[Federal Register Volume 63, Number 89 (Friday, May 8, 1998)]
[Proposed Rules]
[Pages 25576-25715]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-12207]
[[Page 25575]]
_______________________________________________________________________
Part III
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
42 CFR Parts 405, 412, and 413
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 1999 Rates; Proposed Rule
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed
Rules
[[Page 25576]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 405, 412, and 413
[HCFA-1003-P]
RIN 0938-AI22
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1999 Rates
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: We are proposing to revise the Medicare hospital inpatient
prospective payment systems for operating costs and capital-related
costs to implement applicable statutory requirements, including section
4407 of the Balanced Budget Act of 1997, as well as 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 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, 1998. We are also setting forth proposed rate-of-
increase limits as well as proposing changes for hospitals and hospital
units excluded from the prospective payment systems.
DATES: Comments will be considered if received at the appropriate
address, as provided below, no later than 5 p.m. on July 7, 1998.
ADDRESSES: Mail written comments (an original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-1003-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,
ashington, 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 HCFA-1003-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.
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FOR FURTHER INFORMATION CONTACT:
Nancy Edwards, (410) 786-4531, Operating Prospective Payment, DRG, and
Wage Index Issues.
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded
Hospitals, and Graduate Medical Education Issues.
SUPPLEMENTARY INFORMATION:
I. Background
A. Summary
Sections 1886(d) and (g) of the Social Security Act (the Act), set
forth 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. Section 1886(g) of the Act requires
the Secretary to pay for the capital-related costs of hospital
inpatient stays under a prospective payment system. Under these
prospective payment systems, Medicare payment for hospital inpatient
operating and capital-related costs is made at predetermined, specific
rates for each hospital discharge. Discharges are classified according
to a list of diagnosis-related groups (DRGs).
Certain specialty hospitals are excluded from the prospective
payment systems. Under section 1886(d)(1)(B) of the Act, the following
hospitals and units are excluded from PPS: psychiatric hospitals or
units, rehabilitation hospitals or units, children's hospitals, long
term care hospitals, and cancer hospitals. For these hospitals and
units, Medicare payment for operating costs is based on reasonable
costs subject to a hospital-specific annual limit.
Under section 1886(a)(4) of the Act, costs incurred in connection
with approved graduate medical education (GME) programs are excluded
from the operating costs of inpatient hospital services. Hospitals with
approved GME programs are paid for the direct costs of GME in
accordance with section 1886(h) of the Act; the amount of payment for
direct GME costs for a cost reporting period is based on the number of
the hospital's residents in that period and the hospital's costs per
resident in a base year.
The regulations governing the hospital inpatient prospective
payment system are located in 42 CFR Part 412. The regulations
governing excluded hospitals are located in both Parts 412 and 413, and
the graduate medical education regulations are found in Part 413.
On August 29, 1997, we published a final rule with comment period
in the Federal Register (62 FR 45966) setting forth both statutorily
required changes and other changes to the Medicare hospital inpatient
prospective payment systems for both operating costs and capital-
related costs, which were effective for discharges occurring on or
after October 1, 1997. This rule also
[[Page 25577]]
implemented changes addressing payments for excluded hospitals and
payments for graduate medical education costs. This final rule with
comment period followed a proposed rule published in the Federal
Register on June 2, 1997 (62 FR 29902) that set forth proposed updates
and changes.
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, 1998.
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 1999 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 the following:
FY 1999 wage index update.
Changes to the data categories included in the wage index.
Revisions to the wage index based on hospital
redesignations.
3. Other Decisions and Changes to the Prospective Payment System for
Inpatient Operating and Graduate Medical Education Costs
In section IV. 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:
Definition of transfer cases.
Rural referral centers.
Disproportionate share adjustment.
Bad debts.
Direct graduate medical education programs.
4. Changes to the Prospective Payment System for Capital-Related Costs
In section V. of this preamble, we discuss several provisions of
the regulations in 42 CFR part 412 and set forth certain proposed
changes and clarifications concerning the following:
Capital indirect medical education payments.
Payments to new hospitals.
5. Changes for Hospitals and Hospital Units Excluded from the
Prospective Payment Systems
In section VI. of this preamble, we discuss the following criteria
governing excluded hospital issues:
Hospital-within-a-hospital.
