[Federal Register Volume 62, Number 60 (Friday, March 28, 1997)]
[Proposed Rules]
[Pages 14851-14878]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-7477]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Part 413
[BPD-808-P]
RIN 0938-AG70
Medicare and Medicaid Programs; Salary Equivalency Guidelines for
Physical Therapy, Respiratory Therapy, Speech Language Pathology, and
Occupational Therapy Services
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule sets forth proposed revisions to the salary
equivalency guidelines for Medicare payment for the reasonable costs of
physical therapy and respiratory therapy services furnished under
arrangements by an outside contractor. The proposed rule also sets
forth proposed new salary equivalency guidelines for Medicare payment
for the reasonable costs of speech language pathology and occupational
therapy services furnished under arrangements by an outside contractor.
The proposed guidelines do not apply to inpatient hospital services and
hospice services. The guidelines would be used by Medicare fiscal
intermediaries to determine the maximum allowable cost of those
services.
The guidelines will not be effective until at least 60 days after
the date of publication of the final rule. However, to illustrate how
the schedules would operate, we have calculated the proposed revised
schedules for physical respiratory therapy services and proposed new
schedules for speech-language pathology and occupational therapy
services as if the guidelines were effective on April 1, 1997.
DATES: Comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on May 27,
1997.
ADDRESSES: Mail written comments (one original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPD-808-P, PO. Box 7517,
Baltimore, MD 21244-0517.
If you prefer, you may deliver your written comments (one original
and three copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW,
Washington, DC 20201, or
Room C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission.
If comments concern information collection or recordkeeping
requirements, please address a copy of comments to the following
address: Office of Management and Budget, Office of Information and
Regulatory Affairs, Room 3206, New Executive Office Building,
Washington, DC 20503, Attention: Allison Herron Eydt.
In commenting, please refer to file code BPD-808-P. Comments
received timely will be available for public inspection as they are
received, generally beginning approximately 3 weeks after publication
of a document, in Room 309-G of the Department's offices at 200
Independence Avenue, SW, Washington, DC, on Monday
[[Page 14852]]
through Friday of each week from 8:30 a.m. to 5 p.m. (phone: (202) 690-
7890).
Comments may also be submitted electronically to the following e-
mail address: [email protected]. E-mail comments must include the
full name and address of the sender and must be submitted to the
referenced address in order to be considered. All comments must be
incorporated in the e-mail message because we may not be able to access
attachments. Electronically submitted comments will be available for
public inspection at the Independence Avenue address below.
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, PO. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $8.00. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
FOR FURTHER INFORMATION CONTACT: Jackie Gordon, (410) 786-4517.
SUPPLEMENTARY INFORMATION:
I. Background
Section 1861(v)(5) of the Social Security Act (the Act) requires
the Secretary to determine the reasonable cost of services furnished to
Medicare beneficiaries ``under an arrangement'' with a provider of
services, by therapists or other health-related personnel. The Health
Care Financing Administration (HCFA) pays the provider directly for
these services, rather than paying the therapist or supplying
organization. Under section 1861(w)(1) of the Act, this payment
discharges the beneficiary from liability to pay for the services.
Section 1861(v)(5) of the Act also specifies that the reasonable costs
for these services may not exceed an amount equal to the salary that
would reasonably have been paid for the services (together with any
additional costs that would have been incurred by the provider or other
organization) to the person performing them if they had been performed
in an employment relationship with a provider or other organization
(rather than under such arrangement), plus allowances for certain
expenses that may be incurred by the contracting therapy organization
in furnishing the services as the Secretary in regulations determines
to be appropriate.
These statutory requirements are implemented in existing
regulations at 42 CFR 413.106. The regulations apply to the services of
physical, occupational, speech, and other therapists and services of
other health specialists (other than physicians) furnished under
arrangements with a provider of services, a clinic, a rehabilitation
agency, or a public health agency. The regulations provide for:
Hourly salary equivalency amounts comprised of:
--A prevailing hourly salary rate based on the 75th percentile of the
range of salaries paid to full-time employee therapists by providers in
the geographic area, by type of therapy.
--Fringe benefit and expense factors to take into account fringe
benefits generally received by an employee therapist, as well as
expenses (such as maintaining an office, insurance, etc.) that a
therapist or therapist organization might incur in furnishing services
under arrangements.
A standard travel allowance to recognize time spent in
traveling to the provider's site or the patient's home.
As provided for in existing regulations at Sec. 413.106(e)
and explained in section 1412 of the Provider Reimbursement Manual, the
following are additional allowances for costs incurred for services
furnished by an outside supplier. In addition to the guidelines
established for the adjusted hourly salary equivalency amount and the
travel allowance, the following costs incurred for services furnished
by an outside supplier are recognized, provided the services are
properly documented as having been received by the provider.
--Overtime, if an outside supplier utilizes the services of its
employees (including the services of aides and assistants) at an
individual provider in excess of the provider's standard workweek;
--Administrative and supervisory duties, if an outside supplier
provides more than one therapist and at least one therapist spends more
than 20 percent of his or her time supervising other therapists and
performing administrative duties;
--Depreciable or leased equipment, including maintenance costs of
equipment remaining at the provider's site, that the outside supplier
uses in furnishing direct services to the provider's patients (may also
include equipment that is transported from one provider site to another
but excludes equipment owned by the provider);
--Supplies furnished by the supplier for direct patient care (e.g.,
gases and sprays for respiratory therapy), excluding items such as
envelopes, stamps, and typewriters that are reimbursed as overhead
expenses and included in the fringe benefit and expense factor;
--Travel expenses, based on 10 times the General Services
Administration mileage rate for each day an outside supplier travels to
a provider site;
--Aides, who are paid as an add-on based on the wage rate of a
comparable employee, such as a nurse's aide (all therapy types use
aides); (Because we have received several inquiries regarding
continuing to use wages of providers'' nurses aides as the basis for
comparison, we welcome comments on other methods for determining
guidelines for aides.)
--Assistants, who are paid as a function of the hourly salary
equivalency amount at 75 percent of these amounts. (All therapy types
use assistants except respiratory therapists.)
The provider must supply the intermediary with documentation that
supports these additional costs to the intermediary's satisfaction.
These are the only additional costs that will be recognized.
The regulations at 42 CFR 431.106 (b)(5) and (c) also provide for
an exemption for limited part-time or intermittent services if the
provider required the services of an outside supplier for a particular
type of therapy service and the total hours of services performed for
the provider, by type of service, average less than 15 hours per week
for those weeks in the cost reporting period during which services were
furnished by nonemployee therapists. (Travel time is not counted in the
computation, even if the actual time is used.) If a provider qualifies
for this exemption, the reasonable cost of such services is evaluated
on a reasonable rate per unit of service basis, except that payment for
these services in the aggregate, during the cost reporting period, may
not exceed the amount that would be allowable had the provider
purchased these services on a regular part-time basis for an average of
15 hours per week for the number of weeks in which services were
furnished. Where the contract provides for a method of payment other
than rate per unit of service (e.g., hourly rate or percentage of
charges), payment cannot
[[Page 14853]]
exceed the guideline adjusted hourly amounts plus other allowable
costs, even though the services are performed on a limited or
intermittent part-time basis.
In addition, the regulations at Sec. 413.106(f)(1) currently
provide for an exception because of a binding contract. An exception
may be granted to a provider that entered into a written binding
contract with a therapist or contracting organization prior to the date
the initial guidelines are published for a particular type of therapy.
This exception would not apply to physical and respiratory therapy
services furnished under arrangements because we have previously
published initial guidelines for these services. Before the exception
may be granted, however, the provider must submit the contract to its
intermediary, subject to review and approval by the HCFA regional
office. This exception may be granted for the contract period, but no
longer than 1 year from the date the guidelines for the particular
therapy are published. During the period in which a binding contract
exception is in effect, the cost of the services will be evaluated
under the prudent buyer concept. (Section 1414.1 of the Provider
Reimbursement Manual contains instructions on this exception.) This
exception does not apply to providers who enter into a contingency
contract with a therapist or contracting organization or another
provider. In a contingency contract, the provider and contractor agree
that if Medicare does not reimburse the provider for the rate that the
contract is set at the provider and contractor agree that the
contractor will make up the difference. We do not consider a
contingency contract a binding contract.
Also, the regulations at Sec. 413.106(f)(2) provide for an
exception for unique circumstances or special labor market conditions.
An exception may be granted when a provider demonstrates that the costs
for therapy services established by the guidelines are inappropriate to
a particular provider because of some unique circumstances or special
labor market conditions in the area. As explained in section 1414.2 of
the Provider Reimbursement Manual, exceptions will be granted only in
extraordinary circumstances. Before the exception may be granted, the
provider must submit appropriate evidence to its intermediary to
substantiate its claim. The provider's request for an exception,
together with substantiating documentation, must be submitted to the
intermediary each year, no later than 150 days after the close of the
provider's cost reporting period. Because providers had been required
to submit cost reports to intermediaries no later than 90 days after
the close of their cost reporting periods, we had required that the
provider's request for an exception, together with substantiating
documentation, also be submitted to the intermediary no later than 90
days after the close of its cost reporting period. On June 27, 1995 (60
FR 33137), we changed the due date for submission of cost reports to
150 days after the close of the provider's cost reporting period.
Accordingly, as explained under Section II.F. of this preamble, we are
proposing to revise the time period for a provider's request for an
exception, together with substantiating documentation, to 150 days
after the close of its cost reporting period. If the circumstances
giving rise to the exception remain unchanged from a prior cost
reporting period, however, the provider need only submit evidence to
the intermediary 150 days after the close of its cost reporting period
to establish that fact.
In order to establish an exception for unique circumstances, the
provider must submit evidence to establish that it has some unique
method of delivering therapy or other services, which affects its
costs, that is different from the other providers in the area. The
exception will be effective no earlier than the onset of the unique
circumstances.
In order to substantiate an exception for special labor market
conditions, the provider must submit evidence enabling the intermediary
to establish that the going rate in the area for a particular type of
service is higher than the guideline limit and that such services are
unavailable at the guideline amounts. It is the duty of the provider to
prove to the satisfaction of the intermediary that it has reasonably
exhausted all possible sources of this service without success.
The intermediary collects information on the rates that other
providers in the area generally pay therapists or other health care
specialists. Once this information is collected, the intermediary will
determine whether other providers in the area, in comparison to the
provider requesting the exception, generally pay therapists or other
health care specialists higher rates than the guideline amounts. (As
discussed in section II.F.3. of this notice, we specifically invite
comments on the exception process.)
Under Sec. 413.106(b)(6), HCFA issues guidelines establishing the
hourly salary equivalency amounts in geographical areas for therapy
services furnished to Medicare beneficiaries under arrangements. These
guidelines apply only to the amount of payment the Medicare program
makes to a provider for therapy services obtained under arrangements.
The guidelines are not intended to dictate or otherwise interfere in
the terms of a contract that a provider may wish to enter into with a
therapist or therapist organization. The guidelines do not apply to
services furnished by employees of a hospital or employees of other
providers. There is also an exception to the guidelines for inpatient
hospital services provided by hospitals paid under the prospective
payment system or subject to rate of increase limits
(Sec. 413.106(f)(4), in which case the services are evaluated under the
Medicare program's reasonable cost provisions as described at
Sec. 413.5). However, as explained under section II.F. of this
preamble, we are proposing regulations that would provide that the
salary equivalency guidelines will apply in situations where
compensation, at least in part, to a therapist employed by the provider
is based on a fee-for-service or on a percentage of income (or
commission). The entire compensation would be subject to the guidelines
in cases where the nature of the arrangements are most like an under
``arrangement'' situation, although technically the provider may treat
the therapists as employees. The guidelines would be applied in this
situation so that an employment relationship is not being used to
circumvent the guidelines. The guidelines would apply to skilled
nursing facilities (SNFs) providing therapy services under arrangements
that elect prospective payment under section 1888(d) of the Act because
that prospective payment system only applies to routine and capital
services and does not apply to ancillary services which include therapy
services.
Section 413.106(d) provides that, prior to the beginning of a
period to which a guideline will be applied, HCFA will publish a notice
in the Federal Register establishing the guideline amounts to be
applied to each geographical area by type of therapy. We have issued
schedules of salary equivalency guidelines for the reasonable costs of
physical therapy services since 1975, and for respiratory therapy
services since 1978. On September 30, 1983, we published a final notice
(48 FR 44922) that revised the methodology used to establish the
schedules, as well as the guidelines themselves. The guidelines
continue to apply to physical therapy and respiratory therapy services
provided under arrangements, as set forth in Sec. 413.106, with
hospitals, home health agencies (HHAs), SNFs, hospital-based HHAs,
hospital-based SNFs,
[[Page 14854]]
comprehensive outpatient rehabilitation facilities (CORFs), and
outpatient rehabilitation providers (ORPs). (Since we are now proposing
to issue guidelines for occupational therapists, the guidelines will
also apply to community mental health centers that provide occupational
therapy services furnished under arrangements.)
The September 30, 1983 final notice provided that, for providers
with cost reporting periods beginning after October 1, 1982, the
published guidelines would be revised upward by the projected 0.6
percent monthly inflation rate, not compounded. It also provided that,
if for any reason we did not publish a new schedule of guidelines to be
effective for cost reporting periods beginning on or after October 1,
1983 or did not announce other changes in the existing schedule, the
existing guidelines would remain in effect, increased by the projected
0.6 percent monthly inflation rate, not compounded, until a new
schedule of guidelines was issued. This monthly inflation rate was
based on a Data Resources Incorporated (DRI) forecast of the annual
rate of increase in each component of the salary equivalency amounts
(that is, salary, fringe benefits, rent, and other expenses), with each
component weighted to form a composite rate of increase for the 12-
month period ending March 31, 1984.
Since the last schedules of guidelines were issued in 1983, we have
received periodic comments on the methodology used to develop the
guidelines. Some of the issues raised in these comments concerned
limitations in the data available to us on therapists' salaries and
other expenses incurred in furnishing services under arrangements with
providers. We have received comments that payments for therapy services
performed in different provider settings and in urban and rural areas
differ and that the guidelines should reflect those differences. Other
commenters have expressed concern that the factors used to update the
fringe benefits and expense factors are not adequate. In addition, some
commenters raised concerns about more technical aspects of the
methodology, such as the method used to update the salary equivalency
amounts to account for inflation. We address all these concerns in this
proposed rule.
We have never issued schedules of salary equivalency guidelines for
speech language pathology and occupational therapy services provided
under arrangements even though section 1861(v)(5) of the Act explicitly
authorizes the Secretary to do so. Currently, payment for these
services is based on reasonable cost. However, we are aware that
without introducing guidelines for contracted speech-language pathology
and occupational therapy services, the Medicare program could be paying
for costs that are unreasonable and in excess of what Congress intended
under section 1861(v)(5) of the Act. In fact, as evidence of this, the
General Accounting Office (GAO) Report, ``Medicare: Tighter Rules
Needed to Curtail Overcharges for Therapy In Nursing Homes'' (GAO/HEHS-
95-23, March 1995) also found that nursing homes may be claiming
substantial amounts of unallowable or unreasonable costs, or both, for
therapy services provided to Medicare beneficiaries. The GAO
recommended ways that HCFA could curb Medicare losses on payments for
rehabilitation therapies provided to nursing home residents. GAO
concluded that, without salary equivalency guidelines for all therapy
services provided under arrangements to nursing homes, Medicare has
little control over payments to providers. In response to GAO's
recommendations, we indicated that, until guidelines were developed for
all therapy services, providers' therapy costs were subject to the test
of reasonableness as required by regulations at 42 CFR 413.9. We also
indicated that we were working on developing revised salary equivalency
guidelines for physical therapy and respiratory services and developing
guidelines for speech-language pathology and occupational therapy
services.
II. Provisions of the Proposed Rule
In this proposed rule, we would revise the methodology for
establishing the schedules for the maximum payment for physical therapy
and respiratory therapy services. We propose to revise the
determination of reasonable cost for physical therapy and respiratory
therapy furnished under arrangements by an outside contractor by
rebasing the guideline amounts.
We also propose to establish salary equivalency guidelines for
speech language pathology and occupational therapy services furnished
under arrangements by an outside contractor using the same methodology
we propose to use for determining reasonable cost for physical therapy
and respiratory therapy services.
In addition, we are proposing to: (1) Eliminate the exception to
the salary equivalency guidelines for a provider that entered into a
written binding contract with a therapist or contracting organization
prior to the date the initial guidelines are published; (2) apply the
salary equivalency guidelines in situations where compensation, at
least in part, to a therapist employed by the provider is based on a
fee-for-service or on a percentage of income (or commission). (Section
II.F. of this preamble contains a detailed discussion of these
proposals and other proposals we're seeking comments on.)
A. Data Sources for Schedules
In all previously issued salary equivalency guideline notices, we
have used the Bureau of Labor Statistics (BLS) hospital and nursing
home industry wage survey data as our sole source in accordance with
the Senate Committee on Finance recommendation (S. Rept. No. 1230, 92nd
Cong., 2nd Sess. 251 (1972)). Specifically, the Committee recommended
that, to the extent feasible, timely and accurate salary data compiled
by BLS on the 75th percentile of salaries should be used in determining
the prevailing salary amounts. However, in this proposed rule we have
decided not to use the BLS data as our sole, or even as our primary
source for developing the guidelines. We have a number of reasons for
this decision.
First, BLS issued its last hospital industry wage surveys in 1989
and 1991 and has discontinued conducting its survey of hospital wages.
Accordingly, even if we had chosen to use BLS survey data as our
primary source for this proposed rule, we would have needed to
investigate other therapy survey data sources for use in future
guidelines. In addition, although, the BLS survey data continue to meet
the rigorous publication standards of BLS and provide the only national
data that we are aware of for wages by occupation that are
statistically reliable, questions have been raised as to whether the
BLS data meet the Senate Committee on Finance's recommendation on
timeliness. We have taken this concern into consideration in this
proposed rule. Furthermore, the BLS hospital industry wage surveys of
1989 and 1991 include only hospital data. (The last BLS nursing home
industry wage survey was performed in 1985.) We believe it is
reasonable to include data on combined hospital and SNF wages in the
determination of the guidelines as was done previously because therapy
wage levels are primarily determined in occupational labor markets, not
industry labor markets. (We also needed to review the SNF therapy data
so that we could determine the wage levels in SNFs holding all other
factors (including local labor market conditions and working
conditions) constant.
