[Federal Register Volume 62, Number 105 (Monday, June 2, 1997)] [Proposed Rules] [Pages 29902-30169] From the Federal Register Online via the Government Publishing Office [www.gpo.gov] [FR Doc No: 97-14248] [[Page 29901]] _______________________________________________________________________ Part III Department of Health and Human Services _______________________________________________________________________ Health Care Financing Administration _______________________________________________________________________ 42 CFR Parts 412, 413, and 489 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 1998 Rates; Proposed Rule Federal Register / Vol. 62, No. 105 / Monday, June 2, 1997 / Proposed Rules [[Page 29902]] DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Care Financing Administration 42 CFR Parts 412, 413, and 489 [BPD-878-P] RIN 0938-AH55 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 1998 Rates AGENCY: Health Care Financing Administration (HCFA), HHS. ACTION: Proposed rule. ----------------------------------------------------------------------- SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the systems. In addition, in the addendum to this proposed rule, we are describing proposed changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes would be applicable to discharges occurring on or after October 1, 1997. We are also setting forth proposed rate-of- increase limits as well as proposing changes for hospitals and hospital units excluded from the prospective payment systems. DATES: Comments will be considered if received at the appropriate address, as provided below, no later than 5 p.m. on August 1, 1997. ADDRESSES: Mail written comments (an original and three copies) to the following address: Health Care Financing Administration, Department of Health and Human Services, Attention: BPD-878-P, P.O. Box 7517, Baltimore, MD 21207- 0517. If you prefer, you may deliver your written comments (an 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, Central Building, 7500 Security Boulevard, Baltimore, MD 21244-1850. Because of staffing and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code BPD-878-P. Comments received timely will be available for public inspection as they are received, generally beginning approximately three weeks after publication of a document, in Room 309- G of the Department's offices at 200 Independence Avenue, SW., Washington, DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. (phone: (202) 690-7890). For comments that relate to information collection requirements, mail a copy of comments to: Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503. Attn: Allison Herron Eydt, HCFA Desk Officer; and Office of Financial and Human Resources, Management Planning and Analysis Staff, Room C2-26-17, 7500 Security Boulevard, Baltimore, MD 21244-1850. Copies: To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512- 2250. The cost for each copy is $8.00. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register. FOR FURTHER INFORMATION CONTACT: Nancy Edwards, (410) 786-4531, Operating Prospective Payment, DRG, and Wage Index Issues. Frank Emerson, (410) 786-4656, Capital Prospective Payment, Excluded Hospitals, and Graduate Medical Education Issues. SUPPLEMENTARY INFORMATION: I. Background A. Summary Under section 1886(d) of the Social Security Act (the Act), a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively-set rates was established effective with hospital cost reporting periods beginning on or after October 1, 1983. Under this system, Medicare payment for hospital inpatient operating costs is made at a predetermined, specific rate for each hospital discharge. All discharges are classified according to a list of diagnosis-related groups (DRGs). The regulations governing the hospital inpatient prospective payment system are located in 42 CFR Part 412. On August 30, 1996, we published a final rule (61 FR 46166) to implement changes to the prospective payment system for hospital operating costs beginning with Federal fiscal year (FY) 1997. As required by section 1886(g) of the Act, effective with cost reporting periods beginning on or after October 1, 1991, we implemented a prospective payment methodology for hospital inpatient capital- related costs. Under the new methodology, a predetermined payment amount per discharge is made for Medicare inpatient capital-related costs. B. Major Contents of This Proposed Rule In this proposed rule, we are setting forth proposed changes to the Medicare hospital inpatient prospective payment systems for both operating costs and capital-related costs. This proposed rule would be effective for discharges occurring on or after October 1, 1997. Following is a summary of the major changes that we are proposing to make: 1. Changes to the DRG Classifications and Relative Weights As required by section 1886(d)(4)(C) of the Act, we must adjust the DRG classifications and relative weights at least annually. Our proposed changes for FY 1998 are set forth in section II. of this preamble. 2. Changes to the Hospital Wage Index In section III. of this preamble, we discuss proposed revisions to the wage index and the annual update of the wage data. Specific issues addressed in this section include:FY 1998 wage index update. Revisions to the wage index based on hospital redesignations. Revised process for wage data verification. 3. Revision of the Operating Hospital Market Baskets In section IV. of this preamble, we discuss our proposal to use a revised hospital market basket in developing the FY 1998 update factor for the operating prospective payment rates and the excluded hospital rate-of-increase limits. [[Page 29903]] 4. Other Changes to the Prospective Payment System for Inpatient Operating Costs In section V. of this preamble, we discuss several provisions of the regulations in 42 CFR Parts 412 and 413 and set forth certain proposed changes concerning the following: Elimination of day outlier payments. Rural referral centers. Indirect medical education. Direct graduate medical education programs. 5. Changes to the Prospective Payment System for Capital-Related Costs In section VI. of this preamble, we discuss several provisions of the regulations in 42 CFR part 412, 413, and 489 and set forth certain proposed changes and clarifications concerning the following: Possible adjustments to capital minimum payment levels. Special exceptions application process. 6. Changes for Hospitals and Hospital Units Excluded From the Prospective Payment Systems In section VII. of this preamble, we discuss the criteria for ``hospitals within hospitals'' seeking exclusion from the prospective payment system. We also discuss technical clarifications concerning exclusion of rehabilitation units. 7. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits In the addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 1998 prospective payment rates for operating costs and capital-related costs. We also are proposing update factors for determining the rate- of-increase limits for cost reporting periods beginning in FY 1998 for hospitals and hospital units excluded from the prospective payment system. 8. Impact Analysis In Appendix A, we set forth an analysis of the impact that the proposed changes described in this proposed rule would have on affected entities. 9. Capital Acquisition Model Appendix B contains the technical appendix on the proposed FY 1998 capital cost model. 10. Revised Market Basket Data Sources Appendix C sets forth the data sources used to determine the market basket relative weights and choice of price proxies. 11. Report to Congress on the Update Factor for Prospective Payment Hospitals and Hospitals Excluded From the Prospective Payment System Section 1886(e)(3)(B) of the Act requires that the Secretary report to Congress on our initial estimate of an update factor for FY 1998 for both hospitals included in and hospitals excluded from the prospective payment systems. This report is included as Appendix D to this proposed rule. 12. Proposed Recommendation of Update Factor for Hospital Inpatient Operating Costs As required by sections 1886 (e)(4) and (e)(5) of the Act, Appendix E provides our recommendation of the appropriate percentage change for FY 1998 for the following: Large urban area and other area average standardized amounts (and hospital-specific rates applicable to sole community hospitals) for hospital inpatient services paid for under the prospective payment system for operating costs. Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the prospective payment system. 13. Discussion of Prospective Payment Assessment Commission Recommendations The Prospective Payment Assessment Commission (ProPAC) is directed by section 1886(e)(2)(A) of the Act to make recommendations on the appropriate percentage change factor to be used in updating the average standardized amounts. In addition, section 1886(e)(2)(B) of the Act directs ProPAC to make recommendations regarding changes in each of the Medicare payment policies under which payments to an institution are prospectively determined. In particular, the recommendations relating to the hospital inpatient prospective payment systems are to include recommendations concerning the number of DRGs used to classify patients, adjustments to the DRGs to reflect severity of illness, and changes in the methods under which hospitals are paid for capital- related costs. Under section 1886(e)(3)(A) of the Act, the recommendations required of ProPAC under sections 1886(e)(2) (A) and (B) of the Act are to be reported to Congress not later than March 1 of each year. We are printing ProPAC's March 1, 1997 report, which includes its recommendations, as Appendix F of this document. The recommendations, and the actions we are proposing to take with regard to them (when an action is recommended), are discussed in detail in the appropriate sections of this preamble, the addendum, or the appendices to this proposed rule. See section VIII. of this preamble for specific information concerning where individual recommendations are addressed. For a brief summary of the ProPAC recommendations, we refer the reader to the beginning of the ProPAC report as set forth in Appendix F of this proposed rule. For further information relating specifically to the ProPAC report, contact ProPAC at (202) 401-8986. II. Proposed Changes to DRG Classifications and Relative Weights A. Background Under the prospective payment system, we pay for inpatient hospital services on the basis of a rate per discharge that varies by the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case takes an individual hospital's payment rate per case and multiplies it by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG relative to the average resources used to treat cases in all DRGs. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. The proposed changes to the DRG classification system and the proposed recalibration of the DRG weights for discharges occurring on or after October 1, 1997 are discussed below. B. DRG Reclassification 1. General Cases are classified into DRGs for payment under the prospective payment system based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). The Medicare fiscal intermediary enters the information into its claims system and subjects it to a [[Page 29904]] series of automated screens called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before classification into a DRG can be accomplished. After screening through the MCE and any further development of the claims, cases are classified by the GROUPER software program into the appropriate DRG. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and demographic information (that is, sex, age, and discharge status). It is used both to classify past cases in order to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights. Currently, cases are assigned to one of 492 DRGs in 25 major diagnostic categories (MDCs). Most MDCs are based on a particular organ system of the body (for example, MDC 6, Diseases and Disorders of the Digestive System); however, some MDCs are not constructed on this basis since they involve multiple organ systems (for example, MDC 22, Burns). In general, principal diagnosis determines MDC assignment. However, there are five DRGs to which cases are assigned on the basis of procedure codes rather than first assigning them to an MDC based on the principal diagnosis. These are the DRGs for liver, bone marrow, and lung transplant (DRGs 480, 481, and 495, respectively) and the two DRGs for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs before classification to an MDC. Within most MDCs, cases are then divided into surgical DRGs (based on a surgical hierarchy that orders individual procedures or groups of procedures by resource intensity) and medical DRGs. Medical DRGs generally are differentiated on the basis of diagnosis and age. Some surgical and medical DRGs are further differentiated based on the presence or absence of complications or comorbidities (hereafter CC). Generally, GROUPER does not consider other procedures; that is, nonsurgical procedures or minor surgical procedures generally not performed in an operating room are not listed as operating room (OR) procedures in the GROUPER decision tables. However, there are a few non-OR procedures that do affect DRG assignment for certain principal diagnoses, such as extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones. The changes we are proposing to make to the DRG classification system for FY 1998 and other decisions concerning DRGs are set forth below. Unless otherwise noted, our DRG analysis is based on a 10 percent random sample of the FY 1996 MedPAR file. 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Stereotactic Radiosurgery. Effective October 1, 1995, procedure code 92.3 (stereotactic radiosurgery) was created and classified as a non-OR procedure. However, because this procedure had previously been coded to procedure codes that are classified as operating room procedures, we assigned procedure code 92.3 to the same surgical DRGs as the predecessor codes. Therefore, in the following DRGs, stereotactic radiosurgery is considered a non-OR procedure that affects DRG assignment: In MDC 1, DRG 1 (Craniotomy Age >17 Except for Trauma), DRG 2 (Craniotomy for Trauma Age >17), and DRG 3 (Craniotomy Age 0-17) and, in MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders), DRG 286 (Adrenal and Pituitary Procedures). In addition, in MDC 17 (Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms), procedure code 92.3 is considered a major OR procedure for purposes of assignment to DRG 400 (Lymphoma and Leukemia with Major OR Procedure) and DRGs 406 and 407 (Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major OR Procedure).1 We stated in the June 2, 1995 proposed rule (60 FR 29207) that we would analyze the stereotactic radiosurgery cases as soon as the FY 1996 cases were available to ensure that these DRG assignments were appropriate. --------------------------------------------------------------------------- \1\ A single title combined with two DRG numbers is used to signify pairs. Generally, the first DRG is for cases with CC and the second DRG is for cases without CC. If a third number is included, it represents cases of patients who are age 0-17. Occasionally, a pair of DRGs is split on age >17 and age 0-17. --------------------------------------------------------------------------- In analyzing the FY 1996 MedPAR file, we find that there were stereotactic radiosurgery cases assigned to DRGs 1, 286, 400, and 407. In DRG 1, the average standardized charges for these cases is approximately $16,400 compared to approximately $27,800 for DRG 1 overall and the lengths of stay are about 3 days and 10 days, respectively. In DRG 286, the average charges for procedure code 92.3 are also much lower than all cases in that DRG, about $11,900 versus $19,400. Again the length of stay is also much lower for stereotactic radiosurgery, just over 1 day compared to almost 7 days for all DRG 286 cases. Clearly, the cases associated with procedure code 92.3 are much less resource intensive than the other cases in the DRGs to which it is assigned. There are two courses of action that we could take. One, we could continue to consider code 92.3 a non-OR procedure that affects DRG assignment and reassign it to more appropriate surgical DRGs in MDC 1 and 11. On the other hand, we could consider it a non-OR code that does not affect DRG assignment. In the latter situation, cases currently assigned to surgical DRGs because of the performance of stereotactic radiosurgery would be reassigned to medical DRGs in the same MDC. A review of the average charges for the medical DRGs in MDCs 1 and 11 to which these cases would be assigned reveals that these DRGs are not as resource intensive as the stereotactic radiosurgery cases. Therefore, due to the higher charges associated with these cases, we are proposing to reassign procedure code 92.3 to DRGs 7 and 8 (Peripheral and Cranial Nerve and Other Nervous System Procedures) in MDC 1 and DRGs 292 and 293 (Other Endocrine, Nutrition and Metabolic OR Procedures). We are also proposing to remove procedure code 92.3 from the list of major OR procedures in MDC 17. Again the average charges of those cases are lower than the other cases assigned to those DRGs. Therefore, these cases would be assigned to DRGs 401 and 402 (Lymphoma and Non- Acute Leukemia with Other OR Procedure) and DRG 408 (Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other OR Procedure). b. Sleep Apnea. In our August 30, 1996 final rule (61 FR 46168), we discussed our review of the DRG assignment of cases in which surgery is performed to correct obstructive sleep apnea (diagnosis code 780.57). When coded as the principal diagnosis, sleep apnea is assigned to DRGs 34 and 35 (Other Disorders of the Nervous System) in MDC 1. The result of our review was to assign several surgical procedures used to correct sleep apnea to DRGs 7 and 8 (Peripheral and Cranial Nerve and Other Nervous System Procedures). These procedures involved repair of the palate [[Page 29905]] or pharynx (procedure codes 27.69, 29.4, and 29.59). Previously, since none of these surgical procedures had been assigned to MDC 1, cases of sleep apnea treated with one of these procedures had been assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis) or DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis). An associated procedure that is also used to treat sleep apnea is correction of cleft palate (procedure code 27.62). Currently, correction of cleft palate is assigned only to DRG 52 (Cleft Lip and Palate Repair) in MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat). Thus, when this procedure is performed for sleep apnea cases, the cases would be assigned to DRG 477. We are proposing to add this surgical procedure to MDC 1. Like the palate and pharynx repair procedures that were addressed last year, these cases are not clinically similar to the other surgical DRGs in MDC 1; thus, we are proposing to include them in DRGs 7 and 8. c. Geniculate Herpes Zoster. Geniculate herpes zoster (diagnosis code 053.11) is an acute viral disease characterized by inflammation of spinal ganglia and by a vesicular eruption along the area of distribution of a sensory nerve. In the August 30, 1996 final rule (61 FR 27447), we moved diagnosis codes 053.10 and 053.19 (Herpes zoster with unspecified nervous system complication and Other herpes zoster, respectively) from DRG 20 (Nervous System Infection Except Viral Meningitis) to DRGs 18 and 19 (Cranial and Peripheral Nerve Disorders). We considered moving diagnosis code 053.11 at that time, however, the higher average charges associated with geniculate herpes zoster and slightly higher length of stay led us to decide instead to leave 053.11 in DRG 20 and to reassess this decision in upcoming years. We conducted an analysis of the cases assigned to DRG 20 using the FY 1996 MedPAR file. The average standardized charges for these cases is approximately $8,430, which is significantly lower than the average charges for the DRG, approximately $21,180. The average length of stay for the geniculate herpes zoster cases, approximately 6 days, is also less than the average length of stay for the DRG, approximately 10 days. Based on these data, we are proposing to reassign diagnosis code 053.11 to DRGs 18 and 19, which have average charges of approximately $8,460 and $5,460, respectively. The average length of stay for DRGs 18 and 19 are approximately 6 days and 4 days, respectively. 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Heart Assist Devices. In November 1995, we amended our general noncoverage decision concerning artificial hearts and related devices. Section 65-15 of the Medicare Coverage Issues manual was revised to allow coverage of the HeartMate Implantable Pneumatic Left Ventricular Assist System (HeartMate IP LVAS) in accordance with its Food and Drug Administration-approved use as a temporary mechanical circulation support in nonreversible left ventricular failure as a bridge to cardiac transplant. In order to receive Medicare coverage, all of the following conditions must be met: The patient is listed as an approved heart transplant candidate by a Medicare-approved heart transplant center. The implantation of the system is done in a Medicare- approved heart transplant center. Written permission from the listing center is needed if the patient has the implantation done at another Medicare-approved center. The patient is on inotropes. The patient is on an intra-aortic balloon pump (if possible). The patient has left atrial pressure or pulmonary capillary wedge pressure 20mm Hg with either-- --Systolic blood pressure 80 mm Hg; or --Cardiac index of 2.0 1/min/m \2\. A procedure code for implant of an implantable, pulsatile heart assist system (37.66), which includes the HeartMate IP LVAS, was created effective October 1, 1995. At that time, the procedure code was assigned to DRGs 110 and 111 (Major Cardiovascular Procedures). Because we now have a full year of cases coded with this procedure (FY 1996 MedPAR file), we have analyzed them to determine if this DRG assignment remains appropriate. In the full (100 percent) FY 1996 MedPAR file, there are 51 cases of implant of an internal heart assist system (procedure code 37.66) in MDC 5. Of these 51 cases, 18 were assigned to DRG 110 and none to DRG 111. The other 33 cases were assigned to DRG 103 (Heart Transplant), DRG 104 (Cardiac Valve Procedures with Cardiac Cath), DRGs 106 and 107 (Coronary Bypass), and DRG 108 (Other Cardiothoracic Procedures). Of the 18 cases assigned to DRG 110, the average charge is about $96,000 and the average length of stay is 22.5 days. The average charges for all cases assigned to DRG 110 is about $36,500 and the average length of stay is 10.1 days. Thus, the cases coded with procedure code 37.66 are much more resource intensive than the other cases assigned to DRG 110. In reviewing the other surgical DRGs in MDC 5 for possible reassignment of this procedure, we find there are two DRGs that contain cases that are clinically similar to implant of heart assist device cases: DRG 103 and DRG 108. For FY 1996, the average charge of cases in DRG 103 is approximately $164,000 and the length of stay is 46 days. For DRG 108, these statistics are about $54,000 and 12.1 days. Thus, the average charge for DRG 103 is approximately $68,000 higher than the average charge of the heart assist device cases and the average charge for DRG 108 is approximately $42,000 lower. Because our general policy is to assign a procedure code to a DRG with clinically similar cases that is the best match in terms of resource use, we are proposing to assign procedure code 37.66 to DRG 108. We realize that there is still a large difference in the resource use for DRG 108 and the heart assist device cases; however, there is not a more appropriate assignment in MDC 5 for these cases. Our proposal would improve the payment for these cases by approximately 46 percent. We note that because DRG 108 is ranked above DRGs 106 and 107 in the MDC 5 surgical hierarchy, the cases coded with 37.66 that would have been classified to these DRGs would be assigned to DRG 108 beginning in FY 1998. b. Automatic Implantable Cardioverter Defibrillators (AICD). For several years, we have received correspondence concerning the appropriate DRG assignment of procedures involving automatic implantable cardioverter defibrillators (AICDs). These cases are currently assigned to DRG 116 (Other Permanent Cardiac Pacemaker Implant or AICD Generator or Lead Procedure), and are represented by the following procedure codes: 37.95 Implantation of automatic cardioverter/defibrillator lead(s) only 37.96 Implantation of automatic cardioverter/defibrillator pulse generator only 37.97 Replacement of automatic cardioverter/defibrillator lead(s) only 37.98 Replacement of automatic cardioverter/defibrillator pulse generator only As explained in detail in the September 1, 1992 final rule (57 FR 39749), the clinical composition and relative weights of the surgical DRGs in MDC 5 do not offer a perfect match with the AICD cases. However, review of those DRGs in terms of clinical coherence and similar resource consumption led to the determination [[Page 29906]] that DRG 116 was the best possible fit. In that document, we stated that we would continue to monitor these cases. We last discussed this issue in the September 1, 1995 final rule (60 FR 45780). At that time, we concluded that, although the average charge for AICD cases was much higher than the average charge for DRG 116 overall, the AICD cases were clinically similar to the DRG 116 cases and should not be moved. In addition, a slight decrease in the average charge for the cases between the FY 1993 and FY 1994 MedPAR files led us to believe further reductions might be forthcoming since there were new AICD devices entering the market that might lead to increased price competition. We reviewed the most current AICD cases as contained in the FY 1996 MedPAR file and found that the average standardized charge for AICD cases assigned to DRG 116 was $28,777 compared to an average charge of $21,330 for all cases in DRG 116. These data demonstrate that the average charge for AICD cases continues to be much higher than the average charge for all other DRG 116 cases. Therefore, in order to more appropriately compensate hospitals for these cases, we are proposing to move them to DRG 115 (Permanent Cardiac Pacemaker Implantation with AMI, Heart Failure or Shock). Although the resource consumption of DRG 115 cases is similar to the AICD cases, they are not clinically similar. In general, the patients classified to DRG 115 are seriously ill and have a relatively long length of stay (10.2 days). However, there are no other suitable DRGs in MDC 5 and we do not wish to create a separate DRG for the AICD cases. As we have often stated in the past, we are reluctant to create device-specific DRGs where the cost of the device dominates the charges. We continue to believe that it is the cost of the AICD device which is responsible for the high average charge for these cases and not the intensity of hospital services required to treat the patient. We are also proposing to revise the title of DRG 115 to ``Permanent Cardiac Pacemaker Implant with AMI, Heart Failure or Shock or AICD Lead or Generator Procedure.'' c. Coronary Artery Stent. Effective October 1, 1995, procedure code 36.06 (Insertion of coronary artery stent(s)) was introduced. As dictated by our longstanding practice, we assigned this code to the same DRG category as its predecessor codes. Therefore, procedure code 36.06 was assigned to DRG 112 (Percutaneous Cardiovascular Procedures), as insertion of a stent is usually performed in conjunction with percutaneous transluminal coronary angioplasty (PTCA). We discussed this assignment and public comments we received in both the September 1, 1995 final rule (60 FR 45785) and the August 30, 1996 final rule (61 FR 46171). Commenters protested the assignment of procedure code 36.06 to DRG 112 because the hospital costs for inserting coronary stents along with an angioplasty are significantly greater than those for conventional angioplasty alone. The commenters presented an analysis of the average charges and length of stay for stent and nonstent cases assigned to DRG 112. Our response to these commenters was that we would review the stent cases as soon as the FY 1996 MedPAR file was available, as these would be the first Medicare data available for these cases. Our analysis of the FY 1996 MedPAR data on coronary stent implantation in Medicare beneficiaries has shown the following findings: The difference between the average length of stay for the stent cases and the nonstent cases is 0.19 days (4.39 days versus 4.20 days). Charges for patients receiving a stent were approximately $23,650, while charges for patients without stent implant were approximately $17,480, for a difference of $6,170. Of those beneficiaries who had a PTCA procedure in FY 1996, approximately 34 percent received a stent. As review of stent cases in DRG 112 has shown a significant variation in hospital charges, we are proposing to move these cases out of that DRG. Although the coronary artery stent cases are not clinically similar to the pacemaker cases in DRG 116, the resource consumption of those cases is very similar. Therefore, absent any other appropriate DRG, we are proposing to add cases including procedure codes for PTCA in combination with insertion of coronary stent into DRG 116. Therefore, we are proposing to move into DRG 116 the following procedure codes when performed in conjunction with procedure code 36.06: 35.96 Percutaneous valvuloplasty 36.01 Single vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy without mention of thrombolytic agent 36.02 Single vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy with mention of thrombolytic agent 36.05 Multiple vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent 36.09 Other removal of coronary artery obstruction 37.34 Catheter ablation of lesion or tissues of the heart We further propose to change the title of DRG 116 to ``Other Permanent Cardiac Pacemaker Implant or PTCA with Coronary Artery Stent Implant.'' We will continue to monitor the stent cases and their assignment to DRG 116. If PTCA cases with stent become a higher percentage of the PTCA cases or the average charge for stent cases falls, we may reconsider this assignment. d. Circulatory Disorders (DRGs 121 and 122). In response to a comment on the May 31, 1996 proposed rule, we stated in the August 30, 1996 final rule (61 FR 46172) that we would conduct a comprehensive review of cases currently assigned to DRG 121 (Circulatory Disorders with Acute Myocardial Infarction (AMI) and Cardiovascular Complications, Discharged Alive) and DRG 122 (Circulatory Disorders with AMI without Cardiovascular Complications, Discharged Alive) to determine whether changes were needed to the list of complicating conditions that can result in assignment to DRG 121. To carry out this review, we analyzed the cases in the FY 1996 MedPAR file that were assigned to either DRG 121 or 122. Through a variety of statistical analyses of length of stay and standardized charge data, we assessed the impact on resource use of all coded secondary diagnoses. Our analysis of these secondary diagnosis codes revealed many cases now assigned to DRG 122 in which certain secondary diagnoses are associated with resource use comparable to cases assigned to DRG 121. Although many of these cases involve secondary diagnoses that are not strictly cardiovascular in nature, such as diagnosis code category 482 (Other bacterial pneumonia), we now believe that it is appropriate to expand DRG 121 to include such major complications when they are represented in significant volume among the cases in the DRG. Continuing to limit DRG 121 only to cases involving the existing list of cardiovascular complications would contribute to large variations in the charges and lengths of stay for cases in DRG 122. Therefore, we are proposing to change the title of DRG 121 to ``Circulatory Disorders with AMI and Major Complications, Discharged Alive,'' and to add the following diagnosis codes to the list of complications that would produce assignment to DRG 121 when present in conjunction with the existing list of AMI diagnoses: [[Page 29907]] 398.91 Rheumatic heart failure 416.0 Primary pulmonary hypertension 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432.0 Nontraumatic extradural hemorrhage 432.1 Subdural hemorrhage 432.9 Unspecified intracranial hemorrhage 433.01 Occluded basilar artery with cerebral infarction 433.11 Occluded carotid artery with cerebral infarction 433.21 Occluded vertebral artery with cerebral infarction 433.31 Occluded multiple and bilateral artery with cerebral infarction 433.81 Occluded specified precerebral artery with cerebral infarction 433.91 Occluded precerebral artery NOS with cerebral infarction 434.00 Cerebral thrombosis 434.01 Cerebral thrombosis with cerebral infarction 434.10 Cerebral embolism 434.11 Cerebral embolism with cerebral infarction 434.90 Cerebral artery occlusion 434.91 Cerebral artery occlusion with cerebral infarction 436 Acute, but ill-defined, cerebrovascular disease 481 Pneumococcal pneumonia 482.xx Other bacterial pneumonia (all 4th and 5th digits) 483.x Pneumonia due to other specified organism (all 4th digits) 484.x Pneumonia in infectious diseases classified elsewhere (all 4th digits) 485 Bronchopneumonia, organism unspecified 486 Pneumonia, organism unspecified 487.0 Influenza with pneumonia 507.x Pneumonitis due to solids and liquids (all 4th digits) 518.0 Pulmonary collapse 518.5 Pulmonary insufficiency following trauma and surgery 518.81 Respiratory failure 707.0 Decubitus ulcer 996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft 996.72 Other complications due to other cardiac device, implant, and graft In conjunction with these proposed changes, we note that the title of DRG 122 would be revised to read ``Circulatory Disorders with AMI without Major Complications, Discharged Alive.'' 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Introduction. As discussed in detail below, we are proposing to create several new DRGs in MDC 8 effective for discharges on or after October 1, 1997. Specifically, we would replace current DRGs 214 and 215 (Back and Neck Procedures) with the following new DRGs: DRG 496 Combined Anterior/Posterior Spinal Fusion DRG 497 Spinal Fusion with CC DRG 498 Spinal Fusion without CC DRG 499 Back and Neck Procedures Except Spinal Fusion with CC DRG 500 Back and Neck Procedures Except Spinal Fusion without CC In addition, we are proposing to replace existing DRGs 221 and 222 (Knee Procedures) with new DRGs 501 and 502 (Knee Procedures with Principal Diagnosis of Infection) and DRG 503 (Knee Procedures without Principal Diagnosis of Infection). We believe that both of these proposals would improve payment equity by increasing the DRG system's ability to capture variations in resource costs for these cases. b. Back and Neck Procedures. Currently, hospital inpatient cases involving back and neck procedures generally are assigned to DRGs 214 and 215 (assuming a principal diagnosis that groups the case to MDC 8). We have received correspondence indicating that within these DRGs, cases involving spinal fusion procedures represent a distinctly more complex and resource-intensive subset, and that payment under DRGs 214 and 215 is inadequate to cover the costs of treating patients that require spinal fusion. Therefore, we conducted an analysis of the cases assigned to DRGs 214 and 215 using the FY 1996 MedPAR file. Within our sample, cases involving fusion procedures (procedure codes 81.00-81.09) constituted approximately 35 percent of cases in DRG 214 (Back and Neck Procedures with CC) and 23 percent of those in DRG 215 (Back and Neck Procedures without CC). In DRG 214, the average standardized charges for the fusion cases were nearly double the charges of the nonfusion cases (approximately $25,300 versus $12,900). There were also significant differences in charges in DRG 215; $14,400 for fusion cases and $8,500 for nonfusion cases. Lengths of stay for fusion cases were also longer, although not dramatically so; 7.1 days for fusion cases versus 5.4 days for other cases in DRG 214, and 3.8 days versus 3.1 days in DRG 215. In view of the volume of cases involved and the clear differences in resource use, we concluded that it would be appropriate to create additional DRGs to separate spinal fusion cases from the other back and neck procedures. Next, we expanded our analysis to determine whether it would be appropriate to subdivide the spinal fusion cases according to whether both anterior and posterior spinal fusion were performed. This combination of procedures, which involves fusing both the front and rear of the vertebrae, typically is performed on patients who have had previous fusions that have not bonded effectively or who have several vertebrae that need extensive fusion on both sides of the spine. As the table below illustrates, the average charges and lengths of stay for the cases involving both anterior and posterior spinal fusion were markedly greater than for the other spinal fusion cases in either DRG 214 or 215. ------------------------------------------------------------------------ Avg. Avg. length of Type of case charges stay (in days) ------------------------------------------------------------------------ Anterior and Posterior Spinal Fusion............ $51,200 12.3 DRG 214--Other Spinal Fusion.................... 24,300 6.9 DRG 215--Other Spinal Fusion.................... 14,300 3.8 ------------------------------------------------------------------------ Even though the cases in which both anterior and posterior spinal fusions were performed represented only about 3 percent of all spinal fusion cases in our sample, we concluded that the magnitude of the differences in both average charges and lengths of stay warranted a further subdivision of the spinal fusion cases. Based on this analysis, we are proposing to replace the two existing DRGs for back and neck procedures with five new DRGs. For ease of reference and classification, current DRGs 214 and 215 would be made invalid and we would establish new DRGs 496 through 500 to contain all the cases that are currently grouped in DRGs 214 and 215. We believe that the division of these cases into the new DRGs would improve clinical coherence and provide for more appropriate payment for both spinal fusion cases and cases involving other back and neck procedures. Discharges would be assigned to each of the five proposed DRGs as follows: DRG 496 Combined Anterior/Posterior Spinal Fusion DRG 496 would include any combination of procedure codes as follows: One or more of the following procedure codes-- 81.02 Other cervical fusion anterior 81.04 Dorsal/dorsulum fusion anterior 81.06 Lumbar/lumbosac fusion anterior AND One or more of the following procedure codes-- 81.03 Other cervical fusion posterior 81.05 Dorsal/dorsulum fusion posterior 81.08 Lumbar/lumbosac fusion posterior [[Page 29908]] DRGs 497 and 498 Spinal Fusion With and Without CC DRGs 497 and 498 would include any of the following procedure codes, as long as any combination of procedure codes would not otherwise result in assignment to proposed DRG 496-- 81.00 Spinal fusion NOS 81.01 Atlas-axis fusion 81.02 Other cervical fusion anterior 81.03 Other cervical fusion posterior 81.04 Dorsal/dorsulum fusion anterior 81.05 Dorsal/dorsulum fusion posterior 81.06 Lumbar/lumbosac fusion anterior 81.07 Lumbar/lumbosac fusion lateral 81.08 Lumbar/lumbosac fusion posterior 81.09 Refusion of spine DRGs 499 and 500 Back and Neck Procedures Except Spinal Fusion With and Without CC All procedure codes in current DRGs 214 and 215 other than procedure codes 81.00 through 81.09 would be assigned to DRGs 499 and 500. c. Knee Procedures. On several occasions, most recently in our September 1, 1993 final rule (58 FR 46286), we have examined cases in DRG 209 (Major Joint and Limb Reattachment of the Lower Extremity) to see whether hip replacement cases that involve infections or other complications should be classified separately from the less complicated cases in DRG 209. We have found that the average charges and lengths of stay for cases with principal diagnoses of infection or complications were only slightly higher than for all cases in DRG 209. When we limited our analysis to cases with a principal diagnosis of infection, we found that the cases had significantly higher charges than for DRG 209 overall, but in view of the small volume of cases (less than 0.5 percent of the total DRG 209 cases), we decided that changes in the classification of cases in DRG 209 were not warranted. In recent months, we have received several letters asking that we revisit the issue of whether DRG refinements are needed to address differences in resource use associated with orthopedic procedures where deep infections are present. Our correspondents stated that these cases are extremely resource intensive, and, because these complex cases are often referred to specialty hospitals, such hospitals routinely receive DRG payments for these cases that are much lower than the costs incurred by the hospital. They believe that we should investigate the possibility of creating a separate DRG for orthopedic surgical cases that have serious infections, specifically, a new DRG for cases involving orthopedic procedures of the lower extremities or spine with a principal diagnosis of deep orthopedic infection of the lower extremity or spine. To evaluate this issue, we analyzed various classifications of cases in MDC 8. We began by identifying all cases with a principal diagnosis indicating deep orthopedic infection of the lower extremities or spine. The diagnosis codes used were as follows: 711.05 Pyogenic arthritis pelvic region and thigh 711.06 Pyogenic arthritis lower leg 711.07 Pyogenic arthritis ankle and foot 711.08 Pyogenic arthritis other specified sites 730.05 Acute osteomyelitis pelvic region and thigh 730.06 Acute osteomyelitis lower leg 730.07 Acute osteomyelitis ankle and foot 730.08 Acute osteomyelitis other specified sites 730.15 Chronic osteomyelitis pelvic region and thigh 730.16 Chronic osteomyelitis lower leg 730.17 Chronic osteomyelitis ankle and foot 730.18 Chronic osteomyelitis other specified sites 730.25 Unspecified osteomyelitis pelvic region and thigh 730.26 Unspecified osteomyelitis lower leg 730.27 Unspecified osteomyelitis ankle and foot 730.28 Unspecified osteomyelitis other specified sites 996.66 Infection and inflammatory reaction due to internal joint prosthesis 996.67 Infection and inflammatory reaction due to other internal orthopedic device For each of the DRGs into which these cases grouped, we then compared the average standardized charges and average length of stay for cases with any of the infection diagnoses listed above with other cases in the DRGs. Unlike in the past, we did not limit our analysis to DRG 209 but examined all DRGs within MDC 8 that focus on surgical procedures of the lower extremities or spine, including DRGs 209; 210, 211, and 212 (Hip and Femur Procedures Except Major Joint); 214 and 215 (Back and Neck Procedures); and 221 and 222 (Knee Procedures). For the most part, we again found that these cases represented only a very small proportion of the total cases in the DRGs in question. In DRG 209, for example, cases with one of the above diagnosis codes as the principal diagnosis continued to constitute less than 1 percent of all cases in the DRG. Moreover, although the average standardized charges for the deep infection cases ($24,834) were approximately 21 percent higher than the charges for the remaining cases in the DRG ($19,297), the differences are well within one standard deviation of the average charge. Given the small volume of cases, we again conclude that changes in DRG 209 are not justified. The only DRGs that we examined in which cases with a principal diagnosis of deep infection represented more than 1 percent of total cases in our sample were DRGs 221 and 222. As illustrated in the chart below, there are significant differences in both average charges and average length of stay between infection cases in these DRGs and other cases in the DRGs. ------------------------------------------------------------------------ Average Number of Average length of Type of case cases * charges (in stay (in dollars) days) ------------------------------------------------------------------------ DRG 221 (All cases).............. 451 16,529 7.2 DRG 221 with infection........... 152 23,174 11.4 DRG 221 w/out infection.......... 299 13,151 5.1 DRG 222 (All cases).............. 340 9,149 3.9 DRG 222 with infection........... 37 14,452 7.0 DRG 222 w/out infection.......... 303 8,502 3.5 ------------------------------------------------------------------------ * Based on the 10-percent random sample of the FY 1996 MedPAR file. Thus, more than one-third of cases in DRG 221 had a principal diagnosis of deep infection, the average length of stay for these cases was more than twice as long as for the remaining cases, and average charges were approximately 76 percent higher. Similarly, for the 12 percent of total DRG 222 cases with infection as the principal diagnosis, the average length of stay was double that for other cases, with average charges approximately 70 percent higher. Given [[Page 29909]] the proportional volume of cases involved, and the significant differences in both average charges and length of stay for infection cases in these DRGs, we concluded that DRG refinements are appropriate. Based on this analysis, we are proposing to replace the two existing DRGs for knee procedures with three new DRGs. Again, for ease of reference and classification, current DRGs 221 and 222 would be made invalid and we would establish new DRGs 501 through 503 to contain all the cases that are currently grouped in DRGs 221 and 222. Discharges would be assigned to each of the 3 proposed DRGs as follows: DRG 501 Knee Procedures With Principal Diagnosis of Infection With CC DRG 502 Knee Procedures With Principal Diagnosis of Infection Without CC DRG 501 and 502 would include any of the operating room procedures now assigned to DRGs 221 and 222, when the principal diagnosis is any of the following: 711.06 Pyogenic arthritis lower leg 730.06 Acute osteomyelitis lower leg 730.16 Chronic osteomyelitis lower leg 730.26 Unspecified osteomyelitis lower leg 996.66 Infection and inflammatory reaction due to internal joint prosthesis 996.67 Infection and inflammatory reaction due to other internal orthopedic device DRG 503 Knee Procedures Without Principal Diagnosis of Infection DRG 503 would include any of the operating room procedures now assigned to DRGs 221 and 222 when the principal diagnosis is not listed above under DRGs 501 and 502. 5. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract) Among the ICD-9-CM coding changes that took effect October 1, 1995 was the addition of new procedure code 59.72 (injection of implant into urethra or bladder neck). Although this procedure is not routinely performed in an operating room, the code was previously included within codes classified as operating room procedures. Thus, as is our practice, we assigned this procedure code to the surgical DRGs to which the procedure had formerly been assigned as a non-OR procedure that affects DRG assignment. Therefore, procedure code 59.72 was assigned to DRGs 308 and 309 (Minor Bladder Procedures) and DRG 356 (Female Reproductive System Reconstructive Procedures). In the June 2, 1995 proposed rule (60 FR 29209), we stated that we would reevaluate the DRG classification of this code when data on its use became available for analysis in 2 years, that is, in preparation for the FY 1998 rulemaking process. We indicated that possible changes would include moving the procedure code to a different surgical DRG or classifying the code as a non-OR procedure that did not affect DRG assignment. In the FY 1996 MedPAR file, there were several cases with procedure code 59.72 assigned to DRGs 308 and 309. The chart below compares average charges and length of stay for cases in these DRGs with and without the injection procedure. ------------------------------------------------------------------------ Avg. charge Avg. length Type of case Number of (in of stay cases * dollars) (in days) ------------------------------------------------------------------------ DRG 308 with procedure 59.72..... 5 6,978 4.2 DRG 308 w/out procedure 59.72.... 910 13,254 6.5 DRG 309 with procedure 59.72..... 7 5,879 1.4 DRG 309 w/out procedure 59.72.... 311 7,888 2.7 ------------------------------------------------------------------------ * Based on the 10-percent random sample of the FY 1996 MedPAR file. As the table illustrates, cases in which injection of implant into the urethra or bladder neck is the only relevant procedure for DRG assignment purposes constitute a very small minority of the cases in DRGs 308 and 309. However, these cases have lower average charges and length of stay than other cases in the DRGs. Thus, we are proposing to reclassify the procedure code as a non-OR procedure that does not affect DRG assignment. Under this proposal, cases currently assigned to DRGs 308 and 309 because of the performance of an implant injection would be reassigned to medical DRGs in MDC 11. We believe that most of the cases involved would be assigned to either DRGs 320, 321, and 322 (Kidney and Urinary Tract Infections) or DRGs 331 and 332 (Other Kidney and Urinary Tract Diagnoses). Both of these sets of DRGs have average charges closely in line with the charges for cases in which procedure 59.72 now determines DRG assignment. We note that this change would also affect DRG 356 in MDC 13 (Diseases and Disorders of the Female Reproductive System). Within the 10 percent sample used for this analysis, only 2 of the 2,689 cases in DRG 356 were assigned based on the presence of procedure code 59.72, and as in DRGS 308 and 309, both the average charges and length of stay were lower than for other cases. 6. Surgical Hierarchies Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different DRG within the MDC to which the principal diagnosis is assigned. It is, therefore, necessary to have a decision rule by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most to least resource intensive, performs that function. Its application ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class. Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibration, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications, to determine if the ordering of classes coincided with the intensity of resource utilization, as measured by the same billing data used to compute the DRG relative weights. A surgical class can be composed of one or more DRGs. For example, in MDC 5, the surgical class ``heart transplant'' consists of a single DRG (DRG 103) and the class ``coronary bypass'' consists of two DRGs (DRGs 106 and 107). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class, therefore, involves weighting each DRG for frequency to determine the average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5, and that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than [[Page 29910]] surgical class B in the surgical hierarchy, we would weight the average charge of each DRG by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of ``other OR procedures'' as discussed below. This methodology may occasionally result in a case involving multiple procedures being assigned to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER searches for the procedure in the most resource-intensive surgical class, which may sometimes occur in cases involving multiple procedures, this result is unavoidable. We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average relative weight is ordered above a surgical class with a higher average relative weight. For example, the ``other OR procedures'' surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the relative weight for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The ``other OR procedures'' class is a group of procedures that are least likely to be related to the diagnoses in the MDC but are occasionally performed on patients with these diagnoses. Therefore, these procedures should only be considered if no other procedure more closely related to the diagnoses in the MDC has been performed. A second example occurs when the difference between the average weights for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy since, by virtue of the hierarchy change, the relative weights are likely to shift such that the higher-ordered surgical class has a lower average weight than the class ordered below it. Based on the preliminary recalibration of the DRGs, we are proposing to modify the surgical hierarchy as set forth below. As we stated in the September 1, 1989 final rule (54 FR 36457), we are unable to test the effects of the proposed revisions to the surgical hierarchy and to reflect these changes in the proposed relative weights due to the unavailability of revised GROUPER software at the time this proposed rule is prepared. Rather, we simulate most major classification changes to approximate the placement of cases under the proposed reclassification and then determine the average charge for each DRG. These average charges then serve as our best estimate of relative resource use for each surgical class. We test the proposed surgical hierarchy changes after the revised GROUPER is received and reflect the final changes in the DRG relative weights in the final rule. Further, as discussed below in section II.C of this preamble, we anticipate that the final recalibrated weights will be somewhat different from those proposed, since they will be based on more complete data. Consequently, further revision of the hierarchy, using the above principles, may be necessary in the final rule. We propose to revise the surgical hierarchy for the Pre-MDC DRGs, MDC 9 (Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast), MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders), and MDC 12 (Diseases and Disorders of the Male Reproductive System) as follows: In the Pre-MDC DRGs, we would reorder Bone Marrow Transplant (DRG 481) above Liver Transplant (DRG 480). In MDC 9, we would reorder Perianal and Pilonidal Procedures (DRG 267) above Breast Procedures (DRGs 257-262). In MDC 10, we would reorder OR Procedures for Obesity (DRG 288) above Skin Graft and Wound Debridement (DRG 287). In MDC 12, we would reorder Circumcision (DRGs 342 and 343) above Transurethral Prostatectomy (DRGs 336 and 337). 7. Refinement of Complications and Comorbidities List There is a standard list of diagnoses that are considered complications or comorbidities (CCs). We developed this list using physician panels to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the standard list of CCs, either by adding new CCs or deleting CCs already on the list. At this time, we do not propose to delete any of the diagnosis codes on the CC list. In the September 1, 1987 final notice concerning changes to the DRG classification system (52 FR 33143), we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered a valid CC in combination with a particular principal diagnosis. Thus, we created the CC Exclusions List. We made these changes to preclude coding of CCs for closely related conditions, to preclude duplicative coding or inconsistent coding from being treated as CCs, and to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. In the May 19, 1987 proposed notice concerning changes to the DRG classification system (52 FR 18877), we explained that the excluded secondary diagnoses were established using the following five principles: Chronic and acute manifestations of the same condition should not be considered CCs for one another (as subsequently corrected in the September 1, 1987 final notice (52 FR 33154)). Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for a condition should not be considered CCs for one another. Conditions that may not co-exist, such as partial/ total, unilateral/bilateral, obstructed/unobstructed, and benign/ malignant, should not be considered CCs for one another. The same condition in anatomically proximal sites should not be considered CCs for one another. Closely related conditions should not be considered CCs for one another. The creation of the CC Exclusions List was a major project involving hundreds of codes. The FY 1988 revisions were intended to be only a first step toward refinement of the CC list in that the criteria used for eliminating certain diagnoses from consideration as CCs were intended to identify only the most obvious diagnoses that should not be considered complications or comorbidities of another diagnosis. For that reason, and in light of comments and questions on the CC list, we have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC. (See the September 30, 1988 final rule for the revision made for the discharges occurring in FY 1989 (53 FR 38485); the September 1, 1989 final rule for the FY 1990 revision (54 FR 36552); the September 4, 1990 final rule for the FY 1991 revision (55 FR 36126); the August 30, 1991 final rule for the FY 1992 revision (56 FR 43209); the September 1, 1992 final rule for the FY 1993 revision (57 FR 39753); the September 1, 1993 final rule for the FY 1994 revisions (58 FR 46278); the September 1, 1994 final rule for the FY 1995 revisions (59 FR 45334); the September 1, 1995 final rule for the FY 1996 revisions (60 FR 45782); and the August 30, 1996 final rule for the FY 1997 revisions (61 FR 46171). We are proposing a limited revision of the CC Exclusions List to take into account the changes that will be made [[Page 29911]] in the ICD-9-CM diagnosis coding system effective October 1, 1997, as well as the proposed CC changes described above. (See section II.B.9, below, for a discussion of ICD-9-CM changes.) These proposed changes are being made in accordance with the principles established when we created the CC Exclusions List in 1987. The changes discussed above have been added to Table 6E, Additions to the CC Exclusions List, in section V. of the Addendum to this proposed rule. Tables 6E and 6F in section V. of the Addendum to this proposed rule contain the proposed revisions to the CC Exclusions List that would be effective for discharges occurring on or after October 1, 1997. Each table shows the principal diagnoses with proposed changes to the excluded CCs. Each of these principal diagnoses is shown with an asterisk and the additions or deletions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis. CCs that are added to the list are in Table 6E--Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 1997, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. CCs that are deleted from the list are in Table 6F--Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 1997 the indented diagnoses will be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. Copies of the original CC Exclusions List applicable to FY 1988 can be obtained from the National Technical Information Service (NTIS) of the Department of Commerce. It is available in hard copy for $92.00 plus $6.00 shipping and handling and on microfiche for $20.50, plus $4.00 for shipping and handling. A request for the FY 1988 CC Exclusions List (which should include the identification accession number, (PB) 88-133970) should be made to the following address: National Technical Information Service; United States Department of Commerce; 5285 Port Royal Road; Springfield, Virginia 22161; or by calling (703) 487-4650. Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, and 1997) and those in Tables 6E and 6F of this document must be incorporated into the list purchased from NTIS in order to obtain the CC Exclusions List applicable for discharges occurring on or after October 1, 1997. Alternatively, the complete documentation of the GROUPER logic, including the current CC Exclusions List, is available from 3M/Health Information Systems (HIS), which, under contract with HCFA, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 14.0, is available for $195.00, which includes $15.00 for shipping and handling. Version 15.0 of this manual, which will include the final FY 1998 DRG changes, will be available in October 1997 for $195.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road; Wallingford, Connecticut 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested. 8. Review of Procedure Codes in DRGs 468, 476, and 477 Each year, we review cases assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis) in order to determine whether it would be appropriate to change the procedures assigned among these DRGs. DRGs 468, 476, and 477 are reserved for those cases in which none of the OR procedures performed is related to the principal diagnosis. These DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. DRG 476 is assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis: 60.0 Incision of prostate 60.12 Open biopsy of prostate 60.15 Biopsy of periprostatic tissue 60.18 Other diagnostic procedures on prostate and periprostatic tissue 60.21 Transurethral prostatectomy 60.29 Other transurethral prostatectomy 60.61 Local excision of lesion of prostate 60.69 Prostatectomy NEC 60.81 Incision of periprostatic tissue 60.82 Excision of periprostatic tissue 60.93 Repair of prostate 60.94 Control of (postoperative) hemorrhage of prostate 60.95 Transurethral balloon dilation of the prostatic urethra 60.99 Other operations on prostate All remaining OR procedures are assigned to DRGs 468 and 477, with DRG 477 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis. The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures if performed with an unrelated principal diagnosis was published in Table 6C in section IV of the Addendum to the September 30, 1988 final rule (53 FR 38591). As part of the final rules published on September 4, 1990, August 30, 1991, September 1, 1992, September 1, 1993, September 1, 1994, September 1, 1995, and August 30, 1996, we moved several other procedures from DRG 468 to 477. (See 55 FR 36135, 56 FR 43212, 57 FR 23625, 58 FR 46279, 59 FR 45336, 60 FR 45783, and 61 FR 46173, respectively.) a. Adding Procedure Codes to MDCs. We annually conduct a review of procedures producing DRG 468 or 477 assignments on the basis of volume of cases in these DRGs with each procedure. Our medical consultants then identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this year's review, we are proposing to move procedure code 54.92 (Removal of foreign body from peritoneal cavity) to MDC 11 and assign it to DRG 315 (Other Kidney and Urinary Tract OR Procedures). We note that, under the current DRGs, when procedure code 54.92 is coded in addition to a principal diagnosis code of 868.14 (injury with open wound into retroperitoneum), the case is assigned to DRG 468. b. Reassignment of Procedures Among DRGs 468, 476, and 477. We also reviewed the list of procedures that produce assignments to DRGs 468, 476, and 477 to ascertain if any of those procedures should be moved from one of these DRGs to another based on average charges and length of stay. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data. Based on our review this year, we are proposing to move one procedure from DRG 468 to DRG 477. In reviewing the list of OR procedures that produce DRG 468 assignments, we analyzed the average charge and length of stay data for cases assigned to that DRG to identify those procedures that are more similar to the discharges that currently group to either DRG 476 or 477. We identified two procedures--other surgical occlusion of abdominal arteries (procedure code 38.86) and other arthrotomy of knee (procedure code 80.16)--that are significantly less resource intensive than the other procedures assigned to DRG 468. [[Page 29912]] Therefore, we are proposing to move procedure codes 38.86 and 80.16 to the list of procedures that result in assignment to DRG 477. In reviewing the list of procedures assigned to DRG 477, we did not identify any procedures that should be assigned to either DRG 468 or 476. All of these proposed changes would be effective with discharges occurring on or after October 1, 1997. 9. Changes to the ICD-9-CM Coding System As discussed above in section II.B.1 of this preamble, the ICD-9-CM is a coding system that is used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD-9-CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee charged with the mission of maintaining and updating the ICD-9-CM. That mission includes approving coding changes, and developing errata, addenda, and other modifications to the ICD-9-CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of Federal and non-Federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system. The Committee is co-chaired by the National Center for Health Statistics (NCHS) and HCFA. The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in Volume 1--Diseases: Tabular List and Volume 2--Diseases: Alphabetic Index, while HCFA has lead responsibility for the ICD-9-CM procedure codes included in Volume 3-- Procedures: Tabular List and Alphabetic Index. The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding fields, such as the American Health Information Management Association (AHIMA) (formerly American Medical Record Association (AMRA)), the American Hospital Association (AHA), and various physician specialty groups as well as physicians, medical record administrators, health information management professionals, and other members of the public to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies. The Committee presented proposals for coding changes at public meetings held on June 6 and December 5 and 6, 1996, and finalized the coding changes after consideration of comments received at the meetings and in writing within 60 days following the December 1996 meeting. The initial meeting for consideration of coding issues for implementation in FY 1999 will be held on June 6, 1997. Copies of the minutes of the June 1996 meeting may be obtained by writing to one of the co- chairpersons representing NCHS and HCFA. The minutes of the December 1996 meeting can be obtained from the HCFA Home Page @ http:// www.hcfa.gov.pubaffr.htm. Paper copies of these minutes will no longer be available and the mailing list will be discontinued. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, Maryland 20782. Comments may be sent by E-mail to: [email protected]. Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; HCFA, Office of Hospital Policy; Division of Prospective Payment System; C5-06-27; 7500 Security Boulevard; Baltimore, Maryland 21244-1850. Comments may be sent by E-mail to: [email protected]. The ICD-9-CM code changes that have been approved will become effective October 1, 1997. The new ICD-9-CM codes are listed, along with their proposed DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in section V. of the Addendum to this proposed rule. As we stated above, the code numbers and their titles were presented for public comment in the ICD- 9-CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. Therefore, we are soliciting comments only on the proposed DRG classification. Further, the Committee has approved the expansion of certain ICD-9- CM codes to require an additional digit for valid code assignment. Diagnosis codes that have been replaced by expanded codes, other codes, or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 1997. The corresponding new or expanded diagnosis codes are included in Table 6A. Revisions to diagnosis code titles are in Table 6D (Revised Diagnosis Code Titles), which also include the proposed DRG assignments for these revised codes. For FY 1998, there are no procedure codes that have been replaced or deleted nor are there any revisions to procedure code titles. 10. Other Issues--MDC 22 (Burns) Under the current DRG system, burn cases generally are assigned to one of six DRGs in MDC 22 (Burns). These DRGs-- DRGs 456 through 460 and 472--have been in place without change since 1986. Recently, we have received several letters from representatives of facilities that specialize in treating burn cases asserting that the existing DRGs do not adequately capture the variation in resource use associated with different types of burn cases. Among these correspondents' concerns are the following: In general, burn centers are disadvantaged because these facilities tend to treat the most complicated and costly burn cases, which are not always adequately defined and compensated under the existing burn DRGs. At the same time, less complicated cases (with lower costs and shorter lengths of stay) in the same DRGs can be treated by hospitals that do not specialize in the treatment of burn cases. As a result, some burn centers are experiencing a net loss of income on cases in each of the burn DRGs. In some cases, this has led to coding decisions that result in burn patients being assigned to non- burn DRGs because these DRGs result in higher payments to hospitals. DRG 456 (Burns, Transferred to Another Acute Care Facility) either should be revised to include only cases transferred to hospitals with a burn center or should be eliminated. This DRG originally was designed to encourage transfers of burn patients to hospitals with burn centers. Although it provides appropriate payment in these situations, problems arise when burn centers treat patients with extensive burns and then transfer them to hospitals closer to the patients' homes for the final stages of acute care. Burn centers might be severely penalized financially for such transfers, even though the transfers may be both cost-effective and in the best interests of the patient. DRG 472 (Extensive Burns with OR Procedure) does not capture fully the universe of critically ill, high cost [[Page 29913]] patients with extensive burn injuries. Currently, a patient must have a burn of at least 50 percent of the total body surface area (or a third degree burn covering at least 10 percent of the body) to be assigned to DRG 472, which is by far the highest-weighted burn DRG. However, some patients not assigned to this DRG experience equally high rates of mortality and morbidity, with concomitant high resource use and long lengths of stay. To address this problem, a new critical care burn DRG should be created that would define patients by age, burn size, and presence of co-morbidities, such as the presence of smoke inhalation, liver or renal failure, and others. To begin to examine these assertions, we have conducted a preliminary analysis of cases assigned to the burn DRGs. Although the overall volume of cases assigned to the burn DRGs is relatively small (a combined total of about 5,000 Medicare cases in FY 1996), there is clearly a large degree of heterogeneity in both charges and lengths of stay for burn cases. For example, although approximately 75 percent of cases in DRG 456 show lengths of stay below the mean of 7.3 days, a small but significant group of cases have lengths of stay of 21 days or more, resulting in DRG 456 having the largest length of stay coefficient of variation of all DRGs (The coefficient of variation is a statistical measure used to evaluate relative dispersions among all values in a set of data.) Other DRGs in MDC 22 also have above-average coefficients of variation. Although indications of statistical heterogeneity are not uncommon in small volume DRGs, we believe that a more in-depth analysis of the burn DRGs is appropriate. Therefore, as part of our FY 1999 rulemaking agenda, we intend to conduct a comprehensive review of MDC 22 to determine whether changes in these DRGs can increase their ability to explain the variation in resource use among burn cases. We welcome public comments on this issue, particularly specific suggestions on the most appropriate ways to categorize related diagnosis and procedure codes to produce DRG groupings that would reflect more homogeneous resource use. We note that any suggestions involving other types of payment adjustments for hospitals designated as burn centers would require legislative action. We intend to discuss our findings and, if appropriate, propose modifications to MDC 22, in the FY 1999 proposed rule. C. Recalibration of DRG Weights We are proposing to use the same basic methodology for the FY 1998 recalibration as we did for FY 1997. (See the August 30, 1996 final rule (61 FR 46176).) That is, we would recalibrate the weights based on charge data for Medicare discharges. However, we would use the most current charge information available, the FY 1996 MedPAR file, rather than the FY 1995 MedPAR file. The MedPAR file is based on fully-coded diagnostic and surgical procedure data for all Medicare inpatient hospital bills. The proposed recalibrated DRG relative weights are constructed from FY 1996 MedPAR data, based on bills received by HCFA through December 1996, from all hospitals subject to the prospective payment system and short-term acute care hospitals in waiver States. The FY 1996 MedPAR file includes data for approximately 11.1 million Medicare discharges. The methodology used to calculate the proposed DRG relative weights from the FY 1996 MedPAR file is as follows: To the extent possible, all the claims were regrouped using the proposed DRG classification revisions discussed above in section II.B of this preamble. As noted in section II.B.6, due to the unavailability of revised GROUPER software, we simulate most major classification changes to approximate the placement of cases under the proposed reclassification. However, there are some changes that cannot be modeled. Charges were standardized to remove the effects of differences in area wage levels, indirect medical education costs, disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment. The average standardized charge per DRG was calculated by summing the standardized charges for all cases in the DRG and dividing that amount by the number of cases classified in the DRG. We then eliminated statistical outliers, using the same criteria as was used in computing the current weights. That is, all cases that are outside of 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG. The average charge for each DRG was then recomputed (excluding the statistical outliers) and divided by the national average standardized charge per case to determine the relative weight. A transfer case is counted as a fraction of a case based on the ratio of its length of stay to the geometric mean length of stay of the cases assigned to the DRG. That is, a 5-day length of stay transfer case assigned to a DRG with a geometric mean length of stay of 10 days is counted as 0.5 of a total case. We established the relative weight for heart and heart- lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner consistent with the methodology for all other DRGs except that the transplant cases that were used to establish the weights were limited to those Medicare-approved heart, heart-lung, liver, and lung transplant centers that have cases in the FY 1995 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from HCFA as transplant centers.) Acquisition costs for kidney, heart, heart-lung, liver, and lung transplants continue to be paid on a reasonable cost basis. Unlike other excluded costs, the acquisition costs are concentrated in specific DRGs (DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant for heart and heart-lung transplants); DRG 480 (Liver Transplant); and DRG 495 (Lung Transplant)). Because these costs are paid separately from the prospective payment rate, it is necessary to make an adjustment to prevent the relative weights for these DRGs from including the effect of the acquisition costs. Therefore, we subtracted the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers. When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We propose to use that same case threshold in recalibrating the DRG weights for FY 1998. Using the FY 1996 MedPAR data set, there are 36 DRGs that contain fewer than 10 cases. We computed the weights for the 36 low-volume DRGs by adjusting the FY 1997 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs. The weights developed according to the methodology described above, using the proposed DRG classification changes, result in an average case weight that is different from the average case weight before recalibration. Therefore, the new weights are normalized by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight before recalibration. This adjustment is intended to ensure that recalibration by itself neither increases [[Page 29914]] nor decreases total payments under the prospective payment system. Section 1886(d)(4)(C)(iii) of the Act requires that beginning with FY 1991, reclassification and recalibration changes be made in a manner that assures that the aggregate payments are neither greater than nor less than the aggregate payments that would have been made without the changes. Although normalization is intended to achieve this effect, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payment to hospitals is affected by factors other than average case weight. Therefore, as we have done in past years and as discussed in section II.A.4.b of the Addendum to this proposed rule, we are proposing to make a budget neutrality adjustment to assure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. III. Proposed Changes to the Hospital Wage Index A. Background Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts ``for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.'' In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by the Office of Management and Budget (OMB). OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprised of two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital wage index, we use the PMSAs rather than CMSAs since they allow a more precise breakdown of labor costs. If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA. Rural areas are areas outside a designated MSA, PMSA, or NECMA. We note that effective April 1, 1990, the term Metropolitan Area (MA) replaced the term Metropolitan Statistical Area (MSA) (which had been used since June 30, 1983) to describe the set of metropolitan areas comprised of MSAs, PMSAs, and CMSAs. The terminology was changed by OMB in the March 30, 1990 Federal Register to distinguish between the individual metropolitan areas known as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes of the prospective payment system, we will continue to refer to these areas as MSAs. Section 1886(d)(3)(E) of the Act also requires that the wage index be updated annually beginning October 1, 1993. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey should measure, to the extent feasible, the earnings and paid hours of employment by occupational category, and must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. We also adjust the wage index, as discussed below in section III.B.3, to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act. B. FY 1998 Wage Index Update The proposed FY 1998 wage index in section V. of the Addendum (effective for hospital discharges occurring on or after October 1, 1997 and before October 1, 1998) is based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 1994 (the FY 1997 wage index was based on FY 1993 wage data). We propose to use the same categories of data that were used in the FY 1997 wage index. Therefore, the proposed FY 1998 wage index reflects the following: Total salaries and hours from short-term, acute care hospitals. Home office costs and hours. Fringe benefits associated with hospital and home office salaries. Direct patient care contract labor costs and hours. The exclusion of salaries and hours for nonhospital type services such as skilled nursing facility services, home health services, or other subprovider components that are not subject to the prospective payment system. We are proposing to calculate a separate Puerto Rico-specific wage index to be applied to the Puerto Rico standardized amount. This wage index will be calculated in the same manner as the national wage index described below, but will be based solely on Puerto Rico's data. For further explanation, see sections II.B.5 and III.A.6 of the Addendum to this proposed rule. Also, in response to a comment in the August 30, 1996 final rule, we considered using data from Worksheet A-8-2 for the purpose of excluding physician Part A salaries from the FY 1998 wage index calculation (61 FR 46177). We stated that we would explore the technical feasibility of using the data from that worksheet. However, primarily because the intermediaries had already begun reviewing the FY 1994 cost report data and finalizing the Worksheet S-3 data, we did not believe it would be appropriate to revise their instructions and require them to make a change to their procedure. Therefore, we will wait for the data from cost reporting periods beginning on or after October 1, 1994, for which we revised the Medicare cost report to provide for the separate reporting of physician salaries. As we have stated previously, we will review and evaluate these salary cost data when considering appropriate changes to the FY 1999 wage index. 1. Verification of Wage Data From the Medicare Cost Report The data for the proposed FY 1998 wage index were obtained from Worksheet S-3, Part II of the Medicare cost report. The data file used to construct the proposed wage index includes FY 1994 data submitted to the Health Care Provider Cost Report Information System (HCRIS) as of the end of January 1997. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data. Of the 5,197 hospitals in the database, 2,652 hospitals had data elements that failed an initial edit. From mid-February 1997 through early March 1997, intermediaries contacted hospitals to revise or verify data elements that resulted in the edit failures. In addition, intermediaries reviewed the database to ensure that no hospitals had been inadvertently excluded from the database. As a result of that review, data for two hospitals were added to the database. Next, to check any revisions since the first edit, as well as to apply additional edits based on the distribution of the data, we subjected all of the data to edits a second time. As of March 14, 1997, 70 hospitals still had unresolved data elements. These unresolved data elements are included in the calculation of the proposed FY 1998 wage index pending their resolution before calculation of the final FY 1998 wage index. We have instructed the intermediaries to complete their verification of questionable data elements and to transmit any changes to the wage data (through HCRIS) no later [[Page 29915]] than June 16, 1997. We expect that all unresolved data elements will be resolved by that date, and that the revised data will be reflected in the final rule. 2. Computation of the Wage Index The method used to compute the proposed wage index is as follows: Step 1--As noted above, we are proposing to base the FY 1998 wage index on wage data reported on the FY 1994 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S-3, Part II of the Medicare cost report for the hospital's cost reporting period beginning on or after October 1, 1993 and before October 1, 1994. In addition, we included data from a few hospitals that had cost reporting periods beginning in September 1993 and reported a cost reporting period exceeding 52 weeks. These data were included because no other data from these hospitals would be available for the cost reporting period described above, and particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 1994 data. Step 2--For each hospital, we subtracted the excluded salaries (that is, direct salaries attributable to skilled nursing facility services, home health services, and other subprovider components not subject to the prospective payment system) from gross hospital salaries to determine net hospital salaries. To determine total salaries plus fringe benefits, we added direct patient care contract labor costs, hospital fringe benefits, and any home office salaries and fringe benefits reported by the hospital, to the net hospital salaries. Step 3--For each hospital, we adjusted the total salaries plus fringe benefits resulting from Step 2 to a common period to determine total adjusted salaries. To make the wage inflation adjustment, we used the percentage change in average hourly earnings estimated for each 30- day increment from October 14, 1993 through April 15, 1995, for hospital industry workers from Standard Industry Classification 806, Bureau of Labor Statistics Employment and Earnings Bulletin. The annual inflation rates used were 3.6 percent for FY 1993, 2.7 percent for FY 1994, and 3.3 percent for FY 1995. The inflation factors used to inflate the hospital's data were based on the midpoint of the cost reporting period as indicated below. Midpoint of Cost Reporting Period ------------------------------------------------------------------------ After Before Adjustment factor ------------------------------------------------------------------------ 10/14/93............... 11/15/93 1.038679 11/14/93............... 12/15/93 1.036376 12/14/93............... 01/15/94 1.034077 01/14/94............... 02/15/94 1.031784 02/14/94............... 03/15/94 1.029496 03/14/94............... 04/15/94 1.027213 04/14/94............... 05/15/94 1.024935 05/14/94............... 06/15/94 1.022662 06/14/94............... 07/15/94 1.020394 07/14/94............... 08/15/94 1.018131 08/14/94............... 09/15/94 1.015873 09/14/94............... 10/15/94 1.013620 10/14/94............... 11/15/94 1.010881 11/14/94............... 12/15/94 1.008150 12/14/94............... 01/15/95 1.005426 01/14/95............... 02/15/95 1.002709 02/14/95............... 03/15/95 1.000000 03/14/95............... 04/15/95 0.997298 ------------------------------------------------------------------------ For example, the midpoint of a cost reporting period beginning January 1, 1994 and ending December 31, 1994 is June 30, 1994. An inflation adjustment factor of 1.020394 would be applied to the wages of a hospital with such a cost reporting period. In addition, for the data for any cost reporting period that began in FY 1994 and covers a period of less than 360 days or greater than 370 days, we annualized the data to reflect a 1-year cost report. Annualization is accomplished by dividing the data by the number of days in the cost report and then multiplying the results by 365. Step 4--For each hospital, we subtracted the reported excluded hours from the gross hospital hours to determine net hospital hours. We increased the net hours by the addition of any direct patient care contract labor hours and home office hours to determine total hours. Step 5--As part of our editing process, we deleted data for 17 hospitals for which we lacked sufficient documentation to verify data that failed edits because the hospitals are no longer participating in the Medicare program or are in bankruptcy status. We retained the data for other hospitals that are no longer participating in the Medicare program because these hospitals reflected the relative wage levels in their labor market areas during their FY 1994 cost reporting period. Step 6--Each hospital was assigned to its appropriate urban or rural labor market area prior to any reclassifications under sections 1886(d)(8)(B) or 1886(d)(10) of the Act. Within each urban or rural labor market area, we added the total adjusted salaries plus fringe benefits obtained in Step 3 for all hospitals in that area to determine the total adjusted salaries plus fringe benefits for the labor market area. Step 7--We divided the total adjusted salaries plus fringe benefits obtained in Step 6 by the sum of the total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area. Step 8--We added the total adjusted salaries plus fringe benefits obtained in Step 3 for all hospitals in the Nation and then divided the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the national average hourly wage is $20.0804. Step 9--For each urban or rural labor market area, we calculated the hospital wage index value by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8. Step 10--Following the process set forth above, we developed a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. We added the total adjusted salaries plus fringe benefits (as calculated in Step 3) for all hospitals in Puerto Rico and divided the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall average hourly wage of $9.1956 for Puerto Rico. For each labor market area in Puerto Rico, we calculated the hospital wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage. 3. Revisions to the Wage Index Based on Hospital Redesignation Under section 1886(d)(8)(B) of the Act, hospitals in certain rural counties adjacent to one or more MSAs are considered to be located in one of the adjacent MSAs if certain standards are met. Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the prospective payment system. The methodology for determining the wage index values for redesignated hospitals is applied jointly to the hospitals located in those rural counties that were deemed urban under section 1886(d)(8)(B) of the Act and those hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to [[Page 29916]] which they have been redesignated. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following: If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals. If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the hospitals that are redesignated are subject to that combined wage index value. If including the wage data for the redesignated hospitals increases the wage index value for the area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred. Rural areas whose wage index values increase as a result of excluding the wage data for the hospitals that have been redesignated to another area have their wage index values calculated exclusive of the wage data of the redesignated hospitals. The wage index value for an urban area is calculated exclusive of the wage data for hospitals that have been reclassified to another area. However, geographic reclassification may not reduce the wage index value for an urban area below the statewide rural wage index value, provided the urban area's wage index value prior to reclassification was greater than the statewide rural wage index value. Reclassification of hospitals may not result in the reduction of the wage index value for any urban area whose wage index value is below the statewide rural wage index value. This provision also applies to any urban area that encompasses an entire State. We note that, except for those rural areas where redesignation would reduce the rural wage index value, and those urban areas whose wage index values are already below the statewide rural wage index value and would be reduced by redesignations, the wage index value for each area is computed exclusive of the wage data for hospitals that have been redesignated from the area for purposes of their wage index. As a result, several urban areas listed in Table 4a have no hospitals remaining in the area. This is because all the hospitals originally in these urban areas have been reclassified to another area by the MGCRB. These areas with no remaining hospitals receive the prereclassified wage index value. The prereclassified wage index value will apply as long as the area remains empty. The proposed revised wage index values for FY 1998 are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule. Hospitals that are redesignated should use the wage index values shown in Table 4C. Areas in Table 4C may have more than one wage index value because the wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. When the wage index value of the area to which a rural hospital is redesignated is lower than the wage index value for the rural areas of the State in which the rural hospital is located, the redesignated rural hospital receives the higher wage index value, that is, the wage index value for the rural areas of the State in which it is located, rather than the wage index value otherwise applicable to the redesignated hospitals. Tables 4D and 4E list the average hourly wage for each labor market area, prior to the redesignation of hospitals, based on the FY 1994 wage data. In addition, Table 3C in the Addendum to this proposed rule includes the adjusted (inflated) average hourly wage for each hospital based on the FY 1994 data. The MGCRB will use the average hourly wage published in the final rule to evaluate a hospital's application for reclassification, unless that average hourly wage is later revised in accordance with the wage data correction policy described in Sec. 412.63(s)(2). In such cases, the MGCRB will use the most recent revised data used for purposes of the hospital wage index. Hospitals that choose to apply before publication of the final rule can use the proposed wage data in applying to the MGCRB for wage index reclassifications that would be effective for FY 1999. We note that in adjudicating these wage index reclassification requests during FY 1998, the MGCRB will use the average hourly wages for each hospital and labor market area that are reflected in the final FY 1998 wage index. At the time this proposed wage index was constructed, the MGCRB had completed its review. The proposed FY 1998 wage index values incorporate all 364 hospitals redesignated for purposes of the wage index (hospitals redesignated under section 1886(d)(8)(B) or 1886(d)(10) of the Act) for FY 1998. The final number of reclassifications may be different because some MGCRB decisions are still under review by the Administrator and because some hospitals may withdraw their requests for reclassification. Any changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process will be incorporated into the wage index values published in the final rule. The changes may affect not only the wage index value for specific geographic areas, but also whether redesignated hospitals receive the wage index value for the area to which they are redesignated, or a wage index value that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected. Under Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of this Federal Register document. The request for withdrawal of an application for reclassification that would be effective in FY 1998 must be received by the MGCRB by July 17, 1997. A hospital that requests to withdraw its application may not later request that the MGCRB decision be reinstated. C. Requests for Wage Data Corrections To allow hospitals more time to evaluate the wage data used to construct the proposed FY 1998 hospital wage index, we have made available to the public a data file containing the FY 1994 hospital wage data. In a memorandum dated February 28, 1997, we instructed all Medicare intermediaries to inform the prospective payment hospitals they serve that the wage data file would be available approximately mid-March 1997. The intermediaries were also instructed to advise hospitals of the alternative availability of these data through the Internet at HCFA's home page (http://www.hcfa.gov), their representative hospital organizations, or directly from HCFA (using order forms provided by the intermediary). Additional details on ordering this data file are discussed in [[Page 29917]] section IX.A. of this preamble, ``Requests for Data from the Public.'' In addition, as discussed in section III.B.3 of this preamble, Table 3C in the Addendum to this proposed rule contains each hospital's adjusted average hourly wage used to construct the proposed wage index values. A hospital can verify its average hourly wage as reflected on its cost report (after taking into account any adjustments made by the intermediary) by dividing the adjusted average hourly wage in Table 3C by the applicable wage inflation adjustment factors as set forth above in Step 3 of the computation of the wage index. An updated Table 3C (along with applicable wage inflation adjustment factors) will be included in the final rule. We believe hospitals have had ample time to ensure the accuracy of their FY 1994 wage data. Moreover, the ultimate responsibility for accurately completing the cost report rests with the hospital, which must attest to the accuracy of the data at the time the cost report is filed. However, if after review of the wage data file or Table 3C, a hospital believes that its FY 1994 wage data have been incorrectly reported, the hospital must submit corrections along with complete, detailed supporting documentation to its intermediary by May 15, 1997. To be reflected in the final wage index, any wage data corrections must be reviewed and verified by the intermediary and transmitted to HCFA (through HCRIS) on or before June 16, 1997. These deadlines, which correspond to the deadlines we used last year for developing the FY 1997 wage index, are necessary to allow sufficient time to review and process the data so that the final wage index calculation can be completed for development of the final prospective payment rates to be published by August 29, 1997. We cannot guarantee that corrections transmitted to HCFA after June 16, 1997, will be reflected in the final wage index. After reviewing requested changes submitted by hospitals, intermediaries will transmit any revised cost reports to HCRIS and forward a copy of the revised Worksheet S-3, Part II to the hospitals. If requested changes are not accepted, fiscal intermediaries will notify hospitals in writing of reasons why the changes were not accepted. This procedure will ensure that hospitals have every opportunity to verify the data that will be used to construct their wage index values. We believe that fiscal intermediaries are generally in the best position to make evaluations regarding the appropriateness of a particular cost and whether it should be included in the wage index data. However, if a hospital disagrees with the intermediary's resolution of a requested change, the hospital may contact HCFA in an effort to resolve the dispute. We note that the June 16 deadline also applies to these requested changes, and we will not consider requests to resolve such disputes that are not received by June 16. We have created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 1998 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage corrections or to dispute the intermediary's decision with respect to requested changes. We intend to make another file available in mid-August that will contain the wage data that will be used to construct the wage index values in the final rule. As with the file made available in March 1997, HCFA will make the August wage data file available to hospital associations and the public. This August file, however, is being made available only for the limited purpose of identifying any potential errors made by HCFA or the intermediary in the entry of the final wage data that result from the process described above, not for the initiation of new wage data correction requests. Hospitals are encouraged to review their hospital wage data promptly after the release of the second file. If, after reviewing the August file, a hospital believes that its wage data are incorrect due to a fiscal intermediary or HCFA error in the entry or tabulation of the final wage data, it should send a letter to both its fiscal intermediary and HCFA. The letters should outline why the hospital believes an error exists and provide all supporting information, including dates. These requests must be received by HCFA and the intermediaries no later than September 15, 1997. Requests mailed to HCFA should be sent to: Health Care Financing Administration; Office of Hospital Policy; Attention: Stephen Phillips, Technical Advisor; Division of Prospective Payment System; C5-06-27; 7500 Security Boulevard; Baltimore, MD 21244-1850. Each request also must be sent to the hospital's fiscal intermediary. The intermediary will review requests upon receipt and contact HCFA immediately to discuss its findings. After mid-August, we will make changes to the hospital wage data only in those very limited situations involving an error by the intermediary or HCFA that the hospital could not have known about before its review of the August wage data file. Specifically, after that point, neither the intermediary nor HCFA will accept the following types of requests in conjunction with this process: Requests for wage data corrections that were submitted too late to be included in the data transmitted to HCRIS on or before June 16, 1997. Requests for correction of errors that were not, but could have been, identified during the hospital's review of the March 1997 data. Requests to revisit factual determinations or policy interpretations made by the intermediary or HCFA during the wage data correction process. Verified corrections to the wage index received timely (that is, by September 15, 1997) will be effective October 1, 1997. Again, we believe the wage data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage data to the intermediary's attention. Moreover, because hospitals will have access to the wage data in mid-August, they will have the opportunity to detect any data entry or tabulation errors made by the intermediary or HCFA before the implementation of the FY 1998 wage index on October 1, 1997. If hospitals avail themselves of this opportunity, the wage index implemented on October 1 should be free of such errors. Nevertheless, in the unlikely event that such errors should occur, we retain the right to make midyear changes to the wage index under very limited circumstances. Specifically, in accordance with Sec. 412.63(s)(2), we may make midyear corrections to the wage index only in those limited circumstances where a hospital can show: (1) That the intermediary or HCFA made an error in tabulating its data; and (2) that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of FY 1998 (that is, by the September 15, 1997 deadline). As indicated earlier, since a hospital will have the opportunity to verify its data, and the intermediary will notify the hospital of any changes, we do not foresee any specific circumstances under which midyear corrections would be made. However, should a midyear correction be necessary, the wage index change for the affected area will be effective prospectively from the date the correction is made. [[Page 29918]] D. Modification of the Process and Timetable for Updating the Wage Index Although the wage data correction process described above has proven successful in the past for ensuring that the wage data used each year to calculate the wage indexes are generally reliable and accurate, we are concerned that there have been an excessive number of wage data revisions occurring after the release of the wage data in mid-March. Last year, in developing the FY 1997 wage index, the wage data were revised between the proposed and the final rules for more than 13 percent of the hospitals (approximately 700 of 5,200). Since hospitals are expected to submit complete and accurate data, and the data are reviewed and edited by the intermediaries and HCFA, we believe that we should be making few revisions after the release of the March wage data file. According to information received from the intermediaries, these late revisions are partly due to the lack of responsiveness of hospitals in providing sufficient information to the intermediaries during the desk reviews (that is, during the intermediary's review of the hospital's cost report). Our analysis of last year's wage data also shows that, although the volume of revisions was high, the effect of the changes on the wage index was minimal. Of the 368 labor market areas affected, only 4 (1.1 percent) experienced a change of 5 percent or more in their wage index value and 39 (10.6 percent) experienced a change of 1 percent or more. Thus, the intensity of work that must be performed in order to incorporate these revisions in the 1 month available between the mid- June date for revision requests and the mid-July date by which we must begin calculation of the final wage index is not warranted in light of the minimal changes to the actual wage index values. Another problem with the current process is that it results in corrections to the final wage index after the September 1 final rule publication and before the October 1 effective date of the wage index. Immediately following the development of the final wage index, a second wage data file is made available in mid-August so that hospitals may again verify the accuracy of their wage data. If a hospital detects an error made by the intermediary or HCFA in the handling (entry or transmission) of the wage data, the hospital may request a correction (this year, by September 15). The corrections are published in the Federal Register after the October 1 implementation date in a correction notice to the final rule. We would prefer to eliminate the need to republish certain wage index values after the final rule is in effect. Finally, hospitals base their geographic reclassification decisions (whether or not to withdraw their applications) on the wage index published in the proposed rule. Although the FY 1997 proposed and final wage indexes were quite similar, we cannot ensure this will happen each year if increasing numbers of hospitals delay the submittal to their intermediaries of wage data supporting documentation until the May 15 deadline. We believe that a more informed reclassification decision could be made if the proposed wage index more closely resembles the final wage index. Therefore, we are proposing to revise the wage data verification process beginning with the FY 1999 wage index. 1. Proposed Process and Timetable The major change we are proposing to the current process would be the requirement that wage data revisions be requested (and resolved) earlier, before publication of the proposed rule. Subsequent corrections would be allowed only for errors in handling the data (our current timetable allows for such corrections after the final rule is published). For example, the FY 1999 wage index will use FY 1995 cost report data (that is, cost reports beginning in FY 1995) and become effective October 1, 1998. Under the proposed timetable, hospitals would be required to submit all requests for wage data revisions to their intermediary by mid-December 1997. This would provide ample opportunity for hospitals to evaluate the results of intermediaries' desk reviews and prepare any requests for corrections. We note that the desk reviews are performed on an ongoing basis as cost reports are received from hospitals and, for the FY 1995 wage data, must be completed prior to the mid-November 1997 deadline for submitting all FY 1995 wage data to HCRIS. As under the current process, after reviewing requests for wage data revisions submitted by hospitals, fiscal intermediaries will transmit any revised cost report to HCRIS and forward a copy of the revised Worksheet S-3, Part II to the hospital. If requested revisions are not accepted, the fiscal intermediaries will notify the hospital in writing of reasons why the changes were not accepted. We believe that fiscal intermediaries are generally in the best position to make evaluations regarding the appropriateness of a particular cost and whether it should be included in the wage index data. However, if a hospital disagrees with the intermediary's resolution of a requested change, the hospital may contact HCFA in an effort to resolve the dispute. All policy issues must be resolved by mid-January. The proposed timetable for developing the annual update to the wage index is as follows (an asterisk indicates no change from prior years): Mid-November * All desk reviews for hospital wage data are completed and revised data transmitted by intermediaries to HCRIS. Mid-December Deadline for hospitals to request wage data revisions and provide adequate documentation to support the request. Mid-January Deadline for intermediaries to submit to HCRIS all revisions resulting from hospitals' requests for adjustments (as of mid-December) (and verification of data submitted to HCRIS (as of mid-November)). Early April Edited wage data are available for release to the public. May 1 * Proposed rule published with 60-day comment period and 45-day withdrawal deadline for geographic reclassification. June 16, 1997 Deadline for hospitals to notify HCFA and intermediary that wage data are incorrect due to mishandling of data (that is, error in data entry or transmission) by intermediary or HCFA. June 30, 1997 Deadline for intermediaries to transmit all revisions to HCRIS. September 1 * Publication of the final rule. October 1 * Effective date of updated wage index. 2. Cost Reporting Timetable This proposed change will not significantly alter the time hospitals have to ensure the accuracy of their data. In developing the wage index for a given fiscal year, we use the most recent, reviewed wage data, that is, wage data from cost reports that began in the fiscal year 4 years earlier. For example, for the FY 1999 wage index, we will use data from cost reporting periods beginning in FY 1995. Hospitals must submit cost reports to their intermediaries within 150 days of the end of their cost reporting periods. Once the cost report is received, the intermediary has 12 months to review and settle it. As part of the settlement process, we require intermediaries to conduct a desk [[Page 29919]] review of the wage data. The desk review program for hospital wage data targets potentially aberrant data and checks the completeness and accuracy of the data, including verifying that reported costs are in conformance with our policy, before it is used in calculating the wage index. The intermediary checks the wage data and supporting documentation submitted by the hospital and contacts the hospital if additional information is needed to verify the accuracy of the data. When it is necessary for the intermediary to adjust a hospital's wage data, the intermediary notifies the hospital in writing of the change to the cost report and hospitals then have the opportunity to request adjustments. This would continue to be the case. Since intermediaries must settle cost reports within 12 months of their receipt, most of the cost reports are settled by the time we compile the data to calculate the wage index. We note, however, that the annual update of the wage index is not tied directly to the cost report settlement process since extensions or reopenings of settled cost reports may be granted. The following is an illustration of the process for settling a typical cost report beginning in FY 1995. Of course, hospitals' cost reporting periods may begin at any time during the year. January 1, 1995 Cost reporting period begins. December 31, 1995 Cost reporting period ends. May 31, 1996 Cost report must be submitted by the hospital to the intermediary. July 31, 1996 Cost report must be transmitted by the intermediary to HCRIS. May 31, 1997 Cost report must be settled by the intermediary. (Desk review of hospital wage data is performed on an ongoing basis by the intermediary before the cost report is settled.) July 31, 1997 Settled cost report must be transmitted by the intermediary to HCRIS. 