 1 2 4 5 9
242..................................... 2644 7.6539 2 4 6 9 15
243..................................... 84034 5.6150 2 3 4 7 10
244..................................... 12041 5.8294 2 3 4 7 11
245..................................... 4472 4.3001 1 2 3 5 8
246..................................... 1391 4.6161 1 2 4 6 9
247..................................... 11132 3.9656 1 2 3 5 8
248..................................... 7135 5.2685 1 2 4 6 10
249..................................... 10593 4.2878 1 1 3 5 9
250..................................... 3360 5.0461 1 2 3 6 9
251..................................... 2227 3.3049 1 1 3 4 6
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 18457 5.8264 2 3 4 7 11
254..................................... 9730 3.8776 1 2 3 5 7
255..................................... 1 2.0000 2 2 2 2 2
256..................................... 4819 5.6921 1 2 4 7 11
257..................................... 24832 3.4341 1 2 3 4 6
258..................................... 19715 2.4910 1 2 2 3 4
259..................................... 4225 3.5089 1 1 2 3 7
260..................................... 5083 1.8702 1 1 2 2 3
261..................................... 2489 2.3403 1 1 2 3 4
262..................................... 749 3.9439 1 1 2 5 8
263..................................... 30590 13.9231 4 6 10 16 28
264..................................... 3714 8.3341 2 4 6 10 16
265..................................... 4518 7.6835 1 3 5 9 16
266..................................... 2849 3.7087 1 1 3 5 8
267..................................... 238 4.3361 1 1 3 5 9
268..................................... 983 4.0651 1 1 2 4 9
269..................................... 10750 9.2391 2 4 7 12 19
270..................................... 3638 3.3966 1 1 2 4 8
271..................................... 22531 8.5207 3 4 7 10 15
272..................................... 6144 7.4653 2 3 6 9 14
273..................................... 1498 5.4820 2 2 4 7 11
274..................................... 2654 7.7939 2 3 5 9 16
275..................................... 258 3.6705 1 1 2 4 8
276..................................... 928 5.0151 1 2 4 6 9
277..................................... 82941 6.7266 3 4 5 8 12
278..................................... 27210 5.1505 2 3 4 6 9
279..................................... 6 4.1667 1 2 3 4 4
280..................................... 13881 5.0709 1 2 4 6 9
281..................................... 6276 3.6109 1 2 3 4 7
283..................................... 5523 5.4677 2 2 4 7 10
284..................................... 1840 3.8408 1 2 3 5 7
285..................................... 5132 13.6613 3 6 10 16 26
286..................................... 2035 8.6993 3 4 6 9 16
287..................................... 6605 13.3889 3 6 9 16 26
288..................................... 1020 6.8824 3 4 5 7 11
289..................................... 5276 3.9780 1 2 2 4 8
290..................................... 8909 2.8289 1 1 2 3 5
291..................................... 91 1.7692 1 1 1 2 3
292..................................... 5308 12.7491 2 5 9 16 25
293..................................... 310 6.7935 1 3 5 8 14
294..................................... 90532 5.6749 2 3 4 7 10
295..................................... 3894 4.2766 1 2 3 5 8
[[Page 46299]]
296..................................... 230483 6.3598 2 3 5 8 12
297..................................... 32946 4.2799 1 2 3 5 8
298..................................... 108 3.3796 1 1 2 4 6
299..................................... 927 5.4132 1 2 4 7 10
300..................................... 14816 7.2798 2 3 6 9 14
301..................................... 2246 4.3780 1 2 3 5 9
302..................................... 8314 12.3018 6 7 9 14 21
303..................................... 19404 10.2201 4 6 8 12 18
304..................................... 13549 10.2932 3 5 7 13 21
305..................................... 2675 4.9073 1 3 4 6 9
306..................................... 11854 6.2386 2 2 4 8 13
307..................................... 2695 2.9796 1 2 2 3 5
308..................................... 9574 7.0326 1 2 5 9 15
309..................................... 3562 3.0230 1 1 2 4 6
310..................................... 30028 4.6161 1 2 3 6 9
311..................................... 10218 2.1747 1 1 2 3 4
312..................................... 2120 4.8198 1 2 3 6 10
313..................................... 788 2.2855 1 1 2 3 5
314..................................... 1 5.0000 5 5 5 5 5
315..................................... 29516 9.3027 1 2 6 12 20
316..................................... 73804 7.4996 2 3 6 9 15
317..................................... 838 2.9033 1 1 2 3 6
318..................................... 6305 7.1543 2 3 5 9 14
319..................................... 520 3.1808 1 1 2 4 7
320..................................... 177433 6.4459 2 3 5 8 11
321..................................... 26621 4.6916 2 3 4 6 8
322..................................... 87 4.3333 2 2 4 5 8
323..................................... 18556 3.5566 1 2 3 4 7
324..................................... 9155 2.0877 1 1 2 3 4
325..................................... 7785 4.5742 1 2 3 5 9
326..................................... 2301 3.4203 1 1 2 4 6
327..................................... 9 3.3333 1 2 2 4 5
328..................................... 853 4.2579 1 2 3 6 8
329..................................... 113 2.7965 1 1 2 3 5
330..................................... 1 1.0000 1 1 1 1 1
331..................................... 40274 6.1795 2 3 5 8 12
332..................................... 4966 3.8494 1 2 3 5 8
333..................................... 379 5.7968 1 3 4 7 13
334..................................... 19982 6.0546 3 4 5 7 9
335..................................... 10308 4.6203 2 3 4 6 7
336..................................... 63893 4.1251 1 2 3 5 8
337..................................... 40540 2.6719 1 2 2 3 4
338..................................... 5063 5.2558 1 2 3 6 11
339..................................... 2416 5.2562 1 2 3 6 11
340..................................... 2 3.0000 1 1 5 5 5
341..................................... 6766 3.2573 1 1 2 4 6
342..................................... 231 4.0649 1 1 2 5 8
344..................................... 4022 3.4510 1 1 2 4 7
345..................................... 1428 4.0210 1 2 3 5 9
346..................................... 5626 6.7600 1 3 5 8 14
347..................................... 443 3.2889 1 1 2 4 7
348..................................... 3188 4.8943 1 2 4 6 9
349..................................... 733 2.9400 1 1 2 4 6
350..................................... 7234 4.7432 2 3 4 6 8
352..................................... 603 3.9005 1 1 3 5 8
353..................................... 2743 8.3252 3 4 6 9 15
354..................................... 10191 6.3351 3 4 5 7 11
355..................................... 5880 3.8566 2 3 4 4 6
356..................................... 30093 3.0252 1 2 3 4 5
357..................................... 6842 9.8297 4 5 8 12 18
358..................................... 28157 4.7538 2 3 4 5 8
359..................................... 28820 3.2702 2 3 3 4 5
360..................................... 17592 3.5444 1 2 3 4 6
361..................................... 655 3.4580 1 1 2 4 7
363..................................... 4555 3.5139 1 2 2 3 6
364..................................... 1879 3.6003 1 1 2 4 8
365..................................... 2522 8.1257 2 3 5 10 18
366..................................... 4697 7.6915 2 3 5 10 16
367..................................... 568 3.2588 1 1 2 4 7
368..................................... 2408 6.9049 2 3 5 8 13
[[Page 46300]]
369..................................... 2531 3.7246 1 1 3 5 7
370..................................... 1201 5.5679 3 3 4 5 9
371..................................... 1044 3.6236 2 3 3 4 5
372..................................... 872 3.3601 1 2 2 3 6
373..................................... 3961 1.9258 1 1 2 2 3
374..................................... 141 2.5957 1 2 2 3 4
375..................................... 5 2.2000 1 1 2 3 4
376..................................... 164 3.3537 1 1 2 4 7
377..................................... 27 3.2963 1 1 2 3 8
378..................................... 172 2.9186 1 2 3 3 5
379..................................... 332 3.0361 1 1 2 3 5
380..................................... 75 2.2800 1 1 2 2 4
381..................................... 209 2.2967 1 1 1 2 5
382..................................... 54 1.5741 1 1 1 1 3
383..................................... 1557 4.0873 1 2 3 5 8
384..................................... 135 3.1481 1 1 1 2 7
385..................................... 4 13.5000 1 1 1 3 49
386..................................... 1 36.0000 36 36 36 36 36
389..................................... 23 10.7391 3 4 8 10 18
390..................................... 11 4.7273 1 2 3 5 9
392..................................... 2622 11.6484 4 6 8 14 24
394..................................... 1734 7.9862 1 2 5 9 16
395..................................... 69281 5.3835 1 2 4 7 10
396..................................... 19 3.7895 1 1 3 5 8
397..................................... 16238 6.0846 2 3 5 7 12
398..................................... 17498 6.5878 2 3 5 8 12
399..................................... 1496 4.4285 1 2 4 6 8
400..................................... 7875 10.4036 2 4 7 13 23
401..................................... 6682 12.3664 2 5 9 16 25
402..................................... 1619 4.7140 1 1 3 6 10
403..................................... 36528 9.2740 2 4 7 12 19
404..................................... 4124 5.0902 1 2 4 7 10
406..................................... 3407 11.2548 3 5 8 14 23
407..................................... 761 4.9304 1 2 4 6 9
408..................................... 3100 8.1632 1 2 5 10 18
409..................................... 5931 6.7132 2 3 4 6 15
410..................................... 89995 3.3580 1 2 3 4 5
411..................................... 58 2.6724 1 1 2 3 7
412..................................... 37 2.9730 1 1 2 4 5
413..................................... 8878 8.3323 2 3 6 10 17
414..................................... 845 5.1361 1 2 4 7 11
415..................................... 40783 15.7224 4 7 12 19 31
416..................................... 201554 8.2165 2 4 7 10 15
417..................................... 54 4.5741 1 2 4 7 10
418..................................... 19614 6.7661 2 3 5 8 13
419..................................... 16497 5.6833 2 3 4 7 10
420..................................... 3010 4.3050 2 2 4 5 8
421..................................... 12216 4.6523 2 2 4 5 8
422..................................... 97 3.8041 1 2 3 4 7
423..................................... 9588 8.7110 2 4 6 10 18
424..................................... 2102 17.9139 3 6 12 20 35
425..................................... 16010 4.8731 1 2 3 6 10
426..................................... 4920 5.5150 1 2 4 7 11
427..................................... 1856 5.2333 1 2 4 6 11
428..................................... 956 8.3347 1 3 5 10 18
429..................................... 40733 8.9700 2 3 6 10 17
430..................................... 55753 9.7545 2 4 7 12 19
431..................................... 200 7.1500 1 3 5 9 13
432..................................... 457 6.5252 1 2 4 6 11
433..................................... 8283 3.4066 1 1 2 4 7
434..................................... 21935 5.8210 2 3 4 7 11
435..................................... 16376 4.8062 1 3 4 6 8
436..................................... 3128 14.3744 4 8 14 21 28
437..................................... 14927 10.8952 4 6 10 14 20
439..................................... 910 8.9264 2 3 6 11 18
440..................................... 5007 9.8354 2 3 6 12 21
441..................................... 648 4.4213 1 1 2 4 8
442..................................... 14657 8.7406 1 3 6 11 18
443..................................... 3465 3.5512 1 1 2 5 7
444..................................... 3543 5.2882 1 3 4 6 10
[[Page 46301]]
445..................................... 1415 3.9046 1 2 3 5 7