[[Page 14855]]
For the above reasons we determined that we would not use the BLS
survey as the sole source of data for determining the guidelines. We,
therefore, decided to seek other survey data sources of hospital and
SNF industry specific occupational wage information. Regulations at 42
CFR 413.106(b)(6) provide that the guidelines may be derived from other
statistically valid survey data, in lieu of HCFA guidelines, provided
that the study designs, questionnaires, and instructions, as well as
the resultant survey data, are submitted to and approved in advance by
HCFA. Beginning in 1994, we solicited the therapy industry for such
statistically valid survey data. The therapy industry had long held
that nursing home wages for therapists were higher than hospital wages
for therapists because it was more difficult to hire and retain
therapists in nursing homes. However, other individuals with experience
in the therapy industry have indicated that some therapists prefer
working in nursing homes for the following reasons: Preference for
working with elderly; location of SNF closer to home; more
opportunities for physical therapy work in SNF; and working flexible
hours. The therapy industry initially provided us data in 1995, but
after our analysis we found the data to be inadequate for use at the
regional or national level for several reasons: The sample was not
representative; the data were not documented or audited; and primarily
large firms paid under contract to the SNF were surveyed.
In March 1996, the National Association for the Support of Long
Term Care (NASL), representing portions of the therapy industry,
submitted an October 1995 sample survey of salaried therapists in
hospitals and nursing homes to HCFA, as allowed under our regulations.
This survey did not meet the requirements of the regulations at
Sec. 413.106(b)(6), since the survey design, questionnaires, and
instructions were not approved by HCFA prior to the start of the
survey. Nevertheless, the survey did provide data that were current in
SNFs and hospitals. We, therefore, conducted a special analysis of this
NASL survey data, including a limited audit of the survey records.
Based on this analysis and limited audit, we determined that the survey
was not adequate as a sole or primary source of data in determining the
guidelines, but could be useful in combination with other data sources.
There were several reasons for this determination:
The data were not audited or certified by an independent
party. We were permitted to conduct an audit of the survey records only
under stringent restrictions designed to protect the confidentiality of
the survey respondents. Those restrictions made it impossible for us to
verify the survey results. For example, we were unable to compare
submitted survey data with data from other sources.
The verification survey, conducted to determine the
reliability of data submitted by mail, did not appear to be adequate.
Only five providers were included in the verification survey.
Specifically, we were not satisfied that the verification sample was
either sufficiently large or adequately representative.
The survey is not sufficiently representative. There were
variable response rates for hospitals and SNFs. The response rate for
hospitals was 10.8 percent and the response rate for SNFs was 29.9
percent. In addition, the sample seemed to include an
overrepresentation of large hospitals and chain-affiliated SNFs.
Because there is an underrepresentation of small hospitals and non-
chain SNFs in the NASL survey, we cannot be assured with this small
response rate that the large hospitals and chain-affiliated SNFs will
adequately represent the small hospitals and non-chain SNFs not
included in the survey. (The GAO stated in its report, ``Medicare Early
Resolution of Overcharges for Therapy in Nursing Homes is Unlikely'',
August 16, 1996, p. 7, regarding the NASL survey data, ``However, the
survey response rate was low (10 percent for hospitals and 30 percent
for SNFs), which raises questions about how representative the data
are.'' In a footnote on that page, GAO points out, ``Official
government surveys generate a much higher response rate. The BLS White
Collar Pay Survey (one component of which was the hospital salary data
survey on which the draft guidelines were based) had an overall
response rate of 82 percent. Typically, BLS response rates exceed 80
percent).''
Despite requests for the raw unedited data file, the file
was not provided to us.
We have questions about the validity of certain edits.
We were also concerned that supervisory time and
compensation in lieu of benefits were not consistently reported.
Additionally, we were concerned that the supervisory time included in
the NASL survey was above a certain threshold that we use in developing
the guidelines.
As we analyzed the NASL survey data, which as discussed above, was
submitted for the purpose of being used to develop the guideline
amounts, we also studied several other surveys of hospitals and nursing
homes, each of which are more recent than the BLS surveys, although
none was specifically submitted to be used in developing the
guidelines.
We analyzed five additional data sources for hospital wage rates
and two for freestanding SNF wage rates. The additional hospital data
sources examined were: the University of Texas National Hospital Survey
(1994 National Survey of Hospital and Medical School Salaries,
University of Texas Medical Branch, Galveston, TX, 1994, pp. 15-19);
the American Rehabilitation Association (ARA) Surveys of Freestanding
Hospitals and of Rehabilitation Units (1995 Salary Survey, American
Rehabilitation Association, pp. 53-59 and 94-101); the Maryland Health
Services Cost Review Commission's census of hospitals; the American
Health Care Association's (AHCA) report that includes hospital data
profile (1994 AHCA Survey, Sec. 1, p. 10, Buck Associates); and the
NASL 1995 survey of hospitals. For SNFs, we analyzed data from the 1995
NASL survey of SNFs, the January 1995 AHCA survey of SNFs (1995 AHCA
Survey, Sec. 3, p. 3, Buck Associates), and the 1996 survey of SNFs by
Mutual of Omaha, a Medicare intermediary. Several of these data sources
had regional wage levels. We drew the following conclusions about the
merits of these data sources for our purposes in determining
appropriate therapy salary guidelines (that is, not in relation to the
original purposes of the surveys):
The University of Texas National Hospital Survey data are
from October 1994. This annual voluntary hospital survey was conducted
for many years for hospitals in various regions of the country to use
to benchmark regional wage levels for specific health professional
occupations. While there are data from all regions of the United
States, the survey was not designed to be representative or
statistically valid at the regional level. It appears to give fairly
reasonable levels at the national level.
The American Health Care Association's report includes
data on both hospitals and SNFs. The SNF data for January 1995 are both
current and industry-specific. The data for SNFs, however, are unevenly
edited and appear to include some supervisors and additional salary in
lieu of benefits. The sample is heavily weighted by large chains that
are members of the Association. The SNF data appear as both employee-
weighted and facility-
[[Page 14856]]
weighted averages, and do not permit computation of accurate median
and 75th percentile levels.
The Maryland Health Services Cost Review Commission
conducts a census of all Maryland hospitals yearly. We analyzed data
from the 1995 census. While this is a complete census covering over 50
hospitals, it is for Maryland only. In addition, speech-language
pathologists are not included as a separate occupational category.
The American Rehabilitation Association's survey of its
members and prospective members collected July 1994 data. The response
rate was low, and the Association indicated in its report that these
data cannot be presumed to represent the full population of
rehabilitation facilities. No information on SNFs was reported due to
an inadequate sample. This survey appears to give reasonable wage
levels at the national level when compared to other data sources.
Mutual of Omaha conducted a 1995 survey of 2,000 SNF
Medicare providers that it services. The data are current and industry-
specific, but include only information on occupational therapists and
speech language pathologists. The survey was national in scope.
Although the survey's response rate was very high, only a small
percentage of records contained information on wage rates for full-time
employed therapists.
Our conclusion from this analysis was that none of the available
data sources met the statistical validity criteria recommended in the
Senate Committee on Finance Report and specified in the regulations
sufficiently well to serve as the sole or even primary source of data
for establishing the guidelines. Based on this examination, we
determined that a different approach was necessary. As we examined all
these potential data sources, we found that mean wage levels at the
national level for the most part clustered when adjustments were made
for definitional differences. This observation suggested to us that,
while no one of the data sources was adequate as a sole or primary
source of data for establishing the guidelines, employing all these
sources together could provide a useful and valid basis for the
guidelines to be used by intermediaries determining the maximum
allowable cost of therapy services furnished under arrangements.
Therefore, we concluded that we could blend data from the several
sources to develop a national ``best estimate'' of prevailing salary
levels as the basis for the guidelines. Under this approach, we give
weight to each data source, but preferential status to none. None of
the data sources or the average of all of the sources could provide
regional variations. A new method would have to be used for regional
variations.
In an occupational market, wage levels across settings for the same
occupation should bear rational relationships in competitive labor
markets when adjustments are made for compensating differentials for
fringe benefits, working conditions, risk of injury, and geographic
areas. This implies that therapists working in hospital and SNF
settings can migrate between practice settings with relatively little
difficulty. Because of the ease of mobility, labor market forces that
affect one therapist practice setting also influence other practice
settings. This is not to say that therapists' practice activities in
all settings are exactly the same. In setting the guideline amounts, we
acknowledged that, because of the ease of mobility of licensed therapy
workers across settings, a salary equivalency rate that is too high
could put upward pressure on the wages paid to therapists in the larger
hospital sector. Similarly, a rate that is too low could make it
difficult for providers subject to the guidelines to attract therapists
from the hospital setting.
We have decided, for the reasons discussed, not to use the NASL
industry survey as the sole or primary data source for setting the
guidelines. However, we do believe that it has sufficient strength to
include its data along with data from the other sources in a blend as
the basis for the salary equivalency guidelines. We have used a blend
of hospital and SNF therapist wages in the past to reflect occupational
markets and the associated mobility between the two settings. We had
considered at one point including a differential between therapist
wages in hospitals and nursing homes in the guideline amounts. We
reconsidered when we looked across all of the other data sources which
included all provider types. We noted clustering of wage levels across
provider types that made such a differential inappropriate for
occupational labor markets when adjustments are made for locality. We
believe that proposing to use the 75th percentile of blended hospital
and SNF wage data (weighted by relative employment levels in hospitals
and SNFs) to measure the occupational market for therapy services is
equitable. Our new approach in which all appropriate data sources were
used but adjusted for the mix of SNF and hospital therapy employees
will, therefore, provide a buffer for costs that SNFs and other
providers may incur in furnishing therapy services to Medicare
beneficiaries. We invite comments on this methodology, which is
described in more detail in section II.B. of this preamble.
We could not use Medicare cost report information for wage rates
because the cost reports for SNFs and other providers do not have
hourly wage rates for employees. The cost reports do provide aggregate
salaries of employees and costs other than salaries that would include
contract labor cost. However, they do not provide the hours worked
either by staff or contractors, except for contracted physical and
respiratory therapy services for which we have developed salary
equivalency guidelines for the services and do require hourly time
records.
We did use 1994 Medicare predominantly settled cost report data for
prospective payment systems (PPS) hospitals to obtain fringe benefit
information. We used Worksheet S-3, Part II from form HCFA-2552. These
data are used to adjust the labor portion of hospital payments under
the PPS. We believe their use is also appropriate here. We use the 1994
Medicare predominantly settled cost report data, because this is the
same data that HCFA used for its wage index update for prospective
payment system hospitals for FY 1997. This is the most recent Medicare
predominantly settled cost report data that has undergone special
scrutiny for the purpose of wage survey data. Moreover, BLS Employment
Cost Index information for March 1994 show that fringe benefits in
hospitals and SNFs are similar for professional and technical workers.
B. Methodology
In order to determine the hourly salary equivalency amounts, we
determined the ``best estimate'' of wages for both hospitals and SNFs.
We first found mean wage rates for each of the data sources listed
above.
BLS surveyed average hourly earnings (AHE) for all four therapies
in 1989. However, their January 1991 survey included the average hourly
earnings only for full-time physical and respiratory therapists. (BLS
January 1991 average hourly earnings for full-time physical and
respiratory therapists were found in the BLS Occupational Wage Survey:
Hospitals, January 1991, pp. 36-119. The hospitals in this survey
employed 50 or more workers.) We, therefore, needed to estimate 1991
average hourly wages for speech language pathology and occupational
therapy. To do so, we started with the BLS 1989 survey of all four
therapies as a baseline (BLS Industry Wage Survey: Hospitals, March
1989 (the latest previous survey), pp 33-118). The
[[Page 14857]]
hospitals in the 1989 survey employed 100 or more workers. Our analysis
of the University of Texas data for U.S. hospitals indicated that the
wages for speech language pathology and respiratory therapy increased
at a similar rate between 1989 and 1993. Wages for occupational therapy
and physical therapy also increased at a similar rate during that
period. Therefore, we determined that we could employ the 1989 ratios
of speech language pathology to respiratory therapy, and of
occupational therapy to physical therapy, in order to estimate 1991
wage levels for speech language pathology and occupational therapy.
Specifically, multiplying the ratio of 1989 average hourly occupational
therapy wages to 1989 average hourly physical therapy wages by 1991
physical therapy wages yielded estimated 1991 occupational therapy
wages. The following formula summarizes the computation (all values are
average hourly wages):
[(March 1989 AHE, OT)/(March 1989 AHE, PT)] x (January 1991
AHE, PT)=(estimated January 1991 AHE, OT).
Similarly, multiplying the ratio of 1989 average hourly speech
language pathology wages to 1989 average hourly respiratory therapy
wages by the 1991 average hourly respiratory therapy wages yielded
estimated 1991 average hourly speech language pathology wages. Again,
the following formula summarizes the computation (all values are
average hourly wages):
[(March 1989 AHE, SLP)/(March 1989 AHE, RT)] x (January 1991
AHE, RT)=estimated January 1991 AHE, SLP.
The American Health Care Association data provided facility-
weighted mean wage rates for SNFs. The Association has estimated that 5
percent of the SNF wage rates represented supervisors and additional
wages paid in lieu of fringe benefits. We used that estimate to reduce
the Association survey wage data to a nonsupervisory, no additional
salary in lieu of benefits basis.
We converted annual data in the American Rehabilitation Association
and University of Texas surveys to hourly wages using a divisor of 2080
hours, which represents a standard work year.
The Maryland Health Services Cost Review Commission census data
provided wage data, paid hours, and numbers of personnel for each
hospital. We eliminated data for employees who worked less than 35
hours or more than 40 hours a week to restrict the computation to full-
time employees only. We then determined the average hourly wage for
each hospital by dividing aggregate wages by the number of paid hours.
Finally, we computed the average hourly wages across all hospitals,
weighted by the number of employees in each hospital.
NASL data were first divided by 52 to arrive at weekly salary, then
divided by the number of hours worked per week which were also given in
the survey, to obtain hourly wage rates. As in the case of the Maryland
census data, we eliminated data for employees who worked less than 35
hours, or more than 40 hours, a week to restrict the computation to
full-time employees only.
We trended all data forward to the fourth quarter of 1995, the base
period for the NASL survey. For data from the University of Texas, the
American Rehabilitation Association, the American Health Care
Association, and the Maryland Commission census (all sources with 1994
or 1995 bases), we trended these data using average hourly earnings for
hospital workers published in the BLS Current Employment Statistics'
Survey, Standard Industrial Code 806 (Hospitals). To update the BLS
survey data from 1991, we derived rates of increase for the period from
January 1991 through January 1994 (the period which predates the other
data sources, which were surveyed in 1994-1996) based 50 percent on
American Hospital Association Panel wage data and 50 percent on the
average hourly earnings for hospital workers published in the BLS
Current Employment Statistics Survey, Standard Industrial Code 806
(Hospitals).
For the period from January 1994 through October 1995, we used only
the BLS Current Employment Statistics Survey as the basis for the rate
of increase in the BLS survey data (as we did for the other data
sources, which date from that period). The American Hospital
Association data had a higher rate of increase during the 1991-1993
period than the BLS data, resulting in cumulating 1995 therapist wage
levels that reflect current market conditions in 1995.
After all data were trended to fourth quarter 1995, we determined
the salary equivalency guideline amounts for April 1997 in five steps.
Those five steps were: (1) Determine average wages by therapy type,
separately for hospitals and nursing homes; (2) blend the hospital and
nursing home average wages by therapy type, to yield average wages by
therapy type for the four occupational markets; (3) approximate the
75th percentile of wages by therapy type; (4) calculate salary
equivalency guideline levels for fourth quarter 1995, by adding amounts
for fringe benefits, rent, etc.; and (5) update these guideline amounts
to April 1997, the proposed effective date.
In the first step, we determined the mean wage levels, by therapy
type, for hospitals in each of the available data sources. (Data
sources used for hospitals were: BLS, Industry Wage Survey: Hospitals,
March 1989 and Occupational Wage Survey: Hospitals, January 199l;
University of Texas National Hospital Survey 1994 National Survey of
Hospital and Medical School Salaries; American Rehabilitation
Association's surveys of freestanding hospitals and of rehabilitation
units, 1995 Salary Survey; Maryland Health Services Cost Review
Commission's census of hospitals; American Health Care Association
hospital report's data profile, 1994 AHCA Survey; and NASL 1995 survey
of hospitals.) We similarly determined the mean wage levels, by therapy
type, for nursing homes in each of the available data sources. (Data
sources used for SNFs were: 1995 NASL survey of SNFs; American Health
Care Association survey of SNFs, 1995 AHCA Survey; and the 1996 survey
of SNFs by Mutual of Omaha.) We then averaged the mean wage levels from
the available data sources by therapy type, separately for hospitals
and nursing homes.
In the second step, we blended the hospital and nursing home
average wage levels by therapy, to yield average wage levels by
therapist type across the four occupational markets. We employed a
blending process used in the previous salary equivalency guidelines
notice (48 FR 44922, September 30, 1983), to weight the occupational
averages by relative employment levels in hospitals and nursing homes,
respectively. To establish appropriate weights, we used employment of
therapists in nursing homes (SIC 805) and in hospitals (SIC 806), as
found in the BLS Occupational Employment Statistics Survey. (The most
recent available survey of employment in nursing homes is for 1993,
while the most recent survey data of employment in hospitals is for
1995.) We applied these weights to the mean hospital and SNF wage rates
by the four therapist types, as determined in the first step. The BLS
Occupational Employment Statistics Survey shows that the hospital
industry is a major employer of therapists of all types, while SNFs
employ fewer salaried therapists. The weights for hospitals and nursing
homes, respectively, are: For physical therapy, 85 percent and 15
percent; for occupational therapy, 85 percent and 15 percent; for
speech language pathology, 82 percent and 18
[[Page 14858]]
percent; and for respiratory therapy, 99 percent and 1 percent.
In the third step we approximated the 75th percentile of the
blended wage rates for each therapy occupation. It was necessary to
approximate the 75th percentile because, unlike our previous
computations of the guidelines, in this proposal we could not determine
percentile values directly from each of the sources. We have observed
in the BLS data and a regression analysis we performed on NASL data
that the 75th percentile was approximately 110 percent of the mean. We,
therefore, increased each of the four blended wage averages by 10
percent to approximate the 75th percentile of wages in each discipline
across the occupational market.
Salary equivalency guidelines are based on the therapists' time in
the facility. Adjustments to average hourly earnings data were
necessary to include a reasonable allowance for vacation, sick leave,
and administrative time. In order to convert the average hourly
earnings from an hours paid basis to an hours worked basis, we applied
a factor of 2080/1808 to the average hourly earnings determined thus
far, which is the same methodology used in the previous notice. The
1808 figure was computed based on 2080 hours (40 hours/week x 52
weeks; a standard work year) less 15 vacation days, 10 sick leave days
and 9 holidays equal to 34 days, or 272 hours. Data on leave benefits
come from the BLS Employee Benefits Survey. (U.S. Department of Labor,
Bureau of Labor Statistics: Employee Benefits in Small Private
Establishments, 1992, Bulletin 2441, U.S. Government Printing Office,
May 1994, pp. 10-20.)
