[Federal Register Volume 62, Number 211 (Friday, October 31, 1997)]
[Notices]
[Pages 59261-59266]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-29028]
Federal Register / Vol. 62, No. 211 / Friday, October 31, 1997 /
Notices
[[Page 59261]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPD-893-FN]
RIN 0938-AI16
Medicare Program; Physician Fee Schedule Conversion Factor for
Calendar Year 1998 and Sustainable Growth Rate for Fiscal Year 1998
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final notice.
-----------------------------------------------------------------------
SUMMARY: This final notice announces the calendar year 1998 Medicare
physician fee schedule conversion factor and the fiscal year 1998
sustainable growth rate for expenditures for physicians' services under
the Medicare Supplementary Medical Insurance (Part B) program as
required by sections 1848(d) and (f), respectively, of the Social
Security Act. The 1998 Medicare physician fee schedule conversion
factor is $36.6873. The sustainable growth rate for fiscal year 1998 is
1.5 percent.
EFFECTIVE DATE: The provisions in this final notice pertaining to the
Medicare sustainable growth rate of increase are effective October 1,
1997, and the provisions pertaining to the Medicare physician fee
schedule conversion factor are effective January 1, 1998, as provided
by the Medicare statute.
ADDRESSES: Copies: To order paper copies of the Federal Register
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FOR FURTHER INFORMATION CONTACT: Ordering information: See ADDRESSES
section.
Content information: Don Thompson, (410) 786-4586.
SUPPLEMENTARY INFORMATION:
I. Background and Summary of Legislation
The following discussion contains references to the conversion
factor and relative value units as components of the Medicare physician
fee schedule. The 1998 physician fee schedule final rule, published
elsewhere in this Federal Register issue, explains how these factors
are used in determining payments under the fee schedule.
A. Calendar Year 1998 Physician Fee Schedule Conversion Factor
There are currently three conversion factors used in the physician
fee schedule: one for primary care services, one for surgical services,
and one for all other services. However, section 1848(d)(1)(C) of the
Social Security Act (the Act), as amended by section 4501 of the
Balanced Budget Act of 1997 (BBA 1997) (Pub. L. 105-33), enacted on
August 5, 1997, states that the 1998 physician fee schedule conversion
factor for all services ``shall be the conversion factor for primary
care services for 1997, increased by the Secretary's estimate of the
weighted average of the three separate updates that would otherwise
occur were it not for the enactment of . . . the Balanced Budget Act of
1997.''
The conversion factor is also affected by section
1848(c)(2)(B)(ii)(II) of the Act, which requires that any changes to
the relative value units of the Medicare physician fee schedule not
cause expenditures to increase or decrease by more than $20 million
from the amount of expenditures that would have been made if such
adjustments had not been made. We implement this requirement through a
uniform budget neutrality adjustment to the conversion factor.
B. Fiscal Year 1998 Medicare Sustainable Growth Rate
Section 1848(f) of the Act, as amended by section 4503 of the BBA
1997, replaces the volume performance standard with a sustainable
growth rate standard. It specifies the formula for establishing yearly
sustainable growth rate expenditure targets for physicians' services
under Medicare. The use of sustainable growth rate targets is intended
to control the actual growth in Medicare expenditures for physicians'
services.
The sustainable growth rate targets are not limits on expenditures.
Payments for services are not withheld if the sustainable growth rate
target is exceeded. Rather, the appropriate fee schedule update, as
specified in section 1848(d)(3)(A) of the Act, is adjusted to reflect
the success or failure in meeting the sustainable growth rate target.
The amended section 1848(f)(2) of the Act now states that ``the
sustainable growth rate for all physicians' services for a fiscal year
(beginning with fiscal year 1998) shall be equal to the product of--
(A) 1.0 plus the Secretary's estimate of the weighted-average
percentage increase (divided by 100) in the fees for all physicians'
services in the fiscal year involved,
(B) 1.0 plus the Secretary's estimate of the percentage change
(divided by 100) in the average number of individuals enrolled under
this part (other than Medicare+Choice plan enrollees) from the previous
fiscal year to the fiscal year involved,
(C) 1.0 plus the Secretary's estimate of the projected percentage
growth in real gross domestic product per capita (divided by 100) from
the previous fiscal year to the year involved, and
(D) 1.0 plus the Secretary's estimate of the percentage change
(divided by 100) in expenditures for all physicians' services in the
fiscal year (compared with the previous fiscal year) that will result
from changes in law or regulations determined without taking into
account estimated changes in
[[Page 59262]]
expenditures resulting from the update adjustment factor determined
under subsection (d)(3)(B), minus 1 and multiplied by 100.