446..................................... 1 1.0000 1 1 1 1 1
447..................................... 3991 2.8013 1 1 2 3 5
448..................................... 88 1.0000 1 1 1 1 1
449..................................... 30267 4.4278 1 2 3 5 9
450..................................... 7175 2.3376 1 1 2 3 5
451..................................... 8 6.0000 2 3 4 5 7
452..................................... 20338 5.4282 1 2 4 6 11
453..................................... 3819 3.1825 1 1 2 4 6
454..................................... 5391 5.1330 1 2 3 6 10
455..................................... 1181 2.8442 1 1 2 3 5
456..................................... 213 8.3803 1 1 4 9 21
457..................................... 135 4.8222 1 1 2 5 12
458..................................... 1650 16.8358 3 7 13 22 35
459..................................... 582 10.2887 2 4 7 13 21
460..................................... 2437 6.6422 1 3 5 8 13
461..................................... 3230 4.8920 1 1 2 5 12
462..................................... 9786 13.7570 4 6 12 18 26
463..................................... 12591 5.1721 1 2 4 6 10
464..................................... 3221 3.7464 1 2 3 5 7
465..................................... 202 3.8762 1 1 2 4 7
466..................................... 1943 4.8101 1 1 2 4 10
467..................................... 1820 4.1264 1 1 2 4 8
468..................................... 59655 15.3127 3 7 12 19 30
471..................................... 9604 8.0717 4 5 6 9 14
472..................................... 159 30.1635 1 9 28 40 61
473..................................... 8643 14.3722 2 4 8 21 36
475..................................... 94974 12.1639 2 5 10 16 24
476..................................... 7280 13.8379 3 7 11 17 25
477..................................... 31806 9.3027 1 3 7 12 19
478..................................... 123973 8.3143 1 3 6 10 17
479..................................... 18593 4.5529 1 2 4 6 9
480..................................... 40 32.5750 12 16 24 34 55
481..................................... 193 32.6166 19 22 28 36 53
482..................................... 7121 14.8666 5 8 11 17 28
483..................................... 38600 45.9567 15 23 37 56 85
484..................................... 366 15.8115 2 6 12 22 32
485..................................... 3426 11.6985 4 6 9 14 22
486..................................... 2316 13.4473 1 6 11 18 28
487..................................... 4136 8.9350 1 3 7 11 18
488..................................... 843 20.4152 5 8 14 25 41
489..................................... 19523 10.6298 2 4 7 13 22
490..................................... 5312 6.5849 1 2 4 8 14
491..................................... 9897 4.2698 2 3 3 5 7
492..................................... 2139 17.3703 3 5 10 28 37
493..................................... 54799 5.8913 1 2 5 8 11
494..................................... 28543 2.4171 1 1 2 3 5
495..................................... 131 22.7176 10 12 17 26 39
----------------
11135858
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8a.--Statewide Average Operating Cost-To-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) August 1996
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.420 0.476
ALASKA................................................ 0.505 0.796
ARIZONA............................................... 0.423 0.568
ARKANSAS.............................................. 0.540 0.495
CALIFORNIA............................................ 0.405 0.540
COLORADO.............................................. 0.513 0.604
CONNECTICUT........................................... 0.553 0.551
DELAWARE.............................................. 0.503 0.500
DISTRICT OF COLUMBIA.................................. 0.525 .......
FLORIDA............................................... 0.414 0.418
GEORGIA............................................... 0.527 0.532
HAWAII................................................ 0.484 0.567
IDAHO................................................. 0.580 0.635
ILLINOIS.............................................. 0.478 0.599
INDIANA............................................... 0.564 0.613
IOWA.................................................. 0.540 0.684
KANSAS................................................ 0.449 0.649
KENTUCKY.............................................. 0.506 0.574
LOUISIANA............................................. 0.475 0.540
MAINE................................................. 0.593 0.570
MARYLAND.............................................. 0.765 0.816
MASSACHUSETTS......................................... 0.574 0.600
MICHIGAN.............................................. 0.489 0.594
MINNESOTA............................................. 0.563 0.641
MISSISSIPPI........................................... 0.525 0.527
MISSOURI.............................................. 0.459 0.529
[[Page 46302]]
MONTANA............................................... 0.513 0.615
NEBRASKA.............................................. 0.526 0.684
NEVADA................................................ 0.321 0.563
NEW HAMPSHIRE......................................... 0.591 0.611
NEW JERSEY............................................ 0.479 .......
NEW MEXICO............................................ 0.484 0.546
NEW YORK.............................................. 0.584 0.679
NORTH CAROLINA........................................ 0.539 0.498
NORTH DAKOTA.......................................... 0.651 0.694
OHIO.................................................. 0.557 0.594
OKLAHOMA.............................................. 0.489 0.558
OREGON................................................ 0.577 0.671
PENNSYLVANIA.......................................... 0.436 0.580
PUERTO RICO........................................... 0.495 0.643
RHODE ISLAND.......................................... 0.587 .......
SOUTH CAROLINA........................................ 0.477 0.501
SOUTH DAKOTA.......................................... 0.559 0.648
TENNESSEE............................................. 0.536 0.572
TEXAS................................................. 0.462 0.565
UTAH.................................................. 0.462 0.675
VERMONT............................................... 0.576 0.587
VIRGINIA.............................................. 0.499 0.536
WASHINGTON............................................ 0.634 0.688
WEST VIRGINIA......................................... 0.578 0.542
WISCONSIN............................................. 0.604 0.665
WYOMING............................................... 0.495 0.734
------------------------------------------------------------------------
Table 8b.--Statewide Average Capital Cost-To-Charge Ratios (Case
Weighted) August 1996
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.055
ALASKA......................................................... 0.077
ARIZONA........................................................ 0.050
ARKANSAS....................................................... 0.056
CALIFORNIA..................................................... 0.040
COLORADO....................................................... 0.052
CONNECTICUT.................................................... 0.037
DELAWARE....................................................... 0.054
DISTRICT OF COLUMBIA........................................... 0.042
FLORIDA........................................................ 0.051
GEORGIA........................................................ 0.052
HAWAII......................................................... 0.051
IDAHO.......................................................... 0.064
ILLINOIS....................................................... 0.044
INDIANA........................................................ 0.058
IOWA........................................................... 0.056
KANSAS......................................................... 0.055
KENTUCKY....................................................... 0.056
LOUISIANA...................................................... 0.069
MAINE.......................................................... 0.044
MARYLAND....................................................... 0.013
MASSACHUSETTS.................................................. 0.060
MICHIGAN....................................................... 0.049
MINNESOTA...................................................... 0.055
MISSISSIPPI.................................................... 0.056
MISSOURI....................................................... 0.053
MONTANA........................................................ 0.061
NEBRASKA....................................................... 0.058
NEVADA......................................................... 0.034
NEW HAMPSHIRE.................................................. 0.066
NEW JERSEY..................................................... 0.045
NEW MEXICO..................................................... 0.055
NEW YORK....................................................... 0.056
NORTH CAROLINA................................................. 0.049
NORTH DAKOTA................................................... 0.074
OHIO........................................................... 0.056
OKLAHOMA....................................................... 0.056
OREGON......................................................... 0.052
PENNSYLVANIA................................................... 0.045
PUERTO RICO.................................................... 0.090
RHODE ISLAND................................................... 0.039
SOUTH CAROLINA................................................. 0.054
SOUTH DAKOTA................................................... 0.066
TENNESSEE...................................................... 0.057
TEXAS.......................................................... 0.055
UTAH........................................................... 0.055
VERMONT........................................................ 0.049
VIRGINIA....................................................... 0.057
WASHINGTON..................................................... 0.063
WEST VIRGINIA.................................................. 0.059
WISCONSIN...................................................... 0.048
WYOMING........................................................ 0.067
------------------------------------------------------------------------
Table 10.--Percentage Difference in Wage Indexes for Areas That Qualify for a Wage Index Excluded Hospitals and
Units
----------------------------------------------------------------------------------------------------------------
1982-1993 1984-1993 1988-1993 1990-1993 1991-1993 1992-1993
Area difference difference difference difference difference difference
----------------------------------------------------------------------------------------------------------------
Rural Connecticut................. 22.9642 25.4054 ........... ........... ........... ...........
Rural Delaware.................... 8.2430 11.4258 8.2051 9.1337 ........... ...........
Rural Hawaii...................... ........... 15.9050 ........... ........... ........... ...........
Rural Massachusetts............... 20.2198 24.1342 ........... ........... ........... ...........
Rural New Hampshire............... ........... 9.8512 ........... ........... ........... ...........
Albany, GA........................ ........... 10.3581 ........... ........... ........... ...........
Anchorage, AK..................... ........... ........... ........... 8.2863 ........... ...........
Andreson, SC...................... ........... ........... 9.1948 17.8927 ........... ...........
Arecibo, PR....................... ........... ........... 11.1448 18.6084 15.7978 ...........
Athens, GA........................ 15.1448 21.0519 13.7293 13.6463 ........... ...........
Atlanta, GA....................... ........... 8.6086 ........... ........... ........... ...........
Atlantic City, NJ................. ........... 12.4784 ........... ........... ........... ...........
Bergen-Passaic, NJ................ 10.5317 12.4189 14.3717 ........... ........... ...........