In the fourth step we added fringe benefit and expense factors to
the prevailing salary rates determined for each therapy type. The
fringe benefit and expense factors are intended to recognize fringe
benefits that are received by an employee therapist, as well as
overhead expenses that a therapist or therapist organization might
incur in furnishing services under arrangements. These factors are
expressed as percentages of the prevailing hourly rate and are applied
to every hour of service furnished at the provider site. Fringe
benefits may include vacation and sick pay, insurance premiums, pension
payments, allowance for job-related training, meals, severance pay,
bonuses, etc.
We computed fringe benefits as a percent of total compensation
using fiscal year 1994 Medicare cost reports for hospitals under the
prospective payment system. We used the Medicare cost reports for
prospective payment system hospitals to obtain fringe benefit
information because these data are carefully scrutinized; they are used
to adjust the labor portion of hospital payments under the prospective
payment system. We believe these data are the best proxy for therapist
fringe benefit information, which is not available for SNFs. Also, the
BLS Employment Cost Index for March 1994 showed that fringe benefits
for professional and technical workers in hospitals and nursing homes
were similar. The fringe benefit component is about 14 percent of the
total salary equivalency amount.
The expense component takes into account expenses a therapist or
therapist organization might have, such as maintaining an office,
purchasing insurance, etc. We based the expense component of the
guidelines on an estimate of the costs of maintaining a therapy
services office. The general methodology for computing the expense
component is similar to that used in the 1983 notice (48 FR 44922,
September 30, 1983) but the factors have been revised. This component
has rental and non-rental portions.
To determine the rental portion of the expense component, we used
the 1991 rental income data (updated to fourth quarter 1995 using
Consumer Price Index (CPI) rental data) compiled by the Building Owners
and Managers Association International (BOMA) and published in the 1992
BOMA Experience Exchange Report for Downtown and Suburban Office
Buildings. (Building Owners and Managers Association International:
1992 BOMA Experience Exchange Report, Washington, DC, 1992, p. 27.)
BOMA reported a national rent average, excluding utility cost, of
$16.87 per square foot per year. We applied an occupancy factor of .971
to take into account the space used for rental building hallways,
elevators, etc., that are included in the BOMA rent figure but that are
not part of the area rented for an office. We then added the BOMA
utilities cost of $1.92 per square foot. We determined total rental
cost assuming a rental area of 250 square feet, the same rental area
used in prior schedules of guidelines. Total 1991 rental cost was
divided by 1808 (the hours factor applied to average hourly earnings)
to compute rental cost per hour worked in 1991.
The expense component includes costs of maintaining an office, such
as wages and salaries of administrative and clerical help, insurance,
telephones, etc. We believe that Medicare should only pay for services
at their reasonable cost. We estimated this component, including rent,
to be reasonable at 30 percent of total expenses in 1991. We based our
30 percent estimate of total expenses on informal discussion with the
rehabilitation industry. We request comments on whether this is a
reasonable estimate. This component had previously been lower because
it was based on a single person maintaining an office out of a home as
opposed to the costs of maintaining a business. The 1991 rent per
square foot amount and the other expenses amount were constant across
the four therapy types, although the weights of these factors vary by
therapy type (the weight for rent is lowest for physical therapy and
highest for respiratory therapy).
The dollar amount for 1991 rent per hour was trended to fourth
quarter 1995, using the proxy selected for rent, the CPI-U for Housing,
published by BLS. The 1991 dollar amounts for the remainder of the
other expenses factor were trended to October 1995, using their
selected proxies. This was done for each of the four therapy types. The
expense factor, including rent, is about 28 percent of the total salary
equivalency amount.
Using the 1994 Medicare cost reports allows us to recognize that
the relative values of certain factors, such as fringe benefits, have
increased more than the relative values of other factors such as rent
or wages and salaries. For instance, if the January 1991 values of the
proxies for office rent and clerical worker fringe benefits are assumed
to be equal to 1.0, then the fourth quarter 1995 values of these two
proxies are 1.131 for rent and 1.249 for clerical worker fringe
benefits. The values of these proxies have increased by different
percentages.
We summed the fourth quarter 1995 dollar values of the ``blended''
wages, fringe benefits, rent, and the remainder of the other expenses
factors to obtain salary equivalency guideline amounts for fourth
quarter 1995. We updated the resultant fourth quarter 1995 salary
equivalency guideline amounts to April 1997, using a DRI/McGraw-Hill
1996:3 forecast. The April 1997 national guidelines below are based on
the amounts determined above:
Physical Therapy.................................................$48.78
Occupational Therapy..............................................46.27
Speech Language Pathology.........................................44.51
Respiratory Therapy...............................................38.51
In previous schedules, statewide therapy guideline amounts were
calculated from the wage data for 22 Metropolitan Statistical Areas
(MSAs) provided by the BLS survey. We averaged prevailing hourly rates
for the surveyed MSAs within each State to
[[Page 14859]]
determine that State's therapy rate. We also grouped contiguous states
into regions and used an average of the surveyed MSA wage rates from
the region in order to determine the rate for States with no MSAs in
the BLS survey. As we acknowledged in the notice of the last schedule
(48 FR 44923), this method has two major shortcomings. First, where BLS
conducted more than one survey in a given State, such as New York,
providers located in the surveyed MSAs were subject to the State rate
even though actual salary data were available for those MSAs. Secondly,
direct application of individual MSA prevailing rates (or an average of
MSA rates) to establish guidelines is relatively insensitive to
geographic variations in wage rates.
Commenters on the existing guidelines have suggested that the
guidelines should both account more fully for local cost variation, and
more accurately reflect the different therapy service costs in urban
and rural regions. In addition, commenters have cautioned us to avoid
any methodology which would create unreasonable differences between
adjoining geographical regions. In developing these proposed
guidelines, we have reconsidered how to account for local cost
variations in the light of those comments. Two other long-term care
Medicare benefit programs, SNF care and home health care, use the
prospective payment system hospital wage index to adjust for local area
variations in labor-related costs. We have decided to employ a modified
version of the prospective payment system hospital wage index as the
best available method for taking local cost variation into account.
Specifically, we propose to employ the pre-reclassified hospital wage
index in order to establish the therapy guideline amounts for urban
areas. (We use the pre-reclassified wage index because
reclassifications apply to hospitals under the prospective payment
system only.) For the rural areas of each State, we propose to use a
weighted average of the wage index values for the urban areas of the
State. This modified geographic adjustment index accounts for two
salient features of the geographical variation in therapy costs. First,
within MSAs there is an association between therapist hourly salary and
fringe benefit rates and overall hospital hourly salary and fringe
benefit rates, because nursing facilities compete in the same labor
market areas as hospitals and other health care providers such as home
health agencies. In addition, the therapy market for rural (non-MSA)
areas tends to reflect the prevailing compensation conditions of the
urban areas in the region.
In order to determine the geographic adjustment for the rural
areas, it is first necessary to determine a weighted average of the
wage index values for the urban areas. We determined the weighted
average of the geographic adjustment index values for the MSAs in each
State by the following method. We began with the pre-reclassified
hospital wage index, based on the fiscal year 1993 Hospital Cost Report
Information System (HCRIS) data set of hospitals under the prospective
payment system, for each MSA. (This is the same data used as the basis
for the hospital wage index effective for hospitals on October 1, 1996
(that is, fiscal year 1997)). For each MSA, we then obtained the number
of total adjusted hours worked in prospective payment system hospitals
from the fiscal 1993 HCRIS data set. We applied two edits to this data.
We excluded all hospital cost reports that showed adjusted hourly
compensation outside of three standard deviations of the mean of the
distribution in order to eliminate erroneous reports. We also excluded
all cost reports from rural areas. A total of 2,837 hospitals under the
prospective payment system satisfied these edits. After obtaining the
number of hours worked in each MSA, we added hours from MSAs in each
State to determine the total number of hours worked in the State. For
MSAs that cover more than one State, we used only the hours from
hospitals inside a State boundary for determining the total hours
worked in the State. Once we determined the total hours worked in the
State, the ratio of hours worked in an MSA to total state hours
provided the weight for each MSA. We then multiplied each MSA's pre-
reclassified hospital wage index by the weight for the MSA, and added
the results to produce the geographic adjustment index for the non-MSA
(rural) areas of the State.
Finally, we normalized the index values to the national average so
that an area with an average geographic adjustment equal to the
national average would have a geographic adjustment index of 1.0. We
first computed a national area geographic adjustment index by
calculating the ratio of hospital hours worked in each MSA to national
hospital hours worked, multiplying this ratio by each MSA's geographic
adjustment index, and adding the results. We then divided this national
geographic adjustment index into the area geographic adjustment index
for each region to produce the normalized therapist geographic
adjustment index.
The results of these calculations are shown in Tables I and II.
Table I shows the geographic adjustment index values and hourly salary
equivalency amounts for each of the 318 MSAs in the 50 States and
Puerto Rico. Table II lists geographic adjustment index values and
hourly salary equivalency upper limits for the rural (that is, non-MSA)
areas of each State and Puerto Rico.
In this proposed rule, we computed the nonurban geographic
adjustment index for a State as a weighted-average index, using
hospital hours for each MSA in the State as the weights. We are
considering computing the nonurban geographic adjustment index by an
alternative method. We are soliciting comments on alternative methods
for determining the nonurban geographic adjustment index under these
guidelines.
C. Specific Number of Schedules
We are proposing one schedule of guidelines for respiratory
therapists, in contrast to the three schedules in the notice of
September 30, 1983. This decision is based on the fact that HCFA does
not differentiate in covering respiratory therapists by different
levels. Therefore, to make coverage conform with payment for
respiratory therapy services, we are proposing one schedule for
respiratory therapists. Information from fiscal intermediaries and the
American Association for Respiratory Care indicates that industry
practice is to use only one schedule. Also, in the BLS 1989 Hospital
Wage Industry Survey, there were four different wage classes and a
summary (weighted average) wage level for respiratory therapists. Only
class III and the summary level were reported for all 18 MSAs surveyed.
For respiratory therapists in 1991, there were two wage classes and a
summary wage level shown. Although the summary level occupational
definitions were comparable from 1989 to 1991, occupational definitions
for basic classes changed between surveys. The summary level was the
consistent category--present for all MSAs in both surveys and
encompassing all nonsupervisory levels of responsibility for both
surveys. We propose to continue to have one schedule of guidelines for
physical therapists. Likewise, we propose to establish one schedule of
guidelines for speech language pathologists and one for occupational
therapists.
The standard travel allowance is 50 percent of the salary
equivalency amount. It is longstanding policy that has been used in all
of the previous guideline notices. For example, the
[[Page 14860]]
proposed standard travel allowance amount for physical therapists in
Bangor, Maine would be determined as follows:
Bangor, Maine hourly salary equivalency amount................ $46.60
Standard travel allowance..................................... x . 50
---------
Section II.B reflects the proposed changes for computing the salary
component and fringe benefit expense factors.
The salary equivalency amount is made up of a salary component and
fringe benefit and expense factors, while the travel allowance, which
is an additional allowance, reflects payment for the therapist's time
spent in traveling to the provider site or to the patient's home. We
are proposing changes in the methodology for computing the salary
component and fringe benefit and expense factors. Although we are not
proposing to change the current methodology with respect to the
standard travel allowance in this proposed rule, we are seeking public
comment on an optional travel allowance methodology for use when
therapy services are furnished in areas in which geographic distance
creates unique labor markets as discussed in section II.F.1 of this
notice.
The schedules of guidelines that follow (Tables I and II) are based
on the projected amounts, while the standard travel allowance is 50
percent of the guideline amount for each therapy type.
D. Tables of Guidelines and Geographic Adjustment Indexes
The salary equivalency guideline amounts for each therapy type are
calculated in three steps: (1) Multiplication of the labor-related
share (83.379 percent of the composite weight) by the geographic
adjustment index and by the national salary equivalency rate for the
therapist type; (2) multiplication of the non-labor related share
(16.621 percent of the composite weight) by the national salary
equivalency rate for the therapist type; and (3) summation of the
results from steps 1 and 2. The salary equivalency guideline amounts
for each therapy type computed by this method are presented in Tables I
and II.
Table I.--Geographic Adjustment Index and Salary Equivalency Upper Guideline for Urban Areas
----------------------------------------------------------------------------------------------------------------
Occu- Speech
Urban area (constituent counties Index Physical pational language Respiratory
or county equivalents) therapy therapy pathology therapy
----------------------------------------------------------------------------------------------------------------
0040.. Abilene, TX, Taylor, TX........... 0.8112 41.10 38.99 37.50 32.45
0060.. Aguadilla, PR, Aguada, PR,
Aguadilla, PR, Moca, PR \1\...... 0.4271 26.29 24.94 23.99 20.75
0080.. Akron, OH, Portage, OH, Summit, OH 0.9931 48.50 46.00 44.25 38.29
0120.. Albany, GA, Dougherty, GA, Lee, GA 0.8665 43.35 41.12 39.56 34.22
0160.. Albany-Schenectady-Troy, NY,
Albany, NY, Montgomery, NY,
Rensselaer, NY, Saratoga, NY,
Schenectady, NY, Schoharie, NY... 0.8692 43.46 41.22 39.66 34.31
0200.. Albuquerque, NM, Bernalillo, NM,
Sandoval, NM, Valencia, NM....... 0.9418 46.41 44.02 42.35 36.64
0220.. Alexandria, LA, Rapides, LA....... 0.8183 41.39 39.26 37.77 32.68
0240.. Allentown-Bethlehem-Easton, PA,
Carbon, PA, Lehigh, PA,
Northampton, PA.................. 1.0071 49.07 46.54 44.77 38.74
0280.. Altoona, PA, Blair, PA............ 0.9585 47.09 44.67 42.97 37.18
0320.. Amarillo, TX, Potter, TX, Randall,
TX............................... 0.8799 43.90 41.64 40.05 34.65
0380.. Anchorage, AK, Anchorage, AK \1\.. 1.3329 64.35 61.04 58.71 50.80
0440.. Ann Arbor, MI, Lenawee, MI,
Livingston, MI, Washtenaw, MI.... 1.1754 55.91 53.04 51.02 44.14
0450.. Anniston, AL, Calhoun, AL......... 0.8087 41.00 38.89 37.41 32.37
0460.. Appleton-Oshkosh-Neenah, WI,
Calumet, WI, Outagamie, WI,
Winnebago, WI.................... 0.8960 44.55 42.26 40.65 35.17
0470.. Arecibo, PR, Arecibo, PR, Camuy,
PR, Hatillo, PR \1\.............. 0.4432 26.94 25.56 24.59 21.27
0480.. Asheville, NC, Buncombe, NC,
Madison, NC...................... 0.9408 46.37 43.99 42.31 36.61
0500.. Athens, GA, Clarke, GA, Madison,
GA, Oconee, GA................... 0.9482 46.67 44.27 42.59 36.85
0520.. Atlanta, GA, 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*........ 1.0112 49.24 46.70 44.93 38.87
0560.. Atlantic City-Cape May, NJ,
Atlantic City, NJ, Cape May, NJ.. 1.1165 53.52 50.76 48.83 42.25
0600.. Augusta-Aiken, GA-SC, Columbia,
GA, McDuffie, GA, Richmond, GA,
Aiken, SC, Edgefield, SC......... 0.8906 44.33 42.05 40.45 35.00
0640.. Austin-San Marcos, TX, Bastrop,
TX, Caldwell, TX, Hays, TX,
Travis, TX, Williamson, TX....... 0.9327 46.04 43.67 42.01 36.35
0680.. Bakersfield, CA, Kern, CA......... 1.0270 49.88 47.31 45.51 39.38
0720.. *Baltimore, MD, Anne Arundel, MD,
Baltimore, MD, Baltimore City,
MD, Carroll, MD, Harford, MD,
Howard, MD, Queen Annes, MD...... 0.9876 48.28 45.79 44.05 38.11
0733.. Bangor, ME, Penobscot, ME......... 0.9465 46.60 44.21 42.52 36.79
0743.. Barnstable-Yarmouth, MA,
Barnstable, MA................... 1.3759 64.07 60.77 58.46 50.58
0760.. Baton Rouge, LA, Ascension, LA,
East Baton Rouge, LA, Livingston,
LA, West Baton Rouge, LA......... 0.85 42.68 40.48 38.94 33.69
0840.. Beaumont-Port Arthur, TX, Hardin,
TX, Jefferson, TX, Orange, TX.... 0.8644 43.26 41.04 39.48 34.16
0860.. Bellingham, WA, Whatcom, WA....... 1.1407 54.50 51.70 49.73 43.03
0870.. Benton Harbor, MI, Berrien, MI.... 0.8573 42.98 40.76 39.21 33.93
[[Page 14861]]
0875.. Bergen-Passaic, NJ, Bergen, NJ,
Passaic, NJ*..................... 1.1878 56.42 53.52 51.48 44.54
0880.. Billings, MT, Yellowstone, MT..... 0.9158 45.36 43.02 41.39 35.81
0920.. Biloxi-Gulfport-Pascagoula, MS,
Hancock, MS, Harrison, MS,
Jackson, MS...................... 0.8622 43.18 40.95 39.40 34.09
0960.. Binghamton, NY, Broome, NY, Tioga,
NY............................... 0.8892 44.27 42.00 40.40 34.94
1000.. Birmingham, AL, Blount, AL,
Jefferson, AL, St. Clair, AL,
Shelby, AL....................... 0.9108 45.15 42.83 41.20 35.65
1010.. Bismarck, ND, Burleigh, ND,
Morton, ND....................... 0.7986 40.59 38.50 37.04 32.04
1020.. Bloomington, IN, Monroe, IN....... 0.8720 43.57 41.33 39.76 34.40
1040.. Bloomington-Normal, IL, McLean, IL 0.9061 44.96 42.65 41.03 35.49
1080.. Boise City, ID, Ada, ID, Canyon,
ID............................... 0.9457 46.57 44.18 42.49 36.77
1123.. Boston-Brockton-Nashua-MA-NH,
Bristol, MA, Essex, MA,
Middlesex, MA, Norfolk, MA,
Plymouth, MA, Suffolk, MA,
Worcester, MA, Hillsborough, NH,
Merrimack, NH, Rockingham, NH,
Strafford, NH*................... 1.1705 55.71 52.85 50.84 43.98
1125.. Boulder-Longmont, CO, Boulder, CO. 0.9597 47.14 44.72 43.01 37.22
1145.. Brazoria, TX, Brazoria, TX........ 0.9274 45.83 43.47 41.82 36.18
1150.. Bremerton, WA, Kitsap, WA......... 1.0987 52.79 50.08 48.17 41.68
1240.. Brownsville-Harlingen-San Benito,
TX, Cameron, TX.................. 0.8610 43.13 40.91 39.35 34.05
1260.. Bryan-College Station,TX, Brazos,
TX............................... 0.8921 44.39 42.11 40.51 35.05
1280.. Buffalo-Niagara Falls, NY, Erie,
NY, Niagara, NY*................. 0.9179 45.44 43.10 41.46 35.87
1303.. Burlington, VT, Chittenden, VT,
Franklin, VT, Grand Isle, VT..... 1.0148 49.38 46.84 45.06 38.99
1310.. Caguas, PR, Caguas, PR, Cayey, PR,
Cidra, PR, Gurabo, PR, San
Lorenzo, PR \1\.................. 0.4609 27.66 26.24 25.24 21.84
1320.. Canton-Massillon, OH, Carroll, OH,
Stark, OH........................ 0.8716 43.56 41.32 39.74 34.39
1350.. Casper, WY, Natrona, WY........... 0.8891 44.27 41.99 40.39 34.95
1360.. Cedar Rapids, IA, Linn, IA........ 0.8525 42.78 40.58 39.04 33.77
1400.. Champaign-Urbana, IL, Champaign,
IL............................... 0.9465 46.60 44.21 42.52 36.76
1440.. Charleston-North Charleston, SC,
Berkeley, SC, Charleston, SC,
Dorchester, SC................... 0.9034 44.85 42.54 40.93 35.41
1480.. Charleston, WV, Kanawha, WV,
Putnam, WV....................... 0.9601 47.16 44.73 43.03 37.23
1520.. Charlotte-Gastonia-Rock Hill, NC-
SC, Cabarrus, NC, Gaston, NC,
Lincoln, NC, Mecklenburg, NC,
Rowan, NC, Union, NC, York, SC*.. 0.9696 47.54 45.10 43.38 37.53
1540.. Charlottesville, VA, Albemarle,
VA, Charlottesville City, VA,
Fluvanna, VA, Greene, VA......... 0.9227 45.64 43.29 41.64 36.03
1560.. Chattanooga, TN-GA, Catoosa, GA,
Dade, GA, Walker, GA, Hamilton,
TN, Marion, TN................... 0.8917 44.38 42.09 40.49 35.03
1580.. Cheyenne, WY, Laramie, WY......... 0.7739 39.58 37.55 36.12 31.25
1600.. Chicago, IL, Cook, IL, DeKalb, IL,
DuPage, IL, Grundy, IL, Kane, IL,
Kendall, IL, Lake, IL, McHenry,
IL, Will, IL*.................... 1.0845 52.22 49.53 47.65 41.22
1620.. Chico-Paradise, CA, Butte, CA..... 1.0499 50.81 48.20 46.36 40.11
1640.. Cincinnati, OH-KY-IN, Dearborn,
IN, Ohio, IN, Boone, KY,
Campbell, KY, Gallatin, KY,
Grant, KY, Kenton, KY, Pendleton,
KY, Brown, OH, Clermont, OH,
Hamilton, OH, Warren, OH*........ 0.9644 47.33 44.90 43.19 37.37
1660.. Clarksville-Hopkinsville, TN-KY,
Christian, KY, Montgomery, TN.... 0.7777 39.74 37.69 36.26 31.37
1680.. Cleveland-Lorain-Elyria, OH,
Ashtabula, OH, Cuyahoga, OH,
Geauga, OH, Lake, OH, Lorain, OH,
Medina, OH*...................... 0.9964 48.63 46.13 44.38 38.39
1720.. Colorado Springs, CO, El Paso, CO. 0.9415 46.40 44.01 42.34 36.63
1740.. Columbia, MO, Boone, MO........... 0.8969 44.59 42.29 40.68 35.20
1760.. Columbia, SC, Lexington, SC,
Richland, SC..................... 0.9233 45.66 43.31 41.66 36.05
1800.. Columbus, GA-AL Russell, AL,
Chattanoochee, GA, Harris, GA,
Muscogee, GA..................... 0.7841 40.00 37.94 36.50 31.58
1840.. Columbus, OH, Delaware, OH,
Fairfield, OH, Franklin, OH,
Licking, OH, Madison, OH,
Pickaway, OH*.................... 0.9758 47.80 45.34 43.61 37.73
1880.. Corpus Christi, TX, Nueces, TX,
San Patricio, TX................. 0.8951 44.51 42.22 40.62 35.14
1900.. Cumberland, MD-WV, Allegany, MD,
Mineral, WV...................... 0.8740 43.66 41.41 39.83 34.46
1920.. Dallas, TX, Collin, TX, Dallas,
TX, Denton, TX, Ellis, TX,
Henderson, TX, Hunt, TX, Kaufman,
TX, Rockwall, TX*................ 0.9806 47.99 45.52 43.79 37.89
1950.. Danville, VA, Danville City, VA,
Pittsylvania, VA................. 0.8564 42.94 40.73 39.18 33.90
1960.. Davenport-Rock Island-Moline, IA-
IL, Scott, IA, Henry, IL, Rock
Island, IL....................... 0.8454 42.49 40.31 38.77 33.55
[[Page 14862]]
2000.. Dayton-Springfield, OH, Clark, OH,
Greene, OH, Miami, OH,
Montgomery, OH................... 0.9635 47.30 44.86 43.16 37.34
2020.. Daytona Beach, FL, Flagler, FL,
Volusia, FL...................... 0.8941 44.47 42.18 40.58 35.11
2030.. Decatur, AL, Lawrence, AL, Morgan,
AL............................... 0.8450 42.48 40.29 38.76 33.53
2040.. Decatur, IL, Macon, IL............ 0.7910 40.28 38.21 36.75 31.80
2080.. Denver, CO, Adams, CO, Arapahoe,
CO, Denver, CO, Douglas, CO,
Jefferson, CO*................... 1.0246 49.78 47.22 45.42 39.30
2120.. Des Moines, IA, Dallas, IA, Polk,
IA, Warren, IA................... 0.8885 44.25 41.97 40.37 34.93
2160.. Detroit, MI, Lapeer, MI, Macomb,
MI, Monroe, MI, Oakland, MI, St.