C. Physicians' Services
Because the scope of physicians' services covered by the
sustainable growth rate is identical to the scope of services that was
covered by the Medicare volume performance standards, we are using the
same definition of physicians' services for the sustainable growth rate
as we did for the Medicare volume performance standard. The November
22, 1996 final notice (61 FR 59717) announcing the fiscal year 1997
volume performance standard rates of increase contains a detailed
description of this scope of services.
II. Provisions of This Final Notice
A. Calendar Year 1998 Physician Fee Schedule Conversion Factor
Under the requirements of the amended section 1848(d)(1)(C) of the
Act, the 1998 physician fee schedule conversion factor is $36.6873. We
determined this conversion factor as follows:
1997 Primary care conversion factor........................... 35.7671
Weighted average update if BBA 1997 not enacted............... 1.034
Budget neutrality adjustment*................................. 0.992
1998 Physician fee schedule conversion factor................. 36.6873
* This adjustment results from section 1848(c)(2)(B)(ii) of the Act and
is described in the 1998 physician fee schedule final rule, published
elsewhere in this Federal Register issue.
Under the requirements of section 1848(d)(1)(D) of the Act, as
amended by section 4504 of the BBA 1997, the 1998 anesthesia conversion
factor is equal to 46 percent of the 1998 physician fee schedule
conversion factor. This calculation yields a 1998 anesthesia conversion
factor of $16.8762.
The specific calculations to determine the conversion factor for
physicians' services for calendar year 1998 are explained in section
III. A. of this notice.
The following table shows the combined effect on calendar year 1998
payments (relative to calendar year 1997) of the move to a single
conversion factor and the changes to the 1998 Medicare physician fee
schedule relative value units (described in the 1998 physician fee
schedule final rule published elsewhere in this Federal Register
issue).
Table 1.--1998 Percent Change in Payments by Specialty*
------------------------------------------------------------------------
Change due
to single Change due Combined
Specialty conversion to relative change
factor value units
------------------------------------------------------------------------
M.D./D.O. Physicians:
Radiation Oncology............... 9.2 -0.7 8.4
Psychiatry................... 9.0 -0.7 8.2
Radiology.................... 9.0 -0.7 8.2
Pathology.................... 9.3 -1.1 8.1
Hematology/Oncology.......... 7.1 0.8 8.0
Neurology.................... 7.9 0.0 7.9
Pulmonary.................... 8.1 -0.4 7.7
Rheumatology................. 5.7 1.4 7.2
Gastroenterology............. 8.5 -1.3 7.1
Internal Medicine............ 6.4 0.6 7.0
Family Practice.............. 5.0 1.3 6.4
Cardiology................... 7.9 -1.4 6.4
Other Physician.............. 6.4 -0.2 6.2
General Practice............. 4.7 1.2 6.0
Nephrology................... 6.0 -1.2 4.7
Clinics...................... 4.5 -0.1 4.4
Emergency Medicine........... 3.8 -0.6 3.2
Anesthesiology............... 1.2 0.9 2.1
Obstetrics/Gynecology........ -2.3 3.0 0.6
Otolaryngology............... -0.1 0.6 0.5
General Surgery.............. -4.0 1.8 -2.3
Vascular Surgery............. -4.0 1.5 -2.6
Urology...................... -3.3 0.4 -2.9
Orthopedic Surgery........... -4.8 0.8 -4.0
Dermatology.................. -4.8 0.2 -4.6
Plastic Surgery.............. -6.9 1.7 -5.3
Ophthalmology................ -3.3 -2.6 -5.8
Neurosurgery................. -5.7 -0.2 -5.9
Thoracic Surgery............. -7.0 -0.2 -7.2
Cardiac Surgery.............. -8.1 -0.7 -8.8
Others:
Chiropractic................. 9.3 -0.8 8.4
Suppliers.................... 9.3 -1.0 8.2
Optometry.................... 5.7 0.1 5.8
Nonphysician practitioners... 5.1 -0.6 4.5
Podiatry..................... -5.2 0.8 -4.4
------------------------------------------------------------------------
* Table reflects changes from 1997 payments due to the relative value
units and single conversion factor, excluding the 0.3 percent volume
and intensity increase associated with the single conversion factor
and the 0.1 percent volume and intensity increase associated with the
relative value unit changes.