Biloxi-Gulfport, MS............... ........... 11.1443 10.6209 12.4040 ........... ...........
Boise City, ID.................... ........... ........... ........... 8.3390 ........... ...........
Boston-Lowell-Brockton-Lawrence-
Salem, MA........................ ........... 9.8215 ........... ........... ........... ...........
Bremerton, WA..................... 11.9762 13.8828 14.2288 14.3007 12.7288 ...........
Bridgeport-Stamford-Norwalk-
Danbury, CT...................... 10.0485 14.3994 ........... ........... ........... ...........
Burlington, NC.................... 11.2298 14.5664 9.4207 ........... ........... ...........
Burlington, VT.................... ........... 8.8170 9.1074 ........... ........... 10.3206
Caguas, PR........................ ........... 15.1271 ........... ........... ........... ...........
Charleston, WV.................... ........... ........... 8.3229 ........... ........... ...........
Charlotte-Gastonia-Rock Hill, NC-
SC............................... ........... 14.9051 ........... ........... ........... ...........
Clarksville-Hopkinsville, TN-KY... ........... ........... 12.9537 ........... ........... ...........
Columbia, SC...................... ........... 8.4912 ........... ........... ........... ...........
Danville, VA...................... ........... 11.3907 13.1106 ........... ........... ...........
Decatur, AL....................... ........... 13.3721 11.9044 ........... ........... ...........
El Paso, TX....................... ........... 8.5187 ........... ........... 9.8283 ...........
Eugene-Springfield, OR............ ........... 10.5206 10.8031 18.7777 ........... ...........
Fayetteville, NC.................. 9.0029 10.4192 8.4909 ........... ........... ...........
Flint, MI......................... ........... ........... ........... ........... 9.2030 ...........
Florence, AL...................... ........... 11.9746 ........... ........... ........... ...........
Florence, SC...................... 12.7213 11.5654 ........... ........... ........... ...........
[[Page 46303]]
Fort Walton Beach, FL............. ........... 12.3564 ........... ........... ........... ...........
Fresno, CA........................ ........... ........... ........... 10.8664 9.4732 8.0939
Gadsden, AL....................... ........... ........... 8.2379 14.6656 9.8985 ...........
Galveston-Texas City, TX.......... ........... ........... 16.5166 11.3722 8.4081 ...........
Greeley, CO....................... ........... ........... ........... 11.0971 ........... ...........
Greensboro-Winston-Salem-High
Point, NC........................ 9.2662 ........... ........... ........... ........... ...........
Hamilton-Middleton, OH............ ........... ........... ........... ........... 8.1472 8.0733
Hartford-Middletown-New Britain,
CT............................... 8.7767 12.4966 3.7059 2.2400 -0.1050 -0.1775
Houma-Thibodaux, LA............... ........... ........... 9.3263 ........... ........... ...........
Jackson, TN....................... ........... 9.6429 ........... ........... ........... ...........
Jersey City, NJ................... ........... ........... 8.0391 ........... ........... ...........
Killeen-Temple, TX................ 18.3848 ........... ........... ........... ........... ...........
Lima, OH.......................... ........... ........... 8.2156 ........... ........... ...........
Macon-Warner Robins, GA........... ........... 13.0975 ........... ........... ........... ...........
McAllen-Edinburg-Mission, TX...... ........... 10.4962 9.8809 ........... ........... ...........
Medford, OR....................... ........... ........... ........... 8.0133 ........... ...........
Merced, CA........................ ........... ........... ........... ........... 8.1676 ...........
Middlesex-Somerset-Hunterdon, NJ.. ........... 9.6183 ........... ........... ........... ...........
Monmouth-Ocean, NJ................ 10.0345 15.4149 9.3349 ........... ........... ...........
Munice, IN........................ ........... ........... 20.3096 13.5593 ........... ...........
Nassau-Suffolk, NY................ ........... 11.9105 ........... ........... ........... ...........
New Bedford-Fall River-Attleboro,
MA............................... 13.7683 16.6368 10.4385 ........... ........... ...........
New Haven-West Haven-Waterbury, CT 11.8620 16.2147 ........... ........... ........... ...........
New London-Norwich, CT............ 11.3300 14.9405 ........... ........... ........... ...........
Newark, NJ........................ ........... 8.8979 ........... ........... ........... ...........
Ocala, FL......................... ........... 11.8261 ........... ........... ........... ...........
Orange County, NY................. 17.1382 21.4157 11.8518 ........... ........... ...........
Portsmouth-Dover-Rochester, NH.... 9.0870 ........... ........... ........... ........... ...........
Poughkeepsie, NY.................. ........... 8.8610 ........... ........... ........... ...........
Providence-Pawtucket-Woonsocket,
RI............................... ........... 13.9497 ........... ........... ........... ...........
Provo-Orem, UT.................... ........... 9.0782 ........... ........... ........... ...........
Redding, CA....................... ........... 17.2205 9.9157 ........... ........... ...........
Richland-Kennewick, WA............ ........... ........... ........... 8.1102 ........... ...........
Salinas-Seaside-Monterey, CA...... 10.6879 9.7202 ........... ........... ........... ...........
Santa Cruz, CA.................... 9.6319 9.7120 ........... ........... ........... ...........
Santa Fe, NM...................... 11.2207 14.0809 18.3339 8.2941 ........... ...........
Sarasota, FL...................... ........... 8.9573 ........... ........... ........... ...........
Savannah, GA...................... 9.0765 14.6762 15.7768 11.1239 ........... ...........
Topeka, KS........................ ........... ........... 8.3342 9.2849 ........... ...........
Tyler, TX......................... ........... ........... ........... 9.5202 ........... ...........
Vallejo-Fairfield-Napa, CA........ ........... 13.6478 ........... 11.7807 ........... ...........
Wilmington, DE-NJ-MD.............. ........... 8.9989 ........... ........... ........... ...........
Wilmington, NC.................... ........... 12.2020 ........... ........... ........... ...........
Worcester-Fitchburg-Leomister, MA. 10.9147 17.9463 ........... ........... ........... ...........
Yuma, AZ.......................... ........... ........... ........... ........... 9.4870 ...........
----------------------------------------------------------------------------------------------------------------
Appendix A--Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612), unless the Secretary certifies that a final rule would
not have a significant economic impact on a substantial number of small
entities. For purposes of the RFA, we consider all hospitals to be
small entities.
Also, section 1102(b) of the Social Security Act (the Act) requires
the Secretary to prepare a regulatory impact analysis for any final
rule that may have a significant impact on the operations of a
substantial number of small rural hospitals. Such an analysis must
conform to the provisions of section 603 of the RFA. With the exception
of hospitals located in certain New England counties, for purposes of
section 1102(b) of the Act, we define a small rural hospital as a
hospital with fewer than 100 beds that is located outside of a
Metropolitan Statistical Area (MSA) or New England County Metropolitan
Area (NECMA). Section 601(g) of the Social Security Amendments of 1983
(Public Law 98-21) designated hospitals in certain New England counties
as belonging to the adjacent NECMA. Thus, for purposes of the
prospective payment system, we classify these hospitals as urban
hospitals.
It is clear that the changes 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 final rule,
constitutes a combined regulatory impact analysis and regulatory
flexibility analysis.
II. Changes in the Final Rule
Any differences in this final rule impact analysis compared to that
in the proposed rule are the result of using more recent or more
complete hospital data. For example, a more complete FY 1995 MedPAR
file (June 1996 update) is
[[Page 46304]]
now available compared to the one available at the time of the proposed
rule. In addition, more recent hospital-specific data, including cost
reports, are used in this analysis.
Our most recent hospital market basket forecasts are: 2.5 percent
for prospective payment system hospitals and 2.5 percent for hospitals
excluded from the prospective payment system. The respective update
factors in the proposed rule were both 2.7 percent. Beyond this change
in the hospital market basket forecast, there are no operating or
capital prospective payment policy changes from those discussed in the
impact analysis in the proposed rule.
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 final 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.
We received no comments on the methodology used for the impact
analysis in the proposed rule.
IV. Hospitals Included In and Excluded From the Prospective Payment
System
The prospective payment systems for hospital inpatient operating
and capital-related costs encompass nearly all general, short-term,
acute care hospitals that participate in the Medicare program. 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, we have included 5,129 hospitals
in our analysis. This represents about 82 percent of all 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, childrens', and
cancer hospitals. The impacts of our policy changes on these hospitals
are discussed below.
V. Impact on Excluded Hospitals and Units
As of August 1996, there were 1,125 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 2,315 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 is 1.5 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 final 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 and 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 Final Policy Changes Under
the Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this final 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 final
changes to each system, beginning here with changes to the operating
prospective payment system. Estimated payment impacts of final FY 1997
changes to the capital prospective payment system are discussed below
in section VII of this Appendix.
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 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 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.
The following changes are discussed separately below:
The effects of the annual reclassification of diagnoses
and procedures and the recalibration of the diagnosis-related group
(DRG) relative
[[Page 46305]]
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 final changes, our
analysis begins with an FY 1997 baseline simulation model using: the FY
1996 GROUPER (version 13.0); the FY 1996 wage indexes (based on FY 1992
data); no MGCRB reclassifications; and current outlier policy (50
percent phase-out of day outlier payments). Outlier payments are
estimated 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
final rule and statutory changes. This allows us to isolate the effects
of each 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 for FY 1997. In accordance with
section 1886(d)(3)(A)(iv) of the Act, we are updating 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
2.5 percent, minus 0.5 percentage points. Thus, the update to the large
urban and other areas standardized amounts is 2.0 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 payment purposes) is also the market basket
increase minus 0.5 percent, or 2.0 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 that 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 4.0 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 final 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. This 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 5,129 hospitals included in the analysis. This is 78 fewer
hospitals than were included in the impact analysis in the FY 1996
final rule (60 FR 45924). Data for 108 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 2,881
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,596 hospitals located in large urban
areas (populations over 1 million), and 1,285 hospitals in other urban
areas (populations of 1 million or fewer). In addition, there are 2,248
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 2,981, 1,791,
1,190, and 2,148, respectively.
The next three groupings examine the impacts of the final 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 4,044 nonteaching
hospitals in our analysis, 850 teaching hospitals with fewer than 100
residents, and 235 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 final 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 (645), and SCH/EACH and RRCs (38) shown
here were not reclassified for purposes of the standardized amount.
There are seven EACHs included in our analysis and four EACH/RRCs.