3. Impact of the Proposed Revised Timetable for Finalizing Wage Data The most significant change from our current process is that we would no longer release a preliminary wage data file prior to hospitals' final opportunity to request corrections. We would instead release a single data file in early April for the limited purpose of identifying errors made by the intermediaries or HCFA in handling the data. We no longer believe that the benefit of releasing the preliminary data file outweighs the disadvantages in terms of increased workload for the intermediaries. Under the current process, intermediaries are required to verify the inclusion and accuracy of all hospitals' wage data twice during the wage index development. Verification is done in December and in July before the wage data public use files are released in mid-March and mid-August. Therefore, hospitals would no longer have until mid-May to request wage data revisions. Instead, hospitals would have to request revisions and provide supporting documentation by mid-December of the previous year, and all policy issues would have to be resolved by mid-January. We believe this proposed timetable for finalizing the wage data used in the hospital wage index gives hospitals ample opportunity to ensure the accuracy of the data and at the same time addresses the concerns we have discussed (the number of revisions, the necessity of making numerous corrections after the final rule, and the differences between the proposed and final wage indexes). Moreover, we do not believe the timetable change would impose any increased burden. Hospitals are required to certify the completeness and the accuracy of the wage data when they submit their cost reports, and the intermediaries complete desk reviews before we begin to develop the wage index for a given year. Hospitals would still have an opportunity to request revisions to the cost report data. Although those requests would have to be made earlier, hospitals would continue to have ample time to request appropriate revisions given the timetable for cost report submission and review. We believe the proposed timetable is a logical step in the evolution of the process for compiling the wage data used to calculate the hospital wage index. For a number of years, the hospital wage index was based on a wage survey that was not updated every year. Applicable policies permitted hospitals to request and receive mid-year corrections to the data on the wage survey. Beginning with FY 1994 (beginning on October 1, 1993), we used wage data submitted by hospitals on Worksheet S-3, Part II of the hospital cost report, and we update the wage data every year. We revised our wage data process accordingly--we stopped making mid-year corrections to the wage data, and instead attempted to finalize the wage data by the final rule. The proposed timetable would shorten the time for revisions somewhat further, in order to finalize wage data as much as possible before publication of the proposed rule. Because we have used cost report data for 5 years now, hospitals should be well aware of the importance of submitting accurate wage data on the worksheet S-3, Part II. And as intermediaries and hospitals have become increasingly familiar with the data collection and verification process, handling the data has become more routine and streamlined. For instance, over the past year, we have greatly improved the overall efficiency of our communications with the intermediaries through greater reliance on electronic transmission of wage data. In short, then, there should be less need for revising wage data after desk reviews, and we believe it is reasonable and appropriate to revise the timetable for requesting and resolving wage data revisions. We would continue to make midyear corrections to the wage index in accordance with Sec. 412.63(s)(2), in those limited circumstances where a hospital can show: (1) That the intermediary or HCFA made an error in tabulating its data; and (2) that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of the fiscal year. Although we do not anticipate that such situations would arise, this regulatory authority would remain unchanged. E. Proposed Wage Index Workgroup We are concerned that the rapid and dramatic changes occurring in hospitals' operating environments, combined with the current time lag in the data used to construct the wage index, is leading to a situation where the wage index may be becoming less representative of hospitals' current labor costs. Hospitals' increasing reliance on contract labor for a broadening array of functions, hospital mergers and the development of integrated delivery systems, and the probable expansion of the prospective payment system to other sites of care are factors that indicate a need for a concerted effort to ensure that the data required for calculating the wage index are available and reliable. Furthermore, despite the improvements that resulted from the work of the special Medicare Technical Advisory Group (MTAG) several years ago, technical questions about the treatment of certain types of labor costs continue to arise. For these reasons, we believe there is a need for an ongoing workgroup to address wage index related issues periodically. We are interested in receiving input from representatives of the hospital industry (and other provider types interested in the collection of wage data) regarding the [[Page 29920]] need for such a workgroup and their willingness to participate. We are also seeking public input regarding the structure and scope of such a workgroup. In particular, we welcome comments on whether the workgroup should be formally established (for example, a special MTAG), encompass other provider types, or operate on an ongoing basis. We will respond to comments we receive on this issue in the final rule. IV. Revising the Hospital Operating Market Baskets A. General Discussion We use a hospital input price index (that is, the hospital ``market basket'') to develop the inflation component update factors for operating costs. Although ``market basket'' technically describes the mix of goods and services used to produce hospital care, this term is also commonly used to denote the input price index (that is, cost category weights and price proxies combined) derived from that market basket. Accordingly, the term ``market basket'' as used in this document refers to the hospital input price index. The terms rebasing and revising, although often used interchangeably, actually denote different activities. Rebasing moves the base year for the structure of costs of an input price index (for example, moving the base year cost structure from FY 1987 to FY 1992). Revising means changing data sources, cost categories, or price proxies used in the input price index for a given base year. In the August 30, 1996 final rule, effective for FY 1997, we both rebased and revised the hospital operating market baskets (61 FR 46186). B. Revising the Hospital Market Basket We propose this year to use a revised hospital market basket in developing the FY 1998 update factor for the operating prospective payment rates. In the August 30, 1996 final rule, we discussed the possibility of revising the market basket when additional data became available (61 FR 46187). Consistent with that discussion, we propose to use a revised market basket which would still have a base year of FY 1992, but would incorporate additional data, specifically the Asset and Expenditure Survey, 1992 Census of Service Industries, by the Bureau of the Census, Economics and Statistics Administration, U.S. Department of Commerce, which did not become available until after the FY 1997 final rule was published. (For further discussion of the differences between the proposed revised market basket and the current market basket, see Appendix C of this proposed rule.) In the current market basket, data for four major expense categories (wages and salaries, employee benefits, pharmaceuticals, and a residual category) are from Medicare hospital cost reports for periods beginning in FY 1992 (that is, periods beginning on or after October 1, 1991 and before October 1, 1992). These cost reports, which we refer to as PPS-9 cost reports (the 9th year of PPS), are reported in the Health Care Provider Cost Report Information System (HCRIS). In the proposed hospital market basket, we still use the cost report data, and categories and weights are unchanged from the current market basket. Within the residual category, the categories and weights for nonmedical professional fees and professional liability insurance are also unchanged. (For a detailed discussion of the determination of weights, see the August 30, 1996 final rule (61 FR 46187)). Table 1 shows a comparison of the current and the proposed revised operating market basket cost categories, weights, and price proxies. For the proposed market basket, weights for the ``Utilities'' and ``All Other'' cost categories, as well as most subcategories, were derived using the Asset and Expenditure Survey, published by the Bureau of the Census, Economics and Statistics Administration, U.S. Department of Commerce, in conjunction with the latest available (1987) Input-Output Table, produced by the Bureau of Economic Analysis (BEA), U.S. Department of Commerce. The 1987 input-output cost shares, aged to 1992 using historical price changes between 1987 and 1992 for each category, were allocated to be consistent with the newly available 1992 asset and expenditure data. The resulting combined data were allocated to be consistent with the 1992 hospital cost report data. Revised relative weights for the base year were then calculated for various expenditure categories. This work resulted in the identification of 22 separate cost categories in the revised market basket. Four categories previously separate were combined with existing categories. Specifically, Business Services, and Computer and Data Processing Services were combined with All Other Labor-Intensive Services. Transportation Services was combined with All Other Nonlabor-Intensive Services, and the Fuel, Oil, Coal etc. category was split between Fuels (nonhighway) and Miscellaneous Products. We combined these categories so that the market basket would conform more closely with the 1992 Asset and Expenditure Survey. Detailed descriptions of each of the four categories and their respective price proxies can be found in the August 30, 1996 final rule (61 FR 46323). Changing the structure of the market basket using the 1992 Asset and Expenditure Survey allows for a more accurate reflection of the cost structures faced by hospitals. When the Bureau of the Census or the BEA improves methodologies for the collection and categorization of data, it is likely the weights will also change. Table 1.--Comparison of Current 1992-Based Prospective Payment Hospital Market Basket With Proposed Revised 1992- Based Prospective Payment Hospital Market Basket ---------------------------------------------------------------------------------------------------------------- Proposed Current revised 1992-based 1992-based Expense categories Price proxy excluded excluded market market basket \1\ basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation............................... ...................................... 61.390 61.390 A. Wages and Salaries..................... HCFA Occupational Wage Index.......... 50.244 50.244 B. Employee Benefits...................... HCFA Occupational Benefits Index...... 11.146 11.146 2. Nonmedical Professional Fees............... ECI-Compensation for Professional, 2.127 2.127 Specialty, and Technical. 3. Utilities.................................. ...................................... 2.470 1.542 A. Electricity............................ PPI Commercial Electric Power......... 1.349 0.927 B. Fuels (Nonhighway)..................... PPI Commercial Natural Gas............ 1.015 0.369 C. Water and Sewerage..................... CPI-U Water and Sewerage Maintenance.. 0.106 0.246 [[Page 29921]] 4. Professional Liability Insurance........... HCFA Professional Liability Insurance 1.189 1.189 Premium Index. 5. All Other Expenses......................... ...................................... 32.825 33.752 A. All Other Products..................... ...................................... 24.033 24.825 (1) Pharmaceuticals................... PPI Ethical (Prescription) Drugs...... 4.162 4.162 (2) Food.............................. ...................................... 3.459 3.386 (a) Direct Purchase............... PPI Processed Foods and Feeds......... 2.363 2.314 (b) Contract Service.............. CPI Food Away From Home............... 1.096 1.072 (3) Chemicals......................... PPI Industrial Chemicals.............. 3.795 3.666 (4) Medical Instruments............... PPI Medical Instruments and Equipment. 3.128 3.080 (5) Photographic Supplies............. PPI Photographic Supplies............. 0.399 0.391 (6) Rubber and Plastics............... PPI Rubber and Plastic Products....... 4.868 4.750 (7) Paper Products.................... PPI Converted Paper and Paperboard 2.062 2.078 Products. (8) Apparel........................... PPI Apparel........................... 0.875 0.869 (9) Machinery and Equipment........... PPI Machinery and Equipment........... 0.211 0.207 (10) Miscellaneous Products........... PPI Finished Goods.................... 1.074 2.236 B. All Other Services..................... ...................................... 8.792 8.927 (1) Postage........................... CPI-U Postage......................... 0.272 0.272 (2) Telephone Services................ CPI-U Telephone Services.............. 0.531 0.581 (3) All Other: Labor Intensive........ ECI Compensation for Private Service 7.457 7.277 Occupations. (4) All Other: Nonlabor Intensive..... CPI-U All Items....................... 0.532 0.796 ------------------------- Total............................. ...................................... 100.000 100.000 ---------------------------------------------------------------------------------------------------------------- Note: Due to rounding, weights may not sum to total. \1\ Expense categories based on proposed 1992-based hospital market basket for comparison purposes. In calculating payments to hospitals, the labor-related portion of the standardized amounts is adjusted by the hospital wage index. As discussed in the August 30, 1996 final rule (61 FR 46189), for purposes of determining the labor-related portion of the standardized amounts, we sum the percentages of the labor-related items (that is, wages and salaries, employee benefits, professional fees, business services, computer and data processing services, postage, and all other labor- intensive services) in the operating hospital market basket. Effective for FY 1997, this summation resulted in a labor-related portion of the hospital market basket of 71.246 percent, and a nonlabor-related portion of 28.754 percent. Thus, since October 1, 1996, we have considered 71.2 percent of operating costs to be labor-related for purposes of the prospective payment system (we rounded to the nearest tenth). In connection with the revisions to the hospital market basket, we have reestimated the labor-related share of the standardized amounts. Based on the relative weights described in Table 2, the labor-related portion (wages and salaries, employee benefits, professional fees, postage, and all other labor-intensive services) is 71.066 percent, and the nonlabor-related portion is 28.934 percent. Accordingly, effective with discharges occurring on or after October 1, 1997, we are proposing to revise the labor-related and nonlabor-related shares of the large urban and other areas' standardized amounts used to establish the prospective payment rates to 71.1 and 28.9, respectively. The amounts in Table 2 reflect the revised labor-related and nonlabor-related portions. We note that the labor-related portions of the rates published in Table 2 have remained approximately the same. The labor- related portion has decreased from 71.246 percent to 71.066 percent. Table 2.--Labor-Related Share of Proposed 1992-Based Prospective Payment Hospital Market Basket ------------------------------------------------------------------------ Cost category Weight ------------------------------------------------------------------------ Wages and salaries........................................... 50.244 Employee benefits............................................ 11.146 Professional fees............................................ 2.127 Postal services.............................................. 0.272 All other labor intensive.................................... 7.277 ---------- Total labor-related...................................... 71.066 ========== Total nonlabor-related................................... 28.934 ------------------------------------------------------------------------ C. Selection of Price Proxies Only four categories that are part of the current hospital market basket do not appear in the proposed revised hospital market basket. Of the 22 categories that are part of both the current and the proposed revised market baskets, only the weights might differ. The wage and price proxies selected for these cost categories are the same as those selected last year. A description and discussion of each price proxy are set forth in the August 30, 1996 final rule (61 FR 46324). The price proxies are shown in Table 1, above. The makeup of the HCFA Blended Occupational Wage Index and the HCFA Blended Occupational Benefits Index used as proxies for Wages and Salaries and Employee Benefits, respectively, remain the same as last year. (See 61 FR 27463.) To examine the impact of the changes to the weights and the reduction of the number of cost categories, we developed a comparison for the period FY 1994 through FY 1999. Using historical data for FY 1994 through FY 1996, and forecasts for FY 1997 through FY 1999 for the prospective payment market basket, we compared the percentage changes for the current and the proposed revised market baskets. [[Page 29922]] Table 3.--Comparison of the Proposed Prospective Payment Hospital Market Basket and the Current Prospective Payment Hospital Market Basket Percent Change, FY 1994-1999 ------------------------------------------------------------------------ Current Proposed hospital hospital Federal fiscal year market market Difference basket basket ------------------------------------------------------------------------ Historical: 1994.................................. 2.6 2.6 0.0 1995.................................. 3.2 3.2 0.0 1996.................................. 2.5 2.4 -0.1 Forecasted: 1997.................................. 2.4 2.3 -0.1 1998.................................. 2.7 2.8 0.1 1999.................................. 3.0 2.9 -0.1 Historical Average: 1994-1996............................. 2.8 2.7 -0.1 Forecasted Average: 1997-1999............................. 2.7 2.7 0.0 ------------------------------------------------------------------------ Note that the historical average rate of growth for 1994 through 1996 for the improved proposed revised prospective payment hospital market basket is almost equal to that of the current market basket. The 0.1 percentage point difference is less than the +/-0.25 percent threshold for corrections for forecast error. The forecasted average rate of growth for 1997 through 1999 for the revised market basket is equal to that of the current market basket. D. Separate Market Basket for Hospitals and Hospital Units Excluded From the Prospective Payment System As in the prospective payment hospital market basket, weights for the six main cost categories contained in the excluded hospital market basket (that is, weights for wages and salaries, employee benefits, professional fees, malpractice insurance, pharmaceuticals, and the residual category) remain the same. Only the weights for ``Utilities'' and the categories within ``All Other'' have been revised. Table 4 below shows weights for the current and proposed excluded hospital market basket. Table 4.--Comparison of Current 1992-Based Excluded Hospital Market Basket With Proposed Revised 1992-Based Excluded Hospital Market Basket ---------------------------------------------------------------------------------------------------------------- Proposed Current revised 1992-based 1992-based Expense categories Price proxy excluded excluded market market basket \1\ basket ---------------------------------------------------------------------------------------------------------------- 1. Compensation............................... ...................................... 63.721 63.721 A. Wages and Salaries..................... HCFA Occupational Wage Index.......... 52.152 52.152 B. Employee Benefits...................... HCFA Occupational Benefits Index...... 11.569 11.569 2. Nonmedical Professional Fees............... ECI-Compensation for Professional, 2.098 2.098 Specialty, and Technical. 3. Utilities.................................. ...................................... 2.557 1.675 A. Electricity............................ WPI Commercial Electric Power......... 1.396 1.007 B. Fuels (Nonhighway)..................... WPI Commercial Natural Gas............ 1.051 0.401 C. Water and Sewerage..................... CPI-U Water and Sewerage Maintenance.. 0.110 0.267 4. Professional Liability Insurance........... HCFA Professional Liability Insurance 1.081 1.081 Premium Index. 5. All Other Expenses......................... ...................................... 30.541 31.425 A. All Other Products..................... ...................................... 23.640 24.227 (1) Pharmaceuticals................... PPI Ethical (Prescription) Drugs...... 3.070 3.070 (2) Food.............................. ...................................... 3.581 3.468 (a) Direct Purchase............... PPI Processed Foods and Feeds......... 2.446 2.370 (b) Contract Service.............. CPI Food Away From Home............... 1.135 1.098 (3) Chemicals......................... PPI Industrial Chemicals.............. 3.929 3.754 (4) Medical Instruments............... PPI Medical Instruments and Equipment. 3.238 3.154 (5) Photographic Supplies............. PPI Photographic Supplies............. 0.413 0.400 (6) Rubber and Plastics............... PPI Rubber and Plastic Products....... 5.039 4.865 (7) Paper Products.................... PPI Converted Paper and Paperboard 2.134 2.182 Products. (8) Apparel........................... PPI Apparel........................... 0.906 0.890 (9) Machinery and Equipment........... PPI Machinery and Equipment........... 0.218 0.212 (10) Miscellaneous Products........... PPI Finished Goods.................... 1.112 2.232 B. All Other Services..................... ...................................... 6.901 7.198 (1) Postage........................... CPI-U Postage......................... 0.282 0.295 (2) Telephone Services................ CPI-U Telephone Services.............. 0.549 0.631 (3) All Other: Labor Intensive........ ECI Compensation for Private Service 5.519 5.439 Occupations. (4) All Other: Nonlabor Intensive..... CPI-U All Items....................... 0.551 0.833 ------------------------- Total............................. ...................................... 100.000 100.000 ---------------------------------------------------------------------------------------------------------------- Note: Due to rounding, weights may not sum to total. \1\ Expense categories based on proposed 1992-based hospital market basket for comparison purposes. [[Page 29923]] V. Other Decisions and Changes to the Prospective Payment System for Inpatient Operating Costs A. Elimination of Day Outlier Payments (Secs. 412.80 and 412.82) Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases, that is, cases involving extraordinarily high costs (cost outliers) or long lengths of stay (day outliers). That section also provides that, beginning with FY 1995, payments for day outliers will be phased out over 3 years. We have discussed this phase out and its implementation in detail in the September 1, 1994, September 1, 1995, and August 30, 1996 final rules (59 FR 45366, 60 FR 45854, and 61 FR 46228, respectively). Since payment for day outliers will be eliminated effective with discharges occurring in FY 1998, we are proposing to make conforming revisions to the regulations at Secs. 412.80, 412.82, 412.84, and 412.86. At the same time, we are making a technical change to the provision concerning outlier payments for transfer cases to conform the regulations text to policies that we have stated in previous prospective payment system rules but did not codify. See the final rules published September 1, 1995 (60 FR 45804) and September 1, 1993 (58 FR 46306-07). B. Rural Referral Centers (Sec. 412.96) Under section 1886(d) of the Act, hospitals generally are paid by the Medicare program for inpatient hospital services covered by Medicare in accordance with the prospective payment system. Certain hospitals, however, receive special treatment under that system. Section 1886(d)(5)(C)(i) of the Act specifically provides for exceptions and adjustments to prospective payment amounts, as the Secretary deems appropriate, to take into account the special needs of rural referral centers. Section 412.96(d) of the regulations provides that, for discharges occurring before October 1, 1994, rural referral centers received the benefit of payment for inpatient operating costs per discharge based on the other urban payment amount rather than the rural standardized amount. As of October 1, 1994, the other urban and rural standardized amounts are the same. However, rural referral centers continue to receive special treatment under both the disproportionate share hospital payment adjustment and the criteria for geographic reclassification. One of the ways that a rural hospital may qualify as a rural referral center is to meet two mandatory criteria (specifying a minimum case-mix index and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or volume of referrals). These criteria are described in detail in 42 CFR 412.96(c). 1. Case-Mix Index Criteria Section 412.96(c)(1) sets forth the case-mix index criteria and provides that, for cost reporting periods beginning on or after October 1, 1986, a hospital's case-mix index for discharges ``during the Federal fiscal year that ended 1 year prior to the beginning of the cost reporting period for which the hospital is seeking referral center status'' must be at least equal to the national case-mix index value as established by HCFA or the median case-mix value for urban hospitals in the region in which the hospital is located (excluding hospitals receiving indirect medical education payments), whichever is lower. It has come to our attention that the language in Sec. 412.96(c)(1) does not clearly address situations in which the Federal fiscal year does not end exactly 1 year prior to the beginning of the cost reporting period for which the hospitals are seeking referral center status. In order to minimize any confusion, we propose to clarify which case-mix index values are used to determine referral center status. Our policy, which we have applied consistently since 1986, is that the case-mix index used for an individual hospital in the determination of whether it meets the case-mix index criterion is the case-mix index for discharges during the most recent Federal fiscal year that ended at least 1 year prior to the beginning of the cost reporting period for which the hospital is seeking referral center status. In this proposed rule, we would revise Sec. 412.96(c)(1) to clarify the time period used to calculate the case-mix index. We emphasize that this clarification represents no substantive change in policy. 2. Updated Case-Mix and Discharge Criteria As noted above, a rural hospital can qualify as a rural referral center if the hospital meets two mandatory criteria (case-mix index and number of discharges) and at least one of three optional criteria (medical staff, source of inpatients, or volume of referrals). With respect to the two mandatory criteria, a hospital may be classified as a rural referral center if its-- Case-mix index is at least equal to the lower of the median case-mix index for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median case-mix index for all urban hospitals nationally; and Number of discharges is at least 5,000 discharges per year or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges per year.) a. Case-Mix Index. Section 412.96(c)(1) provides that HCFA will establish updated national and regional case-mix index values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. In determining the proposed national and regional case-mix index values, we follow the same methodology we used in the November 24, 1986 final rule, as set forth in regulations at Sec. 412.96(c)(1)(ii). Therefore, the proposed national case-mix index value includes all urban hospitals nationwide, and the proposed regional values are the median values of urban hospitals within each census region, excluding those with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in Sec. 412.105). These values are based on discharges occurring during FY 1996 (October 1, 1995 through September 30, 1996) and include bills posted to HCFA's records through December 1996. Therefore, in addition to meeting other criteria, we are proposing that to qualify for initial rural referral center status or to meet the triennial review standards for cost reporting periods beginning on or after October 1, 1997, a hospital's case-mix index value for FY 1996 would have to be at least-- 1.3525; or Equal to the median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in Sec. 412.105) calculated by HCFA for the census region in which the hospital is located. The median case-mix values by region are set forth in the table below: ------------------------------------------------------------------------ Case- mix Region index value ------------------------------------------------------------------------ 1. New England (CT, ME, MA, NH, RI, VT)........................ 1.2324 2. Middle Atlantic (PA, NJ, NY)................................ 1.2424 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)......... 1.3671 4. East North Central (IL, IN, MI, OH, WI)..................... 1.2625 5. East South Central (AL, KY, MS, TN)......................... 1.3076 [[Page 29924]] 6. West North Central (IA, KS, MN, MO, NE, ND, SD)............. 1.2089 7. West South Central (AR, LA, OK, TX)......................... 1.3270 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................... 1.3449 9. Pacific (AK, CA, HI, OR, WA)................................ 1.3429 ------------------------------------------------------------------------ The above numbers will be revised in the final rule to the extent required to reflect the updated MedPAR file, which will contain data from additional bills received for discharges through September 30, 1996. For the benefit of hospitals seeking to qualify as referral centers or those wishing to know how their case-mix index value compares to the criteria, we are publishing each hospital's FY 1996 case-mix index value in Table 3C in section IV. of the Addendum to this proposed rule. In keeping with our policy on discharges, these case-mix index values are computed based on all Medicare patient discharges subject to DRG- based payment. b. Discharges. Section 412.96(c)(2)(i) provides that HCFA will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining referral center status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. However, we are proposing to update the regional standards. The proposed regional standards are based on discharges for urban hospitals' cost reporting periods that began during FY 1995 (that is, October 1, 1994 through September 30, 1995). That is the latest year for which we have complete discharge data available. Therefore, in addition to meeting other criteria, we are proposing that to qualify for initial rural referral center status or to meet the triennial review standards for cost reporting periods beginning on or after October 1, 1997, the number of discharges a hospital must have for its cost reporting period that began during FY 1996 would have to be at least-- 5,000; or Equal to the median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the table below. ------------------------------------------------------------------------ Number of Region discharges ------------------------------------------------------------------------ 1. New England (CT, ME, MA, NH, RI, VT)..................... 6725 2. Middle Atlantic (PA, NJ, NY)............................. 8511 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 6991 4. East North Central (IL, IN, MI, OH, WI).................. 6607 5. East South Central (AL, KY, MS, TN)...................... 5805 6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 4625 7. West South Central (AR, LA, OK, TX)...................... 5085 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 8167 9. Pacific (AK, CA, HI, OR, WA)............................. 5945 ------------------------------------------------------------------------ We reiterate that, to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 1997, an osteopathic hospital's number of discharges for its cost reporting period that began during FY 1996 would have to be at least 3,000. 3. Retention of Referral Center Status Section 412.96(f) states that each hospital receiving the referral center adjustment is reviewed every 3 years to determine if the hospital continues to meet the criteria for referral center status. To retain status as a referral center, a hospital must meet the criteria for classification as a referral center specified in Sec. 412.96 (b)(1) or (b)(2) or (c) for 2 of the last 3 years, or for the current year. A hospital may meet any one of the three sets of criteria for individual years during the 3-year period or the current year. For example, a hospital may meet the two mandatory requirements in Sec. 412.96(c)(1) (case-mix index) and (c)(2) (number of discharges) and the optional criterion in paragraph (c)(3) (medical staff) during the first year. During the second or third year, the hospital may meet the criteria under Sec. 412.96(b)(1) (rural location and appropriate bed size). A hospital must meet all of the criteria within any one of these three sections of the regulations in order to meet the retention requirement for a given year. That is, it will have to meet all of the criteria of Sec. 412.96(b)(1) or Sec. 412.96(b)(2) or Sec. 412.96(c). For example, if a hospital meets the case-mix index standards in Sec. 412.96(c)(1) in years 1 and 3 and the number of discharge standards in Sec. 412.96(c)(2) in years 2 and 3, it will not meet the retention criteria. All of the standards would have to be met in the same year. In accordance with Sec. 412.96(f)(2), the review process is limited to the hospital's compliance during the last 3 years. Thus, if a hospital meets the criteria in effect for at least 2 of the last 3 years or if it meets the criteria in effect for the current year (that is, the criteria for FY 1998 outlined above in this section of the preamble), it will retain its status for another 3 years. We have constructed the following chart and example to aid hospitals that qualify as referral centers under the criteria in Sec. 412.96(c) in projecting whether they will retain their status as a referral center. Under Sec. 412.96(f), to qualify for a 3-year extension effective with cost reporting periods beginning in FY 1998, a hospital must meet the criteria in Sec. 412.96(c) for FY 1998 or it must meet the criteria for 2 of the last 3 years as follows: ---------------------------------------------------------------------------------------------------------------- Use the discharges for For the cost reporting period Use hospital's case-mix the hospital's cost Use numerical standards beginning during FY index for FY reporting period as published in the beginning during FY Federal Register on ---------------------------------------------------------------------------------------------------------------- 1997............................. 1995.................... 1995.................... Aug. 30, 1996. 1996............................. 1994.................... 1994.................... Sept. 1, 1995. 1995............................. 1993.................... 1993.................... Sept. 1, 1994. ---------------------------------------------------------------------------------------------------------------- Example: A hospital with a cost reporting period beginning July 1 qualified as a referral center effective July 1, 1995. The hospital has fewer than 275 beds. Its 3-year status as a referral center is protected through June 30, 1998 (the end of its cost reporting period beginning July 1, 1997). To determine if the hospital should retain its status as a referral center for an additional 3-year period, we will review its compliance with the applicable criteria for its cost reporting periods beginning July 1, 1995, July 1, 1996, and July 1, 1997. The hospital must meet the criteria in effect either for its cost reporting period beginning July 1, 1998, or for two out of the three past periods. For example, to be found to have met the criteria at Sec. 412.96(c) for its cost reporting period beginning July 1, [[Page 29925]] 1996, the hospital's case-mix index value during FY 1994 must have equaled or exceeded the lower of the national or the appropriate regional standard as published in the September 1, 1995 final rule with comment period. The hospital's total number of discharges during its cost reporting year beginning July 1, 1994, must have equaled or exceeded 5,000 or the regional standard as published in the September 1, 1995 final rule with comment period. For those hospitals that seek to retain referral center status by meeting the criteria of Sec. 412.96(b)(1) (i) and (ii) (that is, rural location and at least 275 beds), we will look at the number of beds shown for indirect medical education purposes (as defined at Sec. 412.105(b)) on the hospital's cost report for the appropriate year. We will consider only full cost reporting periods when determining a hospital's status under Sec. 412.96(b)(1)(ii). This definition varies from the number of beds criterion used to determine a hospital's initial status as a referral center because we believe it is important for a hospital to demonstrate that it has maintained at least 275 beds throughout its entire cost reporting period, not just for a particular portion of the year. C. Determining the Total Number of Full-Time Equivalent Residents for Indirect Medical Education Adjustment (Sec. 412.105) Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education program receive an additional payment to reflect the higher indirect operating costs associated with graduate medical education. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are at Sec. 412.105. The additional payment is calculated by multiplying a hospital's DRG revenue (including outlier payments) by the applicable IME adjustment factor. The adjustment factor is calculated by using a hospital's ratio of residents-to-beds in the formula set forth at section 1886(d)(5)(B)(ii) of the Act. The criteria governing whether a program is considered approved are at Sec. 412.105(g)(1)(i). These criteria are the same as those used to identify approved programs for the direct graduate medical education payment under Sec. 413.86(b). In the August 30, 1991 final rule (56 FR 43237), we added a criterion to Sec. 413.86(b), but inadvertently did not add it to Sec. 412.105(g)(1)(i). This criterion added the Annual Report and Reference Handbook of the American Board of Medical Specialties (ABMS) as another publication to be used to identify approved programs. To correct this inadvertent omission, we are proposing a technical change to Sec. 412.105(g)(1) to parallel the provisions of Sec. 413.86(b). In addition, we are proposing to delete Sec. 412.105(g)(1)(iv), which excludes from the IME resident count any anesthesiology residents employed to replace anesthetists. This exclusion was originally intended to prevent hospitals from hiring residents in lieu of nonphysician anesthetists. Given that certain rural hospitals continue to receive pass-through cost reimbursement for their anesthetist costs, we no longer believe this provision is warranted. Nor are we aware of any specific instances where it has been applied. D. Direct Graduate Medical Education: Newly Participating Hospitals (Sec. 413.86) Under section 1886(h) of the Act and implementing regulations, Medicare pays hospitals for the direct costs of graduate medical education on the basis of per resident costs in a 1984 base year. Under existing regulations at Sec. 413.86(e)(4), if a hospital did not have residents in the 1984 base period but later participates in teaching activities, the fiscal intermediaries calculate a per resident amount based on a weighted average of all the hospitals in the same geographic wage area. There must be at least three hospitals for this calculation. If there are fewer than three hospitals, the regulations require the fiscal intermediary to contact the HCFA Central Office for a determination of the appropriate amount to use. We are proposing to modify the regulations for determining base year per resident amounts for hospitals that participated in residency training after the 1984 base period. Under the proposed changes to Sec. 413.86(e)(4)(i)(B), we would sequentially follow the criteria listed below until we can base the weighted average calculation on a minimum of 3 per resident amounts: If there are fewer than three hospitals in the hospital's geographic wage area, the intermediary will determine a weighted average based on the per resident amounts for all hospitals in the hospital's own wage area, plus hospitals in geographically contiguous wage areas. If there are still fewer than three hospitals in the hospital's own wage area, plus hospitals in contiguous wage areas, the weighted average will be based on the per resident amounts for all hospitals in the State. If there are fewer than three hospitals in the entire State, the weighted average will be based on the per resident amounts for all hospitals in that State plus hospitals in contiguous States. If there are fewer than three hospitals in that State and contiguous States, the weighted average per resident amount will be based on the national average per resident amount. E. Technical Change: Correction of Statutory Citation The August 30, 1996 final rule (61 FR 46165) included an amendment to Sec. 489.27 that reprinted the statutory reference governing the distribution of an ``Important Message from Medicare.'' This reference, ``section 1886(a)(1)(M)'', was incorrect. We propose to correct this reference to read ``section 1866(a)(1)(M)''. VI. Changes to the Prospective Payment System for Capital-Related Costs A. Possible Adjustment to Capital Prospective Payment System Minimum Payment Levels Section 412.348(b) of the regulations provides that, during the capital prospective payment system transition period, any hospital may receive an additional payment under an exceptions process if its total inpatient capital-related payments under its payment methodology (that is, fully prospective or hold-harmless) are less than a minimum percentage of its allowable Medicare inpatient capital-related costs. The minimum payment levels are established by class of hospitals under Sec. 412.348(c). The minimum payment levels for portions of cost reporting periods occurring in FY 1997 are: Sole community hospitals (located in either an urban or rural area), 90 percent; Urban hospitals with at least 100 beds and a disproportionate share patient percentage of at least 20.2 percent and urban hospitals with at least 100 beds that qualify for disproportionate share payments under Sec. 412.106(c)(2), 80 percent; and, All other hospitals, 70 percent. Under Sec. 412.348(d), the amount of the exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital prospective payment system to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to that system. Any amount by which the hospital's cumulative payments for previous cost reporting periods exceed its cumulative minimum payment is deducted from the additional payment that would otherwise be payable for a cost reporting period. Section 412.348(g) also provides for a separate special exceptions process for hospitals undertaking major renovations or replacement of aging facilities during the decade of the transition. For as long [[Page 29926]] as 10 years beyond the end of the transition period, certain hospitals may be eligible to receive special exceptions payments at a 70 percent minimum payment level. For hospitals that qualify for the special exceptions provision before the end of the transition, the general and special exceptions provisions will run concurrently during the later years of the transition. However, since the minimum payment level for the special exceptions provision is at the same level that applies to all hospitals under the general provision (currently 70 percent), the special exceptions provision will generate no additional payment to hospitals until the end of the transition period. Section 412.348(h) further provides that total estimated exceptions payments under both the regular exceptions process and the special exceptions process may not exceed 10 percent of the total estimated capital prospective payments (exclusive of hold-harmless payments for old capital) for the same fiscal year. In the FY 1997 final rule implementing the prospective payment system for capital-related costs, we stated that the minimum payment levels in subsequent transition years would be revised, if necessary, to keep the projected percentage of payments under the exceptions process at no more than 10 percent of capital prospective payments. In section III of the Addendum to this proposed rule, we discuss the factors and adjustments used to develop the FY 1998 Federal and hospital-specific rates. In particular, we discuss the FY 1998 exceptions payment reduction factor. This factor adjusts the annual payment rates for the estimated amount of additional payments for exceptions in FY 1998. In this proposed rule, we estimate that exceptions will equal 7.24 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We will develop a new estimate of the level of exceptions payments in FY 1998, and revise the exceptions payment adjustment factor accordingly, on the basis of the data that becomes available to us in time for developing the final rule for FY 1998. While it is not necessary at this time to propose reductions in the minimum payment levels, it is possible that it will be necessary to implement adjustments to the minimum payment levels in the final rule. Our current projections show that it will almost certainly be necessary to adjust the minimum payment levels for FY 1999. We are therefore providing public notification that adjustments to the minimum payment levels are possible in the final rule, and almost certain for FY 1999. When it does become necessary to adjust the minimum payment levels in accordance with Sec. 412.348(h), our current intent is to adjust each of the existing levels (that is, 90 percent for sole community hospitals, 80 percent for large urban DSH hospitals, and 70 percent for all other hospitals and special exceptions) by 5 percentage point increments until estimated exceptions payments are within the 10 percent limit. For example, we would set minimum payment levels at 85 percent for sole community hospitals, 75 percent for large urban DSH hospitals, and 65 percent for all other hospitals and special exceptions, provided that aggregate exceptions payments at those minimum payment levels were projected to be no more than 10 percent of total rate-based payments. We believe that this policy appropriately provides for all classes of hospitals to share in the reduction in exceptions payments, while simultaneously preserving the special protections provided by higher minimum payment levels for sole community hospitals and large urban DSH hospitals relative to all other hospitals. If aggregate exceptions payments at those minimum payment levels still exceed 10 percent of total rate-based payments, we would continue to reduce the minimum payment levels by 5 percentage point increments each until the requirement of Sec. 412.348(h) was satisfied. We are providing notification of our current thinking on this issue in order to allow opportunity for public comment on the appropriate method for adjusting the minimum payment levels. We made a similar proposal on the possibility of adjusting minimum payment levels in the FY 1997 proposed rule (61 FR 27481). In the FY 1997 final rule (61 FR 46219) we noted that some commenters objected to our proposed method for handling necessary reductions to the minimum payment levels. One commenter suggested that we develop a more sophisticated methodology that would allow more refined adjustment of the minimum payment levels. Another commenter suggested a 1- or 2- percent reduction increment, rather than the proposed 5-percent increment. We will take these comments into consideration when it becomes necessary to adjust the minimum payment levels in accordance with Sec. 412.348(h). We welcome other comments on this matter as well. B. Special Exceptions Application Process As discussed section VI.A. above, a separate special exceptions provision extends protection to certain hospitals undertaking major renovation or replacement of aging facilities during the decade of the transition. The regulation establishing eligibility for this special exceptions provision, and describing the criteria by which eligible hospitals qualify for special exceptions payments (Sec. 412.348(g)), was finalized on September 1, 1994 (59 FR 45385). At this time, we are not proposing to make any policy changes to the special exceptions provision. (We are (or may be), however, revising the minimum payment level for this exceptions provision, along with the minimum payment levels under the regular exceptions provision, as described in section VI.A. above). However, we have received questions from hospitals and intermediaries about the special exceptions process, and we would therefore like to clarify a few aspects of that process. Providers seeking special exceptions payments should submit documentation to their fiscal intermediary to demonstrate that they meet the eligibility and qualifying requirements in Sec. 412.348(g). Documentation establishing that the hospital meets one of the eligibility criteria, the project need requirement, the age of assets test, and the project size requirement must be submitted to the intermediary no later than the date on which the cost report is due for the first cost reporting period in which the exceptions payment is expected. (As noted in section VI.A. above, since the 70-percent minimum payment level for the special exceptions provision is at the same level that applies to all hospitals under the general provision, the special exceptions provision will generate no additional payment to hospitals until the end of the transition period.) The fiscal intermediary will make an initial determination of whether the provider has met these criteria for receiving special exceptions payments. Further documentation demonstrating that the hospital continues to meet one of the eligibility criteria, that it meets the excess capacity test, as required, and that the hospital's regular payments fall short of the minimum payment level (accounting for the cumulative payment comparison and offsetting amounts, Sec. 412.348(g)(8)) will be required for each successive cost reporting period in which the exception is claimed. To qualify, an eligible hospital must meet both project need and project size [[Page 29927]] requirements. For hospitals in States with CON requirements, the project need requirement is satisfied by obtaining CON approval. A copy of the State CON approval should be submitted to the intermediary. For other hospitals, the project need requirement is satisfied by meeting an age of assets test. To meet the age of asset test, a hospital must have an average age of buildings and fixed equipment at or above the 75th percentile nationally in the first year of capital prospective payment. The hospital should submit to the intermediary copies of Worksheets A-7 and G from the first cost reporting under the capital prospective payment system, and a calculation of its average age of assets for that cost reporting year. The average age of assets is determined as the ratio of accumulated depreciation for buildings and fixed equipment to current depreciation for buildings and fixed equipment. (The data required for the age of assets computation are found on HCFA 2552-92, Worksheet G, lines 14, 14.01, 16, 16.01, 18, 18.01, 20, and 20.01, and Worksheet A-7, Part III, Column 9, lines 1 and 3.) At the time that the special exceptions process was finalized in the September 1, 1994 final rule (59 FR 45385), data from the June 1994 update of the cost report file showed that the 75th percentile for buildings and fixed equipment was 16.4 years. At that time, we stated that we would make a final determination of the 75th percentile on the basis of more complete cost report information for FY 1992. We believe that the cost report information for FY 1992 is now sufficiently complete and reliable to make the final determination of the 75th percentile. As computed from the December 1996 update of the cost report data, the 75th percentile nationally for buildings and fixed equipment is 15.4 years. We note that, in making this computation, we took account of the fact that hospitals do not always report accumulated and current year depreciation amounts consistently. For example, a hospital might report accumulated depreciation amounts on Worksheet G on an accelerated depreciation basis. In such a case, current year depreciation amounts on Worksheet A-7 should be adjusted to reflect straight line depreciation. This is because the program recognizes only straight line depreciation for cost accounting and payment purposes. Obviously, the numerator and denominator of the ratio used to establish average age of assets must be consistent. In determining the 75th percentile of average age of assets for FY 1992, we have employed only 4,611 hospitals. We eliminated hospitals that did not report both accumulated and current year depreciation on a straight line basis in their FY 1992 cost reports. We also eliminated any hospital whose computed age of assets was greater than 35.0 years. We took this step to eliminate obvious outliers and to assure that hospitals are not disadvantaged in meeting the 75th percentile requirement by the inclusion of hospitals whose computed age of assets is relatively higher merely because the Worksheet G data were not thoroughly audited. Eliminating these latter hospitals is to the advantage of hospitals trying to qualify for an exception, since it results in a lower threshold for meeting the average age of assets test. Eliminating these latter hospitals from the computation is the major reason why the 75th percentile has declined to 15.4 years from the 16.4 years that we previously estimated. We note that, in the case of an individual hospital that reported accumulated and current depreciation on a different basis, it would be necessary to reconstruct accumulated depreciation for fixed assets that were in use for patient care in FY 1992 for purposes of determining whether that hospital met the average age of assets test. The following information would be necessary for this purpose: the purchase prices for each fixed asset in use in 1992, useful life of each asset, and the number of years each asset had been in use prior to FY 1992. Reconstructing FY 1992 accumulated depreciation for each asset would involve dividing the purchase price by the useful life and multiplying the result by the years in which the asset had been in service. A hospital must also demonstrate that it meets a project size requirement to qualify for a special exceptions payment. The project size requirement is satisfied if the hospital completes, during the capital PPS transition period, a project whose costs for replacement and/or renovation of fixed assets (buildings and fixed equipment, but not movable equipment) are at least $200 million, or 100 percent of its operating costs during the first cost reporting period under the prospective payment system. The hospital should, therefore, submit to the intermediary auditable documentation establishing the costs for its project to replace and/or renovate fixed assets. This documentation also should establish that this project was completed during the capital PPS transition period (that is, not before the start of its first cost reporting period beginning on or before October 1, 1991, and not later than the end of its last cost reporting period beginning before October 1, 2001). Relevant documentation would include, but would not be restricted to, the plans for the relevant construction and/or renovation project, the total bills for construction and/or renovation related to the project, and records showing that the new or renovated facilities entered service for patient care during the capital PPS transition period. For hospitals in States without CON requirements, an urban hospital must demonstrate either that it is in a MSA that does not have an overall occupancy rate less than 80 percent, or that its capacity is no more than 80 percent of its capacity (in terms of bed size) prior to the completion of its qualifying project of construction or renovation of fixed assets. (This test does not apply to rural hospitals.) An urban hospital in a non-CON State must thus meet one of two tests in order to satisfy the excess capacity requirement. We have been contacted by hospitals and fiscal intermediaries about how to determine if the excess capacity requirement has been met. Therefore, we would like to clarify what is necessary to satisfy both the excess capacity tests for urban hospitals. For the bed size test, we use the same definition of bed size that is used for indirect graduate medical education and DSH payments. Under Sec. 412.105(b), the number of beds in a hospital is determined by counting the number of available bed days during the cost reporting period, not including beds or bassinets in the healthy newborn nursery, custodial care beds, or beds in excluded distinct part hospital units, and dividing that number by the number of days in the cost reporting period. The number of beds is computed, using this formula, and entered on Worksheet S-3 of the cost report. Section 2405.3 of the Medicare Provider Reimbursement Manual provides additional information on bed size. Bed size must be determined for the last cost reporting period prior to completion of the qualifying project, and for each cost reporting period, subsequent to the completion of that project, for which a special exceptions payment is claimed. The ratio of bed size in the latter period to bed size in the former period must be less than or equal to 0.80. Hospitals electing to satisfy the excess capacity requirement by meeting the bed size test must satisfy this requirement for each year in which an exceptions payment might be claimed. In other words, a hospital does not qualify for an exceptions payment during any year in which its bed size ratio is greater than 0.80, even if its ratio [[Page 29928]] was less than or equal to 0.80 in a previous year. For the MSA occupancy test, overall average occupancy is determined by dividing total patient days for all PPS hospitals in the MSA by available beds days (as defined in prior paragraph) for all those hospitals. Total patient days and available bed days are found on Worksheet S-3 of the Medicare cost report. We would use the same restrictions, as applicable, that were used in the definition of bed size. HMO, organ acquisition, or observation bed days are not included. Hospitals electing to meet the excess capacity requirement by satisfying the MSA occupancy test must satisfy this requirement for each year in which an exceptions payment might be claimed. In other words, a hospital does not qualify for an exceptions payment during any year in which overall average occupancy in its MSA is less than 80 percent, even if the occupancy in its MSA was greater than or equal to 80 percent in a previous year. We welcome further questions and requests for clarification of these requirements. As appropriate we will respond to the questions and requests in future PPS rules. VII. Proposed Changes for Hospitals and Units Excluded From the Prospective Payment System A. New Requirements for Certain Hospitals Excluded From the Prospective Payment System (Sec. 412.22(e)) In the September 1, 1994 final rule (59 FR 45330), we established several additional criteria for excluding long-term care hospitals that occupy space in the same building or on the same campus as another hospital from the PPS (Sec. 412.23(e)). Under these criteria, such facilities (sometimes called ``hospitals within hospitals'') could qualify for exclusion only if the two entities have separate governing bodies, chief executive officers, medical staffs, and chief medical officers. In addition, they were required to be capable of performing certain basic hospital functions without assistance from the hospitals with which they are co-located, or they had to receive at least 75 percent of their inpatients from sources other than the co-located hospital. We further revised these regulations on September 1, 1995 (60 FR 45778), by adding a third option under which hospitals that did not meet the criteria specified above could establish separate operation by showing that no more than 15 percent of their inpatient operating costs were attributable to the hospital with which they share space. The regulations were necessary to prevent inappropriate Medicare payments to entities that are effectively long-stay units of other hospitals. At the same time, the regulations set forth criteria to ensure that entities may qualify for exclusion from the PPS if an exclusion is warranted. Exclusion of long-term care hospitals from the PPS is appropriate when hospitals have few short-stay or low-cost cases and might be systematically underpaid if the PPS were applied to them. These reasons for exclusion do not apply if the entity that provides the long-term care is part of a larger hospital, which does have short- stay and low-cost cases and can be paid appropriately under the PPS. ProPAC has recommended that HCFA monitor the growth in the number of long term care hospitals within hospitals and evaluate whether the current Medicare certification rules that apply to these facilities should be changed (Recommendation 31). ProPAC noted that there is concern that the hospital within a hospital model was devised as a way for acute care hospitals to receive higher payments for their long-stay cases. At the same time, the model may be an appropriate and efficient alternative to acute inpatient care for cases that require additional services, but at a more intensive level than those provided in other post-acute settings. ProPAC recommended that HCFA conduct a comprehensive study of the characteristics, patient mix, treatment patterns, costs, and financial performance of hospitals within hospitals. We have been monitoring the development of the hospital within a hospital model. We agree with ProPAC that our policy should simultaneously strive to prevent inappropriate exclusions of units as separate hospitals, while allowing an appropriate degree of flexibility for facilities to respond to changing patient care needs. As a result of our monitoring efforts, we are proposing two changes to the hospital-within-a-hospital regulations. We propose to add a new Sec. 412.22(f) to address hospitals that are unable to meet certain exclusion criteria solely because of State law. In addition, we propose to extend the application of these rules to other classes of facilities that might seek exclusion from the PPS as hospitals within hospitals. The first proposed change concerns the relationship between the exclusion criteria and State laws. Following publication of the original regulations governing long-term care hospitals within hospitals, we received comments stating that it would not be equitable to abruptly impose new criteria on long-term care hospitals that had operated for many years under other organizational patterns. To accommodate these hospitals, we allowed them an additional one-year delay in the effective date of the ``hospital within a hospital'' regulations. Thus, a hospital that was excluded under prior rules was not required to meet the new criteria until its first cost reporting period beginning on or after October 1, 1995. (For other hospitals, the rule was effective for the first cost reporting period beginning on or after October 1, 1994.) By delaying the effective date of these regulations for hospitals within hospitals that had been excluded from the PPS before October 1, 1994, we intended to allow the hospitals adequate time to restructure themselves to comply with the new criteria. However, it has since become clear that some hospitals within hospitals operated by State universities have not been able to make the necessary changes, because the hospitals are required by State law to be subject to the ultimate authority of the governing body of the same entity (the university) that operates the hospital from which they obtain space. Thus, these hospitals have not been able to comply with the hospital-within-a- hospital criteria. We continue to believe that it is important to exclude, as hospitals, only facilities that actually operate as separate hospitals, not as units of larger hospitals. At the same time, however, we are concerned that certain hospitals might, as a matter of State law, be unable to make the necessary organizational changes to meet our criteria. We believe two considerations justify exclusion of these facilities. First, the organizational arrangements under which they operate were in place when the new regulation was adopted, and to the extent the arrangements are required by State law, we believe they do not reflect attempts by entities to establish nominal hospitals and, in turn, seek inappropriate exclusions. Second, we believe it would be inequitable to deny exclusions to hospitals solely because State statutory requirements prevent them from having the same flexibility as other institutions to reorganize themselves to meet our criteria. Accordingly, we propose to add Sec. 412.22(f) to provide that if a hospital cannot meet the criteria in Secs. 412.23(e)(3) (i) or (iii) (proposed to be redesignated as Secs. 412.22(e) (1) and (3)) solely because its governing body or medical staff is under the control of a third entity that also controls the [[Page 29929]] hospital with which it shares a building or a campus or cannot meet the criteria in Secs. 412.23(e)(3) (ii) or (iv) (proposed to be redesignated as Secs. 412.22 (e)(2) and (e)(4)) solely because its chief medical officer or chief executive officer is employed by, or under contract with such a third entity, the hospital can nevertheless qualify for an exclusion if that hospital meets the other applicable criteria and: Is owned and operated by a State university; Has been continuously owned and operated by that university since October 1, 1994; Is required by State law to be subject to the ultimate authority of the university's governing body; and Was excluded from the prospective payment system as a long-term care hospital for any cost reporting period beginning on or after October 1, 1993, but before October 1, 1994. We wish to emphasize that we intend to allow an exception to the criteria in Sec. 412.23(e)(3) (i) through (iv) only if the hospital cannot meet those criteria because of State law. We do not intend to provide similar treatment for other State university or other hospitals which are not subject to such statutory requirements but have chosen not to undertake such a reorganization. We welcome comments and suggestions on this issue and on whether the language of the proposed rule effectively addresses the situation of hospitals disadvantaged by State law. We also propose to redesignate the specific criteria for hospitals within hospitals now in Sec. 412.23 (e)(3) through (e)(5) under a new Sec. 412.22 (e), (g), and (h). At the time of the adoption of the final rule governing long-term care hospitals within hospitals, we did not extend its application to other types of excluded facilities that might seek to organize themselves on that model. Since the publication of the final rule governing long-term care hospitals within hospitals, we have received scattered inquiries from some providers and regional offices about the appropriateness of other types of facilities organizing themselves as hospitals within hospitals. It has become apparent that, while rehabilitation and psychiatric facilities may be granted exemptions from the PPS as units of larger hospitals, there may be cases where such facilities may rather seek exclusion as hospitals within hospitals in order to take advantage of certain payment rules that favor hospitals. For example, new hospitals within hospitals qualify for the new hospital exemption from the rate of increase ceiling, which is not available to new units. We believe that extension of the hospital-within-a-hospital rules is appropriate to avoid recognizing nominal hospitals, while allowing adequate flexibility for legitimate and efficient sharing of services. We continue to believe it is important to exclude only separate long- term care hospitals, not units, of larger hospitals. We believe that the same principle should apply to cancer and children's facilities, which the statute provides for excluding only as hospitals, not as units. We also believe that it is important to exclude, as hospitals, only separate rehabilitation and psychiatric hospitals that may share space with another hospital. Rehabilitation and psychiatric facilities that actually function as units of larger hospitals should seek exclusion as units rather than as hospitals. As stated earlier, we are proposing to extend the application of the hospital-within-a-hospital rules to all types of facilities that can be excluded from the PPS. We would also incorporate, within this extended hospital-within-a-hospital rule, the provision that we have proposed above for facilities owned and operated by a State university. At the same time, we are considering whether it is appropriate for new hospitals within hospitals to receive the exemption from the TEFRA rate-of-increase ceiling during the first 2 years of operation. The purpose of the new hospital exemption is to recognize that a hospital might face a period of cost distortions as it begins operations and tries to establish its presence in its market. We do not believe that newly established hospitals within hospitals would necessarily face the same degree of cost distortion during their initial periods of operation. This is because such hospitals begin operation within other hospitals that have established facilities and identifiable market presence. While we are not formally proposing elimination of the new hospital exemption for hospitals within hospitals at this time, we are considering whether to adopt such a provision in this year's final rule. We invite comment on whether elimination of the new hospital exemption for hospitals within hospitals would be advisable. Finally, we will continue monitoring the development of the hospital within a hospital model. While we have not yet conducted the kind of comprehensive study of these facilities that ProPAC has recommended, we will consider whether doing so is worthwhile within the limits our available resources. B. Exclusion of New Rehabilitation Units and Expansion of Existing Rehabilitation Units (Sec. 412.30(b)(4)) In the September 1, 1995 final rule (60 FR 45839), we made certain changes to clarify the regulations applicable to the exclusion of new rehabilitation units and the expansion of units already excluded. These changes were intended only to clarify existing policy, not to change it. However, in making these changes we inadvertently omitted a paragraph that explicitly allowed newly participating hospitals to open new rehabilitation units and also to allow the new rehabilitation units to be excluded immediately from the PPS. In omitting this paragraph, we had no intention of rescinding the policy. We are proposing to restore this paragraph to the regulations, which this proposed rule would redesignate at Sec. 412.30(b)(4), to correct this omission and to reaffirm current policy. (For further information on this policy, see the Federal Register published September 1, 1992 (57 FR 39746).) C. Delicensing and Relicensing of Beds (Sec. 412.30) We have received a number of questions about cases in which hospitals remove some bed capacity from their State license and Medicare certifications, then later increase the number of their licensed and certified beds and seek to have the bed capacity ``added'' and considered part of a new, or newly expanded, PPS-exempt rehabilitation unit. Assuming that simultaneous delicensure and relicensure of beds would not be accepted as the addition of new bed capacity, we also have been asked how long bed capacity would have to be excluded from a hospital's licensure and certification to be considered ``new'' for purposes of the PPS exclusion rules at Sec. 412.30. Section 412.30 establishes separate ways for new and converted units to meet the exclusion criterion related to the type of patient population treated. New units are allowed to qualify for initial exclusion based in part on a certification regarding their intent to treat a patient population of the kind described in Sec. 412.23(b)(2), rather than on a showing that they have actually treated such a population during the hospital's most recent cost reporting period. Converted units may not be excluded based on a certification, but must show that they actually met the Sec. 412.23(b) requirement during the hospital's most recent 12-month cost reporting period. New units are defined as those that are part of a hospital that [[Page 29930]] has not previously sought exclusion for any rehabilitation unit and that comprise greater than 50 percent of the newly licensed and certified bed capacity, while converted units are those that do not qualify as new. Section 412.30 also provides for separate treatment of new and converted bed capacity that is used to expand existing units. Different rules apply to the addition of new (as opposed to converted) bed capacity, and it would not be appropriate to recognize an ``increase'' in the bed capacity that coincides with a decrease in bed capacity in another area, resulting in no net increase in the hospital's total licensed and certified bed capacity. Similarly, it would not be appropriate to allow a hospital to circumvent those rules simply by removing some bed capacity from its licensure and certification on a temporary basis, and then increasing its bed size a few days, weeks, or months later. Thus, when a hospital seeks to add a new PPS-excluded rehabilitation unit, or to increase the size of an existing unit by adding new bed capacity, the bed size of the hospital in the past must be taken into account. The current regulations do not specify how long a decrease in a hospital's bed capacity must be effective before a subsequent increase in the hospital's licensure and certification can be considered as ``new'' capacity. However, to ensure consistent and equitable treatment of all hospitals with PPS-excluded rehabilitation units, we propose to provide in the regulations (proposed Sec. 412.30(a)) that a decrease in capacity must remain effective for at least a full 12-month cost reporting period before an equal or lesser number of beds can be added to the hospital's licensure and certification and considered ``new''. This means that when a hospital seeks to establish a new unit, or to enlarge an existing unit, under the criteria in Sec. 412.30, the Regional Office will review its records on the facility to determine whether any beds have been delicensed and decertified during the 12- month cost reporting period before the period for which the new beds are to be added. To the extent that bed capacity was removed from the hospital's licensure and certification during that period, that amount of bed capacity cannot be considered ``new'' under Sec. 412.30. For example, if a hospital with a calendar year cost reporting period had removed 15 beds from its licensure and certification in calendar year 1997 and, for calendar year 1998, sought to set up a new rehabilitation unit that would include 20 beds that would be added to its licensure and certification as of January 1, 1998, only 5 of those beds could be considered ``new'' under section 412.30. The remaining beds would be considered converted beds. This guideline applies to changes in a hospital's total licensed and certified bed capacity, regardless of whether specific beds or physical areas within a hospital have previously been operational and available to rehabilitation patients. Thus, if a hospital delicenses 25 beds on one floor in the third month of a cost reporting period and, 2 months later, increases its licensure and certification by adding a 25- bed unit in a previously unoccupied area on another floor, that unit could not be considered ``new'' under Sec. 412.30 even though it occupies different space from the beds that represented the delicensed capacity. This guideline applies only for purposes of PPS exclusion and is not intended to limit a hospital's ability to add to its licensed and certified bed capacity for the provision of services paid for under the PPS. VIII. ProPAC Recommendations We have reviewed the March 1, 1997 report submitted by ProPAC to Congress and have given its recommendations careful consideration in conjunction with the proposals set forth in this document. Recommendation 2, concerning the update for the prospective payment system operating payment rates, is discussed in Appendix E of this proposed rule. Recommendations 3 and 4, concerning the prospective payment system capital payment rates, are discussed in section III. of the Addendum of this proposed rule. Recommendation 13, concerning updating the target amounts for PPS-excluded hospitals and distinct part units, is discussed in section VII. of this proposed rule. Recommendation 31, concerning long-term care hospitals within hospitals, is discussed in section VI. of this proposed rule. The remaining recommendations are discussed below. A. Ensuring Quality of Care (Recommendation 1) Recommendation: The Medicare program needs to be vigilant in monitoring and improving the quality of care delivered to its beneficiaries in both the fee-for-service and risk contracting options. ProPAC supports a comprehensive approach to quality assurance that includes both pattern analysis and systematic review of individual cases. Response: We concur with ProPAC's recommendation that ``continuous quality improvement activities need to be accompanied by effective methods to identify and monitor providers with questionable performance.'' We are pursuing two complementary strategies in this area: strengthening the mechanisms for soliciting, investigating, and monitoring complaints; and establishing an ongoing pattern monitoring system. We believe that there is ample evidence that returning to case review of randomly selected cases would not be an effective way to monitor providers with questionable performance. Beneficiary Complaints Peer Review Organizations (PROs) have had greater success identifying quality of care concerns through the beneficiary complaint process than through traditional case review. The number of such complaints is relatively small but has proven in the past to be an excellent source of problem identification. Complaints provide PROs with the opportunity to identify and remedy instances of poor quality. We are committed to improving the beneficiary complaint process. We have formed the Beneficiary Protection and Documentation Issues Task Force as a subgroup of the Medicare Technical Advisory Group. This task force includes representatives from PROs, intermediaries, carriers, provider groups, consumer organizations, the Office of the Inspector General, and the Office of the General Counsel. The task force is charged with reexamining the PRO beneficiary complaint process. Its work plan includes the development of a proposed rule concerning the beneficiary complaint process (expected to be published soon) that will enable the PRO to be more responsive to beneficiary needs; and to conduct studies that evaluate potential alternative approaches to handling beneficiary complaints. The studies are being designed to test a variety of new and innovative methods of investigating complaints including exploring the possibility of working with other entities such as licensing agencies, private accreditation bodies, State medical societies, and consumer groups, in the resolution of beneficiary complaints. The final report is due to the Medicare Technical Advisory Group in January 1999. A vital element of our strategy is to increase awareness among beneficiaries of their rights as patients to file complaints, and the ease with which they can submit their complaints. A number of efforts are underway. HCFA plans to test a toll free hotline in four States that will, for the first time, provide a single 1-800 number for all [[Page 29931]] beneficiary inquiries. Complaints about the quality of care will be automatically routed to the appropriate HCFA agent (for example, the PRO or the End Stage Renal Disease (ESRD) Network) for action. This hotline will be advertised to ensure that Medicare beneficiaries are aware of this service. The conditions of participation for Medicare providers are being revised to transition towards a patient outcome-based system, and to stimulate improvements in processes, outcomes of care, and patient satisfaction. Under the revised conditions, providers would be required to prominently display a list of patient's rights, including the patient's right to complain about the quality of the care provided. In response to concerns expressed about the managed care appeals process, we have recently published a final rule with comment period that will require managed care plans contracting with Medicare to add an expedited appeals procedure to their appeals process. This will allow Medicare enrollees to obtain coverage decisions as well as to have those decisions reconsidered within very short timeframes in certain time-sensitive situations. We also are developing a separate notice of proposed rulemaking that would shorten the timeframes for standard appeals that are not time-sensitive and therefore not expedited. Currently, Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) have 60 days to make decisions regarding the necessity of beneficiary requests for services and 60 days to complete reconsiderations. These timeframes will be reduced significantly. In addition to improving the beneficiary complaint process, there are efforts underway to ensure that these complaints are consolidated and analyzed to improve our ability to identify and correct problems. They currently arrive at a variety of points of contact, including HCFA central office, 10 regional offices, PROs, ESRD Networks, fiscal intermediaries, and carriers. We are developing a standard set of definitions for use by HCFA and all of its agents in categorizing inquiries, along with developing an integrated automated system to continually track issues, provide timely and accurate responses, and effectuate improvements. The enhancements in the responsiveness of PROs to beneficiary complaints, the pilots to improve our accessibility to beneficiaries, the activities underway to improve beneficiary awareness of their right to file a complaint, and the development of systems to categorize, track, and analyze beneficiary inquiries will all improve our effectiveness in identifying providers with questionable performance. Pattern Monitoring We recently implemented a national surveillance system for PROs to use in identifying patterns, trends, and variations in the health and health care of Medicare beneficiaries and in identifying sentinel events or clusters that may indicate less-than-optimal care. We are analyzing data from HCFA's National Claims History files to present national and State-specific descriptive epidemiology of the Medicare population, overall health care utilization, and selected markers of potential quality issues. Updates will be provided on a quarterly basis. PROs have the capacity to refine the analyses to the community or hospital-specific level, in order to identify providers with questionable performance and will use the surveillance information to identify and act on opportunities to improve care. We do not currently have encounter data for managed care plans, and thus the national surveillance system does not focus on managed care providers. There is a pilot program underway to test the development and use of such data. In addition, there are efforts underway to ensure that managed care plans with questionable performance are identified, and actions taken to resolve concerns. All managed care plans will be required to provide Health Plan Employer Data and Information System (HEDIS) quality measures by the summer of 1997. In addition, we are participating in the development of the Foundation for Accountability (FACCT) measures and will be testing their use in at least five States. To complement the collection of these quality of care measures from the plans, we have developed a Medicare-specific consumer satisfaction survey in collaboration with the Agency for Health Care Policy and Research through its Consumer Assessment of Health Plan Study (CAHPS) process. The survey will be plan-specific and administered on an annual basis. It is designed to collect information on satisfaction with quality of care, access, and utilization of care and will provide another source of information about care provided by managed care plans. Other Sources We also have other sources for identifying poor performers. PROs are still obligated to review cases referred to them by carriers and intermediaries, usually for quality concerns that may affect coverage and payment. Hospitals are required to provide patients with a Notice of Noncoverage if they believe that a beneficiary does not require inpatient level of care. If the beneficiary disagrees with the hospital's decision, he or she may ask the PRO to review the case. The PRO may identify a quality concern in the process that would require some type of intervention at the hospital or physician level. B. Improving the Distribution of Medicare's Indirect Medical Education (IME) Payments (Recommendation 5) Recommendation: Medicare's IME payments should reflect the historical relationship between hospital costs and teaching intensity. Further, they should continue to be based on the hospital's volume of Medicare patients. These payments should no longer change in proportion to annual variations in the number of residents or beds. In addition, the payment method should be flexible enough to allow and support training in settings outside of the hospital. Response: The President's FY 1998 budget includes several proposals consistent with ProPAC's recommendations. As set forth in those proposals, the total number of residents and the number of nonprimary care residents would be capped on a hospital-specific basis; the resident-to-bed ratios would be capped at the level of hospitals' cost reporting periods ending on or before December 31, 1996; residents would be counted based on a multi-year rolling average; and hospitals could include residents training in nonhospital-based training sites in their resident-to-bed ratios (as long as the hospital continues to pay the residents' salaries). We believe the incentives associated with the current IME adjustment are contrary to the Administration's policy of decreasing the number of residents trained in the United States, increasing the relative number of residents trained in primary care, and encouraging more training in nonhospital-based sites. Our proposals would end the incentives to increase the number of residents, encourage more training in primary care, decrease the financial penalty for reducing the number of residents trained (thereby encouraging that reduction over time), and provide funding for training in nonhospital-based sites. C. Reducing the Level of Medicare's Indirect Medical Education Payments (Recommendation 6) Recommendation: The indirect medical education adjustment should be [[Page 29932]] reduced from its current level of 7.7 percent to 7.0 percent in fiscal year 1998. Response: We agree with ProPAC that the current level of payment for the indirect costs of medical education is too high. The President's FY 1998 budget would reduce the adjustment to 7.4 percent in FY 1998, 7.0 percent in FY 1999, 6.8 percent in FY 2000, 6.6 percent in FY 2001, and 5.5 percent in FY 2002 and thereafter. A gradual reduction in IME adjustment over several years would allow teaching hospitals time to adjust to lower payments, while accomplishing our objective of reducing the adjustment to a more analytically justifiable level, which we estimate to be in the 4-to-5 percent range. D. Improving Medicare's Payments for Direct Graduate Medical Education (GME) Costs (Recommendation 7) Recommendation: Medicare's payments to hospitals for the direct costs of GME programs should not change in proportion to annual variations in the number of residents trained. The method for determining the level and distribution of these payments should be as neutral as possible concerning the number and speciality mix of residents and the site of their training. Response: We share many of ProPAC's concerns regarding the way Medicare currently pays for direct medical education, and we are hopeful that the graduate medical education demonstration in New York State will provide insights into how Medicare can establish more appropriate incentives. Under the demonstration, participating New York hospitals will receive declining financial protections for residency reductions. We believe that these financial protections, which will phase out over 6 years, will provide incentives for participating hospitals to realize appropriate reductions in their residency programs, to increase the proportion of residents in primary care training, and to provide more training opportunities in ambulatory sites. Although we do not support lump sum payments to hospitals for direct graduate medical education, the President's FY 1998 budget includes proposals that would address ProPAC concerns. For instance, the budget provisions would base a hospital's direct graduate medical education payment on a 3-year rolling average of full-time equivalent (FTE) residents. This measure would reduce the adverse financial impact on a hospital that reduces the size of its residency programs. The proposals would further encourage training in primary care specialties by providing payments to nonhospitals (federally qualified health centers, rural health clinics, and health maintenance organizations) for residents when the residents' salaries are not paid by hospitals. E. Establishing a Broader-Based Financing Mechanism for Graduate Medical Education and Teaching Hospitals (Recommendation 8) Recommendation: Explicit payments for graduate medical education and teaching hospital costs should not be limited to the Medicare program. Mechanisms to broaden financial support for training physicians in hospitals and other locations should be developed. The payments should reflect the reasonable costs of training at each facility and protect the access of beneficiaries and other populations to the services they provide. Response: We agree that all payers should contribute their fair share toward physician training, particularly for the patient care services that are provided in the course of this training. In addition, we agree that academic medical centers play an important role as training and research centers and are an integral part of our health care system. In response to ProPAC's observation that Medicare is the only payer that explicitly supports graduate medical education, we note that some Medicaid programs explicitly pay hospitals for the indirect and direct costs of graduate medical education in a manner similar to Medicare. In addition, some States (for example, New York, through the New York Health Care Reform Act) provide explicit support for teaching hospitals using private payers. We note that although the President's health care reform bill in 1993 attempted to involve private insurers in directly supporting medical education, we do not currently have a proposal to broaden support for teaching hospitals beyond that currently provided by Medicare. We have, however, proposed to broaden financial support for teaching hospitals by changing the way Medicare funds medical education through its managed care programs. Currently, Medicare payments to HMOs are based on the average cost of providing services to Medicare patients in the fee-for-service part of Medicare. These Medicare payments to HMOs include payments for medical education. We have proposed revising Medicare's payments to HMOs to exclude the portion associated with medical education. Instead, we would pay these funds directly to teaching hospitals and managed care plans with teaching programs. Our proposal would thus benefit teaching hospitals, by increasing their Medicare payments, as well as more appropriately target Medicare funds designated for medical education. F. Principles for Improving Medicare's Disproportionate Share (DSH) Payment Adjustment (Recommendation 9) Recommendation: Medicare's DSH payments should be aimed at protecting access to hospital care for its beneficiaries. Payments should be distributed based on each hospital's share of low-income patient care and volume of Medicare cases. The low-income share measure should reflect the costs of services provided to low-income groups in both inpatient and outpatient settings. These groups include Medicare patients eligible for SSI, patients sponsored by Medicaid and local indigent care programs, and uninsured and underinsured patients as represented by uncompensated care. Response: The Medicare disproportionate share adjustment is linked to hospital payments under the prospective payment system. In this way, Medicare funds a share of the inpatient costs generated by hospitals that are caring for a large number of indigent patients. The Medicare disproportionate share adjustment was established by Congress effective May 1, 1986, under section 1886(d)(5)(F) of the Act. It was intended to be a mechanism through which hospitals that treated a high proportion of indigent patients could be compensated for the higher Medicare costs associated with treating that population. Medicaid also provides a disproportionate share adjustment. When the disproportionate share adjustment was enacted, eligible hospitals were expected to be the exception, not the rule. However, almost half of the hospitals under the prospective payment system currently receive some level of Medicare disproportionate share payments. In addition, as a result of recent court decisions concerning HCFA's interpretation of Medicaid eligible days, not only will payments increase to currently eligible disproportionate share hospitals, but we expect that additional hospitals will qualify for disproportionate share payments. ProPAC believes that HCFA should continue to use a combination of Medicare, Supplemental Security Income (SSI), and Medicaid data as eligibility criteria and, in addition, uncompensated care data should be collected on an individual hospital basis and included in the calculation. We are [[Page 29933]] seeking to move away from the SSI and Medicaid measures that currently exist within this adjustment formula due to the concerns outlined in the May 31, 1996 proposed rule (61 FR 27473). None of the public comments we received in response to these concerns suggested the collection of uncompensated care data. In addition, such data would be unverifiable, except through arduous auditing procedures, which would be expensive and time-consuming for the fiscal intermediaries and the hospitals. The President's FY 1998 budget includes a provision to freeze disproportionate share payment adjustments for 2 years while we develop an alternative methodology for identifying and paying hospitals that treat a disproportionate share of low-income patients. Our intention is to move away from the current eligibility measures and to target payments to those hospitals with the highest shares of low-income patients. G. Improving the Distribution of Disproportionate Share Payments (Recommendation 10) Recommendation: DSH payments should be concentrated among hospitals with the highest shares of poor patients. Therefore, a minimum threshold should be established for the low-income patient cost share. Hospitals falling just above the threshold should receive only a minimal per case payment, with the amount then increasing as low-income share rises. The same general approach for distributing payments should apply to all PPS hospitals. Response: Congress set the current threshold payments for Medicare disproportionate share hospitals in section 6003(c) of the Omnibus Budget Reconciliation Act of 1989. This provision expanded both the number of hospitals that could qualify for disproportionate share payments as well as the level of those payments for some categories. We note that large urban hospitals already receive payments based on this graduated payment structure. ProPAC notes that 95 percent of the hospitals receiving disproportionate share payments are designated as large urban hospitals. A May 1990 Congressional Budget Office (CBO) report to Congress, found that only large urban hospitals were overburdened by the cost of caring for the indigent population. We agree with ProPAC that the disproportionate share payments should be concentrated on the hospitals in greatest need of assistance. H. Collecting Data To Support Disproportionate Share Payment Reform (Recommendation 11) Recommendation: The Secretary should collect the data necessary to implement a revised DSH payment mechanism. Due to recent and planned changes in the Medicaid and SSI programs, the measure now used to distribute DSH payments is becoming increasingly untenable. Although several new data elements would be required, this need not substantially increase the current hospital reporting burden. Periodic audits of these data would also be necessary. Response: Currently, hospitals are not required to distinguish between bad debts and uncollectible accounts. When a patient does not pay a bill, the hospital is required to proceed through a series of steps in an attempt to collect the amount before it can be declared a bad debt. If the hospital were also seeking to collect data on uncompensated care, it would be required to further investigate whether or not the patient had the ability to pay. This could be a very burdensome task. ProPAC's solution to this problem is to include bad debts and charity care as a lump sum. However, Medicare currently pays hospitals for bad debts, and bad debts are removed from the exception to the disproportionate share adjustment calculation under our regulations at Sec. 412.106(c)(2). In addition, we believe that the inclusion of bad debts in this calculation would encourage some hospitals to relax their collection efforts, at Medicare's expense. In any event, cost reporting forms would have to be changed and any data collected would have to be audited extensively by the fiscal intermediaries. Therefore, we question whether a data collection effort is feasible. Our preference would be to use data that are already available and verifiable on a national basis for the Medicare disproportionate share adjustment calculation. We are currently pursuing such data sources as we fashion our legislative proposal. I. Making Teaching and Disproportionate Share Payments to Facilities That Treat Medicare Risk Plan Enrollees (Recommendation 12) Recommendation: Facilities that receive explicit direct GME, IME, or DSH payments for their Medicare fee-for-service patients should also receive additional payments for their Medicare risk plan patients. Mechanisms should be developed to distribute these payments in a way that reflects the policy goals of the Medicare program. Response: ProPAC is concerned that explicit support for teaching and disproportionate share hospitals is eroding as managed care plans enroll more Medicare patients. According to ProPAC, managed care plans may be unwilling to pay the extra costs that these hospitals incur and separate mechanisms need to be developed to allow teaching and disproportionate share hospitals to remain competitive with other hospitals. We are concerned that Medicare's payment to managed care plans includes compensation for direct and indirect graduate medical education and a disproportionate share adjustment that may not be reflected in the payments managed care plans are making to teaching and disproportionate share hospitals. The President's FY 1998 budget includes a proposal to remove funding included in Medicare's payment to managed care plans for teaching and disproportionate share activities and to pay these funds directly to teaching and disproportionate share hospitals based on their Medicare risk plan discharges. J. Modifying the Tax Equity and Fiscal Responsibility Act (TEFRA) Payment System (Recommendation 14) Recommendation: Congress should consider modifying the TEFRA payment system to correct for the payment disparity between new and old providers. Response: HCFA has developed legislative proposals to modify the TEFRA payment system. Our proposals include rebasing the target rates for excluded hospitals and units using an average of each facility's two most recent cost reporting periods. This measure would realign payment rates with costs for both old and new providers. In conjunction with rebasing, the new target rates would be capped at 150 percent of a national mean rate for each type of facility in order to prevent newer high cost hospitals from receiving excessive target rates. Lower cost hospitals would be protected by establishing a floor of 70 percent of the national mean rate for each type of facility. Incentive payments would be modified by providing that no such payment would be made where a provider incurs costs that are less than or equal to 110 percent of the target amount. Finally, the President's FY 1998 budget proposal would revise the payment of capital costs to excluded hospitals and units by reducing reimbursement for capital to 85 percent of reasonable costs. TEFRA providers are the only hospitals that continue to be reimbursed for capital on a dollar-for- [[Page 29934]] dollar basis; consequently, they have no incentive to control their capital expenditures. This policy would make capital reimbursement policy more consistent among all hospitals and provide a needed incentive for cost control, particularly for newer excluded hospitals and units that may have more resources for capital expenditures because they are not as limited by the target rates on inpatient operating costs. K. Prospective Payment System for Hospital Outpatient Services (Recommendation 15) Recommendation: The Secretary should implement a prospective payment system for hospital outpatient services as soon as possible. Such a system should incorporate methods for controlling the volume of services. Response: We agree with the need to implement a prospective payment system for outpatient services. Under the President's FY 1998 budget, a prospective payment system for outpatient services would be implemented on January 1, 1999. While we await legislative authority, we will continue to develop and refine the Medicare-specific factors of the ambulatory patient group (APG) classification system that we recommend using. We plan to analyze the payments that would be made across sites (for example in ambulatory surgical centers (ASCs) or physician radiology practices) to ensure that we have not created unwarranted incentives to perform procedures in a given setting for financial reasons. We are concerned as well about the potential for increases in the volume of services provided, both in outpatient departments and in other settings. We are examining approaches to volume measurement and control, including the level of packaging for ancillary services and the monitoring of patterns of care. For example, we could track whether Medicare beneficiaries received more clinic visits per patient under APGs than they did under reasonable cost-based payment. If so, we could take corrective action in one of two ways: We could adjust for the over utilization of outpatient services under a prospective payment system by incorporating the adjustments into the total system, which may impact on all hospitals; or we could target the specific hospitals identified as over utilizing services and apply the corrective action specifically to them. L. Reducing Beneficiary Liability for Hospital Outpatient Services (Recommendation 16) Recommendation: Beneficiary liability for hospital outpatient services should be reduced from 20 percent of charges to 20 percent of the allowed payment, as it is for other services. Further, Congress should correct the blended payment formula. This would help offset the increase in Medicare outlays resulting from a reduction in beneficiary liability. Response: We agree that the issue of beneficiary coinsurance should be addressed and that the blended payment formula should be corrected. As part of the President's FY 1998 budget proposal, coinsurance for outpatient services would be reduced to 20 percent by 2007 as part of the implementation of a prospective payment system for these services. M. Improving Dialysis Facility Data (Recommendation 17) Recommendation: HCFA should regularly audit a representative sample of dialysis facility cost reports to ensure that it has accurate data to assess the adequacy of the composite rates. Further, it should systematically track quality indicators for these providers. Response: HCFA does not audit renal facilities on a regular basis since audits do not result in recoupment of Medicare funds. This is because renal facilities are paid the composite rate, which is a set fee. Thus, there is no cost reimbursement. In recent years, Medicare funds for audits have been reduced. To manage these limited resources, HCFA has instructed contractors to audit those entities that generate the most return on audit dollars spent. With renal audits, the only payback is recoupment of unallowable bad debts, which are limited under the current payment system. Generally, audit funds in the budget are not used to review cost reports that have little or no effect on Medicare providers' payments. We are also concerned about the quality of the data regarding dialysis facility costs in the Health Care Provider Cost Report Information System (HCRIS). Procedures and edits are in place to review data that do not appear reasonable. However, these procedures and edits cannot guarantee that renal facilities report their costs in accordance with Medicare reasonable cost principles. To accomplish this task, fiscal intermediaries perform desk reviews of cost reports for the purpose of finding errors or for identifying cost reports that should be audited. Because of limited resources, only in rare instances would a fiscal intermediary audit a renal facility's cost report. HCRIS edits are designed to ensure that data are within acceptable ranges or to identify facilities with missing data. The best way to ensure that cost reports are completed correctly is through education of individuals who are responsible for completing renal cost reports. The National Renal Administrator Association has been helpful in accomplishing this task and in improving the quality of the renal cost reporting data in HCRIS. To address ProPAC's concern, we will review the current procedures and edits in HCRIS for renal facilities to address cost reporting data elements that appear out of line. We also will revise instructions to clarify problem areas in renal facility cost reporting. In addition, if and when our contractors' funding levels permit, we will conduct a limited set of audits on independent renal facilities. However, based on our prior experience, we do not believe it is necessary to audit hospital-based renal facilities, since these audits resulted in only minor changes to reported costs. Since independent facilities furnish about 75 percent of all dialysis treatments, we believe audit activity should focus on those facilities. As in prior years, we would provide ProPAC with the results of any audits and the percentage adjustment between reported and audited costs. To improve the quality of care renal patients are receiving, we are in the process of developing revised ESRD conditions for coverage. The proposed regulations are patient-centered and outcome-oriented. The proposed conditions for coverage will focus on facilities achieving an optimal level of health and well-being for all dialysis patients. When published, these regulations should address ProPAC's recommendation that HCFA monitor treatment patterns and patient outcomes. After publication of a notice of proposed rulemaking, we plan to meet with the renal community to develop complete clinical data sets to monitor patient outcomes and medical conditions. These data will then be used to evaluate the quality of dialysis services furnished by renal facilities. In the short term, we are planning to require renal facilities to report values for Kt/V (which indicates whether the patient has too much urea in the blood after dialysis) or urea rate reduction to assess the adequacy of patient dialysis treatments furnished by facilities. [[Page 29935]] N. Update to the Composite Rate for Dialysis Services (Recommendation 18) Recommendation: For FY 1998, the composite rate for dialysis services should be increased by 2.8 percent to ensure that beneficiaries receive quality care. This level reflects the projected increase in the market basket index for dialysis services and the Commission's judgment about the likely effects of scientific and technological advances and productivity gains on facilities' costs. Response: We share ProPAC's concerns about the relationship among patient outcomes, adequacy of dialysis, and payment. As we acknowledged in last year's response to a similar recommendation, we recognize that an increase in the composite payment rate may be appropriate in the future. However, we do not believe an across-the-board rate increase is warranted. It may be appropriate to recommend payment increases based on the number of treatments that a renal facility furnishes, since dialysis facilities exhibit economies of scale. In proposing a future increase, we would want to examine the need to adjust payment increases for volume and the effects a new wage index would have on payments. The results of the National Kidney Foundation Dialysis Outcomes Quality Initiatives should provide us with information on the relationship between patient outcomes and costs and thus provide us with a basis for recommending an appropriate payment rate increase. However, our position is that any payment increase should be linked to implementation of the revised conditions for coverage for ESRD facilities. Until these conditions are published in final, we will continue to monitor facilities' costs and other factors to determine if it is appropriate to recommend a payment rate increase. Moreover, any dialysis rate increase must be considered within the context of the Medicare budgetary concerns. O. Prospective Payment System for Skilled Nursing Facilities (SNFs) (Recommendation 19) Recommendation: A case-mix adjusted prospective payment system for skilled nursing facilities should be implemented as soon as possible. Response: We concur with the recommendation to implement a prospective payment system for SNFs as soon as possible. The President's FY 1998 budget includes a provision for a prospective payment system for SNFs to be implemented on July 1, 1998. This system will include payment for all costs (routine, ancillary, and capital) related to the services furnished to beneficiaries under Medicare Part A. By including all costs of services in the payment rates, spending growth per day of care can be contained. In addition, the provision includes authority to adjust payments to providers where inappropriate utilization (that is, excessive lengths of stay) of SNF services is found. Finally, the proposed prospective payment system would include case-mix adjustments using a resident classification system based on resource utilization groups. These resource utilization groups are tied to elements contained on the Minimum Data Set (MDS) 2.0 resident assessment instrument for nursing homes. P. Controlling Payments for Skilled Nursing Facility Ancillary Services (Recommendation 20) Recommendation: Until a prospective payment system is developed, the Secretary should take steps to control SNF expenditures by limiting payments for ancillary services. Response: We agree that the rapid growth in payments for SNF ancillary services must be curbed. As indicated in the previous response, the President's FY 1998 budget includes