Adjustments to the target amounts for FY 1999.
6. 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 1999
prospective payment rates for operating costs and capital-related
costs. We are also proposing update factors for determining the rate-
of-increase limits for cost reporting periods beginning in FY 1999 for
hospitals and hospital units excluded from the prospective payment
system.
7. 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.
8. Capital Acquisition Model
Appendix B contains the technical appendix on the proposed FY 1999
capital cost model.
9. 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 a recommended update factor for
FY 1999 for both hospitals included in and hospitals excluded from the
prospective payment systems. This report is included as Appendix C to
this proposed rule.
10. Proposed Recommendation of Update Factor for Hospital Inpatient
Operating Costs
As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix
D provides our recommendation of the appropriate percentage change for
FY 1999 for the following:
Large urban area and other area average standardized
amounts (and hospital-specific rates applicable to sole community and
Medicare-dependent, small rural 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.
11. Discussion of Medicare Payment Advisory Commission Recommendations
The Balanced Budget Act of 1997 abolished the Prospective Payment
Assessment Commission (ProPAC) and created the Medicare Payment
Advisory Commission (MedPAC). Under section 1805(b) of the Act, MedPAC
is required to submit a report to Congress, not later than March 1 of
each year, that reviews and makes recommendations on Medicare payment
policies. The March 1, 1998 report made several recommendations
concerning hospital inpatient payment policies. We reviewed those
recommendations and this document sets forth our responses to those
recommendations.
Although it has been our practice to include a reprint of ProPAC's
March 1 report as an appendix to the proposed rule, we are not
following that practice with MedPAC reports. For further information
relating specifically to that report or to obtain a copy of the report,
contact MedPAC at (202) 653-7220.
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, 1998 are discussed
below.
[[Page 25578]]
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 Revision, Clinical
Modification (ICD-9-CM). The Medicare fiscal intermediary enters the
information into its claims system and subjects it to a series of
automated screens called the Medicare Code Editor (MCE). These screens
are designed to identify cases that require further review before
classification into a DRG can be accomplished.
After screening through the MCE and any further development of the
claims, cases are classified by the GROUPER software program into the
appropriate DRG. The GROUPER program was developed as a means of
classifying each case into a DRG on the basis of the diagnosis and
procedure codes and demographic information (that is, sex, age, and
discharge status). It is used both to classify past cases in order to
measure relative hospital resource consumption to establish the DRG
weights and to classify current cases for purposes of determining
payment. The records for all Medicare hospital inpatient discharges are
maintained in the Medicare Provider Analysis and Review (MedPAR) file.
The data in this file are used to evaluate possible DRG classification
changes and to recalibrate the DRG weights.
Currently, cases are assigned to one of 496 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, cases are assigned to an MDC based on the principal
diagnosis, before assignment to a DRG. However, there are five DRGs to
which cases are directly assigned on the basis of procedure codes.
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 1999 and other decisions concerning DRGs are set forth
below. Unless otherwise noted, our DRG analysis is based on the full
(100 percent) FY 1997 MedPAR file based on bills received through
September 1997.
2. MDC 5 (Diseases and Disorders of the Circulatory System)
In the August 29, 1997 hospital inpatient final rule with comment
period (62 FR 45974), we noted that, because of the many recent changes
in heart surgery, we were considering conducting a comprehensive review
of the MDC 5 surgical DRGs. We have begun that review, and based upon
our analysis thus far, we believe it is appropriate to propose some DRG
changes immediately. These proposed changes are set forth below.
a. Coronary Bypass. There are two DRGs that capture coronary bypass
procedures: DRG 106 (Coronary Bypass with Cardiac Catheterization) and
DRG 107 (Coronary Bypass without Cardiac Catheterization). The
procedures that allow a coronary bypass case to be assigned to DRG 106
include percutaneous valvuloplasty, percutaneous transluminal coronary
angioplasty (PTCA), cardiac catheterization, coronary angiography, and
arteriography.
In analyzing the FY 1997 MedPAR file, we noted that, of cases
assigned to DRG 106, the average standardized charges for coronary
bypass cases with PTCA were significantly higher than those cases
without PTCA. There were approximately 4,400 cases in DRG 106 where
PTCA is performed as a secondary procedure. These cases have an average
standardized charge of approximately $69,000. The average charge of the
approximately 95,000 cases in DRG 106 without PTCA is approximately
$52,000.