[[Page 46306]]
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). Cost
report data needed to determine hospital ownership and to calculate
Medicare utilization percentages were unavailable for 116 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.
Table I.--Impact Analysis of Changes for FY 1997 Operating Prospective Payment System
[Percent changes in payments per case]
Combined MGCRB Day outlier
Number of DRG recali- New wage wage and reclassifi- policy All FY 97
hospitals bration \2\ data \3\ recal \4\ cation \5\ changes \6\ changes \7\
(0) (1) (2) (3) (4) (5) (6)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Geographic Location)
--------------------------------------------------------------------------------------------------------------------------------------------------------
All hospitals............................................... 5,129 0.1 0.1 0.0 0.0 0.0 2.9
Urban hospitals............................................. 2,881 0.1 0.1 0.0 -0.4 -0.1 2.9
Large urban............................................. 1,596 0.1 0.1 0.0 -0.4 -0.1 2.9
Other urban............................................. 1,285 0.1 0.1 0.0 -0.2 0.1 3.0
Rural hospitals............................................. 2,248 0.0 0.0 -0.1 2.3 0.1 2.4
Bed size (urban):
0-99 beds............................................... 715 0.0 -0.1 -0.3 -0.5 0.1 2.7
100-199 beds............................................ 945 0.0 -0.1 -0.2 -0.4 0.1 2.6
200-299 beds............................................ 576 0.1 0.0 0.0 -0.4 0.0 2.9
300-499 beds............................................ 478 0.1 0.1 0.1 -0.4 -0.1 3.1
500 or more beds........................................ 167 0.1 0.1 0.1 -0.2 -0.2 3.1
Bed size (rural):
0-49 beds............................................... 1,177 -0.1 0.1 -0.1 0.0 0.1 2.4
50-99 beds.............................................. 657 -0.1 0.1 -0.1 1.0 0.1 2.4
100-149 beds............................................ 241 0.0 0.1 -0.1 3.1 0.1 2.6
150-199 beds............................................ 98 0.1 0.0 0.0 2.7 0.1 2.7
200 or more beds........................................ 75 0.1 -0.1 -0.1 4.9 0.1 1.9
Urban by census division:
New England............................................. 160 0.1 0.0 0.0 -0.2 -0.1 2.0
Middle Atlantic......................................... 434 0.0 0.4 0.3 -0.2 -0.7 3.3
South Atlantic.......................................... 419 0.1 -0.2 -0.2 -0.4 0.1 3.1
East North Central...................................... 483 0.1 0.4 0.4 -0.3 0.1 2.5
East South Central...................................... 163 0.1 -0.2 -0.2 -0.5 0.2 3.1
West North Central...................................... 193 0.1 0.0 0.0 -0.5 0.2 3.3
West South Central...................................... 376 0.1 0.1 0.0 -0.5 0.2 3.6
Mountain................................................ 127 0.2 -0.3 -0.3 -0.4 0.2 2.9
Pacific................................................. 478 0.1 -0.4 -0.4 -0.5 0.1 2.5
Puerto Rico............................................. 48 -0.1 -1.2 -1.4 -0.5 0.0 1.9
Rural by census division:
New England............................................. 53 0.1 -0.9 -1.0 2.0 0.2 1.2
Middle Atlantic......................................... 85 0.0 -0.5 -0.6 0.9 -0.1 1.7
South Atlantic.......................................... 297 -0.1 -0.4 -0.5 3.0 0.1 2.3
East North Central...................................... 304 0.1 0.3 0.3 2.0 0.1 2.6
East South Central...................................... 278 -0.1 0.3 0.1 2.4 0.1 1.9
West North Central...................................... 525 0.0 0.1 0.0 2.1 0.1 2.5
West South Central...................................... 349 -0.1 0.5 0.2 3.1 0.1 2.8
Mountain................................................ 211 0.1 -0.1 -0.1 0.8 0.1 2.6
Pacific................................................. 141 0.1 0.6 0.5 2.3 0.1 3.7
Puerto Rico............................................. 5 -0.2 -4.2 -4.5 3.3 0.0 1.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Payment Categories)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Urban hospitals............................................. 2,981 0.1 0.1 0.0 -0.3 0.0 2.9
[[Page 46307]]
Large urban............................................. 1,791 0.1 0.1 0.0 -0.2 -0.1 2.9
Other urban............................................. 1,190 0.1 0.0 0.0 -0.4 0.1 3.0
Rural hospitals............................................. 2,148 0.0 0.0 -0.1 1.9 0.1 2.2
Teaching status:
Non-teaching............................................ 4,044 0.0 0.0 -0.1 0.3 0.1 2.8
Less than 100 residents................................. 850 0.1 0.1 0.0 -0.3 0.0 3.0
100+ residents.......................................... 235 0.1 0.2 0.2 -0.2 -0.4 2.8
Disproportionate Share Hospitals (DSH):
Non-DSH................................................. 3,201 0.1 0.0 0.0 0.2 0.1 2.9
Urban DSH:
100 beds or more........................................ 1,410 0.0 0.1 0.0 -0.3 -0.1 2.9
Fewer than 100 beds..................................... 101 -0.2 -0.3 -0.6 -0.3 0.2 2.2
Rural DSH:
Sole community (SCH)................................ 156 -0.1 0.0 -0.3 0.3 0.0 3.6
Referral centers (RRC).............................. 27 0.0 0.1 -0.1 3.7 0.0 3.3
Other rural DSH hospitals:
100 beds or more.................................... 83 0.0 -0.1 -0.2 2.4 0.2 0.3
Fewer than 100 beds................................. 151 -0.2 0.0 -0.3 -0.3 0.1 2.0
Urban teaching and DSH:
Both teaching and DSH................................... 692 0.0 0.2 0.1 -0.4 -0.2 2.8
Teaching and no DSH..................................... 339 0.2 0.0 0.1 -0.1 0.0 3.0
No teaching and DSH..................................... 819 0.0 -0.1 -0.2 0.0 0.1 3.0
No teaching and no DSH.................................. 1,131 0.1 0.0 -0.1 -0.3 0.2 3.1
Rural hospital types Nonspecial status:
Hospitals............................................... 1,375 0.0 0.0 -0.1 1.7 0.1 1.6
RRC..................................................... 90 0.1 0.1 0.1 5.0 0.1 3.4
SCH/each................................................ 645 -0.1 0.0 -0.2 0.3 0.0 2.6
SCH/each and RRC........................................ 38 0.1 0.1 0.0 1.1 -0.1 2.7
Type of ownership:
Voluntary............................................... 2,951 0.1 0.1 0.1 -0.1 -0.1 2.9
Proprietary............................................. 696 0.0 -0.2 -0.4 0.3 0.2 2.9
Government.............................................. 1,366 0.0 0.0 -0.1 0.1 0.0 2.6
Unknown................................................. 116 -0.2 0.6 0.3 -0.4 -1.3 2.1
Medicare utilization as a percent of inpatient days:
0-25.................................................... 258 -0.1 -0.1 -0.3 -0.4 -0.2 2.0
25-50................................................... 1,284 0.1 0.0 0.0 -0.2 -0.1 2.9
50-65................................................... 2,097 0.1 0.1 0.0 0.2 0.0 2.9
Over 65................................................. 1,374 0.0 0.0 -0.1 0.2 0.1 2.9
Unknown................................................. 116 -0.2 0.6 0.3 -0.4 -1.3 2.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hospitals Reclassified by the Medicare Geographic Review Board
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reclassification status during FY96 and FY97:
Reclassified during both FY96 and FY97.................. 379 0.1 0.2 0.2 5.9 0.0 2.7
Urban............................................... 130 0.1 0.4 0.4 3.5 -0.1 3.0
Rural............................................... 249 0.0 0.0 -0.1 8.9 0.1 2.5
Reclassified during FY97 only........................... 98 0.2 0.3 0.3 3.8 -0.3 8.3
Urban............................................... 29 0.2 0.4 0.5 2.5 -0.5 7.6
Rural............................................... 69 0.0 -0.1 -0.1 7.1 0.1 10.2
Reclassified during FY96 only........................... 253 0.1 -0.5 -0.5 -1.2 0.1 -0.5
Urban............................................... 91 0.1 -0.8 -0.8 -1.7 0.0 0.6
Rural............................................... 162 0.0 0.0 -0.1 -0.4 0.2 -2.2
FY 97 reclassifications:
All reclassified hospitals.......................... 477 0.1 0.2 0.2 5.4 -0.1 3.8
Standard amount only................................ 119 0.1 0.1 0.1 1.7 0.0 2.8
Wage index only..................................... 272 0.1 -0.2 -0.2 8.2 -0.1 3.3
Both................................................ 86 0.1 0.9 0.9 4.7 -0.2 5.5
Nonreclassified..................................... 4,625 0.1 0.0 0.0 -0.6 0.0 2.8
All urban reclassifed................................... 159 0.1 0.4 0.4 3.3 -0.2 4.1
Standard amount only................................ 62 0.1 0.2 0.1 0.9 0.0 2.9
Wage index only..................................... 27 0.2 -0.6 -0.5 7.2 -0.4 3.7
Both................................................ 70 0.1 1.0 1.0 3.4 -0.2 5.1
[[Page 46308]]
Nonreclassified..................................... 2,722 0.1 0.0 0.0 -0.6 0.0 2.9
All rural reclassified.................................. 318 0.0 0.0 -0.1 8.6 0.1 3.5
Standard amount only................................ 57 0.1 -0.1 -0.1 4.4 0.2 2.5
Wage index only..................................... 245 0.0 0.0 -0.1 8.6 0.1 3.2
Both................................................ 16 0.1 -0.1 -0.1 18.5 0.2 9.2
Nonreclassified..................................... 1,903 0.0 0.1 -0.1 -0.4 0.1 1.9
Other reclassifed:
Hospitals (section 1886(d)(8)(B))....................... 27 0.1 0.2 0.1 1.2 0.1 2.7
\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.
\4\ This column displays the combined impacts of the reclassification and recalibration of the DRGs, the updated wage data used to calculate the wage
index, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act.
Thus, it represents the combined impacts shown in columns 1 and 2, and the FY 1997 budget neutrality factor of 0.998702.
\5\ 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.
\6\ This column illustrates the payment impacts of phasing out day outlier payments and increasing cost outlier payments, in accordance with section
1886(d)(5) of the Act.