Clair, MI, Wayne, MI*............ 1.0809 52.07 49.36 47.51 41.11
2180.. Dothan, AL, Dale, AL, Houston, AL. 0.7801 39.84 37.79 36.35 31.45
2190.. Dover, DE, Kent, DE............... 0.9068 44.99 42.67 41.05 35.5
2200.. Dubuque, IA, Dubuque, IA.......... 0.8176 41.36 39.23 37.74 32.65
2240.. Duluth-Superior, MN-WI, St. Louis,
MN, Douglas, WI.................. 0.9491 46.71 44.31 42.62 36.88
2281.. Dutchess County, NY, Dutchess, NY. 1.0673 51.52 48.87 47.01 40.67
2290.. Eau Claire, WI, Chippewa, WI, Eau
Claire, WI....................... 0.8747 43.68 41.44 39.86 34.49
2320.. El Paso, TX, El Paso, TX.......... 0.9539 46.91 44.49 42.80 37.03
2330.. Elkhart-Goshen, IN, Elkhart, IN... 0.8871 44.19 41.91 40.32 34.88
2335.. Elmira, NY, Chemung, NY........... 0.8484 42.61 40.42 38.88 33.64
2340.. Enid, OK, Garfield, OK............ 0.7924 40.34 38.26 36.81 31.84
2360.. Erie, PA, Erie, PA................ 0.9232 45.66 43.31 41.66 36.04
2400.. Eugene-Springfield, OR, Lane, OR.. 1.1360 54.31 51.52 49.56 42.88
2440.. Evansville-Henderson, IN-KY,
Posey, IN, Vanderburgh, IN,
Warrick, IN, Henderson, KY....... 0.9054 44.93 42.62 41.00 35.47
2520.. Fargo-Moorhead, ND-MN, Clay, MN,
Cass, ND......................... 0.9117 45.19 42.86 41.23 35.67
2560.. Fayetteville, NC, Cumberland, NC.. 0.9078 45.03 42.71 41.09 35.55
2580.. Fayetteville-Springdale-Rogers,
AR, Benton, AR, Washington, AR... 0.7277 37.70 35.76 34.40 29.77
2620.. Flagstaff, AZ-UT, Coconino, AZ,
Kane, UT......................... 0.9090 45.08 42.76 41.13 35.59
2640.. Flint, MI, Genesee, MI............ 1.1337 54.22 51.43 49.47 42.80
2650.. Florence, AL, Colbert, AL,
Lauderdale, AL................... 0.8001 40.65 38.56 37.09 32.09
2655.. Florence, SC, Florence, SC........ 0.8662 43.34 41.11 39.54 34.21
2670.. Fort Collins-Loveland, CO,
Larimer, CO...................... 1.0646 51.41 48.76 46.91 40.58
2680.. Ft. Lauderdale, FL, Broward, FL*.. 1.0632 51.35 48.71 46.86 40.54
2700.. Fort Myers-Cape Coral, FL, Lee, FL 0.9104 45.14 42.81 41.18 35.63
2710.. Fort Pierce-Port St. Lucie, FL,
Martin, FL, St. Lucie, FL........ 1.0250 49.80 47.23 45.44 39.31
2720.. Fort Smith, AR-OK, Crawford, AR,
Sebastian, AR, Sequoyah, OK...... 0.7926 40.34 38.27 36.81 31.85
2750.. Fort Walton Beach, FL, Okaloosa,
FL............................... 0.9265 45.79 43.43 41.78 36.15
2760.. Fort Wayne, IN, Adams, IN, Allen,
IN, DeKalb, IN, Huntington, IN,
Wells, IN, Whitley, IN........... 0.8870 44.18 41.91 40.32 34.88
2800.. Forth Worth-Arlington, TX Hood,
TX, Johnson, TX, Parker, TX,
Tarrant, TX*..................... 1.0233 49.73 47.17 45.37 39.26
2840.. Fresno, CA, Fresno, CA, Madera, CA 1.1265 53.93 51.15 49.20 42.57
2880.. Gadsden, AL, Etowah, AL........... 0.8951 44.51 42.22 40.62 35.14
2900.. Gainesville, FL, Alachua, FL...... 0.9509 46.78 44.38 42.69 36.93
2920.. Galveston-Texas City, TX,
Galveston, TX.................... 1.1084 53.19 50.45 48.53 41.99
2960.. Gary, IN Lake, IN, Porter, IN..... 0.9717 47.63 45.18 43.46 37.60
2975.. Glens Falls, NY, Warren, NY,
Washington, NY................... 0.8630 43.21 40.98 39.43 34.11
2980.. Goldsboro, NC, Wayne, NC.......... 0.8459 42.51 40.32 38.79 33.56
2985.. Grand Forks, ND-MN, Polk, MN,
Grand Forks, ND.................. 0.9082 45.05 42.73 41.10 35.56
2995.. Grand Junction, CO, Mesa, CO...... 0.8402 42.28 40.11 38.58 33.38
3000.. Grand Rapids-Muskegon-Holland, MI,
Allegan, MI, Kent, MI, Muskegon,
MI, Ottawa, MI................... 1.0199 49.59 47.04 45.25 39.15
3040.. Great Falls, MT, Cascade, MT...... 0.8750 43.70 41.45 39.87 34.50
3060.. Greeley, CO, Weld, CO............. 0.9767 47.83 45.37 43.65 37.76
3080.. Green Bay, WI, Brown, WI.......... 0.9110 45.16 42.84 41.21 35.65
3120.. Greensboro-Winston-Salem-High
Point, NC, Alamance, NC,
Davidson, NC, Davie, NC, Forsyth,
NC, Guilford, NC, Randolph, NC,
Stokes, NC, Yadkin, NC*.......... 0.9388 46.29 43.91 42.24 36.54
3150.. Greenville, NC, Pitt, NC.......... 0.9150 45.32 42.99 41.36 35.78
3160.. Greenville-Spartanburg-Anderson,
SC, Anderson, SC, Cherokee, SC,
Greenville, SC, Pickens, SC,
Spartanburg, SC.................. 0.8998 44.70 42.40 40.79 35.29
3180.. Hagerstown, MD, Washington, MD.... 0.9248 45.72 43.37 41.72 36.10
3200.. Hamilton-Middletown, OH, Butler,
OH............................... 0.9565 47.01 44.59 42.90 37.11
3240.. Harrisburg-Lebanon-Carlisle, PA,
Cumberland, PA, Dauphin, PA,
Lebanon, PA, Perry, PA........... 1.0238 49.75 47.19 45.39 39.27
[[Page 14863]]
3283.. Hartford, CT, Hartford, CT,
Litchfield, CT, Middlesex, CT,
Tolland, CT*..................... 1.2465 58.81 55.78 53.66 46.42
3285.. Hattiesburg, MS, Forrest, MS,
Lamar, MS........................ 0.7309 37.84 35.89 34.52 29.87
3290.. Hickory-Morganton-Lenoir, NC,
Alexander, NC, Burke, NC,
Caldwell, NC, Catawba, NC........ 0.8694 43.47 41.23 39.66 34.32
3320.. Honolulu, HI, Honolulu, HI \1\.... 1.1552 56.92 53.99 51.93 44.93
3350.. Houma, LA, Lafourche, LA,
Terrebonne, LA................... 0.7915 40.30 38.23 36.77 31.82
3360.. Houston, TX, Chambers, TX, Fort
Bend, TX, Harris, TX, Liberty,
TX, Montgomery, TX, Waller, TX*.. 1.0079 49.10 46.57 44.80 38.76
3400.. Huntington-Ashland, WV-KY-OH,
Boyd, KY, Carter, KY, Greenup,
KY, Lawrence, OH, Cabell, WV,
Wayne, WV........................ 0.9247 45.72 43.37 41.72 36.09
3440.. Huntsville, AL, Limestone, AL,
Madison, AL...................... 0.8271 41.75 39.60 38.09 32.96
3480.. Indianapolis, IN, Boone, IN,
Hamilton, IN, Hancock, IN,
Hendricks, IN, Johnson, IN,
Madison, IN, Marion, IN, Morgan,
IN, Shelby, IN*.................. 0.9981 48.70 46.20 44.44 38.45
3500.. Iowa City, IA, Johnson, IA........ 0.9435 46.48 44.09 42.41 36.70
3520.. Jackson, MI, Jackson, MI.......... 0.9117 45.19 42.86 41.23 35.67
3560.. Jackson, MS, Hinds, MS, Madison,
MS, Rankin, MS................... 0.7946 40.43 38.35 36.89 31.91
3580.. Jackson, TN, Madison, TN.......... 0.8354 42.09 39.92 38.40 33.33
3600.. Jacksonville, FL, Clay, FL, Duval,
FL, Nassau, FL, St. Johns, FL.... 0.9158 45.36 43.02 41.39 35.81
3605.. Jacksonville, NC, Onslow, NC...... 0.7111 37.03 35.12 33.79 29.23
3610.. Jamestown, NY, Chautaqua, NY...... 0.7731 39.55 37.52 36.09 31.22
3620.. Janesville-Beloit, WI, Rock, WI... 0.8713 43.55 41.30 39.73 34.38
3640.. Jersey City, NJ, Hudson, NJ....... 1.1472 54.77 51.95 49.97 43.24
3660.. Johnson City-Kingsport-Bristol, TN-
VA, Carter, TN, Hawkins, TN,
Sullivan, TN, Unicoi, TN,
Washington, TN, Bristol City, VA,
Scott, VA, Washington, VA........ 0.8954 44.53 42.23 40.63 35.15
3680.. Johnstown, PA, Cambria, PA,
Somerset, PA..................... 0.8464 42.53 40.34 38.81 33.58
3700.. Jonesboro, AR..................... 0.7277 37.70 35.76 34.40 29.77
3710.. Joplin, MO, Jasper, MO, Newton, MO 0.7698 39.42 37.39 35.97 31.12
3720.. Kalamazoo-Battlecreek, MI,
Calhoun, MI, Kalamazoo, MI, Van
Buren, MI........................ 1.0625 51.32 48.68 46.83 40.52
3740.. Kankakee, IL, Kankakee, IL........ 0.9187 45.47 43.13 41.49 35.90
3760.. Kansas City, KS-MO, Johnson, KS,
Leavenworth, KS, Miami, KS,
Wyandotte, KS, Cass, MO, Clay,
MO, Clinton, MO, Jackson, MO,
Lafayette, MO, Platte, MO, Ray,
MO*.............................. 0.9553 46.96 44.55 42.85 37.07
3800.. Kenosha, WI, Kenosha, WI.......... 0.9217 45.60 43.25 41.60 36.00
3810.. Killeen-Temple, TX, Bell, TX,
Coryell, TX...................... 1.0474 50.71 48.10 46.27 40.03
3840.. Knoxville, TN, Anderson, TN,
Blount, TN, Knox, TN, Loudon, TN,
Sevier, TN, Union, TN............ 0.8569 42.96 40.75 39.20 33.92
3850.. Kokomo, IN, Howard, IN, Tipton, IN 0.8658 43.32 41.09 39.53 34.20
3870.. La Crosse, WI-MN, Houston, MN, La
Crosse, WI....................... 0.8686 43.44 41.20 39.63 34.29
3880.. Lafayette, LA, Acadia, LA,
Lafayette, LA, St. Landry, LA,
St. Martin, LA................... 0.8228 41.57 39.43 37.93 32.82
3920.. Lafayette, IN, Clinton, IN,
Tippecanoe, IN................... 0.8851 44.11 41.84 40.25 34.82
3960.. Lake Charles, LA, Calcasieu, LA... 0.8098 41.04 38.93 37.45 32.40
3980.. Lakeland-Winter Haven, FL, Polk,
FL............................... 0.8843 44.07 41.81 40.22 34.80
4000.. Lancaster, PA, Lancaster, PA...... 0.9659 47.39 44.95 43.24 37.42
4040.. Lansing-East Lansing, MI, Clinton,
MI, Eaton, MI, Ingham, MI........ 1.0089 49.14 46.61 44.84 38.80
4080.. Laredo, TX, Webb, TX.............. 0.7129 37.10 35.19 33.86 29.29
4100.. Las Cruces, NM, Dona Ana, NM...... 0.8564 42.94 40.73 39.18 33.90
4120.. Las Vegas, NV-AZ, Mohave, AZ,
Clark, NV, Nye, NV*.............. 1.0956 52.67 49.96 48.06 41.58
4150.. Lawrence, KS, Douglas, KS......... 0.8665 43.35 41.12 39.56 34.22
4200.. Lawton, OK, Comanche, OK.......... 0.8431 42.40 40.22 38.69 33.47
4243.. Lewiston-Auburn, ME, Androscoggin,
ME............................... 0.9484 46.68 44.28 42.60 36.85
4280.. Lexington, KY, Bourbon, KY, Clark,
KY, Fayette, KY, Jessamine, KY,
Madison, KY, Scott, KY, Woodford,
KY............................... 0.8359 42.11 39.94 38.42 33.24
4320.. Lima, OH, Allen, OH, Auglaize, OH. 0.8801 43.90 41.64 40.06 34.66
4360.. Lincoln, NE, Lancaster, NE........ 0.9234 45.66 43.31 41.67 36.05
4400.. Little Rock-North Little Rock, AR,
Faulkner, AR, Lonoke, AR,
Pulaski, AR, Saline, AR.......... 0.8665 43.35 41.12 39.56 34.22
4420.. Longview-Marshall, TX, Gregg, TX,
Harrison, TX, Upshur, TX......... 0.8713 43.55 41.30 39.73 34.38
4480.. Los Angeles-Long Beach, CA, Los
Angeles, CA*..................... 1.2441 58.71 55.69 53.57 46.35
[[Page 14864]]
4520.. Louisville, KY-IN, Clark, IN,
Floyd, IN, Harrison, IN, Scott,
IN, Bullitt, KY, Jefferson, KY,
Oldham, KY....................... 0.9522 46.84 44.43 42.74 36.98
4600.. Lubbock, TX, Lubbock, TX.......... 0.8577 42.99 40.78 39.23 33.94
4640.. Lynchburg, VA, Amherst, VA,
Bedford, VA, Bedford City, VA,
Campbell, VA, Lynchburg City, VA. 0.8116 41.12 39.00 37.52 32.46
4680.. Macon, GA, Bibb, GA, Houston, GA,
Jones, GA, Peach, GA, Twiggs, GA. 0.8894 44.28 42.00 40.41 34.96
4720.. Madison, WI, Dane, WI............. 1.0100 49.19 46.66 44.88 38.83
4800.. Mansfield, OH, Crawford, OH,
Richland, OH..................... 0.8591 43.05 40.83 39.28 33.99
4840.. Mayaguez, PR, Anasco, PR, Cabo
Rojo, PR, Hormigueros, PR,
Mayaguez, PR, Sabana Grande, PR,
San German, PR\1\................ 0.4248 26.20 24.85 23.90 20.68
4880.. McAllen-Edinburg-Mission, TX,
Hidalgo, TX...................... 0.8552 42.89 40.68 39.14 33.86
4890.. Medford-Ashland, OR, Jackson, OR.. 1.0148 49.38 46.84 45.06 38.99
4900.. Melbourne-Titusville-Palm Bay, FL,
Brevard FL....................... 0.9140 45.28 42.95 41.32 35.75
4920.. Memphis, TN-AR-MS, Crittenden, AR,
DeSoto, MS, Fayette, TN, Shelby,
TN, Tipton, TN*.................. 0.8231 41.59 39.45 37.94 32.83
4940.. Merced, CA, Merced, CA............ 1.0744 51.81 49.14 47.27 40.90
5000.. Miami, FL, Dade, FL*.............. 1.0017 48.85 46.34 44.57 38.56
5015.. Middlesex-Somerset-Hunterdon, NJ,
Hunterdon, NJ, Middlesex, NJ,
Somerset, NJ*.................... 1.0969 52.72 50.01 48.11 41.62
5080.. Milwaukee-Waukesha, WI, Milwaukee,
WI, Ozaukee, WI, Washington, WI,
Waukesha, WI*.................... 0.9721 47.65 45.19 43.47 37.61
5120.. Minneapolis-St. Paul, MN-WI,
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*....................... 1.0862 52.29 49.60 47.71 41.28
5160.. Mobile, AL, Baldwin, AL, Mobile,
AL............................... 0.8044 40.82 38.72 37.25 32.23
5170.. Modesto, CA, Stanislaus, CA....... 1.0684 51.56 48.91 47.05 40.73
5190.. Monmouth-Ocean, NJ, Monmouth, NJ,
Ocean, NJ*....................... 1.0919 52.52 49.82 47.92 41.46
5200.. Monroe, LA, Ouachita, LA.......... 0.8276 41.77 39.62 38.11 32.97
5240.. Montgomery, AL, Autauga, AL,
Elmore, AL, Montgomery, AL....... 0.7938 40.39 38.31 36.86 31.89
5280.. Muncie, IN, Delaware, IN.......... 0.9791 47.93 45.46 43.73 37.84
5330.. Myrtle Beach, SC, Horry, SC....... 0.7852 40.04 37.98 36.54 31.61
5345.. Naples, FL, Collier, FL........... 1.0280 49.92 47.35 45.55 39.41
5360.. Nashville, TN, Cheatham, TN,
Davidson, TN, Dickson, TN,
Robertson, TN, Rutherford TN,
Sumner, TN, Williamson, TN,
Wilson, TN*...................... 0.9153 45.34 43.00 41.37 35.79
5380.. Nassau-Suffolk, NY, Nassau, NY,
Suffolk, NY*..................... 1.3654 63.64 60.37 58.07 50.24
5483.. New Haven-Bridgeport-Stamford-
Danbury-Waterbury, CT Fairfield,
CT New Haven, CT*................ 1.2805 60.19 57.09 54.92 47.52
5523.. New London-Norwich, CT, New
London, CT....................... 1.2359 58.37 55.37 53.26 46.08
5560.. New Orleans, LA, Jefferson, LA,
Orleans, LA, Plaquemines, LA, St.