Based on this analysis, we are proposing to create a new DRG for
coronary bypass cases with PTCA. The cases currently in DRG 106 without
PTCA would be assigned to another DRG and the cases currently assigned
to DRG 107 would be unmodified. Because we would replace two DRGs with
three new DRGs, we would revise the DRG numbers and titles accordingly.
The new DRGs and their titles are set forth below:
DRG 106 Coronary Bypass with PTCA
DRG 107 Coronary Bypass with Cardiac Catheterization
DRG 109 Coronary Bypass without Cardiac Catheterization
We note that DRG 109 has been an empty DRG for the last several
years.
b. Implantable Heart Assist System and Annuloplasty. In the August
29, 1997 final rule with comment period, we moved implant of an
implantable, pulsatile heart assist system (procedure code 37.66) from
DRGs 110 and 111 (Major Cardiovascular Procedures) 1 to DRG
108 (Other Cardiothoracic Procedures). Although this move improved
payment for these procedures, they were still much more expensive than
the other cases in DRG 108 ($96,000 for heart assist versus an average
of $54,000 for all other cases in the FY 1996 MedPAR file). We stated
that we would continue to review the MDC 5 surgical DRGs in an attempt
to find a DRG placement for these cases that would be more similar in
terms of resource use.
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\1\ A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second DRG is for cases without CC. If a third number is included,
it represents cases with patients who are age 0-17. Occasionally, a
pair of DRGs is split between age >17 and age 0-17.
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In reviewing the FY 1997 MedPAR file, we note that heart assist
system implant continues to be the most expensive procedure in DRG 108.
In fact, other than heart transplant, heart assist system implant is
the most expensive procedure in MDC 5. The average FY 1997 charge for
these cases, when assigned to DRG 108, is over $150,000 compared to
about $53,000 for all cases in DRG 108. Obviously, the charges for
heart assist implant are increasing at a much greater rate than the
average charges for DRG 108. In addition, the length of stay for cases
coded with 37.66 is approximately 32 days compared to about 11 days for
all other DRG 108 cases.
[[Page 25579]]
One possibility for improving payment for these cases is to move
them to DRGs 104 and 105 (Cardiac Valve Procedures). Those DRGs, which
split on the basis of the performance of cardiac catheterization, have
average charges of approximately $66,000 and $51,000, respectively.
While heart assist implant cases are still more expensive than the
average case in these DRGs, payment would be improved. Clinically,
placement of heart assist implant in DRGs 104 and 105 is not without
precedent. Effective with FY 1988, we placed implant of a total
automatic implantable cardioverter defibrillator (AICD) in these DRGs.
In addition, the vast majority of procedures assigned to DRG 108
involve surgically splitting open the sternum to perform the procedure.
However, implant of the heart assist device does not require this
approach.
While reviewing the DRG 108 cases, we also noted that procedure
code 35.33 (annuloplasty) is assigned to this DRG. Annuloplasty is a
valve procedure and is clinically more similar to the cases assigned to
DRGs 104 and 105 than it is to the cases assigned to DRG 108. In
addition, the average standardized charge for annuloplasty cases
assigned to DRG 108 is about $67,000, well above the overall average
charge of approximately $53,000 for cases in DRG 108. Therefore, we are
proposing to move annuloplasty from DRG 108 to DRGs 104 and 105.
In order to more accurately reflect the cases assigned to DRGs 104
and 105, we would retitle them as follows:
DRG 104 Cardiac Valve and Other Major Cardiothoracic Procedures
with Cardiac Catheterization
DRG 105 Cardiac Valve and Other Major Cardiothoracic Procedures
without Cardiac Catheterization.
3. MDC 22 (Burns)
Under the current DRG system, burn cases are assigned to one of six
DRGs in MDC 22 (Burns), which have not been revised since 1986. In our
FY 1998 hospital inpatient proposed rule (June 2, 1997; 62 FR 29912),
in response to inquiries we had received, we indicated that we would
conduct a comprehensive review of MDC 22 to determine whether changes
in these DRGs could more appropriately capture the variation in
resource use associated with different classes of burn patients. We
solicited public comments on this issue, particularly asking for
recommendations on ways to categorize related diagnosis and procedure
codes to produce DRG groupings that would be more homogeneous in terms
of resource use.