a provision for an SNF prospective payment system, to be implemented on July 1, 1998, that will include payment for all the costs of services furnished to Medicare beneficiaries in a single prospective rate. Under this system, spending growth for ancillary and other services will be appropriately contained. In addition, on March 28, 1997, we issued proposed revised salary equivalency guidelines for physical and respiratory therapy and new guidelines for occupational and speech therapy (62 FR 14851). We hope to finalize these guidelines prior to implementation of a SNF prospective payment system. The guidelines will have a significant impact on cost containment per hour of service billed for therapies provided in SNFs and other providers. However, it is unlikely that we will be able to implement other limits on ancillary services in the limited time available before implementation of the SNF prospective payment system. The suggestion that prospective payment rates for ancillary services could be adopted is obviated by the absence of any implementing authority in the current statute. Cost limits could be adopted but would take time to develop and implement. For example, using the resource based relative value scale (RBRVS) to set payment limits on ancillary services would require SNFs (as well as HCFA and fiscal intermediary claims processing systems) to begin using the HCFA Common Procedure Coding System (HCPCS) on Part A SNF bills in order to match a service with the appropriate fee schedule amount. With the planned implementation of the SNF prospective payment system in only a year, it would not seem practical to invest resources in the development and implementation of a RBRVS-based limit system that would not have any impact on the volume of services provided. Q. Consolidated Billing for Skilled Nursing Facility Services (Recommendation 21) Recommendation: The Secretary should require consolidated billing for all services furnished to beneficiaries during a Part A-covered SNF stay. Further, SNFs should use consistent, procedure-level codes for these services. Response: We concur with ProPAC's observations regarding the need for and potential benefits of establishing such requirements, and we note that the President's FY 1998 budget proposal includes provisions that adopt this recommendation by requiring consolidated billing for Medicare services provided to SNF residents beginning in FY 1998, as well as the use of HCPCS codes on SNF bills. We would like to comment in greater detail on ProPAC's suggestion that the consolidated billing proposal should specifically define the ancillary services to be included. We note that a similar comprehensive Medicare billing requirement for hospitals (section 1862(a)(14) of the Act), which has been in effect for well over a decade, defines the hospital's billing responsibility in terms of a blanket inclusion of all services that a hospital patient receives, with specific exemptions for the services of certain types of medical practitioners (for example, physicians, certified nurse-midwives, qualified psychologists, and certified registered nurse anesthetists) that are not regarded as falling within the scope of the hospital benefit. Existing law in the material following section 1861(h)(7) of the Act, defines the scope of the SNF benefit, in part, as excluding those types of services that would not be coverable under the inpatient hospital benefit when furnished to a hospital inpatient. Accordingly, our SNF consolidated billing proposal would similarly provide for a blanket inclusion of all services that the SNF's resident receives (with specific exceptions for certain types of medical practitioner services), in order to maintain consistency with the longstanding hospital provision. [[Page 29936]] R. Eliminating the Cost Limit Exemption for New Skilled Nursing Facilities (Recommendation 22) Recommendation: The exemption from Medicare's routine cost limits for new providers should be eliminated. All SNFs should be subject to these limits. Response: We concur with the recommendation to eliminate the exemption to the Medicare routine cost limits for new skilled nursing facilities. The rapid rise in the number of SNF beds and significant growth in payments both generally and specifically to SNFs with exemptions have demonstrated the diminished value of the exemption to the Medicare program and necessitated its elimination. Under the SNF prospective payment system proposed in the President's FY 1998 budget, exemptions, as an artifact of reasonable cost-based payment, will be eliminated with the implementation of the system on July 1, 1998. Even so, we are moving to eliminate the new provider exemption through issuance of regulations in the near future. The issue of how the new policy will be applied relative to providers currently operating under the exemption is being addressed as part of the development of this regulation. S. Defining the Home Health Care Benefit (Recommendation 23) Recommendation: Congress should more specifically define the scope of Medicare's home health care benefit. The absence of clear coverage constraints limits the program's ability to control home health utilization. Response: We agree with ProPAC's recommendation that clearer eligibility and coverage guidelines would aid the program's ability to control improper and abusive home health care utilization. The President's FY 1998 budget contains provisions regarding the definition of homebound and intermittent skilled nursing care, as well as the statutory authority for HCFA to develop and apply normative standards. T. Prospective Payment System for Home Health Care Agencies (Recommendation 24) Recommendation: A case-mix adjusted prospective payment system for home health care agencies should be implemented as soon as possible. Response: We concur with ProPAC's recommendations. We agree that research to develop a robust case-mix measure is necessary and we have taken all available actions to expedite such research. In August 1996, a contract was awarded to develop a case-mix measurement for a home health prospective payment system. Under the terms of this contract, extensive information about the characteristics of patients and resource utilization will be collected. Agencies participating in this project will collect patient information using the Outcome and Assessment Information Set (OASIS) for home health, supplemented by additional items that may be predictive of resource utilization. Information will also be collected about visit lengths and procedures performed during all home health visits during an episode of care. We hope to recruit 90 agencies from 8 States for this project. Recruitment began in April 1997. We expect to have recommendations for a case-mix measurement for home health services by January 1999. U. Interim Home Health Payment Method (Recommendation 25) Recommendation: Congress should implement an interim home health payment method to control Medicare outlays until a fully prospective payment system is in place. Response: The President's FY 1998 budget proposal includes an interim system, which would be effective on October 1, 1997. We are prepared to begin implementation of this system as soon as we are granted the necessary statutory authority. V. Home Health Visit Coding (Recommendation 26) Recommendation: Medicare should require consistent home health visit coding. Such information is essential for monitoring and evaluating the home health benefit and developing an effective case-mix adjustment system. Response: Currently, there is no standard definition of what comprises a visit and there is variation in the type of service and length of time for providing those services. We agree such information is critical to developing an effective case-mix measure for a home health prospective payment system. In the case-mix research we are beginning, we will collect information on the length of time and procedures performed during a visit. This information will feed into the development of a prospective payment system and related coding system. We cannot proceed with specific coding refinements until the findings are available and a prospective payment system is designed. We are researching aspects of that approach rather than imposing reporting burdens on all home health agencies. W. Home Health Copayments (Recommendation 27) Recommendation: Modest beneficiary copayments, subject to an annual limit, should be introduced for home health care services. Response: We are concerned about the impact that higher beneficiary out-of-pocket expenses would have on poorer Medicare beneficiaries who are not covered by Medicaid and cannot afford supplemental insurance. Poorer beneficiaries spend a greater proportion of their income on out- of-pocket costs. Our proposed interim system of limits should help control the growth in service use. X. Controlling Long-Term Home Health Use (Recommendation 28) Recommendation: The Secretary should analyze the growing number of beneficiaries who are receiving home health care for prolonged periods. Additional policies may be needed to address the spending associated with these beneficiaries. Response: This is one of the many areas that are under evaluation in several payment-related research projects that are currently underway. We agree with ProPAC that there may need to be special provisions under the payment system we develop to address the needs of this type of patient. As the findings from the research become available, we are sure that this issue will be more clearly identified and we will propose whatever changes appear to best address these patient's needs. Y. Prospective Payment System for Rehabilitation Hospitals and Distinct-Part Units (Recommendation 29) Recommendation: A case-mix adjusted prospective payment system for rehabilitation hospitals and distinct-part units should be implemented as soon as possible. Response: We have sponsored research on possible patient classification systems for rehabilitation care. In particular, a study by the RAND Corporation evaluated the prospects for a prospective payment system based on the rehabilitation coding system known as Functional Independence Measure (FIM) and the patient classification system known as Function-Related Groups (FRGs). The final report on this research will soon be complete. However, the preliminary results indicate much work would be necessary before a prospective payment system based on FRGs could be implemented. There are at least two important implementation issues: The reliability of the patient status measures and the [[Page 29937]] recognition of patient complications and comorbidities. In addition, implementation of a case-mix payment system for rehabilitation hospitals and units would require significant program resources and impose data reporting and collection requirements on providers. As a result, fewer resources would be available for research into developing an integrated payment approach for payment of rehabilitation care across all settings (excluded hospitals, SNFs, HHAs, comprehensive outpatient rehabilitation facilities, etc.) Thus, we prefer to focus our efforts on developing a coordinated payment system for post acute care that relies on a core assessment tool. Z. Prospective Payment System for Long-Term Care Hospitals (Recommendation 30) Recommendation: A case-mix adjusted prospective payment system for long-term care hospitals should be developed and implemented as soon as possible. Response: We continually examine data and analyze proposals to simplify payment mechanisms and ensure that Medicare payments reflect efficient and high quality health care. We will be interested in evaluating the results of independent studies on case-mix measurement for long-stay hospital patients. At the same time, it is evident that many long-term care hospitals furnish extensive rehabilitation care that overlaps with care furnished in rehabilitation hospitals. Thus, a prospective payment system for post-acute care providers which includes SNFs and rehabilitation hospitals and units could conceivably be used for patients in long-term care hospitals. As a result, we have concerns that the development and implementation of a separate prospective payment system for fewer than 200 Medicare-certified, long-term care hospitals may not be an efficient use of program resources and may result in overlapping complexity and manipulation of payment. AA. Elimination of the New Provider Exemption Period (Recommendation 32) Recommendation: The initial exemption period for new PPS-excluded providers should be eliminated. Medicare payments for new providers should be based on an average target amount for facilities serving comparable types of patients. Response: New hospitals that are excluded from the prospective payment system are exempt from the rate-of-increase ceiling during their first 2 years of operation. The purpose of this exemption is to recognize certain cost distortions that may be present as a hospital begins operation and tries to establish its presence in the market. However, the growth of new excluded hospitals increasingly includes a large number of hospitals that are reconfigurations of existing structures. These new hospitals do not require the same length of time to establish market presence and increase patient load. As a result, there is evidence that the new hospital exemption does not always serve its original purpose and might create incentives to increase its costs in the exempt years when it is not subject to cost limitation. The President's budget proposal would limit payment during the exempt years to reasonable costs not to exceed 150 percent of the national mean cost per case for each type of excluded hospital. This modification should eliminate the incentive to increase costs in the first years of a new excluded hospital's operation. BB. Coordinating Post-Acute Care Provider Payment Methods (Recommendation 33) Recommendation: The Commission urges the Congress and the Secretary to consider the overlap in services and beneficiaries across post-acute care providers as they modify Medicare payment policies. Changes to one provider's payment method could shift utilization to other sites and thus fail to curb overall spending. To this end, ProPAC commends HCFA's efforts to identify elements common to the various facility-specific patient classification systems to use in comparing beneficiaries across settings. Response: We concur with the recommendation to coordinate payment methods for post-acute providers. Our long-term strategy for Medicare post-acute services centers on the development of a fully integrated payment and delivery system for post-acute care that is as neutral as possible regarding physicians' and patients' decisions about the use of particular services. This system should provide payments sufficient to ensure that beneficiaries receive quality care in the appropriate settings and that transfers between settings occur when medically necessary and not to generate higher or duplicate revenues for comparable services. In addition, we believe that care should be beneficiary-specific, relying on a standardized assessment of each patient's care needs while offering them choices in the care that they will receive. This system must have long-term financial integrity through controlling both payment per service and the volume of services offered. Essential to achieving this long-term goal is the near-term coordination of the separate payment methods for post-acute providers. Through the development and implementation of prospective payment systems that complement each other, Medicare can impose greater coordination in the financing and delivery of post-acute services. This will minimize quality and payment problems associated with site/service substitution and allow for an easier transition to a fully integrated system in the future. The key to the function of these prospective payment systems, as well as any future integrated system for post-acute services, is the adoption of principles for identifying patient resource needs that have common elements from system to system so that ultimately there can be a broader classification system and more standardized methods for grouping patients and payments. Basic to this process is the development of a core screening and assessment tool. An assessment methodology is critical to addressing systematic issues related to quality, payment, and utilization. The President's FY 1998 budget contains proposed language giving the Secretary authority to implement an integrated payment system for Medicare post-acute services after FY 2001. This language also provides authority to collect the data necessary to develop and implement such a system prior to that date. We are in the early stages of designing the post-acute core screening and assessment tool that will provide much of the necessary data. CC. Linking Payments for an Episode of Care (Recommendation 34) Recommendation: The Secretary should begin a demonstration project that links payments for the acute and post-acute portions of an episode of care. It should be designed to test whether this approach can reduce expenditures and improve continuity of care. Response: As discussed in our previous response to recommendation 33, our long-term strategy for Medicare post-acute services centers on the development of a fully integrated payment and delivery system. Within the framework of this strategy and the basic concepts we have outlined, there are a variety of different options for structuring a payment and delivery system for Medicare post-acute services. These include various case management approaches, integrated delivery/payment systems, and more traditional resource based prospective payment models. Certainly a system that links payment for the acute and post- acute [[Page 29938]] portions of an episode would fall within the scope of this framework. Conceptually, the idea of linking (or ``bundling'') payment for the acute and post-acute portions of an episode makes sense and has great potential for effective cost containment under the Medicare model. As a practical matter, this approach is extremely complex, involving a range of difficult technical and policy issues related to rate setting, patient classification, quality, outcomes, accountability, and payment arrangements (that is, which entity should receive the payment). HCFA has funded several studies in this area. These studies have discussed the complexity of this approach and concluded by citing the need for additional research before going forward with a demonstration. In addition, two other provisions in the President's FY 1998 budget proposal give HCFA the authority to try this approach in certain circumstances. The Centers of Excellence proposal expands the set of conditions for which we could pay a single flat rate for all diagnostic and physician services to include other heart procedures, knee surgery and hip replacement. This might allow us to experiment with including some postacute services in the bundled package of services. We are also seeking legislative authority that would allow us to selectively contract with providers for a package of services for a specific condition, which would be another opportunity to experiment with arrangements including postacute care. DD. Improving the Risk Adjustment Method (Recommendation 35) Recommendation: A combination of techniques should be used to adjust Medicare's capitation payments so that they better reflect enrollees' likely use of services. The Secretary should adopt risk adjusters based on diagnosis, health status, or both as well as an outlier policy for costly cases. Partial capitation arrangements should be tested. Plans should provide data to Medicare to support improved risk adjustment. The new risk adjustment system should be phased in. Response: ProPAC recommends using risk adjustment methods that would explain more of the variances in health care spending. Currently, we are testing risk adjusters as part of the Medicare Choices demonstration. The Administration is developing a new payments methodology that incorporates more refined health status adjusters. A proposal could be ready for Congressional consideration as early as 1999, with implementation beginning as early as 2001. HCFA would want to apply risk adjusters as soon as technically feasible. Also, ProPAC has suggested, as a part of risk adjustment, a partial capitation method of payment, using an outlier approach to capitation payment. We are trying to establish an outlier demonstration in the Seattle area. One of the problems we have encountered is finding a sufficient number of plans able to supply encounter data. We wanted at least three plans included in the demonstration. To date, two of the three plans have not demonstrated an ability to produce the data required. The President's budget proposal includes a partial risk method that we prefer to the outlier approach recommended by ProPAC. Under the President's budget proposal, the partial risk method would replace cost based payments. This method would allow organizations to share with HCFA in either savings or losses if the payment mechanism requires amounts to be paid either below or above the risk capitation rate. EE. Excluding Teaching and Disproportionate Share Payments From the Capitation Rates (Recommendation 36) Recommendation: The fee-for-service spending estimates Medicare uses to calculate capitation rates should exclude special payments to hospitals with graduate medical education (GME) programs and to those serving a disproportionate share of low-income patients. Response: We agree with ProPAC's recommendation to remove GME and DSH components from the capitation rates. The President's budget proposal removes these components from the capitation payments over a 2-year period. The funds removed from the capitation rates will be paid directly to teaching and DSH hospitals when they care for managed care enrollees. Managed care plans with approved teaching programs would also be eligible for direct payment for graduate medical education expenses. FF. Increasing Capitation Rates to Reflect Use of Services Covered by Other Government Programs (Recommendation 37) Recommendation: Medicare should increase the capitation rates to include estimated spending for covered services that program beneficiaries receive in facilities operated by the Departments of Veterans Affairs and Defense. Response: Under the Administration's proposal to revise the payment methodology, the current link between local fee-for-service payments and managed care payments rates is not retained. By 2002, 30 percent of the county rate will be based on national average payment levels. In addition, rates will be updated based on the national average per capita rate of growth in the Medicare program. In view of the reduced weight of local fee-for-service payment levels and the anticipated transition to a new methodology, we believe the need to further examine the impact of spending for services provided to Medicare beneficiaries in Veterans Affairs and Defense facilities is significantly reduced. Additionally, when we undertook such an examination a few years ago, we had problems with the data submitted and could not establish an appropriate adjustment to the capitation payments. GG. Reducing the Variation in Payment Rates (Recommendation 38) Recommendation: The variation in capitation rates across counties should be narrowed. The lowest rates should be raised to a minimum amount, without increasing aggregate program spending. Medicare should evaluate the adequacy and appropriateness of its payment rates, however they are determined. Response: The Administration supports narrowing the variation in capitation rates across counties and creating a minimum payment amount. The FY 1998 budget proposal to revise the payment methodology includes both of these elements. By 2002, the difference between the highest and the lowest county rates is reduced from the current difference of about 250 percent to about 100 percent. The Administration's proposal also addresses the appropriateness of the rates by making an adjustment for favorable selection into managed care plans, beginning in 2000. This adjustment is consistent with the judgement of the General Accounting Office, the Physician Payment Review Commission, as well as ProPAC, that managed care plans are currently significantly overpaid because of favorable selection. Also, as noted above, the Administration is developing a new payment methodology that incorporates more refined health status adjusters. A proposal could be ready for Congressional consideration as early as 1999, with phase-in beginning as early as 2001. HH. Updating Capitation Rates (Recommendation 39) Recommendation: Medicare should use a national update framework rather than fee-for-service spending increases to determine the annual changes in risk plan payment rates. [[Page 29939]] Response: Under the current methodology, rates are updated based on local fee-for-service spending patterns. Under the Administration's proposal to revise the payment methodology, rates would be updated based on the national average per capita rate of growth in the Medicare program, which incorporates changes at the national level in both price and utilization of services. In developing the revised methodology noted above, which we expect to have ready for Congressional consideration as early as 1999, we will examine appropriate update mechanisms. II. Evaluating Alternative Methods for Determining Capitation Rates (Recommendation 40) Recommendation: The Medicare program should continue to evaluate other methods for determining payment rates, including competitive bidding and negotiation between the program and risk plans. Response: We are in the process of developing several demonstration projects for evaluation purposes. One project concentrates on competitive bids, including the use of a third party enroller. In this project, HMOs could be paid an amount based on bids they submit. In addition, the Choices project will have participants receiving payments that start with 95 percent of the Adjusted Average per Capita Cost (AAPCC) (HCFA's normal payment method). Later in the project, these payments will be modified using risk adjusters. This project will also include contracting with organizations that may not qualify as HMOs. Finally, we are trying to establish an outlier project in Seattle, as mentioned above. However, we have not yet been able to acquire sufficient data to begin this project. JJ. Data to Improve Plan Payments (Recommendation 41) Recommendation: The Secretary should require risk plans to provide information on the costs of furnishing services to Medicare enrollees. These data are necessary to determine the appropriateness of payment rates and improve Medicare payment methods. Response: We are in the process of revising the adjusted community rate (ACR) proposal and process. Some of the concepts included in this review include requiring the ACR to contain and use certain cost data to establish the plan's charge structure. In addition, we are considering incorporating into the approval process a comparison of ACR data to other required financial reports. KK. Evaluating Plan Quality of Care (Recommendation 42) Recommendation: The Commission supports the Secretary's efforts to evaluate Medicare risk plans through the use of the Health Plan Employer Data and Information Set (HEDIS) and satisfaction surveys. The Secretary should, in cooperation with the appropriate organizations, continue to adapt and improve measurement tools to evaluate plan performance. Response: In addition to our use of HEDIS to evaluate Medicare risk plans, we will survey all of the enrollees of HMO and CMP contractors (both risk and cost) on their satisfaction with various aspects of their plan. This effort is in cooperation with the Agency for Health Care Policy and Research. LL. Improving Information for Beneficiary Choice (Recommendation 43) Recommendation: The Commission supports the Secretary's efforts to improve beneficiary information about managed care options. All beneficiaries should receive quality and satisfaction data for risk plans and the fee-for-service option to help them decide about enrolling in a risk plan. Cost and benefit definitions should be standardized so that beneficiaries can better compare plans. Additionally, the Secretary should periodically assess whether such information could be improved. Response: We are continually trying to improve the information given to the Medicare beneficiary. We are in the process of developing a comparison chart comparing benefits and charges among HMOs within a specified service area. Later this year, HEDIS data and consumer survey results will be released. In addition, HCFA is in the process of releasing national marketing guidelines that require HMOs to produce marketing materials that fully disclose, in a clear and understandable manner, information to be used by the Medicare beneficiary. The Administration's FY 1998 budget also includes proposals addressing the provision of information to beneficiaries. It would require the Secretary to develop and provide comparative information to beneficiaries on all managed care plans and Medigap plans in their area, and it would require Medigap and managed care plans to finance the associated costs. It would also require the Secretary to establish standardized packages for certain additional benefits offered by Medicare managed care plans. For example, if the Secretary established a standardized package for outpatient prescription drugs, plans could only offer enrollees this benefit according to the benefit structure established by the Secretary. IX. Other Required Information A. Requests for Data From the Public In order to respond promptly to public requests for data related to the prospective payment system, we have set up a process under which commenters can gain access to the raw data on an expedited basis. Generally, the data are available in computer tape format or cartridges; however, some files are available on diskette, and on the Internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. Data files are listed below with the cost of each. Anyone wishing to purchase data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to HCFA-PUF) to cover the cost, to the following address: Health Care Financing Administration, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, Maryland 21207-0520, (410) 786-3691. Files on the Internet may be downloaded without charge. 1. Expanded Modified MEDPAR-Hospital (National) The Medicare Provider Analysis and Review (MEDPAR) file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in the United States. (The file is a Federal fiscal year file which means discharges occurring October 1 through September 30.) The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the 6- position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the Federal Register on December 24, 1984 (49 FR 49941), and amended by the July 2, 1985 notice (50 FR 27361). The national file consists of approximately 11 million records. Under the requirements of these notices, a data release agreement must be signed by the purchaser before release of these data. For all files requiring a signed data release agreement, please write or call to obtain a blank agreement form before placing an order. Two versions of this file are created each year. They support the following: Notice of Proposed Rulemaking (NPRM) published in the Federal Register, usually available by the end of May. This file is derived from the MedPAR file with a cutoff of 3 months [[Page 29940]] after the end of the fiscal year (December file). Final Rule published in the Federal Register, usually available by the first week of September. This file is derived from the MedPAR file with a cutoff of 9 months after the end of the fiscal year (June file). Media: Tape/Cartridge File Cost: $3,415.00 per fiscal year Periods Available: FY 1988 through FY 1996 2. Expanded Modified MedPAR-Hospital (State) The State MedPAR file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in a particular State. The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the 6- position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the December 24, 1984 Federal Register notice, and amended by the July 2, 1985 notice. This file is a subset of the Expanded Modified MedPAR-Hospital (National) as described above. Under the requirements of these notices, a data release must be signed by the purchaser before release of these data. Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually available by the end of May. This file is derived from the MedPAR file with a cutoff of 3 months after the end of the fiscal year (December file). Final Rule published in the Federal Register, usually available by the first week of September. This file is derived from the MedPAR file with a cutoff of 9 months after the end of the fiscal year (June file). Media: Tape/Cartridge File Cost: $1,050.00 per State per year Periods Available: FY 1988 through FY 1996 3. HCFA Hospital Wage Index Data File This file is composed of four separate diskettes. Included are: (1) The hospital hours and salaries for FY 1994 used to create the proposed FY 1998 prospective payment system wage index; (2) a history of all wage indexes used since October 1, 1983; (3) a list of State and county codes used by SSA and FIPS (Federal Information Processing Standards), county name, and Metropolitan Statistical Area (MSA); and (4) a file of hospitals that were reclassified for the purpose of the proposed FY 1998 wage index. Two versions of these files are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final Rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet File Cost: $500.00 Periods Available: FY 1998 PPS Update We note that the files also are available individually as indicated below. (1) HCFA Hospital Wage Index Survey Only (usually available by the end of March for the NPRM and the middle of August for the final rule). (2) Urban and Rural Wage Indices Only. (3) PPS SSA/FIPS MSA State and County Crosswalk Only (usually available by the end of March). (4) Reclassified Hospitals by Provider Only. Media: Diskette/Internet File cost: $145.00 per file 4. PPS-IV to PPS-XIII Minimum Data Sets The Minimum Data Set contains cost, statistical, financial, and other information from Medicare hospital cost reports. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare participating hospital by the Medicare Fiscal Intermediary to HCFA. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge ------------------------------------------------------------------------ Periods beginning And before on or after ------------------------------------------------------------------------ PPS IV........................................ 10/01/86 10/01/87 PPS V......................................... 10/01/87 10/01/88 PPS VI........................................ 10/01/88 10/01/89 PPS VII....................................... 10/01/89 10/01/90 PPS VIII...................................... 10/01/90 10/01/91 PPS IX........................................ 10/01/91 10/01/92 PPS X......................................... 10/01/92 10/01/93 PPS XI........................................ 10/01/93 10/01/94 PPS XII....................................... 10/01/94 10/01/95 PPS XIII...................................... 10/01/95 10/01/96 ------------------------------------------------------------------------ (Note: The PPS XIII Minimum Data Set covering FY 1996 will not be available until July 31, 1997.) File Cost: $715.00 per year 5. PPS-IX to PPS-XIII Capital Data Set The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare certified hospital by the Medicare fiscal intermediary to HCFA. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge ------------------------------------------------------------------------ Periods beginning And before on or after ------------------------------------------------------------------------ PPS IX........................................ 10/01/91 10/01/92 PPS X......................................... 10/01/92 10/01/93 PPS XI........................................ 10/01/93 10/01/94 PPS XII....................................... 10/01/94 10/01/95 PPS XIII...................................... 10/01/95 10/01/96 ------------------------------------------------------------------------ (Note: The PPS XIII Capital Data Set covering FY 1996 will not be available until July 31, 1997.) File Cost: $715.00 per year 6. Provider-Specific File This file is a component of the PRICER program used in the fiscal intermediary's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements. Media: Tape/Cartridge File Cost: $500.00 per file Periods Available: FY 1987 through FY 1997 (December updates) Media: Diskette/Internet File Cost: $265.00 Periods Available: FY 1997 PPS Update 7. HCFA Medicare Case-Mix Index File This file contains the Medicare case-mix index by provider number as published in each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet [[Page 29941]] Price: $145.00 per year Periods Available: FY 1985 through FY 1996 (Internet--FY 1996) 8. Table 5 DRG File This file contains a listing of DRGs, DRG narrative description, relative weight, and geometric and arithmetic mean lengths of stay as published in the Federal Register. The hardcopy image has been copied to diskette. There are two versions of this file as published in the Federal Register: a. NPRM, usually published by the end of May. b. Final rule, usually published by the first week of September. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1998 PPS Update 9. PPS Payment Impact File This file contains data used to estimate payments under Medicare's hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the Federal Register. This file is available for release 1 month after the proposed and final rules are published in the Federal Register. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1998 PPS Update 10. AOR/BOR Tables This file contains data used to develop the DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by DRG for length of stay and standardized charges. The BOR tables are ``Before Outliers Removed'' and the AOR is ``After Outliers Removed.'' (Outliers refers to statistical outliers, not payment outliers.) Two versions of this file are created each year. They support the following: NPRM published in the Federal Register, usually by the end of May. Final rule published in the Federal Register, usually by the first week of September. Media: Diskette/Internet File Cost: $145.00 Periods Available: FY 1998 PPS Update 11. HCFA FY 1992 Capital-Related Tax File This file contains data used to develop a proposed FY 1996 special property tax adjustment to the capital prospective payment system for capital-related costs. This proposed adjustment was not implemented. The data set includes a preliminary hospital-specific add-on amount for all PPS hospitals. The data set also contains the information used to propose an adjustment to the Federal rate so that the tax add-on is budget neutral. The proposed property tax adjustment provides special treatment to qualified hospitals who pay capital-related property taxes. The add-on was determined using base year tax costs per discharge attributable to Medicare. The data are taken from the FY 1992 Medicare hospital cost report and a special request for validation by the fiscal intermediaries. Media: Diskette File cost: $145.00 Period available: FY 1992 For further information concerning these data tapes, contact Mary R. White at (410) 786-0168. Commenters interested in obtaining or discussing any other data used in constructing this rule should contact Stephen Phillips at (410) 786-4548. B. Public Comments Because of the large number of items of correspondence we normally receive on a proposed rule, we are not able to acknowledge or respond to them individually. However, in preparing the final rule, we will consider all comments concerning the provisions of this proposed rule that we receive by the date and time specified in the ``Dates'' section of this preamble and respond to those comments in the preamble to that rule. We emphasize that, given the statutory requirement under section 1886(e)(5) of the Act that our final rule for FY 1998 be published by September 1, 1997, we will consider only those comments that deal specifically with the matters discussed in this proposed rule. Subject to the provisions of the Contract With America Advancement Act of 1996, (Pub. L. 104-121), these changes would be applicable to discharges occurring on or after October 1, 1997. List of Subjects 42 CFR Part 412 Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 413 Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 489 Health facilities, Medicare, Reporting and recordkeeping requirements. 42 CFR chapter IV would be amended as set forth below: A. Part 412 is amended as follows: PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES 1. The authority citation for part 412 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 2. Section 412.22 is amended by adding new paragraphs (e), (f), (g), and (h) to read as follows: Sec. 412.22 Excluded hospitals and hospital units: General rules. * * * * * (e) Hospitals within hospitals. Except as provided in paragraph (f) of this section, for cost reporting periods beginning on or after October 1, 1994, a hospital that occupies space in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital, must meet the following criteria: (1) Separate governing body. The hospital has a governing body that is separate from the governing body of the hospital occupying space in the same building or on the same campus. The hospital's governing body is not under the control of the hospital occupying space in the same building or on the same campus, or of any third entity that controls both hospitals. (2) Separate chief medical officer. The hospital has a single chief medical officer who reports directly to the governing body and who is responsible for all medical staff activities of the hospital. The chief medical officer of the hospital is not employed by or under contract with either the hospital occupying space in the same building or on the same campus or any third entity that controls both hospitals. (3) Separate medical staff. The hospital has a medical staff that is separate from the medical staff of the hospital occupying space in the same building or on the same campus. The hospital's medical staff is directly accountable to the governing body for the quality of medical care provided in the hospital, and adopts and enforces bylaws governing medical staff activities, including criteria and procedures for recommending to the governing body the privileges to be granted to individual practitioners. [[Page 29942]] (4) Chief executive officer. The hospital has a single chief executive officer through whom all administrative authority flows, and who exercises control and surveillance over all administrative activities of the hospital. The chief executive office is not employed by, or under contract with, either the hospital occupying space in the same building or on the same campus or any third entity that controls both hospitals. (5) Performance of basic hospital functions. The hospital meets one of the following criteria: (i) The hospital performs the basic functions specified in Secs. 482.21 through 482.27, 482.30, and 482.42 of this chapter through the use of employees or under contracts or other agreements with entities other than the hospital occupying space in the same building or on the same campus, or a third entity that controls both hospitals. Food and dietetic services and housekeeping, maintenance, and other services necessary to maintain a clean and safe physical environment could be obtained under contracts or other agreements with the hospital occupying space in the same building or on the same campus, or with a third entity that controls both hospitals. (ii) For the same period of at least 6 months used to determine compliance with the length-of-stay criterion in Sec. 412.23(e)(2), the cost of the services that the hospital obtained under contracts or other agreements with the hospital occupying space in the same building or on the same campus, or with a third entity that controls both hospitals, is no more than 15 percent of the hospital's total inpatient operating costs, as defined in Sec. 412.2(c). For purposes of this paragraph (e)(5)(ii), however, the costs of preadmission services are those specified under Sec. 413.40(c)(2) rather than those specified under Sec. 412.2(b)(5). (iii) For the same period of at least 6 months used to determine compliance with the length-of-stay criterion in Sec. 412.23(e)(2), the hospital has an inpatient population of whom at least 75 percent were referred to the hospital from a source other than another hospital occupying space in the same building or on the same campus. (f) Special provision for certain hospitals. If a hospital cannot meet the criteria in paragraph (e)(1) or (e)(3) of this section solely because its governing body or medical staff is under the control of a third entity that also controls the hospital with which it shares a building or campus, or cannot meet the criteria in paragraph (e)(2) or (e)(4) of this section solely because its chief medical officer or chief executive officer is employed by or under contract with such a third entity, the hospital can nevertheless qualify for an exclusion if it meets other applicable criteria and-- (1) Is owned and operated by a State university, and has been continuously owned and operated by that university since October 1, 1994; (2) Is required by State law to be subject to the ultimate authority of the university's governing body; and (3) Was excluded from the prospective payment systems under this section for any cost reporting period beginning on or after October 1, 1993, but before October 1, 1994. (g) Effective date for certain hospitals. If a hospital has been excluded from the prospective payment systems under this section for any cost reporting period beginning on or after October 1, 1993, but before October 1, 1994, the criteria in paragraph (e) of this section do not apply to the hospital until the hospital's first cost reporting period beginning on or after October 1, 1995. (h) Definition of control. For purposes of this section, control exists if an individual or an organization has the power, directly or indirectly, significantly to influence or direct the actions or policies of an organization or institution. Sec. 412.23 [Amended] 3. Section 412.23 is amended by removing paragraphs (e)(3) through (e)(5). 4. Section 412.30 is amended by redesignating paragraphs (a) through (d) as paragraphs (b) through (e), respectively, and adding a new paragraph (a). Redesignated paragraph (b) is further amended by redesignating paragraph (b)(4) as paragraph (b)(5), and adding a new paragraph (b)(4) to read as follows: Sec. 412.30 Exclusion of new rehabilitation units and expansion of units already excluded. (a) Bed capacity in units. A decrease in bed capacity must remain in effect for at least a full 12-month cost reporting period before an equal or lesser number of beds can be added to the hospital's licensure and certification and considered ``new'' under paragraph (b) of this section. Thus, when a hospital seeks to establish a new unit under the criteria under paragraph (b) of this section, or to enlarge an existing unit under the criteria under paragraph (d) of this section, the regional office will review its records on the facility to determine whether any beds have been delicensed and decertified during the 12- month cost reporting period before the period for which the hospital seeks to add the beds. To the extent bed capacity was removed from the hospital's licensure and certification during that period, that amount of bed capacity may not be considered ``new'' under paragraph (b) of this section. (b) New units. (5) * * * * * * * * (4) If a hospital that has not previously participated in the Medicare program seeks exclusion of a rehabilitation unit, it may designate certain beds as a new rehabilitation unit for the first full 12-month cost reporting period that occurs after it becomes a Medicare- participating hospital. The written certification described in paragraph (b)(2) of this section also is effective for any cost reporting period of not less than 1 month and not more than 11 months occurring between the date the hospital began participating in Medicare and the start of the hospital's regular 12-month cost reporting period. * * * * * 5. Section 412.80 is revised to read as follows: Sec. 412.80 General provisions. (a) Basic rule--(1) Discharges occurring on or after October 1, 1994 and before October 1, 1997. For discharges occurring on or after October 1, 1994, and before October 1, 1997, except as provided in paragraph (b) of this section concerning transferring hospitals, HCFA provides for additional payment, beyond standard DRG payments, to a hospital for covered inpatient hospital services furnished to a Medicare beneficiary if either of the following conditions is met: (i) The beneficiary's length of stay (including days at the SNF level of care if a SNF bed is not available in the area) exceeds the mean length-of-stay for the applicable DRG by the lesser of the following: (A) A fixed number of days, as specified by HCFA; or (B) A fixed number of standard deviations, as specified by HCFA. (ii) The beneficiary's length of stay does not exceed criteria established under paragraph (a)(1)(i) of this section, but the hospital's charges for covered services furnished to the beneficiary, adjusted to operating costs and capital costs by applying cost-to- charge ratios as described in Sec. 412.84(h), exceed the DRG payment for the case plus a fixed dollar amount (adjusted for geographic variation in costs) as specified by HCFA. (2) Discharges occurring on or after October 1, 1997. For discharges occurring on or after October 1, 1997, [[Page 29943]] except as provided in paragraph (b) of this section concerning transfers, HCFA provides for additional payment, beyond standard DRG payments, to a hospital for covered inpatient hospital services furnished to a Medicare beneficiary if the hospital's charges for covered services, adjusted to operating costs and capital costs by applying cost-to-charge ratios as described in Sec. 412.84(h), exceed the DRG payment for the case plus a fixed dollar amount (adjusted for geographic variation in costs) as specified by HCFA. (b) Outlier cases in transferring hospitals. HCFA provides cost outlier payments to a transferring hospital that does not receive payment under Sec. 412.2(b) for discharges specified in Sec. 412.4(d)(2), if the hospital's charges for covered services furnished to the beneficiary, adjusted to cost by applying a national cost/charge ratio, exceed the DRG payment for the case plus a fixed dollar amount (adjusted for geographic variation in costs) as specified by HCFA, divided by the geometric mean length of stay for the DRG and multiplied by the beneficiary's length of stay plus 1 day. (c) Publication and revision of outlier criteria. HCFA will issue threshold criteria for determining outlier payment in the annual notice of the prospective payment rates published in accordance with Sec. 412.8(b). (d) Relation to hospitals that incur indirect costs for graduate medical education programs and that serve as disproportionate share of low-income patients. The outlier payment amounts are included in total DRG revenue for purposes of determining payments to hospitals that incur indirect costs for graduate medical education programs under Sec. 412.105 and to hospitals that serve a disproportionate share of low-income patients under Sec. 412.106. Sec. 412.82 [Amended] 6. In Sec. 412.82(a), in the first sentence, the word ``If'' is removed and the phrase ``For discharges occurring before October 1, 1997, if'' is added in its place. Sec. 412.84 [Amended] 7. In Sec. 412.84 in the first sentence of paragraph (a), the reference ``Sec. 412.80(a)(1)(ii)'' is revised to read ``Sec. 412.80(a)''. Sec. 412.86 [Amended] 8. In the introductory text to Sec. 412.86, the word ``If'' is removed and the phrase ``For discharges occurring before October 1, 1997, if'' is added in its place. 9. In Sec. 412.96, the introductory text of paragraph (c)(1) is revised to read as follows: Sec. 412.96 Special treatment: Referral centers. * * * * * (c) * * * (1) Case mix index. HCFA sets forth national and regional case-mix index values in each year's annual notice of prospective payment rates published under Sec. 412.8(b). The methodology HCFA uses to calculate these criteria is described in paragraph (g) of this section. The case- mix index value to be used for an individual hospital in the determination of whether it meets the case-mix index criteria is that calculated by HCFA from the hospital's own billing records for Medicare discharges as processed by the fiscal intermediary and submitted to HCFA. The hospital's case-mix index for discharges (not including discharges from units excluded from the prospective payment system under subpart B of this part) during the most recent Federal fiscal year that ended at least one year prior to the beginning of the cost reporting period for which the hospital is seeking referral center status must be at least equal to-- * * * * * 10. In Sec. 412.105, paragraph (g)(1)(i) is republished, paragraph (g)(1)(i)(B) is revised, and paragraph (g)(1)(iv) is removed, to read as follows: Sec. 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs. * * * * * (g) Determining the total number of full-time equivalent residents for cost reporting periods beginning on or after July 1, 1991. (1) For cost reporting periods beginning on or after July 1, 1991, the count of full-time equivalent residents for the purpose of determining the indirect medical education adjustment is determined as follows: (i) The residents must be enrolled in an approved teaching program. An approved teaching program is one that meets one of the following requirements: * * * * * (B) May count towards certification of the participant in a specialty or subspecialty listed in the current edition of either of the following publications: (1) The Directory of Graduate Medical Education Programs published by the American Medical Association. (2) The Annual Report and Reference Handbook published by the American Board of Medical Specialties. * * * * * B. Part 413 is amended as set forth below: PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES 1. The authority citation for Part 413 continues to read as follows: Authority: Secs. 1102, 1861(v)(1)(A), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh). 2. In Sec. 413.86, paragraph (e)(4)(i)(B) is revised to read as follows: Sec. 413.86 Direct graduate medical education payments. * * * * * (e) Determining per resident amounts for the base period. * * * (4) Exceptions. (i) Base period for certain hospitals. * * * (B) The mean value of per resident amounts of hospitals located in the same geographic wage area, as that term is used in the prospective payment system under part 412 of this chapter, for cost reporting periods beginning in the same fiscal years. If there are fewer than three amounts that can be used to calculate the mean value, the calculation of the per resident amounts includes all hospitals in the hospital's geographic wage area and in geographically contiguous wage areas. If there are still fewer than three hospitals with per resident amounts in the hospital's own wage area, plus contiguous wage areas, this calculation will include all hospitals with per resident amounts in the State. If there are fewer than three hospitals with per resident amounts in the State, this calculation will include the per resident amounts for all hospitals in the State plus hospitals in contiguous States. If there are still fewer than three hospitals in that State plus contiguous States, this calculation will be based on the national average per resident amount. * * * * * C. Part 489 is amended as set forth below: PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 1. The authority citation for Part 489 continues to read as follows: Authority: Secs. 1102, 1819, 1861, 1864(m), 1866, and 1871 of the Social Security Act (42 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, and 1395hh). [[Page 29944]] Sec. 489.27 [Amended] 2. In Sec. 489.27, the reference ``section 1886(a)(1)(M) of the Act'' is revised to read ``section 1866(a)(1)(M) of the Act''. (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance) Dated: May 1, 1997. Bruce C. Vladeck, Administrator, Health Care Financing Administration. Dated: May 23, 1997. Donna E. Shalala, Secretary. [Editorial Note: The following addendum and appendixes will not appear in the Code of Federal Regulations.] Addendum--Proposed Schedule of Standardized Amounts Effective With Discharges Occurring on or After October 1, 1997 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning on or After October 1, 1997 I. Summary and Background In this addendum, we are setting forth the proposed amounts and factors for determining prospective payment rates for Medicare inpatient operating costs and Medicare inpatient capital-related costs. We are also setting forth proposed rate-of-increase percentages for updating the target amounts for hospitals and hospital units excluded from the prospective payment system. For discharges occurring on or after October 1, 1997, except for sole community hospitals and hospitals located in Puerto Rico, each hospital's payment per discharge under the prospective payment system will be based on 100 percent of the Federal national rate. Sole community hospitals are paid based on whichever of the following rates yields the greatest aggregate payment: The Federal national rate, the updated hospital-specific rate based on FY 1982 cost per discharge, or the updated hospital-specific rate based on FY 1987 cost per discharge. For hospitals in Puerto Rico, the payment per discharge is based on the sum of 75 percent of a Puerto Rico rate and 25 percent of a national rate (section 1886(d)(9)(A) of the Act). As discussed below in section II, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs. The changes, to be applied prospectively, would affect the calculation of the Federal rates. In section III, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs. Section IV sets forth our proposed changes for determining the rate-of-increase limits for hospitals excluded from the prospective payment system. The tables to which we refer in the preamble to the proposed rule are presented at the end of this addendum in section V. II. Proposed Changes to Prospective Payment Rates for Inpatient Operating Costs for FY 1998 The basic methodology for determining prospective payment rates for inpatient operating costs is set forth at Sec. 412.63 for hospitals located outside of Puerto Rico. The basic methodology for determining the prospective payment rates for inpatient operating costs for hospitals located in Puerto Rico is set forth at Secs. 412.210 and 412.212. Below, we discuss the manner in which we are changing some of the factors used for determining the prospective payment rates. The Federal and Puerto Rico rate changes, once issued as final, would be effective with discharges occurring on or after October 1, 1997. As required by section 1886(d)(4)(C) of the Act, we must also adjust the DRG classifications and weighting factors for discharges in FY 1998. In summary, the proposed standardized amounts set forth in Tables 1A and 1C of section V of this addendum reflect-- Updates of 2.8 percent for all areas (that is, the market basket percentage increase); An adjustment to ensure budget neutrality as provided for in sections 1886 (d)(4)(C)(iii) and (d)(3)(E) of the Act by applying new budget neutrality adjustment factors to the large urban and other standardized amounts; An adjustment to ensure budget neutrality as provided for in section 1886(d)(8)(D) of the Act by removing the FY 1997 budget neutrality factor and applying a revised factor; An adjustment to apply the revised outlier offset by removing the FY 1997 outlier offsets and applying a new offset; and An adjustment in the Puerto Rico standardized amounts to reflect the application of a Puerto Rico-specific wage index. A. Calculation of Adjusted Standardized Amounts 1. Standardization of Base-Year Costs or Target Amounts Section 1886(d)(2)(A) of the Act required the establishment of base-year cost data containing allowable operating costs per discharge of inpatient hospital services for each hospital. The preamble to the September 1, 1983 interim final rule (48 FR 39763) contains a detailed explanation of how base-year cost data were established in the initial development of standardized amounts for the prospective payment system and how they are used in computing the Federal rates. Section 1886(d)(9)(B)(i) of the Act required that Medicare target amounts be determined for each hospital located in Puerto Rico for its cost reporting period beginning in FY 1987. The September 1, 1987 final rule contains a detailed explanation of how the target amounts were determined and how they are used in computing the Puerto Rico rates (52 FR 33043, 33066). The standardized amounts are based on per discharge averages of adjusted hospital costs from a base period or, for Puerto Rico, adjusted target amounts from a base period, updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. Sections 1886(d)(2) (B) and (C) of the Act required that the base-year per discharge costs be updated for FY 1984 and then standardized in order to remove from the cost data the effects of certain sources of variation in cost among hospitals. These include case mix, differences in area wage levels, cost of living adjustments for Alaska and Hawaii, indirect medical education costs, and payments to hospitals serving a disproportionate share of low- income patients. Under sections 1886 (d)(2)(H) and (d)(3)(E) of the Act, in making payments under the prospective payment system, the Secretary estimates from time to time the proportion of costs that are wages and wage-related costs. Since October 1, 1996, when the market basket was last revised and rebased, we have considered 71.2 percent of costs to be labor-related for purposes of the prospective payment system. As discussed in section IV of the preamble, we are proposing to include data not available when the market basket was last rebased to adjust the market basket effective for FY 1998. Based on the proposed revised market basket, we are revising the labor and nonlabor proportions of the standardized amounts. Effective with discharges occurring on or after October 1, 1997, we are proposing a labor-related proportion of 71.1 percent and a nonlabor-related proportion of 28.9 percent. (We are revising the Puerto Rico standardized amounts by the average labor share in Puerto Rico of 71.3 percent. We are revising the discharged-weighted national standardized amount to reflect the proportion of discharges in large urban and other areas from the FY 1996 MedPAR file.) 2. Computing Large Urban and Other Area Averages Sections 1886(d) (2)(D) and (3) of the Act require the Secretary to compute two average standardized amounts for discharges occurring in a fiscal year: one for hospitals located in large urban areas and one for hospitals located in other areas. In addition, under sections 1886(d)(9) (B)(iii) and (C)(i) of the Act, the average standardized amount per discharge must be determined for hospitals located in urban and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a blend of 75 percent of the applicable Puerto Rico standardized amount and 25 percent of a national standardized payment amount. Section 1886(d)(2)(D) of the Act defines ``urban area'' as those areas within a Metropolitan Statistical Area (MSA). A ``large urban area'' is defined as an urban area with a population of more than 1,000,000. In addition, section 4009(i) of Public Law 100-203 provides that a New England County Metropolitan Area (NECMA) with a population of more than 970,000 is classified as a large urban area. As required by section 1886(d)(2)(D) of the Act, population size is determined by the Secretary based on the latest population data published by the Bureau of the Census. Urban areas that do not meet the definition of a ``large urban area'' are referred to as ``other urban areas.'' Areas that are not included in MSAs are considered ``rural areas'' under section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals located in large urban areas will be [[Page 29945]] based on the large urban standardized amount. Payment for discharges from hospitals located in other urban and rural areas will be based on the other standardized amount. Based on 1995 population estimates published by the Bureau of the Census, 56 areas meet the criteria to be defined as large urban areas for FY 1998. These areas are identified by an asterisk in Table 4A. 3. Updating the Average Standardized Amounts Under section 1886(d)(3)(A) of the Act, we update the area average standardized amounts each year. In accordance with section 1886(d)(3)(A)(iv) of the Act, we are proposing to update the large urban and the other areas average standardized amounts for FY 1998 using the applicable percentage increases specified in section 1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XIII) of the Act specifies that, for hospitals in all areas, the update factor for the standardized amounts for FY 1998 is equal to the market basket percentage increase. The percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient care. The most recent forecast of the proposed revised hospital market basket increase for FY 1998 is 2.8 percent. Thus, for FY 1998, the proposed update to the average standardized amounts equals 2.8 percent. (See section IV. of the preamble of this proposed rule for a discussion of the adjustments to the market basket.) As in the past, we are adjusting the FY 1997 standardized amounts to remove the effects of the FY 1997 geographic reclassifications and outlier payments before applying the FY 1998 updates. That is, we are increasing the standardized amounts to restore the reductions that were made for the effects of geographic reclassification and outliers. After including offsets to the standardized amounts for outliers and geographic reclassification, we estimate that there will be an overall increase of 2.9 percent to the large urban and other area standardized amounts. Although the update factor for FY 1998 is set by law, we are required by section 1886(e)(3)(B) of the Act to report to Congress on our initial recommendation of update factors for FY 1998 for both prospective payment hospitals and hospitals excluded from the prospective payment system. For general information purposes, we have included the report to Congress as Appendix D to this proposed rule. Our proposed recommendation on the update factors (which is required by sections 1886 (e)(4)(A) and (e)(5)(A) of the Act), as well as our responses to ProPAC's recommendation concerning the update factor, are set forth as Appendix E to this proposed rule. 4. Other Adjustments to the Average Standardized Amounts a. Recalibration of DRG Weights and Updated Wage Index--Budget Neutrality Adjustment. Section 1886(d)(4)(C)(iii) of the Act specifies that beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II of the preamble, we normalized the recalibrated DRG weights by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight prior to recalibration. Section 1886(d)(3)(E) of the Act specifies that the hospital wage index must be updated on an annual basis beginning October 1, 1993. This provision also requires that any updates or adjustments to the wage index must be made in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. To comply with the requirement of section 1886(d)(4)(C)(iii) of the Act that DRG reclassification and recalibration of the relative weights be budget neutral, and the requirement in section 1886(d)(3)(E) of the Act that the updated wage index be budget neutral, we used historical discharge data to simulate payments and compared aggregate payments using the FY 1997 relative weights and wage index to aggregate payments using the proposed FY 1998 relative weights and wage index. The same methodology was used for the FY 1997 budget neutrality adjustment. (See the discussion in the September 1, 1992 final rule (57 FR 39832).) Based on this comparison, we computed a budget neutrality adjustment factor equal to 0.998400. We adjust the Puerto Rico-specific standardized amounts for the effect of DRG reclassification and recalibration. We computed a budget neutrality adjustment factor for Puerto Rico- specific standardized amounts equal to 0.999224. These budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 1997 budget neutrality adjustments. We do not remove the prior budget neutrality adjustment because estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition. In addition, we are proposing to continue to apply the same FY 1998 adjustment factor to the hospital-specific rates that are effective for cost reporting periods beginning on or after October 1, 1997, in order to ensure that we meet the statutory requirement that aggregate payments neither increase nor decrease as a result of the implementation of the FY 1998 DRG weights and updated wage index. (See the discussion in the September 4, 1990 final rule (55 FR 36073).) b. Reclassified Hospitals--Budget Neutrality Adjustment. Section 1886(d)(8)(B) of the Act provides that certain rural hospitals are deemed urban effective with discharges occurring on or after October 1, 1988. In addition, section 1886(d)(10) of the Act provides for the reclassification of hospitals based on determinations by the Medicare Geographic Classification Review Board (MGCRB). Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the standardized amount or the wage index, or both. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that total aggregate payments under the prospective payment system after implementation of the provisions of sections 1886(d)(8) (B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. To calculate this budget neutrality factor, we used historical discharge data to simulate payments, and compared total prospective payments (including IME and DSH payments) prior to any reclassifications to total prospective payments after reclassifications. We are applying an adjustment factor of 0.995127 to ensure that the effects of reclassification are budget neutral. The adjustment factor is applied to the standardized amounts after removing the effects of the FY 1997 budget neutrality adjustment factor. We note that the proposed FY 1998 adjustment reflects wage index and standardized amount reclassifications approved by the MGCRB or the Administrator as of February 27, 1997. The effects of any additional reclassification changes resulting from appeals and reviews of the MGCRB decisions for FY 1998 or from a hospital's request for the withdrawal of a reclassification request will be reflected in the final budget neutrality adjustment required under section 1886(d)(8)(D) of the Act and published in the final rule for FY 1998. c. Outliers. Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases, cases involving extraordinarily high costs (cost outliers) or long lengths of stay (day outliers). Section 1886(d)(3)(B) of the Act requires the Secretary to adjust both the large urban and other area national standardized amounts by the same factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to adjust the large urban and other standardized amounts applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year must be projected to be not less than 5 percent nor more than 6 percent of total payments based on DRG prospective payment rates. Beginning with FY 1995, section 1886(d)(5)(A) of the Act requires the Secretary to phase out payments for day outliers (correspondingly, payments for cost outliers would increase). Under the requirements of section 1886(d)(5)(A)(v), the proportion of day outlier payments to total outlier payments is reduced from FY 1994 levels as follows: 75 percent of FY 1994 levels in FY 1995, 50 percent of FY 1994 levels in FY 1996, and 25 percent of FY 1994 levels in FY 1997. For discharges occurring after September 30, 1997, the Secretary will no longer pay for day outliers under the provisions of section 1886(d)(5)(A)(i) of the Act. i. Proposed FY 1998 Outlier Payment Thresholds. For FY 1997, the day outlier threshold is the geometric mean length of stay for each DRG plus the lesser of 24 days [[Page 29946]] or 3.0 standard deviations. The marginal cost factor for day outliers (the percent of Medicare's average per diem payment paid for each outlier day) is 33 percent for FY 1997. The fixed loss cost outlier threshold is equal to the prospective payment for the DRG plus $9,700 ($8,850 for hospitals that have not yet entered the prospective payment system for capital-related costs). The marginal cost factor for cost outliers (the percent of costs paid after costs for the case exceed the threshold) is 80 percent. We applied an outlier adjustment to the FY 1997 standardized amounts of 0.948766 for the large urban and other areas rates and 0.9481 for the capital Federal rate. As noted above, section 1886(d)(5)(A)(v) of the Act provides that payment will not be made for day outliers beginning with discharges occurring in FY 1998. We are proposing a fixed loss cost outlier threshold in FY 1998 equal to the prospective payment rate for the DRG plus $7,600 ($6,950 for hospitals that have not yet entered the prospective payment system for capital-related costs). In addition, we are proposing to maintain the marginal cost factor for cost outliers at 80 percent. In accordance with section 1886(d)(5)(A)(iv) of the Act, we calculated proposed outlier thresholds so that outlier payments are projected to equal 5.1 percent of total payments based on DRG prospective payment rates. In accordance with section 1886(d)(3)(E), we reduced the proposed FY 1998 standardized amounts by the same percentage to account for the projected proportion of payments paid to outliers. As stated in the September 1, 1993 final rule (58 FR 46348), we establish outlier thresholds that are applicable to both inpatient operating costs and inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a higher percentage of outlier payments for capital-related costs than for operating costs. We project that the proposed thresholds for FY 1998 will result in outlier payments equal to 5.1 percent of operating DRG payments and 5.5 percent of capital payments based on the Federal rate. The proposed outlier adjustment factors applied to the standardized amounts for FY 1998 are as follows: ------------------------------------------------------------------------ Operating standardized amounts ------------------------------------------------------------------------ National.................................................. 0.949117 Puerto Rico............................................... 0.961488 ------------------------------------------------------------------------ (Note: The proposed outlier adjustment factors applied to the capital Federal rate are found at section III.A.2. of the Addendum.) We would apply the proposed outlier adjustment factors after removing the effects of the FY 1997 outlier adjustment factors on the standardized amounts. ii. Other Changes Concerning Outliers. Table 8A in section V of this addendum contains the updated Statewide average operating cost- to-charge ratios for urban hospitals and for rural hospitals to be used in calculating cost outlier payments for those hospitals for which the intermediary is unable to compute a reasonable hospital- specific cost-to-charge ratio. These Statewide average ratios would replace the ratios published in the August 30, 1996 final rule (61 FR 46302), effective October 1, 1997. Table 8B contains comparable Statewide average capital cost-to-charge ratios. These average ratios would be used to calculate cost outlier payments for those hospitals for which the intermediary computes operating cost-to- charge ratios lower than 0.230118 or greater than 1.30054 and capital cost-to-charge ratios lower than 0.01289 or greater than 0.19057. This range represents 3.0 standard deviations (plus or minus) from the mean of the log distribution of cost-to-charge ratios for all hospitals. We note that the cost-to-charge ratios in Tables 8A and 8B would be used for all cost reports settled during FY 1998 (regardless of the actual cost reporting period) when hospital-specific cost-to-charge ratios are either not available or outside the three standard deviations range. iii. FY 1996 and FY 1997 Outlier Payments. In the August 30, 1996 final rule (61 FR 46229), we stated that, based on available data, we estimated that actual FY 1996 outlier payments would be approximately 4.0 percent of actual total DRG payments. This was computed by simulating payments using actual FY 1995 bill data available at the time. That is, the estimate of actual outlier payments did not reflect actual FY 1996 bills but instead reflected the application of FY 1996 rates and policies to available FY 1995 bills. Our current estimate, using available FY 1996 bills, is that actual outlier payments for FY 1996 were approximately 4.1 percent of actual total DRG payments. We note that the MedPAR file for FY 1996 discharges continues to be updated. We currently estimate that actual outlier payments for FY 1997 will be approximately 4.9 percent of actual total DRG payments (slightly lower than the 5.1 percent we projected in setting outlier policies for FY 1997). This estimate is based on simulations using the December 1996 update of the provider-specific file and the December 1996 update of the FY 1996 MedPAR file (discharge data for FY 1996 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 1997 by applying FY 1997 rates and policies to available FY 1996 bills. In FY 1994, we began using a cost inflation factor rather than a charge inflation factor to update billed charges for purposes of estimating outlier payments. This refinement was made to improve our estimation methodology. We believe that actual FY 1996 and FY 1997 outlier payments as a percentage of total DRG payments may be lower than expected in part because actual hospital costs may be lower than reflected in the methodology used to set outlier thresholds for those years. Our most recent data on hospital costs show that rates of increase are continuing to decline. Thus, the cost inflation factor of 0.871 percent used to set FY 1996 outlier policy (based on the best data then available) appears to have been overstated. For FY 1997, we used a cost inflation factor of minus 1.906 percent (a cost per case decrease of 1.906 percent). For FY 1998, based on more recent data, we are proposing a cost inflation factor of minus 1.969 percent to set outlier thresholds. We will reevaluate this factor when we develop the final rule for FY 1998. At that time, more recent data should be available for analysis, specifically, cost report data for cost reporting periods beginning in FY 1996. Although we estimate that FY 1996 outlier payments will approximate 4.1 percent of total DRG payments, we note that the estimate of the market basket rate of increase used to set the FY 1996 rates was 3.5 percentage points, while the latest FY 1996 market basket rate of increase forecast is 2.7 percent. Thus, the net effect is that hospitals received higher FY 1996 payments than would have been established based on a more recent forecast of the market basket rate of increase. 5. FY 1998 Standardized Amounts The adjusted standardized amounts are divided into labor and nonlabor portions. Table 1A contains the two national standardized amounts that we are proposing be applicable to all hospitals, except for hospitals in Puerto Rico. Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount and the national other standardized amount (as set forth in Table 1A). The labor and nonlabor portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C. This table also includes the Puerto Rico standardized amounts. The Puerto Rico standardized amounts reflect application of Puerto Rico-specific wage index for FY 1998. Thus, before application of the wage index, the proposed FY 1998 Puerto Rico standardized amounts are lower than the FY 1997 standardized amounts. However, after application of the wage index, the FY 1998 Puerto Rico rate is higher than for FY 1997. This is due to the higher Puerto Rico wage index values that will be applied to these standardized amounts in calculating the FY 1998 Puerto Rico rate. Below, we use two wage areas to illustrate that the proposed FY 1998 Puerto Rico wage-adjusted standardized amounts are higher than the FY 1997 Puerto Rico wage-adjusted standardized amounts. [[Page 29947]] Puerto Rico Standardized Amounts ---------------------------------------------------------------------------------------------------------------- FY 1997 Proposed FY 1998 Area --------------------------------------------------------------- Labor Nonlabor Labor Nonlabor ---------------------------------------------------------------------------------------------------------------- Large Urban..................................... $2,488.70 $518.65 $1,346.08 $541.83 Other Areas..................................... 2,449.31 510.45 1,324.77 533.25 ---------------------------------------------------------------------------------------------------------------- Puerto Rico Wage Adjusted Standardized Amount for the San Juan MSA and Rural Puerto Rico ------------------------------------------------------------------------ Proposed FY FY 1997 1998 ------------------------------------------------------------------------ San Juan Wage Index..................... 0.4506 1.0273 Wage-Adjusted Standardized Amount....... $1,640.06 $1,924.66 Rural Wage Index........................ 0.4026 0.8732 Wage-Adjusted Standardized Amount....... $1,496.54 $1,690.04 ------------------------------------------------------------------------ B. Adjustments for Area Wage Levels and Cost of Living Tables 1A and 1C, as set forth in this addendum, contain the proposed labor-related and nonlabor-related shares that would be used to calculate the prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico. This section addresses two types of adjustments to the standardized amounts that are made in determining the prospective payment rates as described in this addendum. 1. Adjustment for Area Wage Levels Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that an adjustment be made to the labor-related portion of the prospective payment rates to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III of the preamble, we discuss certain revisions we are making to the wage index. These changes include the calculation of a Puerto Rico-specific wage index that would be applied to the Puerto Rico standardized amounts. The wage index is set forth in Tables 4A through 4F of this addendum. 2. Adjustment for Cost of Living in Alaska and Hawaii Section 1886(d)(5)(H) of the Act authorizes an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher labor-related costs for these two States are taken into account in the adjustment for area wages described above. For FY 1998, we propose to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor portion of the standardized amounts by the appropriate adjustment factor contained in the table below. If the Office of Personnel Management releases revised cost-of-living adjustment factors before August 1, 1997, we will publish them in the final rule and use them in determining FY 1998 payments. Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals ------------------------------------------------------------------------ ------------------------------------------------------------------------ Alaska--All areas............................................. 1.25 Hawaii: County of Honolulu.......................................... 1.225 County of Hawaii............................................ 1.15 County of Kauai............................................. 1.225 County of Maui.............................................. 1.225 County of Kalawao........................................... 1.225 ------------------------------------------------------------------------ (The above factors are based on data obtained from the U.S. Office of Personnel Management.) C. DRG Relative Weights As discussed in section II. of the preamble, we have developed a classification system for all hospital discharges, assigning them into DRGs, and have developed relative weights for each DRG that reflect the resource utilization of cases in each DRG relative to Medicare cases in other DRGs. Table 5 of section V of this addendum contains the relative weights that we propose to use for discharges occurring in FY 1998. These factors have been recalibrated as explained in section II. of the preamble. D. Calculation of Prospective Payment Rates for FY 1998 General Formula for Calculation of Prospective Payment Rates for FY 1998 Prospective payment rate for all hospitals located outside Puerto Rico except sole community hospitals = Federal rate. Prospective payment rate for sole community hospitals = Whichever of the following rates yields the greatest aggregate payment: 100 percent of the Federal rate, 100 percent of the updated FY 1982 hospital-specific rate, or 100 percent of the updated FY 1987 hospital-specific rate. Prospective payment rate for Puerto Rico = 75 percent of the Puerto Rico rate + 25 percent of a discharge-weighted average of the national large urban standardized amount and the national other standardized amount. 1. Federal Rate For discharges occurring on or after October 1, 1997 and before October 1, 1998, except for sole community hospitals and hospitals in Puerto Rico, the hospital's payment is based exclusively on the Federal national rate. Section 1866(d)(1)(A)(iii) of the Act provides that the Federal rate is comprised of 100 percent of the Federal national rate. The payment amount is determined as follows: Step 1--Select the appropriate national standardized amount considering the type of hospital and designation of the hospital as large urban or other (see Tables 1A, section V of this addendum). Step 2--Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located (see Tables 4A, 4B, and 4C of section V of this addendum). Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the appropriate cost-of-living adjustment factor. Step 4--Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted if appropriate under Step 3). Step 5--Multiply the final amount from Step 4 by the relative weight corresponding to the appropriate DRG (see Table 5 of section V of this addendum). 2. Hospital-Specific Rate (Applicable Only to Sole Community Hospitals) Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide that sole community hospitals are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate, the updated hospital-specific rate based on FY 1982 cost per discharge, or the updated hospital-specific rate based on FY 1987 cost per discharge. Hospital-specific rates have been determined for each of these hospitals based on both the FY 1982 cost per discharge and the FY 1987 cost per discharge. For a more detailed discussion of the calculation of the FY 1982 hospital-specific rate and the FY 1987 hospital-specific rate, we refer the reader to the September 1, 1983 interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); and the September 4, 1990 final rule (55 FR 35994). a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for FY 1998. We are [[Page 29948]] proposing to increase the hospital-specific rates by 2.8 percent (the hospital market basket percentage increase) for sole community hospitals located in all areas in FY 1998. Section 1886(b)(3)(C)(ii) of the Act provides that the update factor applicable to the hospital-specific rates for sole community hospitals equals the update factor provided under section 1886(b)(3)(B)(ii) of the Act, which, for FY 1998, is the market basket rate of increase. b. Calculation of Hospital-Specific Rate. For sole community hospitals, the applicable FY 1998 hospital-specific rate would be calculated by multiplying a hospital's hospital-specific rate for the preceding fiscal year by the applicable update factor (2.8 percent), which is the same as the update for all prospective payment hospitals. In addition, the hospital-specific rate would be adjusted by the budget neutrality adjustment factor (that is, 0.998400) as discussed in section II.A.4.a of this Addendum. This resulting rate would be used in determining under which rate a sole community hospital is paid for its discharges beginning on or after October 1, 1997, based on the formula set forth above. 3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning on or After October 1, 1997 and Before October 1, 1998 a. Puerto Rico Rate. The Puerto Rico prospective payment rate is determined as follows: Step 1--Select the appropriate adjusted average standardized amount considering the large urban or other designation of the hospital (see Table 1C of section V of the addendum). Step 2--Multiply the labor-related portion of the standardized amount by the appropriate Puerto Rico-specific wage index (see Table 4F of section V of the addendum). Step 3--Add the amount from Step 2 and the nonlabor-related portion of the standardized amount. Step 4--Multiply the result in Step 3 by 75 percent. Step 5--Multiply the amount from Step 4 by the appropriate DRG relative weight (see Table 5 of section V of the addendum). b. National Rate. The national prospective payment rate is determined as follows: Step 1--Multiply the labor-related portion of the national average standardized amount (see Table 1C of section V of the addendum) by the appropriate national wage index (see Tables 4A and 4B of section V of the addendum). Step 2--Add the amount from Step 1 and the nonlabor-related portion of the national average standardized amount. Step 3--Multiply the result in Step 2 by 25 percent. Step 4--Multiply the amount from Step 3 by the appropriate DRG relative weight (see Table 5 of section V of the addendum). The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico. III. Proposed Changes to Payment Rates for Inpatient Capital-Related Costs for FY 1998 The prospective payment system for hospital inpatient capital- related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period and during a 10-year transition period extending through FY 2001, hospital inpatient capital-related costs are paid on the basis of an increasing proportion of the capital prospective payment system Federal rate and a decreasing proportion of a hospital's historical costs for capital. The basic methodology for determining Federal capital prospective rates is set forth at Secs. 412.308 through 412.352. Below we discuss the factors that we used to determine the proposed Federal rate and the hospital-specific rates for FY 1998. The rates will be effective for discharges occurring on or after October 1, 1997. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the prospective payment system by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992 we update the standard Federal rate, as provided in Sec. 412.308(c)(1), to account for capital input price increases and other factors. Also, Sec. 412.308(c)(2) provides that the Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the Federal rate to total capital payments under the Federal rate. In addition, Sec. 412.308(c)(3) requires that the Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for exceptions under Sec. 412.348. Furthermore, Sec. 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral. For FYs 1992 through 1995, Sec. 412.352 required that the Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. For each hospital, the hospital-specific rate was calculated by dividing the hospital's Medicare inpatient capital-related costs for a specified base year by its Medicare discharges (adjusted for transfers), and dividing the result by the hospital's case mix index (also adjusted for transfers). The resulting case-mix adjusted average cost per discharge was then updated to FY 1992 based on the national average increase in Medicare's inpatient capital cost per discharge and adjusted by the exceptions payment adjustment factor and the budget neutrality adjustment factor to yield the FY 1992 hospital-specific rate. Since FY 1992, the hospital-specific rate has been updated annually for inflation and for changes in the exceptions payment adjustment factor. For FYs 1992 through 1995, the hospital-specific rate was also adjusted by a budget neutrality adjustment factor. To determine the appropriate budget neutrality adjustment factor and the exceptions payment adjustment factor, we developed a dynamic model of Medicare inpatient capital-related costs, that is, a model that projects changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the model is still used to estimate the exceptions payment adjustment and other factors. The model and its application are described in greater detail in Appendix B. In accordance with section 1886(d)(9)(A) of the Act, under the prospective payment system for inpatient operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. These hospitals are paid a blended rate that is comprised of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. Section 412.374 provides for the use of this blended payment system for payments to Puerto Rico hospitals under the prospective payment system for inpatient capital-related costs. Accordingly, for capital-related costs we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital. Hospitals in Puerto Rico are paid based on 75 percent of the Puerto Rico rate and 25 percent of the Federal rate. A. Determination of Federal Inpatient Capital-Related Prospective Payment Rate Update For FY 1997, the Federal rate is $438.92. With the changes we are proposing to the factors used to establish the Federal rate, the proposed FY 1998 Federal rate is $438.43. In the discussion that follows, we explain the factors that were used to determine the proposed FY 1998 Federal rate. In particular, we explain why the FY 1998 Federal rate has decreased 0.11 percent compared to the FY 1997 Federal rate. Nevertheless, as explained in section VII of Appendix A, capital payments per case are estimated to increase 4.68 percent. Taking into account the effects of increases in projected discharges, we also estimate that aggregate capital payments will increase 7.19 percent. The major factor contributing to the decrease in the proposed FY 1998 rate in comparison to the FY 1997 rate is the change in the exceptions reduction factor. We have expected the number and amount of exceptions payments generally to increase throughout the transition period. Total payments to hospitals under the prospective payment system are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1 percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital prospective payment transition system are estimated to increase in FY 1998 compared to FY 1997. Specifically, we estimate that aggregate payments in FY 1998 will be 7.19 percent higher than they were in FY 1997. Changes in aggregate payments [[Page 29949]] include changes in capital payments per discharge and changes in the number of discharges. Under the prospective payment system for capital-related costs, payments per discharge (or case) are estimated to increase 4.68 percent in FY 1998 compared to FY 1997. ProPAC recommends that the rate be adjusted to a more appropriate level (Recommendation 3). ProPAC believes that the rate is 15 to 17 percent too high and attributes this to overstatement of the 1992 base payment rates and the method used to update the rates prior to implementation of the update framework. ProPAC notes that there are several approaches for adjusting the rate. For example, they note that the base capital rates could be replaced by the actual rates used in FY 1995, which reflected the budget neutrality adjustment, updated to the current year using the update factor. We agree with ProPAC that the capital rates are too high. The President's FY 1998 budget includes a provision to reduce the base Federal and hospital-specific rates by approximately the magnitude suggested by ProPAC. This proposal incorporates ProPAC's suggestion that the FY 1995 budget neutrality adjustment could be built permanently into the rates. As we stated in the final rule for FY 1997 (61 FR 46216), we continue to believe that it is most appropriate to make such adjustments to the capital rates in the context of a comprehensive package of Medicare program changes. We are, therefore, not proposing to implement this revision to the base capital rates by regulation at this time. 1. Standard Federal Rate Update a. Description of the Update Framework. Section 412.308(c)(1) has provided that the standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index and other factors. The update framework consists of a capital input price index (CIPI) and several policy adjustment factors. Specifically, we have adjusted the projected CIPI rate of increase as appropriate each year for case-mix index related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 1998 under that framework is 1.1 percent. This proposal is based on a projected 1.3 percent increase in the CIPI, and on policy adjustment factors of -0.2. We explain the basis for the FY 1998 CIPI projection in section D of this addendum. Here we describe the policy adjustments that have been applied. The case-mix index is the measure of the average DRG weight for cases paid under the prospective payment system. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments. The case-mix index can change for any of several reasons: The average resource use of Medicare patients changes (``real'' case-mix change); Changes in hospital coding of patient records result in higher weight DRG assignments (``coding effects''); and The annual DRG reclassification and recalibration changes may not be budget neutral (``reclassification effect''). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher- weighted DRGs but do not reflect higher resource requirements. In the update framework for the prospective payment system for operating costs, we adjust the update upwards to allow for real case-mix change, but remove the effects of coding changes on the case-mix index. We also remove the effect on total payments of prior changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than patient severity. (For example, we adjusted for the effects of the FY 1992 DRG reclassification and recalibration as part of our FY 1994 update recommendation.) The operating adjustment consists of a reduction for total observed case-mix change, an increase for the portion of case-mix change that we determine is due to real case-mix change rather than coding modifications, and an adjustment for the effect of prior DRG reclassification and recalibration changes. We have adopted this case-mix index adjustment in the capital update framework as well. For FY 1998, we are projecting a 1.0 percent increase in the case-mix index. We estimate that real case-mix increase will equal 0.8 percent in FY 1998. Therefore, the proposed net adjustment for case-mix change in FY 1998 is -0.2 percentage points. We estimate that DRG reclassification and recalibration resulted in a 0.0 percent change in the case mix when compared with the case- mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. The current operating update framework contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year there may be unanticipated price fluctuations that may result in differences between the actual increase in prices faced by hospitals and the forecast used in calculating the update factors. In setting a prospective payment rate under the proposed framework, we make an adjustment for forecast error only if our estimate of the capital input price index rate of increase for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of the forecast error. Thus, for example, we would adjust for a forecast error made in FY 1996 through an adjustment to the FY 1998 update. Because we only introduced this analytical framework in FY 1996, FY 1998 is the first year in which a forecast error adjustment could be required. We estimate that the FY 1996 CIPI was .20 percentage points higher than our current data show, which means that we estimate a forecast error of .20 percentage points for FY 1996. Therefore no adjustment for forecast error will be made in FY 1998. Under the capital prospective payment system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data as in the framework for the operating prospective payment system. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, changes in within-DRG severity, and expected modification of practice patterns to remove cost-ineffective services. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI hospital component), and changes in real case mix. The use of total charges in the calculation of the proposed intensity factor makes it a total intensity factor, that is, charges for capital services are already built into the calculation of the factor. We have, therefore, incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the revised operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one- half of the estimated annual increase in intensity to allow for within-DRG severity increases and the adoption of quality-enhancing technology. For FY 1998, we have developed a Medicare-specific intensity measure based on a 5-year average using FY 1991-1995. In determining case-mix constant intensity, we found that observed case-mix increase was 2.8 percent in FY 1991, 1.8 percent in FY 1992, 0.9 percent in FY 1993, 0.8 percent in FY 1994, 1.7 percent in FY 1995, and 1.6 percent in FY 1996. For FY 1992, FY 1995, and FY 1996, we estimate that real case-mix increase was 1.0 to 1.4 percent each year. The estimate for those years is supported by past studies of case-mix change by the RAND Corporation. The most recent study was ``Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988'' by G. M. Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC(1991). The study suggested that real case-mix change was not dependent on total change, but was rather a fairly steady 1.0 to 1.5 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. Following that study, we consider up to 1.4 percent of observed case-mix change as real for FY 1991 through FY 1995. Based on this analysis, we believe that all of the observed case-mix increase for FY 1993 and FY 1994 is real. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI hospital component), and changes in real [[Page 29950]] case-mix. Given estimates of real case-mix increase of 1.0 percent for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.0 percent for FY 1995, and 1.0 percent for FY 1996, we estimate that case-mix constant intensity declined by an average 1.4 percent during FYs 1992 through 1996, for a cumulative decrease of 7.0 percent. If we assume that real case-mix increase was 1.4 percent for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.4 percent for FY 1995, and 1.4 percent for FY 1996, we estimate that case-mix constant intensity declined by an average 1.6 percent during FYs 1992 through 1996, for a cumulative decrease of 7.5 percent. Since we estimate that intensity has declined during that period, we are recommending a 0.0 percent intensity adjustment for FY 1998. b. Comparison of HCFA and ProPAC Update Recommendations. ProPAC recommends (Recommendation 4) a zero update to the standard Federal rate and we have recommended a 1.1 percent update. There are some significant differences between the HCFA and ProPAC update frameworks, which account for the difference in the respective update recommendations. A major difference is the input price index which each framework uses as a beginning point to estimate the change in input prices since the previous year. The HCFA input price index (the CIPI) includes price measures for interest expense, which are an indicator of the interest rates facing hospitals during their capital purchasing decisions. The ProPAC capital market basket does not include interest expense; instead the ProPAC update framework includes an adjustment when necessary to account for the prolonged changes in interest rates. HCFA's CIPI is vintage-weighted, meaning that it takes into account price changes from past purchases of capital when determining the current period update. ProPAC's capital market basket is not vintage-weighted, accounting only for the current year price changes. This year, due to the difference between HCFA's and ProPAC's input price index, the percentage change in HCFA's CIPI is 1.3 percent, and the percentage change in ProPAC's market basket is 2.4 percent. ProPAC and HCFA also differ in the adjustments they make to their price indices. (See Table 1 for a comparison of HCFA and ProPAC's update recommendations.) ProPAC makes an adjustment for productivity, while HCFA has not adopted an adjustment for capital productivity or efficiency. ProPAC employs the same productivity adjustment in its operating and capital framework. We have identified a total intensity factor but have not identified an adequate total productivity measure. We discuss the differences related to the intensity adjustment in section III of Appendix E of this proposed rule in our discussion of the operating update framework. For FY 1998 ProPAC recommends a -3.0 to a -1.0 productivity adjustment. We recommend a 0.0 intensity adjustment. We recommend a -0.2 total case mix adjustment since we are projecting a 1.0 percent increase in the case mix index and we estimate that real case-mix increase will equal 0.8 percent in FY 1998. ProPAC recommends no case mix adjustment. We also discuss the differences in these recommendations in section III of Appendix E. The net result of these adjustments is that ProPAC's capital update framework suggests a -0.2 to a 1.8 percent update. ProPAC has recommended a zero update to the rate for FY 1998 because they believe that a zero update applied to revised base rates would permit hospitals to maintain quality of care while meeting Medicare's responsibility to act as a prudent purchaser. We describe the basis for our proposed 1.1 percent total update in the preceding section. The two update recommendations are quite close, with ProPAC recommending no update and HCFA recommending a modest one. As stated previously, the President's FY 1998 budget contains a provision to reduce the rate by 15.7 percent in order to extend the expired budget neutrality provision. We believe that legislation is the appropriate mechanism for dealing with cutting the rate. Table 1.--HCFA's FY 1998 Update Factor and ProPAC's Recommendation ------------------------------------------------------------------------ HCFA's update ProPAC's factor recommendation ------------------------------------------------------------------------ Capital Input Price Index............... 1.3 2.4 Policy Adjustment Factors: Productivity........................ ........... -3.0 to -1.0 Intensity........................... 0.0 ................. Science and Technology.......... ........... 0.4 Intensity....................... ........... (\1\) Real within DRG Change.......... ........... (\2\) ------------------------------- Subtotal.................... 0.0 -2.6 to -0.6 Case-Mix Adjustment Factors: Projected Case-Mix Change........... -1.0 ................. Real across DRG Change.............. 0.8 ................. Real within DRG Change.............. (\3\) 0.0 ------------------------------- Subtotal.................... -0.2 0.0 Effect of FY 1996 Reclassification and Recalibration.......................... 0.0 ................. Forecast Error Correction............... 0.0 0.0 Total Update........................ 1.1 -0.2 to 1.8 ------------------------------------------------------------------------ \1\ Included in ProPAC's productivity measure. \2\ Included in ProPAC's case-mix adjustment. \3\ Included in HCFA's intensity factor. 2. Outlier Payment Adjustment Factor Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Outlier payments are made only on the portion of the Federal rate that is used to calculate the hospital's inpatient capital-related payments (for example, 70 percent for cost reporting periods beginning in FY 1998 for hospitals paid under the fully prospective methodology). Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of outlier payments under the Federal rate to total inpatient capital-related payments under the Federal rate. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments. The inpatient capital-related outlier reduction factor reflects the inpatient capital-related outlier payments that would be made if all hospitals were paid according to 100 percent of the Federal rate. For purposes of calculating the outlier thresholds and the outlier reduction factor, we model all hospitals as if they were paid 100 percent of the Federal rate because, as explained above, outlier payments are made only on the portion of the Federal rate that is included in the hospital's inpatient capital-related payments. In the August 30, 1996 final rule, we estimated that outlier payments for capital in FY 1997 would equal 5.19 percent of inpatient capital-related payments based on [[Page 29951]] the Federal rate. Accordingly, we applied an outlier adjustment factor of 0.9481 to the Federal rate. Based on the thresholds as set forth in section II.A.4.d of this Addendum, we estimate that outlier payments for capital will equal 5.51 percent of inpatient capital- related payments based on the Federal rate in FY 1998. We are, therefore, proposing an outlier adjustment factor of 0.9449 to the Federal rate. Thus, estimated capital outlier payments for FY 1998 represent a higher percentage of total capital standard payments than in FY 1997. The outlier reduction factors are not built permanently into the rates; that is, they are not applied cumulatively in determining the Federal rate. Therefore, the proposed net change in the outlier adjustment to the Federal rate for FY 1998 is 0.9966 (0.9449/ 0.9481). Thus, the outlier adjustment decreases the FY 1998 Federal rate by 0.34 percent (0.9966--1) compared with the FY 1997 outlier adjustment. 3. Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the Geographic Adjustment Factor Section 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that aggregate payments for the fiscal year based on the Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the basis of the Federal rate without such changes. We use the actuarial model described in Appendix B to estimate the aggregate payments that would have been made on the basis of the Federal rate without changes in the DRG classifications and weights and in the GAF. We also use the model to estimate aggregate payments that would be made on the basis of the Federal rate as a result of those changes. We then use these figures to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. For FY 1997, we calculated a GAF/DRG budget neutrality factor of 0.9987. For FY 1998, we are proposing a GAF/DRG budget neutrality factor of 1.0001. The GAF/DRG budget neutrality factors are built permanently into the rates; that is, they are applied cumulatively in determining the Federal rate. This follows from the requirement that estimated aggregate payments each year be no more than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The proposed incremental change in the adjustment from FY 1997 to FY 1998 is 1.0001. The proposed cumulative change in the rate due to this adjustment is 1.0013 (the product of the incremental factors for FY 1993, FY 1994, FY 1995, FY 1996, FY 1997 and the proposed incremental factor for FY 1998: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9987 x 1.0001 = 1.0014). This factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the GAF of FY 1998 geographic reclassification decisions made by the MGCRB compared to FY 1997 decisions. However, it does not account for changes in payments due to changes in the disproportionate share and indirect medical education adjustment factors or in the large urban add-on. 4. Exceptions Payment Adjustment Factor Section 412.308(c)(3) requires that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of additional payments for exceptions under Sec. 412.348 relative to total payments under the hospital-specific rate and Federal rate. We use the model originally developed for determining the budget neutrality adjustment factor to determine the exceptions payment adjustment factor. We describe that model in Appendix B to this proposed rule. For FY 1997, we estimated that exceptions payments would equal 6.42 percent of aggregate payments based on the Federal rate and the hospital-specific rate. Therefore, we applied an exceptions reduction factor of 0.9358 (1--0.0642) in determining the Federal rate. For this proposed rule, we estimate that exceptions payments for FY 1998 will equal 7.24 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We are, therefore, proposing an exceptions payment reduction factor of 0.9276 to the Federal rate for FY 1998. The proposed exceptions reduction factor for FY 1998 is thus 0.88 percent lower than the factor for FY 1997. We have expected the number and amount of exceptions payments generally to increase throughout the transition period. The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the Federal rate. Therefore, the proposed net adjustment to the FY 1998 Federal rate is 0.9276/0.9358, or 0.9912. 