\7\ This column shows changes in payments from FY 1996 to FY 1997. It incorporates all of the changes displayed in columns 3 through 5 (the changes
displayed in columns 1 and 2 are included in column 3). 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 columns 3 through 5 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 Final 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 final rule. Section 1886(d)(4)(C)(i) of the Act
requires us each year to make appropriate classification changes and to
recalibrate the DRG weights in order to reflect changes in treatment
patterns, technology, and any other factors that may change the
relative use of hospital resources.
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 rural (over 150 beds) and urban (over 200 beds)
hospitals.
The largest negative effect on any of the hospital categories
examined is a 0.2 percent decrease in payments for smaller urban (100
or fewer beds) and rural hospitals that receive DSH payments, as well
as 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 making 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 final 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.
The results indicate that the new wage data do not have a
significant overall impact on hospital payments. 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. 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.
Among urban hospitals in the 50 States and the District of
Columbia, the largest increases (0.4 percent) are in the Middle
Atlantic and the East North Central census divisions. Significantly,
New York City's wage index rises by over 2.4 percent (this also
contributes to the 0.2 percent increase among major
[[Page 46309]]
teaching hospitals and the 0.6 percent increase in the Unknown category
under the Type of Ownership and the Medicare Utilization rows, where a
cluster of New York City hospitals that file manual cost reports are
grouped). 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 (outside of Puerto Rico, which is discussed separately
below) occurs in the Pacific census division, with a decline of 0.4
percent.
Among the rural hospitals, the largest increases are in the Pacific
census division (0.6 percent) and the West South Central census
division (0.5 percent); the largest decreases are in the census
divisions of New England (0.9 percent), the Middle Atlantic (0.5
percent) and the South Atlantic (0.4 percent). The decrease among rural
New England hospitals is primarily due to a 2.7 percent decrease in the
wage index for rural Connecticut and rural New Hampshire hospitals.
Among rural hospitals last year, the Pacific rural hospitals
experienced one of the greatest increases (0.6 percent), while the
rural West South Central hospitals experienced one of the greatest
decreases (0.4 percent).
In Puerto Rico, payments decline by 4.2 percent for the five rural
hospitals and by 1.2 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 4.2 percent overall decline. Also, all six urban areas
in Puerto Rico experience decreases in their wage index values. Two of
these six experience a decline of more than 5 percent. These MSAs have
relatively few hospitals (two and five), thus the decreases appear to
be the result of one hospital in each area having a decrease of more
than 5 percent in its average hourly wage.
The final 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 continue to decrease.
This expectation is borne out by comparing the 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
(334) experience less than a 5 percent change. Only 19 labor market
areas experience a change between 5 and 10 percent; 10 of those
experience increases. Still fewer labor markets experience a change of
more than 10 percent; one experiences an increase and three experience
decreases. For FY 1996, by comparison, 10 labor market areas
experienced an increase in their wage index value of more than 10
percent.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values -------------------
FY 1997 FY 1996
------------------------------------------------------------------------
Increase more than 10 percent....................... 1 6
Increase between 5 and 10 percent, (inclusive)...... 10 19
Increase/decrease below 5 percent................... 334 323
Decrease between 5 and 10 percent, (inclusive)...... 9 6
Decrease more than 10 percent....................... 3 0
------------------------------------------------------------------------
Note: There are two new MSAs in FY 1997. Also, there are some MSAs that,
after geographic reclassification have no providers remaining and,
therefore, are not reflected in this table.
Under the final FY 1997 wage index, 96.6 percent of urban hospitals
and 93.9 percent of rural hospitals would experience a change in their
wage index of less than 5 percent. Approximately 2.6 percent of urban
hospitals and 1.4 percent of rural hospitals would experience a change
of between 5 and 10 percent, and 0.9 percent of urban hospitals and 4.6
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.
------------------------------------------------------------------------
Percent of
hospitals (by
Percentage change in area wage index values urban/rural)
-------------------
Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent....................... 0.3 2.6
Increase between 5 and 10 percent (inclusive)....... 1.5 0.4
Increase or decrease less than 5 percent............ 96.6 93.9
Decrease between 5 and 10 percent (inclusive)....... 1.1 1.0
Decrease more than 10 percent....................... 0.6 2.0
------------------------------------------------------------------------
Note: The sum of the columns may not total to 100 due to rounding.
D. Combined Impact of DRG and Wage Index Changes--Including Budget
Neutrality Adjustment (Column 3)
The impact of DRG 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) of the Act specifies
that any updates or adjustments to the wage index are budget neutral.
As pointed out in the Addendum to this final rule, we compared
aggregate payments using the FY 1996 DRG relative weights and wage
index to aggregate payments using the 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 are
shown in column 3. The 0.0 percent impact for All Hospitals
demonstrates that these changes, in combination with the budget
neutrality factor, are budget neutral.
For the most part, the changes in this column are the sum of the
changes in columns 1 and 2, minus the approximately 0.2 percent
decrease attributable to the budget neutrality factor. In calculating
the total changes shown in column 6, readers should begin with this
column and add across, excluding the impacts shown in columns 1 and 2.
E. The Impact of MGCRB Reclassifications (Column 4)
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
hospitals in rural counties that are deemed urban under section
1886(d)(8)(B) of the Act). The changes in column 4 reflect the per case
payment impact of 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
[[Page 46310]]
hospitals reclassified for purposes of receiving the large urban
standardized amount also qualify to be treated as urban for purposes of
the DSH adjustment. However, effective FY 1997, rural hospitals can no
longer be reclassified to an other urban area for purposes of the
standardized amount in order to receive a higher 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.)
This impact analysis incorporates all of the MGCRB's
reclassification decisions for FY 1997. It also reflects any decisions
made by the HCFA Administrator through the appeals and review process.
Additional changes that resulted from a request by a hospital to
withdraw its application are also reflected in this final rule.
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 0.993511 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4 of the
Addendum to this final 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 0.4
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 these
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 0.1
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 Mountain division. This division has relatively few
MGCRB reclassifications. Among urban census divisions, the New England
and the Middle Atlantic display the smallest negative impact, 0.2
percent.
Among the 90 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 due to MGCRB reclassification. This group
is not shown separately in the table, but this large increase is
reflected in several of the rural hospital categories. For example,
rural hospitals with 200 or more beds have a 4.9 percent increase in
payments in column 4, largely due to this effect.
Rural hospitals reclassified for FY 1996 and FY 1997 experience an
8.9 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 1.7 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 2.5 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 18.5 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, 245 rural hospitals reclassified for the wage index receive
an 8.6 percent payment increase. The overall impact on reclassified
hospitals is to increase their payments per case by an average of 5.4
percent for FY 1997.
Among the 27 rural hospitals deemed to be urban under section
1886(d)(8)(B) of the Act, payments increase 1.2 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 subject to annual review, like the MGCRB
reclassifications), they are still 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 1.2
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 0.6 percent, which corresponds
closely with the geographic reclassification budget neutrality factor.
Rural nonreclassified hospitals decrease slightly less, 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 205 in FY 1997. This is not surprising
because of the elimination of standardized amount reclassifications
from rural to other urban areas for individual hospitals. Individual
rural (and other urban) 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
272 in FY 1997.
F. Outlier Changes (Column 5)
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, the day outlier
threshold will be equal to the geometric mean length of stay for each
DRG plus the lesser of 24 days or 3.0 standard deviations. The marginal
cost factor for day outliers is 33 percent. For FY 1997, a case would
receive cost outlier payments if its costs exceed the DRG payment plus
$9,700.
[[Page 46311]]
We are maintaining 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 (0.7 percent and 0.1 percent declines,
respectively); urban hospitals with 300-499 beds and those with 500 or
more beds (0.1 and 0.2 percent declines, respectively); teaching
hospitals with 100 or more residents (0.4 percent decline); and
hospitals for which data were unavailable to calculate type of
ownership or Medicare utilization rates (1.3 percent decline). As noted
previously in the wage index discussion, this last category contains a
number of New York City hospitals because they file manual cost
reports. 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 of 0.2 percent affected
numerous hospital groups.
G. All Changes (Column 6)
Column 6 compares our estimate of payments per case incorporating
all of our changes for FY 1997 to our estimate of payments per case in
FY 1996. It also includes the effects of the 2.0 percent update to the
standardized amounts and the hospital-specific rates for SCHs and
EACHs, and the 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 (4.0 percent), as
described in the introduction to this Appendix and the Addendum.
Also, column 6 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 4 are offset by the effects of reclassification on hospitals' FY
1996 payments (column 4 of Table I, September 1, 1995 final rule; 60 FR
45926). That is, column 4 of Table I 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 4. 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 0.0 percent.
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. In the proposed
rule, we indicated that this was interpreted to mean that there was no
transfer budget neutrality factor applied after FY 1996, and we
estimated the impact of this to be a 0.2 percent increase in FY 1997
payments. As discussed in the Addendum to this final rule, we have
corrected this interpretation so that we will continue to apply this
budget neutrality factor of 0.997575 in FY 1997, and in the future.
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. This effect is attributable to particular census
divisions, as discussed below.
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 6 may not equal the sum of columns
3 through 5 plus the other impacts that we are able to identify. The
point should be repeated here, as well, that when comparing the percent
changes in column 6 attributable to the isolated changes in the prior
columns in this table, columns 1 and 2 are incorporated into column 3.
Therefore, just the effect in column 3 should be added into the total
change shown in column 6.
The overall payment increase from FY 1997 to FY 1996 for all
hospitals is a 2.9 percent increase. This reflects the 0.0 percent net
change in total payments due to the final changes for FY 1997 shown in
columns 3 through 5, the 2.0 percent update for FY 1997, the 1.1
percent higher outlier payments in FY 1997 compared to FY 1996, and the
0.2 overall negative effect of eliminating the regional floor.
Hospitals in urban areas experience a 2.9 percent rise in payments
per case over FY 1996. Similar to all hospitals nationally, this is
primarily due to the factors discussed above: the 2.0 percent update; a
1.1 percent impact of the higher level of outlier payments estimated
for FY 1997; and the effect of the expiration of the regional floor.
Hospitals in large and other urban areas experience 2.9 percent and
3.0 percent increases, respectively. The lower increase for hospitals
in large urban areas appears to be attributable primarily to the 0.1
percent negative impact of the continuing phase-out of day outliers.