Among the comments we received was a proposal (endorsed by the
American Burn Association (ABA)) for restructuring the DRGs based on
several statistical and clinical criteria, including age, severity of
the burn, and the presence of complications or comorbidities. Although
this proposal was structured for a patient population encompassing all
ages of patients, we believed that it showed great promise for Medicare
patients as well. During the last several months, we have worked
closely with representatives of the ABA and with the clinicians who
developed the proposal in order to refine it for Medicare purposes.
Based on this work, we are proposing a new set of DRGs for burn
cases. Under this proposal, we would replace the six existing DRGs in
MDC 22 with eight new DRGs. For ease of reference and classification,
the current DRGs in MDC 22, DRGs 456 through 460 and 472, would no
longer be valid, and we would establish new DRGs 504 through 511 to
contain all cases that currently group to MDC 22. (The complete titles
of the new DRGs are set forth below.)
In reviewing the Medicare burn cases, we found that the most
important distinguishing characteristic in terms of resource use was
the amount of body surface affected by the burn and how much of that
burn was a 3rd degree burn. The second most important factor was
whether or not the patient received a skin graft. Thus, a patient with
burns covering at least 20 percent of body area, with at least 10
percent of that a 3rd degree burn, consumed the most resources.
However, if a patient met these criteria and did not receive a skin
graft, then the case was much less expensive and the average length of
stay fell from over 30 days to 8 days. The first two proposed burn DRGs
would reflect these distinctions (DRGs 504 and 505).
After classifying the most extensive burn cases, we found that the
patients with 3rd degree burns that did not meet the criteria to be
assigned to DRGs 504 and 505 were the most expensive of the remaining
cases (that is, those patients whose burns that did not meet the at
least 20 percent body area or at least 10 percent 3rd degree criteria).
These burns are referred to clinically as ``full-thickness burns.'' A
subset of these full-thickness burn cases, those with skin graft or an
inhalation injury, were much more expensive than the other cases. After
dividing these patients into two groups, with or without skin graft or
inhalation injury, we examined whether other factors had an influence
on resource use. We found that patients who had a CC (complication or
comorbidity) or a concomitant significant trauma consumed more
resources whether or not they had a skin graft or inhalation injury.
Thus, the next four DRGs were defined as full-thickness burns with skin
graft or inhalation injury with or without CC or significant trauma, or
full-thickness burns without skin graft or inhalation injury with or
without CC or significant trauma (DRGs 506 through 509).
Finally, the last two proposed DRGs (510 and 511) are for cases
with nonextensive burns. These cases are also split on the basis of CCs
or concomitant significant trauma.
Consistent with the recommendations of several commenters on last
year's proposed rule, the new burn DRGs would no longer include a
separate DRG for cases in which burn patients were transferred to
another acute care facility. Overall, we estimate that these proposed
changes would increase by more than 25 percent the amount of variation
in resource use explained by the DRGs in MDC 22. They would also
improve the clinical coherence of the cases within each DRG. Thus, we
believe that the proposed DRGs would provide for improved payment for
cases assigned to MDC 22.