5. Standard Capital Federal Rate for FY 1998 For FY 1997, the capital Federal rate was $438.92. With the changes we are proposing to the factors used to establish the Federal rate, the FY 1998 Federal rate would be $438.43. The proposed Federal rate for FY 1998 was calculated as follows: The proposed FY 1998 update factor is 1.0110, that is, the proposed update is 1.10 percent. The proposed FY 1998 budget neutrality adjustment factor that is applied to the standard Federal payment rate for changes in the DRG relative weights and in the GAF is 1.0001. The proposed FY 1998 outlier adjustment factor is 0.9449. The proposed FY 1998 exceptions payments adjustment factor is 0.9276. Since the Federal rate has already been adjusted for differences in case mix, wages, cost of living, indirect medical education costs, and payments to hospitals serving a disproportionate share of low-income patients, we propose to make no additional adjustments in the standard Federal rate for these factors other than the budget neutrality factor for changes in the DRG relative weights and the GAF. We are providing a chart that shows how each of the factors and adjustments for FY 1998 affected the computation of the proposed FY 1998 Federal rate in comparison to the FY 1997 Federal rate. The proposed FY 1998 update factor has the effect of increasing the Federal rate by 1.10 percent compared to the rate in FY 1997, while the proposed geographic and DRG budget neutrality factor has the effect of increasing the Federal rate by 0.01 percent. The proposed FY 1998 outlier adjustment factor has the effect of decreasing the Federal rate by 0.34 percent compared to FY 1997. The proposed FY 1998 exceptions reduction factor has the effect of decreasing the Federal rate by 0.88 percent compared to the exceptions reduction for FY 1997. The combined effect of all the proposed changes is to decrease the proposed Federal rate by 0.11 percent compared to the Federal rate for FY 1997. Comparison of Factors and Adjustments: FY 1997 Federal Rate and Proposed FY 1998 Federal Rate ---------------------------------------------------------------------------------------------------------------- FY 97 Proposed FY 98 Change Percent change ---------------------------------------------------------------------------------------------------------------- Update factor \1\............................... 1.0070 1.0110 1.0110 1.10 GAF/DRG Adjustment Factor \1\................... 0.9987 1.0001 1.0001 0.01 Outlier Adjustment Factor \2\................... 0.9481 0.9449 0.9966 -0.34 Exceptions Adjustment Factor \2\................ 0.9358 0.9276 0.9912 -0.88 Federal Rate.................................... $438.92 $438.43 0.9988 -0.11 ---------------------------------------------------------------------------------------------------------------- \1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for example, the incremental change from FY 1997 to FY 1998 resulting from the application of the 1.0001 GAF/DRG budget neutrality factor for FY 1998 is 1.0001. \2\ The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates; that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net change resulting from the application of the FY 1998 outlier reduction factor is 0.9449/0.9481, or 0.9966. [[Page 29952]] 6. Special Rate for Puerto Rico Hospitals As explained at the beginning of this section, hospitals in Puerto Rico are paid based on 75 percent of the Puerto Rico rate and 25 percent of the Federal rate. The Puerto Rico rate is derived from the costs of Puerto Rico hospitals only, while the Federal rate is derived from the costs of all acute care hospitals participating in the prospective payment system (including Puerto Rico). To adjust hospitals' capital payments for geographic variations in capital costs, we apply a geographic adjustment factor (GAF) to both portions of the blended rate. The GAF is calculated using the operating PPS wage index and varies depending on the MSA or rural area in which the hospital is located. Since the GAF is based on the wage index, we plan to revise the method of accounting for geographical variation in Puerto Rico, to parallel the change that is being proposed on the operating rate, where a Puerto Rico- specific wage index is being calculated (section III.B.). Specifically, we propose to use the new Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital blended rate and retain the use of the national wage index to determine the GAF for the national part of the blended rate. Hospitals in Puerto Rico would still be paid based on 75 percent of the Puerto Rico rate and 25 percent of the Federal rate. This means that, in computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the rate will be multiplied by the Puerto Rico-specific GAF for the MSA in which the hospital is located, and the national portion of the rate will be multiplied by the national GAF for the MSA in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). We have adjusted the Puerto Rico rate to account for the application of Puerto Rico-specific GAFs. We did this in order to be consistent with the method by which we originally determined the national and Puerto Rico rates. This resulting standard Puerto Rico rate does not translate into a reduction in payments to Puerto Rico hospitals. The Puerto Rico-specific GAFs are higher than the national GAFs because they use the Puerto Rico mean only rather than the national mean. As a result, application of Puerto Rico-specific GAFs means Puerto Rico hospitals receive more money. For FY 1997, before application of the GAF, the special rate for Puerto Rico hospitals was $337.63. With the changes we are proposing to the factors used to determine the rate, the proposed FY 1998 special rate for Puerto Rico is $204.46. After application of the GAF, the proposed FY 1998 capital rates for Puerto Rico hospitals are higher than the FY 1997 rates. The example below is based on the proposed FY 1998 San Juan- Bayamon GAF and Puerto Rico capital rate in comparison to the final FY 1997 San Juan-Bayamon GAF and Puerto Rico capital rate. (For purposes of simplicity we have not included all elements involved in computing a payment to a particular hospital. For a more complete description of calculating the payment for a specific discharge see Section C. below. In addition the Puerto Rico rate and GAF would be used to compute 75 percent of a Puerto Rico hospital's payment. The remaining 25 percent would be based on the national rate and GAF.) San Juan-Bayamon MSA ------------------------------------------------------------------------ FY 1997 Proposed final FY 1998 ------------------------------------------------------------------------ Rate.............................................. $337.63 $204.46 GAF............................................... .5793 1.0186 Rate X GAF =...................................... $195.59 $208.26 ------------------------------------------------------------------------ The example illustrates that based on the changes we are proposing to the FY 1998 Puerto Rico GAF and capital rate, all other factors being equal, a hospital in the San Juan-Bayamon MSA would receive a larger payment with the proposed FY 1998 capital rate and GAF compared with the final FY 1997 capital rate and GAF. B. Determination of Hospital-Specific Rate Update Section 412.328(e) of the regulations provides that the hospital-specific rate for FY 1998 be determined by adjusting the FY 1997 hospital-specific rate by the following factors: 1. Hospital-Specific Rate Update Factor The hospital-specific rate is updated in accordance with the update factor for the standard Federal rate determined under Sec. 412.308(c)(1). For FY 1998, we are proposing that the hospital- specific rate be updated by a factor of 1.0110. 2. Exceptions Payment Adjustment Factor For FYs 1992 through FY 2001, the updated hospital-specific rate is multiplied by an adjustment factor to account for estimated exceptions payments for capital-related costs under Sec. 412.348, determined as a proportion of the total amount of payments under the hospital-specific rate and the Federal rate. For FY 1998, we estimate that exceptions payments will be 7.24 percent of aggregate payments based on the Federal rate and the hospital-specific rate. We therefore propose that the updated hospital-specific rate be reduced by a factor of 0.9276. The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the hospital-specific rate. Therefore, the proposed net adjustment to the FY 1998 hospital- specific rate is 0.9276/0.9358, or 0.9912. 3. Net Change to Hospital-Specific Rate We are providing a chart to show the net change to the hospital- specific rate. The chart shows the factors for FY 1997 and FY 1998 and the net adjustment for each factor. It also shows that the proposed cumulative net adjustment from FY 1997 to FY 1998 is 1.0021, which represents a proposed increase of 0.21 percent to the hospital-specific rate. For each hospital, the proposed FY 1998 hospital-specific rate is determined by multiplying the FY 1997 hospital-specific rate by the cumulative net adjustment of 1.0021. Proposed FY 1998 Update and Adjustments to Hospital-Specific Rates ---------------------------------------------------------------------------------------------------------------- FY 97 Proposed FY 98 Net adjustment Percent change ---------------------------------------------------------------------------------------------------------------- Update Factor................................... 1.0070 1.0110 1.0110 1.10 Exceptions Payment Adjustment Factor............ 0.9358 0.9276 0.9912 -0.88 Cumulative Adjustments.......................... 0.9424 0.9444 1.0021 0.21 ---------------------------------------------------------------------------------------------------------------- Note: The update factor for the hospital-specific rate is applied cumulatively in determining the rates. Thus, the incremental increase in the update factor from FY 1997 to FY 1998 is 1.0110. In contrast, the exceptions payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the exceptions reduction factor from FY 1997 to FY 1998 is 0.9276/ 0.9358, or 0.9912. C. Calculation of Inpatient Capital-Related Prospective Payments for FY 1998 During the capital prospective payment system transition period, a hospital is paid for the inpatient capital-related costs under one of two alternative payment methodologies; the fully prospective payment methodology or the hold-harmless methodology. The payment methodology applicable to a particular hospital is determined when a hospital comes under the prospective payment system for capital- related costs by comparing its hospital-specific rate to the Federal rate applicable to the hospital's first cost reporting period under the prospective payment system. The applicable Federal rate was determined by making adjustments as follows: For outliers by dividing the standard Federal rate by the outlier reduction factor for that fiscal year; and, For the payment adjustment factors applicable to the hospital (that is, the hospital's GAF, the disproportionate share adjustment factor, and the indirect medical [[Page 29953]] education adjustment factor, when appropriate). If the hospital-specific rate is above the applicable Federal rate, the hospital is paid under the hold-harmless methodology. If the hospital-specific rate is below the applicable Federal rate, the hospital is paid under the fully prospective methodology. For purposes of calculating payments for each discharge under both the hold-harmless payment methodology and the fully prospective payment methodology, the standard Federal rate is adjusted as follows: (Standard Federal Rate) x (DRG weight) x (GAF) x (Large Urban Add-on, if applicable) x (COLA adjustment for hospitals located in Alaska and Hawaii) x (1+Disproportionate Share Adjustment Factor+IME Adjustment Factor, if applicable). The result is termed the adjusted Federal rate. Payments under the hold-harmless methodology are determined under one of two formulas. A hold-harmless hospital is paid the higher of: 100 percent of the adjusted Federal rate for each discharge; or An old capital payment equal to 85 percent (100 percent for sole community hospitals) of the hospital's allowable Medicare inpatient old capital costs per discharge for the cost reporting period plus a new capital payment based on a percentage of the adjusted Federal rate for each discharge. The percentage of the adjusted Federal rate equals the ratio of the hospital's allowable Medicare new capital costs to its total Medicare inpatient capital- related costs in the cost reporting period. Once a hospital receives payment based on 100 percent of the adjusted Federal rate in a cost reporting period beginning on or after October 1, 1994 (or the first cost reporting period after obligated capital that is recognized as old capital under Sec. 412.302(c) is put in use for patient care, if later), the hospital continues to receive capital prospective payment system payments on that basis for the remainder of the transition period. Payment for each discharge under the fully prospective methodology is the sum of: The hospital-specific rate multiplied by the DRG relative weight for the discharge and by the applicable hospital- specific transition blend percentage for the cost reporting period; and The adjusted Federal rate multiplied by the Federal transition blend percentage. The blend percentages for cost reporting periods beginning in FY 1998 are 70 percent of the adjusted Federal rate and 30 percent of the hospital-specific rate. Hospitals may also receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. Outlier payments are made only on that portion of the Federal rate that is used to calculate the hospital's inpatient capital-related payments. For fully prospective hospitals, that portion is 70 percent of the Federal rate for discharges occurring in cost reporting periods beginning during FY 1998. Thus, a fully prospective hospital will receive 70 percent of the capital- related outlier payment calculated for the case for discharges occurring in cost reporting periods beginning in FY 1998. For hold- harmless hospitals paid 85 percent of their reasonable costs for old inpatient capital, the portion of the Federal rate that is included in the hospital's outlier payments is based on the hospital's ratio of Medicare inpatient costs for new capital to total Medicare inpatient capital costs. For hold-harmless hospitals that are paid 100 percent of the Federal rate, 100 percent of the Federal rate is included in the hospital's outlier payments. The proposed outlier thresholds for FY 1998 are published in section II.A.4.c of this Addendum. For FY 1998, a case qualifies as a cost outlier if the cost for the case (after standardization for the indirect teaching adjustment and disproportionate share adjustment) is greater than the prospective payment rate for the DRG plus $7,600. During the capital prospective payment system transition period, a hospital may also receive an additional payment under an exceptions process if its total inpatient capital-related payments are less than a minimum percentage of its allowable Medicare inpatient capital-related costs. The minimum payment level is established by class of hospital under Sec. 412.348. The proposed minimum payment levels for portions of cost reporting periods occurring in FY 1998 are: Sole community hospitals (located in either an urban or rural area), 90 percent; Urban hospitals with at least 100 beds and a disproportionate share patient percentage of at least 20.2 percent; and Urban hospitals with at least 100 beds that qualify for disproportionate share payments under Sec. 412.106(c)(2), 80 percent; and All other hospitals, 70 percent. Under Sec. 412.348(d), the amount of the exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital prospective payment system to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to that system. Any amount by which the hospital's cumulative payments exceed its cumulative minimum payment is deducted from the additional payment that would otherwise be payable for a cost reporting period. New hospitals are exempted from the capital prospective payment system for their first 2 years of operation and are paid 85 percent of their reasonable costs during that period. A new hospital's old capital costs are its allowable costs for capital assets that were put in use for patient care on or before the later of December 31, 1990 or the last day of the hospital's base year cost reporting period, and are subject to the rules pertaining to old capital and obligated capital as of the applicable date. Effective with the third year of operation, we will pay the hospital under either the fully prospective methodology, using the appropriate transition blend in that Federal fiscal year, or the hold-harmless methodology. If the hold-harmless methodology is applicable, the hold-harmless payment for assets in use during the base period would extend for 8 years, even if the hold-harmless payments extend beyond the normal transition period. D. Capital Input Price Index 1. Background In the following section we explain why we are not proposing to revise the Capital Input Price Index (CIPI) as we are the operating input price index to incorporate more recent data from Bureau of the Census. (This change to the operating price index is described in section IV. of the preamble.) Like the prospective payment hospital operating input price index, the Capital Input Price Index (CIPI) is a fixed-weight price index. A fixed-weight price index measures how much it would cost at a later date to purchase the same mix of goods and services purchased in the base period. For the prospective payment hospital operating and capital input price indices, the base period is selected and cost category weights are determined using available data on hospitals. Next, appropriate price proxy indices are chosen for each cost category. Then a price proxy index level for each expenditure category is multiplied by the comparable cost category weight. The sum of these products (that is, weights multiplied by price proxy index levels) for all cost categories yields the composite index level of the market basket for a given year. Repeating the step for other years produces a time series of composite market basket index levels. Dividing an index level by a later index level produces a rate of growth in the input price index. Since the percent change is computed for the fixed mix of total capital inputs with a 1992 base, the index is fixed-weight. Like the operating input price index, the CIPI measures the price changes associated with costs during a given year. In order to do so, the CIPI must differ from the operating input price index in one important aspect. The CIPI must reflect the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year. Using Medicare cost reports, AHA data, and Securities Data Corporation data, a vintage-weighted price index was developed to measure price increases associated with capital expenses. We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. Currently, both the operating input price index and the CIPI are based on FY 1992. They were rebased in FY 1997. The process for updating the CIPI was explained in the May 31, 1996 Federal Register (61 FR 27466) and the August 30, 1996 Federal Register (61 FR 46196). The following Federal Register documents also describe development and [[Page 29954]] revisions of the methodology involved with the construction of the CIPI: September 1, 1992 (57 FR 40016), May 26, 1993 (58 FR 30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), and September 1, 1995 (60 FR 45815) 2. Research on Reweighting the CIPI After analyzing various data sources and methodologies for determining capital weights for the HCFA PPS CIPI, we propose to continue using the weights published in the August 30, 1996 Federal Register. In developing the rebased CIPI for the FY 1997 proposed and final rules, we stated that we had planned to use the 1992 Department of Commerce data for developing capital cost category weights but the data was not available in time. The data has since become available, and although we are planning to use it to revise the operating market basket, we are not planning to do so for the capital input price index. The weights for the 1992 rebased CIPI were developed from the 1992 Medicare Cost Reports and the 1992 AHA Annual Survey. We analyzed the newly available 1992 Census of Service Industries Asset and Expenditures Survey from the Bureau of the Census, Department of Commerce. There are three major reasons we are proposing to continue using the current 1992 HCFA PPS CIPI without modifying the weights using the 1992 Asset and Expenditures Survey. First, HCFA's preference in determining index weights is to continue to use the Medicare Cost Reports for the Medicare subset of hospitals (PPS only). Beginning in 1992, detailed capital cost data for PPS hospitals was available from the Medicare Cost Reports. This data includes depreciation, interest, and other capital-related expenses. We used the 1992 AHA Annual Survey as the source for interest expenses because of its strength in measuring interest compared to the Medicare Cost Reports. All of the other cost category weights in the HCFA PPS CIPI were developed from the 1992 Medicare Cost Reports. Using these two data sources we were able to produce weights for PPS hospitals only, as opposed to all nonfederal hospitals as reported in the Asset and Expenditures Survey. Because this detailed capital data will be available in Medicare Cost Reports in future years, we believe the Medicare Cost Reports are the most appropriate source for determining the weights in the HCFA PPS CIPI. The second major reason we are proposing to continue using the current HCFA PPS CIPI is that the capital cost shares are similar to those provided by the 1992 Asset and Expenditures Survey. The 1992 Asset and Expenditures Survey reports capital cost shares for buildings, structures, and related facilities depreciation (fixed) and machinery, equipment, and other depreciation (movable), as well as total depreciation as a percentage of total hospital ``operating'' expenses (operating and capital expenses). Hospital expenses in the 1992 Asset and Expenditures Survey are based on information collected from a probability sample of both PPS and non- PPS hospitals. The CIPI weights from the 1992 Medicare Cost Reports and the 1992 AHA Annual Survey are based on a universal count of PPS hospitals only. Despite these methodological differences, capital cost shares as measured by these data sources are similar. Specifically, the 1992 Medicare Cost Reports show building and fixed equipment depreciation was 46.4 percent of total depreciation and movable equipment depreciation was 53.6 percent. The distribution for the 1992 Asset and Expenditures Survey was 44.4 percent for buildings, structures, and related facilities depreciation and 55.6 percent for machinery, equipment, and other depreciation. These differences are acceptable given the differences in universe and methodologies of the two data sources. A simulation of the CIPI using each set of weights showed a less than 0.1 percentage point impact on the percent change of the CIPI for each year between 1980- 2007. Another comparison between cost shares in the Medicare Cost Reports and the Asset and Expenditures Survey produced minor differences as well. The 1992 Asset and Expenditures Survey shows depreciation as a percentage of total ``operating'' expenses (operating and capital expenses) of 5.0 percent. A similar calculation of PPS hospitals from the 1992 Medicare Cost Reports shows depreciation as 5.3 percent of total ``operating'' expenses. Given the differences in universe and methodologies between the Asset and Expenditure Survey and the Medicare Cost Reports we consider this 0.3 percentage point difference to be within the range of reasonableness. The last major reason for continuing to use the 1992 Medicare Cost Reports in determining capital weights for the HCFA PPS CIPI is that the detail needed for future rebasing of the index will be available from this data source. The 1997 Asset and Expenditures Survey, which is being renamed the Business Expenditures survey, will not include data on fixed assets, interest expense, and capital leases. Also, detail on capital expenditures and depreciation, including the breakout of structures and movable equipment, will not be part of the 1997 survey. The lack of this detailed capital data would create an obstacle to rebasing in the future. This survey data is appropriate for use in the operating PPS index because it provides operating expense information not available from the Medicare cost reports and which will be available in the 1997 survey. The Bureau of Census now considers the principal source of data on fixed assets and capital expenditures for health industries to be the Annual Capital Expenditures Survey, which began in 1993. The Annual Capital Expenditures Survey will not include the detail needed for determining weights for the CIPI, such as depreciation at the hospital level. However, we will continue to consider and monitor the Annual Capital Expenditures Survey as a possible data source for future rebasing. For the three major reasons explained above we are proposing to stay with the current HCFA PPS CIPI and to not modify the index using the newly available 1992 Asset and Expenditures Survey. 3. Forecast of the CIPI for Federal Fiscal Year 1998 DRI forecasts a 1.3 percent increase in the CIPI for FY 1998. This is the outcome of a projected 2.3 percent increase in vintage- weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.0 percent increase in other capital expense prices in FY 1998, partially offset by a 1.6 percent decline in vintage-weighted interest rates in FY 1998. The weighted average of these three factors produces the 1.3 percent increase for the CIPI as a whole. IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages The inpatient operating costs of hospitals and hospital units excluded from the prospective payment system are subject to rate-of- increase limits established under the authority of section 1886(b) of the Act, which is implemented in Sec. 413.40 of the regulations. Under these limits, an annual target amount (expressed in terms of the inpatient operating cost per discharge) is set for each hospital, based on the hospital's own historical cost experience trended forward by the applicable rate-of-increase percentages (update factors). The target amount is multiplied by the number of Medicare discharges in a hospital's cost reporting period, yielding the ceiling on aggregate Medicare inpatient operating costs for the cost reporting period. Effective with cost reporting periods beginning on or after October 1, 1991, a hospital that has Medicare inpatient operating costs in excess of its ceiling is paid its ceiling plus 50 percent of its costs in excess of the ceiling. Total payment may not exceed 110 percent of the ceiling. A hospital that has inpatient operating costs less than its ceiling is paid its costs plus the lower of-- Fifty percent of the difference between the allowable inpatient operating costs and the ceiling; or Five percent of the ceiling. Each hospital's target amount is adjusted annually, at the beginning of its cost reporting period, by an applicable rate-of- increase percentage. Section 1886(b)(3)(B) of the Act provides that for cost reporting periods beginning on or after October 1, 1997 and before October 1, 1998, the applicable rate-of-increase percentage is the market basket percentage. In order to determine a hospital's target amount for its cost reporting period beginning in FY 1998, the hospital's target amount for its cost reporting period that began in FY 1997 is increased by the market basket percentage increase for FY 1998. The most recent forecast of the market basket increase for FY 1998 for hospitals and hospital units excluded from the prospective payment system is 2.8 percent. [[Page 29955]] V. Tables This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. For purposes of this proposed rule, and to avoid confusion, we have retained the designations of Tables 1 through 5 that were first used in the September 1, 1983 initial prospective payment final rule (48 FR 39844). Tables 1A, 1C, 1D, 3C, 4A, 4B, 4C, 4D, 4E, 4F, 5, 6A, 6B, 6C, 6D, 6E, 6F, 7A, 7B, 8A, and 8B are presented below. The tables presented below are as follows: Table 1A--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D--Capital Standard Federal Payment Rate Table 3C--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1996 and Hospital Average Hourly Wage for Federal Fiscal Year 1998 Wage Index Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified Table 4D--Average Hourly Wage for Urban Areas Table 4E--Average Hourly Wage for Rural Areas Table 4F--Puerto Rico Wage Index and Captial Geographic Adjustment Factor (GAF) Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean Length of Stay. Table 6A--New Diagnosis Codes Table 6B--New Procedure Codes Table 6C--Invalid Diagnosis Codes Table 6D--Revised Diagnosis Code Titles Table 6E--Additions to the CC Exclusions List Table 6F--Deletions to the CC Exclusions List Table 7A--Medicare Prospective Payment System; Selected Percentile Lengths of Stay (FY 96 MEDPAR Update 12/96 GROUPER V14.0) Table 7B--Medicare Prospective Payment System; Selected Percentile Lengths of Stay (FY 96 MEDPAR Update 12/96 GROUPER V15.0) Table 8A--Statewide Average Operating Cost-to-Charge Ratios [for Urban and Rural Hospitals] (Case Weighted) April 1997 Table 8B--Statewide Average Capital Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) April 1997 Table 1A.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor ---------------------------------------------------------------------------------------------------------------- Large urban areas Other areas ---------------------------------------------------------------------------------------------------------------- Labor-related Nonlabor-related Labor-related Nonlabor-related ---------------------------------------------------------------------------------------------------------------- $2,857.85.................. $1,161.63 $2,812.62 $1,143.24 ---------------------------------------------------------------------------------------------------------------- Table 1C.--Adjusted Operating Standardized Amounts For Puerto Rico, Labor/Nonlabor ---------------------------------------------------------------------------------------------------------------- Large urban areas Other areas --------------------------------------------------- Labor Nonlabor Labor Nonlabor ---------------------------------------------------------------------------------------------------------------- National.................................................... $2,833.30 $1,151.64 $2,833.30 $1,151.64 Puerto Rico................................................. 1,346.08 541.83 1,324.77 533.25 ---------------------------------------------------------------------------------------------------------------- Table 1D.--Capital Standard Federal Payment Rate ------------------------------------------------------------------------ Rate ------------------------------------------------------------------------ National................................................... $438.43 Puerto Rico................................................ 204.46 ------------------------------------------------------------------------ [[Page 29956]] Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1996; Hospital Average Hourly Wage for Federal Fiscal Year 1998 Wage Index Page 1 of 16 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Avg. Avg. Avg. Avg. Avg. Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 010001....................... 01.4816 15.78 010095.......... 00.9851 12.06 030004......... 01.0965 13.75 040002......... 01.1972 12.84 040107......... 01.2002 15.29 010004....................... 00.9673 11.63 010097.......... 00.9083 14.47 030006......... 01.5609 18.02 040003......... 01.0142 12.72 040109......... 01.1817 13.56 010005....................... 01.2080 15.57 010098.......... 01.2511 11.65 030007......... 01.3217 16.96 040004......... 01.6321 15.84 040114......... 01.8843 17.60 010006....................... 01.4488 15.81 010099.......... 01.1678 14.38 030008......... 02.3039 19.75 040005......... 01.0108 12.83 040116......... 01.3793 19.05 010007....................... 01.0717 13.52 010100.......... 01.2630 15.26 030009......... 01.3451 16.25 040007......... 01.8418 17.91 040118......... 01.2192 14.54 010008....................... 01.1631 12.11 010101.......... 01.0605 14.05 030010......... 01.4365 17.79 040008......... 01.0326 11.22 040119......... 01.1562 14.58 010009....................... 01.1280 15.17 010102.......... 01.0060 13.60 030011......... 01.5199 18.32 040010......... 01.3163 15.80 040124......... 01.1377 13.82 010010....................... 01.0749 14.78 010103.......... 01.8573 18.70 030012......... 01.2362 16.41 040011......... 00.9931 10.85 040126......... 00.9510 11.98 010011....................... 01.6404 19.62 010104.......... 01.7047 18.20 030013......... 01.2703 19.56 040014......... 01.1907 16.40 040132......... 00.5050 11.69 010012....................... 01.3067 16.65 010108.......... 01.2350 14.48 030014......... 01.4912 18.50 040015......... 01.2905 13.52 050002......... 01.5782 35.29 010015....................... 01.0958 13.70 010109.......... 01.1090 13.36 030016......... 01.2444 17.47 040016......... 01.6623 16.02 050006......... 01.4562 19.54 010016....................... 01.2774 16.88 010110.......... 01.0535 14.12 030017......... 01.5058 18.11 040017......... 01.3308 11.89 050007......... 01.6175 27.21 010018....................... 00.9336 16.77 010112.......... 01.1875 15.28 030018......... 01.8046 19.31 040018......... 01.2282 18.03 050008......... 01.5162 26.68 010019....................... 01.3220 14.52 010113.......... 01.6944 15.80 030019......... 01.2816 19.75 040019......... 01.1372 13.94 050009......... 01.7341 29.57 010021....................... 01.2458 15.75 010114.......... 01.3221 16.45 030022......... 01.4807 15.25 040020......... 01.6074 15.06 050013......... 01.8298 21.70 010022....................... 01.0181 17.25 010115.......... 00.8522 12.02 030023......... 01.3285 18.26 040021......... 01.2537 14.96 050014......... 01.1688 22.16 010023....................... 01.6504 15.43 010117.......... 00.8712 13.59 030024......... 01.7123 20.56 040022......... 01.6764 14.96 050015......... 01.3865 23.94 010024....................... 01.4635 15.95 010118.......... 01.3322 18.41 030025......... 01.1326 14.24 040024......... 01.0654 14.26 050016......... 01.1635 17.87 010025....................... 01.4620 13.24 010119.......... 00.9593 18.53 030027......... 01.0596 15.39 040025......... 00.9155 12.38 050017......... 02.0494 25.36 010027....................... 00.8288 14.12 010120.......... 00.9722 15.39 030030......... 01.7325 18.21 040026......... 01.6071 16.65 050018......... 01.3046 20.37 010029....................... 01.5715 15.54 010121.......... 01.3081 15.80 030033......... 01.2195 15.72 040027......... 01.2929 12.96 050021......... 01.5263 25.59 010031....................... 01.2306 15.57 010123.......... 01.3122 15.81 030034......... 01.0042 15.05 040028......... 01.0932 11.93 050022......... 01.5026 23.58 010032....................... 00.9618 12.86 010124.......... 01.3739 13.53 030035......... 01.2767 18.82 040029......... 01.2899 15.78 050024......... 01.2995 21.10 010033....................... 01.9459 17.26 010125.......... 01.0064 15.83 030036......... 01.1913 18.51 040030......... 00.9480 11.36 050025......... 01.6853 21.84 010034....................... 01.0864 12.64 010126.......... 01.1851 14.11 030037......... 02.0991 19.86 040032......... 00.9572 10.60 050026......... 01.4624 28.03 010035....................... 01.2549 15.94 010127.......... 01.3443 16.36 030038......... 01.6421 18.39 040035......... 00.9651 10.26 050028......... 01.3776 15.43 010036....................... 01.1249 16.08 010128.......... 01.0020 12.39 030040......... 01.1481 16.07 040036......... 01.5225 17.87 050029......... 01.4317 22.42 010038....................... 01.3209 17.78 010129.......... 01.0948 14.62 030041......... 00.9799 13.77 040037......... 01.1133 11.92 050030......... 01.3242 20.23 010039....................... 01.6825 17.26 010130.......... 01.0351 14.47 030043......... 01.2510 17.86 040039......... 01.2290 13.00 050032......... 01.2355 26.01 010040....................... 01.5937 18.14 010131.......... 01.3336 18.57 030044......... 01.0839 16.15 040040......... 00.9725 14.02 050033......... 01.4509 26.08 010043....................... 01.1350 10.75 010134.......... 00.8545 09.70 030046......... 00.9632 18.53 040041......... 01.3625 15.91 050036......... 01.6816 19.57 010044....................... 01.1641 14.54 010137.......... 01.2902 16.93 030047......... 00.9383 20.45 040042......... 01.2370 14.76 050038......... 01.4549 28.87 010045....................... 01.1886 13.05 010138.......... 00.9275 10.96 030049......... 00.9881 14.67 040044......... 01.0305 11.22 050039......... 01.6191 21.51 010046....................... 01.5217 16.79 010139.......... 01.6895 19.60 030054......... 00.8543 12.51 040045......... 01.0233 15.07 050040......... 01.2696 22.01 010047....................... 00.9803 10.30 010143.......... 01.2914 16.04 030055......... 01.2187 16.56 040047......... 01.1375 15.13 050042......... 01.3519 20.78 010049....................... 01.1619 14.77 010144.......... 01.3019 16.49 030059......... 01.3916 18.88 040048......... 01.1836 14.02 050043......... 01.6119 30.35 010050....................... 01.1203 13.88 010145.......... 01.3030 15.59 030060......... 01.1395 16.21 040050......... 01.1609 12.27 050045......... 01.2819 18.28 010051....................... 00.8551 09.93 010146.......... 01.1732 15.81 030061......... 01.6802 17.13 040051......... 01.1004 13.76 050046......... 01.2703 21.20 010052....................... 01.0499 09.88 010148.......... 01.0017 12.52 030062......... 01.2660 15.94 040053......... 01.1198 13.04 050047......... 01.5698 31.60 010053....................... 01.0792 13.31 010149.......... 01.3645 16.73 030064......... 01.7579 18.53 040054......... 01.0614 12.44 050051......... 01.0469 17.04 010054....................... 01.2098 17.02 010150.......... 01.1036 16.28 030065......... 01.7255 19.65 040055......... 01.4708 15.29 050054......... 01.2054 20.60 010055....................... 01.4421 16.99 010152.......... 01.4914 17.56 030067......... 01.0541 15.78 040058......... 01.0292 13.64 050055......... 01.4035 27.81 010056....................... 01.4314 18.78 010155.......... 01.0479 06.99 030068......... 01.0721 15.77 040060......... 00.9858 10.20 050056......... 01.3667 29.73 010058....................... 01.0865 12.93 020001.......... 01.5659 26.31 030069......... 01.3277 20.13 040062......... 01.6837 15.85 050057......... 01.5598 19.64 010059....................... 01.1118 14.92 020002.......... 01.2468 23.88 030071......... 00.9685 ....... 040064......... 01.0588 11.19 050058......... 01.4525 21.47 010061....................... 01.1872 15.20 020004.......... 01.1123 25.46 030072......... 00.8385 ....... 040066......... 01.2238 15.86 050060......... 01.5314 20.46 010062....................... 01.0345 14.36 020005.......... 00.8208 25.53 030073......... 01.0067 ....... 040067......... 01.0916 12.18 050061......... 01.4666 21.87 010064....................... 01.7943 18.52 020006.......... 01.2547 25.07 030074......... 00.8781 ....... 040069......... 01.1556 14.87 050063......... 01.3998 21.02 010065....................... 01.3457 15.39 020007.......... 01.0349 22.76 030075......... 00.8559 ....... 040070......... 00.9325 13.68 050065......... 01.6382 22.84 010066....................... 00.9485 10.41 020008.......... 01.1378 29.10 030076......... 01.1098 ....... 040071......... 01.6792 15.73 050066......... 01.2676 20.99 010068....................... 01.3084 16.70 020009.......... 00.9842 21.88 030077......... 00.8398 ....... 040072......... 01.0978 13.94 050067......... 01.3721 21.53 010069....................... 01.1900 13.10 020010.......... 01.0900 26.44 030078......... 01.1353 ....... 040074......... 01.3194 14.39 050068......... 01.0664 18.92 010072....................... 01.2155 13.45 020011.......... 00.9844 22.61 030079......... 00.8800 ....... 040075......... 01.1179 11.73 050069......... 01.6450 24.14 010073....................... 01.0213 10.31 020012.......... 01.2438 24.23 030080......... 01.5975 21.05 040076......... 01.0526 16.33 050070......... 01.2820 33.06 010078....................... 01.2760 16.51 020013.......... 01.0503 24.21 030083......... 01.3152 21.06 040077......... 00.9257 11.30 050071......... 01.3290 32.76 010079....................... 01.2562 15.43 020014.......... 01.1749 22.13 030084......... 01.0320 ....... 040078......... 01.5605 17.77 050072......... 01.3209 32.63 010080....................... 01.0102 11.89 020017.......... 01.6705 24.50 030085......... 01.5592 23.63 040080......... 01.1210 14.65 050073......... 01.3310 32.63 010081....................... 01.8549 14.84 020018.......... 00.7773 ....... 030086......... 01.3315 18.01 040081......... 00.9561 10.75 050074......... 01.3610 38.56 010083....................... 01.0100 15.43 020019.......... 00.7868 ....... 030087......... 01.6332 18.93 040082......... 01.1568 14.31 050075......... 01.3928 32.75 010084....................... 01.4845 17.66 020020.......... 00.7727 ....... 030088......... 01.4131 19.07 040084......... 01.1207 14.18 050076......... 01.8220 32.11 010085....................... 01.2689 17.11 020021.......... 00.9217 ....... 030089......... 01.5795 19.68 040085......... 01.1916 14.81 050077......... 01.5826 22.86 010086....................... 01.0829 13.70 020024.......... 01.0856 23.72 030092......... 01.6107 20.36 040088......... 01.4006 14.36 050078......... 01.2964 24.76 010087....................... 01.8442 18.51 020025.......... 00.9808 24.32 030093......... 01.4071 17.81 040090......... 00.9231 13.54 050079......... 01.5662 29.34 010089....................... 01.2639 15.60 020026.......... 01.3114 ....... 030094......... 01.3476 18.46 040091......... 01.2636 19.81 050080......... 01.3940 20.59 010090....................... 01.5840 17.57 020027.......... 01.0992 ....... 030095......... 01.1396 18.24 040093......... 01.0221 10.11 050081......... 01.7055 22.17 010091....................... 01.0096 14.57 030001.......... 01.3338 20.07 030098......... 00.9581 ....... 040100......... 01.3213 13.29 050082......... 01.5543 21.60 010092....................... 01.4078 16.49 030002.......... 01.8051 21.04 030099......... 00.9322 ....... 040105......... 01.0263 13.29 050084......... 01.6775 23.55 010094....................... 01.2357 15.11 030003.......... 01.9788 20.23 040001......... 01.1189 12.95 040106......... 01.2177 14.08 050088......... 01.0368 23.02 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29957]] Page 2 of 16 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Avg. Avg. Avg. Avg. Avg. Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 050089....................... 01.4270 20.50 050188.......... 01.3814 26.59 050298......... 01.2566 21.05 050421......... 01.3715 24.84 050546......... 00.7841 22.14 050090....................... 01.2899 23.06 050189.......... 01.0628 21.87 050299......... 01.3557 22.62 050423......... 01.0305 19.52 050547......... 00.8692 21.94 050091....................... 01.1899 22.02 050191.......... 01.4973 20.99 050300......... 01.3977 22.60 050424......... 01.8000 22.86 050549......... 01.7307 25.79 050092....................... 00.9919 15.98 050192.......... 01.1874 18.17 050301......... 01.3383 22.43 050425......... 01.3230 33.00 050550......... 01.5796 23.60 050093....................... 01.5661 23.33 050193.......... 01.3126 23.13 050302......... 01.3709 27.57 050426......... 01.3336 15.00 050551......... 01.3057 24.63 050095....................... 00.7794 29.00 050194.......... 01.2784 28.01 050305......... 01.5728 30.80 050427......... 00.8401 17.79 050552......... 01.2447 21.99 050096....................... 01.3114 19.75 050195.......... 01.6021 32.79 050307......... 01.3612 21.59 050430......... 00.8449 17.06 050557......... 01.5644 21.58 050097....................... 01.4624 18.53 050196.......... 01.4108 17.33 050308......... 01.5171 28.30 050431......... 01.0903 19.94 050559......... 01.4051 24.92 050099....................... 01.4748 23.23 050197.......... 01.8369 28.44 050309......... 01.3657 24.67 050432......... 01.6711 24.04 050560......... 01.4220 ...... 050100....................... 01.7332 28.66 050204.......... 01.4986 24.18 050310......... 01.2224 19.66 050433......... 01.1020 17.37 050561......... 01.1900 32.17 050101....................... 01.4316 28.42 050205.......... 01.3796 17.74 050312......... 01.9978 24.02 050434......... 01.2094 20.09 050564......... 01.1456 17.84 050102....................... 01.4300 18.79 050207.......... 01.2951 20.37 050313......... 01.2181 21.97 050435......... 01.2977 23.02 050565......... 01.1278 21.68 050103....................... 01.6336 26.99 050208.......... 00.9009 28.83 050315......... 01.2135 19.97 050436......... 00.9672 14.81 050566......... 00.9102 23.47 050104....................... 01.5240 22.61 050211.......... 01.3135 30.44 050317......... 01.3276 18.92 050438......... 01.7527 25.46 050567......... 01.6176 24.19 050107....................... 01.4804 20.75 050213.......... 01.5230 21.12 050320......... 01.2950 27.83 050440......... 01.3228 21.46 050568......... 01.3603 19.64 050108....................... 01.7167 21.54 050214.......... 01.4986 20.90 050324......... 01.9039 25.52 050441......... 01.9990 28.23 050569......... 01.3434 23.05 050109....................... 02.4142 24.01 050215.......... 01.5369 28.12 050325......... 01.2371 21.42 050443......... 00.9281 16.07 050570......... 01.7731 23.41 050110....................... 01.3001 19.33 050217.......... 01.3369 20.45 050327......... 01.5881 22.32 050444......... 01.3847 23.82 050571......... 01.4455 22.36 050111....................... 01.3067 19.39 050219.......... 01.1287 20.76 050328......... 01.5403 30.01 050446......... 00.9652 21.02 050573......... 01.6557 23.85 050112....................... 01.5378 24.56 050222.......... 01.5800 32.40 050329......... 01.3530 22.38 050447......... 01.1539 19.37 050575......... 01.2038 ...... 050113....................... 01.3294 29.69 050224.......... 01.6083 22.29 050331......... 01.4116 26.07 050448......... 01.2603 20.75 050577......... 01.4073 19.70 050114....................... 01.4974 20.53 050225.......... 01.4961 20.34 050333......... 01.1134 19.36 050449......... 01.3295 20.38 050578......... 01.2091 24.65 050115....................... 01.5820 20.21 050226.......... 01.3728 23.58 050334......... 01.7827 31.52 050454......... 01.8485 27.56 050579......... 01.5011 27.75 050116....................... 01.4915 23.17 050228.......... 01.3595 27.09 050335......... 01.4150 21.78 050455......... 01.8798 21.07 050580......... 01.3781 26.95 050117....................... 01.3267 20.76 050230.......... 01.2951 25.94 050336......... 01.4130 20.42 050456......... 01.1970 20.18 050581......... 01.3780 24.80 050118....................... 01.2333 23.37 050231.......... 01.6985 24.69 050337......... 01.1495 ....... 050457......... 01.9703 28.16 050583......... 01.6354 23.49 050121....................... 01.3937 19.17 050232.......... 01.7553 25.52 050342......... 01.3623 18.03 050459......... 01.2277 28.95 050584......... 01.3226 19.70 050122....................... 01.6961 25.77 050233.......... 01.2032 27.97 050343......... 01.0670 16.57 050464......... 01.8576 23.28 050585......... 01.3155 25.79 050124....................... 01.2423 19.10 050234.......... 01.3174 22.79 050348......... 01.6714 23.57 050468......... 01.4960 16.95 050586......... 01.3724 21.47 050125....................... 01.3763 27.26 050235.......... 01.6109 27.60 050349......... 00.9553 14.75 050469......... 01.1143 18.34 050588......... 01.3158 27.41 050126....................... 01.4878 23.86 050236.......... 01.4932 23.47 050350......... 01.3648 23.74 050470......... 01.1174 18.14 050589......... 01.3257 24.78 050127....................... 01.3437 23.71 050238.......... 01.5338 22.98 050351......... 01.4728 25.95 050471......... 01.8590 22.75 050590......... 01.4087 23.26 050128....................... 01.6436 23.71 050239.......... 01.5382 23.40 050352......... 01.3239 24.08 050476......... 01.3723 21.89 050591......... 01.3400 24.97 050129....................... 01.6051 21.10 050240.......... 01.4190 25.28 050353......... 01.6095 24.23 050477......... 01.5035 30.71 050592......... 01.3555 10.96 050131....................... 01.2869 30.45 050241.......... 01.1960 25.59 050355......... 00.9765 14.97 050478......... 00.9902 20.58 050593......... 01.2968 29.77 050132....................... 01.3955 24.69 050242.......... 01.4397 28.77 050357......... 01.6573 22.99 050481......... 01.4393 25.47 050594......... 01.7813 24.64 050133....................... 01.3425 21.73 050243.......... 01.5606 20.95 050359......... 01.3035 19.88 050482......... 00.9919 17.87 050597......... 01.2725 22.40 050135....................... 01.4336 26.20 050245.......... 01.4468 22.03 050360......... 01.4611 31.81 050483......... 01.2206 22.32 050598......... 01.3740 28.26 050136....................... 01.3719 29.32 050248.......... 01.2339 24.55 050366......... 01.4397 20.59 050485......... 01.6234 22.39 050599......... 01.6928 23.22 050137....................... 01.4283 33.54 050251.......... 01.0786 18.41 050367......... 01.2671 27.02 050486......... 01.4114 24.19 050601......... 01.5776 28.97 050138....................... 01.8936 33.14 050253.......... 00.4249 18.80 050369......... 01.3266 23.77 050488......... 01.3891 29.71 050603......... 01.4318 20.95 050139....................... 01.3165 32.31 050254.......... 01.1859 20.57 050373......... 01.4503 23.73 050491......... 01.2715 24.39 050604......... 01.5600 32.65 050140....................... 01.3987 31.70 050256.......... 01.7909 19.46 050376......... 01.5219 29.05 050492......... 01.3803 21.96 050607......... 01.1803 21.26 050144....................... 01.6121 25.92 050257.......... 01.1417 21.76 050377......... 01.0124 16.26 050494......... 01.3433 24.67 050608......... 01.3295 18.75 050145....................... 01.3641 30.22 050260.......... 00.9856 19.43 050378......... 01.1789 21.42 050496......... 01.7109 32.54 050609......... 01.4415 33.78 050146....................... 01.3641 ....... 050261.......... 01.2236 18.54 050379......... 01.2054 16.93 050497......... 00.7910 ....... 050613......... 01.1557 19.90 050147....................... 00.7180 22.54 050262.......... 01.9911 26.95 050380......... 01.6584 29.85 050498......... 01.2855 22.93 050615......... 01.6609 25.67 050148....................... 01.0787 19.07 050264.......... 01.4171 28.04 050382......... 01.4257 22.15 050502......... 01.6392 21.94 050616......... 01.3575 21.21 050149....................... 01.4959 22.14 050267.......... 01.6375 27.72 050385......... 01.3302 23.94 050503......... 01.3527 23.35 050618......... 01.1704 20.05 050150....................... 01.2339 22.69 050270.......... 01.3328 22.02 050388......... 00.9225 18.08 050506......... 01.3768 24.66 050623......... 01.1288 23.78 050152....................... 01.4212 25.51 050272.......... 01.3318 20.79 050390......... 01.2320 22.09 050510......... 01.3484 32.12 050624......... 01.3772 22.51 050153....................... 01.6647 27.98 050274.......... 00.9872 19.47 050391......... 01.3468 23.34 050512......... 01.5363 33.56 050625......... 01.6035 25.18 050155....................... 01.1114 25.69 050276.......... 01.1317 26.93 050392......... 01.0001 18.23 050515......... 01.3442 31.82 050630......... 01.4327 21.18 050158....................... 01.3645 25.37 050277.......... 01.5093 19.57 050393......... 01.4457 23.72 050516......... 01.5803 24.92 050633......... 01.2943 21.92 050159....................... 01.3879 21.88 050278.......... 01.6159 22.89 050394......... 01.6193 20.12 050517......... 01.3033 20.14 050635......... 01.3173 32.77 050167....................... 01.2549 22.00 050279.......... 01.2261 21.00 050396......... 01.6130 22.02 050522......... 01.3420 31.46 050636......... 01.4701 22.13 050168....................... 01.5423 23.71 050280.......... 01.6858 24.62 050397......... 01.0483 18.22 050523......... 01.3228 29.32 050638......... 01.0334 19.35 050169....................... 01.5157 21.82 050281.......... 01.4700 15.36 050401......... 01.1322 19.06 050526......... 01.3239 24.45 050641......... 01.1904 18.27 050170....................... 01.5731 21.33 050282.......... 01.3631 23.18 050404......... 01.1013 16.60 050528......... 01.3543 21.06 050643......... 00.7614 ...... 050172....................... 01.2439 18.44 050283.......... 01.1133 26.91 050406......... 01.0326 15.92 050531......... 01.1911 20.24 050644......... 00.8962 22.79 050173....................... 01.3510 20.24 050286.......... 00.9424 17.82 050407......... 01.3244 28.37 050534......... 01.4107 24.32 050660......... 01.3534 ...... 050174....................... 01.6347 29.60 050289.......... 01.8865 26.67 050410......... 01.0841 16.71 050535......... 01.4621 22.87 050661......... 00.8437 20.15 050175....................... 01.3595 27.08 050290.......... 01.6523 20.42 050411......... 01.3695 31.16 050537......... 01.2746 21.53 050662......... 00.8828 22.31 050177....................... 01.2512 20.35 050291.......... 01.2337 25.51 050414......... 01.3022 24.60 050539......... 01.2842 22.25 050663......... 01.1210 25.63 050179....................... 01.3096 19.55 050292.......... 01.0680 21.76 050417......... 01.3212 21.54 050541......... 01.5481 32.88 050666......... 00.8825 20.95 050180....................... 01.6205 30.28 050293.......... 01.1601 18.95 050418......... 01.3206 22.71 050542......... 01.2260 14.92 050667......... 00.9872 24.80 050183....................... 01.1407 20.36 050295.......... 01.4637 21.39 050419......... 01.3491 20.46 050543......... 00.9027 21.76 050668......... 01.1151 28.90 050186....................... 01.3286 23.83 050296.......... 01.2014 22.43 050420......... 01.5295 23.03 050545......... 00.7731 21.20 050670......... 00.8073 ...... ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29958]] Page 3 of 16 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Avg. Avg. Avg. Avg. Avg. Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 050674....................... 01.2954 30.71 060047.......... 01.1034 11.84 080004......... 01.3341 18.52 100071......... 01.3325 16.21 100167......... 01.4623 19.21 050675....................... 01.8399 17.60 060049.......... 01.4757 17.92 080005......... 01.3296 18.53 100072......... 01.3143 16.55 100168......... 01.3935 20.23 050676....................... 00.9699 14.37 060050.......... 01.2723 14.36 080006......... 01.3738 19.73 100073......... 01.7698 21.99 100169......... 01.8560 16.01 050677....................... 01.4370 34.53 060052.......... 01.1001 13.04 080007......... 01.4058 17.29 100075......... 01.5932 18.14 100170......... 01.4614 16.86 050678....................... 01.1080 24.44 060053.......... 01.0018 14.81 090001......... 01.5364 21.36 100076......... 01.3528 16.80 100172......... 01.3770 13.93 050680....................... 01.2311 26.19 060054.......... 01.3927 17.69 090002......... 01.3037 19.74 100077......... 01.4090 15.42 100173......... 01.6803 16.87 050682....................... 00.8934 15.55 060056.......... 00.9289 14.05 090003......... 01.3498 23.25 100078......... 01.1911 16.86 100174......... 01.5814 20.80 050684....................... 01.2017 21.85 060057.......... 01.0787 21.47 090004......... 01.8148 23.95 100079......... 01.6046 20.49 100175......... 01.2544 16.65 050685....................... 01.2131 28.69 060058.......... 00.9425 13.87 090005......... 01.3491 17.58 100080......... 01.6282 23.98 100176......... 02.1176 22.94 050686....................... 01.3182 32.30 060060.......... 00.8513 12.53 090006......... 01.3510 19.70 100081......... 01.0520 17.93 100177......... 01.3700 18.76 050688....................... 01.2694 27.87 060062.......... 00.9321 14.11 090007......... 01.2584 20.10 100082......... 01.4548 17.52 100179......... 01.6364 19.38 050689....................... 01.3900 29.96 060063.......... 00.9561 11.82 090008......... 01.5315 23.59 100083......... 01.3327 17.98 100180......... 01.3695 19.01 050690....................... 01.5039 32.26 060064.......... 01.4618 20.71 090010......... 01.1727 22.39 100084......... 01.4579 18.10 100181......... 01.2703 19.10 050693....................... 01.6237 28.58 060065.......... 01.3182 14.86 090011......... 01.9773 24.55 100085......... 01.4195 18.83 100183......... 01.3921 19.62 050694....................... 01.5207 22.78 060066.......... 00.9712 12.79 090015......... 01.1274 ....... 100086......... 01.3141 22.05 100187......... 01.4035 18.31 050695....................... 01.1018 25.42 060068.......... 01.1354 13.46 100001......... 01.5673 18.08 100087......... 01.8739 21.91 100189......... 01.4259 20.87 050696....................... 02.1043 28.17 060070.......... 01.0209 16.03 100002......... 01.4874 19.11 100088......... 01.7311 17.43 100191......... 01.3112 18.63 050697....................... 01.2505 18.05 060071.......... 01.2358 14.39 100004......... 01.0671 13.13 100090......... 01.4104 16.46 100199......... 01.4317 18.30 050698....................... 00.8012 ....... 060073.......... 00.9705 15.25 100006......... 01.6470 19.01 100092......... 01.4498 16.27 100200......... 01.3445 22.72 050699....................... 00.6001 23.01 060075.......... 01.3273 21.20 100007......... 01.8747 19.21 100093......... 01.5386 15.36 100203......... 01.3411 19.70 050700....................... 01.4896 32.32 060076.......... 01.4849 13.62 100008......... 01.7746 20.00 100098......... 01.1597 18.36 100204......... 01.6738 20.97 050701....................... 01.3527 29.00 060085.......... 00.9510 10.30 100009......... 01.5014 19.22 100099......... 01.2979 13.12 100206......... 01.4404 19.98 050702....................... 00.9243 19.02 060087.......... 01.7036 21.04 100010......... 01.5354 22.50 100102......... 01.0888 17.62 100207......... 01.0774 20.37 050704....................... 01.0827 20.41 060088.......... 01.0237 13.86 100012......... 01.6869 15.28 100103......... 01.0707 15.41 100208......... 01.5797 16.92 050707....................... 01.0506 25.90 060090.......... 00.8707 14.19 100014......... 01.4598 18.79 100105......... 01.4627 18.87 100209......... 01.6114 18.40 050708....................... 00.9840 27.17 060096.......... 01.0806 21.65 100015......... 01.3417 18.06 100106......... 01.1273 16.92 100210......... 01.6360 19.34 050709....................... 01.3181 20.44 060100.......... 01.4796 21.75 100017......... 01.5577 16.86 100107......... 01.4057 18.26 100211......... 01.3500 18.47 050710....................... 01.3371 ....... 060103.......... 01.3605 22.66 100018......... 01.3518 20.31 100108......... 01.0616 13.74 100212......... 01.6492 18.75 050711....................... 02.0879 ....... 060104.......... 01.2898 21.84 100019......... 01.5364 18.40 100109......... 01.3631 18.44 100213......... 01.5701 18.46 050712....................... 01.5251 ....... 060107.......... 01.0436 ....... 100020......... 01.3436 20.82 100110......... 01.4229 16.99 100217......... 01.2964 ...... 050713....................... 00.8063 ....... 070001.......... 01.7262 26.42 100022......... 01.8721 23.14 100112......... 01.0127 12.61 100220......... 01.9442 18.82 050714....................... 01.3703 ....... 070002.......... 01.7806 26.03 100023......... 01.3697 16.89 100113......... 02.1202 19.34 100221......... 01.6958 19.65 050715....................... 02.2781 ....... 070003.......... 01.1168 25.30 100024......... 01.4016 19.26 100114......... 01.4427 19.70 100222......... 01.4041 18.63 060001....................... 01.5984 20.29 070004.......... 01.2524 23.33 100025......... 01.8800 16.92 100117......... 01.3105 18.77 100223......... 01.4932 16.45 060003....................... 01.2655 18.34 070005.......... 01.4032 25.79 100026......... 01.7148 16.88 100118......... 01.2401 17.18 100224......... 01.4284 21.35 060004....................... 01.3542 20.06 070006.......... 01.3358 28.36 100027......... 00.9139 14.31 100121......... 01.3113 15.75 100225......... 01.4062 20.63 060006....................... 01.1546 16.89 070007.......... 01.4037 23.69 100028......... 01.2619 17.30 100122......... 01.3634 16.54 100226......... 01.4159 18.07 060007....................... 01.2449 14.98 070008.......... 01.2639 23.02 100029......... 01.3393 19.04 100124......... 01.3671 18.33 100228......... 01.3737 20.28 060008....................... 01.0674 14.75 070009.......... 01.3504 23.68 100030......... 01.4017 18.54 100125......... 01.3002 16.50 100229......... 01.3309 16.98 060009....................... 01.4335 19.81 070010.......... 01.6217 23.63 100032......... 01.9242 18.08 100126......... 01.4880 19.41 100230......... 01.4372 15.90 060010....................... 01.5793 21.74 070011.......... 01.3434 25.98 100034......... 01.7166 18.88 100127......... 01.6988 18.39 100231......... 01.6893 16.90 060011....................... 01.2307 20.17 070012.......... 01.2220 23.53 100035......... 01.6482 17.26 100128......... 02.1378 21.19 100232......... 01.2861 18.29 060012....................... 01.4715 17.66 070013.......... 01.3776 26.05 100038......... 01.5648 21.34 100129......... 01.2621 17.91 100234......... 01.5404 19.22 060013....................... 01.3133 19.42 070015.......... 01.4373 24.61 100039......... 01.5732 21.69 100130......... 01.2312 19.48 100235......... 01.4464 18.19 060014....................... 01.7955 22.41 070016.......... 01.3392 24.32 100040......... 01.6729 17.79 100131......... 01.3970 19.68 100236......... 01.4010 18.22 060015....................... 01.5779 20.04 070017.......... 01.3520 24.82 100043......... 01.4528 15.07 100132......... 01.3756 15.46 100237......... 02.1842 21.32 060016....................... 01.1926 13.66 070018.......... 01.4167 27.48 100044......... 01.4332 19.66 100134......... 01.0399 14.63 100238......... 01.5887 16.14 060018....................... 01.2616 16.68 070019.......... 01.1970 25.50 100045......... 01.4239 16.32 100135......... 01.6195 16.63 100239......... 01.4591 19.01 060020....................... 01.6409 14.96 070020.......... 01.3560 25.82 100046......... 01.4950 18.40 100137......... 01.3807 21.08 100240......... 00.9283 19.10 060022....................... 01.6775 18.46 070021.......... 01.2941 25.42 100047......... 01.8196 18.47 100138......... 00.9561 12.12 100241......... 00.9737 13.68 060023....................... 01.6634 15.59 070022.......... 01.8463 24.06 100048......... 00.9771 12.80 100139......... 01.0680 14.97 100242......... 01.4962 16.47 060024....................... 01.7967 23.68 070024.......... 01.3761 24.79 100049......... 01.3198 18.49 100140......... 01.1669 17.64 100243......... 01.4282 17.93 060027....................... 01.6756 20.38 070025.......... 01.8566 25.92 100050......... 01.2296 15.21 100142......... 01.3324 18.12 100244......... 01.4739 18.36 060028....................... 01.5305 20.69 070026.......... 01.1905 25.91 100051......... 01.1793 17.96 100144......... 01.2104 15.29 100246......... 01.4073 20.33 060029....................... 00.9064 11.90 070027.......... 01.2373 25.65 100052......... 01.3796 15.15 100145......... 01.3341 19.01 100248......... 01.7055 17.76 060030....................... 01.2935 18.79 070028.......... 01.5062 24.91 100053......... 01.3598 17.17 100146......... 01.0783 16.01 100249......... 01.3764 19.46 060031....................... 01.6877 18.97 070029.......... 01.4135 22.06 100054......... 01.2986 18.00 100147......... 01.0937 13.18 100252......... 01.2389 19.72 060032....................... 01.5162 17.36 070030.......... 01.3100 26.51 100055......... 01.4205 17.02 100150......... 01.4297 19.30 100253......... 01.4813 19.73 060033....................... 01.1006 12.53 070031.......... 01.2796 22.20 100056......... 01.5140 18.89 100151......... 01.7801 19.37 100254......... 01.6127 17.99 060034....................... 01.4657 22.34 070033.......... 01.3636 26.22 100057......... 01.3902 16.01 100154......... 01.6729 19.96 100255......... 01.2334 19.80 060036....................... 01.0976 14.70 070034.......... 01.3693 27.52 100060......... 01.8124 16.57 100156......... 01.1557 19.34 100256......... 01.9105 18.54 060037....................... 01.0476 13.16 070035.......... 01.4415 23.11 100061......... 01.4729 20.71 100157......... 01.6173 20.46 100258......... 01.6459 21.27 060038....................... 01.0356 12.96 070036.......... 01.6087 27.46 100062......... 01.7513 17.75 100159......... 00.9174 12.79 100259......... 01.4894 17.21 060041....................... 00.9054 14.99 070038.......... 00.6569 ....... 100063......... 01.3311 16.56 100160......... 01.2252 18.48 100260......... 01.4652 18.18 060042....................... 01.1308 16.83 070039.......... 00.9118 ....... 100067......... 01.4572 16.77 100161......... 01.7302 20.07 100262......... 01.4437 18.87 060043....................... 00.9450 13.31 080001.......... 01.6693 24.79 100068......... 01.3737 16.37 100162......... 01.4419 17.78 100263......... 01.4108 17.42 060044....................... 01.2748 16.98 080002.......... 01.2468 17.15 100069......... 01.3912 17.95 100165......... 01.1801 17.55 100264......... 01.3963 17.27 060046....................... 01.0985 16.64 080003.......... 01.3453 20.79 100070......... 01.4493 18.13 100166......... 01.5356 20.44 100265......... 01.3893 14.57 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29959]] Page 4 of 16 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Avg. Avg. Avg. Avg. Avg. Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 100266....................... 01.3543 16.53 110066.......... 01.5373 18.78 110163......... 01.4677 18.54 130010......... 00.9218 15.97 140045......... 01.0701 13.11 100267....................... 01.3514 15.67 110069.......... 01.2620 17.45 110164......... 01.4743 19.38 130011......... 01.3019 17.11 140046......... 01.3156 14.84 100268....................... 01.2084 23.23 110070.......... 01.0204 12.19 110165......... 01.3629 18.35 130012......... 01.0249 20.53 140047......... 01.1477 14.21 100269....................... 01.4373 19.39 110071.......... 01.1790 10.43 110166......... 01.5340 17.45 130013......... 01.2660 17.73 140048......... 01.4300 22.08 100270....................... 00.8331 14.31 110072.......... 01.0020 12.37 110168......... 01.7276 21.92 130014......... 01.3861 16.50 140049......... 01.5619 20.48 100271....................... 01.7336 20.00 110073.......... 01.2235 13.04 110169......... 01.1751 21.80 130015......... 00.8553 13.50 140051......... 01.5442 19.42 100275....................... 01.4056 21.30 110074.......... 01.4581 18.47 110171......... 01.4776 23.10 130016......... 00.9448 17.37 140052......... 01.3719 18.11 100276....................... 01.3013 22.26 110075.......... 01.3606 15.50 110172......... 01.4150 19.98 130017......... 01.1906 12.16 140053......... 01.9805 18.04 100277....................... 01.0705 13.03 110076.......... 01.4330 18.51 110174......... 00.9635 13.19 130018......... 01.7039 17.05 140054......... 01.3509 24.77 100279....................... 01.3599 18.73 110078.......... 01.7041 20.66 110176......... 01.4679 20.47 130019......... 01.1199 14.30 140055......... 01.0282 12.61 100280....................... 01.3737 16.76 110079.......... 01.3878 19.53 110177......... 01.5641 26.95 130021......... 01.0063 11.89 140058......... 01.2459 15.74 100281....................... 01.2632 20.52 110080.......... 01.2776 18.15 110178......... 01.4847 17.04 130022......... 01.2181 16.88 140059......... 01.1721 13.96 100282....................... 01.1209 14.86 110082.......... 02.0374 20.53 110179......... 01.2260 21.81 130024......... 01.1046 16.52 140061......... 01.0962 14.14 110001....................... 01.3058 17.26 110083.......... 01.7844 20.63 110181......... 00.9761 12.32 130025......... 01.0914 14.90 140062......... 01.2671 25.30 110002....................... 01.3046 15.75 110086.......... 01.2415 16.50 110183......... 01.4246 19.97 130026......... 01.1239 17.95 140063......... 01.4646 24.56 110003....................... 01.3363 12.66 110087.......... 01.3388 19.53 110184......... 01.2673 18.82 130027......... 00.9775 17.34 140064......... 01.3532 17.02 110004....................... 01.3702 14.62 110088.......... 00.9425 12.52 110185......... 01.1239 12.44 130028......... 01.2678 18.86 140065......... 01.5856 23.89 110005....................... 01.1514 19.77 110089.......... 01.2376 16.07 110186......... 01.3833 16.69 130029......... 01.0342 15.77 140066......... 01.3043 14.92 110006....................... 01.3756 17.90 110091.......... 01.3391 20.01 110187......... 01.3434 18.27 130030......... 00.9961 17.62 140067......... 01.7847 18.79 110007....................... 01.5428 15.29 110092.......... 01.1754 12.84 110188......... 01.4308 18.16 130031......... 01.0830 12.21 140068......... 01.2187 18.58 110008....................... 01.3479 16.25 110093.......... 00.9511 12.42 110189......... 01.1175 18.39 130034......... 00.9851 17.80 140069......... 01.0051 14.69 110009....................... 00.9912 13.65 110094.......... 01.0069 11.90 110190......... 01.1013 14.95 130035......... 01.0837 19.75 140070......... 01.2390 17.12 110010....................... 02.1120 21.49 110095.......... 01.3192 14.45 110191......... 01.3753 18.34 130036......... 01.3057 13.11 140074......... 00.9695 14.23 110011....................... 01.2439 16.73 110096.......... 01.1454 13.95 110192......... 01.4536 18.88 130037......... 01.1830 16.09 140075......... 01.4767 18.16 110013....................... 01.1025 14.97 110097.......... 01.0230 13.43 110193......... 01.2409 17.43 130043......... 01.0042 15.45 140077......... 01.1605 16.68 110014....................... 01.0251 14.25 110098.......... 01.0549 12.75 110194......... 01.0103 13.81 130044......... 01.1615 12.49 140079......... 01.2434 19.72 110015....................... 01.2373 16.42 110100.......... 01.0948 12.76 110195......... 01.0547 11.35 130045......... 01.0107 12.07 140080......... 01.6408 21.22 110016....................... 01.3073 14.79 110101.......... 01.1688 11.58 110198......... 01.3706 24.04 130048......... 01.0862 13.31 140081......... 01.0883 13.46 110017....................... 00.8645 13.54 110103.......... 00.9623 10.15 110200......... 01.8308 17.05 130049......... 01.2816 18.00 140082......... 01.4304 19.59 110018....................... 01.1509 17.79 110104.......... 01.0884 14.01 110201......... 01.5058 17.52 130054......... 00.8937 17.61 140083......... 01.2423 17.22 110020....................... 01.3489 16.21 110105.......... 01.1793 14.60 110203......... 00.9981 16.30 130056......... 00.8623 11.05 140084......... 01.2287 18.60 110023....................... 01.3467 18.43 110107.......... 01.8204 18.50 110204......... 00.8066 14.34 130058......... 00.7980 14.21 140086......... 01.0844 14.36 110024....................... 01.4873 15.86 110108.......... 00.9459 11.26 110205......... 01.1262 17.06 130060......... 01.3289 19.41 140087......... 01.3932 16.15 110025....................... 01.4274 17.54 110109.......... 01.0965 13.22 110207......... 01.0879 14.02 130061......... 00.9433 ....... 140088......... 01.6631 24.52 110026....................... 01.2118 14.59 110111.......... 01.0973 16.55 110208......... 00.9425 16.97 140001......... 01.2830 14.89 140089......... 01.2551 16.59 110027....................... 01.0878 13.41 110112.......... 01.0848 19.36 110209......... 00.7485 16.39 140002......... 01.3158 18.78 140090......... 01.5315 27.83 110028....................... 01.6494 19.36 110113.......... 01.0936 12.40 110211......... 00.8833 ....... 140003......... 01.0172 14.52 140091......... 01.8017 17.27 110029....................... 01.4094 18.29 110114.......... 01.0742 14.35 110212......... 01.1701 ....... 140004......... 01.1085 16.34 140093......... 01.2049 17.01 110030....................... 01.3314 17.58 110115.......... 01.6026 18.83 110213......... 00.5511 ....... 140005......... 00.9613 09.56 140094......... 01.3951 19.46 110031....................... 01.3083 19.99 110118.......... 00.9744 13.49 120001......... 01.8187 25.27 140007......... 01.4808 21.10 140095......... 01.3952 20.09 110032....................... 01.2678 12.68 110120.......... 01.0246 12.28 120002......... 01.1919 21.80 140008......... 01.5798 19.43 140097......... 00.9670 12.49 110033....................... 01.4341 19.79 110121.......... 01.2022 12.83 120003......... 00.9988 22.69 140010......... 01.3776 22.90 140100......... 01.2499 18.78 110034....................... 01.6158 17.89 110122.......... 01.3880 15.07 120004......... 01.2650 21.72 140011......... 01.1965 16.24 140101......... 01.2224 18.49 110035....................... 01.4328 20.02 110124.......... 01.0850 15.63 120005......... 01.2505 18.94 140012......... 01.2713 18.60 140102......... 01.1118 14.37 110036....................... 01.6901 18.85 110125.......... 01.2330 15.97 120006......... 01.3095 24.62 140013......... 01.5804 15.59 140103......... 01.3585 16.25 110037....................... 01.1697 11.02 110127.......... 00.9362 18.26 120007......... 01.6730 20.90 140014......... 01.1703 16.36 140105......... 01.3031 20.28 110038....................... 01.4654 15.98 110128.......... 01.1824 19.01 120009......... 01.0345 20.40 140015......... 01.2864 14.20 140107......... 01.0708 11.82 110039....................... 01.3778 18.62 110129.......... 01.7854 15.69 120010......... 01.8705 22.71 140016......... 00.9579 11.89 140108......... 01.3575 21.81 110040....................... 01.1216 15.52 110130.......... 01.1667 11.11 120011......... 01.2427 31.56 140018......... 01.4000 19.38 140109......... 01.1766 13.08 110041....................... 01.2723 15.82 110132.......... 01.1264 12.99 120012......... 00.9018 20.20 140019......... 01.1706 12.65 140110......... 01.1931 17.31 110042....................... 01.2740 14.90 110134.......... 00.8904 12.19 120014......... 01.4446 22.59 140024......... 01.0067 13.99 140112......... 01.2240 13.42 110043....................... 01.7886 16.83 110135.......... 01.2960 14.04 120015......... 00.9683 22.77 140025......... 01.0618 16.65 140113......... 01.5112 17.90 110044....................... 01.1491 14.51 110136.......... 01.1904 17.74 120016......... 00.8833 24.58 140026......... 01.2848 15.90 140114......... 01.3527 19.55 110045....................... 01.3219 21.18 110140.......... 01.0308 16.75 120018......... 00.9540 20.92 140027......... 01.3401 16.37 140115......... 01.3235 19.66 110046....................... 01.3498 17.14 110141.......... 00.9566 12.29 120019......... 01.2393 19.16 140029......... 01.3537 21.43 140116......... 01.3021 20.98 110048....................... 01.3678 13.59 110142.......... 00.9492 11.78 120021......... 00.9401 18.74 140030......... 01.8105 21.56 140117......... 01.5387 20.42 110049....................... 01.1275 14.58 110143.......... 01.4530 20.77 120022......... 01.7012 20.74 140031......... 01.2692 13.76 140118......... 01.6525 23.74 110050....................... 01.2031 13.35 110144.......... 01.1556 17.41 120026......... 01.2605 24.26 140032......... 01.2649 16.71 140119......... 01.7173 23.27 110051....................... 01.0351 16.68 110146.......... 01.1397 15.09 120027......... 01.5865 23.43 140033......... 01.2696 19.82 140120......... 01.4595 15.45 110052....................... 01.1211 10.83 110149.......... 01.1585 17.31 120028......... 01.0161 ....... 140034......... 01.1737 17.31 140121......... 01.5411 11.54 110054....................... 01.3426 16.74 110150.......... 01.3211 17.62 130001......... 01.0074 15.75 140035......... 00.9195 11.22 140122......... 01.6593 21.47 110056....................... 01.1733 14.40 110152.......... 01.1023 14.44 130002......... 01.4327 15.30 140036......... 01.2057 16.60 140124......... 01.2337 23.81 110059....................... 01.3170 13.38 110153.......... 01.0180 17.19 130003......... 01.3671 19.28 140037......... 01.1044 12.49 140125......... 01.3616 15.71 110061....................... 01.0750 12.61 110154.......... 00.8218 13.98 130005......... 01.5290 19.49 140038......... 01.1781 16.23 140127......... 01.3910 17.45 110062....................... 00.8945 10.97 110155.......... 01.0541 13.62 130006......... 01.8432 17.59 140040......... 01.2866 14.72 140128......... 01.1137 14.92 110063....................... 01.1481 12.76 110156.......... 01.0382 12.34 130007......... 01.6299 18.20 140041......... 01.3305 16.02 140129......... 01.2232 14.94 110064....................... 01.3361 17.46 110161.......... 01.3274 21.00 130008......... 01.0035 11.00 140042......... 01.0146 14.16 140130......... 01.3672 21.74 110065....................... 01.0387 13.40 110162.......... 00.7936 ....... 130009......... 00.9623 10.74 140043......... 01.2329 17.04 140132......... 01.4410 19.03 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29960]] Page 5 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 140133....................... 01.3400 21.21 140231.......... 01.5870 20.80 150044......... 01.2616 18.32 150128......... 01.2192 19.14 160074......... 01.0986 14.30 140135....................... 01.3070 14.91 140233.......... 01.7833 18.47 150045......... 01.1013 15.68 150129......... 01.2359 22.47 160075......... 01.1442 13.73 140137....................... 01.0581 14.58 140234.......... 01.2879 16.47 150046......... 01.5287 15.90 150130......... 01.3560 16.61 160076......... 01.0721 15.50 140138....................... 00.9783 12.15 140236.......... 00.9655 13.24 150047......... 01.5605 22.77 150132......... 01.4103 19.24 160077......... 01.1832 10.60 140139....................... 01.1368 14.70 140239.......... 01.6835 18.73 150048......... 01.2059 16.52 150133......... 01.2128 14.12 160079......... 01.4062 16.28 140140....................... 01.1377 13.06 140240.......... 01.4846 20.44 150049......... 01.1576 13.29 150134......... 01.1751 17.17 160080......... 01.2016 16.06 140141....................... 01.2472 13.84 140242.......... 01.6315 21.68 150050......... 01.2017 14.73 150136......... 01.0663 18.42 160081......... 01.0645 14.77 140143....................... 01.1457 16.54 140245.......... 01.1638 14.66 150051......... 01.4787 18.34 150138......... 01.2073 17.33 160082......... 01.8251 16.81 140144....................... 01.0257 17.83 140246.......... 01.0831 12.05 150052......... 01.1501 14.14 150139......... 01.4731 14.62 160083......... 01.6764 18.37 140145....................... 01.1812 15.14 140250.......... 01.3778 21.98 150053......... 01.0493 18.10 160001......... 01.2878 17.61 160085......... 01.0834 11.50 140146....................... 01.0443 16.38 140251.......... 01.3828 19.16 150054......... 01.1551 12.55 160002......... 01.1687 13.74 160086......... 00.9998 13.93 140147....................... 01.2805 16.29 140252.......... 01.4489 23.41 150056......... 01.7685 22.38 160003......... 01.0196 12.61 160088......... 01.1633 12.63 140148....................... 01.8467 17.11 140253.......... 01.4151 17.49 150057......... 02.3203 18.94 160005......... 01.1311 13.80 160089......... 01.1878 14.80 140150....................... 01.6206 25.55 140258.......... 01.5776 20.93 150058......... 01.7210 19.57 160007......... 01.0312 12.37 160090......... 00.9814 15.58 140151....................... 01.1093 16.64 140271.......... 01.0919 13.06 150059......... 01.4075 19.81 160008......... 01.1302 13.78 160091......... 01.0794 10.80 140152....................... 01.1163 22.91 140275.......... 01.2383 16.50 150060......... 01.1786 14.93 160009......... 01.2377 13.73 160092......... 01.0801 13.23 140155....................... 01.2995 16.96 140276.......... 01.9625 21.37 150061......... 01.2371 15.73 160012......... 01.0291 13.15 160093......... 01.1951 13.86 140158....................... 01.3072 21.36 140280.......... 01.3139 17.16 150062......... 01.1015 16.55 160013......... 01.2292 15.35 160094......... 01.1253 14.17 140160....................... 01.2239 15.93 140281.......... 01.6445 20.89 150063......... 01.0944 17.57 160014......... 01.0153 12.59 160095......... 01.0906 12.79 140161....................... 01.2177 17.76 140285.......... 01.2804 15.37 150064......... 01.2152 15.84 160016......... 01.2509 16.32 160097......... 01.1359 13.00 140162....................... 01.7534 17.96 140286.......... 01.1234 17.93 150065......... 01.1597 18.49 160018......... 00.9242 13.27 160098......... 00.9679 14.70 140164....................... 01.3867 17.44 140288.......... 01.8467 23.17 150066......... 00.9997 15.93 160020......... 01.0709 12.38 160099......... 00.9646 11.69 140165....................... 01.1387 12.90 140289.......... 01.3203 15.75 150067......... 01.1300 15.48 160021......... 01.0687 13.57 160101......... 01.1660 18.64 140166....................... 01.3636 17.21 140290.......... 01.4618 20.95 150069......... 01.2618 16.90 160023......... 01.0402 12.35 160102......... 01.3899 17.51 140167....................... 01.1291 14.97 140291.......... 01.4050 22.95 150070......... 01.0287 18.09 160024......... 01.5249 16.77 160103......... 01.0446 13.57 140168....................... 01.1873 15.57 140292.......... 01.1495 20.63 150071......... 01.1161 13.86 160026......... 01.0600 14.43 160104......... 01.3168 17.37 140170....................... 01.1138 12.53 140294.......... 01.1852 16.20 150072......... 01.2073 15.48 160027......... 01.1589 13.19 160106......... 01.0593 14.03 140171....................... 00.9150 13.87 140297.......... 01.5631 27.06 150073......... 01.0115 19.47 160028......... 01.3379 17.39 160107......... 01.1798 14.12 140172....................... 01.6113 18.71 140300.......... 01.4454 18.71 150074......... 01.5934 18.80 160029......... 01.5125 18.14 160108......... 01.2054 14.95 140173....................... 00.9277 13.77 150001.......... 01.1133 17.36 150075......... 01.1691 14.49 160030......... 01.3826 17.37 160109......... 01.0404 12.35 140174....................... 01.5699 18.33 150002.......... 01.5414 18.35 150076......... 01.2161 20.39 160031......... 01.1167 13.37 160110......... 01.5247 17.97 140176....................... 01.3078 21.33 150003.......... 01.7125 19.57 150077......... 01.1793 16.58 160032......... 01.0998 15.56 160111......... 01.0180 11.04 140177....................... 01.1662 16.52 150004.......... 01.4341 19.97 150078......... 01.0763 15.66 160033......... 01.7830 16.80 160112......... 01.4226 15.00 140179....................... 01.3202 20.12 150005.......... 01.1919 18.43 150079......... 01.1320 13.96 160034......... 01.2076 14.53 160113......... 01.0012 12.03 140180....................... 01.5077 21.03 150006.......... 01.2247 17.31 150082......... 01.5096 17.44 160035......... 01.0372 12.57 160114......... 01.0662 14.21 140181....................... 01.3839 19.20 150007.......... 01.2098 17.98 150084......... 01.8769 22.28 160036......... 00.9736 14.66 160115......... 01.0262 14.32 140182....................... 01.3671 20.67 150008.......... 01.3547 20.70 150086......... 01.3257 16.45 160037......... 01.1645 15.14 160116......... 01.1796 15.68 140184....................... 01.2548 14.26 150009.......... 01.3733 17.26 150088......... 01.3481 17.20 160039......... 01.0816 15.84 160117......... 01.4541 15.96 140185....................... 01.4162 16.78 150010.......... 01.1830 15.87 150089......... 01.4270 18.39 160040......... 01.3227 16.30 160118......... 01.0209 13.15 140186....................... 01.3504 17.74 150011.......... 01.2275 17.83 150090......... 01.2518 18.72 160041......... 01.0845 13.45 160120......... 01.0221 10.62 140187....................... 01.4914 16.54 150012.......... 01.6921 21.01 150091......... 01.1366 15.75 160043......... 01.0364 13.44 160122......... 01.1309 16.24 140188....................... 01.0421 10.77 150013.......... 01.1237 13.90 150092......... 01.0316 15.04 160044......... 01.3189 13.86 160123......... 01.0588 13.19 140189....................... 01.1944 16.64 150014.......... 01.5046 19.79 150094......... 01.0077 16.85 160045......... 01.7635 17.72 160124......... 01.2795 15.87 140190....................... 01.1407 15.99 150015.......... 01.2149 18.14 150095......... 01.1046 17.97 160046......... 01.0030 12.75 160126......... 01.0158 13.59 140191....................... 01.4516 21.87 150017.......... 01.8590 17.20 150096......... 01.1653 17.34 160047......... 01.3670 15.37 160129......... 01.0246 13.75 140193....................... 01.0427 13.31 150018.......... 01.2907 18.23 150097......... 01.1390 17.09 160048......... 01.0373 11.54 160130......... 01.1767 13.02 140197....................... 01.2638 16.96 150019.......... 01.1001 15.47 150098......... 01.1528 13.03 160049......... 00.9469 12.21 160131......... 01.0519 13.55 140199....................... 01.1019 15.72 150020.......... 01.1480 12.96 150099......... 01.2917 17.79 160050......... 01.0771 14.64 160134......... 01.0526 11.84 140200....................... 01.4726 21.79 150021.......... 01.6365 18.34 150100......... 01.7156 17.65 160051......... 00.9637 13.54 160135......... 01.0985 13.67 140202....................... 01.3552 19.71 150022.......... 01.0915 16.65 150101......... 01.1103 14.50 160052......... 01.0883 14.79 160138......... 01.1359 14.36 140203....................... 01.1613 19.32 150023.......... 01.5060 18.19 150102......... 01.0408 14.93 160054......... 01.0719 12.37 160140......... 01.1723 14.75 140205....................... 00.8789 13.64 150024.......... 01.4332 15.82 150103......... 01.0084 15.02 160055......... 00.9789 12.37 160142......... 01.0866 13.98 140206....................... 01.0990 20.81 150025.......... 01.3792 17.57 150104......... 01.0962 15.63 160056......... 01.0863 13.11 160143......... 01.0288 14.24 140207....................... 01.3958 19.86 150026.......... 01.1848 18.29 150105......... 01.3476 16.20 160057......... 01.3468 15.91 160145......... 01.1210 14.16 140208....................... 01.6902 24.07 150027.......... 01.0464 15.55 150106......... 01.0814 16.06 160058......... 01.7356 19.00 160146......... 01.4325 14.59 140209....................... 01.6613 15.85 150029.......... 01.3153 20.17 150109......... 01.4622 16.85 160060......... 01.0454 13.44 160147......... 01.3032 16.09 140210....................... 01.1163 14.00 150030.......... 01.2106 16.69 150110......... 00.9996 17.16 160061......... 01.0424 14.27 160151......... 01.0503 13.74 140211....................... 01.1915 20.84 150031.......... 01.0708 15.56 150111......... 01.1600 14.02 160062......... 00.9471 12.22 160152......... 00.9953 13.78 140212....................... 01.2953 22.47 150032.......... 01.8803 19.50 150112......... 01.3072 17.78 160063......... 01.1653 15.88 160153......... 01.7411 17.48 140213....................... 01.2786 22.67 150033.......... 01.6072 21.09 150113......... 01.2223 17.88 160064......... 01.7118 17.38 170001......... 01.1836 16.35 140215....................... 01.1334 13.49 150034.......... 01.3818 21.18 150114......... 01.0013 14.58 160065......... 01.0236 14.73 170004......... 01.0749 13.28 140217....................... 01.3176 21.67 150035.......... 01.5327 18.97 150115......... 01.3813 17.55 160066......... 01.1729 14.74 170006......... 01.1484 15.02 140218....................... 00.9967 13.65 150036.......... 01.0338 17.43 150122......... 01.1229 17.11 160067......... 01.4129 17.13 170008......... 01.0274 14.53 140220....................... 01.0930 15.16 150037.......... 01.2700 18.20 150123......... 01.2055 12.98 160068......... 01.0648 13.52 170009......... 01.1970 16.31 140223....................... 01.6460 28.23 150038.......... 01.4024 17.22 150124......... 01.1018 15.97 160069......... 01.4530 16.42 170010......... 01.2510 15.77 140224....................... 01.3861 22.97 150039.......... 00.9659 16.33 150125......... 01.3901 18.69 160070......... 01.0492 14.47 170011......... 01.2378 15.40 140228....................... 01.6912 18.22 150042.......... 01.2935 16.00 150126......... 01.5100 20.17 160072......... 01.0731 11.60 170012......... 01.4736 16.07 140230....................... 00.9252 10.84 150043.......... 01.0842 21.96 150127......... 01.0222 13.90 160073......... 00.9698 12.18 170013......... 01.3223 15.33 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29961]] Page 6 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 170014....................... 01.0370 16.40 170099.......... 01.2690 11.34 180024......... 01.3887 17.24 180123......... 01.4782 20.98 190089......... 01.0797 11.47 170015....................... 01.0654 14.36 170100.......... 00.9894 14.47 180025......... 01.2127 17.17 180124......... 01.4883 16.52 190090......... 01.1658 16.84 170016....................... 01.6878 19.52 170101.......... 00.9489 13.26 180026......... 01.2402 12.39 180125......... 00.9989 16.46 190092......... 01.3924 ...... 170017....................... 01.2514 15.34 170102.......... 00.9926 13.11 180027......... 01.2872 15.58 180126......... 01.2403 12.22 190095......... 01.0682 14.66 170018....................... 01.1580 13.13 170103.......... 01.2089 15.62 180028......... 00.9956 16.39 180127......... 01.4064 17.22 190098......... 01.5365 18.91 170019....................... 01.2248 15.65 170104.......... 01.4523 19.81 180029......... 01.2726 15.97 180128......... 01.1777 16.64 190099......... 01.1522 17.98 170020....................... 01.2902 14.98 170105.......... 01.0963 15.91 180030......... 01.2394 13.31 180129......... 01.0122 14.45 190102......... 01.5599 17.77 170022....................... 01.1764 14.80 170106.......... 00.8931 12.18 180031......... 01.2156 12.60 180130......... 01.4719 17.90 190103......... 00.8797 09.75 170023....................... 01.4631 16.42 170109.......... 01.0364 14.50 180032......... 00.9268 15.83 180132......... 01.2955 15.20 190106......... 01.1725 17.69 170024....................... 01.1492 12.84 170110.......... 00.9602 13.67 180033......... 01.1365 12.86 180133......... 01.3516 24.67 190109......... 01.2172 13.50 170025....................... 01.2269 15.81 170112.......... 00.9859 13.90 180034......... 01.2666 14.14 180134......... 01.0388 13.87 190110......... 00.9373 12.43 170026....................... 01.0364 12.83 170113.......... 01.1485 14.95 180035......... 01.5519 18.73 180136......... 01.6117 16.47 190111......... 01.5969 18.33 170027....................... 01.3447 15.50 170114.......... 01.0128 13.80 180036......... 01.2054 17.01 180137......... 01.8051 18.38 190112......... 01.5890 19.46 170030....................... 01.0153 13.99 170115.......... 01.0256 11.34 180037......... 01.3404 19.24 180138......... 01.2089 17.99 190113......... 01.3609 18.49 170031....................... 00.9092 12.62 170116.......... 01.0473 15.74 180038......... 01.4099 15.04 180139......... 01.1534 18.64 190114......... 01.0160 12.20 170032....................... 01.1650 14.89 170117.......... 00.9415 13.50 180040......... 02.0155 19.20 180140......... 00.8781 ....... 190115......... 01.2261 18.33 170033....................... 01.3716 14.59 170119.......... 00.9812 12.09 180041......... 01.1039 13.42 180141......... 01.7722 ....... 190116......... 01.1859 ...... 170034....................... 00.9986 14.61 170120.......... 01.2988 16.06 180042......... 01.1997 13.59 190001......... 00.8676 17.98 190118......... 01.0970 12.38 170035....................... 00.8593 14.82 170122.......... 01.7448 19.93 180043......... 01.0024 15.90 190002......... 01.6866 18.15 190120......... 00.9968 13.75 170036....................... 00.9019 13.19 170123.......... 01.7674 18.76 180044......... 01.1640 16.29 190003......... 01.3870 17.41 190122......... 01.2395 15.70 170037....................... 01.2455 16.31 170124.......... 01.0109 14.25 180045......... 01.2625 16.79 190004......... 01.4157 15.24 190124......... 01.6469 20.23 170038....................... 00.9237 11.46 170126.......... 00.9450 11.50 180046......... 01.2350 16.65 190005......... 01.6124 17.60 190125......... 01.5554 17.99 170039....................... 01.1505 13.62 170128.......... 00.9794 14.42 180047......... 01.0274 13.80 190006......... 01.3045 14.32 190128......... 01.0863 18.56 170040....................... 01.6034 18.83 170131.......... 01.2140 09.38 180048......... 01.2862 16.16 190007......... 01.0078 13.52 190130......... 01.0375 12.09 170041....................... 00.9985 11.29 170133.......... 01.1290 14.20 180049......... 01.3311 15.45 190008......... 01.6673 17.72 190131......... 01.2029 17.84 170043....................... 01.0095 13.49 170134.......... 00.9481 12.48 180050......... 01.2534 16.12 190009......... 01.1641 13.79 190133......... 00.9749 12.08 170044....................... 01.1071 14.42 170137.......... 01.1889 17.30 180051......... 01.4337 14.78 190010......... 01.0476 16.62 190134......... 01.0178 14.79 170045....................... 01.0563 10.72 170139.......... 01.0392 11.82 180053......... 01.0870 14.30 190011......... 01.1711 14.41 190135......... 01.4595 22.58 170049....................... 01.2895 18.28 170142.......... 01.3506 16.49 180054......... 01.1032 13.92 190013......... 01.3959 15.95 190136......... 01.2005 11.22 170051....................... 00.9202 13.66 170143.......... 01.1130 13.82 180055......... 01.1664 14.00 190014......... 01.1136 15.35 190138......... 00.8846 17.51 170052....................... 01.0579 12.60 170144.......... 01.6118 14.73 180056......... 01.0755 16.38 190015......... 01.2530 17.78 190140......... 01.0159 12.16 170053....................... 00.9493 15.39 170145.......... 01.1398 14.83 180058......... 00.9913 12.63 190017......... 01.4476 16.02 190142......... 00.9058 12.39 170054....................... 01.0865 13.19 170146.......... 01.5215 19.54 180059......... 00.9162 12.59 190018......... 01.1915 15.92 190144......... 01.3106 15.22 170055....................... 01.0974 14.55 170147.......... 01.2724 20.70 180060......... 01.0317 10.17 190019......... 01.6064 18.39 190145......... 00.9991 13.66 170056....................... 00.9193 13.72 170148.......... 01.4116 17.64 180063......... 00.9932 10.79 190020......... 01.1832 15.85 190146......... 01.6309 19.61 170057....................... 01.0322 13.90 170150.......... 01.0943 13.41 180064......... 01.3330 14.03 190025......... 01.3568 13.62 190147......... 01.0221 13.69 170058....................... 01.1684 15.80 170151.......... 01.0380 11.66 180065......... 01.0489 10.82 190026......... 01.4936 16.17 190148......... 00.9041 12.77 170060....................... 01.0552 13.41 170152.......... 00.9840 12.99 180066......... 01.1569 18.09 190027......... 01.5788 16.49 190149......... 01.0591 11.47 170061....................... 01.1327 12.90 170160.......... 00.9803 11.17 180067......... 01.8083 16.40 190029......... 01.1538 15.40 190151......... 01.2260 11.73 170063....................... 00.8933 10.92 170164.......... 00.9859 14.42 180069......... 01.0091 15.33 190033......... 00.9378 09.66 190152......... 01.5214 21.27 170064....................... 01.0420 12.09 170166.......... 01.1972 13.65 180070......... 01.1191 14.66 190034......... 01.2430 ....... 190155......... 01.0392 12.29 170066....................... 00.9793 12.58 170168.......... 00.9222 09.33 180072......... 01.0659 13.91 190035......... 01.4118 ....... 190156......... 00.8732 11.99 170067....................... 01.1330 11.76 170171.......... 01.0743 11.22 180075......... 00.9983 14.13 190036......... 01.6967 19.09 190158......... 01.1908 21.59 170068....................... 01.3072 15.24 170175.......... 01.3540 17.53 180078......... 01.1598 17.57 190037......... 00.8920 10.84 190160......... 01.3271 17.03 170069....................... 00.8338 14.01 170176.......... 01.6202 19.83 180079......... 01.3369 13.03 190039......... 01.4018 17.21 190161......... 01.1264 12.65 170070....................... 01.0108 12.56 170182.......... 01.2299 19.43 180080......... 01.0551 15.57 190040......... 01.4401 19.32 190162......... 01.0457 18.47 170073....................... 01.0686 14.67 170183.......... 02.0352 ....... 180085......... 02.3962 17.70 190041......... 01.5646 19.72 190164......... 01.2250 16.05 170074....................... 01.2471 14.34 170184.......... 01.1905 ....... 180087......... 01.1701 13.74 190043......... 01.0428 10.34 190166......... 00.9327 14.04 170075....................... 00.9439 10.67 180001.......... 01.2316 17.03 180088......... 01.5598 19.99 190044......... 01.1694 17.11 190167......... 01.2322 18.49 170076....................... 01.0567 11.60 180002.......... 01.0603 16.78 180092......... 01.2643 15.25 190045......... 01.4023 20.17 190170......... 00.9471 13.08 170077....................... 00.9418 12.07 180004.......... 01.1035 14.42 180093......... 01.3779 16.05 190046......... 01.4623 17.58 190173......... 01.4783 20.12 170079....................... 01.0260 12.66 180005.......... 01.1740 18.54 180094......... 01.0364 11.51 190048......... 01.2789 13.72 190175......... 01.3210 20.26 170080....................... 00.9810 10.65 180006.......... 00.9885 08.94 180095......... 01.2462 12.94 190049......... 00.9967 15.70 190176......... 01.7349 19.11 170081....................... 01.0204 10.44 180007.......... 01.5360 16.29 180099......... 01.3197 12.31 190050......... 01.0290 14.58 190177......... 01.6625 22.84 170082....................... 01.0284 10.80 180009.......... 01.4054 19.11 180101......... 01.3214 18.01 190053......... 01.0739 12.11 190178......... 00.9580 10.87 170084....................... 00.9523 10.93 180010.......... 01.8420 18.19 180102......... 01.4763 16.35 190054......... 01.3377 14.09 190182......... 00.9720 20.02 170085....................... 00.9654 12.69 180011.......... 01.2795 15.29 180103......... 02.1547 17.93 190059......... 00.9194 13.44 190183......... 01.1242 14.79 170086....................... 01.7214 18.21 180012.......... 01.4058 17.50 180104......... 01.5746 18.07 190060......... 01.4488 15.43 190184......... 01.0785 13.09 170087....................... 16.1090 18.78 180013.......... 01.4535 16.63 180105......... 01.0040 12.82 190064......... 01.5938 18.33 190185......... 01.3607 18.53 170088....................... 00.9760 10.80 180014.......... 01.7162 19.99 180106......... 00.8943 12.27 190065......... 01.4991 14.71 190186......... 00.9454 13.16 170089....................... 00.9506 15.53 180015.......... 01.3127 15.02 180108......... 00.8581 13.54 190071......... 00.9010 12.15 190189......... 01.0752 13.17 170090....................... 01.0355 09.80 180016.......... 01.3250 14.50 180115......... 01.0279 14.65 190077......... 00.9526 13.65 190190......... 00.9250 12.66 170092....................... 00.8276 11.80 180017.......... 01.3434 13.87 180116......... 01.4586 15.66 190078......... 01.1684 11.60 190191......... 01.3301 17.54 170093....................... 01.0000 11.76 180018.......... 01.2521 15.27 180117......... 01.1156 17.03 190079......... 01.2501 16.98 190196......... 00.8663 16.29 170094....................... 00.9536 15.42 180019.......... 01.3262 16.70 180118......... 01.0381 12.03 190081......... 00.9078 10.23 190197......... 01.2379 18.98 170095....................... 01.1355 13.69 180020.......... 01.0743 15.86 180120......... 01.0578 13.12 190083......... 01.0626 15.02 190199......... 01.1913 16.26 170097....................... 01.0695 13.17 180021.......... 01.1152 13.69 180121......... 01.2250 13.68 190086......... 01.4134 15.47 190200......... 01.5587 21.70 170098....................... 01.0500 17.00 180023.......... 00.8814 13.12 180122......... 01.0903 15.01 190088......... 01.3480 ....... 190201......... 01.2833 18.93 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29962]] Page 7 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 190202....................... 01.4766 17.85 210016.......... 01.7183 23.30 220052......... 01.3219 23.88 230020......... 01.7229 22.21 230119......... 01.2933 22.31 190203....................... 01.5123 20.83 210017.......... 01.2282 14.51 220053......... 01.2587 19.48 230021......... 01.6139 17.90 230120......... 01.1815 17.47 190204....................... 01.5847 20.85 210018.......... 01.2505 21.26 220055......... 01.3458 23.52 230022......... 01.3630 18.27 230121......... 01.2515 19.69 190205....................... 01.9222 17.90 210019.......... 01.4996 18.17 220057......... 01.4090 21.39 230024......... 01.4377 23.71 230122......... 01.4048 19.20 190206....................... 01.5538 21.53 210022.......... 01.4510 20.79 220058......... 01.0836 16.26 230027......... 01.1378 15.73 230124......... 01.1675 16.89 190207....................... 01.2984 16.42 210023.......... 01.3643 20.78 220060......... 01.3023 25.32 230029......... 01.5813 20.36 230125......... 01.2969 14.51 190208....................... 00.8122 11.17 210024.......... 01.5608 19.73 220062......... 00.5837 18.78 230030......... 01.2185 16.47 230128......... 01.3868 21.24 190218....................... 01.2002 15.33 210025.......... 01.4079 18.21 220063......... 01.2284 19.40 230031......... 01.4399 19.72 230129......... 01.7831 19.91 190223....................... 00.4249 16.58 210026.......... 01.3745 19.52 220064......... 01.2327 20.51 230032......... 01.7422 19.08 230130......... 01.6706 23.74 190227....................... 00.8285 ....... 210027.......... 01.3025 18.58 220065......... 01.2262 19.58 230034......... 01.2308 17.99 230132......... 01.4109 23.25 190231....................... 01.3101 16.00 210028.......... 01.2213 17.19 220066......... 01.3308 20.73 230035......... 01.1162 16.17 230133......... 01.2205 15.07 190233....................... 02.1157 ....... 210029.......... 01.3148 17.99 220067......... 01.2855 22.58 230036......... 01.2797 19.20 230134......... 01.1074 17.91 190234....................... 01.0506 ....... 210030.......... 01.1531 19.44 220068......... 00.5284 16.67 230037......... 01.1244 17.40 230135......... 01.2667 20.25 190235....................... 01.2925 ....... 210031.......... 01.5487 16.42 220070......... 01.2510 18.77 230038......... 01.7094 21.21 230137......... 01.1940 18.51 190236....................... 01.2520 ....... 210032.......... 01.1786 17.97 220071......... 01.9203 21.67 230040......... 01.2241 20.53 230141......... 01.6811 22.44 200001....................... 01.3789 16.92 210033.......... 01.2619 18.58 220073......... 01.4122 24.14 230041......... 01.2166 20.75 230142......... 01.2194 18.90 200002....................... 01.0690 17.70 210034.......... 01.3724 20.34 220074......... 01.1891 22.82 230042......... 01.2296 19.32 230143......... 01.3149 16.58 200003....................... 01.0950 16.03 210035.......... 01.2687 18.11 220075......... 01.2648 19.51 230046......... 01.8829 25.32 230144......... 01.2245 21.19 200006....................... 01.0479 14.97 210037.......... 01.2430 17.38 220076......... 01.1779 25.46 230047......... 01.3366 20.37 230145......... 01.1813 15.96 200007....................... 01.1177 17.01 210038.......... 01.3268 21.63 220077......... 01.7898 22.92 230053......... 01.6418 24.16 230146......... 01.3082 19.56 200008....................... 01.2260 20.19 210039.......... 01.1902 15.94 220079......... 01.1685 21.68 230054......... 01.8205 21.45 230147......... 01.4359 19.70 200009....................... 01.8101 19.95 210040.......... 01.3322 21.01 220080......... 01.2694 19.58 230055......... 01.1631 18.26 230149......... 01.1837 15.51 200012....................... 01.1118 16.55 210043.......... 01.3061 21.32 220081......... 01.0022 24.81 230056......... 00.9878 14.55 230151......... 01.3894 22.02 200013....................... 01.1203 15.69 210044.......... 01.2653 19.38 220082......... 01.3094 23.04 230058......... 01.1530 18.69 230153......... 01.1308 19.70 200015....................... 01.2329 17.41 210045.......... 01.0746 11.42 220083......... 01.1973 20.43 230059......... 01.4442 19.01 230154......... 00.9371 12.43 200016....................... 01.0114 15.76 210048.......... 01.2062 23.30 220084......... 01.3131 23.23 230060......... 01.3135 17.97 230155......... 00.9376 16.93 200017....................... 01.2508 17.94 210049.......... 01.1553 17.77 220086......... 01.6454 26.01 230062......... 01.0219 14.41 230156......... 01.7147 22.91 200018....................... 01.1950 15.20 210051.......... 01.4237 20.03 220088......... 01.6091 22.68 230063......... 01.3162 19.15 230157......... 01.2050 20.15 200019....................... 01.2411 18.59 210054.......... 01.3298 21.05 220089......... 01.3364 22.69 230065......... 01.3398 19.44 230159......... 01.4900 19.64 200020....................... 01.1431 20.96 210055.......... 01.2663 24.26 220090......... 01.2573 20.95 230066......... 01.3895 20.58 230162......... 01.0467 15.60 200021....................... 01.1730 17.78 210056.......... 01.3807 17.67 220092......... 01.2338 20.66 230068......... 01.4452 22.15 230165......... 01.8500 21.91 200023....................... 00.9047 16.15 210057.......... 01.4127 25.76 220094......... 01.4159 19.82 230069......... 01.1623 21.95 230167......... 01.8077 19.21 200024....................... 01.3239 19.84 210058.......... 01.5368 18.09 220095......... 01.2495 19.06 230070......... 01.5719 19.57 230169......... 01.3462 20.88 200025....................... 01.0831 19.51 210059.......... 01.2633 21.44 220098......... 01.2547 19.71 230071......... 01.1318 22.00 230171......... 01.0260 14.42 200026....................... 01.0264 15.97 210060.......... 01.1827 23.61 220100......... 01.2637 23.69 230072......... 01.2319 19.32 230172......... 01.2802 18.87 200027....................... 01.1198 17.27 210061.......... 01.1772 17.65 220101......... 01.4389 23.41 230075......... 01.4721 19.41 230174......... 01.2980 19.50 200028....................... 00.9739 16.24 220001.......... 01.2891 21.80 220104......... 01.2663 24.79 230076......... 01.3549 22.67 230175......... 03.2600 11.15 200031....................... 01.2810 15.26 220002.......... 01.5403 23.02 220105......... 01.2690 22.16 230077......... 02.0661 18.62 230176......... 01.2365 20.69 200032....................... 01.3464 18.90 220003.......... 01.0737 16.71 220106......... 01.2609 22.14 230078......... 01.1320 15.79 230178......... 01.0169 17.92 200033....................... 01.7900 20.16 220004.......... 01.1625 18.66 220107......... 01.1935 19.21 230080......... 01.2235 20.92 230180......... 01.1055 15.79 200034....................... 01.2370 18.05 220006.......... 01.4299 21.04 220108......... 01.1996 21.13 230081......... 01.2880 16.73 230184......... 01.1528 17.45 200037....................... 01.1965 16.09 220008.......... 01.2944 20.45 220110......... 02.0104 31.74 230082......... 01.2051 15.97 230186......... 01.2241 17.37 200038....................... 01.1089 18.23 220010.......... 01.3126 21.44 220111......... 01.2673 21.76 230085......... 01.1173 17.76 230188......... 01.1832 16.01 200039....................... 01.2710 19.03 220011.......... 01.1495 27.00 220116......... 01.9996 24.40 230086......... 00.9982 14.88 230189......... 00.9248 14.93 200040....................... 01.1083 17.37 220012.......... 01.3759 30.46 220118......... 02.0700 27.44 230087......... 01.0511 17.12 230190......... 01.0342 20.21 200041....................... 01.0939 16.19 220015.......... 01.2326 20.94 220119......... 01.3155 24.27 230089......... 01.2833 21.86 230191......... 00.9127 16.65 200043....................... 00.5261 16.46 220016.......... 01.3818 20.87 220123......... 01.0410 22.86 230092......... 01.3125 18.29 230193......... 01.2154 16.97 200050....................... 01.1881 17.84 220017.......... 01.3923 23.16 220126......... 01.3402 20.63 230093......... 01.2189 18.91 230194......... 01.1126 15.94 200051....................... 00.9540 18.29 220019.......... 01.1528 17.57 220128......... 01.2030 22.97 230095......... 01.1979 16.51 230195......... 01.3113 20.94 200052....................... 00.9785 14.12 220020.......... 01.2405 18.68 220133......... 00.8368 29.15 230096......... 01.1742 20.60 230197......... 01.3274 21.41 200055....................... 01.1748 15.29 220021.......... 01.3591 23.88 220135......... 01.2410 24.67 230097......... 01.5896 19.03 230199......... 01.1798 16.61 200062....................... 00.9125 15.03 220023.......... 01.1731 19.92 220153......... 00.9842 19.37 230099......... 01.1193 18.90 230201......... 01.1765 14.03 200063....................... 01.2559 18.27 220024.......... 01.1999 20.61 220154......... 01.0045 20.83 230100......... 01.2045 14.82 230204......... 01.3907 20.13 200066....................... 01.2145 15.65 220025.......... 01.2157 19.07 220162......... 01.1096 ....... 230101......... 01.0786 17.28 230205......... 01.0309 13.00 210001....................... 01.4356 19.45 220028.......... 01.4895 21.29 220163......... 02.0500 24.21 230103......... 01.0544 17.37 230207......... 01.2603 21.19 210002....................... 02.0230 16.46 220029.......... 01.1509 23.54 220171......... 01.6484 21.72 230104......... 01.6079 21.24 230208......... 01.2419 18.18 210003....................... 01.5440 22.78 220030.......... 01.1149 17.02 230001......... 01.1916 18.72 230105......... 01.6872 19.47 230211......... 00.9353 14.11 210004....................... 01.3603 21.20 220031.......... 02.0045 27.24 230002......... 01.2647 18.80 230106......... 01.3041 18.64 230212......... 01.0711 22.89 210005....................... 01.2340 18.52 220033.......... 01.3841 19.62 230003......... 01.1461 18.79 230107......... 00.9245 11.54 230213......... 01.0327 13.19 210006....................... 01.0978 17.09 220035.......... 01.3154 19.49 230004......... 01.6848 24.03 230108......... 01.2343 18.02 230216......... 01.6063 19.50 210007....................... 01.6805 20.55 220036.......... 01.5943 22.33 230005......... 01.2552 18.69 230110......... 01.3941 17.31 230217......... 01.2397 19.60 210008....................... 01.3375 19.03 220038.......... 01.2899 21.60 230006......... 01.1051 15.91 230111......... 00.9878 20.02 230219......... 00.9329 16.58 210009....................... 01.8279 19.93 220041.......... 01.2094 21.02 230007......... 01.0602 17.82 230113......... 00.9779 18.07 230221......... 01.1053 17.78 210010....................... 01.1891 16.40 220042.......... 01.2025 25.43 230012......... 00.8670 11.92 230114......... 00.6687 25.66 230222......... 01.3897 18.46 210011....................... 01.2786 21.24 220046.......... 01.3746 22.27 230013......... 01.3024 20.55 230115......... 01.0054 15.79 230223......... 01.3120 21.86 210012....................... 01.6309 21.50 220049.......... 01.3183 21.16 230015......... 01.1332 19.54 230116......... 00.9536 14.84 230227......... 01.4688 22.63 210013....................... 01.2397 18.65 220050.......... 01.0938 18.78 230017......... 01.5764 20.51 230117......... 01.9408 25.77 230230......... 01.6754 21.30 210015....................... 01.2814 18.58 220051.......... 01.2100 20.56 230019......... 01.4991 22.60 230118......... 01.2214 16.37 230232......... 00.9775 18.31 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29963]] Page 8 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 230235....................... 01.0781 14.12 240066.......... 01.4071 18.87 240153......... 01.0196 15.01 250058......... 01.1577 13.20 260013......... 01.1118 13.85 230236....................... 01.2952 21.82 240069.......... 01.2110 18.58 240154......... 01.0483 14.45 250059......... 01.0878 14.15 260014......... 01.7489 18.62 230239....................... 01.1617 16.38 240071.......... 01.1304 17.67 240155......... 00.9544 16.25 250060......... 00.7824 10.79 260015......... 01.3467 12.13 230241....................... 