Hospitals in rural areas experience a 2.4 percent increase. Their
FY 1997 payments are estimated to be 0.4 percent higher than for FY
1996 due to higher outlier payments, in contrast to the national
average of 1.1 percent. 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 6 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 2.4 percent to 2.7 percent, with the exception of rural
hospitals with 200 or more beds. Payments per case for this group of
hospitals are estimated to increase 1.9 percent during FY 1997. This
below average increase appears to be attributable primarily to a
smaller, though still significant, impact of MGCRB reclassifications
for FY 1997 compared to FY 1996. In column 4, 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 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
census division, the impacts are a 1.0 percent reduction for urban
[[Page 46312]]
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 census division are largely offset by higher
estimated outlier payments in FY 1997 compared to FY 1996, the 0.4
percent higher payments due to the FY 1993 wage data (column 2), and
the 0.1 percent increase due to the phase-out of day outliers (column
5). Urban New England hospitals' higher outlier payments in FY 1997 are
also offset by the negative impacts of the expiration of the regional
floor. Rural New England hospitals also see a 0.9 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 East South
Central, and rural Puerto Rico. With the exception of the 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 (0.9 percent compared to 1.5 percent in FY
1996). A smaller FY 1997 reclassification impact (2.4 percent compared
to 3.7 percent in FY 1996) is also the reason for the relatively small
(1.9 percent) rate of increase in the rural East South Central census
division. In rural Puerto Rico, although hospitals experience the
greatest negative impact due to the updated wage data, this group
benefits from reclassifications by the MGCRB in FY 1997 (of the five
rural Puerto Rico hospitals, one is reclassified), with a 3.3 percent
increase compared to a 0.5 percent decrease in their FY 1996 payments
due to the reclassification budget neutrality factor.
Conversely, the urban Middle Atlantic, urban West North Central,
urban West South Central, and rural Pacific census divisions all have
overall increases 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 (1.5 percent). 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 0.7 percent decrease due to the phase-out of day outliers.
Rural Pacific hospitals benefit from geographic reclassification in FY
1997 (2.3 percent compared to 1.4 percent in FY 1996) and the new wage
data (0.5 percent).
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 a slight
payment increase over FY 1996 (0.6 percent), while the rural hospitals
lose 2.2 percent. On the other hand, hospitals reclassified for FY 1997
that were not reclassified for FY 1996 experience the greatest payment
increases: 10.2 percent for 69 rural hospitals in this category and 7.8
percent for 29 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 6. For example, among
hospital groups identified in the discussion of the impacts of MGCRB
reclassifications for FY 1997 (column 4), all have overall increases
above the national average. 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 2.8
percent. The average payment increase for all reclassified hospitals is
3.8 percent.
Among SCH/EACHs, the payment increase is 2.6 percent. 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 1.6 percent increase. This below average
increase is largely attributable to 123 hospitals in this category that
lost their reclassification status from FY 1996 to FY 1997.
Another notably small increase appearing in this column is the 0.3
percent increase for rural DSH hospitals with 100 or more beds. This
impact is primarily due to a number of hospitals in this category that
lost their MGCRB reclassification from FY 1996 to FY 1997, stemming
from the elimination of standardized amount reclassifications solely
for higher DSH payments.
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 per payment per All changes
case case
(1) (2) \1\ (3) \1\ (4)
----------------------------------------------------------------------------------------------------------------
(By Geographic Location)
----------------------------------------------------------------------------------------------------------------
All hospitals............................................... 5,129 6,478 6,664 2.9
Urban hospitals............................................. 2,881 7,013 7,218 2.9
Large urban areas........................................... 1,596 7,544 7,762 2.9
Other urban areas........................................... 1,285 6,313 6,502 3.0
Rural areas................................................. 2,248 4,297 4,400 2.4
Bed size (urban):
0-99 beds............................................... 715 4,705 4,832 2.7
100-199 beds............................................ 945 5,951 6,108 2.6
200-299 beds............................................ 576 6,527 6,715 2.9
300-499 beds............................................ 478 7,444 7,674 3.1
500 or more beds........................................ 167 9,147 9,426 3.1
Bed size (rural):
0-49 Beds............................................... 1,177 3,538 3,622 2.4
50-99 beds.............................................. 657 3,992 4,090 2.4
[[Page 46313]]
100-149 beds............................................ 241 4,462 4,579 2.6
150-199 beds............................................ 98 4,594 4,716 2.7
200 or more beds........................................ 75 5,417 5,518 1.9
Urban by census div.:
New England............................................. 160 7,525 7,672 2.0
Middle Atlantic......................................... 434 7,718 7,973 3.3
South Atlantic.......................................... 419 6,682 6,889 3.1
East North Central...................................... 483 6,735 6,905 2.5
East South Central...................................... 163 6,181 6,374 3.1
West North Central...................................... 193 6,645 6,866 3.3
West South Central...................................... 376 6,508 6,743 3.6
Mountain................................................ 127 6,766 6,962 2.9
Pacific................................................. 478 8,102 8,304 2.5
Puerto Rico............................................. 48 2,595 2,644 1.9
Rural by census div.:
New England............................................. 53 5,242 5,304 1.2
Middle Atlantic......................................... 85 4,691 4,769 1.7
South Atlantic.......................................... 297 4,473 4,578 2.3
East North Central...................................... 304 4,321 4,434 2.6
East South Central...................................... 278 3,969 4,045 1.9
West North Central...................................... 525 4,004 4,105 2.5
West South Central...................................... 349 3,845 3,952 2.8
Mountain................................................ 211 4,569 4,689 2.6
Pacific................................................. 141 5,307 5,505 3.7
Puerto Rico............................................. 5 2,038 2,073 1.7
----------------------------------------------------------------------------------------------------------------
(By Payment Categories)
----------------------------------------------------------------------------------------------------------------
Urban hospitals............................................. 2,981 6,968 7,174 2.9
Large urban areas........................................... 1,791 7,370 7,586 2.9
Other urban areas........................................... 1,190 6,317 6,504 3.0
Rural areas................................................. 2,148 4,263 4,358 2.2
Teaching status:
Non-teaching............................................ 4,044 5,288 5,437 2.8
Fewer than 100 Residents................................ 850 6,895 7,099 3.0
100 or More residents................................... 235 10,565 10,865 2.8
Disproportionate share hospitals (DSH):
Non-DSH................................................. 3,201 5,595 5,755 2.9
Urban DSH:
100 beds or more.................................... 1,410 7,614 7,834 2.9
Fewer than 100 beds................................. 101 4,806 4,911 2.2
Rural DSH:
Sole community (SCH)................................ 156 4,349 4,507 3.6
Referral centers (RRC).............................. 27 5,179 5,352 3.3
Other Rural DSH hosp.:
100 beds or more.................................... 83 4,198 4,211 0.3
Fewer than 100 beds................................. 151 3,432 3,500 2.0
Urban teaching and DSH:
Both teaching and DSH................................... 692 8,587 8,832 2.8
Teaching and no DSH..................................... 339 7,095 7,310 3.0
No teaching and DSH..................................... 819 6,126 6,309 3.0
No teaching and no DSH................................. 1,131 5,438 5,605 3.1
Rural hospital types:
Nonspecial status hospitals............................. 1,375 3,895 3,958 1.6
RRC..................................................... 90 5,076 5,246 3.4
SCH/Each................................................ 645 4,405 4,519 2.6
SCH/Each and RRC........................................ 38 5,213 5,352 2.7
Type of ownership:
Voluntary............................................... 2,951 6,629 6,823 2.9
Proprietary............................................. 696 5,948 6,120 2.9
Government.............................................. 1,366 6,040 6,195 2.6
Unknown................................................. 116 7,564 7,724 2.1
Medicare Utilization as a percent of Inpatient days:
0-25.................................................... 258 8,741 8,917 2.0
25-50................................................... 1,284 7,878 8,103 2.9
50-65................................................... 2,097 5,947 6,122 2.9
[[Page 46314]]
Over 65................................................. 1,374 5,055 5,204 2.9
Unknown................................................. 116 7,564 7,724 2.1
----------------------------------------------------------------------------------------------------------------
Hospitals Reclassified by the Medicare Geographic Review Board
----------------------------------------------------------------------------------------------------------------
Reclassification status during FY96 and FY97
Reclassified during both FY96 and FY97.................. 379 5,780 5,939 2.7
Urban............................................... 130 6,606 6,802 3.0
Rural............................................... 249 5,012 5,136 2.5
Reclassified during FY97 only........................... 98 6,132 6,642 8.3
Urban............................................... 29 7,307 7,860 7.6
Rural............................................... 69 4,369 4,815 10.2
Reclassified during FY96 only........................... 253 5,893 5,861 -0.5
Urban............................................... 91 7,497 7,543 0.6
Rural............................................... 162 4,503 4,403 -2.2
FY97 Reclassifications:
All reclassified hosp............................... 477 5,845 6,069 3.8
Stand. amt. only.................................... 119 5,753 5,914 2.8
Wage index only..................................... 272 5,665 5,854 3.3
Both................................................ 86 6,254 6,600 5.5
Nonreclass.......................................... 4,625 6,563 6,744 2.8
All urban reclass....................................... 159 6,760 7,035 4.1
Stand. amt. only.................................... 62 6,218 6,398 2.9
Wage index only..................................... 27 8,949 9,282 3.7
Both................................................ 70 6,446 6,777 5.1
Nonreclass.......................................... 2,722 7,031 7,231 2.9
All Rural Reclass....................................... 318 4,916 5,088 3.5
Stand. amt. only.................................... 57 4,622 4,737 2.5
Wage index only..................................... 245 4,977 5,136 3.2
Both................................................ 16 4,904 5,354 9.2
Nonreclass.......................................... 1,903 4,051 4,127 1.9
Other reclassifed:
Hospitals (Section 1886(d)(8)(B))....................... 27 4,620 4,743 2.7
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
Table II presents the projected impact of the final 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 6 of Table I.
VII. Impact of 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 June
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 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 several
ways. Specifically, 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
[[Page 46315]]
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 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 FY 1997 Actuarial 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 final 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 June 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 July 1, 1996 in the Provider-Specific file.