The specific diagnosis and procedure codes that would be included
in each of the eight DRGs and their titles are as follows:
DRGs 504 and 505--Extensive 3rd Degree Burns with and without Skin
Graft
DRGs 504 and 505 would include all cases with burns involving at
least 20 percent of body surface area combined with a 3rd degree burn
covering at least 10 percent of body surface area. Thus, these cases
would have diagnosis codes of 948.xx, with a fourth digit of 2 or
higher (indicating that burn extends over 20 percent or more of body
surface) and a fifth digit of 1 or higher (indicating a 3rd degree burn
extending over 10 percent or more of body surface). Cases with the
appropriate diagnosis codes would be classified into DRG 504 if one of
the following skin graft procedure codes is present:
85.82 Split-thickness graft to breast
85.83 Full-thickness graft to breast
85.84 Pedicle graft to breast
86.60 Free skin graft, NOS
86.61 Full-thickness skin graft to hand
86.62 Other skin graft to hand
86.63 Full-thickness skin graft to other sites
86.65 Heterograft to skin
86.66 Homograft to skin
86.67 Dermal regenerative graft (new code in FY 1999--see Table 6A
in section V. of the Addendum)
86.69 Other skin graft to other sites
86.70 Pedicle of flap graft, NOS
[[Page 25580]]
86.71 Cutting and preparation of pedicle grafts or flaps
86.72 Advancement of pedicle graft
86.73 Attachment of pedicle or flap graft to hand
86.74 Attachment of pedicle or flap graft to other sites
86.75 Revision of pedicle or flap graft
86.93 Insertion of tissue expander
DRGs 506 and 507--Full Thickness Burn with Skin Graft or Inhalation
Injury with or without CC or Significant Trauma
These DRGs would include all other cases of 3rd degree burns that
also have either a skin graft or an inhalation injury. Thus, these
cases would have diagnosis codes of 941.xx through 946.xx, and 949.xx,
with a fourth digit of 3 or higher, as well as cases with codes of
948.xx that did not group into DRGs 504 or 505 (that is, 948.00,
948.01, and 948.1x through 948.9x with a fifth digit of 0). In
addition, cases classified into DRGs 506 and 507 must have either one
of the skin graft procedure codes listed above or one of the following
diagnosis codes for inhalation injuries:
518.5 Pulmonary insufficiency following trauma and surgery
518.81 Respiratory failure
518.84 Acute and chronic respiratory failure (new code in FY 1999--
see Table 6A in section V. of the Addendum)
947.1 Burn of larynx, trachea, or lung
987.9 Toxic effect of gas, fume, or vapor, NOS
Cases that meet both of these coding criteria would be assigned to
DRG 506 if there is a diagnosis code indicating either a CC (based on
the standard DRG CC list) or concomitant significant trauma (based on
the significant trauma diagnosis codes, listed by body site, used for
classification in MDC 24).
DRGs 508 and 509--Full Thickness Burn without Skin Graft or Inhalation
Injury with or without CC or Significant Trauma
These DRGs would include all other cases of 3rd degree burns. Thus,
these DRGs would include all cases without a skin graft or inhalation
injury that have diagnosis codes of 941.xx through 946.xx, and 949.xx,
with a fourth digit of 3 or higher, as well as cases with codes of
948.xx that did not group into DRGs 504 or 505. DRG 508 would also
require a secondary diagnosis from the standard CC list or the trauma
list based on the significant trauma diagnosis codes, listed by body
site, used for classification in MDC 24.
DRGs 510 and 511--Nonextensive Burns with and without CC or Significant
Trauma
The remaining burn cases would be classified into one of these two
DRGs, depending on whether or not the claim included a diagnosis code
reflecting the presence of a CC or a significant trauma, as explained
above.
4. Legionnaires' Disease
Effective with discharges occurring on or after October 1, 1997, a
new diagnosis code was created for pneumonia due to Legionnaires'
disease (code 482.84). In the August 29, 1997 final rule with comment
period, we assigned this code to DRGs 79, 80, and 81 (Respiratory
Infections and Inflammations) (62 FR 46090). However, we did not
include this code as a human immunodeficiency virus (HIV) major related
condition in MDC 25 (HIV Infections). Because pneumonia due to
Legionnaires' disease is a serious respiratory condition that has a
deleterious effect on patients with HIV, we are proposing to assign
diagnosis code 482.84 to DRG 489 (HIV with Major Related Condition) as
a major related condition. In addition, we did not assign the code as a
major problem in DRGs 387 (Prematurity with Major Problems) and 389
(Full Term Neonate with Major Problems). These DRGs are assigned to MDC
15 (Newborns and Other Neonates with Conditions Originating in the
Perinatal Period). Again, as a part of this proposed rule, we would
assign diagnosis code 482.84 as a major problem in DRGs 387 and 389
because of its effect on resource use in treating newborns.
5. 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 ``major cardiovascular procedures''
consists of two DRGs (DRGs 110 and 111). 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
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.