01.1064 17.56 240072.......... 01.0864 17.53 240157......... 01.1171 11.54 250061......... 00.8592 09.59 260017......... 01.2916 14.90 230244....................... 01.3649 21.20 240073.......... 00.9499 15.03 240160......... 00.9811 15.61 250063......... 00.8532 12.96 260018......... 00.9287 10.14 230253....................... 00.9665 18.09 240075.......... 01.1872 19.26 240161......... 00.9741 14.77 250065......... 00.9879 11.60 260019......... 01.0354 12.50 230254....................... 01.2851 21.85 240076.......... 01.1127 20.82 240162......... 00.9969 15.08 250066......... 00.9303 14.05 260020......... 01.6667 20.95 230257....................... 00.8588 18.77 240077.......... 00.9355 12.01 240163......... 00.9492 14.68 250067......... 01.1448 15.22 260021......... 01.5105 18.46 230259....................... 01.1900 19.63 240078.......... 01.5064 21.81 240166......... 01.0768 15.70 250068......... 00.8507 09.05 260022......... 01.2935 16.51 230264....................... 01.0350 19.01 240079.......... 01.0497 13.53 240169......... 00.9590 15.46 250069......... 01.4085 13.92 260023......... 01.3238 16.81 230269....................... 01.3679 22.82 240080.......... 01.4036 21.73 240170......... 01.1704 14.40 250071......... 00.9017 10.90 260024......... 00.9481 12.58 230270....................... 01.2231 20.42 240082.......... 01.0921 15.87 240171......... 01.0490 14.30 250072......... 01.3515 16.19 260025......... 01.2386 14.22 230273....................... 01.5750 21.61 240083.......... 01.3718 16.80 240172......... 01.0622 14.86 250076......... 01.5698 08.95 260027......... 01.5497 20.66 230275....................... 00.5014 16.62 240084.......... 01.3050 17.76 240173......... 00.9755 14.79 250077......... 00.9412 11.54 260029......... 01.1498 16.88 230276....................... 00.6978 17.39 240085.......... 00.9625 15.55 240179......... 01.0886 15.05 250078......... 01.4494 14.35 260030......... 01.1773 10.35 230277....................... 01.2413 21.07 240086.......... 01.0751 15.22 240184......... 01.0883 11.77 250079......... 00.8992 13.59 260031......... 01.5413 18.47 230278....................... 01.8525 21.54 240087.......... 01.1768 15.74 240187......... 01.1726 18.89 250081......... 01.3362 15.13 260032......... 01.6098 18.24 230279....................... 00.6928 15.06 240088.......... 01.4371 18.72 240193......... 01.0850 15.54 250082......... 01.2704 12.99 260034......... 01.0286 15.30 230280....................... 01.0834 14.88 240089.......... 00.9741 15.79 240196......... 00.6150 22.86 250083......... 01.0222 10.67 260035......... 01.0464 11.67 240001....................... 01.5829 22.07 240090.......... 01.0683 13.53 240200......... 00.9031 13.54 250084......... 01.1161 15.95 260036......... 01.0354 18.28 240002....................... 01.7321 20.58 240093.......... 01.3423 16.86 240205......... 01.0263 ....... 250085......... 00.9835 12.43 260037......... 01.4487 15.56 240004....................... 01.5187 21.05 240094.......... 00.9944 17.38 240206......... 00.9489 ....... 250088......... 00.9095 14.66 260039......... 01.1663 12.17 240005....................... 01.0260 15.07 240096.......... 00.9798 14.74 240207......... 01.2775 22.23 250089......... 01.1705 13.27 260040......... 01.6606 15.94 240006....................... 01.1157 20.02 240097.......... 01.1033 16.59 240210......... 01.2460 22.69 250093......... 01.1086 12.75 260042......... 01.2618 16.91 240007....................... 01.0770 15.81 240098.......... 00.9404 16.39 240211......... 00.9749 11.52 250094......... 01.2615 14.92 260044......... 01.0947 14.86 240008....................... 01.0674 16.32 240099.......... 01.0613 10.76 250001......... 01.4462 16.92 250095......... 01.0173 14.72 260047......... 01.4608 15.90 240009....................... 01.0015 14.35 240100.......... 01.2931 18.57 250002......... 00.8377 14.44 250096......... 01.2796 15.77 260048......... 01.2353 19.25 240010....................... 01.9721 21.16 240101.......... 01.1796 17.70 250003......... 01.0188 15.17 250097......... 01.3210 13.86 260050......... 01.0944 14.63 240011....................... 01.1609 15.71 240102.......... 00.9246 12.87 250004......... 01.4728 16.68 250098......... 00.8666 14.72 260052......... 01.3374 16.89 240013....................... 01.3128 16.96 240103.......... 01.0718 13.76 250005......... 01.0621 10.43 250099......... 01.3193 12.67 260053......... 01.1600 10.83 240014....................... 01.0888 19.10 240104.......... 01.1878 21.72 250006......... 00.9609 14.73 250100......... 01.2720 14.27 260054......... 01.3127 14.83 240016....................... 01.3772 16.31 240105.......... 01.0170 12.35 250007......... 01.2969 18.24 250101......... 00.8782 09.75 260055......... 01.0240 08.93 240017....................... 01.1960 15.66 240106.......... 01.3854 23.85 250008......... 00.9267 11.91 250102......... 01.6506 14.59 260057......... 01.1561 14.12 240018....................... 01.3341 17.17 240107.......... 00.9699 14.74 250009......... 01.1981 15.81 250104......... 01.4465 16.31 260059......... 01.2358 11.75 240019....................... 01.1978 20.69 240108.......... 00.9818 12.35 250010......... 01.0279 11.88 250105......... 00.9253 11.52 260061......... 01.1336 11.91 240020....................... 01.1520 20.05 240109.......... 00.9741 12.06 250012......... 00.9496 13.18 250107......... 00.8880 14.99 260062......... 01.2041 17.75 240021....................... 01.0040 13.13 240110.......... 00.9880 14.66 250015......... 01.1038 10.43 250109......... 00.9626 12.97 260063......... 01.1241 15.61 240022....................... 01.1175 18.13 240111.......... 01.0008 15.65 250017......... 00.9756 14.92 250112......... 00.9502 14.95 260064......... 01.3140 15.06 240023....................... 01.1030 16.17 240112.......... 01.0031 14.22 250018......... 01.0885 11.21 250117......... 01.0120 13.39 260065......... 01.7943 16.07 240025....................... 01.1264 14.54 240114.......... 00.8987 13.21 250019......... 01.4959 16.51 250119......... 01.1151 11.59 260066......... 01.0288 15.31 240027....................... 01.0390 15.50 240115.......... 01.6552 21.53 250020......... 00.9499 11.47 250120......... 01.0895 13.47 260067......... 00.9511 10.89 240028....................... 01.1812 18.14 240116.......... 00.9626 12.54 250021......... 00.9247 08.33 250122......... 01.2652 ....... 260068......... 01.6948 19.07 240029....................... 01.2178 17.00 240117.......... 01.1416 17.40 250023......... 00.8534 ....... 250123......... 01.3253 18.31 260070......... 01.0659 12.16 240030....................... 01.2841 17.33 240119.......... 00.8875 17.45 250024......... 00.9649 08.37 250124......... 00.9106 11.28 260073......... 01.0302 11.87 240031....................... 00.9917 13.83 240121.......... 00.9321 17.85 250025......... 01.1328 15.43 250125......... 01.3287 18.00 260074......... 01.3216 17.26 240036....................... 01.5683 19.89 240122.......... 01.0774 16.25 250027......... 01.0193 11.14 250126......... 00.9981 13.81 260077......... 01.7111 16.86 240037....................... 01.0458 17.05 240123.......... 01.0910 13.80 250029......... 00.8793 11.91 250127......... 00.7920 10.67 260078......... 01.2189 14.84 240038....................... 01.4741 24.33 240124.......... 00.9979 16.84 250030......... 00.9896 11.25 250128......... 01.1005 11.81 260079......... 01.0347 11.96 240040....................... 01.1842 19.00 240125.......... 00.8791 12.16 250031......... 01.3389 17.65 250131......... 00.9868 10.41 260080......... 01.0511 10.85 240041....................... 01.2649 15.42 240127.......... 01.1121 12.16 250032......... 01.2654 15.27 250134......... 00.9827 15.67 260081......... 01.5218 18.50 240043....................... 01.2140 17.60 240128.......... 01.1105 14.99 250033......... 01.1181 12.63 250136......... 00.9255 15.06 260082......... 01.1931 13.85 240044....................... 01.1785 16.75 240129.......... 01.0693 13.13 250034......... 01.6285 13.70 250138......... 01.2517 16.52 260085......... 01.5637 18.89 240045....................... 01.1184 18.25 240130.......... 01.0707 15.14 250035......... 00.8781 13.38 250141......... 01.2420 16.11 260086......... 00.9979 13.83 240047....................... 01.5057 19.66 240132.......... 01.2513 21.26 250036......... 01.0177 10.97 250145......... 00.9900 ....... 260089......... 01.0806 12.16 240048....................... 01.2505 21.83 240133.......... 01.1407 16.89 250037......... 00.8362 09.52 250146......... 01.0321 12.44 260091......... 01.6471 20.21 240049....................... 01.7838 21.16 240135.......... 00.8896 11.98 250038......... 00.9499 12.49 250148......... 01.1361 15.43 260094......... 01.2145 17.53 240050....................... 01.1393 22.26 240137.......... 01.2269 15.99 250039......... 01.0330 12.23 250149......... 00.9132 13.16 260095......... 01.4120 15.92 240051....................... 00.9412 14.60 240138.......... 00.9554 12.39 250040......... 01.3374 16.36 260001......... 01.6349 16.67 260096......... 01.5939 23.01 240052....................... 01.2644 18.14 240139.......... 00.9722 14.07 250042......... 01.2430 13.72 260002......... 01.4569 20.60 260097......... 01.1570 16.79 240053....................... 01.5109 19.37 240141.......... 01.1688 18.92 250043......... 01.0013 11.48 260003......... 00.9755 13.10 260100......... 01.0555 13.31 240056....................... 01.2706 21.66 240142.......... 01.1018 15.56 250044......... 00.9982 14.17 260004......... 01.0307 12.81 260102......... 01.0503 17.58 240057....................... 01.7848 21.08 240143.......... 01.1208 11.76 250045......... 01.1343 17.75 260005......... 01.6937 20.17 260103......... 01.3951 16.96 240058....................... 00.9673 10.32 240144.......... 01.0057 13.66 250047......... 00.9900 11.39 260006......... 01.4647 16.81 260104......... 01.7016 19.61 240059....................... 01.1120 19.63 240145.......... 00.9274 12.01 250048......... 01.5333 14.39 260007......... 01.6398 14.42 260105......... 01.8395 21.04 240061....................... 01.7782 21.05 240146.......... 00.9883 18.68 250049......... 00.9030 11.19 260008......... 01.2717 16.18 260107......... 01.4283 19.39 240063....................... 01.5142 22.26 240148.......... 01.0886 08.84 250050......... 01.2902 12.79 260009......... 01.2279 15.64 260108......... 01.8648 18.57 240064....................... 01.2569 20.39 240150.......... 00.8880 12.16 250051......... 00.8720 08.88 260011......... 01.6382 17.12 260109......... 00.9885 11.86 240065....................... 01.0639 10.79 240152.......... 01.0422 18.29 250057......... 01.2899 14.84 260012......... 01.1117 12.21 260110......... 01.5646 14.92 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29964]] Page 9 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 260113....................... 01.0840 14.31 270036.......... 00.9396 09.94 280051......... 01.1961 13.85 290022......... 01.6834 20.50 310043......... 01.2814 19.99 260115....................... 01.2379 14.59 270039.......... 01.0701 12.96 280052......... 00.9828 12.52 290027......... 00.9705 15.03 310044......... 01.3355 20.03 260116....................... 01.1035 13.89 270040.......... 01.0918 19.79 280054......... 01.2699 16.10 290032......... 01.4454 18.24 310045......... 01.4264 27.62 260119....................... 01.1902 13.28 270041.......... 01.0742 11.52 280055......... 00.9226 12.19 290036......... 01.0395 13.90 310047......... 01.3550 24.05 260120....................... 01.2141 14.60 270044.......... 01.1489 14.40 280056......... 01.0135 13.28 290038......... 00.9396 17.61 310048......... 01.2514 21.34 260122....................... 01.1460 13.40 270046.......... 00.9270 13.70 280057......... 00.9801 15.61 290039......... 01.3445 ....... 310049......... 01.3215 23.91 260123....................... 01.0152 14.74 270048.......... 01.0798 14.13 280058......... 01.3647 14.36 300001......... 01.3832 21.03 310050......... 01.2306 21.48 260127....................... 00.9860 13.88 270049.......... 01.8351 19.31 280060......... 01.5777 18.24 300003......... 01.8909 21.59 310051......... 01.3464 23.27 260128....................... 01.0214 09.22 270050.......... 01.0761 17.43 280061......... 01.4895 15.95 300005......... 01.2724 19.13 310052......... 01.2876 21.19 260129....................... 01.2044 13.52 270051.......... 01.3392 18.76 280062......... 01.1457 12.55 300006......... 01.1393 17.36 310054......... 01.3052 23.97 260131....................... 01.4057 15.91 270052.......... 01.0912 12.73 280064......... 01.0808 13.94 300007......... 01.1629 17.04 310056......... 01.3867 20.63 260134....................... 01.1566 14.28 270053.......... 00.9396 09.78 280065......... 01.2724 17.49 300008......... 01.2128 18.30 310057......... 01.2933 23.67 260137....................... 01.5528 14.25 270057.......... 01.2166 12.70 280066......... 01.0334 11.48 300009......... 01.1536 18.16 310058......... 01.0905 26.79 260138....................... 01.8916 21.17 270058.......... 00.9506 11.51 280068......... 01.0867 09.89 300010......... 01.2286 17.88 310060......... 01.1999 18.73 260141....................... 01.9538 17.10 270059.......... 00.8656 15.65 280070......... 01.0111 10.30 300011......... 01.3592 22.07 310061......... 01.2544 20.23 260142....................... 01.2385 13.99 270060.......... 00.9132 13.26 280073......... 01.0115 13.94 300012......... 01.3391 21.42 310062......... 01.2896 24.98 260143....................... 00.9915 11.96 270063.......... 00.9457 14.23 280074......... 01.1316 12.68 300013......... 01.1451 17.06 310063......... 01.3667 21.28 260147....................... 01.0192 12.91 270068.......... 00.9009 15.59 280075......... 01.2286 13.10 300014......... 01.2207 19.36 310064......... 01.2739 22.29 260148....................... 00.9522 09.30 270072.......... 00.7732 11.39 280076......... 01.0462 12.93 300015......... 01.1783 18.08 310067......... 01.3277 23.76 260158....................... 01.1073 11.77 270073.......... 01.1623 11.16 280077......... 01.3438 17.26 300016......... 01.2027 15.73 310069......... 01.2844 20.03 260159....................... 01.0850 19.81 270074.......... 00.8727 ....... 280079......... 01.2143 10.42 300017......... 01.2359 21.96 310070......... 01.4051 22.98 260160....................... 01.0956 11.84 270075.......... 00.9757 ....... 280080......... 01.0583 12.11 300018......... 01.2174 19.62 310072......... 01.2857 20.57 260162....................... 01.5758 19.55 270076.......... 00.7920 ....... 280081......... 01.6898 18.79 300019......... 01.2701 18.77 310073......... 01.6784 23.53 260163....................... 01.3316 15.35 270079.......... 00.9171 13.66 280082......... 01.0127 13.48 300020......... 01.2718 20.72 310074......... 01.4649 22.61 260164....................... 00.9996 12.17 270080.......... 01.2061 15.83 280083......... 01.0991 14.54 300021......... 01.1855 15.34 310075......... 01.3852 23.13 260166....................... 01.2350 21.39 270081.......... 01.0741 12.39 280084......... 01.0433 11.01 300022......... 01.1119 17.22 310076......... 01.4347 28.74 260172....................... 00.9974 13.47 270082.......... 01.0739 14.18 280088......... 01.7879 17.98 300023......... 01.2955 19.78 310077......... 01.5659 23.51 260173....................... 01.0051 11.78 270083.......... 01.0517 16.28 280089......... 01.0322 14.37 300024......... 01.1815 16.74 310078......... 01.2978 24.59 260175....................... 01.1637 14.99 270084.......... 00.9318 14.12 280090......... 00.9935 13.49 300028......... 01.2393 16.75 310081......... 01.2833 21.29 260176....................... 01.7266 18.43 280001.......... 01.1165 12.98 280091......... 01.2101 14.18 300029......... 01.3274 22.44 310083......... 01.2856 22.33 260177....................... 01.3281 20.42 280003.......... 02.0364 18.79 280092......... 00.8896 12.18 300033......... 01.1182 13.69 310084......... 01.3535 20.99 260178....................... 01.4918 18.91 280005.......... 01.4366 16.76 280094......... 01.0535 14.07 300034......... 02.0357 23.32 310086......... 01.2273 21.30 260179....................... 01.6454 18.70 280009.......... 01.7536 17.25 280097......... 01.0852 12.27 310001......... 01.7927 25.90 310087......... 01.2824 19.26 260180....................... 01.6989 20.07 280011.......... 00.8644 11.91 280098......... 00.9677 10.40 310002......... 01.7252 26.26 310088......... 01.2278 20.64 260183....................... 01.5585 16.14 280012.......... 01.3033 15.43 280101......... 01.0917 13.18 310003......... 01.2649 24.08 310090......... 01.2311 24.50 260186....................... 01.2994 15.97 280013.......... 01.8329 20.31 280102......... 01.1442 12.76 310005......... 01.2313 20.54 310091......... 01.3337 20.80 260188....................... 01.2526 18.64 280014.......... 00.9614 13.39 280104......... 00.9770 10.84 310006......... 01.2035 19.56 310092......... 01.3119 20.70 260189....................... 00.8480 11.26 280015.......... 01.0138 15.19 280105......... 01.3787 17.28 310008......... 01.3813 22.73 310093......... 01.1685 19.79 260190....................... 01.2487 18.90 280017.......... 01.1011 13.94 280106......... 00.9285 13.93 310009......... 01.2826 22.80 310096......... 01.8614 23.17 260191....................... 01.2524 17.92 280018.......... 01.0931 13.35 280107......... 01.0876 11.13 310010......... 01.2543 20.81 310105......... 01.2399 23.63 260193....................... 01.2325 18.75 280020.......... 01.6141 18.93 280108......... 01.2094 13.96 310011......... 01.2880 21.55 310108......... 01.4305 21.85 260195....................... 01.1677 14.49 280021.......... 01.3229 15.49 280109......... 00.9160 09.80 310012......... 01.5919 24.30 310110......... 01.2375 20.38 260197....................... 01.1436 17.26 280022.......... 01.0087 12.52 280110......... 01.0169 11.19 310013......... 01.2782 21.84 310111......... 01.3032 20.46 260198....................... 01.3417 15.86 280023.......... 01.4104 14.77 280111......... 01.2167 15.63 310014......... 01.6890 24.26 310112......... 01.3240 21.02 260200....................... 01.3591 19.10 280024.......... 00.9413 13.05 280114......... 00.9785 12.99 310015......... 01.9538 24.97 310113......... 01.2381 20.60 270002....................... 01.2857 15.06 280025.......... 00.9422 12.14 280115......... 00.9481 14.77 310016......... 01.2557 22.34 310115......... 01.2937 19.31 270003....................... 01.2209 19.76 280026.......... 01.0322 15.28 280117......... 01.1926 14.47 310017......... 01.3633 23.40 310116......... 01.2358 21.84 270004....................... 01.7072 19.74 280028.......... 01.0549 14.53 280118......... 00.9922 15.17 310018......... 01.1279 20.55 310118......... 01.2541 22.53 270006....................... 01.0910 14.78 280029.......... 01.2160 14.02 280119......... 00.8653 ....... 310019......... 01.6089 23.53 310119......... 01.6063 30.37 270007....................... 00.9226 13.18 280030.......... 01.7242 24.40 280123......... 00.9506 15.63 310020......... 01.2426 21.55 310120......... 01.0681 17.44 270009....................... 01.0828 15.34 280031.......... 01.0182 13.10 290001......... 01.6689 21.85 310021......... 01.3936 22.03 310121......... 01.1650 20.34 270011....................... 01.0735 15.52 280032.......... 01.3285 15.57 290002......... 00.9842 17.79 310022......... 01.2809 21.47 320001......... 01.4673 17.14 270012....................... 01.6735 18.11 280033.......... 01.1021 14.24 290003......... 01.6564 20.74 310024......... 01.3576 22.85 320002......... 01.3450 20.13 270013....................... 01.4138 17.77 280034.......... 01.3125 13.86 290005......... 01.4911 19.03 310025......... 01.2579 22.27 320003......... 01.1854 15.65 270014....................... 01.7993 16.86 280035.......... 00.9238 11.81 290006......... 01.1665 16.15 310026......... 01.2329 22.67 320004......... 01.2651 17.19 270016....................... 00.9333 13.23 280037.......... 01.0189 14.28 290007......... 01.9072 27.06 310027......... 01.3359 20.94 320005......... 01.3181 18.87 270017....................... 01.3074 18.67 280038.......... 01.0809 14.53 290008......... 01.1850 18.73 310028......... 01.1829 21.21 320006......... 01.3623 15.96 270019....................... 01.0378 14.02 280039.......... 01.1314 13.99 290009......... 01.5619 22.25 310029......... 01.9763 22.49 320009......... 01.5982 16.52 270021....................... 01.1585 16.23 280040.......... 01.6182 18.67 290010......... 01.1281 11.93 310031......... 02.8592 24.35 320011......... 01.0288 17.06 270023....................... 01.3591 20.08 280041.......... 00.9200 11.80 290011......... 01.0270 14.67 310032......... 01.3459 21.17 320012......... 00.9809 16.21 270024....................... 00.9898 13.05 280042.......... 01.1024 13.11 290012......... 01.3986 20.67 310034......... 01.2650 21.26 320013......... 01.1612 19.19 270026....................... 00.9412 12.95 280043.......... 01.0606 14.76 290013......... 01.0582 15.39 310036......... 01.1459 19.86 320014......... 01.1014 11.24 270027....................... 01.0785 11.91 280045.......... 01.2844 13.63 290014......... 01.0288 16.38 310037......... 01.3381 26.92 320016......... 01.1858 13.77 270028....................... 01.0843 15.37 280046.......... 01.1494 11.04 290015......... 01.0017 15.15 310038......... 02.0243 23.35 320017......... 01.1639 16.85 270029....................... 00.9485 16.24 280047.......... 01.0939 15.34 290016......... 01.2292 19.81 310039......... 01.2854 21.42 320018......... 01.5091 17.37 270032....................... 01.1184 15.80 280048.......... 01.1833 12.06 290019......... 01.3453 19.06 310040......... 01.2606 24.06 320019......... 01.5428 22.95 270033....................... 00.8853 12.19 280049.......... 01.0480 13.30 290020......... 01.0868 17.66 310041......... 01.3379 21.96 320021......... 01.7525 17.31 270035....................... 01.0156 17.11 280050.......... 00.9680 13.11 290021......... 01.6469 19.51 310042......... 01.2137 22.13 320022......... 01.2437 16.07 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29965]] Page 10 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 320023....................... 00.9909 16.72 330059.......... 01.5929 29.90 330171......... 01.3206 21.95 330268......... 01.0351 14.44 340023......... 01.4078 17.97 320030....................... 01.0522 18.27 330061.......... 01.3120 23.60 330175......... 01.1547 14.34 330270......... 01.9728 32.47 340024......... 01.1778 15.07 320031....................... 00.9076 12.36 330062.......... 01.1602 15.58 330177......... 01.0010 13.74 330273......... 01.3703 23.35 340025......... 01.1795 14.80 320032....................... 00.9382 15.10 330064.......... 01.4487 29.63 330179......... 00.8711 14.38 330275......... 01.3086 18.58 340027......... 01.1882 15.59 320033....................... 01.1251 20.90 330065.......... 01.1874 17.24 330180......... 01.1878 16.40 330276......... 01.1943 17.02 340028......... 01.5461 17.32 320035....................... 00.9732 14.60 330066.......... 01.3105 17.53 330181......... 01.3086 30.46 330277......... 01.1399 16.32 340030......... 02.0657 20.58 320037....................... 01.2259 15.59 330067.......... 01.3362 20.60 330182......... 02.4681 28.41 330279......... 01.3463 18.52 340031......... 01.0087 11.97 320038....................... 01.2177 13.85 330072.......... 01.3519 27.86 330183......... 01.5110 18.72 330285......... 01.7826 22.52 340032......... 01.3862 18.60 320046....................... 01.2515 18.15 330073.......... 01.1568 14.87 330184......... 01.3693 26.85 330286......... 01.3178 24.25 340035......... 01.1812 15.73 320048....................... 01.3042 17.40 330074.......... 01.2164 17.15 330185......... 01.3284 25.44 330290......... 01.7803 29.90 340036......... 01.2483 17.33 320056....................... 00.9777 ....... 330075.......... 01.0811 17.25 330186......... 00.8858 19.79 330293......... 01.1544 13.43 340037......... 01.1212 15.85 320057....................... 00.9961 ....... 330078.......... 01.3881 17.05 330188......... 01.2058 18.28 330304......... 01.2543 26.20 340038......... 01.0711 15.42 320058....................... 00.8563 ....... 330079.......... 01.2322 17.05 330189......... 01.4328 16.85 330306......... 01.4671 27.44 340039......... 01.2888 19.52 320059....................... 01.1577 ....... 330080.......... 01.4470 27.21 330191......... 01.3327 17.06 330307......... 01.2478 19.43 340040......... 01.7915 18.22 320060....................... 00.9420 ....... 330084.......... 01.0602 16.46 330193......... 01.3167 27.97 330308......... 01.2513 29.68 340041......... 01.2345 17.24 320061....................... 01.1055 ....... 330085.......... 01.3285 18.64 330194......... 01.8377 25.39 330309......... 01.2698 24.10 340042......... 01.1974 14.01 320062....................... 00.9114 ....... 330086.......... 01.2430 24.99 330195......... 01.6497 29.85 330314......... 01.4597 22.18 340044......... 01.0183 13.44 320063....................... 01.2900 12.84 330088.......... 01.0583 24.62 330196......... 01.3112 28.36 330315......... 16.1090 25.23 340045......... 00.9957 09.61 320065....................... 01.3717 16.38 330090.......... 01.5512 16.76 330197......... 01.0557 14.99 330316......... 01.2631 21.85 340047......... 01.8712 18.39 320067....................... 00.8637 17.64 330091.......... 01.3277 18.50 330198......... 01.4009 22.87 330327......... 00.9920 16.17 340048......... 00.9368 14.02 320068....................... 00.8811 14.99 330092.......... 01.1181 14.07 330199......... 01.4019 26.06 330331......... 01.2272 29.77 340049......... 00.6961 13.94 320069....................... 00.9953 10.67 330094.......... 01.1757 16.51 330201......... 01.6400 27.62 330332......... 01.2979 25.01 340050......... 01.1971 17.37 320070....................... 00.9025 ....... 330095.......... 01.2329 17.55 330202......... 01.6494 28.76 330333......... 01.2530 23.81 340051......... 01.3335 16.08 320074....................... 01.0790 17.04 330096.......... 01.0910 15.45 330203......... 01.3914 19.06 330336......... 01.3462 28.99 340052......... 01.0094 18.41 320079....................... 01.1541 17.22 330097.......... 01.2372 15.36 330204......... 01.3917 28.09 330338......... 01.2385 23.09 340053......... 01.6620 19.08 330001....................... 01.1750 25.49 330100.......... 00.7187 26.07 330205......... 01.1520 20.29 330339......... 00.8847 18.73 340054......... 01.1119 13.09 330002....................... 01.4149 25.22 330101.......... 01.7628 33.56 330208......... 01.2512 24.55 330340......... 01.1888 21.17 340055......... 01.1909 17.40 330003....................... 01.3160 17.67 330102.......... 01.3509 17.47 330209......... 01.2145 23.11 330350......... 01.8002 28.27 340060......... 01.1481 16.69 330004....................... 01.3302 19.08 330103.......... 01.2729 16.46 330211......... 01.1985 17.23 330353......... 01.3364 30.33 340061......... 01.6989 19.91 330005....................... 01.7965 20.49 330104.......... 01.3856 26.74 330212......... 01.1045 21.12 330354......... 01.5239 ....... 340063......... 01.0467 13.08 330006....................... 01.2737 23.92 330106.......... 01.5963 34.42 330213......... 01.1784 15.72 330357......... 01.3755 33.49 340064......... 01.2127 17.10 330007....................... 01.3460 17.71 330107.......... 01.3256 21.55 330214......... 01.7511 29.72 330359......... 00.9233 19.54 340065......... 01.3418 14.39 330008....................... 01.2046 15.62 330108.......... 01.2169 16.28 330215......... 01.2278 15.66 330372......... 01.2025 24.47 340067......... 01.2760 15.88 330009....................... 01.3758 30.32 330111.......... 01.0618 14.81 330218......... 01.1332 17.94 330381......... 01.1984 28.03 340068......... 01.2350 14.77 330010....................... 01.2804 15.07 330114.......... 00.9802 16.13 330219......... 01.6757 19.13 330385......... 01.1745 26.83 340069......... 01.7385 19.47 330011....................... 01.3292 17.98 330115.......... 01.2205 15.23 330221......... 01.3401 27.53 330386......... 01.1994 23.03 340070......... 01.3821 17.57 330012....................... 01.7032 31.01 330116.......... 00.9768 14.21 330222......... 01.2792 17.64 330387......... 01.0268 23.95 340071......... 01.0850 15.08 330013....................... 02.0647 17.36 330118.......... 01.6278 18.94 330223......... 01.0631 15.37 330389......... 01.7543 29.43 340072......... 01.0658 15.20 330014....................... 01.3775 28.72 330119.......... 01.7614 33.48 330224......... 01.2427 18.20 330390......... 01.2733 30.36 340073......... 01.5479 20.23 330016....................... 01.0528 15.47 330121.......... 01.0392 16.10 330225......... 01.1712 24.38 330393......... 01.7116 27.22 340075......... 01.2024 16.26 330019....................... 01.2906 25.33 330122.......... 01.0841 21.84 330226......... 01.2737 16.28 330394......... 01.5398 18.37 340080......... 01.0616 12.72 330020....................... 01.0589 15.26 330125.......... 01.8638 19.53 330229......... 01.3073 15.69 330395......... 01.2975 30.64 340084......... 01.0587 15.61 330023....................... 01.2488 23.30 330126.......... 01.1887 22.34 330230......... 01.4289 28.69 330396......... 01.3518 31.58 340085......... 01.1725 15.65 330024....................... 01.8102 30.17 330127.......... 01.3382 25.03 330231......... 01.0965 29.91 330397......... 01.2796 25.47 340087......... 01.1033 16.01 330025....................... 01.1843 16.20 330128.......... 01.3718 27.71 330232......... 01.2398 16.42 330398......... 01.2707 26.92 340088......... 01.1389 16.22 330027....................... 01.4582 30.93 330132.......... 01.0795 14.60 330233......... 01.5355 29.70 330399......... 01.2655 29.65 340089......... 01.0362 12.85 330028....................... 01.4159 24.95 330133.......... 01.3670 30.50 330234......... 02.2504 29.60 340001......... 01.5501 19.47 340090......... 01.1535 17.15 330029....................... 01.0093 19.09 330135.......... 01.1584 18.28 330235......... 01.1446 18.33 340002......... 01.8976 18.38 340091......... 01.7185 19.42 330030....................... 01.2056 16.22 330136.......... 01.2983 16.54 330236......... 01.4017 27.87 340003......... 01.1485 17.08 340093......... 01.0725 12.10 330033....................... 01.2685 13.82 330140.......... 01.7550 17.51 330238......... 01.2317 14.19 340004......... 01.4880 17.16 340094......... 01.4425 17.65 330034....................... 00.7483 32.72 330141.......... 01.3513 24.27 330239......... 01.1938 15.39 340005......... 01.1584 13.24 340096......... 01.1689 17.33 330036....................... 01.2233 22.66 330144.......... 00.9795 13.70 330240......... 01.3306 27.41 340006......... 01.0906 14.60 340097......... 01.1822 16.61 330037....................... 01.1592 14.92 330148.......... 01.0842 14.58 330241......... 01.9041 22.30 340007......... 01.1627 16.20 340098......... 01.7248 19.46 330038....................... 01.2091 14.81 330151.......... 01.0739 14.55 330242......... 01.3798 23.99 340008......... 01.1478 16.55 340099......... 01.1578 12.70 330039....................... 00.8379 14.25 330152.......... 01.4451 28.88 330245......... 01.3025 17.35 340009......... 01.4763 19.70 340101......... 01.1697 11.80 330041....................... 01.3314 30.19 330153.......... 01.7110 17.15 330246......... 01.3563 25.33 340010......... 01.3230 16.97 340104......... 00.8557 12.36 330043....................... 01.3067 26.43 330154.......... 01.6447 ....... 330247......... 00.7683 25.98 340011......... 01.1353 14.36 340105......... 01.3824 17.94 330044....................... 01.2714 17.50 330157.......... 01.3606 19.48 330249......... 01.1711 15.98 340012......... 01.3201 15.92 340106......... 01.2125 18.52 330045....................... 01.4023 26.05 330158.......... 01.4101 23.06 330250......... 01.3091 16.77 340013......... 01.2494 15.63 340107......... 01.4157 16.68 330046....................... 01.4855 29.75 330159.......... 01.3179 18.08 330252......... 00.8801 15.72 340014......... 01.5841 22.01 340109......... 01.3465 16.84 330047....................... 01.2553 16.37 330160.......... 01.4447 28.65 330254......... 01.1655 15.21 340015......... 01.2963 17.05 340111......... 01.1815 13.75 330048....................... 01.2233 16.94 330161.......... 00.7222 16.75 330258......... 01.3709 26.99 340016......... 01.2058 15.58 340112......... 01.0676 13.87 330049....................... 01.3230 17.81 330162.......... 01.2585 26.51 330259......... 01.5058 22.66 340017......... 01.2663 15.96 340113......... 01.9984 21.03 330053....................... 01.1834 15.15 330163.......... 01.2525 18.88 330261......... 01.2898 25.24 340018......... 01.1806 15.29 340114......... 01.5616 19.74 330055....................... 01.4840 31.04 330164.......... 01.3791 19.40 330263......... 01.0205 18.52 340019......... 01.0455 13.86 340115......... 01.5419 18.15 330056....................... 01.3098 27.72 330166.......... 01.0009 15.11 330264......... 01.2445 23.18 340020......... 01.2079 17.65 340116......... 01.8193 20.54 330057....................... 01.6936 16.97 330167.......... 01.7072 28.82 330265......... 01.3598 16.53 340021......... 01.2692 16.22 340119......... 01.2909 16.28 330058....................... 01.3085 16.22 330169.......... 01.4102 32.57 330267......... 01.2237 23.35 340022......... 01.0376 14.98 340120......... 01.0939 12.31 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29966]] Page 11 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 340121....................... 01.1272 15.36 350043.......... 01.7063 16.69 360064......... 01.6051 21.61 360145......... 01.6513 17.67 370015......... 01.2714 14.88 340123....................... 01.1203 16.92 350044.......... 00.8706 10.29 360065......... 01.2767 17.59 360147......... 01.2402 15.85 370016......... 01.4234 15.52 340124....................... 01.0590 13.70 350047.......... 01.1747 16.78 360066......... 01.4340 18.88 360148......... 01.1244 17.65 370017......... 01.0984 11.48 340125....................... 01.4925 18.36 350049.......... 01.2578 10.74 360067......... 01.2694 12.77 360149......... 01.2274 17.72 370018......... 01.3359 16.48 340126....................... 01.4255 16.47 350050.......... 00.9351 10.74 360068......... 01.7278 22.41 360150......... 01.2493 19.17 370019......... 01.2722 13.17 340127....................... 01.2939 15.72 350051.......... 00.9967 15.46 360069......... 01.1325 16.74 360151......... 01.3575 17.46 370020......... 01.2996 12.51 340129....................... 01.2947 17.50 350053.......... 01.0948 10.34 360070......... 01.7308 17.18 360152......... 01.4717 17.88 370021......... 00.8951 09.76 340130....................... 01.4418 17.46 350055.......... 00.8596 12.12 360071......... 01.3511 16.78 360153......... 01.1783 14.12 370022......... 01.2960 16.91 340131....................... 01.5306 17.10 350056.......... 00.9765 12.81 360072......... 01.2123 16.99 360154......... 01.0363 12.79 370023......... 01.3264 15.36 340132....................... 01.4381 13.48 350058.......... 00.8581 12.32 360074......... 01.3755 19.42 360155......... 01.3328 19.43 370025......... 01.3632 16.03 340133....................... 01.0955 14.59 350060.......... 00.7725 07.81 360075......... 01.4503 20.74 360156......... 01.3471 17.17 370026......... 01.4139 16.34 340137....................... 01.1470 16.93 350061.......... 01.0750 14.05 360076......... 01.3497 17.88 360159......... 01.2236 19.63 370028......... 01.9000 19.01 340138....................... 01.0564 14.77 350063.......... 00.8496 ....... 360077......... 01.5372 19.34 360161......... 01.2522 19.38 370029......... 01.2231 13.67 340141....................... 01.6712 19.46 350064.......... 00.9598 ....... 360078......... 01.3085 20.54 360162......... 01.2461 18.42 370030......... 01.2222 15.66 340142....................... 01.2328 14.52 350066.......... 00.4249 ....... 360079......... 01.8680 21.00 360163......... 01.8359 19.83 370032......... 01.5723 15.46 340143....................... 01.4477 17.07 360001.......... 01.3378 16.97 360080......... 01.1089 15.47 360164......... 00.9012 14.82 370033......... 01.0214 11.30 340144....................... 01.3647 18.62 360002.......... 01.2156 16.93 360081......... 01.3825 19.32 360165......... 01.1732 14.70 370034......... 01.2608 13.35 340145....................... 01.4178 16.83 360003.......... 01.7711 21.00 360082......... 01.3422 20.33 360166......... 01.2022 14.95 370035......... 01.6224 16.49 340146....................... 01.0449 12.52 360006.......... 01.7569 20.88 360083......... 01.2835 16.28 360170......... 01.3679 17.38 370036......... 01.1150 10.48 340147....................... 01.3116 18.57 360007.......... 01.0845 16.02 360084......... 01.6050 19.41 360172......... 01.3918 16.51 370037......... 01.7463 17.69 340148....................... 01.5003 18.58 360008.......... 01.2538 17.40 360085......... 01.7758 20.40 360174......... 01.3082 17.57 370038......... 00.9813 11.67 340151....................... 01.2153 15.08 360009.......... 01.3941 17.80 360086......... 01.4419 18.21 360175......... 01.2537 18.78 370039......... 01.4120 14.24 340153....................... 01.8958 19.07 360010.......... 01.1953 16.42 360087......... 01.4087 17.90 360176......... 01.1682 14.85 370040......... 01.0735 12.21 340155....................... 01.4075 20.03 360011.......... 01.3112 18.17 360088......... 01.2554 16.38 360177......... 01.3012 16.97 370041......... 01.0348 14.17 340156....................... 00.8391 ....... 360012.......... 01.2910 19.29 360089......... 01.1463 17.74 360178......... 01.1912 16.88 370042......... 00.8602 12.67 340158....................... 01.2118 16.64 360013.......... 01.1166 17.72 360090......... 01.2393 19.06 360179......... 01.2984 19.34 370043......... 00.9396 13.83 340159....................... 01.1739 17.58 360014.......... 01.1725 17.98 360091......... 01.2353 19.17 360180......... 02.1422 22.61 370045......... 01.0172 10.45 340160....................... 01.1173 13.34 360016.......... 01.5863 17.93 360092......... 01.1745 18.70 360184......... 00.4826 16.57 370046......... 01.0071 11.67 340162....................... 01.1881 17.44 360017.......... 01.8234 20.42 360093......... 01.2346 16.69 360185......... 01.2323 17.09 370047......... 01.3660 15.46 340164....................... 01.5854 18.61 360018.......... 01.6349 19.27 360094......... 01.3179 19.51 360186......... 01.1303 14.23 370048......... 01.2382 14.10 340166....................... 01.3581 20.11 360019.......... 01.2464 19.11 360095......... 01.2963 17.00 360187......... 01.3922 16.45 370049......... 01.3876 15.65 340168....................... 00.5171 14.86 360020.......... 01.4455 19.77 360096......... 01.1048 16.11 360188......... 00.9743 15.83 370051......... 00.9683 12.64 340171....................... 01.1309 20.34 360021.......... 01.2171 17.75 360098......... 01.3545 17.96 360189......... 01.0832 16.02 370054......... 01.4892 15.09 340173....................... 01.2673 ....... 360024.......... 01.4066 18.60 360099......... 01.0438 15.01 360192......... 01.3251 20.42 370056......... 01.5847 18.24 350001....................... 01.0123 11.96 360025.......... 01.2789 18.44 360100......... 01.2631 16.54 360193......... 01.3592 16.93 370057......... 01.1516 13.78 350002....................... 01.7485 15.76 360026.......... 01.3183 16.15 360101......... 01.5633 19.00 360194......... 01.2185 16.98 370059......... 01.1145 17.59 350003....................... 01.1883 16.16 360027.......... 01.5006 19.53 360102......... 01.3173 20.31 360195......... 01.1450 18.15 370060......... 01.0938 12.84 350004....................... 01.9386 17.55 360028.......... 01.3927 16.15 360103......... 01.3791 19.64 360197......... 01.2415 18.15 370063......... 01.0275 13.43 350005....................... 01.1692 12.94 360029.......... 01.1968 17.00 360106......... 01.0835 14.96 360200......... 01.0110 14.16 370064......... 01.0078 10.63 350006....................... 01.4616 15.92 360030.......... 01.2855 16.35 360107......... 01.2884 17.73 360203......... 01.1551 15.13 370065......... 00.9984 15.50 350007....................... 00.9387 11.95 360031.......... 01.3350 18.56 360108......... 01.0393 15.34 360204......... 01.1958 17.97 370071......... 01.0541 11.99 350008....................... 00.9665 15.65 360032.......... 01.0939 18.26 360109......... 01.0943 17.32 360210......... 01.1513 19.78 370072......... 00.9059 12.83 350009....................... 01.2060 15.95 360034.......... 01.2933 13.90 360112......... 01.8152 22.51 360211......... 01.2508 18.78 370076......... 01.2821 12.00 350010....................... 01.2000 12.15 360035.......... 01.5996 20.13 360113......... 01.3358 19.54 360212......... 01.3943 19.17 370077......... 01.1968 16.27 350011....................... 01.9051 17.35 360036.......... 01.3867 17.62 360114......... 01.0899 17.10 360213......... 01.1498 17.17 370078......... 01.6755 14.49 350012....................... 01.2168 11.99 360037.......... 02.0410 20.51 360115......... 01.2893 17.95 360218......... 01.3251 16.46 370079......... 00.9520 12.41 350013....................... 01.0734 15.32 360038.......... 01.5770 18.07 360116......... 01.1193 16.64 360230......... 01.5118 19.37 370080......... 00.9631 11.68 350014....................... 01.0043 15.46 360039.......... 01.3058 16.07 360118......... 01.3823 18.32 360231......... 01.0811 12.11 370082......... 00.8621 13.46 350015....................... 01.6873 15.63 360040.......... 01.4255 17.31 360121......... 01.2332 17.90 360234......... 01.3514 18.54 370083......... 00.9402 11.35 350016....................... 01.0383 10.92 360041.......... 01.3554 18.33 360123......... 01.1988 18.37 360236......... 01.2821 17.59 370084......... 01.1283 11.02 350017....................... 01.4320 15.24 360042.......... 01.1544 17.62 360125......... 01.0770 17.38 360239......... 01.3231 19.51 370085......... 00.8919 14.52 350018....................... 01.0665 11.21 360044.......... 01.1752 15.64 360126......... 01.2087 20.09 360241......... 00.5984 18.86 370086......... 01.1210 07.79 350019....................... 01.6314 18.43 360045.......... 01.5364 20.90 360127......... 01.2267 16.48 360242......... 01.6845 ....... 370089......... 01.2563 13.16 350020....................... 01.7038 20.24 360046.......... 01.1470 19.88 360128......... 01.1952 14.73 360243......... 00.7548 15.52 370091......... 01.7651 17.18 350021....................... 01.0657 11.41 360047.......... 01.1546 13.65 360129......... 01.0119 14.59 360244......... 00.6196 15.74 370092......... 01.0486 14.38 350023....................... 00.9037 15.30 360048.......... 01.7847 21.55 360130......... 01.1375 15.59 360245......... 00.7558 14.33 370093......... 01.8654 18.71 350024....................... 01.0898 15.40 360049.......... 01.2053 18.18 360131......... 01.3635 17.38 360247......... 00.4249 ....... 370094......... 01.4086 17.00 350025....................... 01.0197 13.34 360050.......... 01.1555 12.37 360132......... 01.3113 18.78 370001......... 01.7020 18.73 370095......... 00.9433 11.66 350027....................... 00.9438 12.32 360051.......... 01.6065 22.36 360133......... 01.4867 18.44 370002......... 01.2595 13.98 370097......... 01.4514 18.02 350029....................... 00.8818 13.02 360052.......... 01.7593 18.41 360134......... 01.7147 19.43 370004......... 01.3100 15.35 370099......... 01.1946 12.65 350030....................... 00.9790 15.93 360054.......... 01.2902 15.83 360135......... 01.1776 16.82 370005......... 01.0107 13.12 370100......... 00.9605 13.45 350033....................... 00.9672 14.33 360055.......... 01.2729 19.12 360136......... 01.0797 15.96 370006......... 01.2229 15.08 370103......... 00.9375 15.07 350034....................... 00.9622 14.56 360056.......... 01.4338 16.47 360137......... 01.6205 18.82 370007......... 01.2258 13.82 370105......... 01.9925 16.23 350035....................... 00.8570 09.95 360057.......... 01.1143 13.87 360140......... 01.0283 16.19 370008......... 01.4034 16.68 370106......... 01.5287 16.46 350038....................... 01.0474 14.07 360058.......... 01.3442 16.66 360141......... 01.4692 21.06 370011......... 01.0552 12.95 370108......... 01.0528 11.73 350039....................... 01.0412 13.84 360059.......... 01.5702 20.39 360142......... 00.9974 15.98 370012......... 00.8901 09.07 370112......... 01.0761 13.21 350041....................... 00.9787 14.99 360062.......... 01.5152 19.27 360143......... 01.3979 18.13 370013......... 01.7959 19.41 370113......... 01.2411 16.23 350042....................... 01.0876 11.16 360063.......... 01.1537 18.08 360144......... 01.3184 20.77 370014......... 01.2915 18.49 370114......... 01.6734 15.49 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29967]] Page 12 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 370121....................... 01.1456 17.38 380035.......... 01.3707 19.01 390037......... 01.3363 18.93 390118......... 01.2116 16.26 390211......... 01.2753 16.99 370122....................... 01.1334 07.58 380036.......... 01.0573 20.26 390039......... 01.1242 15.66 390119......... 01.3751 17.59 390213......... 01.0005 16.41 370123....................... 01.2119 12.32 380037.......... 01.1645 19.53 390040......... 00.9636 13.13 390121......... 01.3408 17.47 390215......... 01.2741 21.06 370125....................... 01.0078 13.37 380038.......... 01.3353 22.64 390041......... 01.3184 17.07 390122......... 01.0708 17.57 390217......... 01.2339 18.51 370126....................... 00.9515 15.34 380039.......... 01.3785 29.30 390042......... 01.5616 21.73 390123......... 01.3538 20.71 390219......... 01.3280 19.67 370131....................... 01.0025 12.88 380040.......... 01.2637 19.96 390043......... 01.1718 14.85 390125......... 01.2277 15.61 390220......... 01.1974 19.37 370133....................... 01.1482 10.09 380042.......... 01.1658 20.57 390044......... 01.6542 19.63 390126......... 01.2947 21.03 390222......... 01.3127 20.33 370138....................... 01.1319 15.23 380047.......... 01.7042 22.12 390045......... 01.7640 18.05 390127......... 01.2463 20.96 390223......... 01.5485 23.11 370139....................... 01.1351 12.56 380048.......... 01.0410 14.68 390046......... 01.6118 19.79 390128......... 01.2129 18.14 390224......... 00.9185 13.35 370140....................... 00.9528 10.99 380050.......... 01.3882 17.45 390047......... 01.7879 28.26 390130......... 01.1528 17.20 390225......... 01.2038 17.25 370141....................... 01.3712 17.30 380051.......... 01.5603 20.05 390048......... 01.1662 16.60 390131......... 01.2893 16.30 390226......... 01.7722 24.15 370146....................... 01.0068 10.73 380052.......... 01.1841 16.75 390049......... 01.6471 20.69 390132......... 01.3456 15.42 390228......... 01.2584 19.38 370148....................... 01.5163 18.46 380055.......... 01.1753 24.14 390050......... 02.1332 22.39 390133......... 01.8248 21.71 390231......... 01.3380 25.11 370149....................... 01.2715 15.35 380056.......... 01.0662 17.36 390051......... 02.2314 25.28 390135......... 01.3067 21.05 390233......... 01.3166 17.22 370153....................... 01.1566 13.86 380060.......... 01.4332 21.98 390052......... 01.2173 19.41 390136......... 01.1980 15.39 390235......... 01.6737 24.38 370154....................... 00.9918 13.05 380061.......... 01.5328 22.07 390054......... 01.2362 16.08 390137......... 01.5014 16.35 390236......... 01.2218 15.88 370156....................... 01.0804 12.49 380062.......... 01.1673 14.40 390055......... 01.8446 21.81 390138......... 01.3175 17.93 390237......... 01.5879 20.36 370158....................... 00.9865 11.75 380063.......... 01.2839 19.01 390056......... 01.1627 16.81 390139......... 01.5583 23.54 390238......... 01.4187 16.51 370159....................... 01.2579 15.59 380064.......... 01.3699 21.25 390057......... 01.2722 18.70 390142......... 01.6478 23.18 390242......... 01.2892 18.48 370163....................... 00.8584 12.16 380065.......... 01.0989 22.49 390058......... 01.3320 18.67 390145......... 01.3920 19.48 390244......... 00.8955 09.83 370165....................... 01.2002 12.46 380066.......... 01.4293 18.58 390060......... 01.1507 16.92 390146......... 01.2908 16.44 390245......... 01.3725 23.05 370166....................... 01.1412 16.32 380068.......... 01.0536 19.05 390061......... 01.4904 19.08 390147......... 01.2386 19.08 390246......... 01.2495 17.25 370169....................... 01.0923 11.25 380069.......... 01.1444 18.59 390062......... 01.2096 16.01 390150......... 01.1114 18.10 390247......... 01.0371 18.26 370170....................... 01.0998 ....... 380070.......... 01.3975 21.24 390063......... 01.7632 19.24 390151......... 01.2811 18.58 390249......... 00.9800 12.06 370171....................... 01.0602 ....... 380071.......... 01.3430 20.07 390065......... 01.2783 19.30 390152......... 01.0751 18.81 390256......... 01.8447 23.21 370172....................... 00.9962 ....... 380072.......... 00.9558 14.66 390066......... 01.3181 17.77 390153......... 01.2365 22.46 390258......... 01.2636 20.08 370173....................... 01.1720 ....... 380075.......... 01.4074 19.72 390067......... 01.7805 18.91 390154......... 01.2353 16.67 390260......... 01.2223 21.36 370174....................... 01.1211 ....... 380078.......... 01.1136 17.41 390068......... 01.2705 17.23 390155......... 01.2835 19.44 390262......... 02.1044 17.77 370176....................... 01.1786 15.29 380081.......... 01.0882 18.84 390069......... 01.2052 17.75 390156......... 01.4384 21.37 390263......... 01.4788 19.16 370177....................... 01.0146 10.09 380082.......... 01.3415 22.96 390070......... 01.2877 20.39 390157......... 01.3442 17.99 390265......... 01.2975 18.82 370178....................... 01.0038 10.96 380083.......... 01.2329 20.06 390071......... 01.1345 13.41 390158......... 01.5815 18.96 390266......... 01.1903 16.81 370179....................... 00.8178 17.33 380084.......... 01.3178 21.43 390072......... 01.0884 15.91 390160......... 01.2481 18.50 390267......... 01.2766 19.80 370180....................... 00.9743 ....... 380087.......... 01.0131 15.38 390073......... 01.6228 19.03 390161......... 01.1216 14.43 390268......... 01.3984 20.44 370183....................... 01.0112 12.06 380088.......... 01.0312 16.16 390074......... 01.3104 16.05 390162......... 01.4567 19.59 390270......... 01.3195 16.67 370186....................... 01.0207 13.15 380089.......... 01.3743 22.25 390075......... 01.3024 16.41 390163......... 01.2442 15.99 390272......... 00.5086 ...... 370189....................... 00.9532 07.82 380090.......... 01.3216 25.71 390076......... 01.3560 21.07 390164......... 02.1520 20.37 390277......... 00.5135 22.55 370190....................... 01.5726 15.31 380091.......... 01.2636 25.13 390078......... 01.0405 16.88 390166......... 01.1028 18.31 390278......... 00.6667 18.42 370192....................... 01.3093 17.57 390001.......... 01.3377 18.25 390079......... 01.7573 16.81 390167......... 01.3539 21.30 390279......... 01.0585 15.32 370194....................... 01.8498 ....... 390002.......... 01.3642 18.62 390080......... 01.3310 19.14 390168......... 01.2630 18.43 390281......... 02.6697 ...... 370195....................... 01.7510 ....... 390003.......... 01.2533 15.88 390081......... 01.3720 22.88 390169......... 01.2861 18.72 390282......... 02.8720 ...... 370196....................... 01.2186 ....... 390004.......... 01.4312 18.12 390083......... 01.1651 22.01 390170......... 01.9027 21.25 400001......... 01.3075 08.65 370197....................... 01.0898 ....... 390005.......... 01.0800 14.24 390084......... 01.1937 15.57 390173......... 01.1957 17.78 400002......... 01.5650 11.00 380001....................... 01.3595 21.21 390006.......... 01.7512 18.17 390086......... 01.2015 15.86 390174......... 01.7556 25.41 400003......... 01.2778 08.44 380002....................... 01.1948 19.35 390007.......... 01.1629 21.90 390088......... 01.3108 22.62 390176......... 01.1738 18.14 400004......... 01.1644 08.18 380003....................... 01.2011 20.71 390008.......... 01.1581 15.47 390090......... 01.8609 18.97 390178......... 01.2971 18.44 400005......... 01.0829 06.61 380004....................... 01.7699 23.34 390009.......... 01.6156 17.81 390091......... 01.1345 17.40 390179......... 01.3028 22.12 400006......... 01.1988 07.59 380005....................... 01.2498 21.15 390010.......... 01.1928 17.10 390093......... 01.1545 14.99 390180......... 01.5562 23.40 400007......... 01.2163 07.46 380006....................... 01.3682 19.26 390011.......... 01.2677 16.82 390095......... 01.1947 14.46 390181......... 01.0663 18.59 400009......... 01.0136 07.71 380007....................... 01.5884 23.43 390012.......... 01.2600 19.73 390096......... 01.3337 17.00 390183......... 01.2197 18.03 400010......... 00.9361 08.53 380008....................... 01.0562 17.82 390013.......... 01.2411 16.90 390097......... 01.3295 21.56 390184......... 01.1453 18.07 400011......... 00.9932 08.12 380009....................... 01.8380 23.30 390015.......... 01.1668 13.12 390098......... 01.7987 20.75 390185......... 01.2103 16.34 400012......... 01.2302 07.40 380010....................... 01.1162 20.67 390016.......... 01.2453 16.40 390100......... 01.6689 20.03 390189......... 01.0957 15.96 400013......... 01.2495 08.19 380011....................... 01.0890 20.97 390017.......... 01.1322 15.43 390101......... 01.2433 16.62 390191......... 01.1789 14.33 400014......... 01.3919 09.06 380013....................... 01.2719 17.76 390018.......... 01.3522 20.05 390102......... 01.3985 20.58 390192......... 01.1862 16.36 400015......... 01.2207 10.98 380014....................... 01.5562 20.77 390019.......... 01.1189 15.59 390103......... 01.0990 18.00 390193......... 01.2159 16.13 400016......... 01.3485 10.89 380017....................... 01.8262 23.17 390022.......... 01.3277 ....... 390104......... 01.0912 14.99 390194......... 01.0905 18.91 400017......... 01.2423 07.70 380018....................... 01.7650 21.22 390023.......... 01.3020 18.98 390106......... 01.0779 15.15 390195......... 01.8842 22.93 400018......... 01.2939 09.80 380019....................... 01.3206 19.33 390024.......... 00.9902 23.26 390107......... 01.2940 19.04 390196......... 01.4403 ....... 400019......... 01.8123 09.34 380020....................... 01.4383 21.87 390025.......... 00.6319 15.97 390108......... 01.3549 20.08 390197......... 01.3000 18.49 400021......... 01.4962 08.79 380021....................... 01.2983 19.44 390026.......... 01.2842 20.94 390109......... 01.1618 14.14 390198......... 01.2260 15.75 400022......... 01.3207 10.01 380022....................... 01.2237 21.01 390027.......... 01.9139 25.88 390110......... 01.5969 18.05 390199......... 01.3087 15.40 400024......... 00.9888 07.79 380023....................... 01.2422 17.43 390028.......... 01.9063 17.78 390111......... 01.8405 27.77 390200......... 01.0941 14.88 400026......... 00.9734 06.74 380025....................... 01.2509 22.55 390029.......... 01.9567 18.83 390112......... 01.1937 12.26 390201......... 01.2601 19.26 400027......... 01.1951 09.06 380026....................... 01.1673 17.54 390030.......... 01.2362 17.37 390113......... 01.2115 16.25 390203......... 01.3880 20.96 400028......... 01.0432 07.89 380027....................... 01.3334 23.09 390031.......... 01.1652 17.15 390114......... 01.2440 22.27 390204......... 01.2807 18.56 400029......... 01.1384 09.92 380029....................... 01.1591 18.45 390032.......... 01.2748 18.10 390115......... 01.3799 22.31 390205......... 01.4152 20.63 400031......... 01.1944 08.50 380031....................... 01.0213 18.48 390035.......... 01.2522 17.79 390116......... 01.2575 21.78 390206......... 01.4067 20.14 400032......... 01.1883 08.21 380033....................... 01.7400 24.13 390036.......... 01.4191 18.06 390117......... 01.1969 15.62 390209......... 01.0490 15.09 400044......... 01.2161 09.13 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29968]] Page 13 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 400048....................... 01.2242 07.12 420056.......... 01.1507 13.66 430062......... 00.8088 10.50 440072......... 01.4213 14.81 440208......... 01.9916 ...... 400061....................... 01.5742 13.14 420057.......... 01.1643 15.20 430064......... 01.1702 12.48 440073......... 01.3464 18.39 440209......... 01.7950 ...... 400079....................... 01.3004 08.37 420059.......... 00.9868 13.80 430065......... 01.0035 10.34 440078......... 01.0317 13.14 440211......... 00.8607 ...... 400087....................... 01.4245 08.10 420061.......... 01.1719 16.99 430066......... 00.9891 11.87 440081......... 01.1813 15.86 450002......... 01.5247 15.76 400094....................... 01.1019 09.07 420062.......... 01.3818 16.51 430073......... 01.0151 13.25 440082......... 02.0414 21.47 450004......... 01.2254 12.21 400098....................... 01.2325 07.84 420064.......... 01.1548 14.32 430076......... 00.9907 10.30 440083......... 01.1353 12.16 450005......... 01.2214 13.65 400102....................... 01.2159 07.59 420065.......... 01.3523 17.37 430077......... 01.6483 16.77 440084......... 01.1861 12.89 450007......... 01.2627 13.51 400103....................... 01.4404 09.09 420066.......... 00.9284 15.38 430079......... 01.0189 11.63 440090......... 00.8532 11.62 450008......... 01.3666 14.74 400104....................... 01.4125 09.01 420067.......... 01.2688 16.48 430081......... 00.9311 ....... 440091......... 01.6476 16.91 450010......... 01.4032 15.09 400105....................... 01.3335 09.08 420068.......... 01.3427 17.07 430082......... 00.9287 ....... 440100......... 01.0717 13.60 450011......... 01.6018 14.66 400106....................... 01.2054 07.87 420069.......... 01.0615 14.29 430083......... 00.7707 ....... 440102......... 01.0749 12.64 450014......... 01.0418 14.53 400109....................... 01.4891 09.67 420070.......... 01.2880 15.76 430084......... 00.9960 ....... 440103......... 01.2611 16.57 450015......... 01.5262 15.25 400110....................... 01.1489 08.39 420071.......... 01.3268 17.29 430085......... 00.8973 ....... 440104......... 01.6975 18.53 450016......... 01.6392 17.49 400111....................... 01.1258 08.52 420072.......... 01.0362 11.62 430087......... 00.9273 08.64 440105......... 01.0672 16.52 450018......... 01.5953 21.98 400112....................... 01.2481 08.03 420073.......... 01.3173 18.17 430089......... 00.8485 ....... 440109......... 01.1135 12.71 450020......... 01.0239 16.23 400113....................... 01.2690 07.41 420074.......... 00.9872 11.49 440001......... 01.1428 12.99 440110......... 00.9608 16.41 450021......... 01.8331 21.68 400114....................... 01.0608 07.55 420075.......... 00.9616 14.51 440002......... 01.6292 16.75 440111......... 01.3704 18.75 450023......... 01.4566 16.60 400115....................... 01.0263 07.86 420078.......... 01.7953 19.92 440003......... 01.1369 15.46 440114......... 01.0812 12.28 450024......... 01.3230 16.74 400117....................... 01.1722 09.01 420079.......... 01.5952 17.29 440006......... 01.4817 18.40 440115......... 01.0718 15.34 450025......... 01.5940 15.72 400118....................... 01.2085 09.52 420080.......... 01.3266 21.07 440007......... 00.9709 11.94 440120......... 01.5405 18.26 450028......... 01.5631 18.19 400120....................... 01.3142 09.23 420081.......... 01.2360 19.59 440008......... 01.0209 12.34 440125......... 01.4775 18.20 450029......... 01.4549 14.12 400121....................... 01.0939 06.53 420082.......... 01.4198 19.00 440009......... 01.2686 14.38 440130......... 01.2126 13.33 450031......... 01.5168 16.40 400122....................... 01.0238 06.66 420083.......... 01.2843 17.31 440010......... 00.9443 10.15 440131......... 01.1300 13.71 450032......... 01.2480 12.89 400123....................... 01.1445 09.36 420085.......... 01.5070 17.06 440011......... 01.3311 16.51 440132......... 01.1379 14.75 450033......... 01.6134 17.70 400124....................... 02.3594 11.32 420086.......... 01.3720 16.96 440012......... 01.5149 18.04 440133......... 01.5674 18.67 450034......... 01.7067 18.08 410001....................... 01.3373 22.95 420087.......... 01.6970 16.86 440014......... 01.1197 09.84 440135......... 01.2783 17.25 450035......... 01.5310 19.16 410004....................... 01.3108 20.70 420088.......... 01.1977 15.27 440015......... 01.7227 18.12 440137......... 01.0167 13.14 450037......... 01.6277 18.03 410005....................... 01.3532 22.65 420089.......... 01.2349 20.60 440016......... 00.9968 12.59 440141......... 01.0482 14.12 450039......... 01.3300 15.55 410006....................... 01.3138 20.73 420091.......... 01.2859 15.25 440017......... 01.6389 20.72 440142......... 01.0271 11.05 450040......... 01.5616 17.73 410007....................... 01.7020 21.60 420093.......... 01.0323 ....... 440018......... 01.4094 17.06 440143......... 01.1050 15.73 450042......... 01.7484 15.78 410008....................... 01.2204 21.52 420094.......... 01.0179 ....... 440019......... 01.7169 17.21 440144......... 01.2388 18.01 450044......... 01.6262 18.91 410009....................... 01.3136 21.34 430004.......... 01.1109 15.06 440020......... 01.2203 15.78 440145......... 00.9912 14.42 450046......... 01.3343 15.81 410010....................... 01.0657 25.32 430005.......... 01.3614 14.44 440022......... 01.1220 14.01 440147......... 01.5238 23.56 450047......... 01.0984 11.06 410011....................... 01.2324 23.69 430007.......... 01.0857 12.77 440023......... 01.0808 13.04 440148......... 01.1480 15.54 450050......... 01.0051 14.35 410012....................... 01.8245 20.26 430008.......... 01.1123 13.56 440024......... 01.3172 16.88 440149......... 01.1537 15.28 450051......... 01.6250 18.53 410013....................... 01.3313 27.36 430010.......... 01.1579 11.70 440025......... 01.1300 13.54 440150......... 01.2962 19.97 450052......... 01.0403 13.01 420002....................... 01.3770 20.19 430011.......... 01.2798 14.49 440029......... 01.2918 16.93 440151......... 01.3053 16.20 450053......... 01.0959 13.82 420004....................... 01.8223 18.16 430012.......... 01.2820 15.03 440030......... 01.2279 12.15 440152......... 01.7854 17.68 450054......... 01.6711 21.71 420005....................... 01.2080 14.51 430013.......... 01.2916 15.39 440031......... 01.0160 13.14 440153......... 01.2929 15.19 450055......... 01.1378 13.89 420006....................... 01.1685 17.19 430014.......... 01.3110 16.99 440032......... 01.0578 14.47 440156......... 01.5822 19.18 450056......... 01.6884 17.92 420007....................... 01.4966 16.92 430015.......... 01.2134 15.17 440033......... 01.1116 14.61 440157......... 01.0406 13.83 450058......... 01.5849 16.46 420009....................... 01.2388 16.92 430016.......... 01.8671 17.78 440034......... 01.5553 17.68 440159......... 01.3164 14.02 450059......... 01.2856 13.85 420010....................... 01.1193 15.13 430018.......... 00.9520 13.13 440035......... 01.3293 16.53 440161......... 01.8760 20.06 450063......... 00.9511 10.66 420011....................... 01.1234 15.28 430022.......... 00.9351 11.95 440039......... 01.6928 17.44 440162......... 01.0104 16.30 450064......... 01.4865 15.57 420014....................... 01.0951 14.36 430023.......... 00.9521 10.34 440040......... 01.0082 10.81 440166......... 01.5684 18.25 450065......... 01.1163 14.73 420015....................... 01.3662 16.84 430024.......... 00.9521 12.07 440041......... 01.0593 12.23 440168......... 01.0424 12.43 450068......... 01.8875 21.36 420016....................... 01.0745 14.21 430026.......... 01.0086 11.18 440046......... 01.2853 15.30 440173......... 01.5484 17.50 450072......... 01.2285 18.67 420018....................... 01.8185 20.00 430027.......... 01.7827 17.63 440047......... 00.9404 14.52 440174......... 01.0215 12.74 450073......... 01.1020 12.06 420019....................... 01.1984 14.70 430028.......... 01.1366 13.29 440048......... 01.8480 17.82 440175......... 01.1777 18.60 450076......... 01.6669 ...... 420020....................... 01.3480 16.94 430029.......... 00.9657 13.84 440049......... 01.6757 16.37 440176......... 01.4491 19.17 450078......... 00.9704 11.75 420023....................... 01.4482 18.50 430031.......... 00.9226 11.58 440050......... 01.3472 16.52 440178......... 01.2515 17.07 450079......... 01.4553 21.93 420026....................... 01.8746 ....... 430033.......... 01.0529 13.10 440051......... 00.9680 13.82 440180......... 01.2303 16.96 450080......... 01.2792 15.99 420027....................... 01.3574 16.82 430034.......... 01.1146 11.59 440052......... 01.1954 14.76 440181......... 01.0357 12.37 450081......... 01.0888 14.50 420030....................... 01.2767 16.95 430036.......... 01.0229 11.83 440053......... 01.3492 16.28 440182......... 01.0196 12.53 450082......... 01.0008 14.70 420031....................... 00.9777 11.88 430037.......... 00.9883 13.15 440054......... 01.2010 14.55 440183......... 01.5112 19.69 450083......... 01.7831 19.58 420033....................... 01.1637 18.91 430038.......... 01.0476 10.83 440056......... 01.1009 13.57 440184......... 01.3998 18.96 450085......... 01.0851 17.24 420036....................... 01.3500 16.42 430040.......... 01.0238 12.64 440057......... 01.0218 12.15 440185......... 01.2194 17.48 450087......... 01.4649 18.74 420037....................... 01.2806 20.66 430041.......... 00.9678 12.47 440058......... 01.2498 16.30 440186......... 01.0749 15.77 450090......... 01.2173 13.26 420038....................... 01.2733 14.80 430043.......... 01.2174 11.82 440059......... 01.3794 14.85 440187......... 01.1423 14.65 450092......... 01.2090 11.88 420039....................... 01.1655 15.64 430044.......... 00.8368 14.07 440060......... 01.3032 14.20 440189......... 01.5094 19.13 450094......... 01.3357 17.87 420042....................... 01.1364 14.05 430047.......... 01.0865 11.92 440061......... 01.1966 15.89 440192......... 01.1998 15.37 450096......... 01.5725 17.19 420043....................... 01.2714 19.12 430048.......... 01.2962 15.48 440063......... 01.6337 17.90 440193......... 01.2956 18.60 450097......... 01.4817 18.51 420048....................... 01.1481 15.56 430049.......... 00.9274 12.70 440064......... 01.1162 14.56 440194......... 01.2216 17.13 450098......... 01.1764 15.10 420049....................... 01.2072 15.85 430051.......... 00.9319 13.84 440065......... 01.2912 17.78 440197......... 01.3735 19.23 450099......... 01.3101 23.18 420051....................... 01.6308 18.01 430054.......... 01.0413 12.79 440067......... 01.2815 14.99 440200......... 01.0981 15.64 450101......... 01.4883 15.44 420053....................... 01.2774 14.99 430056.......... 00.8740 09.56 440068......... 01.2253 17.28 440203......... 00.9109 13.09 450102......... 01.7049 17.58 420054....................... 01.2582 17.08 430057.......... 00.9229 10.73 440070......... 01.1015 14.28 440205......... 01.1096 15.47 450104......... 01.2444 14.23 420055....................... 01.0221 14.59 430060.......... 00.9262 08.64 440071......... 01.3899 16.32 440206......... 01.0802 13.80 450107......... 01.6233 22.05 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29969]] Page 14 of 16 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Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 450108....................... 00.9815 12.48 450222.......... 01.6052 18.35 450388......... 01.8099 17.12 450597......... 01.0314 14.53 450716......... 01.2930 19.56 450109....................... 00.9148 14.70 450224.......... 01.3658 20.66 450389......... 01.3230 17.71 450603......... 00.7195 16.81 450717......... 01.2558 23.86 450110....................... 01.2769 19.30 450229.......... 01.5642 15.41 450393......... 01.3196 19.70 450604......... 01.4409 14.00 450718......... 01.2324 19.03 450111....................... 01.2174 18.93 450231.......... 01.6420 18.25 450395......... 01.0474 13.74 450605......... 01.3903 17.67 450723......... 01.3871 18.21 450112....................... 01.3148 14.31 450234.......... 01.0004 13.07 450399......... 01.0593 15.59 450609......... 00.9173 11.77 450724......... 01.3694 17.44 450113....................... 01.2852 17.93 450235.......... 01.0302 13.46 450400......... 01.1860 11.76 450610......... 01.5468 17.21 450725......... 00.9483 17.49 450118....................... 01.5829 20.36 450236.......... 01.2196 13.99 450403......... 01.2999 21.22 450614......... 01.0061 12.53 450727......... 01.2086 10.80 450119....................... 01.3813 17.13 450237.......... 01.6231 16.83 450411......... 00.9126 12.20 450615......... 01.0935 12.80 450728......... 00.9365 12.62 450121....................... 01.5542 19.99 450239.......... 01.0605 13.70 450417......... 01.0959 19.31 450617......... 01.3517 20.12 450730......... 01.3301 21.46 450123....................... 01.0936 15.98 450241.......... 00.9264 12.67 450418......... 01.4986 21.43 450620......... 01.1357 12.16 450733......... 01.3644 16.88 450124....................... 01.7106 16.25 450243.......... 00.7792 09.65 450419......... 01.2778 17.19 450623......... 01.1891 16.71 450735......... 01.0419 12.02 450126....................... 01.3628 16.01 450246.......... 00.9464 17.09 450422......... 00.8249 24.65 450626......... 01.0657 16.03 450742......... 01.2935 19.47 450128....................... 01.1960 12.44 450249.......... 00.9685 09.95 450423......... 01.5847 21.56 450628......... 00.9294 12.34 450743......... 01.4234 17.79 450130....................... 01.4849 16.93 450250.......... 00.9480 11.36 450424......... 01.2491 17.77 450630......... 01.6663 23.25 450746......... 01.0195 13.81 450131....................... 01.4085 18.24 450253.......... 01.3010 11.92 450429......... 01.1054 12.87 450631......... 01.7531 20.15 450747......... 01.3630 17.04 450132....................... 01.7189 16.46 450258.......... 01.1072 10.85 450431......... 01.6301 18.76 450632......... 00.9769 11.39 450749......... 01.0131 14.63 450133....................... 01.5938 17.90 450259.......... 01.1636 18.29 450438......... 01.2603 11.50 450633......... 01.6373 20.20 450750......... 01.0217 12.20 450135....................... 01.6826 23.54 450264.......... 00.8770 13.08 450446......... 00.6484 12.67 450634......... 01.6146 23.56 450751......... 01.3430 15.58 450137....................... 01.5005 22.19 450269.......... 01.0728 13.96 450447......... 01.3879 18.07 450638......... 01.5891 22.00 450754......... 00.9520 13.49 450140....................... 00.9941 17.44 450270.......... 01.2548 08.84 450451......... 01.1562 16.96 450639......... 01.4390 21.06 450755......... 01.1665 15.54 450142....................... 01.4559 20.28 450271.......... 01.2644 14.84 450457......... 01.7826 17.34 450641......... 01.0419 13.24 450757......... 00.9463 13.62 450143....................... 01.0346 11.10 450272.......... 01.3480 15.38 450460......... 01.0543 12.46 450643......... 01.2287 17.43 450758......... 02.0308 21.92 450144....................... 01.0940 15.29 450276.......... 01.0121 12.63 450462......... 01.7703 20.49 450644......... 01.5108 19.07 450760......... 01.2570 18.35 450145....................... 00.8190 13.36 450278.......... 00.9870 13.64 450464......... 01.0046 15.15 450646......... 01.6546 31.36 450761......... 01.1320 09.57 450146....................... 00.9883 20.32 450280.......... 01.5295 23.09 450465......... 01.3413 16.93 450647......... 01.9647 23.27 450763......... 01.0156 16.60 450147....................... 01.4166 17.72 450283.......... 01.1089 12.43 450467......... 00.9719 14.01 450648......... 00.9843 09.48 450766......... 02.0743 20.76 450148....................... 01.2606 20.21 450286.......... 01.0057 16.36 450469......... 01.3764 17.25 450649......... 01.0397 14.06 450769......... 00.9968 13.40 450149....................... 01.4187 19.53 450288.......... 01.2657 13.67 450473......... 00.9945 15.03 450651......... 01.7497 22.80 450770......... 01.0425 14.57 450150....................... 00.9226 13.75 450289.......... 01.4333 19.14 450475......... 01.1405 14.96 450652......... 00.8637 13.96 450771......... 01.7860 22.32 450151....................... 01.1247 14.16 450292.......... 01.2492 21.03 450484......... 01.4464 18.03 450653......... 01.2233 15.20 450774......... 01.0941 21.24 450152....................... 01.2598 15.74 450293.......... 00.9756 12.41 450488......... 01.3242 16.08 450654......... 00.9512 12.28 450775......... 01.2818 17.09 450153....................... 01.6202 18.44 450296.......... 01.3760 15.38 450489......... 01.0196 12.72 450656......... 01.5372 17.19 450776......... 00.9164 11.18 450154....................... 01.1969 13.12 450299.......... 01.3407 13.00 450497......... 01.1733 12.88 450658......... 00.9714 12.32 450777......... 01.0384 16.60 450155....................... 01.0262 14.09 450303.......... 00.9926 11.50 450498......... 01.0536 13.15 450659......... 01.5376 20.54 450779......... 01.2550 21.36 450157....................... 00.9708 12.80 450306.......... 01.2021 12.82 450508......... 01.4210 13.21 450661......... 01.2312 18.51 450780......... 01.4170 16.91 450160....................... 00.9461 17.12 450307.......... 00.7810 14.25 450514......... 01.1932 18.47 450662......... 01.6120 17.38 450781......... 01.5749 11.01 450162....................... 01.2508 18.76 450309.......... 01.0665 14.17 450517......... 00.9085 11.11 450665......... 00.9174 12.95 450785......... 01.0228 16.39 450163....................... 01.1399 16.82 450315.......... 01.0404 18.63 450518......... 01.5597 16.38 450666......... 01.3365 19.72 450788......... 01.4465 19.31 450164....................... 01.1216 12.83 450320.......... 01.3540 18.45 450523......... 01.5809 19.54 450668......... 01.5985 19.60 450794......... 01.4278 16.20 450165....................... 01.0205 10.46 450321.......... 01.0170 13.51 450530......... 01.3722 14.27 450669......... 01.3372 19.26 450795......... 00.8684 20.22 450166....................... 01.0252 13.06 450322.......... 00.8216 16.61 450534......... 01.0396 18.02 450670......... 01.3101 17.24 450797......... 00.7374 16.67 450169....................... 01.0085 11.97 450324.......... 01.6983 15.77 450535......... 01.2947 21.25 450672......... 01.6189 20.69 450798......... 00.8432 08.88 450170....................... 00.9952 12.46 450325.......... 00.9022 11.47 450537......... 01.3071 19.69 450673......... 01.0516 12.14 450801......... 01.4775 22.80 450176....................... 01.2954 15.32 450327.......... 01.0143 12.60 450538......... 01.2092 20.77 450674......... 00.9786 19.88 450802......... 01.2334 ...... 450177....................... 01.2766 11.10 450330.......... 01.1500 15.62 450539......... 01.4110 14.67 450675......... 01.5234 20.99 450803......... 00.8631 ...... 450178....................... 01.0184 15.84 450334.......... 01.0516 12.11 450544......... 01.3641 19.25 450677......... 01.4283 17.43 450804......... 01.5585 ...... 450181....................... 01.0644 14.13 450337.......... 01.1601 13.85 450545......... 01.2684 20.93 450678......... 01.5025 20.85 450807......... 00.9198 ...... 450184....................... 01.5231 13.53 450340.......... 01.3229 12.68 450547......... 01.1540 15.13 450683......... 01.3410 17.23 450808......... 00.9783 ...... 450185....................... 01.0793 08.69 450341.......... 01.0487 15.87 450550......... 01.0672 18.37 450684......... 01.3031 21.41 450809......... 01.6796 ...... 450187....................... 01.2402 16.51 450346.......... 01.4259 15.73 450551......... 01.2241 13.01 450686......... 01.6052 14.14 450810......... 01.3049 ...... 450188....................... 01.0927 12.80 450347.......... 01.1507 16.68 450558......... 01.7279 20.85 450688......... 01.3639 19.63 450811......... 02.1669 ...... 450190....................... 01.1709 ....... 450348.......... 00.9843 11.20 450559......... 00.9392 12.26 450690......... 01.4058 21.41 450812......... 01.5923 ...... 450191....................... 01.0842 15.87 450351.......... 01.1951 17.71 450561......... 01.6915 17.18 450691......... 00.9630 ....... 460001......... 01.8018 20.73 450192....................... 01.2916 17.51 450352.......... 01.1046 16.53 450563......... 01.2766 23.92 450694......... 01.1385 18.16 460003......... 01.6984 17.86 450193....................... 02.0357 21.80 450353.......... 01.2637 16.98 450565......... 01.2685 16.10 450696......... 01.9697 22.02 460004......... 01.7275 21.45 450194....................... 01.2661 17.65 450355.......... 01.1523 13.03 450570......... 01.0784 15.81 450697......... 01.4970 13.82 460005......... 01.6827 18.56 450196....................... 01.4873 16.93 450358.......... 02.0795 20.80 450571......... 01.4769 15.53 450698......... 00.9778 11.65 460006......... 01.4501 19.40 450200....................... 01.4249 17.40 450362.......... 01.1675 13.83 450573......... 01.0612 14.35 450700......... 00.9476 13.15 460007......... 01.3572 20.40 450201....................... 01.0038 15.45 450369.......... 01.0553 13.10 450574......... 00.9359 11.72 450702......... 01.5805 18.94 460008......... 01.3860 15.91 450203....................... 01.2170 17.46 450370.......... 01.2765 11.11 450575......... 01.0735 16.62 450703......... 01.5428 18.24 460009......... 01.8462 19.39 450209....................... 01.4952 21.78 450371.......... 01.1605 12.16 450578......... 00.9338 12.99 450704......... 01.4192 18.02 460010......... 02.0177 20.86 450210....................... 01.1667 12.30 450372.......... 01.3132 21.02 450580......... 01.1376 13.29 450705......... 00.9145 18.50 460011......... 01.4613 16.34 450211....................... 01.4111 16.52 450373.......... 01.1587 13.38 450583......... 00.9816 13.04 450706......... 01.2508 22.63 460013......... 01.5206 16.74 450213....................... 01.6457 15.42 450374.......... 00.9148 11.66 450584......... 01.1817 13.02 450709......... 01.3400 19.78 460014......... 01.0850 15.12 450214....................... 01.4227 19.51 450376.......... 01.4827 17.78 450586......... 01.0491 11.16 450711......... 01.5979 18.18 460015......... 01.2184 20.40 450217....................... 01.0015 11.56 450378.......... 01.1028 19.87 450587......... 01.2525 15.98 450712......... 00.7899 11.12 460016......... 00.9611 12.50 450219....................... 01.1518 14.78 450379.......... 01.5239 21.62 450591......... 01.1497 18.92 450713......... 01.4954 20.85 460017......... 01.5581 16.40 450221....................... 01.1688 14.40 450381.......... 00.9929 12.86 450596......... 01.3942 17.15 450715......... 01.3740 18.59 460018......... 00.9973 15.45 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29970]] Page 15 of 16 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Avg. Avg. Avg. Avg. Avg. Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour index wage index wage index wage index wage index wage ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 460019....................... 01.1179 14.45 490035.......... 01.1338 13.02 490130......... 01.2939 15.07 500097......... 01.2116 17.46 510071......... 01.3174 15.64 460020....................... 01.0427 16.33 490037.......... 01.2373 13.99 490131......... 00.9879 14.74 500098......... 01.0380 15.44 510072......... 01.0597 13.24 460021....................... 01.3861 19.46 490038.......... 01.2643 13.43 490132......... 01.0342 ....... 500101......... 01.0064 15.92 510077......... 01.1812 15.36 460022....................... 00.9383 19.23 490040.......... 01.4769 21.68 500001......... 01.3664 21.66 500102......... 01.0235 19.46 510080......... 01.2137 11.53 460023....................... 01.2249 21.08 490041.......... 01.2707 16.21 500002......... 01.4348 19.10 500104......... 01.3261 19.88 510081......... 01.1592 12.97 460024....................... 01.0133 14.78 490042.......... 01.3538 15.75 500003......... 01.3881 25.32 500106......... 00.9016 20.08 510082......... 01.2159 12.89 460025....................... 00.8148 13.73 490043.......... 01.4488 20.60 500005......... 01.8225 21.58 500107......... 01.1551 15.79 510084......... 00.9547 13.24 460026....................... 00.9812 17.03 490044.......... 01.3525 17.15 500007......... 01.3876 21.79 500108......... 01.7177 21.74 510085......... 01.3537 17.90 460027....................... 00.9312 19.08 490045.......... 01.2318 18.29 500008......... 01.9449 23.18 500110......... 01.2300 19.44 510086......... 01.0856 15.08 460029....................... 01.0389 18.60 490046.......... 01.4958 17.80 500011......... 01.4259 22.64 500118......... 01.1761 21.92 520002......... 01.2177 18.84 460030....................... 01.1718 17.32 490047.......... 01.0908 16.50 500012......... 01.4808 21.18 500119......... 01.3377 20.39 520003......... 01.1201 15.41 460032....................... 01.0291 21.16 490048.......... 01.6102 17.44 500014......... 01.4972 20.92 500122......... 01.2814 21.99 520004......... 01.1861 16.78 460033....................... 00.9685 17.97 490050.......... 01.4630 21.02 500015......... 01.3782 21.85 500123......... 00.8465 18.56 520006......... 01.0231 18.17 460035....................... 00.9265 12.17 490052.......... 01.6078 15.45 500016......... 01.4757 23.26 500124......... 01.3142 22.83 520007......... 01.2287 14.55 460036....................... 01.0220 20.05 490053.......... 01.2686 14.77 500019......... 01.3364 21.38 500125......... 01.0100 11.61 520008......... 01.5752 22.49 460037....................... 00.9878 17.48 490054.......... 01.1012 14.36 500021......... 01.5592 21.91 500129......... 01.7381 23.35 520009......... 01.6581 17.31 460039....................... 01.0927 20.36 490057.......... 01.5483 17.69 500023......... 01.2130 19.53 500132......... 00.9524 18.51 520010......... 01.1686 19.33 460041....................... 01.2537 20.90 490059.......... 01.6177 19.41 500024......... 01.6817 22.23 500134......... 00.6974 15.59 520011......... 01.2161 16.85 460042....................... 01.4822 17.04 490060.......... 01.0839 17.79 500025......... 01.8740 23.44 500138......... 03.9749 ....... 520013......... 01.3799 18.80 460043....................... 01.2702 21.71 490063.......... 01.7052 22.93 500026......... 01.4019 23.85 500139......... 01.5091 21.25 520014......... 01.1396 16.08 460044....................... 01.1845 19.83 490066.......... 01.3637 18.00 500027......... 01.5352 25.23 500141......... 01.3275 22.22 520015......... 01.1912 16.72 460046....................... 00.9068 12.27 490067.......... 01.2271 15.82 500028......... 01.1235 14.69 500143......... 00.7385 15.20 520016......... 01.1027 13.21 460047....................... 01.7432 19.82 490069.......... 01.4520 14.96 500029......... 00.9534 13.71 500146......... 01.1734 26.11 520017......... 01.1540 17.45 460049....................... 01.9647 17.85 490071.......... 01.5024 18.60 500030......... 01.5279 22.55 510001......... 01.8125 17.35 520018......... 01.1214 16.17 460050....................... 01.2748 21.99 490073.......... 01.4695 17.55 500031......... 01.3419 20.58 510002......... 01.2928 14.18 520019......... 01.3048 16.63 460051....................... 01.2923 32.89 490074.......... 01.3688 16.77 500033......... 01.2759 18.41 510004......... 01.1211 13.65 520021......... 01.3122 19.90 470001....................... 01.1614 18.73 490075.......... 01.3977 16.37 500036......... 01.3202 19.95 510005......... 00.9608 14.19 520024......... 01.0463 13.11 470003....................... 01.7901 20.70 490077.......... 01.2584 17.87 500037......... 01.1682 18.70 510006......... 01.2948 17.42 520025......... 01.1116 18.58 470004....................... 01.1007 15.85 490079.......... 01.3240 15.15 500039......... 01.3867 22.10 510007......... 01.4908 17.98 520026......... 01.0837 17.49 470005....................... 01.2726 20.26 490083.......... 00.7754 15.02 500041......... 01.2893 23.23 510008......... 01.1457 15.55 520027......... 01.2413 19.27 470006....................... 01.2468 17.83 490084.......... 01.3000 15.43 500042......... 01.3518 22.37 510012......... 01.1036 14.37 520028......... 01.3033 17.76 470008....................... 01.1912 16.76 490085.......... 01.2391 13.39 500043......... 01.1927 17.16 510013......... 01.1691 15.80 520029......... 00.9692 16.94 470010....................... 01.1212 19.03 490088.......... 01.1817 14.44 500044......... 01.9850 20.96 510015......... 00.9444 12.51 520030......... 01.6451 21.19 470011....................... 01.1945 19.82 490089.......... 01.1287 16.18 500045......... 01.1350 20.81 510016......... 00.9168 12.66 520031......... 01.1198 15.24 470012....................... 01.2433 17.88 490090.......... 01.2018 15.17 500048......... 00.9633 16.46 510018......... 01.1807 15.26 520032......... 01.2371 15.25 470015....................... 01.2218 16.67 490091.......... 01.2793 18.78 500049......... 01.4916 19.24 510020......... 01.1194 10.56 520033......... 01.1663 16.22 470018....................... 01.2205 20.53 490092.......... 01.2074 15.13 500050......... 01.4321 20.96 510022......... 01.8872 19.16 520034......... 01.1973 17.64 470020....................... 00.9787 15.18 490093.......... 01.3622 15.83 500051......... 01.6718 23.18 510023......... 01.1987 16.62 520035......... 01.3370 15.87 470023....................... 01.2848 19.08 490094.......... 01.1740 14.52 500052......... 01.3138 ....... 510024......... 01.4379 18.43 520037......... 01.6533 19.06 470024....................... 01.1442 18.26 490095.......... 01.4751 16.79 500053......... 01.3072 20.42 510026......... 01.0140 12.33 520038......... 01.3030 16.45 490001....................... 01.2391 19.51 490097.......... 01.1539 14.52 500054......... 01.8790 21.08 510027......... 00.9461 14.62 520039......... 00.9943 16.33 490002....................... 01.0988 14.56 490098.......... 01.2285 11.67 500055......... 01.1227 20.13 510028......... 01.0819 18.99 520040......... 01.4729 19.34 490003....................... 00.5817 17.19 490099.......... 00.9532 16.51 500057......... 01.3062 17.22 510029......... 01.2900 16.78 520041......... 01.1752 14.93 490004....................... 01.2302 16.97 490100.......... 01.4486 17.21 500058......... 01.5259 20.32 510030......... 01.0514 14.39 520042......... 01.0956 16.42 490005....................... 01.5903 16.31 490101.......... 01.2168 22.93 500059......... 01.1436 20.76 510031......... 01.4818 15.97 520044......... 01.4078 16.15 490006....................... 01.1307 13.82 490104.......... 00.8468 16.07 500060......... 01.4042 23.27 510033......... 01.3546 15.30 520045......... 01.7365 18.68 490007....................... 02.0885 17.16 490105.......... 00.6278 18.83 500061......... 01.0337 18.19 510035......... 01.3607 16.81 520047......... 00.9913 15.41 490009....................... 01.8640 18.27 490106.......... 00.8554 16.48 500062......... 01.1311 18.80 510036......... 01.0693 11.64 520048......... 01.4698 18.11 490010....................... 01.1608 17.32 490107.......... 01.3315 22.98 500064......... 01.5874 22.08 510038......... 01.1630 13.36 520049......... 02.0300 18.52 490011....................... 01.4254 17.33 490108.......... 00.9003 15.39 500065......... 01.2122 18.72 510039......... 01.3322 15.48 520051......... 01.7856 20.21 490012....................... 01.2232 15.30 490109.......... 00.9328 17.44 500068......... 01.0306 18.40 510043......... 00.9306 11.52 520053......... 01.1223 15.45 490013....................... 01.2160 16.75 490110.......... 01.4165 15.07 500069......... 01.2223 19.76 510046......... 01.2749 15.91 520054......... 01.0828 17.03 490014....................... 01.4808 22.42 490111.......... 01.2440 15.83 500071......... 01.2861 19.80 510047......... 01.2457 18.06 520056......... 01.7830 18.87 490015....................... 01.4311 18.76 490112.......... 01.6006 18.51 500072......... 01.2065 22.83 510048......... 01.0990 18.22 520057......... 01.1254 16.59 490017....................... 01.3601 16.73 490113.......... 01.3494 21.59 500073......... 01.0524 16.74 510050......... 01.5722 16.11 520058......... 01.1042 18.17 490018....................... 01.2981 17.15 490114.......... 01.1413 15.47 500074......... 01.1555 15.67 510053......... 01.0304 14.12 520059......... 01.4123 18.74 490019....................... 01.1876 16.46 490115.......... 01.2226 14.46 500077......... 01.3811 21.68 510055......... 01.2691 19.68 520060......... 01.4284 15.26 490020....................... 01.2060 15.76 490116.......... 01.3299 15.48 500079......... 01.3672 21.40 510058......... 01.1974 17.03 520062......... 01.3510 16.73 490021....................... 01.2422 17.30 490117.......... 01.1828 12.41 500080......... 00.8662 11.72 510059......... 01.4747 14.25 520063......... 01.1983 17.63 490022....................... 01.4383 19.31 490118.......... 01.7803 21.05 500084......... 01.1847 20.78 510060......... 01.1523 15.55 520064......... 01.7057 20.15 490023....................... 01.2993 18.01 490119.......... 01.3740 16.40 500085......... 01.0690 19.55 510061......... 01.0363 13.37 520066......... 01.5302 18.82 490024....................... 01.8166 16.27 490120.......... 01.3266 17.49 500086......... 01.3071 20.03 510062......... 01.1784 15.77 520068......... 00.9859 16.85 490027....................... 01.1596 13.29 490122.......... 01.4671 21.19 500088......... 01.3442 23.37 510063......... 00.9557 16.84 520069......... 01.1921 17.13 490028....................... 01.3111 20.17 490123.......... 01.1856 15.29 500089......... 01.0273 15.05 510065......... 01.0484 11.49 520070......... 01.6335 17.38 490030....................... 01.1728 10.83 490124.......... 01.2023 17.12 500090......... 00.9361 13.67 510066......... 01.1335 11.93 520071......... 01.1575 17.53 490031....................... 01.1124 13.00 490126.......... 01.4227 14.85 500092......... 01.0544 17.86 510067......... 01.2735 17.97 520074......... 01.0679 15.42 490032....................... 01.7731 19.42 490127.......... 01.0020 14.52 500094......... 00.9089 15.30 510068......... 01.1169 14.34 520075......... 01.4644 18.02 490033....................... 01.2333 16.48 490129.......... 01.1425 19.20 500096......... 00.9886 18.51 510070......... 01.3315 15.86 520076......... 01.1607 15.11 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ [[Page 29971]] Page 16 of 16 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Case Avg. Case Avg. Provider mix hour Provider mix hour index wage index wage ---------------------------------------------------------------------------------------------------- 520077.............................. 00.8551 14.03 530003................. 01.0202 12.47 520078.............................. 01.6182 18.63 530004................. 00.9980 14.18 520082.............................. 01.2818 16.43 530005................. 01.0061 13.47 520083.............................. 01.6772 21.60 530006................. 01.1369 16.52 520084.............................. 01.0951 16.87 530007................. 01.0829 12.98 520087.............................. 01.6988 18.12 530008................. 01.3394 16.82 520088.............................. 01.3099 17.98 530009................. 01.0060 16.77 520089.............................. 01.5179 19.50 530010................. 01.4102 16.12 520090.............................. 01.2381 16.18 530011................. 01.1085 16.94 520091.............................. 01.3629 18.13 530012................. 01.5449 18.11 520092.............................. 01.1204 15.74 530014................. 01.4213 15.18 520094.............................. 00.7915 16.12 530015................. 01.2755 18.00 520095.............................. 01.3651 17.84 530016................. 01.2972 14.93 520096.............................. 01.4356 18.94 530017................. 00.8748 16.97 520097.............................. 01.3151 18.65 530018................. 01.0355 18.67 520098.............................. 01.8153 20.17 530019................. 01.0136 15.32 520100.............................. 01.2531 16.72 530022................. 01.0909 16.71 520101.............................. 01.1237 16.09 530023................. 00.8526 18.57 520102.............................. 01.2023 19.37 530025................. 01.2398 18.76 520103.............................. 01.3275 17.94 530026................. 01.0928 15.48 520107.............................. 01.3021 17.50 530027................. 00.9181 10.62 520109.............................. 01.0056 17.63 530029................. 01.0278 13.46 520110.............................. 01.1489 17.94 530031................. 00.8952 11.67 520111.............................. 00.9540 16.01 530032................. 01.0874 17.89 520112.............................. 01.1191 16.89 520113.............................. 01.2037 19.18 520114.............................. 01.0845 13.27 520115.............................. 01.2574 16.02 520116.............................. 01.2507 18.13 520117.............................. 01.0619 15.78 520118.............................. 00.9442 10.53 520120.............................. 00.9138 12.70 520121.............................. 00.9503 15.67 520122.............................. 00.9742 14.73 520123.............................. 01.0924 16.93 520124.............................. 01.1427 14.93 520130.............................. 01.0475 13.47 520131.............................. 01.0271 16.78 520132.............................. 01.1689 14.48 520134.............................. 01.0805 15.97 520135.............................. 00.9428 17.28 520136.............................. 01.5019 19.05 520138.............................. 01.8566 19.44 520139.............................. 01.2786 19.89 520140.............................. 01.6085 21.15 520141.............................. 01.0486 15.86 520142.............................. 00.8723 13.20 520144.............................. 01.0324 16.42 520145.............................. 00.9102 16.59 520146.............................. 01.0848 13.94 520148.............................. 01.0827 15.34 520149.............................. 00.9713 13.44 520151.............................. 01.0919 15.42 520152.............................. 01.1630 17.07 520153.............................. 00.9224 13.81 520154.............................. 01.0978 17.71 520156.............................. 01.1062 16.69 520157.............................. 01.0441 13.77 520159.............................. 00.9343 16.85 520160.............................. 01.7963 19.07 520161.............................. 01.0063 15.94 520170.............................. 01.2376 19.95 520171.............................. 00.9321 13.23 520173.............................. 01.1559 18.34 520174.............................. 01.3534 21.51 520177.............................. 01.5919 20.16 520178.............................. 01.0908 15.23 530002.............................. 01.1953 19.16 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Note: Case mix indexes do not include discharges from PPS-exempt units. Case mix indexes include cases received in HCFA central office through December 1996 [[Page 29972]] Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas ------------------------------------------------------------------------ Wage Urban area (constituent counties) index GAF ------------------------------------------------------------------------ 0040 Abilene, TX................................... 0.8294 0.8798 Taylor, TX 0060 Aguadilla, PR................................. 0.4191 0.5513 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH..................................... 0.9736 0.9818 Portage, OH Summit, OH 0120 Albany, GA.................................... 0.7920 0.8524 Dougherty, GA Lee, GA 0160 Albany-Schenectady-Troy, NY................... 0.8485 0.8936 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM............................... 0.9336 0.9540 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA................................ 0.8275 0.8784 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA................ 1.0093 1.0064 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA................................... 0.9144 0.9406 Blair, PA 0320 Amarillo, TX.................................. 0.9503 0.9657 Potter, TX Randall, TX 0380 Anchorage, AK................................. 1.3015 1.1978 Anchorage, AK 0440 Ann Arbor, MI................................. 1.1794 1.1196 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL.................................. 0.8272 0.8782 Calhoun, AL 0460 Appleton-Oshkosh-Neenah, WI................... 0.9003 0.9306 Calumet, WI Outagamie, WI Winnebago, WI 0470 Arecibo, PR................................... 0.4221 0.5540 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC................................. 0.9078 0.9359 Buncombe, NC Madison, NC 0500 Athens, GA.................................... 0.9093 0.9370 Clarke, GA Madison, GA Oconee, GA 0520 *Atlanta, GA.................................. 0.9812 0.9871 Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Pickens, GA Rockdale, GA Spalding, GA Walton, GA 0560 Atlantic-Cape May, NJ......................... 1.0732 1.0496 Atlantic, NJ Cape May, NJ 0600 Augusta-Aiken, GA-SC.......................... 0.9341 0.9544 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 Austin-San Marcos, TX......................... 0.8690 0.9083 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 Bakersfield, CA............................... 1.0021 1.0014 Kern, CA 0720 *Baltimore, MD................................ 0.9696 0.9791 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME.................................... 0.9485 0.9644 Penobscot, ME 0743 Barnstable-Yarmouth, MA....................... 1.4302 1.2777 Barnstable, MA 0760 Baton Rouge, LA............................... 0.8416 0.8886 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX...................... 0.8576 0.9001 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA................................ 1.1229 1.0826 Whatcom, WA 0870 Benton Harbor, MI............................. 0.8640 0.9047 Berrien, MI 0875 *Bergen-Passaic, NJ........................... 1.1573 1.1052 Bergen, NJ Passaic, NJ 0880 Billings, MT.................................. 0.9728 0.9813 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8422 0.8890 Hancock, MS Harrison, MS Jackson, MS 0960 Binghamton, NY................................ 0.9088 0.9366 Broome, NY Tioga, NY 1000 Birmingham, AL................................ 0.8933 0.9256 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND.................................. 0.7874 0.8490 Burleigh, ND Morton, ND 1020 Bloomington, IN............................... 0.9134 0.9399 Monroe, IN 1040 Bloomington-Normal, IL........................ 0.8783 0.9150 McLean, IL 1080 Boise City, ID................................ 0.8893 0.9228 Ada, ID Canyon, ID 1123 *Boston-Worcester-Lawrence-Lowell-Brockton, MA- NH................................................. 1.1430 1.0958 Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1125 Boulder-Longmont, CO.......................... 1.0023 1.0016 Boulder, CO 1145 Brazoria, TX.................................. 0.9136 0.9400 Brazoria, TX 1150 Bremerton, WA................................. 1.1007 1.0679 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX.......... 0.8699 0.9090 Cameron, TX 1260 Bryan-College Station, TX..................... 0.7040 0.7864 Brazos, TX 1280 *Buffalo-Niagara Falls, NY.................... 0.9266 0.9491 Erie, NY Niagara, NY 1303 Burlington, VT................................ 1.0098 1.0067 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR.................................... 0.4551 0.5833 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320 Canton-Massillon, OH.......................... 0.8968 0.9281 [[Page 29973]] Carroll, OH Stark, OH 1350 Casper, WY.................................... 0.9019 0.9317 Natrona, WY 1360 Cedar Rapids, IA.............................. 0.8535 0.8972 Linn, IA 1400 Champaign-Urbana, IL.......................... 0.8740 0.9119 Champaign, IL 1440 Charleston-North Charleston, SC............... 0.8739 0.9118 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV................................ 0.9148 0.9408 Kanawha, WV Putnam, WV 1520 *Charlotte-Gastonia-Rock Hill, NC-SC.......... 0.9758 0.9834 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Union, NC York, SC 1540 Charlottesville, VA........................... 0.9065 0.9350 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA............................ 0.8664 0.9065 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 Cheyenne, WY.................................. 0.7560 0.8257 Laramie, WY 1600 *Chicago, IL.................................. 1.0829 1.0561 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 Chico-Paradise, CA............................ 1.0394 1.0268 Butte, CA 1640 *Cincinnati, OH-KY-IN......................... 0.9565 0.9700 Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 1660 Clarksville-Hopkinsville, TN-KY............... 0.7857 0.8478 Christian, KY Montgomery, TN 1680* Cleveland-Lorain-Elyria, OH.................. 0.9811 0.9870 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 Colorado Springs, CO.......................... 0.9323 0.9531 El Paso, CO 1740 Columbia, MO.................................. 0.8887 0.9224 Boone, MO 1760 Columbia, SC.................................. 0.9222 0.9460 Lexington, SC Richland, SC 1800 Columbus, GA-AL............................... 0.8294 0.8798 Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 1840 *Columbus, OH................................. 0.9800 0.9863 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX............................ 0.8951 0.9269 Nueces, TX San Patricio, TX 1900 Cumberland, MD-WV............................. 0.8829 0.9182 Allegany, MD Mineral, WV 1920 *Dallas, TX................................... 0.9624 0.9741 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA.................................. 0.8152 0.8694 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL........... 0.8411 0.8883 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH........................ 0.9292 0.9510 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL............................. 0.8356 0.8843 Flagler, FL Volusia, FL 2030 Decatur, AL................................... 0.8292 0.8796 Lawrence, AL Morgan, AL 2040 Decatur, IL................................... 0.7920 0.8524 Macon, IL 2080 *Denver, CO................................... 1.0299 1.0204 Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA................................ 0.8718 0.9103 Dallas, IA Polk, IA Warren, IA 2160 *Detroit, MI.................................. 1.0844 1.0571 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL.................................... 0.8076 0.8639 Dale, AL Houston, AL 2190 Dover, DE..................................... 0.9222 0.9460 Kent, DE 2200 Dubuque, IA................................... 0.8094 0.8652 Dubuque, IA 2240 Duluth-Superior, MN-WI........................ St. Louis, MN 0.9786 0.9853 Douglas, WI 2281 Dutchess County, NY........................... 1.0644 1.0437 Dutchess, NY 2290 Eau Claire, WI................................ 0.8771 0.9141 Chippewa, WI Eau Claire, WI 2320 El Paso, TX................................... 0.9719 0.9807 El Paso, TX 2330 Elkhart-Goshen, IN............................ 0.9087 0.9365 Elkhart, IN 2335 Elmira, NY.................................... 0.8253 0.8768 Chemung, NY 2340 Enid, OK...................................... 0.7968 0.8559 Garfield, OK 2360 Erie, PA...................................... 0.8869 0.9211 Erie, PA 2400 Eugene-Springfield, OR........................ 1.1700 1.1135 Lane, OR 2440 Evansville-Henderson, IN-KY................... 0.8648 0.9053 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN......................... 0.8844 0.9193 Clay, MN Cass, ND [[Page 29974]] 2560 Fayetteville, NC.............................. 0.8740 0.9119 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR............ 0.7466 0.8186 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT.............................. 0.9122 0.9390 Coconino, AZ Kane, UT 2640 Flint, MI..................................... 1.1191 1.0801 Genesee, MI 2650 Florence, AL.................................. 0.7722 0.8378 Colbert, AL Lauderdale, AL 2655 Florence, SC.................................. 0.8243 0.8761 Florence, SC 2670 Fort Collins-Loveland, CO..................... 1.0255 1.0174 Larimer, CO 2680 *Ft. Lauderdale, FL........................... 1.0802 1.0543 Broward, FL 2700 Fort Myers-Cape Coral, FL..................... 0.8384 0.8863 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL................ 0.9782 0.9850 Martin, FL St. Lucie, FL 2720 Fort Smith, AR-OK............................. 0.7775 0.8417 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL......................... 0.8555 0.8986 Okaloosa, FL 2760 Fort Wayne, IN................................ 0.8907 0.9238 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800 *Forth Worth-Arlington, TX.................... 0.9691 0.9787 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA.................................... 1.0601 1.0408 Fresno, CA Madera, CA 2880 Gadsden, AL................................... 0.8821 0.9177 Etowah, AL 2900 Gainesville, FL............................... 0.9603 0.9726 Alachua, FL 2920 Galveston-Texas City, TX...................... 1.0572 1.0388 Galveston, TX 2960 Gary, IN...................................... 0.9276 0.9498 Lake, IN Porter, IN 2975 Glens Falls, NY............................... 0.8359 0.8845 Warren, NY Washington, NY 2980 Goldsboro, NC................................. 0.8449 0.8910 Wayne, NC 2985 Grand Forks, ND-MN............................ 0.8853 0.9200 Polk, MN Grand Forks, ND 2995 Grand Junction, CO............................ 0.8557 0.8988 Mesa, CO 3000 Grand Rapids-Muskegon-Holland, MI............. 1.0154 1.0105 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT............................... 0.9321 0.9530 Cascade, MT 3060 Greeley, CO................................... 1.0104 1.0071 Weld, CO 3080 Green Bay, WI................................. 0.9592 0.9719 Brown, WI 3120 *Greensboro-Winston-Salem-High Point, NC...... 0.9357 0.9555 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC................................ 0.9071 0.9354 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC........... 0.9066 0.9351 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD................................ 0.9688 0.9785 Washington, MD 3200 Hamilton-Middletown, OH....................... 0.8862 0.9206 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA............... 1.0159 1.0109 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 *Hartford, CT................................. 1.2572 1.1697 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 Hattiesburg, MS............................... 0.7197 0.7983 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC.................. 0.8291 0.8796 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI.................................. 1.1826 1.1217 Honolulu, HI 3350 Houma, LA..................................... 0.7859 0.8479 Lafourche, LA Terrebonne, LA 3360 *Houston, TX.................................. 0.9633 0.9747 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH.................. 0.9159 0.9416 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL................................ 0.8491 0.8940 Limestone, AL Madison, AL 3480 *Indianapolis, IN............................. 0.9851 0.9898 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA................................. 0.9408 0.9591 Johnson, IA 3520 Jackson, MI................................... 0.9058 0.9345 Jackson, MI 3560 Jackson, MS................................... 0.7799 0.8435 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN................................... 0.8529 0.8968 Madison, TN Chester, TN 3600 Jacksonville, FL.............................. 0.8986 0.9294 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 Jacksonville, NC.............................. 0.6978 0.7816 Onslow, NC 3610 Jamestown, NY................................. 0.7551 0.8250 Chautauqua, NY 3620 Janesville-Beloit, WI......................... 0.8831 0.9184 Rock, WI 3640 Jersey City, NJ............................... 1.1420 1.0952 Hudson, NJ 3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.9120 0.9389 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA [[Page 29975]] Scott, VA Washington, VA 3680 Johnstown, PA................................. 0.8384 0.8863 Cambria, PA Somerset, PA 3700 Jonesboro, AR................................. 0.7449 0.8174 Craighead, AR 3710 Joplin, MO.................................... 0.7519 0.8226 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI..................... 1.0676 1.0458 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL.................................. 0.8655 0.9058 Kankakee, IL 3760 *Kansas City, KS-MO........................... 0.9571 0.9704 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800 Kenosha, WI................................... 0.9203 0.9447 Kenosha, WI 3810 Killeen-Temple, TX............................ 1.0259 1.0177 Bell, TX Coryell, TX 3840 Knoxville, TN................................. 0.8837 0.9188 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN.................................... 0.8422 0.8890 Howard, IN Tipton, IN 3870 La Crosse, WI-MN.............................. 0.8755 0.9130 Houston, MN La Crosse, WI 3880 Lafayette, LA................................. 0.8226 0.8748 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN................................. 0.9181 0.9432 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA.............................. 0.7781 0.8421 Calcasieu, LA 3980 Lakeland-Winter Haven, FL..................... 0.8812 0.9170 Polk, FL 4000 Lancaster, PA................................. 0.9492 0.9649 Lancaster, PA 4040 Lansing-East Lansing, MI...................... 1.0093 1.0064 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX.................................... 0.7330 0.8084 Webb, TX 4100 Las Cruces, NM................................ 0.8664 0.9065 Dona Ana, NM 4120 *Las Vegas, NV-AZ............................. 1.0601 1.0408 Mohave, AZ Clark, NV Nye, NV 4150 Lawrence, KS.................................. 0.8615 0.9029 Douglas, KS 4200 Lawton, OK.................................... 0.9052 0.9341 Comanche, OK 4243 Lewiston-Auburn, ME........................... 0.9543 0.9685 Androscoggin, ME 4280 Lexington, KY................................. 0.8422 0.8890 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH...................................... 0.9192 0.9439 Allen, OH Auglaize, OH 4360 Lincoln, NE................................... 0.9093 0.9370 Lancaster, NE 4400 Little Rock-North Little Rock, AR............. 0.8496 0.8944 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX......................... 0.8611 0.9027 Gregg, TX Harrison, TX Upshur, TX 4480 *Los Angeles-Long Beach, CA................... 1.2290 1.1517 Los Angeles, CA 4520 Louisville, KY-IN............................. 0.9498 0.9653 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX................................... 0.8345 0.8835 Lubbock, TX 4640 Lynchburg, VA................................. 0.8199 0.8729 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA..................................... 0.9069 0.9353 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI................................... 1.0062 1.0042 Dane, WI 4800 Mansfield, OH................................. 0.8645 0.9051 Crawford, OH Richland, OH 4840 Mayaguez, PR.................................. 0.4486 0.5776 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX.................. 0.8034 0.8608 Hidalgo, TX 4890 Medford-Ashland, OR........................... 1.0361 1.0246 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL............. 0.8825 0.9180 Brevard, Fl 4920 *Memphis, TN-AR-MS............................ 0.8595 0.9015 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 Merced, CA.................................... 1.0913 1.0617 Merced, CA 5000 *Miami, FL.................................... 0.9301 0.9516 Dade, FL 5015 *Middlesex-Somerset-Hunterdon, NJ............. 1.0883 1.0597 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 *Milwaukee-Waukesha, WI....................... 0.9826 0.9881 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 *Minneapolis-St. Paul, MN-WI.................. 1.0739 1.0500 Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Sherburne, MN Washington, MN Wright, MN Pierce, WI St. Croix, WI 5160 Mobile, AL.................................... 0.8458 0.8916 Baldwin, AL Mobile, AL 5170 Modesto, CA................................... 1.0384 1.0261 Stanislaus, CA 5190 *Monmouth-Ocean, NJ........................... 1.0912 1.0616 [[Page 29976]] Monmouth, NJ Ocean, NJ 5200 Monroe, LA.................................... 0.8420 0.8889 Ouachita, LA 5240 Montgomery, AL................................ 0.7818 0.8449 Autauga, AL Elmore, AL Montgomery, AL 5280 Muncie, IN.................................... 0.9156 0.9414 Delaware, IN 5330 Myrtle Beach, SC.............................. 0.7978 0.8567 Horry, SC 5345 Naples, FL.................................... 1.0116 1.0079 Collier, FL 5360 *Nashville, TN................................ 0.9189 0.9437 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 *Nassau-Suffolk, NY........................... 1.3276 1.2142 Nassau, NY Suffolk, NY 5483 *New Haven-Bridgeport-Stamford-Waterbury- Danbury, CT........................................ 1.2629 1.1733 Fairfield, CT New Haven, CT 5523 New London-Norwich, CT........................ 1.2266 1.1501 New London, CT 5560 *New Orleans, LA.............................. 0.9566 0.9701 Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA 5600 *New York, NY................................. 1.4352 1.2807 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 *Newark, NJ................................... 1.1101 1.0741 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA............................... 1.1291 1.0867 Orange, NY Pike, PA 5720 *Norfolk-Virginia Beach-Newport News, VA-NC... 0.8314 0.8812 Currituck, NC Chesapeake City, VA Gloucester, VA Hampton City, VA Isle of Wight, VA James City, VA Mathews, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City, VA Williamsburg City, VA York, VA 5775 *Oakland, CA.................................. 1.5239 1.3344 Alameda, CA Contra Costa, CA 5790 Ocala, FL..................................... 0.9039 0.9332 Marion, FL 5800 Odessa-Midland, TX............................ 0.8666 0.9066 Ector, TX Midland, TX 5880 *Oklahoma City, OK............................ 0.8487 0.8937 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA................................... 1.0866 1.0585 Thurston, WA 5920 Omaha, NE-IA.................................. 0.9406 0.9589 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 *Orange County, CA............................ 1.1408 1.0944 Orange, CA 5960 *Orlando, FL.................................. 0.9328 0.9535 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY................................. 0.7486 0.8201 Daviess, KY 6015 Panama City, FL............................... 0.8343 0.8833 Bay, FL 6020 Parkersburg-Marietta, WV-OH................... 0.8052 0.8621 Washington, OH Wood, WV 6080 Pensacola, FL................................. 0.8199 0.8729 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL.............................. 0.8555 0.8986 Peoria, IL Tazewell, IL Woodford, IL 6160 *Philadelphia, PA-NJ.......................... 1.1380 1.0926 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 *Phoenix-Mesa, AZ............................. 0.9451 0.9621 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR................................ 0.7832 0.8459 Jefferson, AR 6280 *Pittsburgh, PA............................... 0.9733 0.9816 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 Pittsfield, MA................................ 1.0623 1.0423 Berkshire, MA 6340 Pocatello, ID................................. 0.9543 0.9685 Bannock, ID 6360 Ponce, PR..................................... 0.4560 0.5841 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME.................................. 0.9634 0.9748 Cumberland, ME Sagadahoc, ME York, ME 6440 *Portland-Vancouver, OR-WA.................... 1.1352 1.0907 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 *Providence-Warwick-Pawtucket, RI............. 1.1062 1.0716 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT................................ 1.0080 1.0055 Utah, UT 6560 Pueblo, CO.................................... 0.8166 0.8705 Pueblo, CO 6580 Punta Gorda, FL............................... 0.8587 0.9009 Charlotte, FL 6600 Racine, WI.................................... 0.8941 0.9262 Racine, WI 6640 Raleigh-Durham-Chapel Hill, NC................ 0.9825 0.9880 Chatham, NC [[Page 29977]] Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660 Rapid City, SD................................ 0.8351 0.8839 Pennington, SD 6680 Reading, PA................................... 0.9523 0.9671 Berks, PA 6690 Redding, CA................................... 1.1781 1.1188 Shasta, CA 6720 Reno, NV...................................... 1.0776 1.0525 Washoe, NV 6740 Richland-Kennewick-Pasco, WA.................. 0.9925 0.9949 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA....................... 0.9175 0.9427 Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, VA 6780 *Riverside-San Bernardino, CA................. 1.1166 1.0785 Riverside, CA San Bernardino, CA 6800 Roanoke, VA................................... 0.8362 0.8847 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN................................. 1.0509 1.0346 Olmsted, MN 6840 *Rochester, NY................................ 0.9498 0.9653 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL.................................. 0.9087 0.9365 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC............................... 0.9038 0.9331 Edgecombe, NC Nash, NC 6920 *Sacramento, CA............................... 1.2225 1.1475 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI.................. 0.9571 0.9704 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN................................. 0.9551 0.9690 Benton, MN Stearns, MN 7000 St. Joseph, MO................................ 0.8372 0.8854 Andrew, MO Buchanan, MO 7040 *St. Louis, MO-IL............................. 0.9145 0.9406 Clinton, IL Jersey, IL Madison, IL Monroe, IL St. Clair, IL Franklin, MO Jefferson, MO Lincoln, MO St. Charles, MO St. Louis, MO St. Louis City, MO Warren, MO 7080 Salem, OR..................................... 0.9942 0.9960 Marion, OR Polk, OR 7120 Salinas, CA................................... 1.4523 1.2911 Monterey, CA 7160 *Salt Lake City-Ogden, UT..................... 0.9869 0.9910 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX................................ 0.7504 0.8215 Tom Green, TX 7240 *San Antonio, TX.............................. 0.8225 0.8748 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 *San Diego, CA................................ 1.2266 1.1501 San Diego, CA 7360 *San Francisco, CA............................ 1.4120 1.2665 Marin, CA San Francisco, CA San Mateo, CA 7400 *San Jose, CA................................. 1.4245 1.2742 Santa Clara, CA 7440 *San Juan-Bayamon, PR......................... 0.4704 0.5966 Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR Dorado, PR Fajardo, PR Florida, PR Guaynabo, PR Humacao, PR Juncos, PR Los Piedras, PR Loiza, PR Luguillo, PR Manati, PR Morovis, PR Naguabo, PR Naranjito, PR Rio Grande, PR San Juan, PR Toa Alta, PR Toa Baja, PR Trujillo Alto, PR Vega Alta, PR Vega Baja, PR Yabucoa, PR 7460 San Luis Obispo-Atascadero-Paso Robles, CA.... 1.1379 1.0925 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.0696 1.0472 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA.................... 1.4199 1.2714 Santa Cruz, CA 7490 Santa Fe, NM.................................. 1.0081 1.0055 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA................................ 1.2609 1.1721 Sonoma, CA 7510 Sarasota-Bradenton, FL........................ 0.9764 0.9838 Manatee, FL Sarasota, FL 7520 Savannah, GA.................................. 0.8678 0.9075 Bryan, GA Chatham, GA Effingham, GA 7560 Scranton-Wilkes-Barre-Hazleton, PA............ 0.8546 0.8980 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 *Seattle-Bellevue-Everett, WA................. 1.1383 1.0928 Island, WA King, WA Snohomish, WA 7610 Sharon, PA.................................... 0.8790 0.9155 Mercer, PA 7620 Sheboygan, WI................................. 0.7868 0.8486 Sheboygan, WI 7640 Sherman-Denison, TX........................... 0.8528 0.8967 Grayson, TX 7680 Shreveport-Bossier City, LA................... 0.9396 0.9582 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE............................. 0.8026 0.8602 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD............................... 0.8718 0.9103 Lincoln, SD [[Page 29978]] Minnehaha, SD 7800 South Bend, IN................................ 0.9887 0.9922 St. Joseph, IN 7840 Spokane, WA................................... 1.0491 1.0334 Spokane, WA 7880 Springfield, IL............................... 0.8719 0.9104 Menard, IL Sangamon, IL 7920 Springfield, MO............................... 0.7969 0.8560 Christian, MO Greene, MO Webster, MO 8003 Springfield, MA............................... 1.0661 1.0448 Hampden, MA Hampshire, MA 8050 State College, PA............................. 0.9642 0.9753 Centre, PA 8080 Steubenville-Weirton, OH-WV................... 0.8652 0.9056 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA............................. 1.1527 1.1022 San Joaquin, CA 8140 Sumter, SC.................................... 0.7848 0.8471 Sumter, SC 8160 Syracuse, NY.................................. 0.9464 0.9630 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 Tacoma, WA.................................... 1.1024 1.0690 Pierce, WA 8240 Tallahassee, FL............................... 0.8338 0.8830 Gadsden, FL Leon, FL 8280 *Tampa-St. Petersburg-Clearwater, FL.......... 0.9191 0.9439 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 Terre Haute, IN............................... 0.8620 0.9033 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana, AR-Texarkana, TX................... 0.9594 0.9720 Miller, AR Bowie, TX 8400 Toledo, OH.................................... 1.0147 1.0100 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS.................................... 0.9365 0.9561 Shawnee, KS 8480 Trenton, NJ................................... 1.0375 1.0255 Mercer, NJ 8520 Tucson, AZ.................................... 0.9187 0.9436 Pima, AZ 8560 Tulsa, OK..................................... 0.8080 0.8642 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL................................ 0.8134 0.8681 Tuscaloosa, AL 8640 Tyler, TX..................................... 0.9516 0.9666 Smith, TX 8680 Utica-Rome, NY................................ 0.8362 0.8847 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA.................... 1.3442 1.2245 Napa, CA Solano, CA 8735 Ventura, CA................................... 1.0551 1.0374 Ventura, CA 8750 Victoria, TX.................................. 0.8517 0.8959 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ.............. 1.0118 1.0081 Cumberland, NJ 8780 Visalia-Tulare-Porterville, CA................ 0.9931 0.9953 Tulare, CA 8800 Waco, TX...................................... 0.7701 0.8362 McLennan, TX 8840 *Washington, DC-MD-VA-WV...................... 1.0786 1.0532 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 8920 Waterloo-Cedar Falls, IA...................... 0.8649 0.9054 Black Hawk, IA 8940 Wausau, WI.................................... 1.0553 1.0375 Marathon, WI 8960 West Palm Beach-Boca Raton, FL................ 1.0331 1.0226 Palm Beach, FL 9000 Wheeling, OH-WV............................... 0.7712 0.8370 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS................................... 0.9369 0.9563 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX............................. 0.7645 0.8320 Archer, TX Wichita, TX 9140 Williamsport, PA.............................. 0.8554 0.8986 Lycoming, PA 9160 Wilmington-Newark, DE-MD...................... 1.1549 1.1036 New Castle, DE Cecil, MD 9200 Wilmington, NC................................ 0.9329 0.9535 New Hanover, NC Brunswick, NC 9260 Yakima, WA.................................... 1.0109 1.0075 Yakima, WA 9270 Yolo, CA...................................... 1.1439 1.0964 Yolo, CA 9280 York, PA...................................... 0.9422 0.9600 York, PA 9320 Youngstown-Warren, OH......................... 0.9944 0.9962 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA................................. 1.0479 1.0326 Sutter, CA Yuba, CA 9360 Yuma, AZ...................................... 0.9739 0.9821 Yuma, AZ ------------------------------------------------------------------------ * Large Urban Area Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas ------------------------------------------------------------------------ Wage Nonurban area index GAF ------------------------------------------------------------------------ Alabama............................................. 0.7257 0.8029 Alaska.............................................. 1.2319 1.1535 Arizona............................................. 0.7995 0.8579 Arkansas............................................ 0.7010 0.7841 California.......................................... 1.0005 1.0003 Colorado............................................ 0.8068 0.8633 Connecticut......................................... 1.2626 1.1731 Delaware............................................ 0.8932 0.9256 Florida............................................. 0.8846 0.9195 Georgia............................................. 0.7747 0.8396 Hawaii.............................................. 1.0236 1.0161 Idaho............................................... 0.8209 0.8736 Illinois............................................ 0.7651 0.8325 Indiana............................................. 0.8176 0.8712 Iowa................................................ 0.7387 0.8127 Kansas.............................................. 0.7207 0.7991 Kentucky............................................ 0.7784 0.8424 Louisiana........................................... 0.7400 0.8137 Maine............................................... 0.8474 0.8928 Maryland............................................ 0.8623 0.9035 Massachusetts....................................... 1.0726 1.0492 Michigan............................................ 0.8939 0.9261 Minnesota........................................... 0.8202 0.8731 [[Page 29979]] Mississippi......................................... 0.6919 0.7771 Missouri............................................ 0.7221 0.8001 Montana............................................. 0.8142 0.8687 Nebraska............................................ 0.7358 0.8105 Nevada.............................................. 0.8922 0.9249 New Hampshire....................................... 0.9730 0.9814 New Jersey \1\...................................... ........ ........ New Mexico.......................................... 0.7893 0.8504 New York............................................ 0.8375 0.8856 North Carolina...................................... 0.7938 0.8537 North Dakota........................................ 0.7347 0.8097 Ohio................................................ 0.8438 0.8902 Oklahoma............................................ 0.7065 0.7883 Oregon.............................................. 0.9988 0.9992 Pennsylvania........................................ 0.8439 0.8903 Puerto Rico......................................... 0.3999 0.5338 Rhode Island \1\.................................... ........ ........ South Carolina...................................... 0.7909 0.8516 South Dakota........................................ 0.6982 0.7819 Tennessee........................................... 0.7357 0.8104 Texas............................................... 0.7322 0.8078 Utah................................................ 0.8932 0.9256 Vermont............................................. 0.9320 0.9529 Virginia............................................ 0.7763 0.8408 Washington.......................................... 1.0223 1.0152 West Virginia....................................... 0.7964 0.8556 Wisconsin........................................... 0.8477 0.8930 Wyoming............................................. 0.8250 0.8766 ------------------------------------------------------------------------ \1\ All counties within the State are classified as urban. Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified ------------------------------------------------------------------------ Wage Urban area index GAF ------------------------------------------------------------------------ Abilene, TX......................................... 0.8294 0.8798 Albuquerque, NM..................................... 0.9336 0.9540 Alexandria, LA...................................... 0.8275 0.8784 Amarillo, TX........................................ 0.9503 0.9657 Anchorage, AK....................................... 1.3015 1.1978 Asheville, NC....................................... 0.9078 0.9359 Athens, GA.......................................... 0.9093 0.9370 Atlanta, GA......................................... 0.9812 0.9871 Austin-San Marcos, TX............................... 0.8690 0.9083 Bangor, ME.......................................... 0.9485 0.9644 Barnstable-Yarmouth, MA............................. 1.3837 1.2491 Baton Rouge, LA..................................... 0.8416 0.8886 Benton Harbor, MI................................... 0.8640 0.9047 Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8939 0.9261 Bergen-Passaic, NJ.................................. 1.1573 1.1052 Billings, MT........................................ 0.9147 0.9408 Birmingham, AL...................................... 0.8933 0.9256 Bismarck, ND........................................ 0.7874 0.8490 Boise City, ID...................................... 0.8893 0.9228 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1430 1.0958 Caguas, PR.......................................... 0.4551 0.5833 Casper, WY.......................................... 0.9019 0.9317 Champaign-Urbana, IL................................ 0.8740 0.9119 Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9758 0.9834 Charlottesville, VA................................. 0.8897 0.9231 Chattanooga, TN-GA.................................. 0.8664 0.9065 Chicago, IL......................................... 1.0829 1.0561 Cincinnati, OH-KY-IN................................ 0.9565 0.9700 Cleveland-Lorain-Elyria, OH......................... 0.9811 0.9870 Columbia, MO........................................ 0.8685 0.9080 Columbus, OH........................................ 0.9800 0.9863 Dallas, TX.......................................... 0.9624 0.9741 Davenport-Moline-Rock Island, IA-IL................. 0.8411 0.8883 Denver, CO.......................................... 1.0299 1.0204 Des Moines, IA...................................... 0.8718 0.9103 Detroit, MI......................................... 1.0844 1.0571 Duluth-Superior, MN-WI.............................. 0.9786 0.9853 Dutchess County, NY................................. 1.0174 1.0119 Eugene-Springfield, OR.............................. 1.1700 1.1135 Fargo-Moorhead, ND-MN............................... 0.8730 0.9112 Fayetteville, NC.................................... 0.8468 0.8924 Flint, MI........................................... 1.1191 1.0801 Florence, AL........................................ 0.7722 0.8378 Florence, SC........................................ 0.8243 0.8761 Ft. Lauderdale, FL.................................. 1.0802 1.0543 Fort Pierce-Port St. Lucie, FL...................... 0.9782 0.9850 Fort Walton Beach, FL............................... 0.8555 0.8986 Fort Worth-Arlington, TX............................ 0.9691 0.9787 Gadsden, AL......................................... 0.8821 0.9177 Gainesville, FL..................................... 0.9603 0.9726 Gary, IN............................................ 0.9121 0.9389 Grand Forks, ND-MN.................................. 0.8853 0.9200 Grand Junction, CO.................................. 0.8557 0.8988 Great Falls, MT..................................... 0.9321 0.9530 Greeley, CO......................................... 0.9798 0.9861 Green Bay, WI....................................... 0.9592 0.9719 Greensboro-Winston-Salem-High Point, NC............. 0.9357 0.9555 Harrisburg-Lebanon-Carlisle, PA..................... 1.0044 1.0030 Honolulu, HI........................................ 1.1826 1.1217 Houma, LA........................................... 0.7859 0.8479 Houston, TX......................................... 0.9633 0.9747 Huntington-Ashland, WV-KY-OH........................ 0.9159 0.9416 Huntsville, AL...................................... 0.8491 0.8940 Indianapolis, IN.................................... 0.9851 0.9898 Iowa City, IA....................................... 0.9192 0.9439 Jackson, MS......................................... 0.7799 0.8435 Johnson City-Kingsport-Bristol, TN-VA............... 0.9120 0.9389 Jonesboro, AR....................................... 0.7449 0.8174 Joplin, MO.......................................... 0.7519 0.8226 Kalamazoo-Battle Creek, MI.......................... 1.0676 1.0458 Kansas City, KS-MO.................................. 0.9571 0.9704 Knoxville, TN....................................... 0.8837 0.9188 Lafayette, LA....................................... 0.8226 0.8748 Lafayette, IN....................................... 0.9181 0.9432 Lansing-East Lansing, MI............................ 1.0093 1.0064 Las Cruces, NM...................................... 0.8664 0.9065 Las Vegas, NV-AZ.................................... 1.0601 1.0408 Lexington, KY....................................... 0.8422 0.8890 Lima, OH............................................ 0.9192 0.9439 Lincoln, NE......................................... 0.8935 0.9258 Little Rock-North Little Rock, AR................... 0.8496 0.8944 Longview-Marshall, TX............................... 0.8508 0.8953 Los Angeles-Long Beach, CA.......................... 1.2290 1.1517 Louisville, KY-IN................................... 0.9498 0.9653 Macon, GA........................................... 0.9069 0.9353 Madison, WI......................................... 1.0062 1.0042 Mansfield, OH....................................... 0.8645 0.9051 Medford-Ashland, OR................................. 1.0361 1.0246 Memphis, TN-AR-MS................................... 0.8595 0.9015 Milwaukee-Waukesha, WI.............................. 0.9826 0.9881 Minneapolis-St. Paul, MN-WI......................... 1.0739 1.0500 Monroe, LA.......................................... 0.8420 0.8889 Montgomery, AL...................................... 0.7818 0.8449 Nashville, TN....................................... 0.9189 0.9437 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2629 1.1733 New London-Norwich, CT.............................. 1.2266 1.1501 New Orleans, LA..................................... 0.9566 0.9701 New York, NY........................................ 1.4352 1.2807 Newark, NJ.......................................... 1.1101 1.0741 Newburgh, NY-PA..................................... 1.1468 1.0983 Oakland, CA......................................... 1.5239 1.3344 Odessa-Midland, TX.................................. 0.8522 0.8963 Oklahoma City, OK................................... 0.8487 0.8937 Omaha, NE-IA........................................ 0.9406 0.9589 Orange County, CA................................... 1.1408 1.0944 Peoria-Pekin, IL.................................... 0.8555 0.8986 Philadelphia, PA-NJ................................. 1.1380 1.0926 Pittsburgh, PA...................................... 0.9591 0.9718 Pocatello, ID....................................... 0.8987 0.9295 Portland, ME........................................ 0.9634 0.9748 Portland-Vancouver, OR-WA........................... 1.1352 1.0907 Provo-Orem, UT...................................... 1.0080 1.0055 Raleigh-Durham-Chapel Hill, NC...................... 0.9825 0.9880 Rapid City, SD...................................... 0.8351 0.8839 Rochester, MN....................................... 1.0509 1.0346 Rockford, IL........................................ 0.9087 0.9365 Sacramento, CA...................................... 1.2225 1.1475 Saginaw-Bay City-Midland, MI........................ 0.9571 0.9704 St. Cloud, MN....................................... 0.9551 0.9690 St. Louis, MO-IL.................................... 0.9145 0.9406 Salinas, CA......................................... 1.4309 1.2781 Salt Lake City-Ogden, UT............................ 0.9869 0.9910 San Diego, CA....................................... 1.2266 1.1501 San Francisco, CA................................... 1.4120 1.2665 Santa Fe, NM........................................ 0.9818 0.9875 Santa Rosa, CA...................................... 1.2447 1.1617 Seattle-Bellevue-Everett, WA........................ 1.1383 1.0928 Sherman-Denison, TX................................. 0.8345 0.8835 Sioux City, IA-NE................................... 0.8026 0.8602 Sioux Falls, SD..................................... 0.8613 0.9028 South Bend, IN...................................... 0.9887 0.9922 [[Page 29980]] Spokane, WA......................................... 1.0316 1.0215 Springfield, IL..................................... 0.8617 0.9031 Springfield, MO..................................... 0.7969 0.8560 Stockton-Lodi, CA................................... 1.1527 1.1022 Syracuse, NY........................................ 0.9464 0.9630 Tampa-St. Petersburg-Clearwater, FL................. 0.9191 0.9439 Texarkana, AR-Texarkana, TX......................... 0.9482 0.9642 Topeka, KS.......................................... 0.9240 0.9473 Tucson, AZ.......................................... 0.9187 0.9436 Tulsa, OK........................................... 0.8080 0.8642 Tyler, TX........................................... 0.9379 0.9570 Vallejo-Fairfield-Napa, CA.......................... 1.3442 1.2245 Washington, DC-MD-VA-WV............................. 1.0786 1.0532 Waterloo-Cedar Falls, IA............................ 0.8649 0.9054 Wausau, WI.......................................... 0.9853 0.9899 Wichita, KS......................................... 0.9130 0.9396 Wichita Falls, TX................................... 0.7645 0.8320 Rural Florida....................................... 0.8846 0.9195 Rural Louisiana..................................... 0.7400 0.8137 Rural Minnesota..................................... 0.8202 0.8731 Rural Missouri...................................... 0.7221 0.8001 Rural New Hampshire................................. 0.9730 0.9814 Rural New Mexico.................................... 0.7893 0.8504 Rural North Carolina................................ 0.7938 0.8537 Rural Oregon........................................ 0.9988 0.9992 Rural Washington.................................... 1.0223 1.0152 Rural West Virginia................................. 0.7964 0.8556 Rural Wyoming....................................... 0.8250 0.8766 ------------------------------------------------------------------------ Table 4D.--Average Hourly Wage for Urban Areas ------------------------------------------------------------------------ Average Urban area hourly wage ------------------------------------------------------------------------ Abilene, TX.................................................. 16.6537 Aguadilla, PR................................................ 8.4161 Akron, OH.................................................... 19.6368 Albany, GA................................................... 15.9028 Albany-Schenectady-Troy, NY.................................. 17.0385 Albuquerque, NM.............................................. 18.7069 Alexandria, LA............................................... 16.4017 Allentown-Bethlehem-Easton, PA............................... 20.2671 Altoona, PA.................................................. 18.3612 Amarillo, TX................................................. 18.9399 Anchorage, AK................................................ 25.8065 Ann Arbor, MI................................................ 23.6829 Anniston, AL................................................. 16.6112 Appleton-Oshkosh-Neenah, WI.................................. 18.0782 Arecibo, PR.................................................. 8.4753 Asheville, NC................................................ 18.2293 Athens, GA................................................... 18.2596 Atlanta, GA.................................................. 19.7032 Atlantic-Cape May, NJ........................................ 22.4152 Augusta-Aiken, GA-SC......................................... 18.7566 Austin-San Marcos, TX........................................ 17.4495 Bakersfield, CA.............................................. 20.1222 Baltimore, MD................................................ 19.4693 Bangor, ME................................................... 19.0467 Barnstable-Yarmouth, MA...................................... 28.7181 Baton Rouge, LA.............................................. 16.9004 Beaumont-Port Arthur, TX..................................... 17.2215 Bellingham, WA............................................... 22.5492 Benton Harbor, MI............................................ 17.3503 Bergen-Passaic, NJ........................................... 24.3291 Billings, MT................................................. 19.5350 Biloxi-Gulfport-Pascagoula, MS............................... 16.9110 Binghamton, NY............................................... 18.2489 Birmingham, AL............................................... 17.9378 Bismarck, ND................................................. 15.4640 Bloomington,IN............................................... 18.3421 Bloomington-Normal, IL....................................... 17.6360 Boise City, ID............................................... 17.7955 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.9698 Boulder-Longmont, CO......................................... 20.1260 Brazoria, TX................................................. 18.7704 Bremerton, WA................................................ 22.1033 Brownsville-Harlingen-San Benito, TX......................... 17.4677 Bryan-College Station, TX.................................... 14.1367 Buffalo-Niagara Falls, NY.................................... 18.6068 Burlington, VT............................................... 20.2766 Caguas, PR................................................... 9.0320 Canton-Massillon, OH......................................... 18.0078 Casper, WY................................................... 18.1110 Cedar Rapids, IA............................................. 17.1383 Champaign-Urbana, IL......................................... 17.5502 Charleston-North Charleston, SC.............................. 17.5483 Charleston, WV............................................... 18.3703 Charlotte-Gastonia-Rock Hill, NC-SC.......................... 19.5947 Charlottesville, VA.......................................... 18.2038 Chattanooga, TN-GA........................................... 17.3976 Cheyenne, WY................................................. 15.1808 Chicago, IL.................................................. 21.7444 Chico-Paradise, CA........................................... 20.8709 Cincinnati, OH-KY-IN......................................... 19.0516 Clarksville-Hopkinsville, TN-KY.............................. 15.7778 Cleveland-Lorain-Elyria, OH.................................. 19.7007 Colorado Springs, CO......................................... 18.7205 Columbia, MO................................................. 17.8452 Columbia, SC................................................. 18.5185 Columbus, GA-AL.............................................. 16.6542 Columbus, OH................................................. 19.6781 Corpus Christi, TX........................................... 17.9745 Cumberland, MD-WV............................................ 17.7280 Dallas, TX................................................... 19.3876 Danville, VA................................................. 16.3692 Davenport-Moline-Rock Island, IA-IL.......................... 16.8903 Dayton-Springfield, OH....................................... 19.3553 Daytona Beach, FL............................................ 16.7797 Decatur, AL.................................................. 16.6503 Decatur, IL.................................................. 15.9047 Denver, CO................................................... 20.6808 Des Moines, IA............................................... 17.5070 Detroit, MI.................................................. 21.7434 Dothan, AL................................................... 16.2160 Dover, DE.................................................... 18.5175 Dubuque, IA.................................................. 16.2530 Duluth-Superior, MN-WI....................................... 19.6500 Dutchess County, NY.......................................... 21.3729 Eau Claire, WI............................................... 17.6122 El Paso, TX.................................................. 19.5169 Elkhart-Goshen, IN........................................... 18.2474 Elmira, NY................................................... 16.5714 Enid, OK..................................................... 16.0002 Erie, PA..................................................... 17.8087 Eugene-Springfield, OR....................................... 23.0592 Evansville, Henderson, IN-KY................................. 17.3648 Fargo-Moorhead, ND-MN........................................ 17.7585 Fayetteville, NC............................................. 17.5510 Fayetteville-Springdale-Rogers, AR........................... 14.9924 Flagstaff, AZ-UT............................................. 18.3168 Flint, MI.................................................... 22.4728 Florence, AL................................................. 15.1732 Florence, SC................................................. 16.5268 Fort Collins-Loveland, CO.................................... 20.5933 Fort Lauderdale, FL.......................................... 20.8970 Fort Myers-Cape Coral, FL.................................... 16.8350 Fort Pierce-Port St. Lucie, FL............................... 19.6424 Fort Smith, AR-OK............................................ 15.6127 Fort Walton Beach, FL........................................ 17.1797 Fort Wayne, IN............................................... 17.8865 Fort Worth-Arlington, TX..................................... 19.3702 Fresno, CA................................................... 21.2867 Gadsden, AL.................................................. 17.7134 Gainesville, FL.............................................. 19.2822 Galveston-Texas City, TX..................................... 21.2286 Gary, IN..................................................... 19.3581 Glens Falls, NY.............................................. 16.7853 Goldsboro, NC................................................ 16.9659 Grand Forks, ND-MN........................................... 17.5737 Grand Junction, CO........................................... 15.6876 Grand Rapids-Muskegon-Holland, MI............................ 20.3894 Great Falls, MT.............................................. 17.9668 Greeley, CO.................................................. 20.2891 Green Bay, WI................................................ 18.2802 Greensboro-Winston-Salem-High Point, NC...................... 18.7901 Greenville, NC............................................... 18.2150 Greenville-Spartanburg-Anderson, SC.......................... 18.2047 Hagerstown, MD............................................... 19.4546 Hamilton-Middletown, OH...................................... 17.7961 Harrisburg-Lebanon-Carlisle, PA.............................. 20.3990 Hartford, CT................................................. 25.2442 Hattiesburg, MS.............................................. 14.4517 Hickory-Morganton-Lenoir, NC................................. 17.4555 Honolulu, HI................................................. 23.7434 Houma, LA.................................................... 15.7820 Houston, TX.................................................. 19.3444 Huntington-Ashland, WV-KY-OH................................. 18.3921 Huntsville, AL............................................... 17.0504 Indianapolis, IN............................................. 19.7810 Iowa City, IA................................................ 18.8914 Jackson, MI.................................................. 18.1893 Jackson, MS.................................................. 15.6018 Jackson, TN.................................................. 17.1259 Jacksonville, FL............................................. 18.0438 Jacksonville, NC............................................. 14.0121 Jamestown, NY................................................ 15.1621 Janesville-Beloit, WI........................................ 17.7327 Jersey City, NJ.............................................. 22.9317 Johnson City-Kingsport-Bristol, TN-VA........................ 18.3136 Johnstown, PA................................................ 16.8349 Jonesboro, AR................................................ 14.9575 Joplin, MO................................................... 15.0332 Kalamazoo-Battlecreek, MI.................................... 21.4383 Kankakee, IL................................................. 17.3802 Kansas City, KS-MO........................................... 19.2182 Kenosha, WI.................................................. 18.4799 Killeen-Temple, TX........................................... 20.6010 Knoxville, TN................................................ 17.7457 [[Page 29981]] Kokomo, IN................................................... 16.9123 La Crosse, WI-MN............................................. 17.5812 Lafayette, LA................................................ 16.4732 Lafayette, IN................................................ 18.4349 Lake Charles, LA............................................. 15.6250 Lakeland-Winter Haven, FL.................................... 17.6957 Lancaster, PA................................................ 19.0606 Lansing-East Lansing, MI..................................... 20.2670 Laredo, TX................................................... 14.7188 Las Cruces, NM............................................... 17.3739 Las Vegas, NV-AZ............................................. 21.2874 Lawrence, KS................................................. 17.2986 Lawton, OK................................................... 18.1767 Lewiston-Auburn, ME.......................................... 19.1630 Lexington, KY................................................ 16.8603 Lima, OH..................................................... 18.4571 Lincoln, NE.................................................. 18.2595 Little Rock-North Little Rock, AR............................ 17.0606 Longview-Marshall, TX........................................ 17.2912 Los Angeles-Long Beach, CA................................... 24.6067 Louisville, KY-IN............................................ 19.0725 Lubbock, TX.................................................. 16.7563 Lynchburg, VA................................................ 16.4640 Macon, GA.................................................... 18.2107 Madison, WI.................................................. 20.2048 Mansfield, OH................................................ 17.3603 Mayaguez, PR................................................. 9.0075 McAllen-Edinburg-Mission, TX................................. 16.1323 Medford-Ashland, OR.......................................... 20.8059 Melbourne-Titusville-Palm Bay, FL............................ 17.7216 Memphis, TN-AR-MS............................................ 17.2589 Merced, CA................................................... 21.9146 Miami, FL.................................................... 19.8627 Middlesex-Somerset-Hunterdon, NJ............................. 22.0067 Milwaukee-Waukesha, WI....................................... 19.7306 Minneapolis-St. Paul, MN-WI.................................. 21.5643 Mobile, AL................................................... 16.9845 Modesto, CA.................................................. 21.6914 Monmouth-Ocean, NJ........................................... 21.9116 Monroe, LA................................................... 16.9075 Montgomery, AL............................................... 15.4155 Muncie, IN................................................... 18.3854 Myrtle Beach, SC............................................. 16.0211 Naples, FL................................................... 20.3132 Nashville, TN................................................ 18.4518 Nassau-Suffolk, NY........................................... 27.7072 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 25.3561 New London-Norwich, CT....................................... 24.1396 New Orleans, LA.............................................. 19.2096 New York, NY................................................. 28.8193 Newark, NJ................................................... 24.0494 Newburgh, NY-PA.............................................. 22.6737 Norfolk-Virginia Beach-Newport News, VA-NC................... 16.6956 Oakland, CA.................................................. 30.4360 Ocala, FL.................................................... 18.1497 Odessa-Midland, TX........................................... 17.4016 Oklahoma City, OK............................................ 17.0417 Olympia, WA.................................................. 21.8203 Omaha, NE-IA................................................. 18.8876 Orange County, CA............................................ 23.0599 Orlando, FL.................................................. 18.7302 Owensboro, KY................................................ 15.0313 Panama City, FL.............................................. 16.7539 Parkersburg-Marietta, WV-OH.................................. 16.1677 Pensacola, FL................................................ 16.4635 Peoria-Pekin, IL............................................. 17.1794 Philadelphia, PA-NJ.......................................... 22.8513 Phoenix-Mesa, AZ............................................. 18.9787 Pine Bluff, AR............................................... 15.7267 Pittsburgh, PA............................................... 19.5446 Pittsfield, MA............................................... 21.3310 Pocatello, ID................................................ 19.1619 Ponce, PR.................................................... 9.1572 Portland, ME................................................. 19.3456 Portland-Vancouver, OR-WA.................................... 22.7959 Providence-Warwick, RI....................................... 22.2138 Provo-Orem, UT............................................... 20.2420 Pueblo, CO................................................... 16.3970 Punta Gorda, FL.............................................. 17.2423 Racine, WI................................................... 17.9536 Raleigh-Durham-Chapel Hill, NC............................... 19.7297 Rapid City, SD............................................... 16.7698 Reading, PA.................................................. 19.1233 Redding, CA.................................................. 23.6558 Reno, NV..................................................... 21.6378 Richland-Kennewick-Pasco, WA................................. 19.9294 Richmond-Petersburg, VA...................................... 18.4237 Riverside-San Bernardino, CA................................. 22.7449 Roanoke, VA.................................................. 16.7913 Rochester, MN................................................ 21.1030 Rochester, NY................................................ 19.0730 Rockford, IL................................................. 18.2476 Rocky Mount, NC.............................................. 18.1482 Sacramento, CA............................................... 24.5491 Saginaw-Bay City-Midland, MI................................. 19.2180 St. Cloud, MN................................................ 19.1778 St. Joseph, MO............................................... 16.8108 St. Louis, MO-IL............................................. 18.3627 Salem, OR.................................................... 19.9649 Salinas, CA.................................................. 29.1634 Salt Lake City-Ogden, UT..................................... 19.8077 San Angelo, TX............................................... 15.0684 San Antonio, TX.............................................. 16.5159 San Diego, CA................................................ 24.5670 San Francisco, CA............................................ 28.5345 San Jose, CA................................................. 28.6049 San Juan-Bayamon, PR......................................... 9.4463 San Luis Obispo-Atascadero-Paso Robles, CA................... 22.8504 Santa Barbara-Santa Maria-Lompoc, CA......................... 21.4774 Santa Cruz-Watsonville, CA................................... 28.5128 Santa Fe, NM................................................. 20.2428 Santa Rosa, CA............................................... 26.2920 Sarasota-Bradenton, FL....................................... 19.6072 Savannah, GA................................................. 17.4249 Scranton-Wilkes Barre-Hazleton, PA........................... 17.1601 Seattle-Bellevue-Everett, WA................................. 22.7858 Sharon, PA................................................... 17.6500 Sheboygan, WI................................................ 15.7984 Sherman-Denison, TX.......................................... 17.1241 Shreveport-Bossier City, LA.................................. 18.8682 Sioux City, IA-NE............................................ 16.1162 Sioux Falls, SD.............................................. 17.5067 South Bend, IN............................................... 19.8290 Spokane, WA.................................................. 21.0664 Springfield, IL.............................................. 17.5080 Springfield, MO.............................................. 15.8980 Springfield, MA.............................................. 21.4074 State College, PA............................................ 19.3613 Steubenville-Weirton, OH-WV.................................. 17.3728 Stockton-Lodi, CA............................................ 23.1020 Sumter, SC................................................... 15.7585 Syracuse, NY................................................. 18.9634 Tacoma, WA................................................... 22.1357 Tallahassee, FL.............................................. 16.7434 Tampa-St. Petersburg-Clearwater, FL.......................... 18.2677 Terre Haute, IN.............................................. 17.3093 Texarkana, AR-Texarkana, TX.................................. 19.2649 Toledo, OH................................................... 20.8792 Topeka, KS................................................... 18.8050 Trenton, NJ.................................................. 20.8336 Tucson, AZ................................................... 18.4477 Tulsa, OK.................................................... 16.2252 Tuscaloosa, AL............................................... 16.3331 Tyler, TX.................................................... 19.1086 Utica-Rome, NY............................................... 16.7919 Vallejo-Fairfield-Napa, CA................................... 27.4125 Ventura, CA.................................................. 21.9959 Victoria, TX................................................. 17.1016 Vineland-Millville-Bridgeton, NJ............................. 20.3170 Visalia-Tulare-Porterville, CA............................... 19.9417 Waco, TX..................................................... 15.4645 Washington, DC-MD-VA-WV...................................... 21.6582 Waterloo-Cedar Falls, IA..................................... 17.3631 Wausau, WI................................................... 21.1907 West Palm Beach-Boca Raton, FL............................... 20.8691 Wheeling, OH-WV.............................................. 15.4868 Wichita, KS.................................................. 18.8137 Wichita Falls, TX............................................ 15.3505 Williamsport, PA............................................. 17.1768 Wilmington-Newark, DE-MD..................................... 23.1911 Wilmington, NC............................................... 18.7325 Yakima, WA................................................... 20.2994 Yolo, CA..................................................... 22.9704 York, PA..................................................... 18.9189 Youngstown-Warren, OH........................................ 19.9688 Yuba City, CA................................................ 21.0423 Yuma, AZ..................................................... 19.5572 ------------------------------------------------------------------------ Table 4E.--Average Hourly Wage For Rural Areas ------------------------------------------------------------------------ Average Nonurban area hourly wage ------------------------------------------------------------------------ Alabama...................................................... 14.5723 Alaska....................................................... 24.7367 Arizona...................................................... 16.0545 Arkansas..................................................... 14.0756 California................................................... 20.0902 Colorado..................................................... 16.2015 Connecticut.................................................. 25.3532 Delaware..................................................... 17.9354 Florida...................................................... 17.7628 Georgia...................................................... 15.5563 Hawaii....................................................... 20.5550 Idaho........................................................ 16.4839 Illinois..................................................... 15.3631 Indiana...................................................... 16.4180 Iowa......................................................... 14.8337 Kansas....................................................... 14.4720 Kentucky..................................................... 15.6298 Louisiana.................................................... 14.8596 Maine........................................................ 17.0166 Maryland..................................................... 17.3152 Massachusetts................................................ 21.5382 Michigan..................................................... 17.9507 Minnesota.................................................... 16.4669 Mississippi.................................................. 13.8932 [[Page 29982]] Missouri..................................................... 14.4980 Montana...................................................... 16.3497 Nebraska..................................................... 14.7745 Nevada....................................................... 17.9159 New Hampshire................................................ 19.5250 New Jersey \1\............................................... ......... New Mexico................................................... 15.8297 New York..................................................... 16.8172 North Carolina............................................... 15.9365 North Dakota................................................. 14.7534 Ohio......................................................... 16.9442 Oklahoma..................................................... 14.1874 Oregon....................................................... 20.0517 Pennsylvania................................................. 16.9465 Puerto Rico.................................................. 8.0298 Rhode Island \1\............................................. ......... South Carolina............................................... 15.8812 South Dakota................................................. 14.0203 Tennessee.................................................... 14.7740 Texas........................................................ 14.7038 Utah......................................................... 17.9362 Vermont...................................................... 18.7155 Virginia..................................................... 15.5887 Washington................................................... 20.5277 West Virginia................................................ 15.9342 Wisconsin.................................................... 17.0214 Wyoming...................................................... 16.5656 ------------------------------------------------------------------------ \1\ All counties within the State are classified as urban. Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) ---------------------------------------------------------------------------------------------------------------- Wage index-- reclass. GAF-- Area Wage index GAF hospitals reclass. hospitals ---------------------------------------------------------------------------------------------------------------- Aguadilla, PR............................................... 0.9152 0.9411 ........... ........... Arecibo, PR................................................. 0.9217 0.9457 ........... ........... Caguas, PR.................................................. 0.9937 0.9957 0.9937 0.9957 Mayaguez, PR................................................ 0.9795 0.9859 ........... ........... Ponce, PR................................................... 0.9958 0.9971 ........... ........... San Juan-Bayamon, PR........................................ 1.0273 1.0186 ........... ........... Rural Puerto Rico........................................... 0.8732 0.9113 ........... ........... ---------------------------------------------------------------------------------------------------------------- Table 5.--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean Length ---------------------------------------------------------------------------------------------------------------- Relative Geometric Arithmetic weights mean LOS mean LOS ---------------------------------------------------------------------------------------------------------------- 1............... 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.0381 6.9 10.0 FOR TRAUMA. 2............... 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.0527 7.9 10.6 >17. 3............... 01 SURG *CRANIOTOMY AGE 0-17....... 1.9470 12.7 12.7 4............... 01 SURG SPINAL PROCEDURES.......... 2.3738 5.5 8.5 5............... 01 SURG EXTRACRANIAL VASCULAR 1.5019 2.9 3.9 PROCEDURES. 6............... 01 SURG CARPAL TUNNEL RELEASE...... .7573 2.2 3.3 7............... 01 SURG PERIPH & CRANIAL NERVE & 2.4812 7.6 11.6 OTHER NERV SYST PROC W CC. 8............... 01 SURG PERIPH & CRANIAL NERVE & 1.1314 2.5 3.6 OTHER NERV SYST PROC W/O CC. 9............... 01 MED SPINAL DISORDERS & INJURIES 1.2570 5.1 7.2 10.............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2176 5.3 7.4 CC. 11.............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .7857 3.2 4.3 O CC. 12.............. 01 MED DEGENERATIVE NERVOUS SYSTEM .9357 5.0 6.8 DISORDERS. 13.............. 01 MED MULTIPLE SCLEROSIS & .7809 4.7 5.8 CEREBELLAR ATAXIA. 14.............. 01 MED SPECIFIC CEREBROVASCULAR 1.1904 5.1 6.8 DISORDERS EXCEPT TIA. 15.............. 01 MED TRANSIENT ISCHEMIC ATTACK & .7249 3.2 4.1 PRECEREBRAL OCCLUSIONS. 16.............. 01 MED NONSPECIFIC CEREBROVASCULAR 1.0452 4.6 6.1 DISORDERS W CC. 17.............. 01 MED NONSPECIFIC CEREBROVASCULAR .6176 2.9 3.7 DISORDERS W/O CC. 18.............. 01 MED CRANIAL & PERIPHERAL NERVE .9400 4.5 5.9 DISORDERS W CC. 19.............. 01 MED CRANIAL & PERIPHERAL NERVE .6290 3.2 4.1 DISORDERS W/O CC. 20.............. 01 MED NERVOUS SYSTEM INFECTION 2.5777 8.0 10.8 EXCEPT VIRAL MENINGITIS. 21.............. 01 MED VIRAL MENINGITIS........... 1.4784 5.4 7.1 22.............. 01 MED HYPERTENSIVE ENCEPHALOPATHY .8687 3.7 4.8 23.............. 01 MED NONTRAUMATIC STUPOR & COMA. .7820 3.3 4.6 24.............. 01 MED SEIZURE & HEADACHE AGE >17 .9588 3.9 5.4 W CC. 25.............. 01 MED SEIZURE & HEADACHE AGE >17 .5809 2.8 3.6 W/O CC. 26.............. 01 MED SEIZURE & HEADACHE AGE 0-17 .9598 3.7 5.0 27.............. 01 MED TRAUMATIC STUPOR & COMA, 1.2609 3.4 5.5 COMA >1 HR. 28.............. 01 MED TRAUMATIC STUPOR & COMA, 1.1684 4.4 6.4 COMA <1 HR AGE >17 W CC. 29.............. 01 MED TRAUMATIC STUPOR & COMA, .6364 2.8 3.8 COMA <1 HR AGE >17 W/O CC. 30.............. 01 MED *TRAUMATIC STUPOR & COMA, .3292 2.0 2.0 COMA <1 HR AGE 0-17. 31.............. 01 MED CONCUSSION AGE >17 W CC.... .8364 3.5 4.8 32.............. 01 MED CONCUSSION AGE >17 W/O CC.. .5087 2.2 3.1 33.............. 01 MED *CONCUSSION AGE 0-17....... .2069 1.6 1.6 34.............. 01 MED OTHER DISORDERS OF NERVOUS 1.0365 4.2 5.8 SYSTEM W CC. 35.............. 01 MED OTHER DISORDERS OF NERVOUS .5930 3.0 3.9 SYSTEM W/O CC. 36.............. 02 SURG RETINAL PROCEDURES......... .6246 1.3 1.5 [[Page 29983]] 37.............. 02 SURG ORBITAL PROCEDURES......... .9697 2.6 3.9 38.............. 02 SURG PRIMARY IRIS PROCEDURES.... .4780 1.9 2.7 39.............. 02 SURG LENS PROCEDURES WITH OR .5414 1.5 2.0 WITHOUT VITRECTOMY. 40.............. 02 SURG EXTRAOCULAR PROCEDURES .7386 2.2 3.3 EXCEPT ORBIT AGE >17. 41.............. 02 SURG *EXTRAOCULAR PROCEDURES .3351 1.6 1.6 EXCEPT ORBIT AGE 0-17. 42.............. 02 SURG INTRAOCULAR PROCEDURES .5659 1.5 2.0 EXCEPT RETINA, IRIS & LENS. 43.............. 02 MED HYPHEMA.................... .4123 2.9 4.0 44.............. 02 MED ACUTE MAJOR EYE INFECTIONS. .6026 4.3 5.3 45.............. 02 MED NEUROLOGICAL EYE DISORDERS. .6709 2.9 3.6 46.............. 02 MED OTHER DISORDERS OF THE EYE .7231 3.7 4.9 AGE >17 W CC. 47.............. 02 MED OTHER DISORDERS OF THE EYE .4635 2.7 3.6 AGE >17 W/O CC. 48.............. 02 MED *OTHER DISORDERS OF THE EYE .2953 2.9 2.9 AGE 0-17. 49.............. 03 SURG MAJOR HEAD & NECK 1.7911 3.8 5.3 PROCEDURES. 50.............. 03 SURG SIALOADENECTOMY............ .8117 1.7 2.1 51.............. 03 SURG SALIVARY GLAND PROCEDURES .8380 2.0 2.9 EXCEPT SIALOADENECTOMY. 52.............. 03 SURG CLEFT LIP & PALATE REPAIR.. 1.2445 2.2 3.2 53.............. 03 SURG SINUS & MASTOID PROCEDURES 1.0663 2.3 3.6 AGE >17. 54.............. 03 SURG *SINUS & MASTOID PROCEDURES .4786 3.2 3.2 AGE 0-17. 55.............. 03 SURG MISCELLANEOUS EAR, NOSE, .8318 2.0 2.9 MOUTH & THROAT PROCEDURES. 56.............. 03 SURG RHINOPLASTY................ .8845 2.1 2.8 57.............. 03 SURG T&A PROC, EXCEPT 1.0234 2.8 4.0 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17. 58.............. 03 SURG *T&A PROC, EXCEPT .2718 1.5 1.5 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0- 17. 59.............. 03 SURG TONSILLECTOMY &/OR .8026 2.2 3.1 ADENOIDECTOMY ONLY, AGE >17. 60.............. 03 SURG *TONSILLECTOMY &/OR .2070 1.5 1.5 ADENOIDECTOMY ONLY, AGE 0- 17. 61.............. 03 SURG MYRINGOTOMY W TUBE 1.1426 2.8 4.6 INSERTION AGE >17. 62.............. 03 SURG *MYRINGOTOMY W TUBE .2931 1.3 1.3 INSERTION AGE 0-17. 63.............. 03 SURG OTHER EAR, NOSE, MOUTH & 1.2390 3.1 4.6 THROAT O.R. PROCEDURES. 64.............. 03 MED EAR, NOSE, MOUTH & THROAT 1.1531 4.4 6.7 MALIGNANCY. 65.............. 03 MED DYSEQUILIBRIUM............. .5174 2.5 3.2 66.............. 03 MED EPISTAXIS.................. .5588 2.8 3.5 67.............. 03 MED EPIGLOTTITIS............... .7881 3.1 3.8 68.............. 03 MED OTITIS MEDIA & URI AGE >17 .6842 3.5 4.3 W CC. 69.............. 03 MED OTITIS MEDIA & URI AGE >17 .5170 2.9 3.5 W/O CC. 70.............. 03 MED OTITIS MEDIA & URI AGE 0-17 .3837 2.7 3.3 71.............. 03 MED LARYNGOTRACHEITIS.......... .6844 3.0 3.9 72.............. 03 MED NASAL TRAUMA & DEFORMITY... .6277 2.7 3.5 73.............. 03 MED OTHER EAR, NOSE, MOUTH & .7661 3.4 4.7 THROAT DIAGNOSES AGE >17. 74.............. 03 MED *OTHER EAR, NOSE, MOUTH & .3330 2.1 2.1 THROAT DIAGNOSES AGE 0-17. 75.............. 04 SURG MAJOR CHEST PROCEDURES..... 3.1862 8.3 10.5 76.............. 04 SURG OTHER RESP SYSTEM O.R. 2.6396 8.7 11.7 PROCEDURES W CC. 77.............. 04 SURG OTHER RESP SYSTEM O.R. 1.1098 3.6 5.1 PROCEDURES W/O CC. 78.............. 04 MED PULMONARY EMBOLISM......... 1.4278 6.6 7.7 79.............. 04 MED RESPIRATORY INFECTIONS & 1.6310 6.8 8.7 INFLAMMATIONS AGE >17 W CC. 80.............. 04 MED RESPIRATORY INFECTIONS & .9138 4.9 6.0 INFLAMMATIONS AGE >17 W/O CC. 81.............. 04 MED *RESPIRATORY INFECTIONS & 1.5079 6.1 6.1 INFLAMMATIONS AGE 0-17. 82.............. 04 MED RESPIRATORY NEOPLASMS...... 1.3326 5.4 7.3 83.............. 04 MED MAJOR CHEST TRAUMA W CC.... .9660 4.6 5.9 84.............. 04 MED MAJOR CHEST TRAUMA W/O CC.. .5235 2.8 3.5 85.............. 04 MED PLEURAL EFFUSION W CC...... 1.2226 5.3 6.9 86.............. 04 MED PLEURAL EFFUSION W/O CC.... .6697 3.1 4.1 87.............. 04 MED PULMONARY EDEMA & 1.3668 4.9 6.5 RESPIRATORY FAILURE. 88.............. 04 MED CHRONIC OBSTRUCTIVE .9746 4.6 5.7 PULMONARY DISEASE. 89.............. 04 MED SIMPLE PNEUMONIA & PLEURISY 1.1033 5.4 6.6 AGE >17 W CC. 90.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .6793 4.0 4.7 AGE >17 W/O CC. 91.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .7951 3.7 4.4 AGE 0-17. 92.............. 04 MED INTERSTITIAL LUNG DISEASE W .1929 5.3 6.6 CC. 93.............. 04 MED INTERSTITIAL LUNG DISEASE W/ .7367 3.6 4.6 O CC. 94.............. 04 MED PNEUMOTHORAX W CC.......... 1.1833 5.1 6.7 95.............. 04 MED PNEUMOTHORAX W/O CC........ .5950 3.2 4.0 96.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .8093 4.2 5.1 W CC. 97.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .5990 3.3 4.0 W/O CC. 98.............. 04 MED BRONCHITIS & ASTHMA AGE 0- .6334 2.2 3.8 17. 99.............. 04 MED RESPIRATORY SIGNS & .6716 2.5 3.2 SYMPTOMS W CC. 100............. 04 MED RESPIRATORY SIGNS & .5105 1.8 2.2 SYMPTOMS W/O CC. 101............. 04 MED OTHER RESPIRATORY SYSTEM .8495 3.5 4.7 DIAGNOSES W CC. 102............. 04 MED OTHER RESPIRATORY SYSTEM .5298 2.3 2.9 DIAGNOSES W/O CC. 103............. 05 SURG HEART TRANSPLANT........... 16.1872 31.7 47.3 104............. 05 SURG CARDIAC VALVE PROCEDURES W 7.3312 10.8 13.4 CARDIAC CATH. [[Page 29984]] 105............. 05 SURG CARDIAC VALVE PROCEDURES W/ 5.6831 8.4 10.2 O CARDIAC CATH. 106............. 05 SURG CORONARY BYPASS W CARDIAC 5.5811 9.8 11.1 CATH. 107............. 05 SURG CORONARY BYPASS W/O CARDIAC 4.0780 7.3 8.3 CATH. 108............. 05 SURG OTHER CARDIOTHORACIC 6.1040 9.5 12.1 PROCEDURES. 109............. ....... .................... NO LONGER VALID............ .0000 .0 .0 110............. 05 SURG MAJOR CARDIOVASCULAR 4.1852 7.7 10.2 PROCEDURES W CC. 111............. 05 SURG MAJOR CARDIOVASCULAR 2.2254 5.4 6.2 PROCEDURES W/O CC. 112............. 05 SURG PERCUTANEOUS CARDIOVASCULAR 1.9997 3.1 4.2 PROCEDURES. 113............. 05 SURG AMPUTATION FOR CIRC SYSTEM 2.6574 9.7 13.1 DISORDERS EXCEPT UPPER LIMB & TOE. 114............. 05 SURG UPPER LIMB & TOE AMPUTATION 1.5397 6.4 8.8 FOR CIRC SYSTEM DISORDERS. 115............. 05 SURG PERM PACE IMPLNT W AMI,HRT 3.5473 6.7 9.2 FAIL OR SHOCK OR AICD LEAD OR GEN PROC. 116............. 05 SURG OTH PERM CARDIAC PACEMAKER 2.5183 3.5 4.7 IMPLANT OR PTCA W CORONARY ART STENT. 117............. 05 SURG CARDIAC PACEMAKER REVISION 1.1922 2.7 4.0 EXCEPT DEVICE REPLACEMENT. 118............. 05 SURG CARDIAC PACEMAKER DEVICE 1.5923 2.0 3.0 REPLACEMENT. 119............. 05 SURG VEIN LIGATION & STRIPPING.. 1.2041 3.1 5.1 120............. 05 SURG OTHER CIRCULATORY SYSTEM 1.9153 5.0 8.5 O.R. PROCEDURES. 121............. 05 MED CIRCULATORY DISORDERS W AMI 1.6563 6.0 7.3 & MAJOR COMP DISCH ALIVE. 122............. 05 MED CIRCULATORY DISORDERS W AMI 1.1474 3.9 4.7 W/O MAJOR COMP DISCH ALIVE. 123............. 05 MED CIRCULATORY DISORDERS W 1.4704 2.7 4.5 AMI, EXPIRED. 124............. 05 MED CIRCULATORY DISORDERS 1.3575 3.6 4.6 EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125............. 05 MED CIRCULATORY DISORDERS .9739 2.3 2.9 EXCEPT AMI, W CARD CATH W/ O COMPLEX DIAG. 126............. 05 MED ACUTE & SUBACUTE 2.4892 10.0 13.1 ENDOCARDITIS. 127............. 05 MED HEART FAILURE & SHOCK...... 1.0219 4.5 5.8 128............. 05 MED DEEP VEIN THROMBOPHLEBITIS. .7832 5.6 6.4 129............. 05 MED CARDIAC ARREST, UNEXPLAINED 1.1434 1.9 3.2 130............. 05 MED PERIPHERAL VASCULAR .9409 5.1 6.3 DISORDERS W CC. 131............. 05 MED PERIPHERAL VASCULAR .6042 4.1 4.9 DISORDERS W/O CC. 132............. 05 MED ATHEROSCLEROSIS W CC....... .6763 2.7 3.3 133............. 05 MED ATHEROSCLEROSIS W/O CC..... .5391 2.2 2.7 134............. 05 MED HYPERTENSION............... .5785 2.8 3.6 135............. 05 MED CARDIAC CONGENITAL & .8331 3.4 4.5 VALVULAR DISORDERS AGE >17 W CC. 136............. 05 MED CARDIAC CONGENITAL & .5732 2.4 3.1 VALVULAR DISORDERS AGE >17 W/O CC. 137............. 05 MED *CARDIAC CONGENITAL & .8125 3.3 3.3 VALVULAR DISORDERS AGE 0- 17. 138............. 05 MED CARDIAC ARRHYTHMIA & .7960 3.2 4.2 CONDUCTION DISORDERS W CC. 139............. 05 MED CARDIAC ARRHYTHMIA & .4979 2.2 2.7 CONDUCTION DISORDERS W/O CC. 140............. 05 MED ANGINA PECTORIS............ .6036 2.6 3.2 141............. 05 MED SYNCOPE & COLLAPSE W CC.... .6998 3.1 4.1 142............. 05 MED SYNCOPE & COLLAPSE W/O CC.. .5220 2.3 2.9 143............. 05 MED CHEST PAIN................. .5193 1.9 2.4 144............. 05 MED OTHER CIRCULATORY SYSTEM 1.0902 3.9 5.4 DIAGNOSES W CC. 145............. 05 MED OTHER CIRCULATORY SYSTEM .6397 2.3 3.0 DIAGNOSES W/O CC. 146............. 06 SURG RECTAL RESECTION W CC...... 2.7395 9.3 10.5 147............. 06 SURG RECTAL RESECTION W/O CC.... 1.5895 6.3 6.9 148............. 06 SURG MAJOR SMALL & LARGE BOWEL 3.3879 10.6 12.6 PROCEDURES W CC. 149............. 06 SURG MAJOR SMALL & LARGE BOWEL 1.5505 6.5 7.1 PROCEDURES W/O CC. 150............. 06 SURG PERITONEAL ADHESIOLYSIS W 2.7137 9.1 11.1 CC. 151............. 06 SURG PERITONEAL ADHESIOLYSIS W/O 1.2634 4.9 6.1 CC. 152............. 06 SURG MINOR SMALL & LARGE BOWEL 1.9120 7.2 8.5 PROCEDURES W CC. 153............. 06 SURG MINOR SMALL & LARGE BOWEL 1.1591 5.2 5.8 PROCEDURES W/O CC. 154............. 06 SURG STOMACH, ESOPHAGEAL & 4.1799 10.8 14.1 DUODENAL PROCEDURES AGE >17 W CC. 155............. 06 SURG STOMACH, ESOPHAGEAL & 1.3360 3.9 5.0 DUODENAL PROCEDURES AGE >17 W/O CC. 156............. 06 SURG *STOMACH, ESOPHAGEAL & .8368 6.0 6.0 DUODENAL PROCEDURES AGE 0- 17. 157............. 06 SURG ANAL & STOMAL PROCEDURES W 1.1844 4.0 5.6 CC. 158............. 06 SURG ANAL & STOMAL PROCEDURES W/ .6286 2.2 2.8 O CC. 159............. 06 SURG HERNIA PROCEDURES EXCEPT 1.2556 3.8 5.1 INGUINAL & FEMORAL AGE >17 W CC. 160............. 06 SURG HERNIA PROCEDURES EXCEPT .7189 2.3 2.8 INGUINAL & FEMORAL AGE >17 W/O CC. 161............. 06 SURG INGUINAL & FEMORAL HERNIA 1.0571 3.0 4.2 PROCEDURES AGE >17 W CC. 162............. 06 SURG INGUINAL & FEMORAL HERNIA .5897 1.7 2.1 PROCEDURES AGE >17 W/O CC. 163............. 06 SURG HERNIA PROCEDURES AGE 0-17. .8538 3.1 4.7 164............. 06 SURG APPENDECTOMY W COMPLICATED 2.3460 7.5 8.7 PRINCIPAL DIAG W CC. 165............. 06 SURG APPENDECTOMY W COMPLICATED 1.2284 4.7 5.4 PRINCIPAL DIAG W/O CC. [[Page 29985]] 166............. 06 SURG APPENDECTOMY W/O 1.4655 4.3 5.4 COMPLICATED PRINCIPAL DIAG W CC. 167............. 06 SURG APPENDECTOMY W/O .8352 2.5 3.0 COMPLICATED PRINCIPAL DIAG W/O CC. 168............. 03 SURG MOUTH PROCEDURES W CC...... 1.1152 3.2 4.7 169............. 03 SURG MOUTH PROCEDURES W/O CC.... .6870 2.0 2.5 170............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 2.7585 8.1 11.8 PROCEDURES W CC. 171............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 1.1221 3.7 5.1 PROCEDURES W/O CC. 172............. 06 MED DIGESTIVE MALIGNANCY W CC.. 1.2870 5.3 7.4 173............. 06 MED DIGESTIVE MALIGNANCY W/O CC .6749 2.8 3.9 174............. 06 MED G.I. HEMORRHAGE W CC....... .9939 4.1 5.2 175............. 06 MED G.I. HEMORRHAGE W/O CC..... .5383 2.7 3.2 176............. 06 MED COMPLICATED PEPTIC ULCER... 1.1050 4.5 5.8 177............. 06 MED UNCOMPLICATED PEPTIC ULCER .8584 3.8 4.7 W CC. 178............. 06 MED UNCOMPLICATED PEPTIC ULCER .6255 2.8 3.3 W/O CC. 179............. 06 MED INFLAMMATORY BOWEL DISEASE. 1.1142 5.2 6.7 180............. 06 MED G.I. OBSTRUCTION W CC...... .9167 4.4 5.7 181............. 06 MED G.I. OBSTRUCTION W/O CC.... .5208 3.1 3.7 182............. 06 MED ESOPHAGITIS, GASTROENT & .7684 3.5 4.6 MISC DIGEST DISORDERS AGE >17 W CC. 183............. 06 MED ESOPHAGITIS, GASTROENT & .5513 2.6 3.2 MISC DIGEST DISORDERS AGE >17 W/O CC. 184............. 06 MED ESOPHAGITIS, GASTROENT & .5679 2.7 3.7 MISC DIGEST DISORDERS AGE 0-17. 185............. 03 MED DENTAL & ORAL DIS EXCEPT .8431 3.5 4.8 EXTRACTIONS & RESTORATIONS, AGE >17. 186............. 03 MED *DENTAL & ORAL DIS EXCEPT .3190 2.9 2.9 EXTRACTIONS & RESTORATIONS, AGE 0-17. 187............. 03 MED DENTAL EXTRACTIONS & .7018 3.0 3.9 RESTORATIONS. 188............. 06 MED OTHER DIGESTIVE SYSTEM 1.0732 4.3 5.8 DIAGNOSES AGE >17 W CC. 189............. 06 MED OTHER DIGESTIVE SYSTEM .5484 2.5 3.4 DIAGNOSES AGE >17 W/O CC. 190............. 06 MED OTHER DIGESTIVE SYSTEM .8567 3.2 4.9 DIAGNOSES AGE 0-17. 191............. 07 SURG PANCREAS, LIVER & SHUNT 4.3141 11.1 14.9 PROCEDURES W CC. 192............. 07 SURG PANCREAS, LIVER & SHUNT 1.6937 5.6 7.1 PROCEDURES W/O CC. 193............. 07 SURG BILIARY TRACT PROC EXCEPT 3.2686 10.6 12.9 ONLY CHOLECYST W OR W/O C.D.E. W CC. 194............. 07 SURG BILIARY TRACT PROC EXCEPT 1.6529 5.9 7.4 ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195............. 07 SURG CHOLECYSTECTOMY W C.D.E. W 2.7190 8.2 9.8 CC. 196............. 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6123 5.5 6.3 O CC. 197............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.3145 7.2 8.7 LAPAROSCOPE W/O C.D.E. W CC. 198............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.1753 4.1 4.7 LAPAROSCOPE W/O C.D.E. W/O CC. 199............. 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3537 7.9 10.7 PROCEDURE FOR MALIGNANCY. 200............. 07 SURG HEPATOBILIARY DIAGNOSTIC 3.0792 7.6 11.4 PROCEDURE FOR NON- MALIGNANCY. 201............. 07 SURG OTHER HEPATOBILIARY OR 3.3934 11.0 15.0 PANCREAS O.R. PROCEDURES. 202............. 07 MED CIRRHOSIS & ALCOHOLIC 1.3281 5.3 7.1 HEPATITIS. 203............. 07 MED MALIGNANCY OF HEPATOBILIARY 1.2603 5.2 7.2 SYSTEM OR PANCREAS. 204............. 07 MED DISORDERS OF PANCREAS 1.2126 4.9 6.4 EXCEPT MALIGNANCY. 205............. 07 MED DISORDERS OF LIVER EXCEPT 1.2165 5.0 6.8 MALIG, CIRR, ALC HEPA W CC. 206............. 07 MED DISORDERS OF LIVER EXCEPT .6588 3.2 4.2 MALIG, CIRR, ALC HEPA W/O CC. 207............. 07 MED DISORDERS OF THE BILIARY 1.0526 4.1 5.4 TRACT W CC. 208............. 07 MED DISORDERS OF THE BILIARY .6065 2.4 3.0 TRACT W/O CC. 209............. 08 SURG MAJOR JOINT & LIMB 2.2348 5.3 5.9 REATTACHMENT PROCEDURES OF LOWER EXTREMITY. 210............. 08 SURG HIP & FEMUR PROCEDURES 1.8260 6.5 7.6 EXCEPT MAJOR JOINT AGE >17 W CC. 211............. 08 SURG HIP & FEMUR PROCEDURES 1.2523 5.0 5.6 EXCEPT MAJOR JOINT AGE >17 W/O CC. 212............. 08 SURG *HIP & FEMUR PROCEDURES 1.1668 11.1 11.1 EXCEPT MAJOR JOINT AGE 0- 17. 213............. 08 SURG AMPUTATION FOR 1.6483 6.3 8.7 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 214............. 08 SURG NO LONGER VALID............ .0000 .0 .0 215............. 08 SURG NO LONGER VALID............ .0000 .0 .0 216............. 08 SURG BIOPSIES OF MUSCULOSKELETAL 2.0988 7.4 10.3 SYSTEM & CONNECTIVE TISSUE. 217............. 08 SURG WND DEBRID & SKN GRFT 2.7938 9.2 13.7 EXCEPT HAND, FOR MUSCSKELET & CONN TISS DIS. 218............. 08 SURG LOWER EXTREM & HUMER PROC 1.4542 4.4 5.6 EXCEPT HIP, FOOT, FEMUR AGE >17 W CC. 219............. 08 SURG LOWER EXTREM & HUMER PROC .9619 2.9 3.4 EXCEPT HIP, FOOT, FEMUR AGE >17 W/O CC. [[Page 29986]] 220............. 08 SURG *LOWER EXTREM & HUMER PROC .5796 5.3 5.3 EXCEPT HIP, FOOT, FEMUR AGE 0-17. 221............. 08 SURG NO LONGER VALID............ .0000 .0 .0 222............. 08 SURG NO LONGER VALID............ .0000 .0 .0 223............. 08 SURG MAJOR SHOULDER/ELBOW PROC, .9015 2.1 2.7 OR OTHER UPPER EXTREMITY PROC W CC. 224............. 08 SURG SHOULDER, ELBOW OR FOREARM .7474 1.8 2.1 PROC, EXC MAJOR JOINT PROC, W/O CC. 225............. 08 SURG FOOT PROCEDURES............ 1.0149 3.1 4.6 226............. 08 SURG SOFT TISSUE PROCEDURES W CC 1.4061 4.1 6.3 227............. 08 SURG SOFT TISSUE PROCEDURES W/O .7715 2.2 2.9 CC. 228............. 08 SURG MAJOR THUMB OR JOINT PROC, .9539 2.3 3.5 OR OTH HAND OR WRIST PROC W CC. 229............. 08 SURG HAND OR WRIST PROC, EXCEPT .6695 1.8 2.4 MAJOR JOINT PROC, W/O CC. 230............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.1279 3.3 5.0 INT FIX DEVICES OF HIP & FEMUR. 231............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.2689 3.1 4.8 INT FIX DEVICES EXCEPT HIP & FEMUR. 232............. 08 SURG ARTHROSCOPY................ 1.0599 2.5 4.2 233............. 08 SURG OTHER MUSCULOSKELET SYS & 2.0155 5.7 8.3 CONN TISS O.R. PROC W CC. 234............. 08 SURG OTHER MUSCULOSKELET SYS & 1.1072 2.9 3.9 CONN TISS O.R. PROC W/O CC. 235............. 08 MED FRACTURES OF FEMUR......... .7709 4.2 5.9 236............. 08 MED FRACTURES OF HIP & PELVIS.. .7341 4.3 5.7 237............. 08 MED SPRAINS, STRAINS, & .5909 3.2 4.2 DISLOCATIONS OF HIP, PELVIS & THIGH. 238............. 08 MED OSTEOMYELITIS.............. 1.3362 7.0 9.4 239............. 08 MED PATHOLOGICAL FRACTURES & .9851 5.3 7.0 MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240............. 08 MED CONNECTIVE TISSUE DISORDERS 1.2071 5.1 7.0 W CC. 241............. 08 MED CONNECTIVE TISSUE DISORDERS .5873 3.3 4.2 W/O CC. 242............. 08 MED SEPTIC ARTHRITIS........... 1.0548 5.5 7.2 243............. 08 MED MEDICAL BACK PROBLEMS...... .7157 4.0 5.1 244............. 08 MED BONE DISEASES & SPECIFIC .7167 4.0 5.4 ARTHROPATHIES W CC. 245............. 08 MED BONE DISEASES & SPECIFIC .5014 3.0 4.0 ARTHROPATHIES W/O CC. 246............. 08 MED NON-SPECIFIC ARTHROPATHIES. .5737 3.4 4.3 247............. 08 MED SIGNS & SYMPTOMS OF .5575 2.8 3.7 MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248............. 08 MED TENDONITIS, MYOSITIS & .7414 3.7 5.0 BURSITIS. 249............. 08 MED AFTERCARE, MUSCULOSKELETAL .6524 2.7 3.9 SYSTEM & CONNECTIVE TISSUE. 250............. 08 MED FX, SPRN, STRN & DISL OF .6984 3.4 4.7 FOREARM, HAND, FOOT AGE >17 W CC. 251............. 08 MED FX, SPRN, STRN & DISL OF .4527 2.3 3.0 FOREARM, HAND, FOOT AGE >17 W/O CC. 252............. 08 MED *FX, SPRN, STRN & DISL OF .2518 1.8 1.8 FOREARM, HAND, FOOT AGE 0- 17. 253............. 08 MED FX, SPRN, STRN & DISL OF .7245 3.9 5.3 UPARM, LOWLEG EX FOOT AGE >17 W CC. 254............. 08 MED FX, SPRN, STRN & DISL OF .4343 2.8 3.5 UPARM, LOWLEG EX FOOT AGE >17 W/O CC. 255............. 08 MED *FX, SPRN, STRN & DISL OF .2932 2.9 2.9 UPARM, LOWLEG EX FOOT AGE 0-17. 256............. 08 MED OTHER MUSCULOSKELETAL .7779 3.9 5.7 SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257............. 09 SURG TOTAL MASTECTOMY FOR .9273 2.6 3.2 MALIGNANCY W CC. 258............. 09 SURG TOTAL MASTECTOMY FOR .7158 2.0 2.3 MALIGNANCY W/O CC. 259............. 09 SURG SUBTOTAL MASTECTOMY FOR .8870 2.1 3.2 MALIGNANCY W CC. 260............. 09 SURG SUBTOTAL MASTECTOMY FOR .6083 1.4 1.7 MALIGNANCY W/O CC. 261............. 09 SURG BREAST PROC FOR NON- .8980 1.8 2.2 MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262............. 09 SURG BREAST BIOPSY & LOCAL .7883 2.6 4.0 EXCISION FOR NON- MALIGNANCY. 263............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0240 8.9 12.5 SKN ULCER OR CELLULITIS W CC. 264............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.0809 5.4 7.3 SKN ULCER OR CELLULITIS W/ O CC. 265............. 09 SURG SKIN GRAFT &/OR DEBRID 1.4947 4.6 7.1 EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266............. 09 SURG SKIN GRAFT &/OR DEBRID .7880 2.6 3.6 EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267............. 09 SURG PERIANAL & PILONIDAL .8551 2.7 4.2 PROCEDURES. 268............. 09 SURG SKIN, SUBCUTANEOUS TISSUE & 1.0173 2.4 3.6 BREAST PLASTIC PROCEDURES. 269............. 09 SURG OTHER SKIN, SUBCUT TISS & 1.5805 5.9 8.5 BREAST PROC W CC. 270............. 09 SURG OTHER SKIN, SUBCUT TISS & .7083 2.2 3.2 BREAST PROC W/O CC. 271............. 09 MED SKIN ULCERS................ 1.0344 6.0 7.7 [[Page 29987]] 272............. 09 MED MAJOR SKIN DISORDERS W CC.. .9940 5.1 6.7 273............. 09 MED MAJOR SKIN DISORDERS W/O CC .6713 4.0 5.4 274............. 09 MED MALIGNANT BREAST DISORDERS 1.1158 4.9 7.2 W CC. 275............. 09 MED MALIGNANT BREAST DISORDERS .5823 2.4 3.8 W/O CC. 276............. 09 MED NON-MALIGANT BREAST .6170 3.8 4.7 DISORDERS. 277............. 09 MED CELLULITIS AGE >17 W CC.... .8374 5.1 6.2 278............. 09 MED CELLULITIS AGE >17 W/O CC.. .5629 4.0 4.8 279............. 09 MED *CELLULITIS AGE 0-17....... .7304 4.2 4.2 280............. 09 MED TRAUMA TO THE SKIN, SUBCUT .6748 3.5 4.7 TISS & BREAST AGE >17 W CC. 281............. 09 MED TRAUMA TO THE SKIN, SUBCUT .4539 2.5 3.4 TISS & BREAST AGE >17 W/O CC. 282............. 09 MED *TRAUMA TO THE SKIN, SUBCUT .2549 2.2 2.2 TISS & BREAST AGE 0-17. 283............. 09 MED MINOR SKIN DISORDERS W CC.. .6927 3.8 5.0 284............. 09 MED MINOR SKIN DISORDERS W/O CC .4355 2.7 3.5 285............. 10 SURG AMPUTAT OF LOWER LIMB FOR 2.1559 8.8 12.1 ENDOCRINE, NUTRIT, & METABOL DISORDERS. 286............. 10 SURG ADRENAL & PITUITARY 2.2472 5.7 7.2 PROCEDURES. 287............. 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8821 8.6 12.1 FOR ENDOC, NUTRIT & METAB DISORDERS. 288............. 10 SURG O.R. PROCEDURES FOR OBESITY 1.9792 4.8 5.9 289............. 10 SURG PARATHYROID PROCEDURES..... .9793 2.4 3.5 290............. 10 SURG THYROID PROCEDURES......... .8990 2.0 2.6 291............. 10 SURG THYROGLOSSAL PROCEDURES.... .7362 1.7 2.2 292............. 10 SURG OTHER ENDOCRINE, NUTRIT & 2.5540 7.6 11.2 METAB O.R. PROC W CC. 293............. 10 SURG OTHER ENDOCRINE, NUTRIT & 1.2228 4.0 5.9 METAB O.R. PROC W/O CC. 294............. 10 MED DIABETES AGE >35........... .7562 4.0 5.3 295............. 10 MED DIABETES AGE 0-35.......... .7347 3.2 4.1 296............. 10 MED NUTRITIONAL & MISC .8655 4.3 5.8 METABOLIC DISORDERS AGE >17 W CC. 297............. 10 MED NUTRITIONAL & MISC .5200 3.0 3.9 METABOLIC DISORDERS AGE >17 W/O CC. 298............. 10 MED NUTRITIONAL & MISC .4116 2.0 2.5 METABOLIC DISORDERS AGE 0- 17. 299............. 10 MED INBORN ERRORS OF METABOLISM .8645 3.9 5.5 300............. 10 MED ENDOCRINE DISORDERS W CC... 1.0787 5.1 6.6 301............. 10 MED ENDOCRINE DISORDERS W/O CC. .5928 3.1 4.4 302............. 11 SURG KIDNEY TRANSPLANT.......... 3.7056 9.2 11.0 303............. 11 SURG KIDNEY, URETER & MAJOR 2.6067 7.8 9.5 BLADDER PROCEDURES FOR NEOPLASM. 304............. 11 SURG KIDNEY, URETER & MAJOR 2.3912 6.9 9.6 BLADDER PROC FOR NON-NEOPL W CC. 305............. 11 SURG KIDNEY, URETER & MAJOR 1.1690 3.4 4.3 BLADDER PROC FOR NON-NEOPL W/O CC. 306............. 11 SURG PROSTATECTOMY W CC......... 1.2212 4.0 5.8 307............. 11 SURG PROSTATECTOMY W/O CC....... .6495 2.1 2.5 308............. 11 SURG MINOR BLADDER PROCEDURES W 1.5142 4.3 6.4 CC. 309............. 11 SURG MINOR BLADDER PROCEDURES W/ .8733 2.1 2.6 O CC. 310............. 11 SURG TRANSURETHRAL PROCEDURES W 1.0253 3.0 4.3 CC. 311............. 11 SURG TRANSURETHRAL PROCEDURES W/ .5867 1.7 2.1 O CC. 312............. 11 SURG URETHRAL PROCEDURES, AGE .9770 3.1 4.7 >17 W CC. 313............. 11 SURG URETHRAL PROCEDURES, AGE .5799 1.8 2.3 >17 W/O CC. 314............. 11 SURG *URETHRAL PROCEDURES, AGE 0- .4912 2.3 2.3 17. 315............. 11 SURG OTHER KIDNEY & URINARY 2.0639 4.9 8.6 TRACT O.R. PROCEDURES. 316............. 11 MED RENAL FAILURE.............. 1.3100 5.1 7.1 317............. 11 MED ADMIT FOR RENAL DIALYSIS... .5551 2.0 2.9 318............. 11 MED KIDNEY & URINARY TRACT 1.1589 4.7 6.7 NEOPLASMS W CC. 319............. 11 MED KIDNEY & URINARY TRACT .5851 2.0 2.8 NEOPLASMS W/O CC. 320............. 11 MED KIDNEY & URINARY TRACT .8796 4.7 5.9 INFECTIONS AGE >17 W CC. 321............. 11 MED KIDNEY & URINARY TRACT .5864 3.6 4.3 INFECTIONS AGE >17 W/O CC. 322............. 11 MED KIDNEY & URINARY TRACT .5236 3.3 4.1 INFECTIONS AGE 0-17. 323............. 11 MED URINARY STONES W CC, &/OR .7559 2.5 3.4 ESW LITHOTRIPSY. 324............. 11 MED URINARY STONES W/O CC...... .4306 1.7 2.0 325............. 11 MED KIDNEY & URINARY TRACT .6224 3.1 4.2 SIGNS & SYMPTOMS AGE >17 W CC. 326............. 11 MED KIDNEY & URINARY TRACT .4206 2.3 2.9 SIGNS & SYMPTOMS AGE >17 W/ O CC. 327............. 11 MED KIDNEY & URINARY TRACT .3394 2.3 3.5 SIGNS & SYMPTOMS AGE 0-17. 328............. 11 MED URETHRAL STRICTURE AGE >17 .6891 2.9 3.9 W CC. 329............. 11 MED URETHRAL STRICTURE AGE >17 .5050 1.9 2.3 W/O CC. 330............. 11 MED *URETHRAL STRICTURE AGE 0- .3164 1.6 1.6 17. 331............. 11 MED OTHER KIDNEY & URINARY .9985 4.4 5.9 TRACT DIAGNOSES AGE >17 W CC. 332............. 11 MED OTHER KIDNEY & URINARY .5845 2.6 3.5 TRACT DIAGNOSES AGE >17 W/ O CC. 333............. 11 MED OTHER KIDNEY & URINARY .8999 4.0 5.7 TRACT DIAGNOSES AGE 0-17. 334............. 12 SURG MAJOR MALE PELVIC 1.6387 4.8 5.4 PROCEDURES W CC. 335............. 12 SURG MAJOR MALE PELVIC 1.2197 3.7 4.1 PROCEDURES W/O CC. 336............. 12 SURG TRANSURETHRAL PROSTATECTOMY .8893 2.9 3.8 W CC. [[Page 29988]] 337............. 12 SURG TRANSURETHRAL PROSTATECTOMY .6159 2.1 2.4 W/O CC. 338............. 12 SURG TESTES PROCEDURES, FOR 1.0997 3.3 5.1 MALIGNANCY. 339............. 12 SURG TESTES PROCEDURES, NON- 1.0073 3.1 4.6 MALIGNANCY AGE >17. 340............. 12 SURG *TESTES PROCEDURES, NON- .2813 2.4 2.4 MALIGNANCY AGE 0-17. 341............. 12 SURG PENIS PROCEDURES........... 1.1129 2.2 3.1 342............. 12 SURG CIRCUMCISION AGE >17....... .8680 3.0 4.2 343............. 12 SURG *CIRCUMCISION AGE 0-17..... .1528 1.7 1.7 344............. 12 SURG OTHER MALE REPRODUCTIVE 1.0265 2.1 3.1 SYSTEM O.R. PROCEDURES FOR MALIGNANCY. 345............. 12 SURG OTHER MALE REPRODUCTIVE .8547 2.7 3.8 SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. 346............. 12 MED MALIGNANCY, MALE .9554 4.5 6.3 REPRODUCTIVE SYSTEM, W CC. 347............. 12 MED MALIGNANCY, MALE .4682 2.2 3.0 REPRODUCTIVE SYSTEM, W/O CC. 348............. 12 MED BENIGN PROSTATIC .6954 3.3 4.5 HYPERTROPHY W CC. 349............. 12 MED BENIGN PROSTATIC .4196 2.1 2.7 HYPERTROPHY W/O CC. 350............. 12 MED INFLAMMATION OF THE MALE .6801 3.8 4.6 REPRODUCTIVE SYSTEM. 351............. 12 MED *STERILIZATION, MALE....... .2345 1.3 1.3 352............. 12 MED OTHER MALE REPRODUCTIVE .6210 2.8 3.9 SYSTEM DIAGNOSES. 353............. 13 SURG PELVIC EVISCERATION, 2.1041 6.4 8.3 RADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354............. 13 SURG UTERINE, ADNEXA PROC FOR 1.4944 5.0 6.0 NON-OVARIAN/ADNEXAL MALIG W CC. 355............. 13 SURG UTERINE, ADNEXA PROC FOR .9167 3.4 3.6 NON-OVARIAN/ADNEXAL MALIG W/O CC. 356............. 13 SURG FEMALE REPRODUCTIVE SYSTEM .7715 2.5 2.8 RECONSTRUCTIVE PROCEDURES. 357............. 13 SURG UTERINE & ADNEXA PROC FOR 2.4197 7.6 9.3 OVARIAN OR ADNEXAL MALIGNANCY. 358............. 13 SURG UTERINE & ADNEXA PROC FOR 1.2028 3.8 4.5 NON-MALIGNANCY W CC. 359............. 13 SURG UTERINE & ADNEXA PROC FOR .8469 2.9 3.1 NON-MALIGNANCY W/O CC. 360............. 13 SURG VAGINA, CERVIX & VULVA .8713 2.7 3.3 PROCEDURES. 361............. 13 SURG LAPAROSCOPY & INCISIONAL 1.1804 2.6 3.7 TUBAL INTERRUPTION. 362............. 13 SURG *ENDOSCOPIC TUBAL .2998 1.4 1.4 INTERRUPTION. 363............. 13 SURG D&C, CONIZATION & RADIO- .7470 2.6 3.5 IMPLANT, FOR MALIGNANCY. 364............. 13 SURG D&C, CONIZATION EXCEPT FOR .7020 2.5 3.5 MALIGNANCY. 365............. 13 SURG OTHER FEMALE REPRODUCTIVE 1.7123 4.7 7.2 SYSTEM O.R. PROCEDURES. 366............. 13 MED MALIGNANCY, FEMALE 1.1898 4.9 7.1 REPRODUCTIVE SYSTEM W CC. 367............. 13 MED MALIGNANCY, FEMALE .5347 2.1 2.9 REPRODUCTIVE SYSTEM W/O CC. 368............. 13 MED INFECTIONS, FEMALE .9733 5.0 6.3 REPRODUCTIVE SYSTEM. 369............. 13 MED MENSTRUAL & OTHER FEMALE .5386 2.5 3.4 REPRODUCTIVE SYSTEM DISORDERS. 370............. 14 SURG CESAREAN SECTION W CC...... 1.0660 4.3 5.6 371............. 14 SURG CESAREAN SECTION W/O CC.... .7057 3.3 3.6 372............. 14 MED VAGINAL DELIVERY W .5552 2.4 3.1 COMPLICATING DIAGNOSES. 373............. 14 MED VAGINAL DELIVERY W/O .3954 1.7 2.0 COMPLICATING DIAGNOSES. 374............. 14 SURG VAGINAL DELIVERY W .7814 2.3 2.9 STERILIZATION &/OR D&C. 375............. 14 SURG *VAGINAL DELIVERY W O.R. .6804 4.4 4.4 PROC EXCEPT STERIL &/OR D&C. 376............. 14 MED POSTPARTUM & POST ABORTION .4882 2.4 3.3 DIAGNOSES W/O O.R. PROCEDURE. 377............. 14 SURG POSTPARTUM & POST ABORTION 1.0654 2.6 4.1 DIAGNOSES W O.R. PROCEDURE. 378............. 14 MED ECTOPIC PREGNANCY.......... .8186 2.3 2.7 379............. 14 MED THREATENED ABORTION........ .4021 2.1 3.0 380............. 14 MED ABORTION W/O D&C........... .3424 1.5 1.8 381............. 14 SURG ABORTION W D&C, ASPIRATION .4595 1.6 2.2 CURETTAGE OR HYSTEROTOMY. 382............. 14 MED FALSE LABOR................ .2107 1.2 1.3 383............. 14 MED OTHER ANTEPARTUM DIAGNOSES .4596 2.8 3.8 W MEDICAL COMPLICATIONS. 384............. 14 MED OTHER ANTEPARTUM DIAGNOSES .3659 2.0 2.9 W/O MEDICAL COMPLICATIONS. 385............. 15 .................... *NEONATES, DIED OR 1.3655 1.8 1.8 TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386............. 15 .................... *EXTREME IMMATURITY OR 4.5029 17.9 17.9 RESPIRATORY DISTRESS SYNDROME, NEONATE. 387............. 15 .................... *PREMATURITY W MAJOR 3.0754 13.3 13.3 PROBLEMS. 388............. 15 .................... *PREMATURITY W/O MAJOR 1.8556 8.6 8.6 PROBLEMS. 389............. 15 .................... FULL TERM NEONATE W MAJOR 1.4625 5.1 6.3 PROBLEMS. 390............. 15 .................... *NEONATE W OTHER 1.3048 3.4 3.4 SIGNIFICANT PROBLEMS. 391............. 15 .................... * NORMAL NEWBORN........... .1514 3.1 3.1 392............. 16 SURG SPLENECTOMY AGE >17........ 3.1584 8.1 10.6 393............. 16 SURG *SPLENECTOMY AGE 0-17...... 1.3376 9.1 9.1 [[Page 29989]] 394............. 16 SURG OTHER O.R. PROCEDURES OF 1.6297 4.5 7.4 THE BLOOD AND BLOOD FORMING ORGANS. 395............. 16 MED RED BLOOD CELL DISORDERS .8191 3.6 5.0 AGE >17. 396............. 16 MED RED BLOOD CELL DISORDERS .6302 2.7 4.1 AGE 0-17. 397............. 16 MED COAGULATION DISORDERS...... 1.2694 4.2 5.8 398............. 16 MED RETICULOENDOTHELIAL & 1.2233 4.9 6.3 IMMUNITY DISORDERS W CC. 399............. 16 MED RETICULOENDOTHELIAL & .6859 3.2 4.0 IMMUNITY DISORDERS W/O CC. 400............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 2.6206 6.3 9.7 O.R. PROCEDURE. 401............. 17 SURG LYMPHOMA & NON-ACUTE 2.5614 8.1 11.7 LEUKEMIA W OTHER O.R. PROC W CC. 402............. 17 SURG LYMPHOMA & NON-ACUTE 1.0130 2.9 4.2 LEUKEMIA W OTHER O.R. PROC W/O CC. 403............. 17 MED LYMPHOMA & NON-ACUTE 1.6930 6.0 8.6 LEUKEMIA W CC. 404............. 17 MED LYMPHOMA & NON-ACUTE .7928 3.3 4.6 LEUKEMIA W/O CC. 405............. 17 .................... *ACUTE LEUKEMIA W/O MAJOR 1.8964 4.9 4.9 O.R. PROCEDURE AGE 0-17. 406............. 17 SURG MYELOPROLIF DISORD OR 2.5952 7.2 10.0 POORLY DIFF NEOPL W MAJ O.R. PROC W CC. 407............. 17 SURG MYELOPROLIF DISORD OR 1.1430 3.5 4.4 POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC. 408............. 17 SURG MYELOPROLIF DISORD OR 1.7314 4.8 7.7 POORLY DIFF NEOPL W OTHER O.R. PROC. 409............. 17 MED RADIOTHERAPY............... .9545 4.3 5.9 410............. 17 MED CHEMOTHERAPY W/O ACUTE .7957 2.6 3.4 LEUKEMIA AS SECONDARY DIAGNOSIS. 411............. 17 MED HISTORY OF MALIGNANCY W/O .4403 1.8 2.3 ENDOSCOPY. 412............. 17 MED HISTORY OF MALIGNANCY W .5176 2.4 3.4 ENDOSCOPY. 413............. 17 MED OTHER MYELOPROLIF DIS OR 1.3771 5.7 8.0 POORLY DIFF NEOPL DIAG W CC. 414............. 17 MED OTHER MYELOPROLIF DIS OR .7072 3.2 4.6 POORLY DIFF NEOPL DIAG W/O CC. 415............. 18 SURG O.R. PROCEDURE FOR 3.5212 10.9 14.9 INFECTIOUS & PARASITIC DISEASES. 416............. 18 MED SEPTICEMIA AGE >17......... 1.4832 5.8 7.7 417............. 18 MED SEPTICEMIA AGE 0-17........ .7530 3.3 4.4 418............. 18 MED POSTOPERATIVE & POST- .9666 5.0 6.3 TRAUMATIC INFECTIONS. 419............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .8810 4.1 5.3 >17 W CC. 420............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .6040 3.2 4.0 >17 W/O CC. 421............. 18 MED VIRAL ILLNESS AGE >17...... .7063 3.3 4.2 422............. 18 MED VIRAL ILLNESS & FEVER OF .5308 2.7 3.9 UNKNOWN ORIGIN AGE 0-17. 423............. 18 MED OTHER INFECTIOUS & 1.5656 5.8 7.9 PARASITIC DISEASES DIAGNOSES. 424............. 19 SURG O.R. PROCEDURE W PRINCIPAL 2.4655 9.9 16.9 DIAGNOSES OF MENTAL ILLNESS. 425............. 19 MED ACUTE ADJUST REACT & .6861 3.2 4.4 DISTURBANCES OF PSYCHOSOCIAL DYSFUNCTION. 426............. 19 MED DEPRESSIVE NEUROSES........ .5648 3.7 5.2 427............. 19 MED NEUROSES EXCEPT DEPRESSIVE. .5805 3.6 5.3 428............. 19 MED DISORDERS OF PERSONALITY & .6946 4.9 7.6 IMPULSE CONTROL. 429............. 19 MED ORGANIC DISTURBANCES & .8713 5.4 7.9 MENTAL RETARDATION. 430............. 19 MED PSYCHOSES.................. .8101 6.5 9.1 431............. 19 MED CHILDHOOD MENTAL DISORDERS. .8425 5.5 8.9 432............. 19 MED OTHER MENTAL DISORDER .7654 3.7 5.8 DIAGNOSES. 433............. 20 .................... ALCOHOL/DRUG ABUSE OR .3037 2.4 3.3 DEPENDENCE, LEFT AMA. 434............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .6852 4.0 5.3 DETOX OR OTH SYMPT TREAT W CC. 435............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .3987 3.6 4.5 DETOX OR OTH SYMPT TREAT W/ O CC. 436............. 20 .................... ALC/DRUG DEPENDENCE W .8107 11.5 14.0 REHABILITATION THERAPY. 437............. 20 .................... ALC/DRUG DEPENDENCE, .7364 8.3 9.9 COMBINED REHAB & DETOX THERAPY. 438............. ....... .................... NO LONGER VALID............ .0000 .0 .0 439............. 21 SURG SKIN GRAFTS FOR INJURIES... 1.6308 5.4 8.5 440............. 21 SURG WOUND DEBRIDEMENTS FOR 1.8261 6.0 9.5 INJURIES. 441............. 21 SURG HAND PROCEDURES FOR .9319 2.2 3.5 INJURIES. 442............. 21 SURG OTHER O.R. PROCEDURES FOR 2.1794 5.4 8.3 INJURIES W CC. 443............. 21 SURG OTHER O.R. PROCEDURES FOR .9109 2.5 3.4 INJURIES W/O CC. 444............. 21 MED TRAUMATIC INJURY AGE >17 W .6988 3.7 4.8 CC. 445............. 21 MED TRAUMATIC INJURY AGE >17 W/ .4849 2.6 3.7 O CC. 446............. 21 MED *TRAUMATIC INJURY AGE 0-17. .2940 2.4 2.4 447............. 21 MED ALLERGIC REACTIONS AGE >17. .4932 2.0 2.6 448............. 21 MED ALLERGIC REACTIONS AGE 0-17 .0952 1.0 1.0 449............. 21 MED POISONING & TOXIC EFFECTS .7859 2.8 4.0 OF DRUGS AGE >17 W CC. 450............. 21 MED POISONING & TOXIC EFFECTS .4416 1.7 2.3 OF DRUGS AGE >17 W/O CC. 451............. 21 MED *POISONING & TOXIC EFFECTS .2611 2.1 2.1 OF DRUGS AGE 0-17. 452............. 21 MED COMPLICATIONS OF TREATMENT .9475 3.7 5.2 W CC. 453............. 21 MED COMPLICATIONS OF TREATMENT .4946 2.3 3.1 W/O CC. 454............. 21 MED OTHER INJURY, POISONING & .9026 3.3 5.2 TOXIC EFFECT DIAG W CC. [[Page 29990]] 455............. 21 MED OTHER INJURY, POISONING & .4431 2.0 2.8 TOXIC EFFECT DIAG W/O CC. 456............. 22 .................... BURNS, TRANSFERRED TO 1.7408 3.7 7.3 ANOTHER ACUTE CARE FACILITY. 457............. 22 MED EXTENSIVE BURNS W/O O.R. 1.5647 2.5 4.9 PROCEDURE. 458............. 22 SURG NON-EXTENSIVE BURNS W SKIN 3.5516 11.1 16.0 GRAFT. 459............. 22 SURG NON-EXTENSIVE BURNS W WOUND 1.5555 6.5 9.3 DEBRIDEMENT OR OTHER O.R. PROC. 460............. 22 MED NON-EXTENSIVE BURNS W/O .9464 4.4 6.3 O.R. PROCEDURE. 461............. 23 SURG O.R. PROC W DIAGNOSES OF 1.0082 2.5 4.6 OTHER CONTACT W HEALTH SERVICES. 462............. 23 MED REHABILITATION............. 1.3997 10.5 13.1 463............. 23 MED SIGNS & SYMPTOMS W CC...... .6904 3.6 4.8 464............. 23 MED SIGNS & SYMPTOMS W/O CC.... .4855 2.7 3.4 465............. 23 MED AFTERCARE W HISTORY OF .5882 2.2 3.8 MALIGNANCY AS SECONDARY DIAGNOSIS. 466............. 23 MED AFTERCARE W/O HISTORY OF .6265 2.6 4.7 MALIGNANCY AS SECONDARY DIAGNOSIS. 467............. 23 MED OTHER FACTORS INFLUENCING .4641 2.3 4.2 HEALTH STATUS. 468............. ....... .................... EXTENSIVE O.R. PROCEDURE 3.6128 9.9 14.1 UNRELATED TO PRINCIPAL DIAGNOSIS. 469............. ....... .................... **PRINCIPAL DIAGNOSIS .0000 .0 .0 INVALID AS DISCHARGE DIAGNOSIS. 470............. ....... .................... **UNGROUPABLE.............. .0000 .0 .0 471............. 08 SURG BILATERAL OR MULTIPLE MAJOR 3.4694 5.8 6.7 JOINT PROCS OF LOWER EXTREMITY. 472............. 22 SURG EXTENSIVE BURNS W O.R. 10.2511 11.7 23.9 PROCEDURE. 473............. 17 .................... ACUTE LEUKEMIA W/O MAJOR 3.4633 7.9 13.6 O.R. PROCEDURE AGE >17. 474............. ....... .................... NO LONGER VALID............ 0000 .0 .0 475............. 04 MED RESPIRATORY SYSTEM 3.7349 8.2 11.6 DIAGNOSIS WITH VENTILATOR SUPPORT. 476............. ....... SURG PROSTATIC O.R. PROCEDURE 2.2284 9.5 12.6 UNRELATED TO PRINCIPAL DIAGNOSIS. 477............. ....... SURG NON-EXTENSIVE O.R. 1.7434 5.5 8.6 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 478............. 05 SURG OTHER VASCULAR PROCEDURES W 2.3179 5.2 7.7 CC. 479............. 05 SURG OTHER VASCULAR PROCEDURES W/ 1.4148 3.2 4.2 O CC. 480............. ....... SURG LIVER TRANSPLANT........... 10.6265 18.7 24.2 481............. ....... SURG BONE MARROW TRANSPLANT..... 11.1194 26.3 29.9 482............. ....... SURG TRACHEOSTOMY FOR FACE, 3.5738 10.5 13.5 MOUTH & NECK DIAGNOSES. 483............. ....... SURG TRACHEOSTOMY EXCEPT FOR 15.9340 33.7 43.3 FACE, MOUTH & NECK DIAGNOSES. 484............. 24 SURG CRANIOTOMY FOR MULTIPLE 5.7304 10.6 15.3 SIGNIFICANT TRAUMA. 485............. 24 SURG LIMB REATTACHMENT, HIP AND 3.0798 8.2 10.4 FEMUR PROC FOR MULTIPLE SIGNIFICANT TR. 486............. 24 SURG OTHER O.R. PROCEDURES FOR 4.8508 8.8 13.4 MULTIPLE SIGNIFICANT TRAUMA. 487............. 24 MED OTHER MULTIPLE SIGNIFICANT 2.0089 5.9 8.3 TRAUMA. 488............. 25 SURG HIV W EXTENSIVE O.R. 4.4739 12.0 17.8 PROCEDURE. 489............. 25 MED HIV W MAJOR RELATED 1.7916 6.7 9.8 CONDITION. 490............. 25 MED HIV W OR W/O OTHER RELATED .9930 4.2 6.0 CONDITION. 491............. 08 SURG MAJOR JOINT & LIMB 1.6585 3.3 3.9 REATTACHMENT PROCEDURES OF UPPER EXTREMITY. 492............. 17 MED CHEMOTHERAPY W ACUTE 4.6072 11.8 17.9 LEUKEMIA AS SECONDARY DIAGNOSIS. 493............. 07 SURG LAPAROSCOPIC 1.7593 4.1 5.7 CHOLECYSTECTOMY W/O C.D.E. W CC. 494............. 07 SURG LAPAROSCOPIC .9434 1.8 2.4 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495............. ....... SURG LUNG TRANSPLANT............ 9.0199 14.4 17.4 496............. 08 SURG COMBINED ANTERIOR/POSTERIOR 5.4752 9.2 11.5 SPINAL FUSION. 497............. 08 SURG SPINAL FUSION W CC......... 2.7641 5.3 6.8 498............. 08 SURG SPINAL FUSION W/O CC....... 1.6140 3.1 3.7 499............. 08 SURG BACK & NECK PROCS EXCEPT 1.4825 4.1 5.3 SPINAL FUSION W CC. 500............. 08 SURG BACK & NECK PROCS EXCEPT .9704 2.6 3.1 SPINAL FUSION W/O CC. 501............. 08 SURG KNEE PROC W PRINCIPAL 2.3780 8.1 10.4 DIAGNOSIS OF INFECTION W CC. 502............. 08 SURG KNEE PROC W PRINCIPAL 1.4616 4.1 5.3 DIAGNOSIS OF INFECTION W/O CC. 503............. 08 SURG KNEE PROCEDURES W/O .9891 2.7 3.4 PRINCIPAL DIAGNOSIS OF INFECTION. ---------------------------------------------------------------------------------------------------------------- *Medicare data have been supplemented by data from 19 states for low volume DRGs. **DRGS 469 and 470 contain cases which could not be assigned to valid DRGs. Note: Geometric mean is used only to determine payment for transfer cases. Note: Arithmetic mean is used only to determine payment for outlier cases. Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients. [[Page 29991]] Table 6A.--New Diagnosis Codes ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 007.4....... Other protozoal intestinal N 6 182, 183, 184 diseases, cryptosporidiosis. 031.2....... Disease due to N 18 423 disseminated 25 489 1 mycobacterium avium- intracellulare complex (DMAC). 038.10...... Staphylococcal septicemia, Y 15 387, 389 2 unspecified. 18 416, 417 25 4891 038.11...... Staphylococcus aureus Y 15 387, 389 2 septicemia. 18 416, 417 25 4891 038.19...... Other staphylococcal Y 15 387, 389 2 septicemia. 18 416,417 25 4891 275.40...... Unspecified disorder of N 10 296, 297, 298 calcium metabolism. 275.41...... Hypocalcemia.............. N 10 296, 297, 298 275.42...... Hypercalcemia............. N 10 296, 297, 298 275.49...... Other disorder of calcium N 10 296, 297, 298 metabolism. 438.0....... Late effect of N 1 12 cerebrovascular disease, cognitive deficits. 438.10...... Late effect of N 1 12 cerebrovascular disease, speech and language deficits, unspecified.. 438.11...... Late effect of N 1 12 cerebrovascular disease, speech and language deficits, aphasia. 438.12...... Late effect of N 1 12 cerebrovascular disease, speech and language deficits, dysphasia. 438.19...... Late effect of N 1 12 cerebrovascular disease, other speech and language deficits. 438.20...... Late effect of N 1 12 cerebrovascular disease, hemiplegia affecting unspecified side. 438.21...... Late effect of N 1 12 cerebrovascular disease, hemiplegia affecting dominant side. 438.22...... Late effect of N 1 12 cerebrovascular disease, hemiplegia affecting nondominant side. 438.30...... Late effect of N 1 12 cerebrovascular disease, monoplegia of upper limb affecting unspecified side. 438.31...... Late effect of N 1 12 cerebrovascular disease, monoplegia of upper limb affecting dominant side. 438.32...... Late effect of N 1 12 cerebrovascular disease, monoplegia of upper limb affecting nondominant side. 438.40...... Late effect of N 1 12 cerebrovascular disease, monoplegia of lower limb affecting unspecified side. 438.41...... Late effect of N 1 12 cerebrovascular disease, monoplegia of lower limb affecting dominant side. 438.42...... Late effect of N 1 12 cerebrovascular disease, monoplegia of lower limb affecting nondominant side. 438.50...... Late effect of N 1 12 cerebrovascular disease, other paralytic syndrome affecting unspecified side. 438.51...... Late effect of N 1 12 cerebrovascular disease, other paralytic syndrome affecting dominant side. 438.52...... Late effect of N 1 12 cerebrovascular disease, other paralytic syndrome affecting nondominant side. 438.81...... Other late effect of N 1 12 cerebrovascular disease, apraxia. 438.82...... Other late effect of N 1 12 cerebrovascular disease, dysphagia. 438.89...... Other late effects of N 1 12 cerebrovascular disease. 438.9....... Unspecified late effects N 1 12 of cerebrovascular disease. 458.8....... Other specified N 5 144, 145 hypotension. 1213 474.00...... Chronic tonsillitis....... N pre 482 3 68, 69, 70 474.01...... Chronic adenoiditis....... N pre 482 3 68, 69, 70 474.02...... Chronic tonsillitis and N pre 482 adenoiditis. 3 68, 69, 70 482.84...... Legionnaires' disease..... Y 4 79, 80, 81 518.6....... Allergic bronchopulmonary Y 4 92, 93 aspergillosis. 655.70...... Decreased fetal movements N 14 469 unspecified as to episode of care or not applicable. 655.71...... Decreased fetal movements N 14 370, 371, 372, 373, 374, 375 delivered, with or without mention of antepartum condition. 655.73...... Decreased fetal movements N 14 383, 384 antepartum condition or complication. 686.00...... Other local infection of N 9 277, 278, 279 skin and subcutaneous tissue, pyoderma, unspecified. [[Page 29992]] 686.01...... Other local infection of N 9 277, 278, 279 skin and subcutaneous tissue, pyoderma gangrenosum. 686.09...... Other local infection of N 9 277, 278, 279 skin and subcutaneous tissue, other pyoderma. 756.70...... Congenital anomaly of N 6 188, 189, 190 abdominal wall, unspecified. 756.71...... Congenital anomaly of N 6 188, 189, 190 abdominal wall, prune belly syndrome. 756.79...... Other congenital anomalies N 6 188, 189, 190 of abdominal wall. 780.31...... Febrile convulsions....... Y 1 24, 25, 26 15 387, 389 2 780.39...... Other convulsions......... Y 1 24, 25, 26 15 387, 389 2 790.94...... Other nonspecific findings N 23 463, 464 on examination of blood, euthyroid sick syndrome. 796.5....... Abnormal findings on N 14 383, 384 antenatal screening. 959.01...... Head injury, unspecified.. N pre 482 21 444, 445, 446 24 significant trauma list 959.09...... Injury of face and neck... N pre 482 21 444, 445, 446 24 significant trauma list V02.60...... Viral hepatitis carrier, N 7 205, 206 unspecified. V02.61...... Hepatitis B carrier....... N 7 205, 206 V02.62...... Hepatitis C carrier....... N 7 205, 206 V02.69...... Other viral hepatitis N 7 205, 206 carrier. V12.40...... Personal history of N 23 467 unspecified disorder of nervous system and sense organs. V12.41...... Personal history of benign N 23 467 neoplasm of the brain. V12.49...... Personal history of other N 23 467 disorder of nervous system and sense organs. V16.40...... Family history of N 23 467 malignant neoplasm of genital organ, unspecified. V16.41...... Family history of N 23 467 malignant neoplasm of ovary. V16.42...... Family history of N 23 467 malignant neoplasm of prostate. V16.43...... Family history of N 23 467 malignant neoplasm of testis. V16.49...... Family history of other N 23 467 malignant neoplasm. V28.6....... Antenatal screening for N 23 467 streptococcus B. V42.81...... Organ or tissue replaced Y 16 398, 399 by transplant, bone marrow. V42.82...... Organ or tissue replaced Y 16 398, 399 by transplant, peripheral stem cells. V42.83...... Organ or tissue replaced Y 7 467 by transplant, pancreas. V42.89...... Other organ or tissue Y 23 467 replaced by transplant. V45.61...... Cataract extraction status N 23 467 V45.69...... Other states following N 23 467 surgery of eye and adnexa. V45.71...... Acquired absence of breast N 23 467 V45.72...... Acquired absence of N 23 467 intestine (large (small). V45.73...... Acquired absence of kidney N 23 467 V53.01...... Fitting and adjustment of N 23 467 cerebral ventricular (communicating) shunt. V53.02...... Fitting and adjustment of N 23 467 neuropacemaker (brain) (peripheral nerve)(Spinal cord). V53.09...... Fitting and adjustment of N 23 467 other devices related to nervous system and special senses. V64.4....... Laparoscopic surgical N 23 467 procedure converted to open procedure. V76.10...... Screening for malignant N 23 467 neoplasm, breast screening, unspecified. V76.11...... Screening mammogram for N 23 467 high-risk patient, malignant neoplasm of breast. V76.12...... Other screening mammogram N 23 467 for malignant neoplasm of breast. V76.19...... Other screening breast N 23 467 examination for malignant neoplasm. ---------------------------------------------------------------------------------------------------------------- \1\ HIV major related condition in this DRG. \2\ Classified as a ``major problem'' in these DRGs. \3\ Classified as a ``major complication'' in this DRG. Table 6B.--New Procedure Codes ---------------------------------------------------------------------------------------------------------------- Procedure code Description OR MDC DRG ---------------------------------------------------------------------------------------------------------------- 37.35....... Partial ventriculectomy... Y 5 108 41.05....... Allogeneic hematopoietic Y pre 481 stem cell transplant. 41.06....... Cord blood stem cell Y pre 481 transplant. ---------------------------------------------------------------------------------------------------------------- [[Page 29993]] Table 6C.--Invalid Diagnosis Codes ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 038.1....... Staphylococcal septicemia. Y 15 387, 389 1 18 416, 417 25 489 2 275.4....... Disorders of calcium N 10 296, 297, 298 metabolism. 438......... Late effects of N 1 12 cerebrovascular disease. 474.0....... Chronic tonsillitis and N pre 482 adenoiditis. 3 68, 69, 70 686.0....... Other local infections of N 9 277, 278, 279 skin and subcutaneous tissue, pyoderma. 756.7....... Other congenital anomalies N 6 188, 189, 190 of abdominal wall. 780.3....... Convulsions............... Y 1 24, 25, 26 15 387, 389 1 959.0....... Injury, other and N pre 482 unspecified of head, 21 444, 445, 446 face, and neck. 24 significant trauma list V02.6....... Carrier or suspected N 7 205, 206 carrier of viral hepatitis. V12.4....... Personal history of N 23 467 disorders of nervous system and sense organs. V16.4....... Family history of N 23 467 malignant neoplasm of genital organs. V42.8....... Unspecified organ or Y 7 205, 206 tissue replaced by transplant. V45.6....... Other postsurgical state N 23 467 following surgery of eye and adnexa. V53.0....... Fitting and adjustment of N 23 467 devices related to nervous system and special senses. V76.1....... Special screening for N 23 467 malignant neoplasm of the breast. ---------------------------------------------------------------------------------------------------------------- \1\ Classified as a ``major problem'' in these DRGs. \2\ HIV major related condition in this DRG. Table 6D.--Revised Diagnosis Code Titles ---------------------------------------------------------------------------------------------------------------- Diagnosis code Description CC MDC DRG ---------------------------------------------------------------------------------------------------------------- 041.04...... Streptococcus infection in N 18 423 conditions classified elsewhere and of unspecified site, Group D [Enterococcus]. 474.0....... Chronic tonsillitis and N 3 68, 69, 70 adenoiditis. 959.0....... Injury, other and N pre 482 unspecified of head, 21 444, 445, 446 face, and neck. 24 significant trauma list ---------------------------------------------------------------------------------------------------------------- [[Page 29994]] Table 6E.