Bernard, LA, St. Charles, LA, St.
James, LA, St. John The Baptist,
LA, St. Tammany, LA*............. 0.9368 46.21 43.83 42.16 36.48
5600.. New York, NY, Bronx, NY, Kings,
NY, New York, NY, Putnam, NY,
Queens, NY, Richmond, NY,
Rockland, NY, Westchester, NY*... 1.4266 66.13 62.73 60.34 52.21
5640.. Newark, NJ, Essex, NJ, Morris, NJ,
Sussex, NJ, Union, NJ, Warren,
NJ*.............................. 1.1855 56.32 53.43 51.39 44.47
5660.. Newburgh, NY-PA, Orange, NY, Pike,
PA............................... 1.0889 52.40 49.70 47.81 41.36
5720.. Norfolk-Virginia Beach-Newport
News, VA-NC, 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*........................ 0.8414 42.33 40.15 38.62 33.42
5775.. Oakland, CA, Alameda, CA, Contra
Costa, CA*....................... 1.5110 69.56 65.98 63.47 54.92
5790.. Ocala, FL, Marion, FL............. 0.9177 45.43 43.09 41.46 35.87
5800.. Odessa-Midland, TX, Ector, TX,
Midland, TX...................... 0.8549 42.88 40.67 38.13 33.85
5880.. Oklahoma City, OK, Canadian, OK,
Cleveland, OK, Logan, OK,
McClain, OK, Oklahoma, OK,
Pottawatomie, OK*................ 0.8437 42.42 40.24 38.71 33.49
5910.. Olympia, WA, Thurston, WA......... 1.0774 51.93 49.26 47.38 41.00
5920.. Omaha, NE-IA, Pottawattamie, IA,
Cass, NE, Douglas, NE, Sarpy, NE,
Washington, NE................... 0.9555 46.97 44.55 42.86 37.08
[[Page 14865]]
5945.. Orange County, CA, Orange, CA*.... 1.2061 57.16 54.22 52.16 45.13
5960.. Orlando, FL, Lake, FL, Orange, FL,
Osceola, FL, Seminole, FL*....... 0.9545 46.93 44.51 42.82 37.05
5990.. Owensboro, KY, Daviess, KY........ 0.7635 39.16 37.15 35.73 30.92
6015.. Panama City, FL, Bay, FL.......... 0.8125 41.15 39.04 37.55 32.49
6020.. Parkersburg-Marietta, WV-OH,
Washington, OH, Wood, WV......... 0.7939 40.40 38.32 36.86 31.89
6080.. Pensacola, FL, Escambia, FL, Santa
Rosa, FL......................... 0.8267 41.73 39.58 38.08 32.95
6120.. Peoria-Pekin, IL, Peoria, IL,
Tazewell, IL, Woodford, IL....... 0.8975 44.61 42.32 40.71 35.22
6160.. Philadelphia, PA-NJ, Burlington,
NJ, Camden, NJ, Gloucester, NJ,
Salem, NJ, Bucks, PA, Chester,
PA, Delaware, PA, Montgomery, PA,
Philadelphia, PA*................ 1.1326 54.17 51.39 49.43 42.77
6200.. Phoenix-Mesa, AZ, Maricopa, AZ,
Pinal, AZ*....................... 0.9888 48.32 45.84 44.09 38.15
6240.. Pine Bluff, AR, Jefferson, AR..... 0.7948 40.43 38.35 36.89 31.92
6280.. Pittsburgh, PA, Allegheny, PA,
Beaver, PA, Butler, PA, Fayette,
PA, Washington, PA, Westmoreland,
PA*.............................. 0.9778 47.88 45.41 43.69 37.80
6323.. Pittsfield, MA, Berkshire, MA..... 1.0636 51.37 48.72 46.87 40.55
6340.. Pocatello, ID, Bannock, ID........ 0.8854 44.12 41.85 40.26 34.83
6360.. Ponce, PR, Guayanilla, PR, Juana
Diaz, PR, Penuelas, PR, Ponce,
PR, Villalba, PR, Yauco, PR \1\.. 0.4722 28.12 26.68 25.66 22.20
6403.. Portland, ME, Cumberland, ME,
Sagadahoc, ME, York, ME.......... 0.9695 47.54 45.09 43.38 37.53
6440.. Portland-Vancouver, OR-WA,
Clackamas, OR, Columbia, OR,
Multnomah, OR, Washington, OR,
Yamhill, OR, Clark, WA*.......... 1.1324 54.17 51.38 49.42 42.76
6483.. Providence-Warwick, RI, Bristol,
RI, Kent, RI, Newport, RI,
Providence, RI, Washington, RI... 1.1180 53.58 50.82 48.89 42.30
6520.. Provo-Orem, UT, Utah, UT.......... 1.0196 49.58 47.03 45.24 39.14
6560.. Pueblo, CO, Pueblo, CO............ 0.8350 42.07 39.90 38.39 33.21
6580.. Punta Gorda, FL, Charlotte, FL.... 0.8419 42.35 40.17 38.64 33.43
6600.. Racine, WI Racine, WI............. 0.8905 44.33 42.05 40.45 34.99
6640.. Raleigh-Durham-Chapel Hill, NC,
Chatham, NC, Durham, NC,
Franklin, NC, Johnston, NC,
Orange, NC, Wake, NC............. 0.9805 47.99 45.52 43.79 37.88
6660.. Rapid City, SD, Pennington, SD.... 0.8522 42.77 40.57 39.02 33.76
6680.. Reading, PA, Berks, PA............ 0.9520 46.83 44.42 42.73 36.97
6690.. Redding, CA, Shasta, CA........... 1.1697 55.68 52.82 50.81 43.96
6720.. Reno, NV, Washoe, NV.............. 1.1105 53.27 50.53 48.61 42.06
6740.. Richland-Kennewick-Pasco, WA,
Benton, WA, Franklin, WA......... 1.0049 48.98 46.46 44.69 38.67
6760.. Richmond-Petersburg, VA, 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......................... 0.9267 45.80 43.44 41.79 36.16
6780.. Riverside-San Bernardino, CA,
Riverside, CA, San Bernardino,
CA*.............................. 1.1468 54.75 51.93 49.96 43.22
6800.. Roanoke, VA, Botetourt, VA,
Roanoke, VA, Roanoke City, VA,
Salem City, VA................... 0.8771 43.78 41.53 39.95 34.56
6820.. Rochester, MN, Olmsted, MN........ 1.0511 50.86 48.24 46.09 39.88
6840.. Rochester, NY, Genesee, NY,
Livingston, NY, Monroe, NY,
Ontario, NY, Orleans, NY, Wayne,
NY*.............................. 0.9725 47.66 45.21 43.49 37.63
6880.. Rockford, IL, Boone, IL, Ogle, IL,
Winnebago, IL.................... 0.9065 44.98 42.66 41.04 35.51
6895.. Rocky Mount, NC, Edgecombe, NC,
Nash, NC......................... 0.9026 44.82 42.51 40.90 35.38
6920.. Sacramento, CA, El Dorado, CA,
Placer, CA, Sacramento, CA*...... 1.2449 58.74 55.72 53.60 46.37
6960.. Saginaw-Bay City-Midland, MI, Bay,
MI, Midland, MI, Saginaw, MI..... 0.9688 47.51 45.07 43.35 37.51
6980.. St. Cloud, MN, Benton, MN,
Stearns, MN...................... 0.9532 46.88 44.46 42.77 37.01
7000.. St. Joseph, MO, Andrews, MO,
Buchanan, MO..................... 0.8619 43.16 40.94 39.38 34.08
7040.. St. Louis, MO-IL, 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*...... 0.9093 45.09 42.77 41.14 35.60
7080.. Salem, OR, Marion, OR, Polk, OR... 0.9805 47.99 45.52 43.79 37.88
7120.. Salinas, CA, Monterey, CA......... 1.3912 64.69 61.36 59.03 51.07
7160.. Salt Lake City-Ogden, UT, Davis,
UT, Salt Lake, UT, Weber, UT*.... 0.9754 47.78 45.32 43.60 37.72
[[Page 14866]]
7200.. San Angelo, TX, Tom Green, TX..... 0.7637 39.17 37.15 35.74 30.92
7240.. San Antonio, TX, Bexar, TX, Comal,
TX, Guadalupe, TX, Wilson, TX*... 0.8456 42.50 40.31 38.78 33.55
7320.. San Diego, CA, San Diego, CA*..... 1.2230 57.85 54.87 52.79 45.67
7360.. San Francisco, CA, Marin, CA, San
Francisco, CA, San Mateo, CA*.... 1.4373 66.57 63.14 60.74 52.55
7400.. San Jose, CA, Santa Clara, CA*.... 1.4634 67.63 64.15 61.71 53.39
7440.. San Juan-Bayamon, PR, 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\1\ *.......................... 0.4542 27.39 25.98 24.99 21.62
7460.. San Luis Obispo-Atascadero-Paso
Robles, CA, San Luis Obispo, CA.. 1.1653 55.50 52.65 50.64 43.82
7480.. Santa Barbara-Santa Maria-Lompoc,
CA, Santa Barbara, CA............ 1.1331 54.19 51.40 49.45 42.78
7485.. Santa Cruz-Watsonville, CA, Santa
Cruz, CA......................... 1.3627 63.53 60.26 57.97 50.16
7490.. Santa Fe, NM, Los Alamos, NM,
Santa Fe, NM..................... 1.0909 52.48 49.78 47.88 41.43
7500.. Santa Rosa, CA, Sonoma, CA........ 1.2586 59.30 56.25 54.11 46.81
7510.. Sarasota-Bradenton, FL, Manatee,
FL, Sarasota, FL................. 0.9866 48.24 45.75 44.01 38.08
7520.. Savannah, GA, Bryan, GA, Chatham,
GA, Effingham, GA................ 0.9725 47.66 45.21 43.49 37.63
7560.. Scranton-Wilkes-Barre-Hazleton,
PA, Columbia, PA, Lackawanna, PA,
Luzerne, PA, Wyoming, PA......... 0.8821 43.98 41.72 40.13 34.72
7600.. Seattle-Bellevue-Everett, WA,
Island, WA, King, WA, Snohomish,
WA*.............................. 1.1474 54.78 51.96 49.98 43.24
7610.. Sharon, PA, Mercer, PA............ 0.8955 44.53 42.24 40.63 35.15
7620.. Sheboygan, WI, Sheboygan, WI...... 0.7825 39.93 37.88 36.44 31.53
7640.. Sherman-Denison, TX, Grayson, TX.. 0.8682 43.42 41.19 39.62 34.28
7680.. Shreveport-Bossier City, LA,
Bossier, LA, Caddo, LA, Webster,
LA............................... 0.9433 46.47 44.08 42.41 36.69
7720.. Sioux City, IA-NE, Woodbury, IA,
Dakota, NE....................... 0.8379 42.19 40.02 38.49 33.31
7760.. Sioux Falls, SD, Lincoln, SD,
Minnehaha, SD.................... 0.8688 43.44 41.21 39.64 34.30
7800.. South Bend, IN, St. Joseph, IN.... 1.0013 48.83 46.32 44.56 38.55
7840.. Spokane, WA, Spokane, WA.......... 1.0607 51.25 48.61 46.76 40.46
7880.. Springfield, IL, Menard, IL,
Sangamon, IL..................... 0.8740 43.66 41.41 39.83 34.46
7920.. Springfield, MO, Christian, MO,
Greene, MO, Webster, MO.......... 0.7885 40.18 38.11 36.66 31.72
8003.. Springfield, MA, Hampden, MA,
Hampshire, MA.................... 1.0670 51.51 48.85 47.00 40.66
8050.. State College, PA, Centre, PA..... 0.9614 47.21 44.78 43.08 37.27
8080.. Steubenville-Weirton, OH-WV,
Jefferson, OH, Brooke, WV,
Hancock, WV...................... 0.8331 41.99 39.83 38.32 33.15
8120.. Stockton-Lodi, CA, San Joaquin, CA 1.1420 54.56 51.75 49.78 43.07
8140.. Sumter, SC, Sumter, SC............ 0.7760 39.67 37.63 36.20 31.32
8160.. Syracuse, NY, Cayuga, NY, Madison,
NY, Onondaga, NY, Oswego, NY..... 0.9469 46.62 44.22 42.54 36.81
8200.. Tacoma, WA, Pierce, WA............ 1.0946 52.63 49.92 48.02 41.55
8240.. Tallahassee, FL, Gadsden, FL,
Leon, FL......................... 0.8379 42.19 40.02 38.49 33.31
8280.. Tampa-St. Petersburg-Clearwater,
FL, Hernando, FL, Hillsborough,
FL, Pasco, FL, Pinellas, FL*..... 0.9323 46.03 43.66 42.00 36.34
8320.. Terre Haute, IN, Clay, IN,
Vermillion, IN, Vigo, IN......... 0.8659 43.33 41.10 39.53 34.20
8360.. Texarkana, AR-Texarkana, TX,
Miller, AR, Bowie, TX............ 0.8570 42.96 40.75 39.20 33.92
8400.. Toledo, OH, Fulton, OH, Lucas, OH,
Wood, OH......................... 1.0443 50.58 47.98 46.15 39.93
8440.. Topeka, KS, Shawnee, KS........... 1.0166 49.46 46.91 45.13 39.04
8480.. Trenton, NJ, Mercer, NJ........... 1.0633 51.35 48.71 46.86 40.54
8520.. Tucson, AZ, Pima, AZ.............. 0.9140 45.28 42.95 41.32 35.75
8560.. Tulsa, OK, Creek, OK, Osage, OK,
Rogers, OK, Tulsa, OK, Wagoner,
OK............................... 0.8159 41.29 39.17 37.68 32.60
8600.. Tuscaloosa, AL, Tuscaloosa, AL.... 0.7846 40.02 37.96 36.52 31.59
8640.. Tyler, TX, Smith, TX.............. 1.0075 49.09 46.56 44.79 38.75
8680.. Utica-Rome, NY, Herkimer, NY,
Oneida, NY....................... 0.8480 42.60 40.41 38.87 33.63
8720.. Vallejo-Fairfield-Napa, CA, Napa,
CA, Solano, CA................... 1.4057 65.28 61.92 59.57 51.54
8735.. Ventura, CA, Ventura, CA.......... 1.1545 55.06 52.23 50.24 43.47
8750.. Victoria, TX, Victoria, TX........ 0.8459 42.51 40.32 38.79 33.56
[[Page 14867]]
8760.. Vineland-Millville-Bridgeton, NJ,
Cumberland, NJ................... 1.0072 49.06 46.55 44.78 38.74
8780.. Visalia-Tulare-Porterville, CA,
Tulare, CA....................... 1.0231 49.72 47.16 45.37 39.25
8800.. Waco, TX, McLennan, TX............ 0.7834 39.97 37.91 36.47 31.56
8840.. Washington, DC-MD-VA-WV, District
of Columbia, DC, Calvert, MD,
Charles, MD, Frederick, MD,
Montgomery, MD, Prince Georges,
MD, Alexandria City, VA,
Arlington, VA, Clarke, VA,
Culpeper, 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*..... 1.0909 52.48 49.78 47.88 41.43
8920.. Waterloo-Cedar Falls, IA, Black
Hawk, IA......................... 0.8774 43.79 41.54 39.96 34.57
8940.. Wausau, WI, Marathon, WI.......... 1.0405 50.43 47.83 46.01 39.81
8960.. West Palm Beach-Boca Raton, FL,
Palm Beach, FL................... 1.0283 49.93 47.36 45.56 39.42
9000.. Wheeling, OH-WV, Belmont, OH,
Marshall, WV, Ohio, WV........... 0.7623 39.11 37.10 35.69 30.88
9040.. Wichita, KS, Butler, KS, Harvey,
KS, Sedgwick, KS................. 0.9443 46.51 44.12 42.44 36.72
9080.. Wichita Falls, TX, Archer, TX,
Wichita, TX...................... 0.8105 41.07 38.96 37.48 32.43
9140.. Williamsport, PA, Lycoming, PA.... 0.8534 42.82 40.61 39.07 33.80
9160.. Wilmington-Newark, DE-MD, New
Castle, DE, Cecil, MD............ 1.1405 54.49 51.69 49.72 43.02
9200.. Wilmington, NC, New Hanover, NC,
Brunswick, NC.................... 0.9118 45.19 42.87 41.24 35.68
9260.. Yakima, WA, Yakima, WA............ 1.0105 49.21 46.68 44.90 38.85
9270.. Yolo, CA Yolo, CA................. 1.1535 55.02 52.19 50.21 43.44
9280.. York, PA, York, PA................ 0.9176 45.43 43.09 41.45 35.86
9320.. Youngstown-Warren, OH, Columbiana,
OH, Mahoning, OH, Trumbull, OH... 0.9819 48.04 45.57 43.84 37.93
9340.. Yuba City, CA, Sutter, CA Yuba, CA 1.0496 50.80 48.18 46.35 40.10
9360.. Yuma, AZ, Yuma, AZ................ 0.9572 47.04 44.62 42.92 37.14
----------------------------------------------------------------------------------------------------------------
\1\ Nonlabor portion increased in the following areas based on cost of living surveys conducted by the U.S.