We used this data to determine the 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 1994, 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 1994. 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....................................................... -0.53
1996....................................................... 5.06
1997....................................................... 5.21
------------------------------------------------------------------------
The Medicare case-mix index will increase by 1.4 percent
in FY 1996 and 1.6 percent in 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 FY 1997
update factor is .7 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:
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 52 56
High Cost Hospital.......................................... 34 38 48 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
[[Page 46316]]
FY 1996 to FY 1997 using the above described actuarial model.
Table III.--Impact of Final 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.............................. 3,363 6,868,405 $411.84 54.85 $200.68 $15.75 $18.28 $646.55
Fully Prospective........................... 1,548 3,287,821 375.12 50.00 237.10 ........... 11.40 623.62
Rebase--Fully Prospective................... 1,483 2,743,898 371.61 50.00 218.24 ........... 27.88 617.74
Rebase--100% Federal Rate................... 228 643,922 793.64 100.00 ........... ........... 0.25 793.89
Rebase--Hold Harmless....................... 104 192,764 335.30 46.49 ........... 561.32 59.11 955.72
High Cost Hospitals............................. 1,741 4,288,642 668.50 86.23 ........... 145.12 19.59 833.21
100% Federal Rate........................... 1,135 3,010,570 785.30 100.00 ........... ........... 2.23 787.53
Hold Harmless............................... 606 1,278,072 393.38 52.33 ........... 486.95 60.48 940.81
Total Hospitals......................... 5,104 11,157,046 510.50 67.15 123.54 65.48 18.78 718.30
--------------------------------------------------------------------------------------------------------------------------------------------------------
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................. 3,363 7,056,653 $471.51 63.97 $157.25 $12.43 $40.25 $681.44 5.40
Fully Prospective.............. 1,548 3,377,933 441.20 60.00 185.78 ........... 30.53 657.51 5.43
Rebase--Fully Prospective...... 1,483 2,819,103 438.15 60.00 171.01 ........... 54.23 663.39 7.39
Rebase--100% Federal Rate...... 238 677,500 778.75 100.00 ........... ........... 2.63 781.38 -1.58
Rebase--Hold Harmless.......... 94 182,117 407.13 56.47 ........... 481.80 144.04 1,032.97 8.08
High Cost Hospitals................ 1,741 4,406,184 694.20 89.74 ........... 117.32 49.69 861.21 3.36
100% Federal Rate.............. 1,173 3,160,803 779.30 100.00 ........... ........... 11.40 790.70 0.40
Hold Harmless.................. 568 1,245,382 478.21 63.00 ........... 415.08 146.89 1,040.17 10.56
Total Hospitals............ 5,104 11,462,838 557.11 74.17 96.80 52.75 43.88 750.54 4.49
--------------------------------------------------------------------------------------------------------------------------------------------------------
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 27.50 percent increase in FY 1996 Medicare
capital payments over the FY 1995 payments. We estimate aggregate
Medicare capital payments will increase by 6.77 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 4.75 percent, and high capital cost hospitals will
experience an average increase of 2.86 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 52.33 percent
to 62.81 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 67.8 percent.)
We expect that the average hospital-specific rate payment per
discharge will decrease from $123.54 in FY 1996 to $96.10 in FY 1997.
This is partly due to the 4.32 percent decrease in the FY 1997
hospital-specific rate compared to FY 1996.
We proposed no changes in our exceptions policies for FY 1997. As a
result, the minimum payment levels will 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 2.61
percent of total capital payments in FY 1996 to 5.97 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.............................. 464 57
High Capital Cost............................. 348 43
-------------------------
Total......................................... 812 100
------------------------------------------------------------------------
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.
[[Page 46317]]
Table IV.--Distribution by Method of Payment (Hold-Harmless/Fully Prospective) of Hospitals Receiving Capital
Payments
----------------------------------------------------------------------------------------------------------------
(2) Hold-harmless
-------------------------- (3)
(1) Total Percentage Percentage
No. 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 15.3 34.8 49.9
Other urban areas (populations of 1 million or fewer)... 1,275 15.8 32.9 51.3
Rural areas............................................. 2,245 9.7 19.6 70.7
Urban hospitals......................................... 2,859 15.5 34.0 50.5
0-99 beds........................................... 697 16.4 27.4 56.2
100-199 beds........................................ 941 19.2 36.9 43.9
200-299 beds........................................ 576 14.4 36.6 49.0
300-499 beds........................................ 478 10.3 34.5 55.2
500 or more beds.................................... 167 10.2 34.1 55.7
Rural hospitals......................................... 2,245 9.7 19.6 70.7
0-49 beds........................................... 1,175 7.0 14.6 78.5
50-99 beds.......................................... 656 12.5 21.6 65.9
100-149 beds........................................ 241 13.7 30.7 55.6
150-199 beds........................................ 98 15.3 22.4 62.2
200 or more beds.................................... 75 8.0 41.3 50.7
By Region:
Urban by Region......................................... 2,859 15.5 34.0 50.5
New England......................................... 160 6.9 25.0 68.1
Middle Atlantic..................................... 434 10.1 29.7 60.1
South Atlantic...................................... 418 20.1 40.2 39.7
East North Central.................................. 480 9.6 30.0 60.4
East South Central.................................. 162 22.8 34.6 42.6
West North Central.................................. 190 18.4 27.4 54.2
West South Central.................................. 367 27.8 46.0 26.2
Mountain............................................ 126 15.9 42.1 42.1
Pacific............................................. 474 12.7 31.2 56.1
Puerto Rico......................................... 48 10.4 25.0 64.6
Rural by Region......................................... 2,245 9.7 19.6 70.7
New England......................................... 53 7.5 15.1 77.4
Middle Atlantic..................................... 84 10.7 15.5 73.8
South Atlantic...................................... 297 11.8 25.6 62.6
East North Central.................................. 304 10.2 11.8 78.0
East South Central.................................. 278 9.7 31.3 59.0
West North Central.................................. 525 7.0 15.2 77.7
West South Central.................................. 347 9.2 24.8 66.0
Mountain............................................ 211 12.3 15.2 72.5
Pacific............................................. 141 11.3 15.6 73.0
Large urban areas (populations over 1 million).......... 1,779 15.2 34.5 50.4
Other urban areas (populations over 1 million or fewer). 1,180 15.8 32.2 51.9
Rural areas............................................. 2,145 9.6 19.5 71.0
Teaching Status:
Non-teaching........................................ 4,019 13.5 26.6 59.8
Fewer than 100 Residents............................ 850 11.3 32.4 56.4
100 or more Residents............................... 235 9.4 27.7 63.0
Disproportionate share hospitals (DSH):
Non-DSH............................................. 3,178 12.3 24.0 63.7
Urban DSH:
100 or more beds................................ 1,409 15.4 36.1 48.5
Less than 100 beds.............................. 100 17.0 23.0 60.0
Rural DSH:
Sole Community (SCH/EACH)....................... 156 11.5 18.6 69.9
Referral Center (RRC/EACH)...................... 27 7.4 37.0 55.6
Other Rural:
100 or more beds............................ 83 8.4 45.8 45.8
Less than 100 beds.......................... 151 7.3 25.8 66.9
Urban teaching and DSH:
Both teaching and DSH............................... 692 11.1 32.2 56.6
Teaching and no DSH................................. 339 11.2 29.8 59.0
No teaching and DSH................................. 817 19.2 37.7 43.1
No teaching and no DSH.............................. 1,111 16.7 32.5 50.9
Rural Hospital Types:
Non special status hospitals........................ 1,372 7.7 19.5 72.8
RRC/EACH............................................ 90 10.0 34.4 55.6
SCH/EACH............................................ 645 13.3 17.2 69.5
[[Page 46318]]
SCH, RRC and EACH................................... 38 13.2 21.1 65.8
Type of Ownership:
Voluntary........................................... 2,951 12.3 27.6 60.1
Proprietary......................................... 696 23.4 46.7 29.9
Government.......................................... 1,366 8.7 17.6 73.7
Medicare Utilization as a Percent of Inpatient Days:
0-25................................................ 258 15.1 25.2 59.7
25-50............................................... 1,284 14.5 33.4 52.1
50-65............................................... 2,097 12.9 28.0 59.1
Over 65............................................. 1,374 10.8 21.6 67.5
----------------------------------------------------------------------------------------------------------------
As we explain in Appendix B, we were not able to determine a
hospital-specific rate for 25 of the 5,129 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
27.5 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 (70.7 percent and 73.7 percent,
respectively by payment classification) are being paid under the fully
prospective methodology. This is a reflection of their lower than
average capital costs per case. In contrast, only 29.9 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 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 July
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 4.99
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 3.9 percent in FY 1997. The results
show that the effect of the Federal rate changes alone is to decrease
payments by 1.3 percent. The decrease attributable to the Federal rate
changes is more than offset by a 5.2 percent increase attributable to
the effects of all other changes.
Our comparison by geographic location shows that overall, urban
hospitals will gain slightly less than rural hospitals from the final
rule changes (increases of 3.8 percent and 4.7 percent, respectively).
Payments per case for urban hospitals will decrease at about the same
rate as payments per case for rural hospitals (1.2 percent and 1.7
percent, respectively) from the Federal rate changes alone. Urban
hospitals will gain slightly less than rural hospitals (5.0 percent
compared to 6.4 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. Changes by region vary from a low of 2.1
percent increase (rural hospitals of the West South Central region) to
a high of 15.2 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, -1.5 percent due to Federal
rate changes and a 6.6 percent positive offset from the effects of all
other changes). Payments to voluntary hospitals will increase 3.8
percent (a 1.3 percent decrease due to Federal rate changes and a 5.1
percent
[[Page 46319]]
positive offset from the effects of all other changes) and payments to
proprietary hospitals will increase 3.4 percent (a 0.9 percent decrease
due to Federal rate changes and a 4.3 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 for FY 1997 as a whole are projected to
experience a 4.5 percent increase in payments (a 0.8 percent decrease
attributable to Federal rate changes and a 5.3 percent positive offset
attributable to the effects of all other changes). Payments to
nonreclassified hospitals will increase slightly less (3.9 percent)
than reclassified hospitals (4.5 percent). Payments to nonreclassified
hospitals will decrease slightly more than reclassified hospitals from
the Federal rate changes (1.3 percent compared to 0.8 percent), but
they will gain about the same from the effects of all other changes
(5.2 percent compared to 5.3 percent).