--Additions to the CC Exclusions List Page 1 of 5 Pages CCs that are added to the list are in Table 6E--Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis. ------------------------------------------------------------------------ ------------------------------------------------------------------------ *0031 48284 48284 48284 01176 01354 01643 01771 03810 *01140 *01186 *01795 01180 01355 01644 01772 03811 48284 48284 48284 01181 01356 01645 01773 03819 *01141 *01190 *01796 01182 01360 01646 01774 *0074 48284 48284 48284 01183 01361 01650 01775 00841 *01142 *01191 *0202 01184 01362 01651 01776 00842 48284 48284 03810 01185 01363 01652 01780 00843 *01143 *01192 03811 01186 01364 01653 01781 00844 48284 48284 03819 01190 01365 01654 01782 00845 *01144 *01193 *0212 01191 01366 01655 01783 00846 48284 48284 48284 01192 01380 01656 01784 00847 *01145 *01194 *0310 01193 01381 01660 01785 00849 48284 48284 48284 01194 01382 01661 01786 *01100 *01146 *01195 *0312 01195 01383 01662 01790 48284 48284 48284 01100 01196 01384 01663 01791 *01101 *01150 *01196 01101 01200 01385 01664 01792 48284 48284 48284 01102 01201 01386 01665 01793 *01102 *01151 *01200 01103 01202 01390 01666 01794 48284 48284 48284 01104 01203 01391 01670 01795 *01103 *01152 *01201 01105 01204 01392 01671 01796 48284 48284 48284 01106 01205 01393 01672 01800 *01104 *01153 *01202 01110 01206 01394 01673 01801 48284 48284 48284 01111 01210 01395 01674 01802 *01105 *01154 *01203 01112 01211 01396 01675 01803 48284 48284 48284 01113 01212 01400 01676 01804 *01106 *01155 *01204 01114 01213 01401 01690 01805 48284 48284 48284 01115 01214 01402 01691 01806 *01110 *01156 *01205 01116 01215 01403 01692 01880 48284 48284 48284 01120 01216 01404 01693 01881 *01111 *01160 *01206 01121 01300 01405 01694 01882 48284 48284 48284 01122 01301 01406 01695 01883 *01112 *01161 *01210 01123 01302 01480 01696 01884 48284 48284 48284 01124 01303 01482 01720 01885 *01113 *01162 *01211 01125 01304 01483 01721 01886 48284 48284 48284 01126 01305 01484 01722 01890 *01114 *01163 *01212 01130 01306 01485 01723 01891 48284 48284 48284 01131 01310 01486 01724 01892 *01115 *01164 *01213 01132 01311 01600 01725 01893 48284 48284 48284 01133 01312 01601 01726 01894 *01116 *01165 *01214 01134 01313 01602 01730 01895 48284 48284 48284 01135 01314 01603 01731 01896 *01120 *01166 *01215 01136 01315 01604 01732 0310 48284 48284 48284 01140 01316 01605 01733 *0362 *01121 *01170 *01216 01141 01320 01606 01734 03810 48284 48284 48284 01142 01321 01610 01735 03811 *01122 *01171 *01280 01143 01322 01611 01736 03819 48284 48284 48284 01144 01323 01612 01740 *0380 *01123 *01172 *01281 01145 01324 01613 01741 03810 48284 48284 48284 01146 01325 01614 01742 03811 *01124 *01173 *01282 01150 01326 01615 01743 03819 48284 48284 48284 01151 01330 01616 01744 *03810 *01125 *01174 *01283 01152 01331 01620 01745 0362 48284 48284 48284 01153 01332 01621 01746 0380 *01126 *01175 *01284 01154 01333 01622 01750 03810 48284 48284 48284 01155 01334 01623 01751 03811 *01130 *01176 *01285 01156 01335 01624 01752 03819 48284 48284 48284 01160 01336 01625 01753 0382 *01131 *01180 *01286 01161 01340 01626 01754 0383 48284 48284 48284 01162 01341 01630 01755 03840 *01132 *01181 *01790 01163 01342 01631 01756 03841 48284 48284 48284 01164 01343 01632 01760 03842 *01133 *01182 *01791 01165 01344 01633 01761 03843 48284 48284 48284 01170 01345 01634 01762 03844 *01134 *01183 *01792 01171 01346 01635 01763 03849 48284 48284 48284 01172 01350 01636 01764 0388 *01135 *01184 *01793 01173 01351 01640 01765 0389 48284 48284 48284 01174 01352 01641 01766 0545 *01136 *01185 *01794 01175 01353 01642 01770 *03811 ------------------------------------------------------------------------ [[Page 29995]] Page 2 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 0362 *0391 03819 *34550 48284 01196 *4838 48284 0380 48284 *04182 78031 *48283 01200 48284 *5078 03810 *04089 03810 78039 48284 01201 *4841 48284 03811 03810 03811 *34551 *48284 01202 48284 *5080 03819 03811 03819 78031 01100 01203 *4843 48284 0382 03819 *04183 78039 01101 01204 48284 *5081 0383 *04100 03810 *34560 01102 01205 *4845 48284 03840 03810 03811 78031 01103 01206 48284 *5088 03841 03811 03819 78039 01104 01210 *4846 48284 03842 03819 *04184 *34561 01105 01211 48284 *5089 03843 *04101 03810 78031 01106 01212 *4847 48284 03844 03810 03811 78039 01110 01213 48284 *5171 03849 03811 03819 *34570 01111 01214 *4848 48284 0388 03819 *04185 78031 01112 01215 48284 *5178 0389 *04102 03810 78039 01113 01216 *485 48284 0545 03810 03811 *34571 01114 0310 48284 *5186 *03819 03811 03819 78031 01115 11505 *486 5186 0362 03819 *04186 78039 01116 11515 48284 *51889 0380 *04103 03810 *34580 01120 1304 *4870 48284 03810 03810 03811 78031 01121 1363 48284 *5198 03811 03811 03819 78039 01122 481 *4871 48284 03819 03819 *04189 *34581 01123 4820 48284 5186 0382 *04104 03810 78031 01124 4821 *494 *5199 0383 03810 03811 78039 01125 4822 48284 48284 03840 03811 03819 *34590 01126 48230 *4950 5186 03841 03819 *0419 78031 01130 48231 48284 *5990 03842 *04105 03810 78039 01131 48232 *4951 99664 03843 03810 03811 *34591 01132 48239 48284 *65570 03844 03811 03819 78031 01133 4824 *4952 66500 03849 03819 *0545 78039 01134 48281 48284 66501 0388 *04109 03810 *3488 01135 48282 *4953 66503 0389 03810 03811 78031 01136 48283 48284 66510 0545 03811 03819 78039 01140 48284 *4954 66511 *0382 03819 *11505 *3489 01141 48289 48284 *65571 03810 *04110 48284 78031 01142 4829 *4955 66500 03811 03810 *11515 78039 01143 4830 48284 66501 03819 03811 48284 *34989 01144 4831 *4956 66503 *0383 03819 *11595 78031 01145 4838 48284 66510 03810 *04111 48284 78039 01146 4841 *4957 66511 03811 03810 *1221 *3499 01150 4843 48284 *65573 03819 03811 48284 78031 01151 4845 *4958 66500 *03840 03819 *1304 78039 01152 4846 48284 66501 03810 *04119 48284 *4800 01153 4847 *4959 66503 03811 03810 *1363 48284 01154 4848 48284 66510 03819 03811 48284 *4801 01155 485 *496 66511 *03841 03819 *1398 48284 01156 486 48284 *68600 03810 *0412 03810 *4802 01160 4870 *500 6800 03811 03810 03811 48284 01161 4950 48284 6801 03819 03811 03819 *4808 01162 4951 *501 6802 *03842 03819 *34500 48284 01163 4952 48284 6803 03810 *0413 78031 *4809 01164 4953 *502 6804 03811 03810 78039 48284 01165 4954 48284 6805 03819 03811 *34501 *481 01166 4955 *503 6806 *03843 03819 78031 48284 01170 4956 48284 6807 03810 *0414 78039 *4820 01171 4957 *504 6808 03811 03810 *34510 48284 01172 4958 48284 6809 03819 03811 78031 *4821 01173 4959 *505 6820 *03844 03819 78039 48284 01174 5060 48284 6821 03810 *0415 *34511 *4822 01175 5061 *5060 6822 03811 03810 78031 48284 01176 5070 48284 6823 03819 03811 78039 *48230 01180 5071 *5061 6825 *03849 03819 *3452 48284 01181 5078 48284 6826 03810 *0416 78031 *48231 01182 5080 *5062 6827 03811 03810 78039 48284 01183 5081 48284 6828 03819 03811 *3453 *48232 01184 5171 *5063 6829 *0388 03819 78031 48284 01185 *48289 48284 684 03810 *0417 78039 *48239 01186 48284 *5064 *68601 03811 03810 *34540 48284 01190 *4829 48284 6800 03819 03811 78031 *4824 01191 48284 *5069 6801 *0389 03819 78039 48284 01192 *4830 48284 6802 03810 *04181 *34541 *48281 01193 48284 *5070 6803 03811 03810 78031 48284 01194 *4831 48284 6804 03819 03811 78039 *48282 01195 48284 *5071 6805 ------------------------------------------------------------------------ [[Page 29996]] Page 3 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 6806 80019 80110 80220 80359 80450 85132 85223 6807 80020 80111 80221 80360 80451 85133 85224 6808 80021 80112 80222 80361 80452 85134 85225 6809 80022 80113 80223 80362 80453 85135 85226 6820 80023 80114 80224 80363 80454 85136 85229 6821 80024 80115 80225 80364 80455 85139 85230 6822 80025 80116 80226 80365 80456 85140 85231 6823 80026 80119 80227 80366 80459 85141 85232 6825 80029 80120 80228 80369 80460 85142 85233 6826 80030 80121 80229 80370 80461 85143 85234 6827 80031 80122 80230 80371 80462 85144 85235 6828 80032 80123 80231 80372 80463 85145 85236 6829 80033 80124 80232 80373 80464 85146 85239 684 80034 80125 80233 80374 80465 85149 85240 *68609 80035 80126 80234 80375 80466 85150 85241 6800 80036 80129 80235 80376 80469 85151 85242 6801 80039 80130 80236 80379 80470 85152 85243 6802 80040 80131 80237 80380 80471 85153 85244 6803 80041 80132 80238 80381 80472 85154 85245 6804 80042 80133 80239 80382 80473 85155 85246 6805 80043 80134 8024 80383 80474 85156 85249 6806 80044 80135 8025 80384 80475 85159 85250 6807 80045 80136 8026 80385 80476 85160 85251 6808 80046 80139 8027 80386 80479 85161 85252 6809 80049 80140 8028 80389 80480 85162 85253 6820 80050 80141 8029 80390 80481 85163 85254 6821 80051 80142 80300 80391 80482 85164 85255 6822 80052 80143 80301 80392 80483 85165 85256 6823 80053 80144 80302 80393 80484 85166 85259 6825 80054 80145 80303 80394 80485 85169 85300 6826 80055 80146 80304 80395 80486 85170 85301 6827 80056 80149 80305 80396 80489 85171 85302 6828 80059 80150 80306 80399 80490 85172 85303 6829 80060 80151 80309 80400 80491 85173 85304 684 80061 80152 80310 80401 80492 85174 85305 *74861 80062 80153 80311 80402 80493 85175 85306 48284 80063 80154 80312 80403 80494 85176 85309 *7790 80064 80155 80313 80404 80495 85179 85310 78031 80065 80156 80314 80405 80496 85180 85311 78039 80066 80159 80315 80406 80499 85181 85312 *7791 80069 80160 80316 80409 8500 85182 85313 78031 80070 80161 80319 80410 8501 85183 85314 78039 80071 80162 80320 80411 8502 85184 85315 *78031 80072 80163 80321 80412 8503 85185 85316 78031 80073 80164 80322 80413 8504 85186 85319 78039 80074 80165 80323 80414 8505 85189 85400 *78039 80075 80166 80324 80415 8509 85190 85401 78031 80076 80169 80325 80416 85100 85191 85402 78039 80079 80170 80326 80419 85101 85192 85403 *7809 80080 80171 80329 80420 85102 85193 85404 78031 80081 80172 80330 80421 85103 85194 85405 78039 80082 80173 80331 80422 85104 85195 85406 *79094 80083 80174 80332 80423 85105 85196 85409 7907 80084 80175 80333 80424 85106 85199 85410 *7998 80085 80176 80334 80425 85109 85200 85411 78031 80086 80179 80335 80426 85110 85201 85412 78039 80089 80180 80336 80429 85111 85202 85413 *95901 80090 80181 80339 80430 85112 85203 85414 80000 80091 80182 80340 80431 85113 85204 85415 80001 80092 80183 80341 80432 85114 85205 85416 80002 80093 80184 80342 80433 85115 85206 85419 80003 80094 80185 80343 80434 85116 85209 9251 80004 80095 80186 80344 80435 85119 85210 9252 80005 80096 80189 80345 80436 85120 85211 *95909 80006 80099 80190 80346 80439 85121 85212 80000 80009 80100 80191 80349 80440 85122 85213 80001 80010 80101 80192 80350 80441 85123 85214 80002 80011 80102 80193 80351 80442 85124 85215 80003 80012 80103 80194 80352 80443 85125 85216 80004 80013 80104 80195 80353 80444 85126 85219 80005 80014 80105 80196 80354 80445 85129 85220 80006 80015 80106 80199 80355 80446 85130 85221 80009 80016 80109 8021 80356 80449 85131 85222 80010 ------------------------------------------------------------------------ [[Page 29997]] Page 4 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 80011 80102 80193 80351 80442 85124 85215 V4282 80012 80103 80194 80352 80443 85125 85216 V4283 80013 80104 80195 80353 80444 85126 85219 V4289 80014 80105 80196 80354 80445 85129 85220 *99685 80015 80106 80199 80355 80446 85130 85221 V4281 80016 80109 8021 80356 80449 85131 85222 *99686 80019 80110 80220 80359 80450 85132 85223 V4283 80020 80111 80221 80360 80451 85133 85224 *99689 80021 80112 80222 80361 80452 85134 85225 V4289 80022 80113 80223 80362 80453 85135 85226 *V090 80023 80114 80224 80363 80454 85136 85229 03810 80024 80115 80225 80364 80455 85139 85230 03811 80025 80116 80226 80365 80456 85140 85231 03819 80026 80119 80227 80366 80459 85141 85232 *V091 80029 80120 80228 80369 80460 85142 85233 03810 80030 80121 80229 80370 80461 85143 85234 03811 80031 80122 80230 80371 80462 85144 85235 03819 80032 80123 80231 80372 80463 85145 85236 *V092 80033 80124 80232 80373 80464 85146 85239 03810 80034 80125 80233 80374 80465 85149 85240 03811 80035 80126 80234 80375 80466 85150 85241 03819 80036 80129 80235 80376 80469 85151 85242 *V093 80039 80130 80236 80379 80470 85152 85243 03810 80040 80131 80237 80380 80471 85153 85244 03811 80041 80132 80238 80381 80472 85154 85245 03819 80042 80133 80239 80382 80473 85155 85246 *V094 80043 80134 8024 80383 80474 85156 85249 03810 80044 80135 8025 80384 80475 85159 85250 03811 80045 80136 8026 80385 80476 85160 85251 03819 80046 80139 8027 80386 80479 85161 85252 *V0950 80049 80140 8028 80389 80480 85162 85253 03810 80050 80141 8029 80390 80481 85163 85254 03811 80051 80142 80300 80391 80482 85164 85255 03819 80052 80143 80301 80392 80483 85165 85256 *V0951 80053 80144 80302 80393 80484 85166 85259 03810 80054 80145 80303 80394 80485 85169 85300 03811 80055 80146 80304 80395 80486 85170 85301 03819 80056 80149 80305 80396 80489 85171 85302 *V096 80059 80150 80306 80399 80490 85172 85303 03810 80060 80151 80309 80400 80491 85173 85304 03811 80061 80152 80310 80401 80492 85174 85305 03819 80062 80153 80311 80402 80493 85175 85306 *V0970 80063 80154 80312 80403 80494 85176 85309 03810 80064 80155 80313 80404 80495 85179 85310 03811 80065 80156 80314 80405 80496 85180 85311 03819 80066 80159 80315 80406 80499 85181 85312 *V0971 80069 80160 80316 80409 8500 85182 85313 03810 80070 80161 80319 80410 8501 85183 85314 03811 80071 80162 80320 80411 8502 85184 85315 03819 80072 80163 80321 80412 8503 85185 85316 *V0980 80073 80164 80322 80413 8504 85186 85319 03810 80074 80165 80323 80414 8505 85189 85400 03811 80075 80166 80324 80415 8509 85190 85401 03819 80076 80169 80325 80416 85100 85191 85402 *V0981 80079 80170 80326 80419 85101 85192 85403 03810 80080 80171 80329 80420 85102 85193 85404 03811 80081 80172 80330 80421 85103 85194 85405 03819 80082 80173 80331 80422 85104 85195 85406 *V0990 80083 80174 80332 80423 85105 85196 85409 03810 80084 80175 80333 80424 85106 85199 85410 03811 80085 80176 80334 80425 85109 85200 85411 03819 80086 80179 80335 80426 85110 85201 85412 *V0991 80089 80180 80336 80429 85111 85202 85413 03810 80090 80181 80339 80430 85112 85203 85414 03811 80091 80182 80340 80431 85113 85204 85415 03819 80092 80183 80341 80432 85114 85205 85416 *V4283 80093 80184 80342 80433 85115 85206 85419 V4283 80094 80185 80343 80434 85116 85209 9251 *V4289 80095 80186 80344 80435 85119 85210 9252 V420 80096 80189 80345 80436 85120 85211 *99664 V421 80099 80190 80346 80439 85121 85212 5990 V422 80100 80191 80349 80440 85122 85213 *99680 V426 80101 80192 80350 80441 85123 85214 V4281 V427 ------------------------------------------------------------------------ [[Page 29998]] Page 5 of 5 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ V4289 *V429 V4281 V4282 V4283 V4289 ------------------------------------------------------------------------ [[Page 29999]] Table 6F.--Deletions to the CC Exclusions List Page 1 of 2 Pages CCs that are deleted from the list are in Table 6G--Deletions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis. ------------------------------------------------------------------------ ------------------------------------------------------------------------ *0031 0381 7803 80039 80123 80226 80360 80444 0381 *0414 *34989 80040 80124 80227 80361 80445 *0202 0381 7803 80041 80125 80228 80362 80446 0381 *0415 *3499 80042 80126 80229 80363 80449 *0362 0381 7803 80043 80129 80230 80364 80450 0381 *0416 *6860 80044 80130 80231 80365 80451 *0380 0381 6800 80045 80131 80232 80366 80452 0381 *0417 6801 80046 80132 80233 80369 80453 *0381 0381 6802 80049 80133 80234 80370 80454 0362 *04181 6803 80050 80134 80235 80371 80455 0380 0381 6804 80051 80135 80236 80372 80456 0381 *04182 6805 80052 80136 80237 80373 80459 0382 0381 6806 80053 80139 80238 80374 80460 0383 *04183 6807 80054 80140 80239 80375 80461 03840 0381 6808 80055 80141 8024 80376 80462 03841 *04184 6809 80056 80142 8025 80379 80463 03842 0381 6820 80059 80143 8026 80380 80464 03843 *04185 6821 80060 80144 8027 80381 80465 03844 0381 6822 80061 80145 8028 80382 80466 03849 *04186 6823 80062 80146 8029 80383 80469 0388 0381 6825 80063 80149 80300 80384 80470 0389 *04189 6826 80064 80150 80301 80385 80471 0545 0381 6827 80065 80151 80302 80386 80472 *0382 *0419 6828 80066 80152 80303 80389 80473 0381 0381 6829 80069 80153 80304 80390 80474 *0383 *0545 684 80070 80154 80305 80391 80475 0381 0381 *7790 80071 80155 80306 80392 80476 *03840 *1398 7803 80072 80156 80309 80393 80479 0381 0381 *7791 80073 80159 80310 80394 80480 *03841 *34500 7803 80074 80160 80311 80395 80481 0381 7803 *7803 80075 80161 80312 80396 80482 *03842 *34501 7803 80076 80162 80313 80399 80483 0381 7803 *7809 80079 80163 80314 80400 80484 *03843 *34510 7803 80080 80164 80315 80401 80485 0381 7803 *7998 80081 80165 80316 80402 80486 *03844 *34511 7803 80082 80166 80319 80403 80489 0381 7803 *9590 80083 80169 80320 80404 80490 *03849 *3452 80000 80084 80170 80321 80405 80491 0381 7803 80001 80085 80171 80322 80406 80492 *0388 *3453 80002 80086 80172 80323 80409 80493 0381 7803 80003 80089 80173 80324 80410 80494 *0389 *34540 80004 80090 80174 80325 80411 80495 0381 7803 80005 80091 80175 80326 80412 80496 *04089 *34541 80006 80092 80176 80329 80413 80499 0381 7803 80009 80093 80179 80330 80414 8500 *04100 *34550 80010 80094 80180 80331 80415 8501 0381 7803 80011 80095 80181 80332 80416 8502 *04101 *34551 80012 80096 80182 80333 80419 8503 0381 7803 80013 80099 80183 80334 80420 8504 *04102 *34560 80014 80100 80184 80335 80421 8505 0381 7803 80015 80101 80185 80336 80422 8509 *04103 *34561 80016 80102 80186 80339 80423 85100 0381 7803 80019 80103 80189 80340 80424 85101 *04104 *34570 80020 80104 80190 80341 80425 85102 0381 7803 80021 80105 80191 80342 80426 85103 *04105 *34571 80022 80106 80192 80343 80429 85104 0381 7803 80023 80109 80193 80344 80430 85105 *04109 *34580 80024 80110 80194 80345 80431 85106 0381 7803 80025 80111 80195 80346 80432 85109 *04110 *34581 80026 80112 80196 80349 80433 85110 0381 7803 80029 80113 80199 80350 80434 85111 *04111 *34590 80030 80114 8021 80351 80435 85112 0381 7803 80031 80115 80220 80352 80436 85113 *04119 *34591 80032 80116 80221 80353 80439 85114 0381 7803 80033 80119 80222 80354 80440 85115 *0412 *3488 80034 80120 80223 80355 80441 85116 0381 7803 80035 80121 80224 80356 80442 85119 *0413 *3489 80036 80122 80225 80359 80443 85120 ------------------------------------------------------------------------ [[Page 30000]] Page 2 of 2 Pages ------------------------------------------------------------------------ ------------------------------------------------------------------------ 85121 85212 V428 85122 85213 *99686 85123 85214 V428 85124 85215 *99689 85125 85216 V428 85126 85219 *V090 85129 85220 0381 85130 85221 *V091 85131 85222 0381 85132 85223 *V092 85133 85224 0381 85134 85225 *V093 85135 85226 0381 85136 85229 *V094 85139 85230 0381 85140 85231 *V0950 85141 85232 0381 85142 85233 *V0951 85143 85234 0381 85144 85235 *V096 85145 85236 0381 85146 85239 *V0970 85149 85240 0381 85150 85241 *V0971 85151 85242 0381 85152 85243 *V0980 85153 85244 0381 85154 85245 *V0981 85155 85246 0381 85156 85249 *V0990 85159 85250 0381 85160 85251 *V0991 85161 85252 0381 85162 85253 *V428 85163 85254 V420 85164 85255 V421 85165 85256 V422 85166 85259 V426 85169 85300 V427 85170 85301 V428 85171 85302 *V429 85172 85303 V428 85173 85304 85174 85305 85175 85306 85176 85309 85179 85310 85180 85311 85181 85312 85182 85313 85183 85314 85184 85315 85185 85316 85186 85319 85189 85400 85190 85401 85191 85402 85192 85403 85193 85404 85194 85405 85195 85406 85196 85409 85199 85410 85200 85411 85201 85412 85202 85413 85203 85414 85204 85415 85205 85416 85206 85419 85209 9251 85210 9252 85211 *99680 ------------------------------------------------------------------------ [[Page 30001]] Table 7A.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay [FY96 MEDPAR Update 12/96 Grouper V14.0] -------------------------------------------------------------------------------------------------------------------------------------------------------- Number Arithmetic 10th 25th 50th 75th 90th DRG discharges mean LOS percentile percentile percentile percentile percentile -------------------------------------------------------------------------------------------------------------------------------------------------------- 1....................................... 36587 10.0378 2 4 7 13 21 2....................................... 6771 10.5860 3 5 8 13 21 3....................................... 1 1.0000 1 1 1 1 1 4....................................... 6231 8.4710 2 3 6 10 18 5....................................... 102519 3.9306 1 2 3 4 8 6....................................... 417 3.2590 1 1 2 4 7 7....................................... 11911 11.6376 3 5 8 13 22 8....................................... 2088 3.8410 1 1 3 5 8 9....................................... 1712 7.0596 1 3 5 9 14 10...................................... 20092 7.2703 2 3 5 9 15 11...................................... 2933 4.2636 1 2 3 6 9 12...................................... 25964 6.8386 2 3 5 8 13 13...................................... 6323 5.7745 2 3 5 7 10 14...................................... 374831 6.7444 2 3 5 8 13 15...................................... 145009 4.0646 1 2 3 5 7 16...................................... 13995 6.0974 2 3 5 7 11 17...................................... 3084 3.7036 1 2 3 5 7 18...................................... 24039 5.7935 2 3 4 7 11 19...................................... 6542 4.0880 1 2 3 5 8 20...................................... 8163 9.4084 2 4 7 12 19 21...................................... 1177 7.0935 2 3 5 9 14 22...................................... 2887 4.7645 2 2 4 6 9 23...................................... 6025 4.5610 1 2 3 6 9 24...................................... 57698 5.3362 1 2 4 6 10 25...................................... 22091 3.6103 1 2 3 4 7 26...................................... 40 5.2500 1 2 4 7 11 27...................................... 3743 5.5060 1 1 3 7 13 28...................................... 12494 6.3374 1 3 4 8 13 29...................................... 3906 3.7384 1 2 3 5 7 30...................................... 1 4.0000 4 4 4 4 4 31...................................... 3008 4.7822 1 2 3 6 9 32...................................... 1389 3.0756 1 1 2 3 6 34...................................... 18440 5.8049 1 3 4 7 11 35...................................... 3698 3.9227 1 2 3 5 7 36...................................... 6706 1.5406 1 1 1 2 2 37...................................... 1756 3.9169 1 1 3 4 8 38...................................... 195 2.7077 1 1 2 3 5 39...................................... 2545 2.0000 1 1 1 2 4 40...................................... 2629 3.4059 1 1 2 4 7 42...................................... 5378 1.9781 1 1 1 2 4 43...................................... 110 4.0182 1 2 3 5 7 44...................................... 1461 5.2005 2 3 4 6 9 45...................................... 2340 3.5949 1 2 3 5 7 46...................................... 2995 4.8417 1 2 4 6 9 47...................................... 1173 3.9599 1 1 3 4 7 49...................................... 2364 5.2563 1 2 4 6 10 50...................................... 3268 2.1068 1 1 2 2 3 51...................................... 348 2.8908 1 1 2 3 6 52...................................... 89 2.9213 1 1 2 4 7 53...................................... 3071 3.5988 1 1 2 4 8 54...................................... 2 5.0000 1 1 9 9 9 55...................................... 1876 2.9302 1 1 2 3 6 56...................................... 729 2.8299 1 1 2 3 6 57...................................... 652 3.9525 1 2 2 5 8 58...................................... 1 2.0000 2 2 2 2 2 59...................................... 103 3.1262 1 1 2 4 6 60...................................... 3 1.0000 1 1 1 1 1 61...................................... 241 4.5726 1 1 3 5 11 63...................................... 3732 4.6072 1 2 3 5 9 64...................................... 3341 6.6417 1 2 5 8 14 65...................................... 29312 3.1709 1 2 3 4 6 66...................................... 6560 3.4703 1 2 3 4 6 67...................................... 492 3.8049 1 2 3 5 7 68...................................... 10175 4.3277 2 2 4 5 8 69...................................... 2943 3.4709 1 2 3 4 6 70...................................... 40 3.3000 1 2 3 4 5 71...................................... 128 3.9297 1 2 3 5 7 72...................................... 705 3.4610 1 2 3 4 7 73...................................... 6206 4.6695 1 2 4 6 9 74...................................... 4 3.2500 1 1 2 3 7 [[Page 30002]] 75...................................... 40909 10.5411 4 5 8 13 20 76...................................... 41015 11.7119 3 6 9 14 22 77...................................... 2184 5.1108 1 2 4 7 10 78...................................... 30978 7.6317 3 5 7 9 13 79...................................... 237994 8.6320 3 4 7 11 16 80...................................... 8120 6.0765 2 3 5 7 11 81...................................... 20 10.7000 1 6 8 11 15 82...................................... 70673 7.3185 2 3 6 9 14 83...................................... 7304 5.8976 2 3 5 7 11 84...................................... 1473 3.4725 1 2 3 4 6 85...................................... 20682 6.8707 2 3 5 9 13 86...................................... 1372 4.0532 1 2 3 5 8 87...................................... 67342 6.4329 1 3 5 8 12 88...................................... 359001 5.6528 2 3 5 7 10 89...................................... 428753 6.5589 3 4 5 8 12 90...................................... 36813 4.6811 2 3 4 6 8 91...................................... 73 5.2466 2 3 4 7 9 92...................................... 13516 6.6268 2 3 5 8 12 93...................................... 1162 4.6145 1 2 4 6 8 94...................................... 13665 6.6447 2 3 5 8 13 95...................................... 1418 3.9810 1 2 3 5 7 96...................................... 58911 5.0549 2 3 4 6 9 97...................................... 23971 4.0015 1 2 3 5 7 98...................................... 28 2.8214 1 1 2 3 6 99...................................... 26524 3.1691 1 1 2 4 6 100..................................... 10188 2.2330 1 1 2 3 4 101..................................... 20391 4.7223 1 2 4 6 9 102..................................... 4493 2.8952 1 1 2 4 5 103..................................... 517 47.0406 9 15 32 71 104 104..................................... 26171 13.3430 5 8 11 16 24 105..................................... 22843 10.1949 5 6 8 12 18 106..................................... 106957 11.0507 6 7 9 13 18 107..................................... 68189 8.3054 5 6 7 9 13 108..................................... 7462 12.0893 4 7 10 15 23 110..................................... 63215 10.0803 3 6 8 12 19 111..................................... 5557 6.1074 2 4 6 7 9 112..................................... 218111 4.2393 1 2 3 6 8 113..................................... 47795 13.1200 4 6 9 16 26 114..................................... 9030 8.8270 2 4 7 11 17 115..................................... 11560 10.2985 4 6 8 13 18 116..................................... 86830 5.0237 1 2 4 6 10 117..................................... 3723 4.0285 1 1 3 5 9 118..................................... 6649 3.0284 1 1 2 4 7 119..................................... 1684 5.1081 1 1 3 7 11 120..................................... 39395 8.4464 1 2 5 11 19 121..................................... 165994 6.9292 2 4 6 9 12 122..................................... 90608 4.6367 1 2 4 6 8 123..................................... 45927 4.4682 1 1 2 6 11 124..................................... 152443 4.5925 1 2 4 6 9 125..................................... 60680 2.9371 1 1 2 4 6 126..................................... 5118 12.8009 4 6 10 16 26 127..................................... 705250 5.7994 2 3 5 7 11 128..................................... 18457 6.3457 3 4 6 7 10 129..................................... 4439 3.1683 1 1 1 3 7 130..................................... 99388 6.2962 2 4 5 8 11 131..................................... 25429 4.8527 1 3 5 6 8 132..................................... 164147 3.3158 1 2 3 4 6 133..................................... 6113 2.8050 1 1 2 3 5 134..................................... 29364 3.6008 1 2 3 4 7 135..................................... 8043 4.4405 1 2 3 5 8 136..................................... 1143 3.0604 1 1 2 4 6 137..................................... 5 6.6000 2 2 4 8 16 138..................................... 207475 4.1925 1 2 3 5 8 139..................................... 65356 2.7468 1 1 2 3 5 140..................................... 134319 3.1700 1 2 3 4 6 141..................................... 78035 4.0805 1 2 3 5 7 142..................................... 35460 2.9406 1 1 2 4 5 143..................................... 137083 2.3957 1 1 2 3 4 144..................................... 75930 5.3732 1 2 4 7 11 145..................................... 6310 2.9853 1 1 2 4 6 [[Page 30003]] 146..................................... 9811 10.5321 6 7 9 12 17 147..................................... 1664 6.9056 4 5 7 8 10 148..................................... 148674 12.6141 6 7 10 15 22 149..................................... 14218 7.1334 4 5 7 8 10 150..................................... 24389 11.1129 4 7 9 14 20 151..................................... 4232 6.1189 2 3 6 8 11 152..................................... 4675 8.4877 4 5 7 10 14 153..................................... 1644 5.7968 3 4 6 7 9 154..................................... 34909 14.0372 4 7 11 17 27 155..................................... 4509 5.0100 2 2 4 7 9 156..................................... 2 18.0000 5 5 31 31 31 157..................................... 9420 5.6036 1 2 4 7 11 158..................................... 4328 2.7872 1 1 2 4 6 159..................................... 18163 5.0726 1 2 4 6 10 160..................................... 9493 2.7740 1 1 2 4 5 161..................................... 14884 4.2139 1 2 3 5 9 162..................................... 7335 2.0923 1 1 1 3 4 163..................................... 11 4.4545 1 1 2 6 10 164..................................... 5335 8.7134 4 5 7 10 15 165..................................... 1586 5.4061 2 3 5 7 8 166..................................... 3342 5.4333 2 3 4 7 10 167..................................... 2247 2.9653 1 2 3 4 5 168..................................... 1853 4.7210 1 2 3 6 9 169..................................... 925 2.5459 1 1 2 3 5 170..................................... 12921 11.7454 2 5 9 15 23 171..................................... 1051 5.1246 1 2 4 6 10 172..................................... 32806 7.3996 2 3 5 9 15 173..................................... 2065 3.9467 1 2 3 5 8 174..................................... 238661 5.1466 2 3 4 6 9 175..................................... 21406 3.2356 1 2 3 4 6 176..................................... 17834 5.7615 2 3 4 7 11 177..................................... 11741 4.7286 2 3 4 6 8 178..................................... 3764 3.3547 1 2 3 4 6 179..................................... 12072 6.7301 2 3 5 8 13 180..................................... 88723 5.6566 2 3 4 7 11 181..................................... 21229 3.7030 1 2 3 5 7 182..................................... 237563 4.5654 1 2 4 6 8 183..................................... 69548 3.1791 1 2 3 4 6 184..................................... 86 3.7093 1 2 3 4 7 185..................................... 4055 4.8222 1 2 4 6 10 186..................................... 2 3.0000 2 2 4 4 4 187..................................... 869 3.9298 1 2 3 5 7 188..................................... 70414 5.7816 1 3 4 7 11 189..................................... 7871 3.3750 1 1 3 4 7 190..................................... 94 4.8830 1 2 3 6 11 191..................................... 11024 14.8159 4 7 11 18 29 192..................................... 775 7.1419 2 4 6 9 13 193..................................... 8299 12.8943 5 7 11 16 23 194..................................... 660 7.4379 2 4 6 9 13 195..................................... 8718 9.8580 4 6 8 12 17 196..................................... 624 6.3462 3 4 6 8 10 197..................................... 27165 8.6986 3 5 7 10 15 198..................................... 7036 4.7172 2 3 4 6 8 199..................................... 2147 10.6954 3 5 8 14 22 200..................................... 1533 11.3503 2 4 8 14 23 201..................................... 1536 14.8932 4 7 11 18 29 202..................................... 28316 7.0896 2 3 5 9 14 203..................................... 29341 7.1571 2 3 6 9 14 204..................................... 52859 6.3341 2 3 5 8 12 205..................................... 22935 6.7787 2 3 5 8 14 206..................................... 1652 4.2240 1 2 3 5 8 207..................................... 36747 5.2866 1 2 4 7 10 208..................................... 9886 3.0404 1 1 2 4 6 209..................................... 356581 5.8918 3 4 5 7 9 210..................................... 142712 7.6249 4 5 6 9 13 211..................................... 26185 5.6079 3 4 5 7 9 212..................................... 40 6.2250 3 4 5 7 9 213..................................... 7121 8.7182 2 4 7 11 17 214..................................... 57899 5.8874 2 3 5 7 11 215..................................... 45203 3.2816 1 2 3 4 6 [[Page 30004]] 216..................................... 6357 10.2902 2 4 8 13 21 217..................................... 20641 13.7099 3 5 9 17 29 218..................................... 24497 5.6195 2 3 4 7 10 219..................................... 18723 3.4439 1 2 3 4 6 220..................................... 4 4.7500 1 1 4 4 10 221..................................... 5113 7.1731 2 3 5 9 14 222..................................... 3453 3.8199 1 2 3 5 7 223..................................... 19460 2.7002 1 1 2 3 5 224..................................... 8049 2.1070 1 1 2 3 4 225..................................... 5842 4.6251 1 2 3 6 10 226..................................... 5513 6.2507 1 2 4 7 13 227..................................... 4322 2.8538 1 1 2 3 5 228..................................... 2967 3.4553 1 1 2 4 7 229..................................... 1216 2.3528 1 1 2 3 4 230..................................... 2473 4.9713 1 2 3 6 10 231..................................... 10932 4.7551 1 2 3 6 10 232..................................... 553 4.2405 1 1 2 5 10 233..................................... 4688 8.2445 2 3 6 10 16 234..................................... 2165 3.8859 1 2 3 5 8 235..................................... 5517 5.8182 1 3 4 6 11 236..................................... 39637 5.5891 2 3 4 7 10 237..................................... 1654 4.2019 1 2 3 5 8 238..................................... 7601 9.3428 3 4 7 11 17 239..................................... 60377 6.9698 2 3 5 8 13 240..................................... 13251 6.9282 2 3 5 8 14 241..................................... 2990 4.2331 1 2 3 5 8 242..................................... 2825 7.1487 2 3 5 9 14 243..................................... 80090 5.1221 2 3 4 6 9 244..................................... 12427 5.3968 1 3 4 6 10 245..................................... 4382 4.0895 1 2 3 5 7 246..................................... 1268 4.2437 1 2 3 5 8 247..................................... 11432 3.6810 1 2 3 5 7 248..................................... 7374 4.9761 1 2 4 6 9 249..................................... 10329 3.9287 1 1 3 5 8 250..................................... 3558 4.6501 1 2 3 5 9 251..................................... 2107 3.0019 1 1 2 4 5 253..................................... 18921 5.2431 1 3 4 6 10 254..................................... 9245 3.5230 1 2 3 4 6 255..................................... 1 6.0000 6 6 6 6 6 256..................................... 4394 5.6445 1 2 4 7 11 257..................................... 22632 3.2017 1 2 3 4 6 258..................................... 16954 2.2782 1 1 2 3 4 259..................................... 3995 3.1975 1 1 2 3 7 260..................................... 4550 1.6642 1 1 1 2 3 261..................................... 2213 2.2350 1 1 2 3 4 262..................................... 659 4.0030 1 1 3 5 8 263..................................... 29107 12.4970 3 5 9 15 24 264..................................... 3357 7.2848 2 3 6 9 14 265..................................... 4141 7.0995 1 2 5 8 14 266..................................... 2553 3.5719 1 1 2 5 7 267..................................... 223 4.1839 1 1 2 5 9 268..................................... 1177 3.7961 1 1 2 4 7 269..................................... 10062 8.5178 2 3 6 11 17 270..................................... 3072 3.2080 1 1 2 4 7 271..................................... 22910 7.7195 3 4 6 9 14 272..................................... 5988 6.6757 2 3 5 8 13 273..................................... 1387 5.3677 1 2 4 6 11 274..................................... 2619 7.1229 1 3 5 9 15 275..................................... 240 3.8042 1 1 2 5 8 276..................................... 939 4.7444 1 3 4 6 8 277..................................... 80070 6.2309 2 3 5 7 11 278..................................... 24752 4.8306 2 3 4 6 8 279..................................... 7 4.4286 2 2 4 6 6 280..................................... 13778 4.7052 1 2 3 6 9 281..................................... 5819 3.3805 1 1 3 4 6 282..................................... 5 12.0000 1 1 3 14 41 283..................................... 5280 5.0146 1 2 4 6 10 284..................................... 1748 3.5463 1 2 3 5 7 285..................................... 5591 12.0757 3 5 9 15 23 286..................................... 2071 7.2038 3 4 5 8 13 [[Page 30005]] 287..................................... 6659 12.2050 3 5 8 14 24 288..................................... 1201 5.8485 3 4 5 6 9 289..................................... 5476 3.4830 1 1 2 3 7 290..................................... 8792 2.5875 1 1 2 3 4 291..................................... 94 2.1596 1 1 2 3 4 292..................................... 5173 11.2101 2 4 8 14 22 293..................................... 271 5.8782 1 2 4 7 12 294..................................... 83801 5.2493 2 3 4 6 10 295..................................... 3650 4.1052 1 2 3 5 8 296..................................... 231553 5.7556 2 3 4 7 11 297..................................... 31811 3.8626 1 2 3 5 7 298..................................... 112 3.1786 1 1 2 4 7 299..................................... 1130 5.4823 1 2 4 7 11 300..................................... 15618 6.6234 2 3 5 8 13 301..................................... 1968 4.3664 1 2 3 5 8 302..................................... 7967 10.9728 5 6 8 13 19 303..................................... 19228 9.4496 4 5 8 11 17 304..................................... 13035 9.5744 2 4 7 11 19 305..................................... 2446 4.3385 1 2 4 5 8 306..................................... 11608 5.7505 1 2 4 7 12 307..................................... 2480 2.5375 1 1 2 3 4 308..................................... 9697 6.4016 1 2 4 8 13 309..................................... 3353 2.5577 1 1 2 3 5 310..................................... 27418 4.3367 1 2 3 5 9 311..................................... 8484 2.0532 1 1 2 2 4 312..................................... 1866 4.6833 1 2 3 6 10 313..................................... 659 2.2656 1 1 2 3 4 315..................................... 28342 8.5520 1 2 5 11 19 316..................................... 84578 6.9970 2 3 5 9 14 317..................................... 841 2.9441 1 1 2 3 6 318..................................... 6158 6.6325 1 3 5 8 13 319..................................... 422 2.8815 1 1 2 4 6 320..................................... 175874 5.8692 2 3 5 7 10 321..................................... 23491 4.2793 2 3 4 5 7 322..................................... 97 4.3196 2 2 3 5 8 323..................................... 17371 3.3739 1 1 2 4 7 324..................................... 7972 2.0066 1 1 2 2 4 325..................................... 6977 4.2005 1 2 3 5 8 326..................................... 2097 2.8994 1 1 2 4 5 327..................................... 15 3.1333 1 1 2 3 12 328..................................... 671 3.9091 1 2 3 5 8 329..................................... 107 2.4393 1 1 2 3 5 331..................................... 43921 5.8404 2 3 4 7 11 332..................................... 4398 3.5489 1 1 3 5 7 333..................................... 338 5.5621 1 2 4 7 11 334..................................... 19279 5.4196 3 4 5 6 8 335..................................... 9751 4.0561 2 3 4 5 6 336..................................... 59003 3.7602 1 2 3 4 7 337..................................... 34115 2.4160 1 2 2 3 4 338..................................... 3724 5.0709 1 2 3 6 11 339..................................... 2119 4.5880 1 2 3 6 10 340..................................... 1 1.0000 1 1 1 1 1 341..................................... 5932 3.1123 1 1 2 3 6 342..................................... 192 4.1927 1 2 3 6 8 344..................................... 3517 3.1137 1 1 2 3 6 345..................................... 1357 3.7900 1 1 3 5 8 346..................................... 5156 6.2853 1 3 5 8 12 347..................................... 372 2.9624 1 1 2 4 6 348..................................... 3204 4.4860 1 2 3 5 8 349..................................... 741 2.6815 1 1 2 3 5 350..................................... 6300 4.6057 2 3 4 6 8 351..................................... 2 2.5000 2 2 3 3 3 352..................................... 541 3.9279 1 1 3 5 8 353..................................... 2701 8.3425 3 4 6 9 16 354..................................... 9931 5.9823 3 3 5 7 10 355..................................... 5561 3.6306 2 3 3 4 5 356..................................... 29723 2.8078 1 2 3 3 4 357..................................... 6569 9.3230 4 5 7 11 17 358..................................... 28651 4.4698 2 3 4 5 7 359..................................... 28099 3.0940 2 2 3 4 4 [[Page 30006]] 360..................................... 18115 3.2832 1 2 3 4 5 361..................................... 671 3.6692 1 1 2 4 8 362..................................... 1 1.0000 1 1 1 1 1 363..................................... 3892 3.4740 1 2 2 3 7 364..................................... 1856 3.4984 1 1 2 4 7 365..................................... 2435 7.1647 1 2 4 9 16 366..................................... 4449 7.0094 1 3 5 9 15 367..................................... 541 2.9704 1 1 2 4 6 368..................................... 2377 6.2680 2 3 5 8 12 369..................................... 2363 3.4435 1 1 2 4 7 370..................................... 1170 5.5453 2 3 4 5 9 371..................................... 1054 3.5911 2 3 3 4 5 372..................................... 876 3.1199 1 2 2 3 5 373..................................... 3973 2.0194 1 1 2 2 3 374..................................... 152 2.9474 1 2 2 3 4 375..................................... 7 8.4286 1 2 5 9 15 376..................................... 214 3.2710 1 1 2 4 7 377..................................... 49 4.1224 1 1 2 4 9 378..................................... 187 2.6578 1 2 2 3 4 379..................................... 358 2.9609 1 1 2 3 5 380..................................... 96 1.8333 1 1 1 2 4 381..................................... 178 2.2022 1 1 1 2 4 382..................................... 47 1.3404 1 1 1 1 2 383..................................... 1583 3.8111 1 2 3 5 8 384..................................... 132 2.9318 1 1 2 3 6 385..................................... 5 4.6000 1 1 2 4 15 389..................................... 24 7.1667 3 3 5 10 13 390..................................... 13 5.3077 2 3 4 7 7 392..................................... 2532 10.5517 4 5 8 13 21 393..................................... 2 11.0000 7 7 15 15 15 394..................................... 1791 7.4199 1 2 5 8 16 395..................................... 67638 4.9800 1 2 4 6 10 396..................................... 19 4.2632 1 1 3 7 7 397..................................... 16823 5.7741 1 2 4 7 11 398..................................... 18282 6.2511 2 3 5 8 11 399..................................... 1299 4.0154 1 2 3 5 8 400..................................... 7810 9.7049 2 3 7 12 21 401..................................... 6739 11.6630 2 5 9 15 24 402..................................... 1499 4.2368 1 1 3 6 9 403..................................... 38891 8.5771 2 3 6 11 18 404..................................... 3799 4.6594 1 2 4 6 9 406..................................... 3452 10.0200 3 4 7 13 21 407..................................... 699 4.4120 1 2 4 6 8 408..................................... 2840 7.6835 1 2 5 9 18 409..................................... 5557 5.9152 2 3 4 6 12 410..................................... 74223 3.3541 1 2 3 4 5 411..................................... 33 2.3030 1 1 1 3 6 412..................................... 30 3.3667 1 1 2 5 7 413..................................... 8747 8.0088 2 3 6 10 16 414..................................... 727 4.5571 1 2 3 6 10 415..................................... 44505 14.8769 4 7 11 18 29 416..................................... 218588 7.6808 2 4 6 9 14 417..................................... 54 4.6111 1 2 4 6 9 418..................................... 20458 6.3064 2 3 5 8 12 419..................................... 14820 5.2356 2 3 4 6 10 420..................................... 2622 3.9714 1 2 3 5 7 421..................................... 10711 4.2451 1 2 3 5 8 422..................................... 84 3.9167 1 2 3 5 6 423..................................... 10805 7.9172 2 3 6 9 16 424..................................... 1925 16.6618 2 6 10 19 31 425..................................... 15459 4.3906 1 2 3 5 8 426..................................... 4692 5.2163 1 2 4 6 11 427..................................... 1679 5.2478 1 2 4 6 11 428..................................... 923 7.6111 1 3 5 9 16 429..................................... 42295 7.8371 2 3 5 9 15 430..................................... 55585 9.0191 2 4 7 11 18 431..................................... 218 8.9037 2 3 5 9 17 432..................................... 404 5.8292 1 2 3 7 12 433..................................... 8177 3.2849 1 1 2 4 7 434..................................... 22419 5.2813 2 3 4 6 10 [[Page 30007]] 435..................................... 16398 4.5144 1 2 4 5 8 436..................................... 3530 13.7382 4 8 13 20 26 437..................................... 15594 9.9086 4 6 9 13 18 439..................................... 1041 8.4476 1 3 6 10 18 440..................................... 4797 9.4951 2 3 6 11 20 441..................................... 604 3.4619 1 1 2 4 7 442..................................... 15541 8.2678 1 3 6 10 17 443..................................... 2981 3.3603 1 1 2 4 7 444..................................... 3303 4.7802 1 2 4 6 9 445..................................... 1229 3.7079 1 1 3 4 6 447..................................... 4148 2.6437 1 1 2 3 5 448..................................... 29 1.0000 1 1 1 1 1 449..................................... 28622 4.0140 1 1 3 5 8 450..................................... 6263 2.2531 1 1 1 3 4 451..................................... 4 3.0000 1 1 1 2 8 452..................................... 21359 5.1382 1 2 4 6 10 453..................................... 3599 3.0889 1 1 2 4 6 454..................................... 3919 5.1832 1 2 3 6 10 455..................................... 884 2.7805 1 1 2 3 6 456..................................... 214 7.3178 1 1 3 8 16 457..................................... 111 4.8649 1 1 2 6 14 458..................................... 1652 15.9994 3 6 12 21 33 459..................................... 567 9.3210 2 4 7 12 19 460..................................... 2285 6.3422 1 3 5 8 13 461..................................... 3199 4.5552 1 1 2 5 11 462..................................... 9980 12.9722 4 6 11 17 24 463..................................... 13387 4.7746 1 2 4 6 9 464..................................... 3180 3.4299 1 2 3 4 7 465..................................... 215 3.7767 1 1 2 4 7 466..................................... 1750 4.7080 1 1 2 5 10 467..................................... 1582 4.2061 1 1 2 4 8 468..................................... 62754 13.9856 3 6 11 18 28 471..................................... 11592 6.7331 3 4 5 8 11 472..................................... 198 23.9192 1 5 18 34 56 473..................................... 8660 13.2808 2 4 7 19 34 475..................................... 100258 11.4467 2 5 9 15 22 476..................................... 6588 12.6252 3 7 11 16 23 477..................................... 29950 8.0288 1 2 6 10 16 478..................................... 126594 7.6907 1 3 6 10 16 479..................................... 17890 4.1892 1 2 3 5 8 480..................................... 513 27.1598 9 12 19 34 58 481..................................... 150 33.5333 19 23 30 41 54 482..................................... 6981 13.4369 5 7 10 15 24 483..................................... 39458 42.8906 14 22 34 52 78 484..................................... 382 15.3822 3 7 11 20 30 485..................................... 3406 10.4055 4 5 8 12 20 486..................................... 2358 13.1768 1 5 10 17 27 487..................................... 4134 8.1265 2 3 6 10 16 488..................................... 1737 16.4531 4 7 12 20 32 489..................................... 18692 9.5287 2 4 7 12 20 490..................................... 5357 6.0062 1 2 4 7 12 491..................................... 10675 3.9154 2 2 3 4 7 492..................................... 2207 17.8691 4 5 14 28 37 493..................................... 56437 5.6673 1 2 4 7 11 494..................................... 24927 2.3773 1 1 2 3 5 495..................................... 117 17.1197 8 11 15 21 30 ---------------- 11086740 -------------------------------------------------------------------------------------------------------------------------------------------------------- Table 7B.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay [FY96 MEDPAR Update 12/96 Grouper V15.0] -------------------------------------------------------------------------------------------------------------------------------------------------------- Number Arithmetic 10th 25th 50th 75th 90th DRG discharges mean LOS percentile percentile percentile percentile percentile -------------------------------------------------------------------------------------------------------------------------------------------------------- 1....................................... 36587 10.0378 2 4 7 13 21 2....................................... 6771 10.5860 3 5 8 13 21 3....................................... 1 1.0000 1 1 1 1 1 4....................................... 6231 8.4710 2 3 6 10 18 [[Page 30008]] 5....................................... 102519 3.9306 1 2 3 4 8 6....................................... 417 3.2590 1 1 2 4 7 7....................................... 12033 11.5494 2 5 8 13 21 8....................................... 2346 3.5904 1 1 2 5 8 9....................................... 1716 7.0752 1 3 5 9 14 10...................................... 20105 7.2766 2 3 5 9 15 11...................................... 2931 4.2610 1 2 3 6 9 12...................................... 25980 6.8468 2 3 5 8 13 13...................................... 6321 5.7765 2 3 5 7 10 14...................................... 374962 6.7449 2 3 5 8 13 15...................................... 145044 4.0652 1 2 3 5 7 16...................................... 14000 6.0985 2 3 5 7 11 17...................................... 3087 3.7036 1 2 3 5 7 18...................................... 25611 5.8649 2 3 4 7 11 19...................................... 7093 4.1081 1 2 3 5 8 20...................................... 6049 10.5016 2 5 8 14 21 21...................................... 1178 7.0976 2 3 5 9 14 22...................................... 2888 4.7666 2 2 4 6 9 23...................................... 6027 4.5603 1 2 3 6 9 24...................................... 57786 5.3375 1 2 4 6 10 25...................................... 22109 3.6065 1 2 3 4 7 26...................................... 45 4.9111 1 2 4 6 11 27...................................... 3806 5.5008 1 1 3 7 13 28...................................... 12739 6.3365 1 3 4 8 13 29...................................... 4009 3.7381 1 2 3 5 7 31...................................... 3088 4.8374 1 2 3 6 9 32...................................... 1441 3.0743 1 1 2 3 6 34...................................... 18454 5.8051 1 3 4 7 11 35...................................... 3693 3.9163 1 2 3 5 7 36...................................... 6707 1.5408 1 1 1 2 2 37...................................... 1756 3.9169 1 1 3 4 8 38...................................... 196 2.7041 1 1 2 3 5 39...................................... 2546 2.0000 1 1 1 2 4 40...................................... 2520 3.3218 1 1 2 4 7 42...................................... 5401 1.9867 1 1 1 2 4 43...................................... 111 3.9910 1 2 3 5 7 44...................................... 1463 5.2160 2 3 4 7 9 45...................................... 2342 3.5956 1 2 3 5 7 46...................................... 3043 4.8478 1 2 4 6 9 47...................................... 1198 3.9307 1 1 3 4 7 49...................................... 2364 5.2563 1 2 4 6 10 50...................................... 3268 2.1068 1 1 2 2 3 51...................................... 348 2.8908 1 1 2 3 6 52...................................... 107 3.1589 1 1 2 3 7 53...................................... 3140 3.6080 1 1 2 4 8 54...................................... 2 5.0000 1 1 9 9 9 55...................................... 1876 2.9302 1 1 2 3 6 56...................................... 729 2.8299 1 1 2 3 6 57...................................... 620 3.9935 1 2 2 5 8 58...................................... 1 2.0000 2 2 2 2 2 59...................................... 103 3.1262 1 1 2 4 6 60...................................... 3 1.0000 1 1 1 1 1 61...................................... 241 4.5726 1 1 3 5 11 63...................................... 3732 4.6072 1 2 3 5 9 64...................................... 3341 6.6417 1 2 5 8 14 65...................................... 29330 3.1723 1 2 3 4 6 66...................................... 6560 3.4703 1 2 3 4 6 67...................................... 492 3.8049 1 2 3 5 7 68...................................... 10182 4.3274 2 2 4 5 8 69...................................... 2937 3.4705 1 2 3 4 6 70...................................... 40 3.3000 1 2 3 4 5 71...................................... 128 3.9297 1 2 3 5 7 72...................................... 734 3.4728 1 2 3 4 7 73...................................... 6210 4.6697 1 2 4 6 9 74...................................... 4 3.2500 1 1 2 3 7 75...................................... 40911 10.5412 4 5 8 13 20 76...................................... 41032 11.7128 3 6 9 14 22 77...................................... 2178 5.0987 1 2 4 7 10 78...................................... 30980 7.6317 3 5 7 9 13 79...................................... 238095 8.6329 3 4 7 11 16 [[Page 30009]] 80...................................... 8060 6.0504 2 3 5 7 11 81...................................... 6 6.8333 3 5 6 7 7 82...................................... 70681 7.3182 2 3 6 9 14 83...................................... 7334 5.8951 2 3 5 7 11 84...................................... 1480 3.4696 1 2 3 4 6 85...................................... 20681 6.8720 2 3 5 9 13 86...................................... 1375 4.0429 1 2 3 5 8 87...................................... 67349 6.4330 1 3 5 8 12 88...................................... 359037 5.6532 2 3 5 7 10 89...................................... 428964 6.5605 3 4 5 8 12 90...................................... 36711 4.6673 2 3 4 6 8 91...................................... 40 4.3750 2 3 4 5 9 92...................................... 13520 6.6271 2 3 5 8 12 93...................................... 1160 4.6147 1 2 4 6 8 94...................................... 13679 6.6439 2 3 5 8 13 95...................................... 1419 3.9831 1 2 3 5 7 96...................................... 58934 5.0552 2 3 4 6 9 97...................................... 23955 3.9986 1 2 3 5 7 98...................................... 22 3.8182 1 1 2 4 10 99...................................... 26526 3.1692 1 1 2 4 6 100..................................... 10188 2.2330 1 1 2 3 4 101..................................... 20410 4.7228 1 2 4 6 9 102..................................... 4491 2.8940 1 1 2 4 5 103..................................... 511 47.3190 9 15 32 71 104 104..................................... 26161 13.3467 5 8 11 16 24 105..................................... 22856 10.1918 5 6 8 12 18 106..................................... 106944 11.0508 6 7 9 13 18 107..................................... 68187 8.3051 5 6 7 9 13 108..................................... 7497 12.1122 4 7 10 15 23 110..................................... 63208 10.0765 3 6 8 12 19 111..................................... 5547 6.1031 2 4 6 7 9 112..................................... 142252 4.2152 1 2 3 6 8 113..................................... 47795 13.1200 4 6 9 16 26 114..................................... 9030 8.8270 2 4 7 11 17 115..................................... 13707 9.2228 2 4 8 12 18 116..................................... 160542 4.6957 1 2 4 6 9 117..................................... 3723 4.0285 1 1 3 5 9 118..................................... 6649 3.0284 1 1 2 4 7 119..................................... 1684 5.1081 1 1 3 7 11 120..................................... 39395 8.4464 1 2 5 11 19 121..................................... 170653 6.9325 2 4 6 9 12 122..................................... 85992 4.5068 1 2 4 6 8 123..................................... 45937 4.4685 1 1 2 6 11 124..................................... 152452 4.5929 1 2 4 6 9 125..................................... 60687 2.9374 1 1 2 4 6 126..................................... 5118 12.8009 4 6 10 16 26 127..................................... 705314 5.7996 2 3 5 7 11 128..................................... 18459 6.3467 3 4 6 7 10 129..................................... 4441 3.1678 1 1 1 3 7 130..................................... 99436 6.2969 2 4 5 8 11 131..................................... 25388 4.8483 1 3 5 6 8 132..................................... 164155 3.3160 1 2 3 4 6 133..................................... 6111 2.8053 1 1 2 3 5 134..................................... 29371 3.6005 1 2 3 4 7 135..................................... 8055 4.4431 1 2 3 5 8 136..................................... 1146 3.0689 1 1 2 4 6 137..................................... 3 9.0000 3 3 8 16 16 138..................................... 207593 4.1945 1 2 3 5 8 139..................................... 65375 2.7460 1 1 2 3 5 140..................................... 134325 3.1700 1 2 3 4 6 141..................................... 78304 4.0837 1 2 3 5 7 142..................................... 35576 2.9415 1 1 2 4 5 143..................................... 137087 2.3957 1 1 2 3 4 144..................................... 75955 5.3738 1 2 4 7 11 145..................................... 6306 2.9802 1 1 2 4 6 146..................................... 9812 10.5317 6 7 9 12 17 147..................................... 1663 6.9056 4 5 7 8 10 148..................................... 148695 12.6142 6 7 10 15 22 149..................................... 14197 7.1277 4 5 7 8 10 150..................................... 24394 11.1136 4 7 9 14 20 [[Page 30010]] 151..................................... 4227 6.1091 2 3 6 8 11 152..................................... 4685 8.4886 4 5 7 10 14 153..................................... 1634 5.7778 3 4 6 7 9 154..................................... 34916 14.0359 4 7 11 17 27 155..................................... 4502 5.0060 2 2 4 7 9 156..................................... 2 18.0000 5 5 31 31 31 157..................................... 9423 5.6030 1 2 4 7 11 158..................................... 4325 2.7866 1 1 2 4 6 159..................................... 18159 5.0739 1 2 4 6 10 160..................................... 9496 2.7724 1 1 2 4 5 161..................................... 14885 4.2146 1 2 3 5 9 162..................................... 7335 2.0907 1 1 1 3 4 163..................................... 10 4.7000 1 1 2 8 10 164..................................... 5342 8.7142 4 5 7 10 15 165..................................... 1579 5.3889 2 3 5 7 8 166..................................... 3344 5.4342 2 3 4 7 10 167..................................... 2245 2.9617 1 2 3 4 5 168..................................... 1816 4.7015 1 2 3 6 9 169..................................... 907 2.5480 1 1 2 3 5 170..................................... 12921 11.7454 2 5 9 15 23 171..................................... 1051 5.1246 1 2 4 6 10 172..................................... 32809 7.3996 2 3 5 9 15 173..................................... 2065 3.9467 1 2 3 5 8 174..................................... 238825 5.1461 2 3 4 6 9 175..................................... 21268 3.2303 1 2 3 4 6 176..................................... 17835 5.7613 2 3 4 7 11 177..................................... 11794 4.7272 2 3 4 6 8 178..................................... 3711 3.3393 1 2 3 4 6 179..................................... 12071 6.7278 2 3 5 8 13 180..................................... 88763 5.6576 2 3 4 7 11 181..................................... 21194 3.6978 1 2 3 5 7 182..................................... 237775 4.5664 1 2 4 6 8 183..................................... 69353 3.1731 1 2 3 4 6 184..................................... 84 3.6548 1 2 3 4 7 185..................................... 4091 4.8238 1 2 4 6 10 186..................................... 2 3.0000 2 2 4 4 4 187..................................... 869 3.9298 1 2 3 5 7 188..................................... 70432 5.7809 1 3 4 7 11 189..................................... 7853 3.3748 1 1 3 4 7 190..................................... 93 4.9247 1 2 3 5 12 191..................................... 11046 14.8284 4 7 11 18 29 192..................................... 775 7.1381 2 4 6 9 13 193..................................... 8318 12.9221 5 7 11 16 23 194..................................... 657 7.4247 2 4 6 9 13 195..................................... 8720 9.8580 4 6 8 12 17 196..................................... 622 6.3344 3 4 6 8 10 197..................................... 27180 8.7010 3 5 7 10 15 198..................................... 7031 4.7165 2 3 4 6 8 199..................................... 2148 10.6909 3 5 8 14 22 200..................................... 1535 11.3759 2 4 8 14 23 201..................................... 1540 14.9247 4 7 11 18 29 202..................................... 28333 7.0992 2 3 5 9 14 203..................................... 29347 7.1592 2 3 6 9 14 204..................................... 52863 6.3342 2 3 5 8 12 205..................................... 22950 6.7923 2 3 5 8 14 206..................................... 1650 4.2218 1 2 3 5 8 207..................................... 36763 5.2874 1 2 4 7 10 208..................................... 9874 3.0353 1 1 2 4 6 209..................................... 356581 5.8918 3 4 5 7 9 210..................................... 142751 7.6248 4 5 6 9 13 211..................................... 26179 5.6064 3 4 5 7 9 212..................................... 9 5.5556 2 3 3 5 6 213..................................... 7121 8.7182 2 4 7 11 17 216..................................... 6357 10.2902 2 4 8 13 21 217..................................... 20641 13.7099 3 5 9 17 29 218..................................... 24494 5.6207 2 3 4 7 10 219..................................... 18726 3.4427 1 2 3 4 6 220..................................... 5 4.2000 1 1 4 4 10 223..................................... 19460 2.7002 1 1 2 3 5 224..................................... 8049 2.1070 1 1 2 3 4 [[Page 30011]] 225..................................... 5842 4.6251 1 2 3 6 10 226..................................... 5512 6.2509 1 2 4 7 13 227..................................... 4323 2.8543 1 1 2 3 5 228..................................... 2967 3.4553 1 1 2 4 7 229..................................... 1216 2.3528 1 1 2 3 4 230..................................... 2473 4.9713 1 2 3 6 10 231..................................... 10931 4.7553 1 2 3 6 10 232..................................... 553 4.2405 1 1 2 5 10 233..................................... 4689 8.2457 2 3 6 10 16 234..................................... 2164 3.8812 1 2 3 5 8 235..................................... 5523 5.8175 1 3 4 6 11 236..................................... 39703 5.5917 2 3 4 7 10 237..................................... 1658 4.1978 1 2 3 5 8 238..................................... 7601 9.3428 3 4 7 11 17 239..................................... 60382 6.9698 2 3 5 8 13 240..................................... 13253 6.9292 2 3 5 8 14 241..................................... 2987 4.2266 1 2 3 5 8 242..................................... 2825 7.1487 2 3 5 9 14 243..................................... 80144 5.1231 2 3 4 6 9 244..................................... 12434 5.3963 1 3 4 6 10 245..................................... 4379 4.0877 1 2 3 5 7 246..................................... 1267 4.2447 1 2 3 5 8 247..................................... 11435 3.6810 1 2 3 5 7 248..................................... 7377 4.9753 1 2 4 6 9 249..................................... 10332 3.9334 1 1 3 5 8 250..................................... 3605 4.6624 1 2 3 5 9 251..................................... 2135 3.0070 1 1 2 4 5 253..................................... 19016 5.2421 1 3 4 6 10 254..................................... 9279 3.5245 1 2 3 4 6 256..................................... 4420 5.6344 1 2 4 7 11 257..................................... 22633 3.2019 1 2 3 4 6 258..................................... 16953 2.2778 1 1 2 3 4 259..................................... 3995 3.1975 1 1 2 3 7 260..................................... 4550 1.6642 1 1 1 2 3 261..................................... 2214 2.2344 1 1 2 3 4 262..................................... 659 4.0030 1 1 3 5 8 263..................................... 29116 12.4972 3 5 9 15 24 264..................................... 3348 7.2694 2 3 6 9 14 265..................................... 4140 7.1005 1 2 5 8 14 266..................................... 2554 3.5717 1 1 2 5 7 267..................................... 223 4.1839 1 1 2 5 9 268..................................... 936 3.5716 1 1 2 4 7 269..................................... 10077 8.5158 2 3 6 11 17 270..................................... 3072 3.1953 1 1 2 4 7 271..................................... 22910 7.7195 3 4 6 9 14 272..................................... 5990 6.6751 2 3 5 8 13 273..................................... 1385 5.3682 1 2 4 6 11 274..................................... 2618 7.1176 1 3 5 9 15 275..................................... 240 3.8042 1 1 2 5 8 276..................................... 939 4.7444 1 3 4 6 8 277..................................... 80128 6.2324 2 3 5 7 11 278..................................... 24698 4.8226 2 3 4 6 8 279..................................... 4 4.5000 2 2 2 6 8 280..................................... 13930 4.7090 1 2 3 6 9 281..................................... 5886 3.3819 1 1 3 4 6 282..................................... 1 1.0000 1 1 1 1 1 283..................................... 5284 5.0157 1 2 4 6 10 284..................................... 1745 3.5415 1 2 3 5 7 285..................................... 5591 12.0757 3 5 9 15 23 286..................................... 2071 7.2038 3 4 5 8 13 287..................................... 6659 12.2050 3 5 8 14 24 288..................................... 1201 5.8485 3 4 5 6 9 289..................................... 5476 3.4830 1 1 2 3 7 290..................................... 8792 2.5875 1 1 2 3 4 291..................................... 94 2.1596 1 1 2 3 4 292..................................... 5173 11.2101 2 4 8 14 22 293..................................... 271 5.8782 1 2 4 7 12 294..................................... 83789 5.2505 2 3 4 6 10 295..................................... 3687 4.0966 1 2 3 5 8 296..................................... 231836 5.7562 2 3 4 7 11 [[Page 30012]] 297..................................... 31640 3.8523 1 2 3 5 7 298..................................... 95 2.5263 1 1 2 3 5 299..................................... 1130 5.4823 1 2 4 7 11 300..................................... 15620 6.6238 2 3 5 8 13 301..................................... 1968 4.3664 1 2 3 5 8 302..................................... 7967 10.9728 5 6 8 13 19 303..................................... 19228 9.4496 4 5 8 11 17 304..................................... 13039 9.5748 2 4 7 11 19 305..................................... 2442 4.3276 1 2 4 5 8 306..................................... 11607 5.7509 1 2 4 7 12 307..................................... 2482 2.5363 1 1 2 3 4 308..................................... 9610 6.4318 1 2 4 8 13 309..................................... 3296 2.5713 1 1 2 3 5 310..................................... 27425 4.3364 1 2 3 5 9 311..................................... 8487 2.0526 1 1 2 2 4 312..................................... 1870 4.6904 1 2 3 6 10 313..................................... 664 2.2651 1 1 2 3 4 315..................................... 28343 8.5525 1 2 5 11 19 316..................................... 84582 6.9972 2 3 5 9 14 317..................................... 841 2.9441 1 1 2 3 6 318..................................... 6162 6.6386 1 3 5 8 13 319..................................... 421 2.8005 1 1 2 4 6 320..................................... 175993 5.8700 2 3 5 7 10 321..................................... 23410 4.2695 2 3 4 5 7 322..................................... 88 4.1023 2 2 3 4 7 323..................................... 17373 3.3754 1 1 2 4 7 324..................................... 7970 2.0041 1 1 2 2 4 325..................................... 7001 4.1964 1 2 3 5 8 326..................................... 2116 2.8767 1 1 2 3 5 327..................................... 15 3.4667 1 1 2 3 12 328..................................... 674 3.9139 1 2 3 5 8 329..................................... 106 2.3491 1 1 2 3 5 331..................................... 43957 5.8366 2 3 4 7 11 332..................................... 4414 3.5353 1 1 3 5 7 333..................................... 352 5.6733 1 2 4 7 12 334..................................... 19282 5.4196 3 4 5 6 8 335..................................... 9747 4.0557 2 3 4 5 6 336..................................... 59009 3.7607 1 2 3 4 7 337..................................... 34107 2.4150 1 2 2 3 4 338..................................... 3724 5.0709 1 2 3 6 11 339..................................... 2118 4.5892 1 2 3 6 10 340..................................... 2 1.5000 1 1 2 2 2 341..................................... 5932 3.1123 1 1 2 3 6 342..................................... 192 4.1927 1 2 3 6 8 344..................................... 3517 3.1137 1 1 2 3 6 345..................................... 1357 3.7900 1 1 3 5 8 346..................................... 5156 6.2853 1 3 5 8 12 347..................................... 372 2.9624 1 1 2 4 6 348..................................... 3204 4.4978 1 2 3 5 8 349..................................... 741 2.6815 1 1 2 3 5 350..................................... 6300 4.6057 2 3 4 6 8 351..................................... 2 2.5000 2 2 3 3 3 352..................................... 541 3.9279 1 1 3 5 8 353..................................... 2701 8.3425 3 4 6 9 16 354..................................... 9927 5.9853 3 3 5 7 10 355..................................... 5565 3.6270 2 3 3 4 5 356..................................... 29685 2.8084 1 2 3 3 4 357..................................... 6569 9.3230 4 5 7 11 17 358..................................... 28653 4.4708 2 3 4 5 7 359..................................... 28097 3.0930 2 2 3 4 4 360..................................... 18115 3.2832 1 2 3 4 5 361..................................... 671 3.6692 1 1 2 4 8 362..................................... 1 1.0000 1 1 1 1 1 363..................................... 3892 3.4740 1 2 2 3 7 364..................................... 1856 3.4984 1 1 2 4 7 365..................................... 2435 7.1647 1 2 4 9 16 366..................................... 4452 7.0106 1 3 5 9 15 367..................................... 538 2.9387 1 1 2 4 6 368..................................... 2377 6.2680 2 3 5 8 12 369..................................... 2399 3.4239 1 1 2 4 7 [[Page 30013]] 370..................................... 1171 5.5448 2 3 4 5 9 371..................................... 1053 3.5897 2 3 3 4 5 372..................................... 876 3.1199 1 2 2 3 5 373..................................... 3973 2.0194 1 1 2 2 3 374..................................... 152 2.9474 1 2 2 3 4 375..................................... 7 8.4286 1 2 5 9 15 376..................................... 214 3.2710 1 1 2 4 7 377..................................... 49 4.1224 1 1 2 4 9 378..................................... 187 2.6578 1 2 2 3 4 379..................................... 358 2.9609 1 1 2 3 5 380..................................... 96 1.8333 1 1 1 2 4 381..................................... 178 2.2022 1 1 1 2 4 382..................................... 47 1.3404 1 1 1 1 2 383..................................... 1583 3.8111 1 2 3 5 8 384..................................... 132 2.9318 1 1 2 3 6 385..................................... 3 6.6667 1 1 4 15 15 389..................................... 16 6.2500 3 3 5 7 12 390..................................... 8 5.1250 2 2 3 5 7 392..................................... 2532 10.5517 4 5 8 13 21 393..................................... 2 11.0000 7 7 15 15 15 394..................................... 1791 7.4199 1 2 5 8 16 395..................................... 67648 4.9800 1 2 4 6 10 396..................................... 17 4.1176 1 1 2 7 7 397..................................... 16824 5.7741 1 2 4 7 11 398..................................... 18292 6.2478 2 3 5 8 11 399..................................... 1293 4.0162 1 2 3 5 8 400..................................... 7808 9.6883 2 3 7 12 21 401..................................... 6732 11.6693 2 5 9 15 24 402..................................... 1499 4.2368 1 1 3 6 9 403..................................... 38817 8.5440 2 3 6 11 17 404..................................... 3788 4.6378 1 2 4 6 9 406..................................... 3452 10.0200 3 4 7 13 21 407..................................... 699 4.4120 1 2 4 6 8 408..................................... 2838 7.6688 1 2 5 9 18 409..................................... 5558 5.9171 2 3 4 6 12 410..................................... 74218 3.3531 1 2 3 4 5 411..................................... 33 2.3030 1 1 1 3 6 412..................................... 30 3.3667 1 1 2 5 7 413..................................... 8746 8.0082 2 3 6 10 16 414..................................... 727 4.5571 1 2 3 6 10 415..................................... 44472 14.8801 4 7 11 18 29 416..................................... 218625 7.6812 2 4 6 9 14 417..................................... 41 4.3171 1 2 4 6 8 418..................................... 20458 6.3064 2 3 5 8 12 419..................................... 14836 5.2358 2 3 4 6 10 420..................................... 2606 3.9643 1 2 3 5 7 421..................................... 10712 4.2451 1 2 3 5 8 422..................................... 84 3.8690 1 2 3 5 5 423..................................... 10806 7.9174 2 3 6 9 16 424..................................... 1855 16.8313 2 6 10 19 31 425..................................... 15463 4.3916 1 2 3 5 8 426..................................... 4693 5.2169 1 2 4 6 11 427..................................... 1680 5.2494 1 2 4 6 11 428..................................... 923 7.6111 1 3 5 9 16 429..................................... 42341 7.8410 2 3 5 9 15 430..................................... 55603 9.0212 2 4 7 11 18 431..................................... 218 8.9037 2 3 5 9 17 432..................................... 404 5.8292 1 2 3 7 12 433..................................... 8182 3.2840 1 1 2 4 7 434..................................... 22447 5.2816 2 3 4 6 10 435..................................... 16417 4.5130 1 2 4 5 8 436..................................... 3531 13.7366 4 8 13 20 26 437..................................... 15598 9.9085 4 6 9 13 18 439..................................... 1041 8.4476 1 3 6 10 18 440..................................... 4797 9.4951 2 3 6 11 20 441..................................... 604 3.4619 1 1 2 4 7 442..................................... 15505 8.2772 1 3 6 10 17 443..................................... 2968 3.3632 1 1 2 4 7 444..................................... 3308 4.7830 1 2 4 6 9 445..................................... 1229 3.6998 1 1 3 4 6 [[Page 30014]] 447..................................... 4148 2.6437 1 1 2 3 5 448..................................... 29 1.0000 1 1 1 1 1 449..................................... 28641 4.0147 1 1 3 5 8 450..................................... 6265 2.2530 1 1 1 3 4 451..................................... 4 3.0000 1 1 1 2 8 452..................................... 21368 5.1393 1 2 4 6 10 453..................................... 3597 3.0770 1 1 2 4 6 454..................................... 3925 5.1827 1 2 3 6 10 455..................................... 892 2.7668 1 1 2 3 6 456..................................... 214 7.3178 1 1 3 8 16 457..................................... 111 4.8649 1 1 2 6 14 458..................................... 1652 15.9994 3 6 12 21 33 459..................................... 567 9.3210 2 4 7 12 19 460..................................... 2286 6.3408 1 3 5 8 13 461..................................... 3190 4.5564 1 1 2 5 11 462..................................... 9980 12.9722 4 6 11 17 24 463..................................... 13395 4.7779 1 2 4 6 9 464..................................... 3180 3.4145 1 2 3 4 7 465..................................... 215 3.7767 1 1 2 4 7 466..................................... 1751 4.7059 1 1 2 5 10 467..................................... 1583 4.2053 1 1 2 4 8 468..................................... 60012 14.0970 3 6 11 18 28 471..................................... 11592 6.7331 3 4 5 8 11 472..................................... 198 23.9192 1 5 18 34 56 473..................................... 8660 13.2826 2 4 7 19 34 475..................................... 100273 11.4470 2 5 9 15 22 476..................................... 6604 12.6364 3 7 11 16 23 477..................................... 29677 8.6003 1 3 6 11 18 478..................................... 126591 7.6914 1 3 6 10 16 479..................................... 17894 4.1872 1 2 3 5 8 480..................................... 388 24.2294 8 12 17 29 49 481..................................... 250 29.8760 17 21 26 36 50 482..................................... 6981 13.4369 5 7 10 15 24 483..................................... 39492 42.9069 14 22 34 52 78 484..................................... 382 15.3822 3 7 11 20 30 485..................................... 3406 10.4055 4 5 8 12 20 486..................................... 2298 13.2820 1 6 10 17 27 487..................................... 4186 8.1388 2 3 6 10 16 488..................................... 906 17.7770 4 7 13 22 37 489..................................... 19468 9.7616 2 4 7 12 20 490..................................... 5412 6.0458 1 2 4 7 12 491..................................... 10675 3.9154 2 2 3 4 7 492..................................... 2207 17.8691 4 5 14 28 37 493..................................... 56448 5.6678 1 2 4 7 11 494..................................... 24916 2.3746 1 1 2 3 5 495..................................... 87 17.3333 7 10 15 22 31 496..................................... 683 11.5344 4 6 9 13 22 497..................................... 19813 6.8081 2 4 5 8 12 498..................................... 10451 3.7528 1 2 3 5 7 499..................................... 37493 5.3005 2 3 4 6 10 500..................................... 34661 3.1298 1 2 3 4 6 501..................................... 2000 10.4195 4 5 8 12 19 502..................................... 3520 5.3301 2 3 4 6 10 503..................................... 3046 3.3700 1 2 3 4 6 ---------------- 11086638 -------------------------------------------------------------------------------------------------------------------------------------------------------- Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) April 1997 ------------------------------------------------------------------------ State Urban Rural ------------------------------------------------------------------------ ALABAMA............................................... 0.400 0.449 ALASKA................................................ 0.517 0.778 ARIZONA............................................... 0.397 0.559 ARKANSAS.............................................. 0.541 0.491 CALIFORNIA............................................ 0.388 0.500 COLORADO.............................................. 0.486 0.609 CONNECTICUT........................................... 0.551 0.555 DELAWARE.............................................. 0.505 0.489 [[Page 30015]] DISTRICT OF COLUMBIA.................................. 0.521 ....... FLORIDA............................................... 0.397 0.397 GEORGIA............................................... 0.508 0.510 HAWAII................................................ 0.458 0.528 IDAHO................................................. 0.557 0.618 ILLINOIS.............................................. 0.474 0.585 INDIANA............................................... 0.559 0.596 IOWA.................................................. 0.529 0.665 KANSAS................................................ 0.447 0.652 KENTUCKY.............................................. 0.503 0.529 LOUISIANA............................................. 0.469 0.531 MAINE................................................. 0.619 0.576 MARYLAND.............................................. 0.764 0.815 MASSACHUSETTS......................................... 0.557 0.597 MICHIGAN.............................................. 0.485 0.585 MINNESOTA............................................. 0.566 0.629 MISSISSIPPI........................................... 0.524 0.522 MISSOURI.............................................. 0.445 0.531 MONTANA............................................... 0.485 0.602 NEBRASKA.............................................. 0.495 0.660 NEVADA................................................ 0.339 0.516 NEW HAMPSHIRE......................................... 0.574 0.598 NEW JERSEY............................................ 0.458 ....... NEW MEXICO............................................ 0.466 0.537 NEW YORK.............................................. 0.569 0.654 NORTH CAROLINA........................................ 0.534 0.475 NORTH DAKOTA.......................................... 0.650 0.673 OHIO.................................................. 0.551 0.593 OKLAHOMA.............................................. 0.477 0.552 OREGON................................................ 0.585 0.638 PENNSYLVANIA.......................................... 0.410 0.540 PUERTO RICO........................................... 0.477 0.521 RHODE ISLAND.......................................... 0.577 ....... SOUTH CAROLINA........................................ 0.474 0.496 SOUTH DAKOTA.......................................... 0.542 0.639 TENNESSEE............................................. 0.532 0.557 TEXAS................................................. 0.445 0.557 UTAH.................................................. 0.596 0.639 VERMONT............................................... 0.610 0.566 VIRGINIA.............................................. 0.494 0.510 WASHINGTON............................................ 0.663 0.666 WEST VIRGINIA......................................... 0.599 0.545 WISCONSIN............................................. 0.597 0.648 WYOMING............................................... 0.514 0.751 ------------------------------------------------------------------------ Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) April 1997 ------------------------------------------------------------------------ State Ratio ------------------------------------------------------------------------ ALABAMA........................................................ 0.054 ALASKA......................................................... 0.073 ARIZONA........................................................ 0.047 ARKANSAS....................................................... 0.055 CALIFORNIA..................................................... 0.040 COLORADO....................................................... 0.055 CONNECTICUT.................................................... 0.039 DELAWARE....................................................... 0.056 DISTRICT OF COLUMBIA........................................... 0.040 FLORIDA........................................................ 0.047 GEORGIA........................................................ 0.048 HAWAII......................................................... 0.046 IDAHO.......................................................... 0.055 ILLINOIS....................................................... 0.044 INDIANA........................................................ 0.059 IOWA........................................................... 0.055 KANSAS......................................................... 0.057 KENTUCKY....................................................... 0.054 LOUISIANA...................................................... 0.068 MAINE.......................................................... 0.045 MARYLAND....................................................... 0.013 MASSACHUSETTS.................................................. 0.063 MICHIGAN....................................................... 0.048 MINNESOTA...................................................... 0.057 MISSISSIPPI.................................................... 0.055 MISSOURI....................................................... 0.051 MONTANA........................................................ 0.058 NEBRASKA....................................................... 0.057 NEVADA......................................................... 0.033 NEW HAMPSHIRE.................................................. 0.067 NEW JERSEY..................................................... 0.045 NEW MEXICO..................................................... 0.053 NEW YORK....................................................... 0.054 NORTH CAROLINA................................................. 0.049 NORTH DAKOTA................................................... 0.074 OHIO........................................................... 0.055 OKLAHOMA....................................................... 0.056 OREGON......................................................... 0.054 PENNSYLVANIA................................................... 0.042 PUERTO RICO.................................................... 0.090 RHODE ISLAND................................................... 0.038 SOUTH CAROLINA................................................. 0.055 SOUTH DAKOTA................................................... 0.061 TENNESSEE...................................................... 0.056 TEXAS.......................................................... 0.053 UTAH........................................................... 0.058 VERMONT........................................................ 0.053 VIRGINIA....................................................... 0.058 WASHINGTON..................................................... 0.067 WEST VIRGINIA.................................................. 0.055 WISCONSIN...................................................... 0.048 WYOMING........................................................ 0.065 ------------------------------------------------------------------------ Appendix A--Regulatory Impact Analysis I. Introduction We generally prepare a regulatory flexibility analysis that is consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 through 612), unless 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, we consider all hospitals to be small entities. Also, section 1102(b) of the Social Security 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 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the prospective payment system, we classify these hospitals as urban hospitals. It is clear that the changes being proposed in this document would affect both a substantial number of small rural hospitals as well as other classes of hospitals, and the effects on some may be significant. Therefore, the discussion below, in combination with the rest of this proposed rule, constitutes a combined regulatory impact analysis and regulatory flexibility analysis. In accordance with the provisions of Executive Order 12866, this proposed rule was reviewed by the Office of Management and Budget. II. Objectives The primary objective of the prospective payment system is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of deficit reduction and restraints on government spending in general. We believe the proposed changes would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences. III. Limitations of Our Analysis As has been the case in previously published regulatory impact analyses, the following quantitative analysis presents the projected effects of our proposed policy changes, as well as statutory changes effective for FY 1998, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but we do not attempt to predict behavioral responses to our policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case mix. As we have done in previous proposed rules, we are soliciting comments and information about the anticipated effects of these changes on hospitals and our methodology for estimating them. IV. Hospitals Included In and Excluded From the Prospective Payment System The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general, short-term, acute care hospitals that participate in the Medicare program. There were 45 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment method for these hospitals. Among other short- term, acute care hospitals, only the 50 such hospitals in Maryland remain excluded from the prospective payment system under the waiver at section 1814(b)(3) of the Act. Thus, as of April 1997, we have included 5,087 [[Page 30016]] hospitals in our analysis. This represents about 82 percent of all Medicare-participating hospitals. The majority of this impact analysis focuses on this set of hospitals. The remaining 18 percent are specialty hospitals that are excluded from the prospective payment system and continue to be paid on the basis of their reasonable costs (subject to a rate-of- increase ceiling on their inpatient operating costs per discharge). These hospitals include psychiatric, rehabilitation, long-term care, children's, and cancer hospitals. The impacts of our proposed policy changes on these hospitals are discussed below. V. Impact on Excluded Hospitals and Units As of April 1997, there were 1,118 specialty hospitals excluded from the prospective payment system and instead paid on a reasonable cost basis subject to the rate-of-increase ceiling under Sec. 413.40. In addition, there were 2,346 psychiatric and rehabilitation units in hospitals otherwise subject to the prospective payment system. These excluded units are also paid in accordance with Sec. 413.40. In accordance with section 1886(b)(3)(B) of the Act, the update factor applicable to the rate-of-increase limit for excluded hospitals and units for FY 1998 would be 2.8 percent (the excluded hospital market basket). The impact on excluded hospitals and units of the proposed update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the percentage increases in the rate-of-increase limits since their base period, the major effect will be on the level of incentive payments these hospitals and units receive. Conversely, for excluded hospitals and units with per-case cost increases above the cumulative update in their rate-of-increase limits, the major effect will be the amount of excess costs that would not be reimbursed. In this context, we note that, under Sec. 413.40(d)(3), an excluded hospital or unit whose costs exceed the rate-of-increase limit is allowed to receive its rate-of-increase limit plus 50 percent of reasonable costs in excess of the limit, not to exceed 110 percent of its limit. In addition, under the various provisions set forth in Sec. 413.40, excluded hospitals and units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit. At the same time, however, by generally limiting payment increases, we continue to provide an incentive for excluded hospitals and units to restrain the growth in their spending for patient services. We are proposing to extend certain exclusion criteria that currently apply only to long-term care hospitals to all other categories of excluded facilities. These criteria define a minimum level of independence and separate control that a facility must have in order to be excluded as a ``hospital within a hospital.'' We expect that this provision will result in a very small decrease in aggregate payment levels (other things being equal) by, for example, preventing new hospital units from inappropriately qualifying for the exemption from the-rate-of-increase ceiling that is available only to new hospitals. To our knowledge, there are fewer than 50 facilities that would be affected by this proposal. We welcome comments on this aspect of the impact analysis. VI. Quantitative Impact Analysis of the Proposed Policy Changes Under the Prospective Payment System for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing policy changes and payment rate updates for the prospective payment systems for operating and capital-related costs. We have prepared separate analyses of the proposed changes to each system. This section deals with changes to the operating prospective payment system. The data used in developing the quantitative analyses presented below are taken from the FY 1996 MedPAR file and the most current provider-specific file that is used for payment purposes. Although the analyses of the changes to the operating prospective payment system do not incorporate cost data, the most recently available hospital cost report data were used to create some of the variables by which hospitals are categorized. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to these proposed policy changes. Second, due to the interdependent nature of the prospective payment system, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available source overall. For individual hospitals, however, some miscategorizations are possible. Using cases in the FY 1996 MedPAR file, we simulated payments under the operating prospective payment system given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the general prospective payment systems (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations. Payments under the capital prospective payment system, or payments for costs other than inpatient operating costs, are not analyzed here. Estimated payment impacts of proposed FY 1998 changes to the capital prospective payment system are discussed below in section VII of this Appendix. The proposed changes discussed separately below are the following: The effects of the annual reclassification of diagnoses and procedures and the recalibration of the DRG relative weights required by section 1886(d)(4)(C) of the Act. The effects of changes in hospitals' wage index values reflecting the wage index update (FY 1994 data). The effects of implementing the Puerto Rico-specific wage index to be applied to the Puerto Rico standardized amounts. The effects of completing the phase-out of payments for extraordinarily lengthy cases (day outlier cases) with a corresponding increase in payments for extraordinarily costly cases (cost outliers), in accordance with section 1886(d)(5)(A)(v) of the Act. The effects of geographic reclassifications by the MGCRB that will be effective in FY 1998. The total change in payments based on FY 1998 policies relative to payments based on FY 1997 policies. To illustrate the impacts of the FY 1998 proposed changes, our analysis begins with a FY 1998 baseline simulation model using: the FY 1997 GROUPER (version 14.0); the FY 1997 wage index; national wage index values applied to the Puerto Rico standardized amounts; FY 1997 outlier policy (75 percent phase-out of day outlier payments); and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total DRG payments. Each proposed and statutory policy change is then added incrementally to this baseline model, finally arriving at an FY 1998 model incorporating all of the changes. This allows us to isolate the effects of each change. Our final comparison illustrates the percent change in payments per case from FY 1997 to FY 1998. Three factors have significant impacts here. First is the update to the standardized amounts. In accordance with section 1886(d)(3)(A)(iv) of the Act, we are proposing to update the large urban and the other areas average standardized amounts for FY 1998 using the most recently forecasted hospital market basket increase for FY 1998 of 2.8 percent. Similarly, section 1886(b)(3)(C)(ii) of the Act provides that the update factor applicable to the hospital-specific rates for sole community hospitals (SCHs) and essential access community hospitals (EACHs) (which are treated as SCHs for payment purposes) is equal to the market basket increase of 2.8 percent. A second significant factor impacting changes in hospitals' payments per case from FY 1997 to FY 1998 is a change in MGCRB reclassification status from one year to the next. That is, hospitals reclassified in FY 1997 that are no longer reclassified in FY 1998 may have a negative payment impact going from FY 1997 to FY 1998; conversely, hospitals not reclassified in FY 1997 that are reclassified in FY 1998 may have a positive impact. In some cases these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage increase in payments for the category may be below the national mean. A third significant factor is that we currently estimate actual outlier payments during FY 1997 will be 4.9 percent of actual total DRG payments. When the FY 1997 final rule was published, we projected FY 1997 outlier payments would be 5.1 percent of total DRG payments, and the standardized amounts were reduced correspondingly. The effects of the slightly lower than expected outlier payments during FY 1997 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below [[Page 30017]] comparing our current estimates of FY 1997 payments per case to estimated FY 1998 payments per case. Table I demonstrates the results of our analysis. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The top row of the table shows the overall impact on the 5,087 hospitals included in the analysis. This is 42 fewer hospitals than were included in the impact analysis in the FY 1997 final rule (61 FR 46305). Data for 82 hospitals that were included in last year's analysis were not available for analysis this year; however, data were available this year for 40 hospitals for which data were not available last year. The next four rows of Table I contain hospitals categorized according to their geographic location (all urban, which is further divided into large urban and other urban, or rural). There are 2,857 hospitals located in urban areas (MSAs or NECMAs) included in our analysis. Among these, there are 1,580 hospitals located in large urban areas (populations over 1 million), and 1,277 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 2,230 hospitals in rural areas. The next two groupings are by bed-size categories, shown separately for urban and rural hospitals. The final groupings by geographic location are by census divisions, also shown separately for urban and rural hospitals. The second part of Table I shows hospital groups based on hospitals' FY 1998 payment classifications, including any reclassifications under section 1886(d)(10) of the Act. For example, the rows labeled urban, large urban, other urban, and rural show the numbers of hospitals being paid based on these categorizations (after consideration of geographic reclassifications) are 2,949, 1,733, 1,216, and 2,138, respectively. The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have residency programs (teaching hospitals that receive an IME adjustment), receive DSH payments, or some combination of these two adjustments. There are 3,996 nonteaching hospitals in our analysis, 849 teaching hospitals with fewer than 100 residents, and 242 teaching hospitals with 100 or more residents. In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural after MGCRB reclassifications. Hospitals in the rural DSH categories, therefore, represent hospitals that were not reclassified for purposes of the standardized amount. (They may, however, have been reclassified for purposes of the wage index.) The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next four rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, rural referral centers (RRCs), and EACHs), as well as rural hospitals not receiving a special payment designation. The RRCs (95), SCH/EACHs (651), and SCH/EACH and RRCs (41) shown here were not reclassified for purposes of the standardized amount. There are four SCHs that will be reclassified for the standardized amount in FY 1998 that, therefore, are not included in these rows. There are eight EACHs included in our analysis and five EACH/RRCs. The next two groupings are based on type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data are taken primarily from the FY 1995 Medicare cost report files, if available (otherwise FY 1994 data are used). Data needed to determine ownership status or Medicare utilization percentages were unavailable for 138 hospitals. For the most part, these are either new hospitals or hospitals filing manual cost reports that are not yet entered into the database. The next series of groupings concern the geographic reclassification status of hospitals. The first three groupings display hospitals that were reclassified by the MGCRB for both FY 1997 and FY 1998, or for either of those 2 years, by urban/rural status. The next rows illustrate the overall number of FY 1998 reclassifications, as well as the numbers of reclassified hospitals grouped by urban and rural location. The final row in Table I contains hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act. Table I.--Impact Analysis of Changes For FY 1998 Operating Prospective Payment System [Percent changes in payments per case] Puerto Rico- Number of DRG New wage Combined wage & specific Day outlier MGCRB All FY 98 hospitals recalibration data \3\ recalibration wage index phaseout reclassification changes \8\ \1\ \2\ \4\ \5\ \6\ \7\ (0) (1) (2) (3) (4) (5) (6) (7) -------------------------------------------------------------------------------------------------------------------------------------------------------- (By Geographic Location) -------------------------------------------------------------------------------------------------------------------------------------------------------- ALL HOSPITALS................ 5,087 0.1 0.1 0.0 0.0 0.0 0.0 3.0 URBAN HOSPITALS.......... 2,857 0.1 0.1 0.0 0.0 -0.1 -0.4 3.0 LARGE URBAN.......... 1,580 0.1 0.1 0.0 0.0 -0.2 -0.4 3.0 OTHER URBAN.......... 1,277 0.1 0.1 0.1 0.0 0.1 -0.3 3.1 RURAL HOSPITALS.......... 2,230 -0.2 0.4 0.0 0.0 0.2 2.1 3.2 BED SIZE (URBAN): 0-99 BEDS................ 720 -0.2 -0.1 -0.4 0.1 0.2 -0.4 2.9 100-199 BEDS............. 948 -0.1 0.0 -0.3 0.1 0.1 -0.4 3.0 200-299 BEDS............. 568 0.1 0.1 0.0 0.0 0.1 -0.4 3.1 300-499 BEDS............. 460 0.2 0.1 0.1 0.0 -0.1 -0.4 2.9 500 OR MORE BEDS......... 161 0.3 0.2 0.4 0.0 -0.3 -0.2 3.1 BED SIZE (RURAL): 0-49 BEDS................ 1,173 -0.4 0.4 -0.2 0.0 0.1 0.1 3.1 50-99 BEDS............... 654 -0.3 0.4 -0.1 0.0 0.2 1.2 3.2 100-149 BEDS............. 237 -0.2 0.5 0.1 0.0 0.2 2.9 3.1 150-199 BEDS............. 90 -0.1 0.4 0.2 0.0 0.2 2.7 3.5 200 OR MORE BEDS......... 76 0.0 0.3 0.2 0.0 0.2 4.0 2.9 URBAN BY CENSUS DIVISION: NEW ENGLAND.............. 159 0.1 -0.4 -0.5 0.0 0.0 -0.3 2.4 MIDDLE ATLANTIC.......... 431 0.1 0.7 0.6 0.0 -1.0 -0.4 2.7 SOUTH ATLANTIC........... 419 0.2 -0.4 -0.4 0.0 0.1 -0.4 2.7 EAST NORTH CENTRAL....... 474 0.1 0.3 0.3 0.0 0.2 -0.3 3.4 [[Page 30018]] EAST SOUTH CENTRAL....... 164 0.2 0.8 0.8 0.0 0.2 -0.3 4.1 WEST NORTH CENTRAL....... 191 0.2 0.1 0.1 0.0 0.2 -0.4 3.5 WEST SOUTH CENTRAL....... 367 0.2 -0.4 -0.4 0.0 0.2 -0.4 2.8 MOUNTAIN................. 129 0.3 -0.5 -0.4 0.0 0.2 -0.3 3.0 PACIFIC.................. 475 0.1 -0.2 -0.3 0.0 0.2 -0.3 2.9 PUERTO RICO.............. 48 0.0 0.5 0.3 5.9 -0.3 -0.3 9.4 RURAL BY CENSUS DIVISION: NEW ENGLAND.............. 53 -0.2 0.7 0.3 0.0 0.2 2.0 3.5 MIDDLE ATLANTIC.......... 85 -0.2 -0.3 -0.7 0.0 0.0 1.1 2.7 SOUTH ATLANTIC........... 298 -0.2 0.4 0.1 0.0 0.2 2.3 2.7 EAST NORTH CENTRAL....... 302 -0.1 0.6 0.3 0.0 0.2 1.2 2.9 EAST SOUTH CENTRAL....... 275 -0.2 0.6 0.3 0.0 0.2 2.5 3.6 WEST NORTH CENTRAL....... 512 -0.3 0.3 -0.1 0.0 0.2 2.4 3.3 WEST SOUTH CENTRAL....... 347 -0.2 0.1 -0.3 0.0 0.2 3.2 3.2 MOUNTAIN................. 212 -0.2 0.0 -0.4 0.0 0.1 1.6 3.5 PACIFIC.................. 141 -0.2 1.1 0.8 0.0 0.1 2.1 3.7 PUERTO RICO.............. 5 -0.4 -1.4 -2.0 7.2 0.0 3.9 8.6 -------------------------------------------------------------------------------------------------------------------------------------------------------- (By Payment Categories) -------------------------------------------------------------------------------------------------------------------------------------------------------- URBAN HOSPITALS.............. 2,949 0.1 0.1 0.1 0.0 -0.1 -0.3 3.0 LARGE URBAN.............. 1,733 0.1 0.2 0.1 0.0 -0.2 -0.3 3.0 OTHER URBAN.............. 1,216 0.1 0.0 -0.1 0.0 0.1 -0.4 3.1 RURAL HOSPITALS.......... 2,138 -0.2 0.3 0.0 0.0 0.2 1.9 3.1 TEACHING STATUS: NON-TEACHING............. 3,996 0.0 0.1 -0.1 0.0 0.2 0.2 3.1 FEWER THAN 100 RESIDENTS. 849 0.1 0.1 0.1 0.0 0.0 -0.4 3.1 100 OR MORE RESIDENTS.... 242 0.2 0.3 0.3 0.0 -0.6 -0.1 2.9 DISPROPORTIONATE SHARE HOSPITALS (DSH): NON-DSH.................. 3,186 0.0 0.1 0.0 0.0 0.2 0.2 3.2 URBAN DSH: 100 BEDS OR MORE..... 1,403 0.1 0.1 0.1 0.0 -0.2 -0.3 2.9 FEWER THAN 100 BEDS.. 91 -0.3 0.0 -0.5 0.0 0.2 -0.2 2.9 RURAL DSH: SOLE COMMUNITY (SCH). 153 -0.3 0.2 -0.3 0.0 0.0 0.1 2.9 REFERRAL CENTERS (RRC)............... 35 -0.1 0.5 0.3 0.0 0.1 3.6 3.4 OTHER RURAL DSH: 100 BEDS OR MORE..... 79 -0.1 0.6 0.3 0.0 0.3 2.5 2.8 FEWER THAN 100 BEDS.. 140 -0.4 0.6 0.1 0.0 0.1 0.8 3.8 URBAN TEACHING AND DSH: BOTH TEACHING AND DSH 703 0.2 0.2 0.2 0.0 -0.3 -0.4 2.9 TEACHING AND NO DSH.. 333 0.2 0.2 0.3 0.0 0.1 -0.2 3.3 NO TEACHING AND DSH.. 791 0.0 0.0 -0.2 0.0 0.1 -0.2 3.0 [[Page 30019]] NO TEACHING AND NO DSH................. 1,122 0.0 0.0 -0.2 0.1 0.2 -0.3 3.1 RURAL HOSPITAL TYPES: NONSPECIAL STATUS HOSPITALS........... 1,351 -0.2 0.4 0.0 0.0 0.2 1.6 3.0 RRC.................. 95 0.0 0.5 0.3 0.0 0.2 5.1 3.8 SCH/EACH............. 651 -0.3 0.1 -0.3 0.0 0.1 0.4 2.8 SCH/EACH AND RRC..... 41 -0.1 0.2 -0.1 0.0 0.0 1.3 2.7 TYPE OF OWNERSHIP: VOLUNTARY................ 2,915 0.1 0.1 0.1 0.0 -0.1 -0.1 3.0 PROPRIETARY.............. 688 0.0 -0.2 -0.3 0.1 0.2 0.1 2.8 GOVERNMENT............... 1,346 0.0 0.3 0.1 0.0 0.0 0.2 3.3 UNKNOWN.................. 138 0.1 0.0 -0.1 0.3 -1.6 -0.2 2.1 MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS: 0-25..................... 266 0.0 -0.4 -0.5 0.0 -0.2 -0.2 2.5 25-50.................... 1,300 0.2 0.0 0.1 0.0 -0.1 -0.2 3.0 50-65.................... 1,985 0.1 0.3 0.2 0.0 0.0 0.1 3.2 OVER 65.................. 1,397 -0.1 0.1 -0.1 0.0 0.1 0.0 2.9 UNKNOWN.................. 138 0.1 0.0 -0.1 0.3 -1.6 -0.2 2.1 -------------------------------------------------------------------------------------------------------------------------------------------------------- Hospitals Reclassified by the Medicare Geographic Review Board -------------------------------------------------------------------------------------------------------------------------------------------------------- RECLASSIFICATION STATUS DURING FY 97 AND FY 98: RECLASSIFIED DURING BOTH FY 97 AND FY 98......... 340 0.0 1.1 0.9 0.0 0.2 5.5 3.3 URBAN................ 102 0.1 1.4 1.4 0.0 0.1 2.9 3.6 RURAL................ 238 0.0 0.6 0.4 0.0 0.3 8.5 3.1 RECLASSIFIED DURING FY 98 ONLY:................... 92 0.2 0.6 0.7 0.1 0.1 3.6 9.0 URBAN................ 15 0.5 0.9 1.2 0.2 0.1 1.0 7.4 RURAL................ 77 -0.2 0.3 0.0 0.0 0.2 7.1 11.0 RECLASSIFIED DURING FY 97 ONLY.................... 203 0.0 0.3 0.2 0.0 0.0 -0.8 -0.3 URBAN................ 88 0.1 0.3 0.2 0.0 -0.1 -1.1 0.1 RURAL................ 115 -0.2 0.3 0.0 0.0 0.2 -0.1 -1.0 FY 98 RECLASSIFICATIONS: ALL RECLASSIFIED HOSPITALS............... 433 0.1 1.0 0.9 0.0 0.2 5.2 4.2 STANDARD AMOUNT ONLY. 96 0.0 1.8 1.7 0.1 0.1 -0.2 3.3 WAGE INDEX ONLY...... 284 0.1 0.4 0.3 0.0 0.2 7.8 4.5 BOTH................. 53 0.0 1.8 1.7 0.0 0.2 3.7 4.6 NONRECLASSIFIED...... 4,627 0.1 0.1 0.0 0.0 -0.1 -0.5 2.9 ALL URBAN RECLASSIFIED... 117 0.2 1.3 1.3 0.0 0.1 2.5 4.2 STANDARD AMOUNT ONLY. 45 0.1 1.8 1.7 0.1 0.0 -0.9 3.3 WAGE INDEX ONLY...... 33 0.3 0.5 0.7 0.0 0.0 6.4 5.1 BOTH................. 39 0.1 1.8 1.7 0.0 0.2 1.8 4.2 NONRECLASSIFIED...... 2,740 0.1 0.0 0.0 0.0 -0.1 -0.5 3.0 [[Page 30020]] ALL RURAL RECLASSIFIED... 316 -0.1 0.6 0.4 0.0 0.2 8.3 4.3 STANDARD AMOUNT ONLY. 51 -0.2 1.9 1.6 0.0 0.4 2.5 3.2 WAGE INDEX ONLY...... 251 -0.1 0.4 0.1 0.0 0.2 8.6 4.2 BOTH................. 14 -0.1 1.8 1.6 0.0 0.5 14.7 6.5 NONRECLASSIFIED...... 1,887 -0.2 0.3 -0.1 0.0 0.1 -0.3 2.7 OTHER RECLASSIFIED: HOSPITALS (SECTION... 1886(d)(8)(B))....... 27 -0.2 0.2 -0.1 0.0 0.2 0.8 3.4 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 1996, and hospital cost report data are from reporting periods beginning in FY 1994 and FY 1995. \2\ This column displays the payment impacts of the recalibration of the DRG weights, based on FY 1996 MedPAR data and the DRG classification changes, in accordance with section 1886(d)(4)(C) of the Act. \3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1994 cost reports. \4\ This column displays the combined impacts of the reclassification and recalibration of the DRGs, the updated wage data used to calculate the wage index, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in columns 1 and 2, and the FY 1998 budget neutrality factor of 0.998400. \5\ This column illustrates the payment impacts of the Puerto Rico-specific wage index, applied to the Puerto Rico standardized amounts. \6\ This column illustrates the payment impacts of completing the phase-out of day outlier payments, and increasing cost outlier payments, in accordance with section 1886(d)(5) of the Act. \7\ Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The effects shown here demonstrate the FY 1998 payment impacts of going from no reclassifications to the reclassifications scheduled to be in effect for FY 1998. Reclassification for prior years has no bearing on the payment impacts shown here. \8\ This column shows changes in payments from FY 1997 to FY 1998. It incorporates all of the changes displayed in columns 3 through 6 (the changes displayed in columns 1 and 2 are included in column 3). It also displays the impacts of the updates to the FY 1998 standardized amounts and the hospital-specific rates, changes in hospitals' reclassification status in FY 1998 compared to FY 1997, and the difference in outlier payments from FY 1997 to FY 1998. The sum of columns 3 through 6 plus these effects may be different from the percentage changes shown here due to rounding and interactive effects. B. Impact of the Proposed Changes to the DRG Classifications and Relative Weights (Column 1) In column 1 of Table I, we present the combined effects of the DRG reclassifications and recalibration, as discussed in section II. of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act requires us each year to make appropriate classification changes and to recalibrate the DRG weights in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. We compared aggregate payments using the FY 1997 DRG relative weights (GROUPER version 14) to aggregate payments using the proposed FY 1998 DRG relative weights (GROUPER version 15). Overall, payments increase by 0.1 percent due to the DRG changes, although this is prior to applying the budget neutrality factor for DRG and wage index changes (see column 3). Consistent with the minor changes we are proposing for the FY 1998 GROUPER, the redistributional impacts of DRG reclassifications and recalibration across hospital groups are very small (a 0.1 percent increase for large and other urban hospitals; a 0.2 percent decrease among rural hospitals). Within hospital categories, the net effects for urban hospitals are small positive changes for larger hospitals (200 or more beds), and slightly negative changes for urban hospitals with fewer than 200 beds. Among rural hospitals, the smallest rural hospitals (fewer than 50 beds) experience a decrease of 0.4 percent. For other rural bed size categories, slight negative impacts prevail. Only the largest rural hospitals (200 or more beds) avoid any negative impact from the changes. The breakdowns by urban census division show that the increase among urban hospitals is spread across all census categories, with the largest increase (0.3 percent) for hospitals in the Mountain census division. For rural hospitals, the largest decrease is 0.4 percent for the five rural hospitals in Puerto Rico. The next largest decrease is 0.3 percent in the West North Central census division. This pattern of negative impacts upon small and rural hospitals is also apparent when examining the effects of DRG changes on hospitals according to special payment categories, with the largest decrease (0.4 percent) among rural DSH hospitals with fewer than 100 beds. Overall, we attribute the changes associated with DRG recalibration to the increasing gap between the relative weights for medical, diagnostic, and less complicated surgical DRGs and the weights for the more complicated surgical DRGs. Since the cases associated with the former DRGs tend to be treated more often in smaller hospitals with fewer resources available, lower relative weights associated with those cases would disproportionately affect these hospitals. In general, small hospitals that serve a disproportionate share of low-income patients fit this definition. In contrast, larger hospitals in both urban and rural areas, which tend to treat the latter group of DRGs, would experience small payment increases. Teaching hospitals, which also treat the more complicated cases, experience similar effects. We note, however, that both the positive and negative impacts are relatively minor. C. Impact of Updating the Wage Data (Column 2) Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the proposed wage index for FY [[Page 30021]] 1998 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 1993 and before October 1, 1994. As with the previous column, the impact of the new data on hospital payments is isolated by holding the other payment parameters constant in the two simulations. That is, column 2 shows the percentage changes in payments when going from a model using the FY 1997 wage index based on FY 1993 wage data before geographic reclassifications to a model using the FY 1998 prereclassification wage index based on FY 1994 wage data. The results indicate that the new wage data have a 0.1 percent increase overall impact on hospital payments (prior to applying the budget neutrality factor, see column 3). Rural hospitals generally appear to benefit from the update. Payments increase for rural hospitals by 0.4 percent. These increases are attributable to relatively large increases in the wage index values for the rural areas of particular States (although all but one changed by less than 5 percent). Urban hospitals as a group are not significantly affected by the updated wage data (0.1 percent increases), although some particular categories of urban hospitals exhibit sizeable changes. Some of the largest changes are found among both urban and rural hospitals grouped by census division. In almost all cases, payments change by less than 1 percent. Our review of the wage data indicates that these changes were attributable to improved reporting, as well as relative changes in labor costs. Among the urban census division categories, the East South Central and the Middle Atlantic census divisions experience the largest increases (0.8 and 0.7 percent, respectively). In the East South Central, the increase stems largely from wage index increases of 6.0 percent in the Mobile, Alabama labor market area, and an increase of 5.2 percent in the Memphis, Tennessee labor market area. In the Middle Atlantic division, New York City's wage index rises by almost 1.4 percent, and Philadelphia's wage index increases by 1.3 percent. The largest decrease among urban hospitals occurs in the Mountain census division with a decline of 0.5 percent. This decrease is primarily due to a 3.7 percent decrease in the wage index for Phoenix, Arizona. Among the rural hospitals, all census divisions experience increases except for the Middle Atlantic (and Puerto Rico, discussed separately below) census division, which experiences a slight decrease of 0.3 percent. The largest increase (1.1 percent) occurs in the Pacific census division. Here, Oregon's rural wage index rises by 3.3 percent, and Washington's rural index increases by 2.9 percent. The second largest increase (0.7 percent) occurs in the New England census division. In this census division, the Vermont index increases by 4.5 percent, and the Maine index increases by 1.9 percent. In Puerto Rico, payments increase by 0.5 percent for the urban hospitals and decrease by 1.4 percent for the five rural hospitals. Although column 4 shows the isolated effects of introducing the Puerto Rico-specific wage index, it is also included in the payment simulations here showing the impacts of the new wage data. Of the six urban areas in Puerto Rico, two experience increases in their national and Puerto Rico-specific wage index values, including the San Juan-Bayamon area (4.4 percent national, and 2.0 percent Puerto Rico-specific), which contains the majority of the urban Puerto Rico hospitals (29 of 48), and the Mayaguez area (6.4 percent national, and 4.0 Puerto Rico-specific). The following chart compares the shifts in wage index values for labor market areas for FY 1998 with those from FY 1997. The majority of labor market areas (336) experience less than a 5 percent change. A total of 31 labor market areas experience a change between 5 and 10 percent; 14 of those experience increases. Still fewer labor markets experience a change of more than 10 percent; one experiences an increase, and two experience decreases. We reviewed the data for any area that experienced a wage index change of 5 percent or more to determine the reason for the fluctuation. ------------------------------------------------------------------------ Number of labor market areas Percentage change in area wage index values --------------------- FY 1997 FY 1998 ------------------------------------------------------------------------ Increase more than 10 percent..................... 