Office of Personnel Management:
------------------------------------------------------------------------
Adjustment
Location factor
------------------------------------------------------------------------
Alaska...................................................... 1.250
Hawaii...................................................... 1.225
Puerto Rico................................................. 1.100
------------------------------------------------------------------------
*Large Urban Area.
Table II.--Geographic Adjustment Index and Salary Equivalency Guideline Amounts for Nonurban Areas
----------------------------------------------------------------------------------------------------------------
Speech
Nonurban area Wage index Physical Occupational language Respiratory
therapy therapy therapy therapy
----------------------------------------------------------------------------------------------------------------
Alabama....................................... 0.8477 42.59 40.39 38.86 33.62
Alaska \1\.................................... 1.3329 64.35 61.04 58.71 50.80
Arizona....................................... 0.9718 47.63 45.18 43.46 37.60
Arkansas...................................... 0.8270 41.74 39.60 38.09 32.96
California.................................... 1.2551 59.16 56.11 53.98 46.70
Colorado...................................... 0.9895 48.35 45.86 44.12 38.17
Connecticut................................... 1.2644 59.53 56.47 54.32 47.00
Delaware...................................... 1.1100 53.25 50.51 48.59 42.04
Florida....................................... 0.9589 47.11 44.68 42.98 37.19
Georgia....................................... 0.9596 47.14 44.71 43.01 37.21
Hawaii \1\.................................... 1.1552 56.92 53.99 51.93 44.93
Idaho......................................... 0.9457 46.57 44.18 42.49 36.77
Illinois...................................... 1.0368 50.28 47.69 45.88 39.69
Indiana....................................... 0.9570 47.03 44.61 42.91 37.13
Iowa.......................................... 0.8889 44.26 41.98 40.39 34.94
Kansas........................................ 0.9553 46.96 44.55 42.85 37.07
Kentucky...................................... 0.9022 44.80 42.50 40.88 35.37
Louisiana..................................... 0.8884 44.24 41.96 40.37 34.93
Maine......................................... 0.9607 47.18 44.75 43.05 37.25
Maryland...................................... 1.0011 48.82 46.31 44.55 38.55
Massachusetts................................. 1.1619 55.36 52.52 50.52 43.71
Michigan...................................... 1.0717 51.70 49.04 47.17 40.81
[[Page 14868]]
Minnesota..................................... 1.0586 51.16 48.53 46.68 40.39
Mississippi................................... 0.8033 40.78 38.68 37.21 32.19
Missouri...................................... 0.8996 44.70 42.40 40.78 35.29
Montana....................................... 0.8980 44.63 42.33 40.72 35.23
Nebraska...................................... 0.9479 46.66 44.26 42.58 36.84
Nevada........................................ 1.1012 52.90 50.17 48.27 41.76
New Hampshire................................. 1.1705 55.71 52.85 50.84 43.98
New Jersey \2\................................ ........... ........... ............ ........... ...........
New Mexico.................................... 0.9501 46.75 44.34 42.66 36.91
New York...................................... 1.2428 58.66 55.64 53.52 46.31
North Carolina................................ 0.9456 46.57 44.17 42.49 36.76
North Dakota.................................. 0.8717 43.56 41.32 39.75 34.39
Ohio.......................................... 0.9764 47.82 45.36 43.63 37.75
Oklahoma...................................... 0.8320 41.95 39.79 38.28 33.12
Oregon........................................ 1.1085 53.19 50.46 48.54 41.99
Pennsylvania.................................. 1.0269 49.87 47.31 45.51 39.37
Puerto Rico \1\............................... 0.4539 27.38 25.97 24.98 21.62
Rhode Island \2\.............................. ........... ........... ............ ........... ...........
South Carolina................................ 0.8964 44.57 42.27 40.67 35.18
South Dakota.................................. 0.8638 43.24 41.02 39.46 34.14
Tennessee..................................... 0.8711 43.54 41.30 39.73 34.37
Texas......................................... 0.9492 46.71 44.31 42.62 36.88
Utah.......................................... 0.9824 48.06 45.59 43.86 37.94
Vermont....................................... 1.0148 49.38 46.84 45.06 38.99
Virginia...................................... 0.9249 45.73 43.37 41.72 36.10
Washington.................................... 1.1105 53.27 50.53 48.61 42.06
West Virginia................................. 0.9145 45.30 42.97 41.34 35.76
Wisconsin..................................... 0.9480 46.67 44.26 42.58 36.84
Wyoming....................................... 0.8386 42.22 40.04 38.52 33.33
----------------------------------------------------------------------------------------------------------------
\1\ Nonlabor portion increased in the following areas based on cost of living surveys conducted by the U.S.
Office of Personnel Management:
------------------------------------------------------------------------
Adjustment
Location factor
------------------------------------------------------------------------
Alaska...................................................... 1.250
Hawaii...................................................... 1.225
Puerto Rico................................................. 1.100
------------------------------------------------------------------------
\2\ All counties within the State are classified urban.
E. Salary Equivalency Amount Updates
The adjusted hourly salary equivalency amounts were developed using
fourth quarter 1995 wage level data, 1994 fringe benefit data as a
share of wage levels, and fourth quarter 1995 dollar amounts for rent
and other expenses (updated from January 1991 to the fourth quarter of
1995 using their price proxies). In order to account for input price
inflation between the base period (fourth quarter 1995), the
illustrative implementation period of April 1997, and subsequent
updated periods, HCFA developed therapy-specific input price indexes,
using as weights the fourth quarter 1995 relative importance factors of
the salary equivalency market baskets guideline. The therapy-specific
input price indexes are fixed-weight, or Laspeyres type, input price
indexes that were constructed in two steps. First, a base period
(fourth quarter 1995) was selected and the proportion of total costs
accounted for by designated cost categories was estimated. In the
second step, a rate of price increase for each cost category was
multiplied by the expenditure's relative importance for that category.
(Section II.B of this preamble discusses the methodology used to
develop the base-period weights (fourth quarter 1995) for each therapy-
specific input price index.) The sum of these products for all cost
categories yielded the percentage change in the input price index.
Five indexes (base = fourth quarter 1995) were developed initially:
One each representing physical therapy, occupational therapy, speech
language pathology, respiratory therapy, and a weighted composite index
of all four therapy types. The individual therapy indexes were built
into the composite index based upon the relative proportion of total
therapy services. All input price indexes have the same cost categories
and price proxies. However the base period weights vary because of
slight differences in the cost structures associated with providing
each type of therapy. Table III presents the therapy-specific base
period weights as well as the price proxies proposed to represent
inflation for each cost category.
[[Page 14869]]
Table III.--Therapy Specific Adjusted Hourly Salary Equivalency Input Price Indexes (Base Period: Fourth Quarter
1995=100.000)
----------------------------------------------------------------------------------------------------------------
Base period weights by therapy type(1)
------------------------------------------------------------------
Speech Composite Proposed price
Physical Occupational language Respiratory therapy proxies
therapy therapy pathology therapy index
----------------------------------------------------------------------------------------------------------------
Total........................ 100.000 100.000 100.000 100.000 100.000
A. Therapist Compensation.... 73.720 72.304 71.208 66.733 71.900
Wages.................... 59.326 58.186 57.304 53.703 57.860 50% ECI
Civilian
Hospital
Workers/50%
ECI Private
Professional &
Technical
Workers Wages.
Benefits................. 14.395 14.118 13.904 13.030 14.039 50% ECI
Civilian
Hospital
Workers/50%
ECI Private
Professional &
Technical
Workers
Benefits.
B. Overhead.................. 26.273 27.696 28.792 33.275 28.099
Other Compensation....... 10.733 11.314 11.762 13.593 11.478
Other Wages.............. 8.779 9.255 9.621 11.119 9.389
Clerical Wages........... 4.422 4.661 4.846 5.600 4.729 ECI Wages
Private
Administrative
Support
Including
Clerical.(2)
Managerial Wages......... 4.357 4.593 4.775 5.519 4.660 ECI Wages
Private
Executive,
Administrative
, &
Managerial.(2)
Other Benefits........... 1.953 2.059 2.141 2.474 2.089
Clerical Benefits........ 0.987 1.041 1.082 1.251 1.056 ECI Benefits
Private
Administrative
Support
Including
Clerical.(2)
Managerial Benefits...... 0.966 1.018 1.059 1.223 1.033 ECI Benefits
Private
Executive,
Administrative
, &
Managerial.(2)
Office Costs............. 6.482 6.834 7.104 8.210 6.933 CPI-U Housing.
Other Costs.............. 9.058 9.549 9.927 11.472 9.688 CPI-U All Items
Less Food &
Energy.
Composite Index Share (3).... 0.313 0.412 0.153 0.122 1.000
----------------------------------------------------------------------------------------------------------------
(1) Base year weights were developed for each type of therapy offered under arrangement. These weights are
multiplied by price index levels to measure composite price change over time.
(2) ECI=Employment Cost Index. ECIs are fixed-weighted indexes which track labor cost free from the influence of
employment shifts among occupations and industries.
(3) The composite index share represents the proportion that each therapy index type represents of the composite
index. These shares were derived from estimates of the 1995 shares of therapy services offered under
arrangement by therapy type.
Despite the differences in the fourth quarter 1995 base-year
weights for the four therapists' input price indexes, there were
virtually no differences in the rates of increase for these indexes.
Therefore, we propose to use the composite index to adjust the hourly
salary equivalency amounts for inflation. Using the composite index is
advantageous because of its administrative simplicity and demonstrated
validity. Because the five indexes produce rates of increase that are
essentially the same, the gain in administrative ease does not come at
the expense of the validity of the inflation adjustment being used.
Table IV, which presents the calendar year rates of increase in the
four therapist indexes and the composite index, demonstrates their
similarity.
Table IV.--Therapy Input Price Indexes for Forecasting the Increase in the Cost of Therapy Services, Calendar
Years 1991-1999
----------------------------------------------------------------------------------------------------------------
Speech
Physical Occupational language Respiratory Composite
Calendar year therapist therapist pathologist therapist therapist
index index index index index \1\
----------------------------------------------------------------------------------------------------------------
Historical
----------------------------------------------------------------------------------------------------------------
1991.......................................... 4.8 4.8 4.8 4.8 4.8
1992.......................................... 4.0 4.0 4.0 4.0 4.0
1993.......................................... 3.5 3.5 3.5 3.5 3.5
1994.......................................... 3.0 3.0 3.1 3.0 3.1
1995.......................................... 2.6 2.6 2.6 2.6 2.6
----------------------------------------------------------------------------------------------------------------
Forecast \2\
----------------------------------------------------------------------------------------------------------------
1996.......................................... 3.1 3.1 3.1 3.1 3.1
1997.......................................... 3.2 3.2 3.2 3.2 3.2
1998.......................................... 3.2 3.2 3.2 3.2 3.2
1999.......................................... 3.3 3.3 3.3 3.3 3.3
----------------------------------------------------------------------------------------------------------------
Released by: HCFA, OACT, Office of National Health Statistics.
\1\ The outlays for services rendered in 1995 were used to develop the outlay-weighted composite therapy index.
\2\ Source: DRI/McGraw-Hill HHC 3rd QTR 1996;@USSIM/TRENDL25YR0896@CISSIM/CONTROL963.
[[Page 14870]]
Table IV shows calendar year rates of inflation for historical
years 1991 through 1995 and forecasted years 1996 through 1999. Salary
equivalency amount adjustments will be made on a monthly basis using
the factors in Table V.
Table V: Adjusted Hourly Salary Equivalency Amount Monthly Inflation
Factors Using Outlay Weighted Composite Index
[An example of how to use the inflation factors follows this table.]
------------------------------------------------------------------------
Salary equivalency period Period
------------------------------------------------------------ inflation
Month Year factors
------------------------------------------------------------------------
1 April......................................... 1997 1.00000
2 May........................................... 1997 1.00272
3 June.......................................... 1997 1.00546
4 July.......................................... 1997 1.00819
5 August........................................ 1997 1.01094
6 September..................................... 1997 1.01369
7 October....................................... 1997 1.01646
8 November...................................... 1997 1.01922
9 December...................................... 1997 1.02200
10 January....................................... 1998 1.02478
11 February...................................... 1998 1.02758
12 March......................................... 1998 1.03037
13 April......................................... 1998 1.03318
14 May........................................... 1998 1.03600
15 June.......................................... 1998 1.03882
16 July.......................................... 1998 1.04165
17 August........................................ 1998 1.04449
18 September..................................... 1998 1.04733
19 October....................................... 1998 1.05018
20 November...................................... 1998 1.05304
21 December...................................... 1998 1.05591
22 January....................................... 1999 1.05879
23 February...................................... 1999 1.06167
24 March......................................... 1999 1.06456
25 April......................................... 1999 1.06746
26 May........................................... 1999 1.07037
27 June.......................................... 1999 1.07329
28 July.......................................... 1999 1.07621
29 August........................................ 1999 1.07914
30 September..................................... 1999 1.08208
31 October....................................... 1999 1.08503
32 November...................................... 1999 1.08799
33 December...................................... 1999 1.09095
34 January....................................... 2000 1.09392
35 February...................................... 2000 1.09690
36 March......................................... 2000 1.09989
------------------------------------------------------------------------
Source: DRI/McGraw-Hill HHC 3rd QTR 1996; @USSIM/TRENDL25YR0896
For example, the proposed national salary equivalency guideline
amount for physical therapists for cost reporting periods beginning
April 1997 is $48.78. The salary equivalency guideline amount for cost
reporting periods beginning in May 1997 would be determined as follows:
April 1997 national physical therapy salary equivalency amount...$48.78
May 1997 monthly inflation factor...............................1.00272
May 1997 national salary equivalency amount......................$48.91
We have developed monthly adjustment factors for May 1997 through
March 2000. If we do not publish new schedules of guidelines for cost
reporting periods beginning on or after April 1, 2000, or do not
announce other changes in the schedules, the schedules would remain in
effect, increased by the appropriate adjustment factor (0.00272
monthly, compounded) 1, until new guideline schedules are issued.
This is equivalent to a compounded annual rate of increase of 3.3
percent. The 3.3 percent rate of increase in the proposed guidelines is
based upon the forecast rate of increase in the composite therapists
input price index that HCFA's Office of the Actuary developed. For the
period between 1997 and 1999, the price proxies in the therapists input
price index were forecast in DRI/McGraw-Hill's 1996 third quarter
forecast.
---------------------------------------------------------------------------
1 The monthly rate of inflation is 0.00272. It is
necessary to create the multiplicative factor that produces the next
monthly level. Each month's factor (Table V) is 1.00272 times the
previous month's factor.
---------------------------------------------------------------------------
The 3.3 percent forecast rate of increase is based upon the average
annual rate of increase for the period between 1997 and 1999. The 3.3
and 7.2 percent rates of increase are applied to their respective
salary equivalency guidelines in different ways. The 3.3 percent is
applied to the guidelines we are now proposing in a multiplicative
fashion. That is, the salary equivalency guideline amount for each
month is multiplied by one plus the 12th root of the 3.3 percent
average annual rate of increase for each month moved away from the
guideline base period. Conversely, the 7.2 percent rate of increase was
applied by adding 0.6 percent of the October 1982 base value to the
adjustment factor for each month after the guideline base period. The
effect of using the additive adjustment factor rather than the
multiplicative factor is that the additive factor gets progressively
smaller in percentage terms each year.
Choosing appropriate wage and price proxies for each expense
category necessarily involved making tradeoffs and exercising judgment.
HCFA used four, sometimes conflicting, criteria to evaluate the
strengths and weaknesses of each proxy in the therapy-specific input
price indexes: relevance, reliability, timeliness, and time-series
length. A relevant price variable should appropriately represent price
changes for specific goods or services within the expense category.
Relevance may encompass judgments about relative efficiency in the
market generating the price and wage increases and may include
normative factors relating to fairness and national policy objectives.