Table V.--Comparison Of Total Payments Per Case
[FY 1996 Payments Compared to FY 1997 Payments]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY Portion
Number of 1996 1997 attibutable
hospitals payments/ payments/ All changes to federal
case case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals.............................. 5,104 718 746 3.9 -1.3
Large urban areas (populations over 1
million).................................. 1,584 823 852 3.6 -1.2
Other urban areas (populations of 1 million
of fewer)................................. 1,275 715 745 4.1 -1.1
Rural areas................................ 2,245 478 501 4.7 -1.7
Urban hospitals............................ 2,859 776 806 3.8 -1.2
0-99 beds.............................. 697 566 589 4.0 -1.3
100-199 beds........................... 941 705 732 3.7 -1.3
200-299 beds........................... 576 744 774 4.0 -1.3
300-499 beds........................... 478 801 830 3.7 -1.2
500 or more beds....................... 167 944 980 3.8 -0.9
Rural hospitals............................ 2,245 478 501 4.7 -1.7
0-49 beds.............................. 1,175 367 385 5.0 -2.0
50-99 beds............................. 656 447 468 4.8 -1.6
100-149 beds........................... 241 511 532 4.2 -1.7
150-199 beds........................... 98 511 540 5.6 -1.4
200 or more beds....................... 75 612 638 4.3 -2.0
By Region:
Urban by Region............................ 2,859 776 806 3.8 -1.2
New England............................ 160 784 817 4.3 -1.9
Middle Atlantic........................ 434 813 848 4.2 -1.2
South Atlantic......................... 418 780 814 4.3 -1.1
East North Central..................... 480 727 749 3.1 -1.2
East South Central..................... 162 707 733 3.7 -0.8
West North Central..................... 190 772 809 4.8 -1.0
West South Central..................... 367 796 823 3.4 -0.4
Mountain............................... 126 775 797 2.7 -1.5
Pacific................................ 474 855 883 3.3 -1.7
Puerto Rico............................ 48 305 326 6.8 -0.4
Rural by Region............................ 2,245 478 501 4.7 -1.7
New England............................ 53 606 698 15.2 -2.3
Middle Atlantic........................ 84 497 525 5.6 -2.7
South Atlantic......................... 297 498 511 2.8 -2.0
East North Central..................... 304 482 510 5.9 -1.3
East South Central..................... 278 446 463 3.8 -1.8
West North Central..................... 525 454 477 5.2 -1.7
West South Central..................... 347 440 449 2.1 -1.3
Mountain............................... 211 504 534 6.1 -0.8
Pacific................................ 141 555 587 5.9 -1.3
By Payment Classification:
All hospitals.............................. 5,104 718 746 3.9 -1.3
Large urban areas (populations over 1
million).................................. 1,779 807 836 3.6 -1.2
Other urban areas (populations of 1 million
of fewer)................................. 1,180 715 746 4.2 -1.1
Rural areas................................ 2,145 472 494 4.7 -1.8
[[Page 46320]]
Teaching Status:
Non-teaching........................... 4,019 622 645 3.8 -1.3
Fewer than 100 Residents............... 850 757 787 3.9 -1.2
100 or more Residents.................. 235 1,034 1,079 4.3 -1.2
Urban DSH:
100 or more beds................... 1,409 813 843 3.7 -1.2
Less than 100 beds................. 100 576 607 5.4 -1.2
Rural DSH:
Sole Community (SCH/EACH).......... 156 449 486 8.1 -1.5
Referral Center (RRC/EACH)......... 27 533 541 1.5 -1.0
Other Rural:
100 or more beds............... 83 488 504 3.3 -2.5
Less than 100 beds............. 151 367 379 3.3 -2.2
Urban teaching and DSH:
Both teaching and DSH.................. 692 879 911 3.6 -1.2
Teaching and no DHS.................... 339 786 821 4.5 -1.1
No teaching and DSH........................ 817 710 737 3.9 -1.2
No teaching and no DSH..................... 1,111 673 697 3.6 -1.1
Rural Hospital Types:
Non special status hospitals............... 1,372 439 458 4.2 -2.2
RRC/EACH................................... 90 559 573 2.6 -1.1
SCH/EACH................................... 645 470 502 6.8 -1.6
SCH, RRC and EACH.......................... 38 582 6.5 5.7 -1.4
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY96 and
FY97:
Reclassified During Both FY96 and FY97. 379 662 685 3.5 -1.5
Reclassified During FY97 Only.............. 98 673 732 8.7 2.0
Reclassified During FY96 Only.............. 230 652 661 1.4 -3.9
FY 97 Reclassifications:
All Reclassified Hospitals............. 477 664 694 4.5 -0.8
All Nonreclassified Hospitals.......... 4,600 726 754 3.9 -1.3
All Urban Reclassified Hospitals....... 159 756 782 3.5 -1.0
Urban Nonreclassified Hospitals........ 2,700 778 808 3.8 -1.2
All Reclassified Rural Hospitals....... 318 570 604 5.9 -0.7
Rural Nonreclassified Hospitals........ 1,900 442 460 4.1 -2.2
Other Reclassified Hospitals (Section 1886
(D)(8)(B))................................ 27 541 561 3.7 -1.8
Type of Ownership:
Voluntary.................................. 2,951 731 760 3.8 -1.3
Proprietary................................ 696 751 777 3.4 -0.9
Government................................. 1,366 625 657 5.1 -1.5
Medicare Utilization as a Percent of Inpatient
Days:
0-25....................................... 258 797 830 4.1 -2.0
25-50...................................... 1,284 843 875 3.9 -1.2
50-60...................................... 2,097 676 703 4.0 -1.2
Over 65.................................... 1,374 603 627 4.0 -1.3
----------------------------------------------------------------------------------------------------------------
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 June 30, 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 July 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
[[Page 46321]]
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................................ 99
Provider-Specific and Audit File........................... 5029
Other...................................................... 1
------------
Total................................................ 5129
------------------------------------------------------------------------
Sixty-six of these hospitals had unusable or missing data. We were
able to backfill a hospital-specific rate for 41 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........................................ 28
------------
Total................................................ 41
------------------------------------------------------------------------
We did not have data for 25 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, 5,064 PPS-X cost
reports, and 4,924 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 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 depreciated
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
[[Page 46322]]
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 final 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, that is, approximately 1.6 percent. Thus, it appears
that the deceleration of case-mix increases in FY 1993 and FY 1994 were
anamolous, 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.
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 0.9987 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 1.0012 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 final 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, FY 1996 and FY 1997, 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 1.0012 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:
[[Page 46323]]
----------------------------------------------------------------------------------------------------------------
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........................................................ 0.70 .9358 N/A \5\ 438.92
1998........................................................ 1.20 .9121 N/A 432.94
1999........................................................ 1.20 .9206 N/A 442.22
2000........................................................ 1.30 9148 N/A 445.15
2001........................................................ 1.30 \6\ N/A N/A 492.93
----------------------------------------------------------------------------------------------------------------
\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 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 1.0012 and the change in the outlier adjustment from 0.9536
in FY 1996 to 0.9481 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.
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 final rule, we
are rebasing and revising the hospital market baskets. This appendix
describes the technical features of the 1992-based indexes that we are
implementing in this rule. For both the prospective payment and
excluded hospital market baskets, the differences between the 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 1992-based operating hospital market baskets.
The 1992-based 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 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 average
length of stay of Medicare patients in the hospital is within 15
percent of the average length of stay of all patients in the hospital
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. As of this writing the Department of Commerce has
not released final 1992 cost data. Therefore we plan to incorporate
these data into the FY 1998 proposed rule.
Below, we describe the source of the six main category weights and
their subcategories in the 1992-based market
[[Page 46324]]
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 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.
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
[[Page 46325]]
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.
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 final rule, we discuss the rebasing of the
capital input price index (CIPI). This appendix describes certain
technical features of the 1992-based index, as well as differences
between the 1992-based CIPI and the 1987-based CIPI. We discussed
[[Page 46326]]
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 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. 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 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.
6. 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.
a. 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.
b. 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.
c. 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
[[Page 46327]]
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).
Appendix D: 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
updating 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 second quarter 1996 forecast of the FY 1997 rebased market
basket increase of 2.5 percent for hospitals subject to the prospective
payment system, the updates in the standardized amounts are 2.0 percent
for hospitals in both large urban and other areas. The update in the
hospital-specific rate applicable to sole community hospitals is 2.0
percent (that is, the market basket rate of increase of 2.5 percent
minus 0.5 percentage points). The update for hospitals excluded from
the prospective payment system is based on the percentage increase in
the excluded hospital market basket (currently estimated at 2.5
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 update can vary between 1.5 and 2.5 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 of each year 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.
Section 1886(e)(4) of the Act requires that the Secretary, taking
into 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 published the FY 1996 update factors
recommended under section 1886(e)(4) of the Act as Appendix E of the
May 31, 1996 final rule (61 FR 27591).
II. Secretary's Final Recommendation for Updating the Prospective
Payment System Standardized Amounts
We did not receive any public comments concerning our proposed
recommendation. Therefore, our final recommendation will be the same as
our proposed recommendation. That is, 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 budget
recommendation.
In recommending these increases, we have followed section
1886(e)(4) of the Act, which requires that we take into account the
amounts necessary for the efficient and effective delivery of medically
appropriate and necessary care of high quality. In addition, as
required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of ProPAC. We believe our analyses,
which measure changes in hospital productivity, scientific and
technological advances, practice pattern changes, and changes in case
mix, support our recommendations. 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, our final recommendation is based on the most recent
forecast of the rebased market basket. (See section IV of the
[[Page 46328]]
preamble to this final rule for a detailed discussion of the market
basket.)
III. Secretary's Final Recommendation for Updating the Rate-of-Increase
Limits for Excluded Hospitals and Units
Our final recommendation is that hospitals and hospital units
excluded from the prospective payment system receive an update equal to
percentage increase in the rebased market basket that measures input
price increases for services furnished by excluded hospitals minus 1.5
percentage points. Thus, given the current estimate of the change in
the market basket rate of increase for excluded hospitals of 2.5
percent (compared with the earlier estimate of 2.7 percent used in the
proposed rule), our final recommendation is for an update of 1.0
percent. This recommendation is consistent with the President's budget,
acknowledging that the market basket rate of increase for these
hospitals was forecast at 3.6 percent at the time the budget was
submitted.
[FR Doc. 96-22145 Filed 8-28-96; 8:45 am]
BILLING CODE 4120-03-P