[[Page 59263]]
B. Physician Sustainable Growth Rate for Fiscal Year 1998
Under the requirements in sections 1848(f)(2)(A) and (B) of the
Act, as amended by section 4503 of the BBA 1997, we have determined
that the sustainable growth rate of increase for physicians' services
for fiscal year 1998 is 1.5 percent.
This determination is based on the following statutory factors:
------------------------------------------------------------------------
Percent
Statutory factors change
------------------------------------------------------------------------
Fees......................................................... 2.3
Enrollment................................................... -2.4
Increase in Gross Domestic Product........................... 1.1
Legislation.................................................. 0.6
----------
Total........................................................ 1.5
------------------------------------------------------------------------
The specific calculations to determine the sustainable growth rate
for physicians' services for fiscal year 1998 are explained in section
III. B. of this notice.
III. Detail on Calculation of the Calendar Year 1998 Physician Fee
Schedule Conversion Factor and the Fiscal Year 1998 Sustainable Growth
Rate
A. Physician Fee Schedule Conversion Factor
1. The Weighted Average Update
The weighted average update if the BBA 1997 had not been enacted is
3.4 percent. This was determined based on the Medicare Economic Index
(MEI) and the Medicare volume performance standard (MVPS) adjustments
as follows:
------------------------------------------------------------------------
Update
Service 1998 MEI MVPS (prior to
adjustment BBA 1997)
------------------------------------------------------------------------
(2)[In Percent]
--------------------------------------
Primary Care..................... 2.2 5.3 7.5
Surgical......................... 2.2 0.3 2.5
All other........................ 2.2 -0.3 1.9
Weighted average................. ........... ........... 3.4
------------------------------------------------------------------------
The MEI and the MVPS adjustments are described below.
2. The Percentage Change in the Medicare Economic Index
The MEI measures the weighted-average annual price change for
various inputs needed to produce physicians' services. The MEI is a
fixed-weight input price index, with an adjustment for the change in
economy-wide labor productivity. This index, which has 1989 base
weights, is comprised of two broad categories: (1) Physician's own
time, and (2) physician's practice expense.
The physician's own time component represents the net income
portion of business receipts and primarily reflects the input of the
physician's own time into the production of physicians' services in
physicians' offices. This category consists of two subcomponents: wages
and salaries, and fringe benefits. These components are adjusted by the
10-year moving average percent change in output per man-hour for the
nonfarm business sector to eliminate double counting for productivity
growth in physicians' offices and the general economy.
The physician's practice expense category represents the rate of
price growth in nonphysician inputs to the production of services in
physicians' offices. This category consists of wages and salaries and
fringe benefits for nonphysician staff and other nonlabor inputs. Like
physician's own time, the nonphysician staff categories are adjusted
for productivity using the 10-year moving average percent change in
output per man-hour for the nonfarm business sector. The physician's
practice expense component also includes the following categories of
nonlabor inputs: office expense, medical materials and supplies,
professional liability insurance, medical equipment, professional car,
and other expense. The table below presents a listing of the MEI cost
categories with associated weights and percent changes for price
proxies for the 1998 update. The calendar year 1998 MEI is 2.2 percent.