The second criterion, reliability, concerns sampling variability. If
the proxy wage-price variable has a high sampling variability or
inexplicable erratic patterns over time, its value is greatly
diminished since it is unlikely to accurately reflect price changes in
the associated expenditure category. In some cases, low sampling
variability can conflict with relevance, since the more specifically
the price variable is defined in terms of service, commodity, or
geographic area, the higher the potential sampling variability. An
example of such a conflict is the tradeoff that must be made when
considering two proxies, one of which is the product of a rigorously
designed survey methodology for a somewhat broader occupational or
industry grouping, while the other more closely surveys the targeted
industry or occupation, but from a nonscientifically designed,
nonrepresentative sample. Timeliness of actual published data is the
third criterion. For this reason, monthly and quarterly data take
priority over annual data. The fourth criterion is the length of time
the time-series data have been available. A well-established time
series is needed to provide a valid base from which to forecast future
price changes in the series.
The price proxies for the therapy-specific input price indexes are
based on BLS data and are one of the two following types:
Employment Cost Indexes (ECIs), which measure the rate of
change in employee wage rates and employer costs for employee benefits
per hour worked. These indexes are fixed-weight indexes that strictly
measure the change in wage rates and employee benefits per hour. They
are not affected by shifts in employment mix.
Consumer Price Indexes (CPIs), which measure change in the
prices of final goods and services purchased by the typical consumer.
They are fixed-weight price measures.
These price proxies ``best balance'' the criteria of relevance,
reliability, timeliness, and time-series length. For reasons that are
discussed later, the main issue in selecting price proxies for the
Therapists Input Price Index is relevance.
In selecting price proxies for updating payment rates for various
provider types (hospitals, offices of physicians, SNFs, home health
agencies, etc.), HCFA considers using internal price proxies (that is,
health-sector-specific data), external price proxies (that is,
exclusively based upon economy-wide
[[Page 14871]]
price proxies), or a blend of internal and external price proxies based
upon the competitive structure of the market and Medicare reasonable
cost principles.2
---------------------------------------------------------------------------
2 See, for example, Changes to the Inpatient Hospital
Prospective Payment System and Fiscal Year 1997 Rates; Final rule.
61 FR 46192, August 30, 1996.
---------------------------------------------------------------------------
It is generally accepted that prices for most nonlabor inputs are
not directly influenced or biased by health-sector-specific market
forces. As a result, we propose to use economy-wide price proxies for
approximate price changes for the nonlabor inputs. However, workers in
the four therapist occupations and industries are potentially affected
by market imperfections associated with both supply and demand.
Imperfections in these labor markets include third party payment, based
at least in part on actual labor costs rather than on costs in
efficiently operating competitive labor markets. Limitations on entry
and restrictions on job content also potentially influence compensation
levels and rates of increase relative to workers with similar
education, skills, and work effort, but in different occupations and
industries. Therefore, compensation of these workers should not be
considered totally free from market imperfections and health industry
influence. To the extent that supply and demand imperfections exist,
using health-sector-specific compensation proxies could manifest these
imperfections and, therefore, would not be the most socially or
economically desirable public policy. The Prospective Payment
Assessment Commission (ProPAC) has affirmed the blending of internal
and external compensation indexes for the prospective payment system.
The Physician Payment Review Commission also has recognized that it is
appropriate to use external compensation proxies for certain health
sector specific occupations such as physicians.
At the same time, it is important to recognize some of the unique
features of the four therapist labor markets that suggested that
health-sector-specific proxies may also have relevance. HCFA has chosen
to balance these internal and external forces by using an equal blend
of sector-specific compensation proxies (ECI Civilian Hospital Workers)
and economy-wide compensation price proxies (ECI Private Professional
and Technical Workers) for measuring therapist compensation price
growth.3 The proxies that are discussed in this section have been
chosen to most closely estimate the changes that will occur in the
different costs that are part of a salary equivalency guideline. We
have already estimated the level of base period costs for the fourth
quarter of 1995 that a provider would pay. The rehabilitation therapist
input price index (IPI) proxies escalate the base level 1995 fourth
quarter costs to the present (using actual price and wage change data)
and into the future (with forecasted data). Thus, a March 1998
guideline reflects what we believe the cost to an efficient provider to
employ a therapist will be in March 1998. The rehabilitation therapist
input price index using these price proxies, weighted by the shares of
costs of the expense categories they represent, is used to forecast the
escalation of these costs over time. The principles being adopted here
are the same as those in HCFA's use of a 50/50 blend of internal and
external price proxies elsewhere in Medicare regulatory policy to
adjust the professional and technical labor compensation component of
the prospective payment system hospital input price index (IPI).4
In other words, under the prospective payment system hospital IPI
(market basket), compensation for physical therapists, occupational
therapists, speech language pathologists, and respiratory therapists is
updated using the same price proxies and blend as are proposed for
these same therapists under arrangements. Consistent with its
application in the hospital IPI, HCFA's proposed therapy-specific input
price indexes apply the blend to professional and technical occupations
only. However, for clerical and managerial workers, who are employed in
significant proportions in nonhealth sectors of the overall economy,
HCFA's therapy-specific input price indexes use economy-wide
compensation proxies to measure price change just as is done in the
prospective payment system hospital IPI for clerical and managerial
workers.
---------------------------------------------------------------------------
3 The ECI for Civilian Hospital Workers provides data on
hospital workers in the total private economy and the public sector,
excluding the Federal Government. Because this price series
represents hospitals, it is health sector-specific.
4 See, for example, Changes to the Inpatient Hospital
Prospective Payment System and Fiscal Year 1997 Rates; Final rule.
61 FR 46192, August 30, 1996.
---------------------------------------------------------------------------
F. Other Proposed Changes in Policies
1. Optional Travel Allowance
We particularly invite comments from the public on a proposal to
extend to other providers the optional travel allowance for therapy
furnished under arrangement by an outside contractor that is currently
available to HHAs. The optional travel allowance could be used when
therapy services are furnished in areas in which geographic distance
creates unique labor markets. The actual number of travel hours could
be used in lieu of the standard travel allowance. This would be used at
the option of the provider, who would maintain time records of visits.
Only the actual time spent in travel to reach the visit site would be
included in the actual travel time. Payment for the actual travel hours
would be based on the adjusted hourly salary equivalency amount for the
area, and this amount would not be affected by the additional allowance
for administrative-supervisory duties or by any other additional
allowances described in section 1412 of the Provider Reimbursement
Manual.
2. Data Sources for Future Salary Equivalency Guidelines
We have learned from the BLS that its 1991 ``Occupational Wage
Survey: Hospitals, January 1991'' is the last edition of the series
that it will produce. Prior BLS occupational wage surveys have been
used to establish salary equivalency guidelines for physical therapy
and respiratory therapy services furnished under arrangements, and we
are proposing to include as two of our data sources the 1989 and 1991
surveys trended forward. We developed our proposed guideline amounts
using many survey sources, we invite comments on alternative data
sources and methodologies for future updates.
3. Application of Guidelines
We are proposing to revise Sec. 413.106(c) to add a new paragraph
(c)(6) that would provide that the salary equivalency guidelines will
apply in situations where compensation to a therapist employed by the
provider is based, at least in part, on a fee-for-service or on a
percentage of income (or commission). The entire compensation would be
subject to the guidelines in cases where the nature of the arrangements
are most like an under ``arrangement'' situation, although technically
the provider may treat the therapists as employees. The guidelines
would be applied in this situation so that an employment relationship
is not being used to circumvent the guidelines.
Since June 1977, there has been longstanding governing policy at
section 1403 of the Provider Reimbursement Manual, Guideline
Application, regarding this issue for making payments to providers.
That instruction states, ``In situations where compensation, at least
in part, is based on a fee-for-service or on a percentage of income (or
commission), these arrangements will be considered
[[Page 14872]]
nonsalary arrangements, and the entire compensation will be subject to
the guidelines in this chapter.'' This instruction clearly requires the
intermediary to apply the salary equivalency guidelines in cases where
the provider is paying the physicial therapists on a fee-for-service
basis. This instruction considered the nature of those arrangements and
that they are most like an under ``arrangement'' situation, although
technically they are employees. Therefore, the instructions further the
statutory purpose as reflected in the legislative history of the salary
equivalency guidelines. This instruction addresses the fact that HCFA
recognizes that certain employment relationships would effectively
circumvent the guidelines and provided for these circumstances in
section 1403 of the Provider Reimbursement Manual.
4. Limiting Contracted Services To 40 Hours
While we were evaluating the data we used in developing the
guideline amounts, we became aware of a tendency for contracted therapy
hours in some cases to exceed 40 hours per therapist a week, the amount
of hours a full-time employee would generally work. While the Medicare
program does not dictate the mode of delivery of therapy services, we
do believe that under section 1861(v)(1)(A) of the Act, in making
payments for services on a reasonable cost basis, costs incurred that
are associated with providing therapy services that exceed the hours of
a full-time employee are unnecessary in the efficient delivery of
needed health services. It is our understanding that providers obtain
services on a contractual basis because the facility does not require
the services of a full-time employee and, therefore, it is more
efficient to contract for therapy services rather than hire a full-time
employee who may spend many hours not delivering services. Therefore,
we propose to eliminate the expense factor where the hours of therapy
services exceed 40 hours. Because the expense factor is associated with
costs of maintaining an outside contractor's office, we believe where
40 or more hours of service are provided per therapist, the contracted
services are being delivered in the same manner as a full-time salaried
employee. We invite comments on this proposal.
5. Outcomes Based Systems
We have received several comments requesting that the guidelines
not restrict differential therapy services (for example, ``full-
service'' programs offering supervision, outcomes measurement, and
therapy department support). Those comments have suggested that for
example, where providers incur additional costs for outcomes
measurement systems where Medicare beneficiaries benefit and thus, the
provider incurs less routine costs, the provider should be allowed to
claim those additional costs related to the outcomes measurement
system. We are aware of no outcomes measurement for therapy services
that would permit the adoption of the proposal for differentiated
services. However, we invite comments on the development of an outcomes
based system.
6. Exception for Binding Contract
Existing regulations at 42 CFR 413.106(f)(1) provide for an
exception to the salary equivalency guidelines for a provider that has
entered into a written binding contract with a therapist or contracting
organization prior to the date the initial guidelines are published.
Before the exception is granted, the provider was required to submit
the contract to its intermediary, subject to review and approval by the
HCFA regional office. The exception may be granted for the contract
period, but no longer than 1 year from the date the guidelines for the
particular therapy are published. During the period in which a binding
contract exception is in effect, the cost of the services is evaluated
under the prudent buyer concept. (Section 1414.1 of the Provider
Reimbursement Manual contains instructions on this exception.)
We are proposing to eliminate this exception. We believe that
providers should have been prudent purchasers of therapy services prior
to the establishment of guidelines for speech language pathology and
occupational therapy services and, therefore, should not be
disadvantaged if contracted speech-language pathology and occupational
therapy services are subject to the proposed guideline amounts. We also
wish to point out that there has never been an exception for providers
who enter into a contingency contract with a therapist or contracting
organization and we are not now providing such an exception. In a
contingency contract, the provider and contractor agree that, if
Medicare does not reimburse the provider for the rate that the contract
is set at, the provider and contractor agree that the provider will not
be liable for the difference.
7. Exceptions Process for Unique Circumstances or Special Labor Market
Conditions
Section 413.106 provides that a provider may request an exception
to the established hourly salary equivalency amount for unique
circumstances or special labor market conditions. The provider must
submit evidence or information to the intermediary, in accordance with
instructions issued in Sec. 1414.2 of the Provider Reimbursement
Manual, so that the intermediary can make a determination on the
request. We invite specific comments on the substantiating
documentation requirements and the process used to determine whether a
provider would be granted an exception for unique circumstances or
special labor market conditions.
8. Time Period for Submission of Exception Requests
We are proposing to revise the time period for a provider to submit
a request for an exception to the salary equivalency guidelines for
unique circumstances or special labor market conditions, to within 150
days after the close of its cost reporting period. Under existing
policy, a provider's request for an exception, together with
substantiating documentation, must be submitted to the intermediary no
later than 90 days after the close of its cost reporting period. In
response to provider claims that 90 days is not long enough for
providers to submit cost reports and, as mentioned earlier, we have
published final regulations to change the due date for submission of
cost reports (60 FR 33137). If the circumstances giving rise to the
exception remain unchanged from a prior cost reporting period, however,
the provider need only submit evidence to the intermediary 150 days
after the close of its cost reporting period to establish that fact.
III. Regulatory Impact
A. Background
For proposed rules such as this, we generally prepare a regulatory
flexibility analysis that is consistent with the Regulatory Flexibility
Act (RFA) (5 U.S.C. 601 through 612), unless we certify that a proposed
rule would not have a significant economic impact on a substantial
number of small entities. For purposes of the RFA, States and
individuals are not considered small entities. All therapists, however,
are treated as small entities.
Also, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any proposed rule that may have a
significant impact on the operations of a substantial number of small
rural hospitals. Such an analysis must conform to the provisions of
section 604 of the RFA. For purposes
[[Page 14873]]
of section 1102(b) of the Act, we define a small rural hospital as a
hospital that is located outside a Metropolitan Statistical Area and
has fewer than 50 beds. We are not preparing a rural hospital impact
statement because we have determined, and we certify, that this
proposed rule would not have a significant economic impact on the
operations of a substantial number of small rural hospitals.
This proposed rule would (1) Revise the methodology for determining
salary equivalency guidelines for physical therapy and respiratory
therapy services furnished under arrangement; (2) apply the revised
methodology for payment of physical therapy and respiratory therapy
services to speech language pathology and occupational therapy
services; and (3) establish revised schedules of salary equivalency
guidelines for physical and respiratory therapy services and initial
schedules of salary equivalency guidelines for speech language
pathology and occupational therapy services. The proposed guidelines
would be used by Medicare fiscal intermediaries to determine the
maximum allowable payment for therapy services furnished under
arrangements.
As we indicated earlier, the salary equivalency guidelines for
physical and respiratory therapy services furnished under arrangements
were last revised in 1983, with provisions for yearly adjustments for
inflation. In addition, although the law gives us explicit authority to
establish salary equivalency guidelines for speech language pathology
and occupational therapy services furnished under arrangements, we have
never previously done so. We have, instead, paid for these services
using reasonable cost methodologies. We now believe that, if we
continue to use these methods to pay for speech language pathology and
occupational therapy services furnished under arrangements, we would be
paying for costs that are in excess of what Congress intended under
section 1861(v)(5) of the Act.
Although we expect that the establishment of these proposed revised
guidelines would be beneficial to the Medicare program as well as to
Medicare beneficiaries, we recognize that a large number of small
entities, such as suppliers of rehabilitation therapy services, would
be affected by these proposed revised guidelines, and a substantial
number of these entities may be required to make changes in their
operations. This analysis, in combination with the remainder of this
preamble, is consistent with the standards for analysis set forth by
the RFA.
B. Anticipated Effects
1. Effects on the Medicare Trust Funds
The proposed guidelines are based upon a provider's reasonable cost
for an employee therapist furnishing therapy services. This cost
includes the prevailing salary levels for therapists, prevailing market
area fringe benefits, as well as a share of the other expenses that
could be attributed to an employee therapist. The estimated savings to
the Medicare Trust Funds result from the differences in the proposed
guidelines relative to current rates of payment after behavioral
offsets for increased add-ons, volume, intensity, mix of services and
other revenue enhancement behaviors have occurred.
Although we were confronted with limited available data on the
effect of the proposed guidelines on the Medicare Trust Funds, we
developed an estimate of that effect. A detailed paper on the
methodology of the impact analysis is available to interested parties
upon request. We had limited data sources with which to develop hourly
salary rates and other expense factors and to develop a projection of
the effect of the proposed guidelines on the Medicare Trust Funds for
proposed versus current levels. We are limited because the Medicare
cost reports and claims data do not furnish us with data on hourly
rates paid to therapists and other relevant expense and net revenue
data. So, we based the hourly salary rates and the effect of the
proposed guidelines on the Medicare Trust Funds on the best data
available to us from HCFA sources and the therapy industry. The hourly
salary rates were based on a blend of hospital and SNF survey data
sources and the impact analysis was based on billing data from HCFA's
Decision Support Access Facility (DSAF) files and SNF cost report data
from the Hospital Cost Reporting Information System file as well as
industry sources. We invite comments on other data sources that may be
used.
Based upon various data sources for 1993, 1994, and 1995 we formed
a base line for purposes of projecting volume of services in future
years for each of the four therapy types. For each therapy type, we
then found the difference between the current rate and the proposed
rate, multiplied that difference by the projected volume in order to
estimate the savings or additional outlays that this proposed rule
would have.
When trend factors from the DRI/McGraw Hill third quarter 1996
forecast of the HCFA rehabilitation therapist input price index are
used, we estimate the proposed guidelines for April 1997 will increase
the current national or aggregate guidelines per hour for physical
therapy by 30.5 percent and the national or aggregate guidelines for
respiratory therapy by 8.1 percent. At the same time, the proposed
guidelines for occupational therapy and speech-language pathology will
decrease estimated current aggregate rates by 42.7 percent and 28.1
percent, respectively.
Our projected savings per year are based on the difference between
current and proposed total costs after a standard behavioral adjustment
is applied for lower proposed prices relative to current payments under
current payment rules.
We followed the Office of the Actuary (OACT) standard practice of
allowing an offset of 35-50 percent for behavioral changes when we
estimated the proposed savings resulting from lowered prices. In recent
years suppliers of therapy services have bundled physical therapy,
occupational therapy, and speech language pathology (but not
respiratory therapy) when they have contracted to furnish therapy
services to SNFs. The 35 percent behavioral offset allows for changes
in behavior that generate increased revenue to the suppliers at the
lower average price for the bundle of services. The behavioral offset
was not applied to respiratory therapy services because proposed prices
are higher than current regulation prices and the respiratory therapy
industry contracts separately with the SNF industry. We chose the lower
end of the range because services are provided in the facility based on
time in facility, not fee for service, thus there are substantially
fewer opportunities for revenue enhancing behavior. Suppliers are
estimated to compensate for about one third of the reduction in prices
by a combination of increased add-ons, volume, intensity, change in
mix, and a shift in the site of service or a change in options for
reimbursement. Suppliers might shift from being suppliers where payment
is controlled by salary equivalency guidelines to being providers where
payment is on a reasonable cost basis not subject to guidelines (unless
as providers they also contract for therapy services); or they may
increase the volume of services in physical therapy where guideline
amounts are higher; or they may use less experienced and therefore
lower salaried therapists. Other revenue enhancement practices may
emerge which cannot be fully anticipated. Using this offset, the 4\1/2\
year impact of the proposed guidelines for 1997
[[Page 14874]]
through 2001 for therapy services under arrangements is estimated to be
a savings of $1,250 million for Medicare Part A and $410 million for
Medicare Part B.