Assume also that the average charge of DRG 1 is higher than that of DRG
3, but the average charges of DRGs 4 and 5 are higher than the average
charge of DRG 2. To determine whether surgical class A should be higher
or lower than surgical class B in the surgical hierarchy, we would
weight the average charge of each DRG by frequency (that is, by the
number of cases in the DRG) to determine average resource consumption
for the surgical class. The surgical classes would then be ordered from
the class with the highest average resource utilization to that with
the lowest, with the exception of ``other OR procedures'' as discussed
below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class 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
[[Page 25581]]
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.
At this time, we would revise the surgical hierarchy for MDC 3
(Diseases and Disorders of the Ear, Nose, Mouth and Throat) as follows:
We would reorder Sinus and Mastoid Procedures (DRGs 53-54)
above Myringotomy with Tube Insertion (DRGs 61-62).
We would reorder Mouth Procedures (DRGs 168-169) above
Tonsil and Adenoid Procedure Except Tonsillectomy and/or Adeniodectomy
Only (DRGs 57-58).
6. Refinement of Complications and Comorbidities List
There is a standard list of diagnoses that are considered 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); the August 30, 1996 final
rule for the FY 1997 revisions (61 FR 46171); and the August 29, 1997
final rule for the FY 1998 revisions (62 FR 45966)).
We are proposing a limited revision of the CC Exclusions List to
take into account the changes that will be made in the ICD-9-CM
diagnosis coding system effective October 1, 1998. (See section II.B.8,
below, for a discussion of ICD-9-CM changes.) These proposed changes
are being made in accordance with the principles established when we
created the CC Exclusions List in 1987.
Tables 6F and 6G 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,
1998. 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 6F--Additions to the CC
Exclusions List. Beginning with discharges on or after October 1, 1998,
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 6G--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 1998 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
[[Page 25582]]
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,
1997, and 1998) and those in Tables 6F and 6G 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, 1998.
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 15.0, is available for $195.00,
which includes $15.00 for shipping and handling. Version 16.0 of this
manual, which will include the final FY 1999 DRG changes, will be
available in October 1998 for $225.00. 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.
7. 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, August 30, 1996, and August 29, 1997, we moved
several other procedures from DRG 468 to 477, as well as moving some
procedures from DRG 477 to 468. (See 55 FR 36135, 56 FR 43212, 57 FR
23625, 58 FR 46279, 59 FR 45336, 60 FR 45783, 61 FR 46173, and 62 FR
45981, 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 did not identify any necessary changes;
therefore, we are not proposing to move any procedures from DRGs 468
and 477 to one of the surgical DRGs.
b. Reassignment of Procedures Among DRGs 468, 476, and 477. We
also reviewed the list of procedures that produce assignments to DRGs
468, 476, and 477 to ascertain if any of those procedures should be
moved from one of these DRGs to another based on average charges and
length of stay. Generally, we move only those procedures for which we
have an adequate number of discharges to analyze the data. Based on our
review this year, we are not proposing to move any procedures from DRG
468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG
477 to DRGS 468 or 476.
8. 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 the Tabular List and Alphabetic
Index for Diseases while HCFA has lead responsibility for the ICD-9-CM
procedure codes included in the Tabular List and Alphabetic Index for
Procedures.
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 5 and December 4 and 5, 1997, and finalized the
coding changes after consideration of comments received at the meetings
and in writing
[[Page 25583]]
within 30 days following the December 1997 meeting. The initial meeting
for consideration of coding issues for implementation in FY 2000 will
be held on June 4, 1998. Copies of the minutes of the 1997 meetings can
be obtained from the HCFA Home Page @ http://www.hcfa.gov/pubaffr.htm,
under the ``What's New'' listing. Paper copies of these minutes are no
longer available and the mailing list has been 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, Center for Health Plans and Providers,
Plan and Provider Purchasing Policy Group, Division of Acute Care; 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, 1998. 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
classifications.
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, 1998. The
corresponding new or expanded diagnosis codes are included in Table 6A.
Procedure codes that have been replaced by expanded codes, other codes,
or have been deleted are in Table 6D (Invalid Procedure Codes).
Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis
Code Titles), which also include the proposed DRG assignments for these
revised codes. For FY 1999, there are no revisions to procedure code
titles.