Increase in the Medicare Economic Index Update for Calendar Year 1998
\1\
------------------------------------------------------------------------
CY 1998
1989 percent
weights \2\ changes
------------------------------------------------------------------------
Medicare Economic Index Total................. 100.0 2.2
1. Physician's Own Time\3\ \4\............ 54.2 2.5
a. Wages and Salaries: Average hourly
earnings private nonfarm, net of
productivity......................... 45.3 2.8
b. Fringe Benefits: Employment Cost
Index, benefits, private nonfarm, net
of productivity...................... 8.8 1.2
2. Physician's Practice Expense \3\....... 45.8 1.9
a. Nonphysician Employee Compensation. 16.3 2.4
1. Wages and Salaries: Employment
Cost Index, wages and salaries,
weighted by occupation, net of
productivity..................... 13.8 2.6
2. Fringe Benefits: Employment
Cost Index, fringe benefits,
white collar, net of productivity 2.5 1.4
b. Office Expense: Consumer Price
Index for Urban Consumers (CPI-U),
housing.............................. 10.3 2.9
c. Medical Materials and Supplies:
Producer Price Index (PPI), ethical
drugs/PPI, surgical appliances and
supplies/CPI-U, medical equipment and
supplies (equally weighted).......... 5.2 1.6
d. Professional Liability Insurance:
HCFA professional liability insurance
survey\5\............................ 4.8 -1.8
e. Medical Equipment: PPI, medical
instruments and equipment............ 2.3 -0.4
f. Other Professional Expense......... 6.9 2.5
1. Professional Car: CPI-U,
private transportation........... 1.4 2.3
2. Other: CPI-U, all items less
food and energy.................. 5.5 2.6
[[Page 59264]]
Addendum:
Productivity: 10-year moving average of
output per man-hour, nonfarm business
sector................................... N/A 0.8
Physician's Own Time, not productivity
adjusted................................. 54.2 3.3
Wages and salaries, not productivity
adjusted............................. 45.3 3.6
Fringe benefits, not productivity
adjusted............................. 8.8 2.0
Nonphysician Employee Compensation, not
productivity adjusted.................... 16.3 3.2
Wages and salaries, not productivity
adjusted............................. 13.8 3.4
Fringe benefits, not productivity
adjusted............................. 2.5 2.2
------------------------------------------------------------------------
\1\ The rates of change are for the 12-month period ending June 30,
1997, which is the period used for computing the calendar year 1998
update. The price proxy values are based upon the latest available
Bureau of Labor Statistics data as of September 1997.
\2\ The weights shown for the MEI components are the 1989 base-year
weights, which may not sum to subtotals or totals because of rounding.
The MEI is a fixed-weight, Laspeyres-type input price index whose
category weights indicate the distribution of expenditures among the
inputs to physicians' services for calendar year 1989. To determine
the MEI level for a given year, the price proxy level for each
component is multiplied by its 1989 weight. The sum of these products
(weights multiplied by the price index levels) over all cost
categories yields the composite MEI level for a given year. The annual
percent change in the MEI levels is an estimate of price change over
time for a fixed market basket of inputs to physicians' services.
\3\ The Physician's Own Time and Nonphysician Employee Compensation
category price measures include an adjustment for productivity. The
price measure for each category is divided by the 10-year moving
average of output per man-hour in the nonfarm business sector. For
example, the wages and salaries component of Physician's Own Time is
calculated by dividing the rate of growth in average hourly earnings
by the 10-year moving average rate of growth of output per man-hour
for the nonfarm business sector. Dividing one plus the decimal form of
the percent change in the average hourly earnings (1+.036=1.036 by one
plus the decimal form of the percent change in the 10-year moving
average of labor productivity (1+.008=1.008) equals one plus the
change in average hourly earnings net of the change in output per
manhour (1.036/1.008=1.028). All Physician's Own Time and Nonphysician
Employee Compensation categories are adjusted in this way. Due to a
higher level of precision the computer calculated quotient may differ
from the quotient calculated from rounded individual percent changes.
\4\ The average hourly earnings proxy, the Employment Cost Index
proxies, as well as the CPI-U, housing and CPI-U, private
transportation are published in the Current Labor Statistics Section
of the Bureau of Labor Statistics' Monthly Labor Review. The remaining
CPIs and PPIs in the revised index can be obtained from the Bureau of
Labor Statistics' CPI Detailed Report or Producer Price Indexes.
\5\ Derived from a HCFA survey of several major insurers (the latest
available historical percent change data are for calendar year 1997).
This is consistent with prior computations of the professional
liability insurance component of the MEI.
n/a Productivity is factored into the MEI compensation categories as an
adjustment to the price variables; therefore, no explicit weight
exists for productivity in the MEI.