1 1 Increase between 5 and 10 percent (inclusive)..... 10 14 Increase or decrease less than 5 percent (inclusive)...................................... 334 336 Decrease between 5 and 10 percent................. 9 17 Decrease more than 10 percent..................... 3 2 ------------------------------------------------------------------------ Under the proposed FY 1998 wage index, 94.2 percent of urban hospitals and 99.9 percent of rural hospitals would experience a change in their wage index of less than 5 percent. Among urban hospitals, 153 would experience a change of between 5 and 10 percent (66 increasing and 87 decreasing), while only 3 rural hospitals fall into this category, all decreasing. Ten urban hospitals and no rural hospitals would experience a change of more than 10 percent. The following chart shows the projected impact for urban and rural hospitals. ------------------------------------------------------------------------ Number of hospitals Percentage change in area wage index values --------------------- Urban Rural ------------------------------------------------------------------------ Increase more than 10 percent..................... 4 0 Increase between 5 and 10 percent (inclusive)..... 66 0 Increase or decrease less than 5 percent.......... 2663 2217 Decrease between 5 and 10 percent (inclusive)..... 87 3 Decrease more than 10 percent..................... 6 0 ------------------------------------------------------------------------ D. Combined Impact of DRG and Wage Index Changes--Including Budget Neutrality Adjustment (Column 3) The impact of DRG reclassifications and recalibration on aggregate payments is required by section 1886(d)(4)(C)(iii) of the Act to be budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As pointed out in the Addendum to this proposed rule, we compared aggregate payments using the FY 1997 DRG relative weights and wage index to aggregate payments using the FY 1998 DRG relative weights and wage index. Based on this comparison, we computed a wage and recalibration budget neutrality factor of 0.998400. In Table I, the combined overall impacts of the effects of both the DRG reclassifications and recalibration and the updated wage index are shown in column 3. The 0.0 percent impact for All Hospitals demonstrates that these changes, in combination with the budget neutrality factor, are budget neutral. For the most part, the changes in this column are the sum of the changes in columns 1 and 2, minus the approximately 0.2 percent decrease attributable to the budget neutrality factor. There may, of course, be some variation of plus or minus 0.1 percent due to rounding. In calculating the total changes shown in column 7, readers should begin with this column and add across, excluding the impacts shown in columns 1 and 2. E. Puerto Rico-Specific Wage Index (Column 4) As described in section III. of the preamble to this proposed rule, we are proposing to adopt a Puerto Rico-specific wage index for FY 1998. These wage index values would be applied to the Puerto Rico standardized amounts. Column 4 shows the effect of implementing this proposed change results in no payment impact for the All Hospitals row. In Puerto Rico, payments increase by 5.9 percent among urban hospitals, and 7.2 percent among rural hospitals. As shown in Table 4F of the Addendum, the Puerto Rico-specific wage index values are considerably higher than Puerto Rico's national wage indexes (shown in Table 4A of the Addendum). This results in the increases shown in this column. As indicated above, this change is shown in isolation here for ease in reading Table I. To actually calculate the national DRG and wage index budget neutrality factors, the Puerto Rico-specific wage index was included. As described in the Addendum, we also computed a DRG reclassification and recalibration budget neutrality adjustment for the Puerto Rico standardized amounts equal to 0.999224. F. Outlier Changes (Column 5) Currently, Medicare provides extra payment in addition to the basic DRG payment amount for extremely costly or extraordinarily lengthy cases (cost outliers and day outliers, respectively). Beginning with FY 1995, section 1886(d)(5)(A) of the Act requires the Secretary to phase-out payments for day outliers. Under the [[Page 30022]] requirements of section 1886(d)(5)(A)(v), the proportion of day outlier payments to total outlier payments is reduced from FY 1994 levels as follows: 75 percent of FY 1994 levels in FY 1995, 50 percent of FY 1994 levels in FY 1996, and 25 percent of FY 1994 levels in FY 1997. For discharges occurring after September 30, 1997, the Secretary will no longer pay for day outliers under the provisions of section 1886(d)(5)(A)(I) of the Act. This reduction in day outlier payments will be offset by an increase in cost outlier payments. As discussed in the Addendum, for FY 1998, we are proposing that a case would receive cost outlier payments if its costs exceed the DRG amount plus $7,600. We are also proposing to maintain the marginal cost factor for cost outliers at 80 percent. The payment impacts of these changes are minimal. Hospital categories negatively affected by phasing-out day outliers are consistent with the categories negatively affected in previous years: urban Middle Atlantic census division (1.0 percent decline); urban hospitals with 500 or more beds (0.3 percent decline); teaching hospitals with 100 or more residents (0.6 percent decline); and hospitals for which data were unavailable to calculate Medicare utilization rates (1.5 percent decline). This last category contains a number of New York City public hospitals that file manual cost reports. Because the changes to the outlier policy result in a shift in payments from cases paid as day outliers to cases paid as cost outliers, this indicates that these categories have higher percentages of day outliers. G. Impact of MGCRB Reclassifications (Column 6) Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on bases other than where they are geographically located, such as hospitals in rural counties that are deemed urban under section 1886(d)(8)(B) of the Act). The changes in column 6 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 1998. As noted below, these decisions affect hospitals' standardized amount and wage index area assignments. In addition, rural hospitals reclassified for purposes of the standardized amount qualify to be treated as urban for purposes of the DSH adjustment. By March 30 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital's reclassification request for the purpose of using the other area's standardized amount, wage index value, or both. Effective FY 1997, rural hospitals can no longer be reclassified to an other urban area for purposes of the standardized amount under section 1886(d)(10) of the Act. The proposed FY 1998 wage index values incorporate all of the MGCRB's reclassification decisions for FY 1998. The wage index values also reflect any decisions made by the HCFA Administrator through the appeals and review process for MGCRB decisions as of March 29, 1997. Additional changes that result from the Administrator's review of MGCRB decisions or a request by a hospital to withdraw its application will be reflected in the final rule for FY 1998. The overall effect of geographic reclassification is required to be budget neutral by section 1886(d)(8)(D) of the Act. Therefore, we applied an adjustment of 0.995127 to ensure that the effects of reclassification are budget neutral. (See section II.A.4 of the Addendum to this proposed rule.) As a group, rural hospitals benefit from geographic reclassification. Their payments rise 2.1 percent, while payments to urban hospitals decline 0.4 percent. Large urban hospitals lose 0.4 percent because, as a group, they have the smallest percentage of hospitals that are reclassified (fewer than 2 percent of large urban hospitals are reclassified). There are enough hospitals in other urban areas that are reclassified to limit the decrease in payments to urban hospitals stemming from the budget neutrality offset to 0.3 percent. Among urban hospital groups generally (that is, bed size, census division, and special payment status), payments generally fall between 0.3 and 0.4 percent. Urban hospitals with 500 or more beds have the lowest decline, only 0.2 percent, owing to the reclassification of 9 hospitals within this category. A positive impact is evident among all rural hospital groups. The smallest effect among the rural census divisions is 1.1 percent for the Middle Atlantic division. The largest impacts are in rural Puerto Rico and the West South Central, with increases of 3.9 percent and 3.2 percent, respectively. Among rural hospitals designated as RRCs, 45 hospitals are reclassified for purposes of the wage index only, leading to the 5.1 percent increase in payments among RRCs overall. This positive impact on RRCs is also reflected in the category of rural hospitals with 200 or more beds, which has a 4.0 percent increase in payments. Rural hospitals reclassified for FY 1997 and FY 1998 experience an 8.5 percent increase in payments. This may be due to the fact that these hospitals have the most to gain from reclassification and have been reclassified for a period of years. Rural hospitals reclassified for FY 1998 only experience a 7.1 percent increase in payments, while rural hospitals reclassified for FY 1997 only experience a 0.1 decrease in payments. Urban hospitals reclassified for FY 1997 but not FY 1998 experience a 1.1 percent decline in payments overall. This appears to be due to the combined impacts of the budget neutrality adjustment, and a number of Bergen-Passaic, New Jersey hospitals in this category that experience a 4.5 percent drop in their wage index after reclassification. Urban hospitals reclassified for FY 1998 but not for FY 1997 experience a 1.0 percent increase in payments. The FY 1998 Reclassification rows of Table I show the changes in payments per case for all FY 1998 reclassified and nonreclassified hospitals in urban and rural locations for each of the three reclassification categories (standardized amount only, wage index only, or both). The table illustrates that the largest impact for reclassified rural hospitals is for those hospitals reclassified for both the standardized amount and the wage index. These hospitals receive a 14.7 percent increase in payments. In addition, rural hospitals reclassified just for the wage index receive an 8.6 percent payment increase. The overall impact on reclassified hospitals is to increase their payments per case by an average of 5.2 percent for FY 1998. Among the 27 rural hospitals deemed to be urban under section 1886(d)(8)(B) of the Act, payments increase 0.8 percent due to MGCRB reclassification. This is because, although these hospitals are treated as being attached to an urban area in our baseline (their redesignation is ongoing, rather than annual like the MGCRB reclassifications), they are eligible for MGCRB reclassification. For FY 1998, one hospital in this category reclassified to a large urban area. The reclassification of hospitals primarily affects payment to nonreclassified hospitals through changes in the wage index and the geographic reclassification budget neutrality adjustment required by section 1886(d)(8)(D) of the Act. Among hospitals that are not reclassified, the overall impact of hospital reclassifications is an average decrease in payments per case of about 0.5 percent, which corresponds closely with the geographic reclassification budget neutrality factor. Rural nonreclassified hospitals decrease slightly less, experiencing a 0.3 percent decrease. This occurs because the wage index values in some rural areas increase after reclassified hospitals are excluded from the calculation of those indexes. The number of reclassifications for purposes of the standardized amount, or for both the standardized amount and the wage index, has declined from 210 in FY 1997 to 149 in FY 1998. The number of wage index only reclassifications increased slightly from 274 in FY 1997 to 284 in FY 1998. The foregoing analysis was based on MGCRB and HCFA Administrator decisions made by March 29 of this year. As previously noted, there may be changes to some MGCRB decisions through the appeals, review, and applicant withdrawal process. The outcome of these cases will be reflected in the analysis presented in the final rule. H. All Changes (Column 7) Column 7 compares our estimate of payments per case, incorporating all changes reflected in this proposed rule for FY 1998 (including statutory changes), to our estimate of payments per case in FY 1997. It includes the effects of the 2.8 percent update to the standardized amounts and the hospital-specific rates for SCHs and EACHs, and reflects the 0.2 percentage point difference between the projected outlier payments in FY 1998 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 1997 (4.9 percent), as described in the introduction to this Appendix and the Addendum. We also note that column 7 includes the impacts of FY 1998 MGCRB reclassifications compared to the payment impacts of FY 1997 reclassifications. Column 6, however, shows [[Page 30023]] the impact of going from no MGCRB reclassifications to the FY 1998 reclassifications. Therefore, when comparing FY 1998 payments to FY 1997, the percent changes due to FY 1998 reclassifications shown in column 6 need to be offset by the effects of reclassification on hospitals' FY 1997 payments (column 4 of Table 1, September 1, 1996 final rule; 61 FR 46306). For example, the impact of MGCRB reclassifications on rural hospitals' FY 1997 payments was approximately a 2.3 percent increase, offsetting the 2.1 percent increase in column 6. Therefore, the net change in FY 1998 payments due to reclassification for rural hospitals is actually closer to a decrease of 0.2 percent relative to FY 1997. However, last year's analysis contained a somewhat different set of hospitals, so this might affect the numbers slightly. There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in column 7 may not equal the sum of the changes in columns 3 through 6, plus the other impacts that we are able to identify. The overall payment increase from FY 1998 to FY 1997 for all hospitals is a 3.0 percent increase. This reflects the 0.0 percent net change in total payments due to the proposed changes for FY 1998 shown in columns 3 through 6, the 2.8 percent update for FY 1998, and the 0.2 percent higher outlier payments in FY 1998 compared to FY 1997, as discussed above. Hospitals in urban areas experience a 3.0 percent rise in payments per case over FY 1997. Similar to all hospitals nationally, this is primarily due to the factors discussed above: the 2.8 percent update and a 0.2 percent higher level of outlier payments estimated for FY 1998. Urban hospitals lose 0.1 percent due to the phase-out of the day outlier policy. Their 0.4 negative impact in FY 1998 due to reclassification is offset by a similar impact from FY 1997 reclassifications. Hospitals in large and other urban areas experience 3.0 percent and 3.1 percent increases, respectively. Hospitals in rural areas experience a 3.2 percent increase. This larger increase for rural hospitals appears to be primarily attributable to RRCs experiencing a 3.8 percent increase in payments overall for FY 1998. The 45 RRCs that were reclassified for the wage index experience a 4.7 percent overall increase in payments from FY 1997 to FY 1998. Although a small number, they tend to be large hospitals and therefore have a disproportionate impact in the rural category. In fact, these 45 hospitals represented 7 percent of all rural discharges during FY 1996 (2 percent of all rural hospitals). Puerto Rico stands out as having large payment increases for FY 1998, with urban Puerto Rico hospitals' payments increasing by 9.4 percent, and rural Puerto Rico hospitals' payments increasing by 8.6 percent. As noted earlier, this is largely due to the proposed implementation of the Puerto Rico-specific wage index during FY 1998. Among other census divisions, urban East South Central displays the largest increase, 4.1 percent. This is related to the 0.8 percent increase due to the new wage data. Similarly, rural Pacific and rural East South Central display above average increases, 3.6 and 3.5 percent respectively. The smallest increase, on the other hand, occurs in urban New England, with a 2.4 percent payment increase. This also appears to be due to the updated wage data (the Boston wage index value declines by 1.5 percent). The only hospital groups with negative payment impacts from FY 1997 to FY 1998 are hospitals that were reclassified for FY 1997 and are not reclassified for FY 1998. Overall, these hospitals lose 0.3 percent. The urban hospitals in this category actually experience slight payment increases over FY 1997 (0.1 percent), while the rural hospitals lose 1.0 percent. On the other hand, hospitals reclassified for FY 1998 that were not reclassified for FY 1997 would experience the greatest payment increases: 11.0 percent for 77 rural hospitals in this category and 7.4 percent for 15 urban hospitals. Reclassification appears to be a significant factor influencing the payment increases for a number of rural hospital groups with above average overall payment increases in column 7. This impact is illustrated most clearly when one examines the rows categorizing hospitals by their reclassification status for FY 1998. All nonreclassified hospitals have an average payment increase of 2.9 percent. The average payment increase for all reclassified hospitals is 4.2 percent. Among SCH/EACHs, the payment increase is 2.8 percent. The primary reason for this below average increase is that there is minimal impact upon these hospitals from the higher estimated FY 1998 outlier payments. Because this hospital group receives their hospital-specific rate if the hospitals exceed the applicable Federal amount (including outliers), and the hospital-specific rate is not adjusted for outliers, there is less of an impact due to changes in outlier payment levels. Table II.--Impact Analysis of Changes for FY 1998 Operating Prospective Payment System [Payments per case] Average FY Average FY Number of 1997 1998 hospitals payment per payment per All changes \1\ case case (1) (2) (3) (4) ---------------------------------------------------------------------------------------------------------------- (By Geographic Location) ---------------------------------------------------------------------------------------------------------------- ALL HOSPITALS.............................................. 5,087 6,759 6,965 3.0 URBAN HOSPITALS........................................ 2,857 7,332 7,554 3.0 LARGE URBAN........................................ 1,580 7,884 8,117 3.0 OTHER URBAN........................................ 1,277 6,624 6,831 3.1 RURAL HOSPITALS........................................ 2,230 4,454 4,594 3.2 BED SIZE (URBAN): 0-99 BEDS.............................................. 720 4,916 5,059 2.9 100-199 BEDS........................................... 948 6,170 6,354 3.0 200-299 BEDS........................................... 568 6,878 7,092 3.1 300-499 BEDS........................................... 460 7,827 8,055 2.9 500 OR MORE BEDS....................................... 161 9,573 9,873 3.1 BED SIZE (RURAL): 0-49 BEDS.............................................. 1,173 3,650 3,763 3.1 50-99 BEDS............................................. 654 4,169 4,302 3.2 100-149 BEDS........................................... 237 4,623 4,768 3.1 150-199 BEDS........................................... 90 4,803 4,972 3.5 200 OR MORE BEDS....................................... 76 5,576 5,740 2.9 URBAN BY CENSUS DIVISION: NEW ENGLAND............................................ 159 7,851 8,039 2.4 MIDDLE ATLANTIC........................................ 431 8,113 8,335 2.7 SOUTH ATLANTIC......................................... 419 7,002 7,190 2.7 [[Page 30024]] EAST NORTH CENTRAL..................................... 474 7,037 7,279 3.4 EAST SOUTH CENTRAL..................................... 164 6,537 6,807 4.1 WEST NORTH CENTRAL..................................... 191 6,945 7,186 3.5 WEST SOUTH CENTRAL..................................... 367 6,815 7,009 2.8 MOUNTAIN............................................... 129 7,101 7,315 3.0 PACIFIC................................................ 475 8,406 8,648 2.9 PUERTO RICO............................................ 48 2,692 2,946 9.4 RURAL BY CENSUS DIVISION: NEW ENGLAND............................................ 53 5,270 5,456 3.5 MIDDLE ATLANTIC........................................ 85 4,745 4,871 2.7 SOUTH ATLANTIC......................................... 298 4,636 4,761 2.7 EAST NORTH CENTRAL..................................... 302 4,501 4,634 2.9 EAST SOUTH CENTRAL..................................... 275 4,125 4,274 3.6 WEST NORTH CENTRAL..................................... 512 4,148 4,284 3.3 WEST SOUTH CENTRAL..................................... 347 4,004 4,133 3.2 MOUNTAIN............................................... 212 4,779 4,947 3.5 PACIFIC................................................ 141 5,578 5,783 3.7 PUERTO RICO............................................ 5 2,074 2,253 8.6 ---------------------------------------------------------------------------------------------------------------- (By Payment Categories) ---------------------------------------------------------------------------------------------------------------- URBAN HOSPITALS............................................ 2,949 7,294 7,515 3.0 LARGE URBAN............................................ 1,733 7,738 7,970 3.0 OTHER URBAN............................................ 1,216 6,634 6,839 3.1 RURAL HOSPITALS............................................ 2,138 4,433 4,570 3.1 TEACHING STATUS: NON-TEACHING........................................... 3,996 5,492 5,662 3.1 FEWER THAN 100 RESIDENTS............................... 849 7,201 7,425 3.1 100 OR MORE RESIDENTS.................................. 242 11,006 11,321 2.9 DISPROPORTIONATE SHARE HOSPITALS (DSH): NON-DSH................................................ 3,186 5,806 5,991 3.2 URBAN DSH: 100 BEDS OR MORE................................... 1,403 7,970 8,203 2.9 FEWER THAN 100 BEDS................................ 91 5,110 5,260 2.9 RURAL DSH: SOLE COMMUNITY (SCH)............................... 153 4,386 4,513 2.9 REFERRAL CENTERS (RRC)............................. 35 5,391 5,576 3.4 OTHER RURAL DSH: 100 BEDS OR MORE................................... 79 4,311 4,431 2.8 FEWER THAN 100 BEDS................................ 140 3,592 3,730 3.8 (1) (2) (3) (4) ---------------------------------------------------------------------------------------------------------------- URBAN TEACHING AND DSH: BOTH TEACHING AND DSH.............................. 703 8,953 9,210 2.9 TEACHING AND NO DSH................................ 333 7,395 7,641 3.3 NO TEACHING AND DSH................................ 791 6,393 6,587 3.0 NO TEACHING AND NO DSH............................. 1,122 5,675 5,853 3.1 RURAL HOSPITAL TYPES: NONSPECIAL STATUS HOSPITALS........................ 1,351 4,001 4,121 3.0 RRC................................................ 95 5,382 5,586 3.8 SCH/EACH........................................... 651 4,555 4,683 2.8 SCH/EACH and RRC................................... 41 5,463 5,609 2.7 TYPE OF OWNERSHIP: VOLUNTARY.............................................. 2,915 6,932 7,143 3.0 PROPRIETARY............................................ 688 6,143 6,315 2.8 GOVERNMENT............................................. 1,346 6,283 6,490 3.3 UNKNOWN................................................ 138 7,582 7,743 2.1 MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS: 0--25.................................................. 266 8,849 9,066 2.5 25--50................................................. 1,300 8,227 8,475 3.0 50--65................................................. 1,985 6,183 6,382 3.2 OVER 65................................................ 1,397 5,251 5,402 2.9 UNKNOWN................................................ 138 7,582 7,743 2.1 ---------------------------------------------------------------------------------------------------------------- [[Page 30025]] Hospitals Reclassified by the Medicare Geographic Review Board ---------------------------------------------------------------------------------------------------------------- RECLASSIFICATION STATUS DURING FY 97 AND FY 98: RECLASSIFIED DURING BOTH FY 97 AND FY 98............... 340 6,123 6,328 3.3 URBAN.............................................. 102 7,231 7,490 3.6 RURAL.............................................. 238 5,248 5,410 3.1 RECLASSIFIED DURING FY 98 ONLY......................... 92 5,843 6,372 9.0 URBAN.............................................. 15 7,940 8,526 7.4 RURAL.............................................. 77 4,384 4,872 11.1 RECLASSIFIED DURING FY 97 ONLY: URBAN.............................................. 203 6,063 6,045 -0.3 RURAL.............................................. 88 7,054 7,062 0.1 FY 98 RECLASSIFICATIONS................................ 115 4,738 4,685 -1.1 ALL RECLASSIFIED HOSPITALS......................... 433 6,077 6,334 4.2 STANDARD AMOUNT ONLY........................... 96 5,927 6,120 3.3 WAGE INDEX ONLY................................ 284 6,085 6,360 4.5 BOTH........................................... 53 6,251 6,539 4.6 NONRECLASSIFIED................................ 4,627 6,836 7,037 2.9 ALL URBAN RECLASSIFIED............................. 117 7,340 7,650 4.2 STANDARD AMOUNT ONLY........................... 45 6,449 6,659 3.3 WAGE INDEX ONLY................................ 33 9,513 9,996 5.1 BOTH........................................... 39 6,457 6,731 4.2 NONRECLASSIFIED................................ 2,740 7,332 7,549 3.0 ALL RURAL RECLASSIFIED............................. 316 5,100 5,317 4.3 STANDARD AMOUNT ONLY........................... 51 4,505 4,651 3.2 WAGE INDEX ONLY................................ 251 5,163 5,381 4.2 BOTH........................................... 14 5,337 5,683 6.5 NONRECLASSIFIED................................ 1,887 4,216 4,329 2.7 OTHER RECLASSIFIED: HOSPITALS (SECTION 1886(d)(8)(B)).............. 27 4,740 4,902 3.4 ---------------------------------------------------------------------------------------------------------------- \1\ These payment amounts per case do not reflect any estimates of annual case-mix increase. Table II presents the projected impact of the proposed changes for FY 1998 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the projected payments per case for FY 1998 with the average estimated per case payments for FY 1997, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the changes presented in Table I. The percentage changes shown in the last column of Table II equal the percentage changes in average payments from column 7 of Table I. VII. Impact of Proposed Changes in the Capital Prospective Payment System A. General Considerations We now have data that were unavailable in previous impact analyses for the capital prospective payment system. Specifically, we have cost report data for the fourth year of the capital prospective payment system (cost reports beginning in FY 1995) available through the December 1996 update of the Health Care Provider Cost Report Information System (HCRIS). We also have updated information on the projected aggregate amount of obligated capital approved by the fiscal intermediaries. However, our impact analysis of payment changes for capital-related costs is still limited by the lack of hospital-specific data on several items. These are the hospital's projected new capital costs for each year, its projected old capital costs for each year, and the actual amounts of obligated capital that will be put in use for patient care and recognized as Medicare old capital costs in each year. The lack of this information affects our impact analysis in the following ways: Major investment in hospital capital assets (for example in building and major fixed equipment) occurs at irregular intervals. As a result, there can be significant variation in the growth rates of Medicare capital-related costs per case among hospitals. We do not have the necessary hospital-specific budget data to project the hospital capital growth rate for individual hospitals. Moreover, our policy of recognizing certain obligated capital as old capital makes it difficult to project future capital- related costs for individual hospitals. Under Sec. 412.302(c), a hospital is required to notify its intermediary that it has obligated capital by the later of October 1, 1992, or 90 days after the beginning of the hospital's first cost reporting period under the capital prospective payment system. The intermediary must then notify the hospital of its determination whether the criteria for recognition of obligated capital have been met by the later of the end of the hospital's first cost reporting period subject to the capital prospective payment system or 9 months after the receipt of the hospital's notification. The amount that is recognized as old capital is limited to the lesser of the actual allowable costs when the asset is put in use for patient care or the estimated costs of the capital expenditure at the time it was obligated. We have substantial information regarding intermediary determinations of projected aggregate obligated capital amounts. However, we still do not know when these projects will actually be put into use for patient care, the actual amount that will be recognized as obligated capital when the project is put into use, or the Medicare share of the recognized costs. Therefore, we do not know actual obligated capital commitments for purposes of the FY 1998 capital cost projections. We discuss in Appendix B the assumptions and computations we employ to generate the amount of obligated capital commitments for use in the FY 1998 capital cost projections. In Table III of this appendix, we present the redistributive effects that are expected to occur between ``hold-harmless'' hospitals and ``fully prospective'' hospitals in FY 1998. In addition, we have integrated sufficient hospital-specific information into our actuarial model to project the impact of the [[Page 30026]] proposed FY 1998 capital payment policies by the standard prospective payment system hospital groupings. We caution that while we now have actual information on the effects of the transition payment methodology and interim payments under the capital prospective payment system and cost report data for most hospitals, we need to randomly generate numbers for the change in old capital costs, new capital costs for each year, and obligated amounts that will be put in use for patient care services and recognized as old capital each year. We continue to be unable to predict accurately FY 1998 capital costs for individual hospitals, but with the more recent data on the experience to date under the capital prospective payment system, there is adequate information to estimate the aggregate impact on most hospital groupings. We present the transition payment methodology by hospital grouping in Table IV. In Table V we present the results of the cross-sectional analysis using the results of our actuarial model. This table presents the aggregate impact of the FY 1998 payment policies. B. Projected Impact Based on the Proposed FY 1998 Actuarial Model 1. Assumptions In this impact analysis, we model dynamically the impact of the capital prospective payment system from FY 1997 to FY 1998 using a capital cost model. The FY 1998 model, described in Appendix B of this proposed rule, integrates actual data from individual hospitals with randomly generated capital cost amounts. We have capital cost data from cost reports beginning in FY 1989 through FY 1995 received through the December 1996 update of HCRIS, interim payment data for hospitals already receiving capital prospective payments through PRICER, and data reported by the intermediaries that include the hospital-specific rate determinations that have been made through January 1, 1997 in the provider-specific file. We used these data to determine the proposed FY 1998 capital rates. However, we do not have individual hospital data on old capital changes, new capital formation, and actual obligated capital costs. We have data on costs for capital in use in FY 1993, and we age that capital by a formula described in Appendix B. We therefore need to randomly generate only new capital acquisitions for any year after FY 1993. All Federal rate payment parameters are assigned to the applicable hospital. Recently available cost report data indicate that old capital costs are declining faster than we previously projected. Consequently, for FY 1998 we are projecting faster declines in old capital. To make up for the larger declines in old capital, we are projecting faster growth in new capital. The combination of these two factors will make the 100-percent Federal rate higher than the hold-harmless rate for some hold-harmless hospitals. Therefore, we are now projecting that more hospitals will move to the 100-percent Federal rate than previously projected. For purposes of this impact analysis, the FY 1998 actuarial model includes the following assumptions: Medicare inpatient capital costs per discharge will increase at the following rates during these periods: ------------------------------------------------------------------------ Average percentage increase in capital costs per discharge ------------------------------------------------------------------------- Percentage Fiscal year increase ------------------------------------------------------------------------ 1996........................................................ 3.84 1997........................................................ 4.46 1998........................................................ 4.50 ------------------------------------------------------------------------ The Medicare case-mix index will increase by 1.0 percent in FY 1997 and FY 1998. The Federal capital rate and hospital-specific rate were updated in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs, and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. The proposed FY 1998 update for inflation is 1.10 percent (see section III of the Addendum). 2. Results We have used the actuarial model to estimate the change in payment for capital-related costs from FY 1997 to FY 1998. Table III shows the effect of the capital prospective payment system on low capital cost hospitals and high capital cost hospitals. We consider a hospital to be a low capital cost hospital if, based on a comparison of its initial hospital-specific rate and the applicable Federal rate, it will be paid under the fully prospective payment methodology. A high capital cost hospital is a hospital that, based on its initial hospital-specific rate, will be paid under the hold- harmless payment methodology. Based on our actuarial model, the breakdown of hospitals is as follows: Capital Transition Payment Methodology ---------------------------------------------------------------------------------------------------------------- FY 1998 FY 1998 Percent of FY 1998 percent of percent of Type of hospital hospitals percent of capital capital discharges costs payments ---------------------------------------------------------------------------------------------------------------- Low Cost Hospital........................................... 66 62 58 59 High Cost Hospital.......................................... 34 38 42 41 ---------------------------------------------------------------------------------------------------------------- A low capital cost hospital may request to have its hospital- specific rate redetermined based on old capital costs in the current year, through the later of the hospital's cost reporting period beginning in FY 1994 or the first cost reporting period beginning after obligated capital comes into use (within the limits established in Sec. 412.302(e) for putting obligated capital in use for patient care). If the redetermined hospital-specific rate is greater than the adjusted Federal rate, these hospitals will be paid under the hold-harmless payment methodology. Regardless of whether the hospital became a hold-harmless payment hospital as a result of a redetermination, we have continued to show these hospitals as low capital cost hospitals in Table III. Assuming no behavioral changes in capital expenditures, Table III displays the percentage change in payments from FY 1997 to FY 1998 using the above described actuarial model. With the proposed Federal rate, we estimate aggregate Medicare capital payments will increase by 7.19 percent in FY 1998. Table III.--Impact of Proposed Changes for FY 1998 on Payments per Discharge [FY 1997 payments per discharge] -------------------------------------------------------------------------------------------------------------------------------------------------------- Adjusted Average Hospital Hold Number of Discharges Federal Federal specific harmless Exceptions Total hospitals payment percent payment payment payment payment -------------------------------------------------------------------------------------------------------------------------------------------------------- Low Cost Hospitals........................................ 3,330 6,844,215 $469.21 63.86 $134.59 $2.72 $56.19 $662.70 Fully Prospective..................................... 3,068 6,162,124 439.28 60.00 149.48 ......... 60.85 649.61 100% Federal Rate..................................... 251 658,508 756.30 100.00 ......... ......... 13.60 769.90 Hold Harmless......................................... 11 23,583 274.74 33.13 ......... 789.18 27.68 1,091.61 High Cost Hospitals....................................... 1,684 4,194,629 745.99 98.04 ......... 20.38 24.58 790.95 [[Page 30027]] 100% Federal Rate..................................... 1,590 4,037,189 760.08 100.00 ......... ......... 24.02 784.10 Hold Harmless......................................... 94 157,441 384.62 49.19 ......... 542.92 39.14 966.68 Total Hospitals................................... 5,014 11,038,844 574.38 77.13 83.44 9.43 44.18 711.44 -------------------------------------------------------------------------------------------------------------------------------------------------------- [FY 1998 payments per discharge] -------------------------------------------------------------------------------------------------------------------------------------------------------- Adjusted Average Hospital Hold Number of Discharges Federal Federal specific harmless Exceptions Total Percent hospitals payment percent payment payment payment payment change -------------------------------------------------------------------------------------------------------------------------------------------------------- Low Cost Hospitals............................. 3,330 7,007,946 $541.97 72.94 $101.16 $1.65 $63.03 $707.81 6.81 Fully Prospective.......................... 3,068 6,309,538 518.20 70.00 112.35 ......... 67.55 698.11 7.47 100% Federal Rate.......................... 254 685,995 763.67 100.00 ......... ......... 21.61 785.29 2.00 Hold Harmless.............................. 8 12,413 371.31 36.27 ......... 931.58 56.43 1,359.32 24.52 High Cost Hospitals............................ 1,684 4,294,976 767.03 99.15 ......... 9.38 28.59 804.99 1.77 100% Federal Rate.......................... 1,618 4,201,847 775.10 100.00 ......... ......... 28.26 803.36 2.46 Hold Harmless.............................. 66 93,129 402.78 57.09 ......... 432.39 43.27 878.44 -9.13 Total Hospitals........................ 5,014 11,302,922 627.49 83.15 62.72 4.59 49.94 744.74 4.68 -------------------------------------------------------------------------------------------------------------------------------------------------------- We project that low capital cost hospitals paid under the fully prospective payment methodology will experience an average increase in payments per case of 6.81 percent, and high capital cost hospitals will experience an average increase of 1.77 percent. For hospitals paid under the fully prospective payment methodology, the Federal rate payment percentage will increase from 60 percent to 70 percent and the hospital-specific rate payment percentage will decrease from 40 to 30 percent in FY 1998. The Federal rate payment percentage for hospitals paid under the hold- harmless payment methodology is based on the hospital's ratio of new capital costs to total capital costs. The average Federal rate payment percentage for high cost hospitals receiving a hold-harmless payment for old capital will increase from 49.19 percent to 57.09 percent. We estimate the percentage of hold-harmless hospitals paid based on 100 percent of the Federal rate will increase from 94.6 percent to 96.2 percent. We expect that the average hospital-specific rate payment per discharge will decrease from $83.44 in FY 1997 to $62.72 in FY 1998. This is partly due to the decrease in the hospital-specific rate payment percentage from 40 percent in FY 1997 to 30 percent in FY 1998. We are proposing no changes in our exceptions policies for FY 1998. As a result, the minimum payment levels would be: 90 percent for sole community hospitals; 80 percent for urban hospitals with 100 or more beds and a disproportionate share patient percentage of 20.2 percent or more; or, 70 percent for all other hospitals. We estimate that exceptions payments will increase from 6.21 percent of total capital payments in FY 1997 to 6.71 percent of payments in FY 1998. The number and amount of exceptions payments is expected to increase throughout the transition period. The projected distribution of the payments is shown in the table below: Estimated FY 1998 Exceptions Payments ------------------------------------------------------------------------ Percent of Type of hospital No. of exceptions hospitals payments ------------------------------------------------------------------------ Low Capital Cost................................. 332 78 High Capital Cost................................ 183 22 ---------------------- Total........................................ 515 100 ------------------------------------------------------------------------ C. Cross-Sectional Comparison of Capital Prospective Payment Methodologies Table IV presents a cross-sectional summary of hospital groupings by capital prospective payment methodology. This distribution is generated by our actuarial model. Table IV.--Distribution by Method of Payment (Hold-Harmless/Fully Prospective) of Hospitals Receiving Capital Payments ---------------------------------------------------------------------------------------------------------------- (2) Hold-harmless -------------------------------- (3) Percentage (1) Total No. Percentage Percentage paid full of hospitals paid hold- paid full Prospective harmless (A) federal (B) rate ---------------------------------------------------------------------------------------------------------------- By Geographic Location: All hospitals............................. 5,014 1.5 37.3 61.2 Large urban areas (populations over 1 million)................................. 1,543 1.7 45.4 52.9 Other urban areas (populations of 1 million or fewer)........................ 1,254 1.6 45.7 52.7 Rural areas............................... 2,217 1.3 27.0 71.8 Urban hospitals........................... 2,797 1.6 45.5 52.8 0-99 beds............................. 671 2.4 39.5 58.1 100-199 beds.......................... 938 2.3 52.1 45.5 200-299 beds.......................... 567 0.9 46.9 52.2 300-499 beds.......................... 460 0.4 40.9 58.7 500 or more beds...................... 161 0.6 41.0 58.4 Rural hospitals........................... 2,217 1.3 27.0 71.8 0-49 beds............................. 1,162 1.2 18.9 79.9 [[Page 30028]] 50-99 beds............................ 652 1.8 32.2 66.0 100-149 beds.......................... 237 0.8 42.2 57.0 150-199 beds.......................... 90 0.0 32.2 67.8 200 or more beds...................... 76 0.0 51.3 48.7 By Region Urban by Region........................... 2,797 1.6 45.5 52.8 New England........................... 158 0.0 27.8 72.2 Middle Atlantic....................... 426 1.4 38.0 60.6 South Atlantic........................ 413 1.9 57.4 40.7 East North Central.................... 471 0.6 36.7 62.6 East South Central.................... 160 0.6 58.8 40.6 West North Central.................... 188 1.6 41.0 57.4 West South Central.................... 344 3.5 64.8 31.7 Mountain.............................. 123 3.3 52.0 44.7 Pacific............................... 466 1.9 39.9 58.2 Puerto Rico........................... 48 0.0 29.2 70.8 Rural by Region........................... 2,217 1.3 27.0 71.8 New England........................... 53 0.0 22.6 77.4 Middle Atlantic....................... 84 2.4 28.6 69.0 South Atlantic........................ 294 1.0 34.4 64.6 East North Central.................... 301 0.0 23.3 76.7 East South Central.................... 273 0.4 37.0 62.6 West North Central.................... 511 1.0 19.8 79.3 West South Central.................... 345 1.4 29.9 68.7 Mountain.............................. 211 5.2 21.8 73.0 Pacific............................... 140 0.7 27.9 71.4 Large urban areas (populations over 1 million) 1,695 1.7 45.0 53.3 Other urban areas (populations of 1 million or fewer)....................................... 1,193 1.5 45.3 53.2 Rural areas................................... 2,126 1.3 26.8 71.9 Teaching Status: Non-teaching.............................. 3,925 1.5 37.2 61.3 Fewer than 100 Residents.................. 848 1.5 39.4 59.1 100 or more Residents..................... 241 0.8 32.8 66.4 Disproportionate share hospitals (DSH): Non-DSH................................... 3,128 1.6 33.7 64.7 Urban DSH: 100 or more beds...................... 1,397 1.1 47.7 51.2 Less than 100 beds.................... 85 2.4 31.8 65.9 Rural DSH: Sole Community (SCH/EACH)............. 153 3.9 22.2 73.9 Referral Center (RRC/EACH)............ 35 0.0 51.4 48.6 Other Rural: 100 or more beds...................... 79 0.0 48.1 51.9 Less than 100 beds.................... 137 0.0 26.3 73.7 Urban teaching and DSH: Both teaching and DSH..................... 702 1.0 38.7 60.3 Teaching and no DSH....................... 332 2.4 35.8 61.7 No teaching and DSH....................... 780 1.4 54.0 44.6 No teaching and no DSH.................... 1,074 1.9 45.7 52.4 Rural Hospital Types: Non special status hospitals.............. 1,340 0.4 25.9 73.7 RRC/EACH.................................. 95 0.0 43.2 56.8 SCH/EACH.................................. 650 3.5 25.2 71.2 SCH, RRC and EACH......................... 41 0.0 41.5 58.5 Type of Ownership: Voluntary................................. Voluntary............................. 2,997 1.2 36.9 61.9 Proprietary........................... 673 3.4 65.7 30.9 Government............................ 1,344 1.0 24.1 74.9 Medicare Utilization as a Percent of Inpatient Days: 0-25...................................... 254 3.1 33.9 63.0 25-50..................................... 1,293 1.9 44.4 53.7 50-65..................................... 1,980 1.2 37.9 61.0 Over 65................................... 1,391 1.2 30.2 68.6 ---------------------------------------------------------------------------------------------------------------- [[Page 30029]] As we explain in Appendix B, we were not able to determine a hospital-specific rate for 73 of the 5,087 hospitals in our database. Consequently, the payment methodology distribution is based on 5,014 hospitals. These data should be fully representative of the payment methodologies that will be applicable to hospitals. The cross-sectional distribution of hospital by payment methodology is presented by: (1) Geographic location, (2) region, and (3) payment classification. This provides an indication of the percentage of hospitals within a particular hospital grouping that will be paid under the fully prospective payment methodology and under the hold-harmless methodology. The percentage of hospitals paid fully Federal (100 percent of the Federal rate) as hold-harmless hospitals is expected to increase to 37.3 percent in FY 1998. Table IV indicates that 61.2 percent of hospitals will be paid under the fully prospective payment methodology. (This figure, unlike the figure of 66 percent for low cost capital hospitals in the previous section, takes account of the effects of redeterminations. In other words, this figure does not include low cost hospitals that, following a hospital-specific rate redetermination, are now paid under the hold-harmless methodology.) As expected, a relatively higher percentage of rural and governmental hospitals (71.8 percent and 74.9 percent, respectively by payment classification) are being paid under the fully prospective methodology. This is a reflection of their lower than average capital costs per case. In contrast, only 30.9 percent of proprietary hospitals are being paid under the fully prospective methodology. This is a reflection of their higher than average capital costs per case. (We found at the time of the August 30, 1991 final rule (56 FR 43430) that 62.7 percent of proprietary hospitals had a capital cost per case above the national average cost per case.) D. Cross-Sectional Analysis of Changes in Aggregate Payments We used our FY 1998 actuarial model to estimate the potential impact of our proposed changes for FY 1998 on total capital payments per case, using a universe of 5,014 hospitals. The individual hospital payment parameters are taken from the best available data, including: the January 1, 1997 update to the provider-specific file, cost report data, and audit information supplied by intermediaries. Table V presents estimates of payments per case under our model for FY 1997 and FY 1998 (columns 2 and 3). Column 4 shows the total percentage change in payments from FY 1997 to FY 1998. Column 5 presents the percentage change in payments that can be attributed to Federal rate changes alone. Federal rate changes represented in Column 5 include the 0.11 percent decrease in the Federal rate, a 1.0 percent increase in case mix, changes in the adjustments to the Federal rate (for example, the effect of the new hospital wage index on the geographic adjustment factor), and reclassifications by the MGCRB. Column 4 includes the effects of the Federal rate changes represented in column 3. Column 4 also reflects the effects of all other changes, including: the change from 60 percent to 70 percent in the portion of the Federal rate for fully prospective hospitals, the hospital- specific rate update, changes in the proportion of new to total capital for hold-harmless hospitals, changes in old capital (for example, obligated capital put in use), hospital-specific rate redeterminations, and exceptions. The comparisons are provided by: (1) geographic location, (2) region, and (3) payment classification. The simulation results show that, on average, capital payments per case can be expected to increase 4.7 percent in FY 1998. The results show that the effect of the Federal rate changes alone is to increase payments by 1.1 percent. In addition to the increase attributable to the Federal rate changes, a 3.6 percent increase is attributable to the effects of all other changes. Our comparison by geographic location shows that capital payments per case to urban and rural hospitals experience similar rates of increase (4.7 percent and 4.4 percent, respectively). Payments per case for urban hospitals will increase at about the same rate as payments per case for rural hospitals (1.2 percent and 0.9 percent, respectively) from the Federal rate changes alone. Urban hospitals will gain the same as rural hospitals (3.5 percent) from the effects of all other changes. By region, there is relatively little variation compared to some previous years. All regions are estimated to receive increases in total capital payments per case, partly due to the increased share of payments that is based on the Federal rate (from 60 to 70 percent). Changes by region vary from a low of 0.7 percent increase (Mountain urban region) to a high of 10.3 percent increase (rural hospitals of the Mountain region). By type of ownership, government hospitals are projected to have the largest rate of increase (5.3 percent, 1.1 percent due to Federal rate changes and 4.2 percent from the effects of all other changes). Payments to voluntary hospitals will increase 4.9 percent (a 1.1 percent increase due to Federal rate changes and a 3.8 percent increase from the effects of all other changes) and payments to proprietary hospitals will increase 2.3 percent (a 1.2 percent increase due to Federal rate changes and a 1.1 percent increase from the effects of all other changes). Section 1886(d)(10) of the Act established the MGCRB. Hospitals may apply for reclassification for purposes of the standardized amount, wage index, or both. Although the Federal capital rate is not affected, a hospital's geographic classification for purposes of the operating standardized amount does affect a hospital's capital payments as a result of the large urban adjustment factor and the disproportionate share adjustment for urban hospitals with 100 or more beds. Reclassification for wage index purposes affects the geographic adjustment factor since that factor is constructed from the hospital wage index. To present the effects of the hospitals being reclassified for FY 1998 compared to the effects of reclassification for FY 1997, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. For FY 1998 reclassifications, we indicate those hospitals reclassified for standardized amount purposes only, for wage index purposes only, and for both purposes. The reclassified groups are compared to all other nonreclassified hospitals. These categories are further identified by urban and rural designation. Hospitals reclassified for FY 1998 as a whole are projected to experience a 5.3 percent increase in payments (a 2.0 percent increase attributable to Federal rate changes and a 3.3 percent increase attributable to the effects of all other changes). Payments to nonreclassified hospitals will increase slightly less (4.8 percent) than reclassified hospitals (5.3 percent) overall. Payments to nonreclassified hospitals will increase slightly less than reclassified hospitals from the Federal rate changes (1.2 percent compared to 2.0 percent), but they will gain about the same from the effects of all other changes (3.6 percent compared to 3.3 percent). Table V.--Comparison of Total Payments Per Case [FY 1997 Payments Compared To FY 1998 Payments] ---------------------------------------------------------------------------------------------------------------- Average FY Average FY Portion Number of 1997 1998 attributable hospitals payments/ payments/ All changes to Federal case case rate change ---------------------------------------------------------------------------------------------------------------- By Geographic Location: All hospitals............................. 5,014 711 745 4.7 1.1 Large urban areas (populations over 1 million)................................. 1,543 798 835 4.6 1.1 Other urban areas (populations of 1 million or fewer)........................ 1,254 682 716 5.0 1.2 Rural areas............................... 2,217 567 592 4.4 0.9 Urban hospitals........................... 2,797 747 782 4.7 1.2 0-99 beds............................. 671 611 640 4.7 0.9 [[Page 30030]] 100-199 beds.......................... 938 675 701 3.7 1.1 200-299 beds.......................... 567 723 753 4.2 1.2 300-499 beds.......................... 460 754 795 5.4 1.1 500 or more beds...................... 161 914 963 5.5 1.4 Rural hospitals........................... 2,217 567 592 4.4 0.9 0-49 beds............................. 1,162 412 447 8.6 0.8 50-99 beds............................ 652 438 461 5.2 1.2 100-149 beds.......................... 237 547 566 3.5 1.1 150-199 beds.......................... 90 494 518 5.0 1.5 200 or more beds...................... 76 1,116 1,140 2.2 0.5 By Region: Urban by Region........................... 2,797 747 782 4.7 1.2 New England........................... 158 734 772 5.1 0.6 Middle Atlantic....................... 426 821 861 4.8 0.9 South Atlantic........................ 413 726 757 4.3 1.0 East North Central.................... 471 690 725 5.1 1.3 East South Central.................... 160 671 714 6.4 2.4 West North Central.................... 188 774 824 6.4 1.4 West South Central.................... 344 736 759 3.1 1.4 Mountain.............................. 123 827 832 0.7 0.9 Pacific............................... 466 812 856 5.4 1.1 Puerto Rico........................... 48 298 309 3.7 1.2 Rural by Region........................... 2,217 567 592 4.4 0.9 New England........................... 53 541 575 6.3 1.8 Middle Atlantic....................... 84 481 494 2.9 0.6 South Atlantic........................ 294 897 919 2.6 0.3 East North Central.................... 301 462 491 6.1 1.0 East South Central.................... 273 427 449 5.0 1.7 West North Central.................... 511 536 556 3.8 1.1 West South Central.................... 345 454 474 4.3 1.2 Mountain.............................. 211 554 611 10.3 1.7 Pacific............................... 140 535 574 7.4 1.4 By Payment Classification: All hospitals............................. 5,014 711 745 4.7 1.1 Large urban areas (populations over 1 million)................................. 1,695 786 822 4.6 1.1 Other urban areas (populations of 1 million or fewer)........................ 1,193 682 716 5.0 1.2 Rural areas............................... 2,126 568 593 4.3 0.9 Teaching Status: Non-teaching.......................... 3,925 624 649 4.0 1.1 Fewer than 100 Residents.............. 848 756 796 5.3 1.1 100 or more Residents................. 241 969 1,021 5.4 1.1 Urban DSH: 100 or more beds.................. 1,397 773 811 4.9 1.1 Less than 100 beds................ 85 579 626 8.2 1.2 Rural DSH: Sole Community (SCH/EACH)......... 153 421 448 6.3 0.7 Referral Center (RRC/EACH)........ 35 1,932 1,964 1.7 0.4 Other Rural: 100 or more beds.................. 79 462 474 2.6 1.1 Less than 100 beds................ 137 446 470 5.5 1.5 Urban teaching and DSH: Both teaching and DSH..................... 702 838 882 5.2 1.1 Teaching and no DSH....................... 332 792 837 5.7 1.2 No teaching and DSH....................... 780 669 697 4.2 1.2 No teaching and no DSH.................... 1,074 644 667 3.5 1.2 Rural Hospital Types: Non special status hospitals.............. 1,340 431 451 4.6 0.9 RRC/EACH.................................. 95 664 693 4.5 1.2 SCH/EACH.................................. 650 465 499 7.4 1.1 SCH, RRC and EACH......................... 41 1,868 1,888 1.1 0.4 Hospitals Reclassified by the Medicare Geographic Classification Review Board: Reclassification Status During FY97 and FY98: Reclassified During Both FY97 and FY98 340 673 704 4.5 1.2 Reclassified During FY98 Only......... 92 581 639 10.0 6.7 Reclassified During FY97 Only......... 172 618 622 0.6 -2.0 FY98 Reclassifications: All Reclassified Hospitals............ 432 658 693 5.3 2.0 [[Page 30031]] All Nonreclassified Hospitals......... 4,510 719 753 4.8 1.2 All Urban Reclassified Hospitals...... 117 726 764 5.2 1.8 Urban Nonreclassified Hospitals....... 2,680 748 783 4.7 1.1 All Reclassified Rural Hospitals...... 315 605 638 5.5 2.1 Rural Nonreclassified Hospitals....... 1,875 555 577 4.0 0.5 Other Reclassified Hospitals (Section 1886(D)(8)(B))........................... 27 512 531 3.8 1.6 Type of Ownership: Voluntary................................. 2,997 715 751 4.9 1.1 Proprietary............................... 673 685 701 2.3 1.2 Government................................ 1,344 712 749 5.3 1.1 Medicare Utilization as a percent of Inpatient Days: 0-25...................................... 254 768 832 8.4 0.5 25-50..................................... 1,293 808 841 4.0 1.2 50-65..................................... 1,980 690 724 5.0 1.1 Over 65................................... 1,391 593 617 4.2 1.0 ---------------------------------------------------------------------------------------------------------------- Appendix B: Technical Appendix on the New Capital Cost Model and Required Adjustments Under section 1886(g)(1)(A) of the Act, we set capital prospective payment rates for FY 1992 through FY 1995 so that aggregate prospective payments for capital costs were projected to be 10 percent lower than the amount that would have been payable on a reasonable cost basis for capital-related costs in that year. To implement this requirement, we developed the capital acquisition model to determine the budget neutrality adjustment factor. Even though the budget neutrality requirement expired effective with FY 1996, we must continue to determine the recalibration and geographic reclassification budget neutrality adjustment factor, and the reduction in the Federal and hospital-specific rates for exceptions payments. To determine these factors, we must continue to project capital costs and payments. We have used the capital acquisition model since the start of prospective payments for capital costs. We now have 4 years of cost reports under the capital prospective payment system. Consequently, we have developed a new capital cost model to replace the capital acquisition model. This new model makes use of the data from these cost reports. The following cost reports are used in the capital cost model for this proposed rule: the December 31, 1996 update of the cost reports for PPS-IX (cost reporting periods beginning in FY 1992), PPS-X (cost reporting periods beginning in FY 1993), PPS-XI (cost reporting periods beginning in FY 1994), and PPS-XII (cost reporting periods beginning in FY 1995). In addition to model payments, we use the January 1, 1997 update of the provider-specific file, and the March 1994 update of the intermediary audit file. Since hospitals under alternative payment system waivers (that is, hospitals in Maryland) are currently excluded from the capital prospective payment system, we excluded these hospitals from our model. We developed FY 1992, FY 1993, FY 1994, FY 1995, FY 1996, and FY 1997 hospital-specific rates using the provider-specific file and the intermediary audit file. (We used the cumulative provider- specific file, which includes all updates to each hospital's records, and chose the latest record for each fiscal year.) We checked the consistency between the provider-specific file and the intermediary audit file. We ensured that increases in the hospital- specific rates were at least as large as the published updates (increases) for the hospital-specific rates each year. We were able to match hospitals to the files as shown in the following table: ------------------------------------------------------------------------ Number of Source hospitals ------------------------------------------------------------------------ Provider-Specific File Only................................ 115 Provider-Specific and Audit File........................... 4,972 ------------ Total.................................................. 5,087 ------------------------------------------------------------------------ Ninety-six of the 5,087 hospitals had unusable or missing data or had no cost reports available. We determined from the cost reports that 23 of the 96 hospitals were paid under the hold- harmless methodology. Since the hospital-specific amount is not used to determine payments for these hospitals, we were able to include these 23 hospitals in the analysis. Seventy-three hospitals could not be used in the analysis because of insufficient information. They account for less than 0.3 percent of admissions so any effect should be minimal. Therefore, we used data from cost reports from 5,014 hospitals for the analysis. We analyzed changes in capital-related costs (depreciation, interest, rent, leases, insurance, and taxes) reported in the cost reports. We found a wide variance among hospitals in the growth of these costs. For hospitals with more than 100 beds, the distribution and mean of these cost increases were different for large (greater than 20 percent) changes in bed-size. We also analyzed changes in the growth in old capital and new capital for cost reports that provided this information. For old capital, we limited the analysis only for decreases in old capital. We did this since the opportunity for most hospitals to treat ``obligated'' capital put into service as old capital has expired. Old capital costs should, therefore, decrease as assets become fully depreciated, and interest costs decrease as the loan is amortized. The new capital cost model separates the hospitals into three mutually exclusive groups. Hold-harmless hospitals with data on old capital were placed in the first group. Of the remaining hospitals, those hospitals with fewer than 100 beds comprise the second group. The third group consists of all hospitals that did not fit into either of the first two groups. Each of these groups displayed unique patterns of growth in capital costs. We found that the gamma distribution is useful in explaining and describing the patterns of increase in capital costs. A gamma distribution is a statistical distribution that can be used to describe patterns of growth rates, with greatest proportion of rates being at the low end. We use the gamma distribution to estimate individual hospital rates of increase. (1) For hold-harmless hospitals, old capital cost changes were fitted to a truncated gamma distribution, that is, a gamma distribution covering only the distribution of cost decreases. New capital costs changes were fitted to the entire gamma distribution allowing for both decreases and increases. (2) For hospitals with fewer than 100 beds (small), total capital cost changes were fitted to the gamma distribution allowing for both decreases and increases. (3) Other (large) hospitals were further separated into three groups: Bed-size decreases over 20 percent (decrease) Bed-size increases over 20 percent (increase) Other (no-change). Capital cost changes for large hospitals were fitted to gamma distributions for each bed-size change group, allowing for both decreases and increases in capital costs. We analyzed the probability distribution of increases and decreases in bed-size for large hospitals. We found the probability somewhat dependent on the prior year [[Page 30032]] change in bed-size and factored this dependence into the analysis. Probabilities of bed-size change were determined. Separate sets of probability factors were calculated to reflect the dependence on prior year change in bed-size (increase, decrease, and no change). The gamma distributions were fitted to changes in aggregate capital costs for the entire hospital. We checked the relationship between aggregate costs and Medicare per discharge costs. For large hospitals, there was a small variance, but the variance was larger for small hospitals. Since costs are used only for the hold-harmless methodology and to determine exceptions, we decided to use the gamma distributions fitted to aggregate cost increases for estimating distributions of cost per discharge increases. Capital costs per discharge calculated from the cost reports were increased by random numbers drawn from the gamma distribution to project costs in future years. Old and new capital were projected separately for hold-harmless hospitals. Aggregate capital per discharge costs were projected for all other hospitals. Because the distribution of increases in capital costs varies with changes in bed-size for large hospitals, we first projected changes in bed-size for large hospitals before drawing random numbers from the gamma distribution. Bed-size changes were drawn from the uniform distribution with the probabilities dependent on the previous year bed-size change. The gamma distribution has a shape parameter and a scaling parameter. (We used different parameters for each hospital group, and for old and new capital.) The average national capital cost per discharge generated by this model is the combined average of many randomly generated increases. This average must equal the projected average national capital cost per discharge, which we projected separately (outside this model). We adjusted the shape parameter of the gamma distributions so that the modeled average capital cost per discharge matches our projected capital cost per discharge. The shape parameter for old capital was not adjusted since we are modeling the aging of ``existing'' assets. This model provides a distribution of capital costs among hospitals that are consistent with our aggregate capital projections. Once each hospital's capital-related costs are generated, the model projects capital payments. We use the actual payment parameters (for example, the case-mix index and the geographic adjustment factor) that are applicable to the specific hospital. To project capital payments, the model first assigns the applicable payment methodology (fully prospective or hold-harmless) to the hospital as determined from the provider-specific file and the cost reports. The model simulates Federal rate payments using the assigned payment parameters and hospital-specific estimated outlier payments. The case-mix index for a hospital is derived from the FY 1996 MedPAR file using the FY 1998 DRG relative weights published in section V. of the Addendum of this proposed rule. The case-mix index is increased each year after FY 1996 based on analysis of past experiences in case-mix increases. Based on analysis of recent case-mix increases, we estimate that case-mix will increase 1.4 percent in FY 1997 and 1.0 percent in FY 1998. (Since we are using FY 1996 cases for our analysis, the FY 1996 increase in case mix has no effect on projected capital payments.) Changes in geographic classification and revisions to the hospital wage data used to establish the hospital wage index affect the geographic adjustment factor. Changes in the DRG classification system and the relative weights affect the case-mix index. Section 412.308(c)(4)(ii) requires that the estimated aggregate payments for the fiscal year, based on the Federal rate after any changes resulting from DRG reclassifications and recalibration and the geographic adjustment factor, equal the estimated aggregate payments based on the Federal rate that would have been made without such changes. For FY 1997, the budget neutrality adjustment factor was 1.00123. To determine the factor for FY 1998, we first determined the portion of the Federal rate that would be paid for each hospital in FY 1998 based on its applicable payment methodology. Using our model, we then compared estimated aggregate Federal rate payments based on the FY 1997 DRG relative weights and the FY 1997 geographic adjustment factor to estimated aggregate Federal rate payments based on the FY 1998 relative weights and the FY 1998 geographic adjustment factor. In making the comparison, we held the FY 1998 Federal rate portion constant and set the other budget neutrality adjustment factor and the exceptions reduction factor to 1.00. We determined that, to achieve budget neutrality for the changes in the geographic adjustment factor and DRG classifications and relative weights, an incremental budget neutrality adjustment of 1.00013 for FY 1998 should be applied to the previous cumulative FY 1997 adjustment of 1.00123, yielding a cumulative adjustment of 1.00136 through FY 1998. The following table summarizes the adjustment factors for each fiscal year: Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factor ------------------------------------------------------------------------ Incremental Cumulative Fiscal year adjustment adjustment ------------------------------------------------------------------------ 1992.................................... -- 1.00000 1993.................................... 0.99800 0.99800 1994.................................... 1.00531 1.00330 1995.................................... 0.99980 1.00310 1996.................................... 0.99940 1.00250 1997.................................... 0.99873 1.00123 1998.................................... 1.00013 1.00136 ------------------------------------------------------------------------ The methodology used to determine the recalibration and geographic (DRG/GAF) budget neutrality adjustment factor is similar to that used in establishing budget neutrality adjustments under the prospective payment system for operating costs. One difference is that, under the operating prospective payment system, the budget neutrality adjustments for the effect of geographic reclassifications are determined separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital prospective payment system, there is a single DRG/GAF budget neutrality adjustment factor for changes in the geographic adjustment factor (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients or the large urban add-on payments. In addition to computing the DRG/GAF budget neutrality adjustment factor, we used the model to simulate total payments under the prospective payment system. Additional payments under the exceptions process are accounted for through a reduction in the Federal and hospital-specific rates. Therefore, we used the model to calculate the exceptions reduction factor. This exceptions reduction factor ensures that aggregate payments under the capital prospective payment system, including exceptions payments, are projected to equal the aggregate payments that would have been made under the capital prospective payment system without an exceptions process. Since changes in the level of the payment rates change the level of payments under the exceptions process, the exceptions reduction factor must be determined through iteration. In the August 30, 1991 final rule (56 FR 43517), we indicated that we would publish each year the estimated payment factors generated by the model to determine payments for the next 5 years. The table below provides the actual factors for FY 1992, FY 1993, FY 1994, FY 1995, FY 1996, and FY 1997, the proposed FY 1998 factor, and the estimated factors that would be applicable through FY 2002. We caution that, except with respect to FY 1992, FY 1993, FY 1994, FY 1995, FY 1996 and FY 1997, these are estimates only, and are subject to revisions resulting from continued methodological refinements, more recent data, and any payment policy changes that may occur. In this regard, we note that in making these projections we have assumed that the cumulative DRG/GAF budget neutrality adjustment factor will remain at 1.0014 for FY 1998 and later because we do not have sufficient information to estimate the change that will occur in the factor for years after FY 1998. The projections are as follows: [[Page 30033]] -------------------------------------------------------------------------------------------------------------------------------------------------------- Exceptions Budget DRG/GAF Outlier Federal rate Fiscal year Update factor reduction neutrality adjustment adjustment Federal rate (after outlier factor factor factor\1\ factor adjustment reduction) -------------------------------------------------------------------------------------------------------------------------------------------------------- 1992.................................... N/A 0.9813 0.9602 .............. .9497 .............. 415.59 1993.................................... 6.07 .9756 .9162 .9980 .9496 .............. 417.29 1994.................................... 3.04 .9485 .8947 1.0053 .9454 \2\.9260 378.34 1995.................................... 3.44 .9734 .8432 .9998 .9414 .............. 376.83 1996.................................... 1.20 .9849 N/A .9994 .9536 \3\.9972 461.96 1997.................................... 0.70 .9358 N/A .9987 .9481 .............. 438.92 1998.................................... 1.10 .9276 N/A 1.0001 .9449 .............. 438.43 1999.................................... 1.30 .9286 N/A \4\1.0000 \4\.9449 .............. 444.61 2000.................................... 1.30 .9173 N/A 1.0000 .9449 .............. 444.91 2001.................................... 1.30 .9070 N/A 1.0000 .9449 .............. 445.63 2002.................................... 1.40 \5\1.0000 N/A 1.0000 .9449 .............. 498.20 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\ Note: The incremental change over the previous year. \2\ Note: OBRA 1993 adjustment. \3\ Note: Adjustment for change in the transfer policy. \4\ Note: Future adjustments are, for purposes of this projection, assumed to remain at the same level. \5\ Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (Sec. 412.348(g) of the regulations) because the regular exceptions provision (Sec. 412.348(e)) expires. Appendix C: Revised Hospital Market Basket Data Sources A. Introduction: Market Basket Relative Weights and Choice of Price Proxy Variables for the Operating Hospital Input Price Indexes In the August 30, 1996 final rule (61 FR 46323), we discussed in detail the current 1992-based hospital market baskets, and noted that we would revise the hospital market baskets when new cost data for 1992 became available. This appendix describes the technical features of the revisions to the 1992-based indexes that we are proposing in this rule in section IV of the preamble. For both the prospective payment and excluded hospital market baskets, the differences between the proposed revised market basket and the current market basket are noted. We present this description of the hospital operating market baskets in three steps: A synopsis of the differences between the current 1992- based market baskets and the proposed revisions to those market baskets. A description of the methodology used to develop the cost category weights in the proposed revised market baskets, making note of the differences from the methodology used to develop the 1992-based current market baskets. A description of the data sources used to measure price change for each component of the proposed revised market baskets, making note of the differences from the price proxies used in the 1992-based current hospital market baskets. B. Synopsis of Differences Two major differences exist between the 1992-based current hospital market baskets and the proposed hospital market baskets. The first major change is that the proposed revised hospital market baskets are based on additional hospital expenditure data--data not available until after the publication of the August 30, 1996 final rule. The 1992-based current market baskets were derived from hospital cost reports for cost reporting periods beginning on or after October 1, 1991 and before October 1, 1992, augmented by information from the latest available (1987) Input-Output Table for the hospital industry, produced by the Bureau of Economic Analysis, U.S. Department of Commerce. In addition to the data sources cited above, the proposed revised hospital market baskets use data from the 1992 Asset and Expenditure Survey, produced by the U.S. Department of Commerce, Economic and Statistics Administration, Bureau of the Census. These are more recent data made available after the publication of the FY 1997 final rule. The second major difference is that some cost categories have been combined with other cost categories to better reflect the new data sources. Specifically, the Transportation Services category has been combined with All Other Non-labor Intensive Services; Business Services and Computer and Data Processing Services with All Other Labor Intensive Services; and part of Fuel Oil, Coal, etc. was combined with Natural Gas into Fuels, Nonhighway. The remainder of the Fuel Oil, Coal, etc. was combined with Miscellaneous Products. These category mergers reflect the Bureau of the Census categories in the Asset and Expenditure Survey and its information on services. C. Methodology for Developing the Proposed Revised Cost Category Weights Cost category weights for the proposed revised market baskets were developed in three stages. First, base weights for the six main categories (wages and salaries, employee benefits, pharmaceuticals, nonmedical professional fees, professional liability insurance, and all other expenses) were obtained from the 1992-based hospital market baskets. As the base year is not changing, these weights, developed last year from HCRIS data and the American Hospital Association (AHA) Annual Survey information, will not change. The weight for All Other Expenses was divided into subcategories using cost shares from the 1992 Asset and Expenditure Survey for Hospitals, U.S. Department of Commerce, Economics and Statistics Administration, Bureau of the Census. These subcategories were further divided using cost shares from the 1987 Input-Output Table for the hospital industry, produced by the U.S. Department of Commerce, Bureau of Economic Analysis (BEA), aged to 1992 using price changes. A description of the source of the six main category weights is found in the August 30, 1996 final rule (61 FR 46323). The weight for the Utilities category, as well as those for the Electricity, Fuels Nonhighway, and Water and Sewerage Maintenance cost categories, was derived from the 1992 Asset and Expenditure Survey. The All Other Goods and Services category has more subcategories than any other market basket category. Goods found in this category include: direct service food, contract service food, pharmaceuticals, chemicals, medical instruments, photo supplies, rubber and plastics, paper products, apparel, machinery and equipment and miscellaneous products. Services found in this category include telephone services, postage, other labor-intensive services, and other nonlabor-intensive services. The share for pharmaceuticals was derived from the 1992 Medicare cost reports. Relative shares for the other subcategories were derived from the 1992 Asset and Expenditure Survey, augmented by data from the 1987 Input-Output Table produced by BEA for the hospital industry, aged forward to 1992 using price changes, and then standardized to be consistent with data from the Asset and Expenditure Survey. D. Price Proxies Used to Measure Cost Category Growth Descriptions of the price proxies used to measure cost category price growth in the current hospital market baskets are found in the August 30, 1996 final rule (61 FR 46324). The price proxies used for the proposed revised hospital market baskets are the same as those for the current market baskets. Four cost categories in the current hospital market baskets have been combined with other cost categories to better reflect new data sources. For further discussion of the rationale for choosing specific price proxies, we refer the reader to the September 3, 1986 final rule (51 FR 31582). Appendix D May 27, 1997 The Honorable Albert Gore, Jr. President of the Senate [[Page 30034]] Washington, D.C. 20510 Dear Mr. President: Section 1886(e)(3)(B) of the Social Security Act (the Act) requires me to report to Congress the initial estimate of the applicable percentage increase in inpatient hospital payment rates for fiscal year (FY) 1998 that I will recommend for hospitals subject to the Medicare prospective payment system (PPS) and for hospitals and units excluded from PPS. This submission constitutes the required report. Current law mandates an update for all PPS hospitals equal to the market basket rate of increase. Based on the recent changes in delivery of hospital inpatient care, with an increasing reliance on hospital outpatient and postacute care services and a corresponding decrease in use of hospital inpatient services, we recommend an update for hospitals in both large urban and other areas of zero percent. Sole community hospitals (SCHs) are the sole source of care in their area and are afforded special payment protection to maintain access to services for Medicare beneficiaries. SCHs are paid the higher of a hospital-specific rate or the Federal PPS rate. Current law mandates that the FY 1998 update to hospital-specific rates for SCHs equal the market basket rate of increase. We recommend an update to hospital-specific rates equal to our recommended increase for all PPS hospitals, zero percent. Hospitals and distinct part hospital units excluded from PPS are paid based on their reasonable costs subject to a limit under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current law mandates an update for all hospitals and distinct part units excluded from PPS equal to the rate of increase in the excluded hospital market basket. Consistent with our recommendation for PPS hospitals, we recommend an increase in the TEFRA limit of zero percent. A final recommendation on the appropriate percentage increases for FY 1998 will be made nearer the beginning of the new Federal fiscal year based on the most current data available at that time. The final recommendation will incorporate our analysis of the latest estimates of all relevant factors, including recommendations by ProPAC. Section 1886(d)(4)(C)(iv) of the Act also requires that I include in my report recommendations with respect to adjustments to the diagnosis-related group (DRG) weighting factors. At this time I do not anticipate recommending any adjustment to the DRG weighting factors for FY 1998. I am pleased to provide this recommendation to you. I am also sending a copy of this letter to the Speaker of the House of Representatives. Sincerely, Donna E. Shalala May 27, 1997 The Honorable Newt Gingrich Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: Section 1886(e)(3)(B) of the Social Security Act (the Act) requires me to report to Congress the initial estimate of the applicable percentage increase in inpatient hospital payment rates for fiscal year (FY) 1998 that I will recommend for hospitals subject to the Medicare prospective payment system (PPS) and for hospitals and units excluded from PPS. This submission constitutes the required report. Current law mandates an update for all PPS hospitals equal to the market basket rate of increase. Based on the recent changes in delivery of hospital inpatient care, with an increasing reliance on hospital outpatient and postacute care services and a corresponding decrease in use of hospital inpatient services, we recommend an update for hospitals in both large urban and other areas of zero percent. Sole community hospitals (SCHs) are the sole source of care in their area and are afforded special payment protection to maintain access to services for Medicare beneficiaries. SCHs are paid the higher of a hospital-specific rate or the Federal PPS rate. Current law mandates that the FY 1998 update to hospital-specific rates for SCHs equal the market basket rate of increase. We recommend an update to hospital-specific rates equal to our recommended increase for all PPS hospitals, zero percent. Hospitals and distinct part hospital units excluded from PPS are paid based on their reasonable costs subject to a limit under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current law mandates an update for all hospitals and distinct part units excluded from PPS equal to the rate of increase in the excluded hospital market basket. Consistent with our recommendation for PPS hospitals, we recommend an increase in the TEFRA limit of zero percent. A final recommendation on the appropriate percentage increases for FY 1998 will be made nearer the beginning of the new Federal fiscal year based on the most current data available at that time. The final recommendation will incorporate our analysis of the latest estimates of all relevant factors, including recommendations by ProPAC. Section 1886(d)(4)(C)(iv) of the Act also requires that I include in my report recommendations with respect to adjustments to the diagnosis-related group (DRG) weighting factors. At this time I do not anticipate recommending any adjustment to the DRG weighting factors for FY 1998. I am pleased to provide this recommendation to you. I am also sending a copy of this letter to the President of the Senate. Sincerely, Donna E. Shalala Appendix E: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background Several provisions of the Act address the setting of update factors for inpatient services furnished in FY 1998 by hospitals subject to the prospective payment system and those excluded from the prospective payment system. Section 1886(b)(3)(B)(i)(XIII) of the Act sets the FY 1998 percentage increase in the operating cost standardized amounts equal to the rate of increase in the hospital market basket for prospective payment hospitals in all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 1998 percentage increase in the hospital-specific rates applicable to sole community hospitals equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act, that is, the same update factor as all other hospitals subject to the prospective payment system, or the rate of increase in the market basket. Section 1886(b)(3)(B)(ii) of the Act sets the FY 1998 percentage increase in the rate of increase limits for hospitals excluded from the prospective payment system equal to the rate of increase in the excluded hospital market basket. In accordance with section 1886(d)(3)(A) of the Act, we are proposing to update the standardized amounts, the hospital-specific rates, and the rate-of-increase limits for hospitals excluded from the prospective payment system as provided in section 1886(b)(3)(B) of the Act. Based on the first quarter 1997 forecast of the FY 1998 revised market basket increase of 2.8 percent for hospitals subject to the prospective payment system, the proposed updates in the standardized amounts are 2.8 percent for hospitals in both large urban and other areas. The proposed update in the hospital-specific rate applicable to sole community hospitals is 2.8 percent (that is, the market basket rate of increase). The proposed update for hospitals excluded from the prospective payment system is the percentage increase in the excluded hospital market basket (currently estimated at 2.8 percent). Sections 1886(e)(2)(A) and (3)(A) of the Act require that the Prospective Payment Assessment Commission (ProPAC) recommend to the Congress by March 1, 1997 an update factor that takes into account changes in the market basket rate of increase index, hospital productivity, technological and scientific advances, the quality of health care provided in hospitals, and long-term cost effectiveness in the provision of inpatient hospital services. In its March 1, 1997 report, ProPAC recommended update factors to the standardized amounts equal to zero percentage points for hospitals in both large urban and other areas (Recommendation 2). ProPAC did not make a separate recommendation for the hospital- specific rates applicable to sole community hospitals. The components of ProPAC's update factor recommendations are described in detail in the ProPAC report, which is published as Appendix F to this document. We discuss ProPAC's recommendations concerning the update factors and our responses to these recommendations below. Section 1886(e)(4) of the Act requires that the Secretary, taking into consideration the recommendations of ProPAC, recommend update factors for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5) of the Act, we are required to publish the update factors recommended under section 1886(e)(4) of the Act. Accordingly, this appendix provides the recommendations of appropriate update factors, the analysis underlying our recommendations, and our responses to the [[Page 30035]] ProPAC recommendations concerning the update factors. II. Secretary's Recommendations Under section 1886(e)(4) of the Act, we are recommending that an appropriate update factor for the standardized amounts is zero percentage points for hospitals located in large urban and other areas. We are also recommending an update of zero percentage points to the hospital-specific rate for sole community hospitals. We believe these recommended update factors would ensure that Medicare acts as a prudent purchaser and provide incentives to hospitals for increased efficiency, thereby contributing to the solvency of the Medicare Part A Trust Fund. We recommend that hospitals excluded from the prospective payment system receive a zero update. This update is consistent with the updates provided to the prospective payment hospitals. We believe this update would ensure that Medicare acts as a prudent purchaser and would provide incentives to hospitals for increased efficiency, thereby contributing to the solvency of the Medicare Part A Trust Fund. As required by section 1886(e)(4) of the Act, we have taken into consideration the recommendations of ProPAC in setting these recommended update factors. Our responses to the ProPAC recommendations concerning the update factors are discussed below. III. ProPAC Recommendation for Updating the Prospective Payment System Standardized Amounts For FY 1998, ProPAC's update framework would support an update between -0.6 percent and 1.4 percent. ProPAC notes the significant changes occurring in health care delivery, including the drop in hospital lengths of stay for Medicare beneficiaries since 1990 and the increase in beneficiaries' use of hospital outpatient services and postacute care. Because payment rates reflect care that is no longer furnished as part of the hospital stay, ProPAC recommends that hospitals in large urban and other areas receive an update of zero percent. However, it emphasizes that, because of uncertainty about the future and the extent of changes in productivity and service delivery, its recommendation applies for only one year. Response: We agree with ProPAC's recommendation that the update for FY 1998 for prospective payment system hospitals located in large urban and other areas be equal to zero percentage point. Our recommendation is supported by the following analyses that measure changes in hospital productivity, scientific and technological advances, practice pattern changes, and changes in case mix: Productivity: Service level productivity is defined as the ratio of total service output to full-time equivalent employees (FTEs). While we recognize that productivity is a function of many variables (for example, labor, nonlabor material, and capital inputs), we use a labor productivity measure since this update framework applies to operating payment. To recognize that we are apportioning the short run output changes to the labor input and not considering the nonlabor inputs, we weight our productivity measure for operating costs by the share of direct labor services in the market basket rate of increase to determine the expected effect on cost per case. Our recommendation for the service productivity component is based on historical trends in productivity and total output for both the hospital industry and the general economy, and projected levels of future hospital service output. ProPAC has also estimated cumulative service productivity growth to be 4.9 percent from 1985- 1989, or 1.2 percent annually. At the same time, ProPAC estimates total output growth at 3.4 percent annually, implying a ratio of service productivity growth to output growth of 0.35. Our Medicare Provider Analysis and Review (MedPAR) file analysis indicates total Medicare service output (charges per admission, adjusted for CPI change) decreased 1.6 percent from 1987-1996, or an approximate average annual decrease of 0.2 percent. Since it is not possible at this time to develop a productivity measure specific to Medicare patients, we examined productivity (output per hour) and output (gross domestic product) for the economy. Depending on the exact time period, annual changes in productivity range from 0.3 to 0.35 percent of the change in output (that is, a 1.0 percent increase in output would be correlated with a 0.3 to 0.35 percent change in output per hour). Under our framework, the recommended update is based in part on expected productivity--that is, projected service output during the year multiplied by the historical ratio of service productivity to total service output, multiplied by the share of labor in total operating inputs, as calculated in the hospital market basket rate of increase. This method estimates an expected labor productivity improvement in the same proportion to expected total service growth that has occurred in the past and assumes that, at a minimum, growth in FTEs changes proportionally to the growth in total service output. Thus, the recommendation allows for unit productivity to be smaller than the historical averages in years that output growth is relatively low and higher in years that output growth is larger than the historical trend. Based on the above estimates from both the hospital industry and the economy, we have chosen to employ the range of ratios of productivity change to output change of 0.30 to 0.35. The expected change in total hospital service output is the product of projected growth in total admissions (adjusted for outpatient usage), projected real case-mix growth, and expected quality enhancing intensity growth, net of expected decline in intensity due to reduction of cost ineffective practice. Case-mix growth and intensity numbers for Medicare are used as proxies for those of the total hospital, since case-mix increases (used in the intensity measure as well) are unavailable for non-Medicare patients. Thus, expected output growth is simply the sum of the expected change in intensity (0.0 percent), projected admissions change (2.4 percent for FY 1998), and projected real case-mix growth (0.8 percent), or 3.2 percent. The share of direct labor services in the market basket rate of increase (consisting of wages, salaries, and employee benefits) is 61.4 percent. Multiplying the expected change in total hospital service output (3.2 percent) by the ratio of historical service productivity change to total service growth of 0.30 to 0.35 and by the direct labor share percentage (0.614) provides our productivity standard of 0.6 to 0.7 percent. ProPAC also believes hospitals should be given an incentive for additional productivity improvement. ProPAC measures productivity as the ratio of hospital admissions (adjusted for case mix and outpatient services) per FTE employee (adjusted for changes in skill mix). ProPAC includes in its productivity measurement the effect of changes in practice patterns. We treat practice pattern changes as a portion of our intensity adjustment, described below. In the past, ProPAC has expected hospitals to achieve productivity gains ranging from 0.5 percent to 2.0 percent per year. This year, recognizing changes in lengths of stay and sites of service, ProPAC believes a productivity adjustment in the range of -3.0 to -1.0 percentage points is required in fiscal year 1998. The adjustment is intended to share productivity equally between hospitals and Medicare. Intensity: We base our intensity standard on the combined effect of three separate factors: changes in the use of quality enhancing services, changes in the use of services due to shifts in within-DRG severity, and changes in the use of services due to reductions of cost-ineffective practices. For FY 1998, we recommend an adjustment of 0.0 percent. The basis of this recommendation is discussed below. We have no empirical evidence that accurately gauges the level of quality-enhancing technology changes. Typically, a specific new technology increases cost in some uses and decreases cost in other uses. Concurrently, health status is improved in some situations while in other situations it may be unaffected or even worsened using the same technology. It is difficult to separate out the relative significance of each of the cost increasing effects for individual technologies and new technologies. The quality enhancing technology component is intended to recognize the use of services that increase cost but whose value in terms of enhanced health-status is commensurate with these costs. Such services may result from technological change, or in some cases, increased use of existing technologies. The latter recognizes that as cost and medical effectiveness studies become available, some increased use of existing, as well as new, services may be warranted. The component for reduction of cost-ineffective practice recognizes that some improvements in practice patterns could be made so that the intensity of services provided is more consistent with the efficient use of limited resources. That is, improvements could be made so that the number of services provided during an inpatient stay, and their complexity, produce an improvement in health status that is consistent with the cost of care. This component of our update recommendation is [[Page 30036]] intended to encourage both hospitals and physicians to more carefully consider the cost-effectiveness of medical care. This component of the framework also accounts for real within-DRG change, since that should be directly reflected in the CMI-adjusted growth in real charges per case. Following methods developed by HCFA's Office of the Actuary for deriving hospital output estimates from total hospital charges, we have developed Medicare-specific intensity measures based on a 5- year average using FY 1992-1996 MedPAR billing data. Case-mix constant intensity is calculated as the change in total Medicare charges per discharge adjusted for changes in the average charge per unit of service as measured by the Medical CPI hospital component and changes in real case mix. Thus, in order to measure changes in intensity, one must measure changes in real case mix. In determining case-mix constant intensity, we found that observed case-mix increase was 1.8 percent in FY 1992, 0.9 percent in FY 1993, 0.8 percent in FY 1994, 1.7 percent in FY 1995, and 1.6 percent in FY 1996. For FY 1992, FY 1995, and FY 1996, we estimate that real case-mix increase was 1.0 to 1.4 percent each year. The estimate for those years is supported by past studies of case-mix change by the RAND Corporation. The most recent study was ``Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988'' by G.M. Carter, J.P. Newhouse, and D.A. Relles, R-4098- HCFA/ProPAC (1991). The study suggested that real case-mix change was not dependent on total change, but was rather a fairly steady 1.0 to 1.5 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. Following that study, we consider up to 1.4 percent of observed case-mix change as real for FY 1991 through FY 1994. Based on this analysis, we believe that all of the observed case-mix increase for FY 1993 and FY 1994 is real. Given estimates of real case-mix increase of 1.0 percent for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.0 percent for FY 1995, and 1.0 percent for FY 1996, we estimate that case-mix constant intensity declined by an average 1.4 percent during FY 1992 through FY 1996, for a cumulative decrease of 7.0 percent. If we assume that real case-mix increase was 1.4 percent for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.4 percent for FY 1995, and 1.4 percent for FY 1996, we estimate that case-mix constant intensity declined by an average 1.6 percent during FY 1992 through FY 1996, for a cumulative decrease of 7.5 percent. Since we estimate that intensity has declined during that period, we are recommending a 0.0 percent intensity adjustment for FY 1998. Quality Enhancing New Science and Technology: For FY 1998, ProPAC has computed the adjustment for scientific and technological advances to be a future-oriented policy target intended to provide additional funds for hospitals to adopt quality- enhancing, cost increasing health care innovations. In the past, ProPAC has included an adjustment ranging from 0.3 to 1.0 percentage points. ProPAC believes that the cost-competitive environment now faced by hospitals may dampen the adoption of new technologies as they closely evaluate their relative costs and benefits. Therefore, ProPAC recommends an adjustment of 0.4 percentage points for the increase in operating costs due to scientific and technological advances. Change in Case Mix: Our analysis takes into account projected changes in case mix, adjusted for changes attributable to improved coding practices. For our FY 1998 update recommendation, we are projecting a 1.0 percent increase in the case-mix index. We define real case-mix increase as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher- weighted DRGs but do not reflect greater resource requirements. For FY 1998, we believe that real case-mix increase is equal to our projected change in case mix less 0.2 percent. We estimate that changes in coding behavior account for an increase of 0.2 percentage points in our projected case-mix change. Our net adjustment to case- mix change for FY 1998 is 0.2 percentage points. The 0.0 percent figure used in the ProPAC framework represents ProPAC's projection for observed case-mix change. ProPAC's net adjustment for case mix is 0.0 percentage points. Effect of FY 1996 DRG Reclassification and Recalibration: We estimate that DRG reclassification and recalibration for FY 1996 resulted in a 0.0 percent increase in the case-mix index when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the GROUPER. ProPAC does not make an adjustment for DRG reclassification and recalibration in its update recommendation. Correction for Market Basket Forecast Error: The estimated market basket percentage increase used to update the FY 1996 payment rates was 3.5 percent. Our most recent data indicate the actual FY 1996 increase was 2.7 percent, primarily reflecting that the actual increase in wages, benefits, and chemical prices was lower than projected. The resulting forecast error in the FY 1996 market basket rate of increase is 0.8 percentage points. Under our update framework, we make a forecast error correction if our estimate is off by 0.25 percentage points or more. Therefore, we are recommending an adjustment of -0.8 percentage points to reflect this overestimation of the FY 1996 market basket rate of increase. The following is a summary of the update ranges supported by our analyses compared to ProPAC's framework. Table 1.--Comparison of FY 1998 Update Recommendations ---------------------------------------------------------------------------------------------------------------- HHS ProPAC ---------------------------------------------------------------------------------------------------------------- Market Basket............................................... MB MB Difference between HCFA & ProPAC Market Baskets............. ........................ 0.0 --------------------------------------------------- Subtotal.............................................. MB MB =================================================== Policy Adjustments Factors: Productivity............................................ -0.6 to -0.7 -3.0 to -1.0 Intensity............................................... 0.0 ........................ Science & Technology................................ ........................ 0.4 Practice Patterns................................... ........................ (1) Real Within DRG Change.............................. ........................ (2) --------------------------------------------------- Subtotal.......................................... -0.6 to -0.7 -2.6 to -0.6 =================================================== Case-Mix Adjustment Factors: Projected Case-Mix Change............................... -1.0 ........................ Real Across DRG Change.................................. 0.8 ........................ Real Within DRG Change.................................. (3) 0.0 --------------------------------------------------- Subtotal.............................................. -0.2 0.0 =================================================== Effect of 1996 Reclassification & Recalibration............. 0.0 ........................ Forecast Error Correction................................... -0.8 -0.8 [[Page 30037]] Total Recommended Update.................................... MB -1.7 to MB -1.6 MB -3.4 to MB -1.4 ---------------------------------------------------------------------------------------------------------------- (1) Included in ProPAC's Productivity Measure. (2) Included in ProPAC's Case-Mix Adjustment. (3) Included in HHS' Intensity Factor. While the above analysis would support a recommendation that the update be no less than market basket minus 1.6 percentage points, we are recommending an update of zero percentage points. We believe that this update factor appropriately adjusts for changes occurring in health care delivery including the relative decrease in use of hospital inpatient services and the corresponding increase in use of hospital outpatient and postacute care services. We agree with ProPAC that a zero update for FY 1998 would not disadvantage the hospital industry nor harm Medicare beneficiaries. We also recommend that the hospital-specific rates applicable to sole community hospitals be increased by the same update, zero percentage points. IV. ProPAC Recommendation for Updating the Rate-of-Increase Limits for Excluded Hospitals ProPAC recommends an update factor equal to a 2.0 percent average increase in TEFRA target amounts for excluded hospitals and units (Recommendation 13). This reflects a reduction of 0.8 percentage points from HCFA's market basket increase forecast of 2.8 percent. The reduction consists of an adjustment of -0.7 percentage points to account for the forecast error in the FY 1996 market basket rate of increase, an adjustment of -0.1 percentage points for the difference between the forecasts for HCFA's and ProPAC's market baskets, and no allowance for new technology. Response: We recommend that hospitals excluded from the prospective payment system also receive a zero update. This update is consistent with the updates provided to the prospective payment hospitals. We believe this update would ensure that Medicare acts as a prudent purchaser and would provide incentives to hospitals for increased efficiency, thereby contributing to the solvency of the Medicare Part A Trust Fund. 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[GRAPHIC] [TIFF OMITTED] TP02JN97.131 [FR Doc. 97-14248 Filed 5-30-97; 8:45 am] BILLING CODE 4120-03-C