9. Other Issues--
a. Palliative Care. Effective October 1, 1996 (FY 1997), we
introduced a diagnosis code to allow the identification of those cases
in which palliative care was delivered to a hospital inpatient. This
code, V66.7 (Encounter for palliative care), was unusual in that there
had been no previous code assignment that included the concept of
palliative care. Since this was a new concept, instructional materials
were developed and distributed by the AHA as well as specialty groups
on the use of this new code. With new codes, it sometimes takes several
years for physician documentation to improve and for coders to become
accustomed to looking for this type of information in order to assign a
code. There is an inclusion note listed under V66.7 which indicates
that this code should be used as a secondary diagnosis only; the
patient's medical problem would always be listed first. Currently, use
of diagnosis code V66.7 does not have an impact on DRG assignment.
Consistent with prior practice, we have waited until the FY 1997 data
became available for analysis before considering any possible
modifications to the DRGs.
In analyzing the FY 1997 bills received through September 1997, we
found that 4,769 discharges included V66.7 as a secondary diagnosis.
These cases were widely distributed throughout 199 DRGs. The vast
majority of these DRGs included five or fewer discharges with use of
palliative care. Only 12 DRGs included more than 100 cases. These were
the following:
------------------------------------------------------------------------
Number of
DRG Title cases
------------------------------------------------------------------------
10............................... Nervous System Neoplasms 144
with CC.
14............................... Specific Cerebrovascular 272
Disorders Except TIA.
79............................... Respiratory Infections 139
and Inflammations Age
>17 with CC.
82............................... Respiratory Neoplasms... 526
89............................... Simple Pneumonia and 200
Pleurisy Age >17 with
CC.
127.............................. Heart Failure and Shock. 184
172.............................. Digestive Malignancy 226
with CC.
203.............................. Malignancy of 285
Hepatobiliary System or
Pancreas.
239.............................. Pathological Fractures 218
and Musculoskeletal and
Connective Tissue
Malignancy.
296.............................. Nutritional and 173
Miscellaneous Metabolic
Disorders Age >17 with
CC.
403.............................. Lymphoma and Non-Acute 178
Leukemia with CC.
416.............................. Septicemia Age >17...... 147
------------------------------------------------------------------------
Six of these DRGs are cancer-related; however, the other DRGs are
quite diverse. Upon further analysis, we found that, for the most part,
discharges with code V66.7 do not significantly differ in length of
stay from the discharges in the same DRG without code V66.7. Discharges
with code V66.7 are sometimes longer and sometimes shorter and the
comparative length of stay for a given DRG tends to vary by only one
day. In general, the average charges for a palliative care case
discharge with a secondary code of V66.7 were lower than the charges
for other discharges within the DRG. However, these differences were
relatively small and were well within the standard variation of charges
for cases in the DRG.
One approach we could take to revise the DRGs would be to divide
those DRGs with a large number of cases coded with V66.7 into two
different DRGs, with and without palliative care. However, the
relatively small proportion of cases in each DRG argues against this
approach; no DRG has more than 1 percent of its cases coded with
palliative care and, in most cases, the percentage is well under 1
percent. An alternative approach would be to group all palliative care
cases, regardless of the underlying disease or condition, into one new
DRG. However, the charges of these cases are so varied that this is not
a logical choice. In addition, there is a lack of clinical coherence in
such an approach. The underlying diagnoses of
[[Page 25584]]
these cases range from respiratory conditions to heart failure to
septicemia. Because there are so few cases in the FY 1997 data and they
are so widely dispersed among different DRGs, we are not proposing a
DRG modification at this time. We will make a more detailed analysis of
these cases over the next year based on a more complete FY 1997 data
file as well as review of the FY 1998 cases that will be available
later this year. As time goes by, hospital coders and physicians should
become more aware of this code and we hope that more complete data will
assist our decision making process.
b. PTCA. Effective with discharges occurring on or after October 1,
1997, we reassigned cases of PTCA with coronary artery stent implant
from DRG 112 to DRG 116. In the August 29, 1997 final rule with comment
period, we responded to several commenters who contended that PTCA
cases treated with platelet inhibitors were as resource intensive as
the PTCA with stent implant cases and that these cases should also be
moved to DRG 116. However, there is currently no code that describes
the infusion of platelet inhibitors. Therefore, we were unable to make
any changes in the DRGs for FY 1998.