When the 4\1/2\ year impact analysis methodology and the expected
percentage increase in Medicare enrollees per year (from 2002 to 2006)
are used to estimate the increased volume of rehabilitation therapy
services for 2002 to 2006, the impact on outlays over 9\1/2\ years is a
savings of $2,920 million for Medicare Part A and $980 million for
Medicare Part B.
For a 9\1/2\ year impact, the expected percentage increase in
Medicare enrollees for 2002-2006 was used in part to compute estimated
volume of services. The results were then multiplied by the estimated
current and proposed guidelines, which had been estimated by extending
the current guidelines by their inflation methods and the proposed
guidelines by their proposed inflation method. Estimated outlays for
each year under current and proposed guideline amounts were calculated.
Again a 35-percent behavioral offset was applied to the aggregate
savings for physical therapy, occupational therapy, and speech language
pathology services, and the resultant outlay savings calculated. The
results using the proposed guideline amounts were additional estimated
savings. When combined with the 4\1/2\ year total impact shown above,
the estimated 9\1/2\ year savings total is $2,920 million for Medicare
Part A and $980 million for Medicare Part B.
Our projected outlays under current guidelines, under the proposed
guidelines, and the difference between the two sets for fiscal year
1997 through fiscal year 2001 are as follows:
Salary Equivalency: Outlays and Savings Estimates--Parts A and B
----------------------------------------------------------------------------------------------------------------
Estimated outlays
------------------------------------------------ Estimated
Under proposed regulations savings after Coinsurance
Federal fiscal year Under current -------------------------------- offset (in (in millions,
regulations After offset millions, rounded)
before offset Before offset of 35 percent rounded)
(in millions) (in millions) (in millions)
----------------------------------------------------------------------------------------------------------------
1997............................ $1,790 $1,530 $1,630 $140 $20
1998............................ 3,900 3,310 3,530 340 30
1999............................ 4,230 3,560 3,810 380 40
2000............................ 4,420 3,730 3,990 390 40
2001............................ 4,620 3,900 4,170 410 40
2002............................ 4,830 4,080 4,360 430 40
2003............................ 5,040 4,270 4,560 440 40
2004............................ 5,260 4,480 4,770 450 40
2005............................ 5,490 4,690 4,990 460 40
2006............................ 5,740 4,930 5,240 460 40
-------------------------------------------------------------------------------
Totals.................... 45,320 38,480 41,050 3900 370
----------------------------------------------------------------------------------------------------------------
The budget outlays and savings include coinsurance and are before the Part B premium offset.
This applies the 35 percent offset to physical therapy, occupational therapy, and speech-language pathology only
and no offset to respiratory therapy.
Estimates are based on an illustrative effective date of April 1, 1997.
Salary Equivalency: Outlays and Savings Estimates \1\--Part A
----------------------------------------------------------------------------------------------------------------
Estimated outlays
------------------------------------------------
Under proposed regulations Estimated
Under current -------------------------------- savings (in
Federal fiscal year regulations After offset millions,
before offset Before offset of 35 percent rounded)
(in millions) (in millions) (in millions)
\2\
----------------------------------------------------------------------------------------------------------------
1997............................................ $1,370 $1,200 $1,270 $100
1998............................................ 2,990 2,590 2,740 250
1999............................................ 3,250 2,780 2,960 290
2000............................................ 3,400 2,910 3,100 300
2001............................................ 3,550 3,050 3,240 310
2002............................................ 3,710 3,190 3,390 320
2003............................................ 3,870 3,330 3,540 330
2004............................................ 4,040 3,490 3,700 340
2005............................................ 4,210 3,660 3,870 340
2006............................................ 4,410 3,850 4,070 340
---------------------------------------------------------------
Totals.................................... 34,800 30,050 31,880 2,920
----------------------------------------------------------------------------------------------------------------
\1\ Estimates are based on an illustrative effective date of April 1, 1997.
\2\ This applies the 35 percent offset to physical therapy, occupational therapy, and speech-language pathology
only and no offset to respiratory therapy.
[[Page 14875]]
Salary Equivalency: Outlays and Savings Estimates \1\--Part B
----------------------------------------------------------------------------------------------------------------
Estimated outlays \2\
-------------------------------------------------------------------------------
Under proposed regulations
Under current -------------------------------- Estimated
Federal fiscal year regulations After offset savings (in Coinsurance
before offset Before offset of 35 percent millions, (in millions,
(in millions) (in millions) (in millions) rounded) rounded)
\3\
----------------------------------------------------------------------------------------------------------------
1997............................ $420 $330 $360 $40 $20
1998............................ 910 720 790 90 30
1999............................ 980 780 850 90 40
2000............................ 1,020 820 890 90 40
2001............................ 1,070 850 930 100 40
2002............................ 1,120 890 970 110 40
2003............................ 1,170 940 1,020 110 40
2004............................ 1,220 990 1,070 110 40
2005............................ 1,280 1,030 1,120 120 40
2006............................ 1,330 1,080 1,170 120 40
Totals.......................... 10,520 8,430 9,170 980 370
----------------------------------------------------------------------------------------------------------------
\1\ Estimates are based on an illustrative effective date of April 1, 1997.
\2\ The budget outlays and savings include coinsurance and are before the Part B premium offset.
\3\ This applies the 35 percent offset to physical therapy, occupational therapy, and speech-language pathology
only and no offset to respiratory therapy.
2. Effects on Providers
We expect that the proposed salary equivalency guidelines will
provide adequate payments for all classes of efficient providers. It is
possible that certain inefficient therapy suppliers may be unwilling to
contract with providers at the proposed salary equivalency rates,
expanding the market for more efficient therapy suppliers. We also
understand that certain therapy suppliers were requiring providers to
purchase a bundled package of physical therapy, occupational therapy,
and speech-language pathology services. By requiring this bundling of
services, suppliers were able to make substantial profits because, even
though there was an hourly payment limit on the physical therapy
services, there were no guidelines for the speech-language pathology
and occupational therapy services. Consequently, the suppliers marked
up the speech-language pathology and occupational therapy services. Our
proposed guidelines for speech-language pathology and occupational
therapy services may eliminate suppliers profiting from excessively
high prices for occupational therapy and speech language pathology. We
expect that providers will continue to provide therapy services at the
proposed published rates. We expect that providers will be able to
furnish the same array of beneficiary services they furnish under
current guidelines amounts or payment on a reasonable cost basis.
3. Effects on Beneficiaries
We believe that the impact of the proposed guidelines on Medicare
beneficiaries will be minimal. Beneficiaries may be slightly affected
by the proposed guidelines for physical therapy, speech language
pathology, and occupational therapy services. With respect to physical
therapy services, the Medicare Part B coinsurance amounts associated
with these services, that must be paid by beneficiaries (20 percent of
the provider's charges to the beneficiary) may increase if providers
increase charges for those services. The charges may increase because
physical therapy hourly amounts recognized by Medicare fiscal
intermediaries to determine the maximum allowable cost of those
services will increase in this proposed rule over the previous
schedules of guidelines. However, the Medicare program does not dictate
a provider's charge structure. We do expect charges to be reasonably
related to cost. Conversely, beneficiary coinsurance would be reduced
for speech language pathology and occupational therapy services because
Medicare payment rates for these services would be reduced by the
establishment of guidelines in this proposed notice and the provider's
charges to the beneficiary may also decrease. Because respiratory
therapy provided in comprehensive outpatient rehabilitation facilities
under arrangements is a Part B service, Medicare Part B coinsurance
amounts related to those services that must be paid by beneficiaries
may increase if providers increase charges for those services. This may
also occur because respiratory therapy hourly amounts recognized by
Medicare fiscal intermediaries to determine the maximum allowable cost
of those services will increase in this proposed notice over the
previous schedules of guidelines. We believe that our proposed
guideline amounts are adequate so that therapy suppliers should
continue to contract with providers to furnish services to
beneficiaries. Since we are now introducing proposed guideline amounts
for occupational therapy and speech language pathology, if providers
are passing along the therapy companies higher charges, then we would
expect providers' charges may be lower for those services.
4. Effects on Therapists and Therapist Companies
The proposed salary equivalency guidelines would have varying
impacts on the four categories of therapists. Speech language
pathologists and occupational therapists working for contract suppliers
should be minimally affected, since the suppliers typically bundle all
therapy services when negotiating rates (including overhead) with
providers. Physical therapists acting as suppliers or employed by
supplying therapy companies may be affected positively because physical
therapy hourly rates recognized by Medicare fiscal intermediaries to
determine the maximum allowable cost of those services will increase in
this proposed notice and, therefore, providers may contract with
physical therapists at a higher amount. Also, providers may contract
with therapy companies at a higher amount and they, in turn, may pay
the therapists higher salaries. Similarly, respiratory therapists
acting as therapy suppliers or employed by therapy suppliers may be
positively affected because respiratory therapy
[[Page 14876]]
hourly amounts recognized by Medicare fiscal intermediaries to
determine the maximum allowable cost of those services will increase in
this proposed notice and, therefore, providers may contract with
respiratory therapy suppliers at a higher amount. Also providers may
contract with therapy companies at a higher amount and they, in turn,
may pay the therapists higher salaries.
We recognize that a large percentage of providers have contracts
with therapy companies that may dominate a market area. We understand
that because the contracted physical therapy services have been limited
by the guidelines, some of these therapy companies have been requiring
providers to sign up for three therapy services, that is, physical,
occupational and speech-language pathology services, but were
overcharging providers for speech-language pathology and occupational
therapy services. These therapy companies may incorrectly claim that
the introduction of our proposed guidelines for contracted speech-
language pathology and occupational therapy services may put them out
of business. Our rates are designed to reflect adequate rates for all
classes of efficient suppliers. Even though we do not pay contracted
therapy companies directly, unless they also act as providers, and
(with the exception of independent physical therapists and occupational
therapists) contracted therapy services are one of the few Medicare
services that have not been targeted in earlier deficit reduction laws.
Other changes in behavior might include a change in the type of
therapy offered (perhaps substituting physical therapy for occupational
therapy and increasing the volume of services furnished in physical
therapy, which has a higher guideline amount), use by suppliers of less
experienced (and therefore lower salaried) therapists, a shift by
suppliers from furnishing therapy services under arrangements to
furnishing therapy services under agreement, in which the therapy
company bills Medicare directly as a provider under Part B. In the
latter case, the providers are paid under Part B on a reasonable cost
basis and are not subject to salary equivalency guidelines unless they
contract for therapy services.
Inefficiently run rehabilitation therapy companies may cut expenses
and become more efficient, as is happening in much of the rest of the
economy. More efficient companies may expand or enter the market,
picking up the therapy services volume which less efficient suppliers
may leave unserved. Therapists'' productivity could increase. Overhead
is a likely candidate for expense reduction. In addition, profit
margins may be reduced, but still be at or above competitive rates for
efficient firms. Individual therapy suppliers may already have lower
overhead than corporate suppliers. Multi-therapy companies may adjust
their service mix away from therapy types for which they are
inefficient producers and expand the therapy types for which they are
efficient producers.
Due to the proposed salary equivalency guidelines, some therapists
who work for inefficient rehabilitation therapy suppliers may have
compensation levels above competitive rates and may find that their
yearly salary and fringe benefit increases lag those of therapists
employed in other more competitive settings of the local therapist
labor market. A deceleration in wage increases for workers with
excessively high compensation levels will continue until wages in
various settings, after compensating non-wage differences, are roughly
comparable for each therapy type. Those therapists whose employers
curtail furnishing services under arrangements with providers may
either furnish therapy for those same employers as employees of
rehabilitation agencies that will bill Medicare directly as providers,
change employers to those efficiently run companies that expand their
contracted therapy services, or become self-employed and contract
directly with providers to furnish therapy services under arrangements.
Therapists who are employed by efficient rehabilitation therapy
suppliers where salaries are in line with those of other therapists
(after adjustments for compensating non-wage differentials) in the
local labor market should notice no substantial effect. The expected
effects described above result in a better functioning, more efficient
health care system.
C. Alternatives Considered
Section 1861(v)(5) of the Act requires us to determine the
reasonable cost of services furnished to Medicare beneficiaries ``under
an arrangement'' with a provider of services, by therapists or other
health-related personnel. Other alternatives to implementing the salary
equivalency program are to continue paying for therapy services
furnished under arrangements using current reasonable cost
methodologies or to use alternative data sources to establish the
proposed salary equivalency guidelines.
We rejected the first alternative because, if we continue to pay
for speech language pathology and occupational therapy services
furnished under arrangements using reasonable cost methodologies, we
will be paying for costs that are in excess of what Congress intended
under section 1861(v)(5) of the Act, to the detriment of the Medicare
Trust Funds. In the case of physical therapy and respiratory therapy
services, current salary equivalency guidelines may reflect less than a
provider's reasonable costs in furnishing these services.
As we indicated in our discussion of data sources we used to
establish the proposed guidelines (see section II.A. of this proposed
rule), we were unable to find a sole or primary source of data on
hourly rates paid to therapists by providers that is timely and
statistically valid. Because the BLS hospital wage industry surveys
were not timely, we were unable to use that data as our sole source as
in prior guideline notices. The rehabilitation therapy industry has
submitted survey data to HCFA that they believe support higher
guideline amounts than are proposed in this proposed rule. Although the
survey data was submitted to us to determine its appropriateness for
use in determining new guideline amounts as provided in 42 CFR
413.106(b)(6), it did not meet the requirements in those regulations,
but we nevertheless evaluated the data. As indicated in Section II.A.
of this preamble, because we were unable to find a sole or primary
source that met our criteria of reliability, validity, and
representativeness, we decided to blend selected hospital and SNF data
sources so that the wages and salary parts of our proposed rule have
been determined using a ``best estimate'' approach, giving equal weight
to each data source, but preferential status to none.
D. Conclusion
Federal Medicare expenditures have grown at an extraordinary rate
in recent years. A study commissioned by the National Association for
Support of Long-Term Care indicates that 75 percent of all therapy
services under arrangements were furnished in SNFs. We also project
that the 65 and over population will nearly double by the year 2025. We
believe that the salary equivalency guidelines proposed in this rule
are in the public interest since they balance the needs of Medicare
program beneficiaries, (taxpayers), providers of therapy services, and
suppliers who furnish therapy services under arrangements.
Nevertheless, we solicit public comments as well as acceptable data on
the extent to which any of the affected entities would be significantly
economically affected by these guidelines.
[[Page 14877]]
We are not preparing a rural impact analysis since we have
determined, and certify, that this proposed rule would not have a
significant impact on the operations of a substantial number of small
rural hospitals.
In accordance with the provisions of Executive Order l2866, this
proposed rule was reviewed by the Office of Management and Budget.
IV. Response to Comments
Because of the large number of items of correspondence we normally
receive on a proposed rule, we are not able to acknowledge or respond
to them individually. However, we will consider all comments that we
receive by the date and time specified in the ``Dates'' section of this
preamble, and if we proceed with the final rule, we will respond to the
comments in the preamble of the final rule.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, agencies are required to
provide a 60-day notice in the Federal Register and solicit public
comment before 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.
This proposed rule contains a collection of information requirement
that would be subject to OMB review and approval. Section 413.106(e)
requires a provider of therapy services to supply its intermediary with
documentation that supports additional costs incurred for services
furnished by an outside supplier. Under Sec. 413.106(f), before an
exception to the application of the guidelines may be granted, the
provider must submit appropriate evidence, in accordance with
instructions issued in section 1414 of the Provider Reimbursement
Manual, to its intermediary to substantiate its claim.
Public reporting burden for this collection of information is
estimated to be 10 providers at 15 minutes each to prepare and submit
to the intermediary documentation that supports the additional costs.
We estimate that 10 providers will request an exception. It will take
intermediaries 2 hours to process each request. The total public burden
is 22\1/2\ hours.
This collection of information request is not effective until it
has been approved by OMB. A notice will be published in the Federal
Register when approval is obtained. Organizations and individuals
desiring to submit comments on this requirement should direct them to
the OMB official whose name appears in the ADDRESSES section of this
preamble.
List of Subjects in 42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR part 413 would be amended as set forth below:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED
PAYMENT 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).
2. In Sec. 413.106, paragraph (c)(5) is redesignated as paragraph
(c)(6) and republished, a new paragraph (c)(5) is added, paragraph
(f)(1) is removed and paragraphs (f) (2), (3), and (4) are redesignated
as (f) (1), (2), and (3) and republished, to read as follows:
Sec. 413.106 Reasonable cost of physical and other therapy services
furnished under arrangements.
* * * * *
(c) Application. * * *
(5) If therapy services are performed in situations where
compensation to a therapist employed by the provider is based, at least
in part, on a fee-for-service or on a percentage of income (or
commission), the guidelines will apply. The entire compensation will be
subject to the guidelines in cases where the nature of the arrangements
is most like an under ``arrangement'' situation, although technically
the provider may treat the therapists as employees. The intent of this
section is to prevent an employment relationship from being used to
circumvent the guidelines.
(6) These provisions are applicable to individual therapy services
or disciplines by means of separate guidelines by geographical area and
apply to costs incurred after issuance of the guidelines but no earlier
than the beginning of the provider's cost reporting period described in
paragraph (a) of this section. Until a guideline is issued for a
specific therapy or discipline, costs are evaluated so that such costs
do not exceed what a prudent and cost-conscious buyer would pay for the
given service.
* * * * *
(f) Exceptions: The following exceptions may be granted but only
upon the provider's demonstration that the conditions indicated are
present:
(1) Exception because of unique circumstances or special labor
market conditions. An exception may be granted under this section by
the intermediary if a provider demonstrates that the costs for therapy
services established by the guideline amounts are inappropriate to a
particular provider because of some unique circumstances or special
labor market conditions in the area. The provider's request for an
exception, together with substantiating documentation, must be
submitted to the intermediary each year, no later than 150 days after
the close of the provider's cost reporting period. If the circumstances
giving rise to the exception remain unchanged from a prior cost
reporting period, however, the provider need only submit evidence of
the intermediary 150 days after the close of its cost reporting period
to establish that fact.
(2) Exception for services furnished by risk-basis HMO providers.
For special rules concerning services furnished to an HMO's enrollees
who are Medicare beneficiaries by a provider owned or operated by a
risk-basis HMO (see Sec. 417.201(b) of this chapter) or related to a
risk-basis HMO by common ownership or control (see Sec. 417.205(c) of
this chapter).
(3) Exception for inpatient hospital services. Effective with cost
reporting periods beginning on or after October 1, 1983, the costs of
therapy services furnished under arrangements to a hospital inpatient
are excepted from the guidelines issued under this section if such
costs are subject to the provisions of Sec. 413.40 or part 412 of this
chapter. The intermediary will grant the exception without request from
the provider.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773
Medicare--Hospital
[[Page 14878]]
Insurance Program and Program No. 93.774, Medicare--Supplementary
Medical Insurance Program)
Dated: November 8, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: January 13, 1997.
Donna E. Shalala,
Secretary.
[FR Doc. 97-7477 Filed 3-26-97; 2:28 pm]
BILLING CODE 4120-01-P