3. Medicare Volume Performance Standard Performance Adjustment
Prior to the enactment of the BBA 1997, the update methodology set
forth in section 1848(d)(3)(B)(i) of the Act would have increased the
primary care services update by 5.3 percentage points, increased the
surgical services update by 0.3 percentage points, and decreased the
update for all other services by 0.3 percentage points. These
adjustments reflect the percentage increase in expenditures between
fiscal year 1995 and fiscal year 1996 relative to the volume
performance standard rates of increase for fiscal year 1996. The volume
performance standard rates of increase were targets for the growth in
Medicare expenditures for physicians' services that have subsequently
been replaced by the sustainable growth rates. The success or failure
in meeting the volume performance standard targets was taken into
account in determining the Medicare physician fee schedule update. The
update methodology prior to the enactment of the BBA 1997 is described
in detail in the November 22, 1996 final notice announcing the
physician fee schedule update for 1997 (61 FR 59717).
The MVPS adjustments were derived as follows:
------------------------------------------------------------------------
FY 1996 FY 1996 MVPS
Service MVPS increase in adjustment
target expenditures difference)
------------------------------------------------------------------------
(2)[In Percent]
---------------------------------------
Primary Care.................... 9.3 4.0 5.3
Surgical........................ -0.5 -0.8 0.3
All other....................... 0.6 0.9 -0.3
------------------------------------------------------------------------
B. Fiscal Year 1998 Sustainable Growth Rate
Below we explain how we determined the increases for each of the
four factors used in determining the sustainable growth rate for fiscal
year 1998.
Factor 1--Percentage Increase in Fees for Physicians' Services (Before
Applying Legislative Adjustments) for Fiscal Year 1998
This factor was calculated as a weighted average of the calendar
year 1997 and 1998 fee increases that apply during fiscal year 1998.
Adjustments to the fee increases, such as the move to a single
conversion factor, are accounted for in Factor 4 (the increase in
expenditures resulting from changes in law or regulations).
Most of the fees for physicians' services (as defined in section I.
C. of this notice) are updated by the MEI. However, laboratory
services, which
[[Page 59265]]
represent about 13 percent of the Medicare allowed charges for
physicians' services, are updated by the Consumer Price Index for Urban
Consumers (CPI-U). The following table, therefore, shows both the MEI
and CPI-U updates that were used in determining the percentage increase
in physicians' fees for fiscal year 1998.
Medicare Economic Index and Consumer Price Index for Urban Consumers for
Calendar Years 1997 and 1998
------------------------------------------------------------------------
1997 1998
------------------------------------------------------------------------
MEI................................................... 2.0 2.2
CPI-U................................................. 2.7 3.0
------------------------------------------------------------------------
After taking into account all the elements described above, we
estimate that the weighted-average increase in fees for physicians'
services in fiscal year 1998 before applying any legislative
adjustments will be 2.3 percent for all physicians' services.
Factor 2--The Percentage Change in the Average Number of Part B
Enrollees from Fiscal Year 1997 to Fiscal Year 1998
Due to the rapid growth in Medicare+Choice plan enrollees (whose
Medicare-covered medical care is outside the scope of the sustainable
growth rate), we estimate that the average number of Medicare Part B
enrollees excluding those in Medicare+Choice plans will decline by 2.4
percent. This was derived as follows:
----------------------------------------------------------------------------------------------------------------
Average Medicare Part B enrollment (in
millions)
------------------------------------------
Overall
Overall Medicare excluding
+Choice* Medicare+Choice
----------------------------------------------------------------------------------------------------------------
FY 1997.............................................................. 36.384 4.461 31.923
FY 1998.............................................................. 36.775 5.627 31.148
Percent change................................................... ........... ........... -2.4%
----------------------------------------------------------------------------------------------------------------
* Because the Medicare+Choice program does not begin until 1998, the 1997 Medicare+Choice enrollment was proxied
by the risk health maintenance organization enrollment.
Differences between projected and actual enrollment will be
adjusted for in subsequent years.
Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in
Fiscal Year 1998
In calculating the sustainable growth rate, section 1848(f)(2)(C)
of the Act, as amended by section 4503 of the BBA 1997, requires the
Secretary to project real gross domestic product per capita growth for
the coming fiscal year. We estimate that this growth will be 1.1
percent in fiscal year 1998.
Differences between projected and actual real gross domestic
product per capita growth will be adjusted for in subsequent years.
Factor 4--Percentage Increase in Expenditures for Physicians' Services
Resulting from Changes in Law or Regulations in Fiscal Year 1998
Compared with Fiscal Year 1997
Legislative changes contained in the BBA 1997 will impact
expenditures for physicians' services in fiscal year 1998. Although the
move to a single conversion factor for the Medicare physician fee
schedule will cause the payments for surgical services to decline, it
will increase the payments for nonsurgical services sufficiently to
cause an overall increase in expenditures for fiscal year 1998 relative
to fiscal year 1997. The Medicare coverage changes for screening
mammography, colorectal cancer screening, screening PAP smears, and
screening pelvic exams will cause increases in Medicare expenditures.
The changes in payments for nurse practitioners, clinical nurse
specialists, and physician assistants will also increase expenditures.
Medicare to be secondary payer and the provisions relating to payments
for laboratory services will cause reductions in Medicare expenditures.
In response to the fee changes associated with implementation of
the 1998 physician fee schedule, we anticipate that the volume and
intensity of physician services provided to Medicare beneficiaries will
increase by 0.1 percent. In order to prevent an increase in
expenditures as a result of this volume and intensity response, an
offsetting 0.1 percent reduction is made to the conversion factor.
Because we incorporate both the volume and intensity response and the
offsetting conversion factor reduction into the sustainable growth rate
target, if the volume and intensity response does not occur, the
sustainable growth rate system returns the offsetting reduction to the
conversion factor in form of higher future updates to the Medicare
physician fee schedule.
After taking into account all the BBA 1997 provisions, the increase
in expenditures for physician services due to changes in law or
regulations is estimated to be 0.6 percent.
IV. Inapplicability of a Notice and Comment Procedure and of a 30-Day
Delay in Effective Date
We find good cause to waive notice and comment procedure for this
final notice. It is an interpretive rule because section 1848 of the
Social Security Act, as amended by sections 4501 and 4503 of the BBA
1997, sets out in detail the factors and procedures necessary to
calculate the conversion factor for calendar year 1998 and the
sustainable growth rate of increase for fiscal year 1998. As required
by the statute, section I. A. of this notice discusses the replacement
of the three conversion factors that are currently used under the
physician fee schedule with a single conversion factor, and the method
used to determine the conversion factor for calendar year 1998. Section
I. B. of this notice discusses the replacement of the volume
performance standard with the sustainable growth rate of increase, and
the formula for establishing the fiscal year 1998 sustainable growth
rate target for physicians' services under Medicare. Therefore, it
would be impracticable and unnecessary to submit this notice to the
public for a notice and comment procedure.
We usually provide a delay of 30 days in the effective date for
final Federal Register documents. In this case, however, the
sustainable growth rates of increase are required by law to be
published by November 1, 1997 and are effective on October 1, 1997.
Thus, the
[[Page 59266]]
Congress has clearly indicated its intent that the rates of increase be
implemented without the usual 30-day delay in the effective date and
has foreclosed any discretion by us in this matter. Therefore, the
requirement for a 30-day delay in the effective date does not apply to
this notice. With regard to the physician fee schedule conversion
factor, the effective date will be January 1, 1998, which exceeds the
30-day requirement for the publication of this notice.
V. Regulatory Impact Statement
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612) unless the Secretary certifies that a notice will not have
a significant economic impact on a substantial number of small
entities. For purposes of the RFA, States and individuals are not
entities, but we consider all physicians to be small entities.
We are not preparing a regulatory flexibility analysis since we
have determined, and the Secretary certifies, that this notice will not
have a significant economic impact on a substantial number of small
entities.
Also, section 1102(b) of the Act requires the Secretary to prepare
a regulatory impact analysis if a notice may have a significant impact
on the operations of a substantial number of small rural hospitals.
This analysis must conform to the provisions of section 604 of the RFA.
For purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 50 beds.
We are not preparing a rural impact analysis since we have
determined, and the Secretary certifies, that this notice will not have
a significant impact on the operations of a substantial number of small
rural hospitals.
In accordance with the provisions of Executive Order 12866, this
notice was reviewed by the Office of Management and Budget.
(Sections 1848(d) and (f) of the Social Security Act) (42 U.S.C.
1395w-4(d) and (f))
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: October 27, 1997.
Nancy-Ann Min DeParle,
Deputy Administrator, Health Care Financing Administration.
Dated: October 28, 1997.
Donna E. Shalala,
Secretary.
[FR Doc. 97-29028 Filed 10-30-97; 8:45 am]
BILLING CODE 4120-01-P