As set forth in Table 6B, New Procedure Codes in section V. of the
addendum to this proposed rule, a new procedure code for injection or
infusion of platelet inhibitors (code 99.20) will be effective with
discharges occurring on or after October 1, 1998. Our usual policy on
new codes is to assign them to the same DRG or DRGs as their
predecessor code. Because infusion of platelet inhibitors is currently
assigned to a non-OR procedure code, we followed our usual practice and
designated code 99.20 as a non-OR code that does not affect DRG
assignment.
We will not have any data on this new code until we receive bills
for FY 1999. Thus, we would be unable to make any changes in DRG
assignment until FY 2001. We note, however, that the Conference Report
that accompanied the Balanced Budget Act of 1997 contained language
stating that ``* * * in order to ensure that Medicare beneficiaries
have access to innovative new drug therapies, the Conferees believe
that HCFA should consider, to the extent feasible, reliable, validated
data other than MedPAR data in annually recalibrating and reclassifying
the DRGs.'' (H.R. Rep. No. 105-217.734). At this time, we have received
no data that would allow us to make an appropriate modification of DRG
112 for PTCA cases with platelet infusion therapy. When we develop the
final rule, we will review and analyze any data we receive about the
use of platelet inhibitors for Medicare beneficiaries. If we believe
that the data are adequate to allow identification of the percentage of
cases in DRG 112 that receive this therapy and the charge and length of
stay data convince us that these cases should be moved, we will
consider such a move effective for discharges occurring on or after
October 1, 1998.
C. Recalibration of DRG Weights
We are proposing to use the same basic methodology for the FY 1999
recalibration as we did for FY 1998. (See the August 29, 1997 final
rule with comment (62 FR 45982).) 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 1997 MedPAR
file, rather than the FY 1996 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 1997 MedPAR data, based on bills received by HCFA through December
1997, from all hospitals subject to the prospective payment system and
short-term acute care hospitals in waiver States. The FY 1997 MedPAR
file includes data for approximately 11.2 million Medicare discharges.
The methodology used to calculate the proposed DRG relative weights
from the FY 1997 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.5, 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 1999. Using the FY 1997 MedPAR
data set, there are 38 DRGs that contain fewer than 10 cases. We
computed the weights for the 38 low-volume DRGs by adjusting the FY
1998 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
[[Page 25585]]
changes, result in an average case weight that is different from the
average case weight before recalibration. Therefore, the new weights
are normalized by an adjustment factor, so that the average case weight
after recalibration is equal to the average case weight before
recalibration. This adjustment is intended to ensure that recalibration
by itself neither increases nor decreases total payments under the
prospective payment system.
Section 1886(d)(4)(C)(iii) of the Act requires that beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payment to hospitals is affected by factors other than average case
weight. Therefore, as we have done in past years and as discussed in
section II.A.4.b of the Addendum to this proposed rule, we are
proposing to make a budget neutrality adjustment to assure that the
requirement of section 1886(d)(4)(C)(iii) of the Act is met.
III. Proposed Changes to the Hospital Wage Index
A. Background
Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary must adjust the standardized amounts ``for area differences
in hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the national average hospital wage level.'' In
accordance with the broad discretion conferred 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.F, 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 1999 Wage Index Update
The proposed FY 1999 wage index in section V of the Addendum
(effective for hospital discharges occurring on or after October 1,
1998 and before October 1, 1999) is based on the data collected from
the Medicare cost reports submitted by hospitals for cost reporting
periods beginning in FY 1995 (the FY 1998 wage index was based on FY
1994 wage data). The proposed FY 1999 wage index includes the following
categories of data, which were also included in the FY 1998 wage index:
Total salaries and hours from short-term, acute care
hospitals.
Home office costs and hours.
Direct patient care contract labor costs and hours.
The proposed wage index also continues to exclude the direct
salaries and hours for nonhospital services such as skilled nursing
facility services, home health services, or other subprovider
components that are not subject to the prospective payment system.
Finally, as discussed in detail in the August 29, 1997 final rule with
comment period, we would calculate a separate Puerto Rico-specific wage
index and apply it to the Puerto Rico standardized amount. (See 62 FR
45984 and 46041) This wage index is based solely on Puerto Rico's data.
For FY 1999 we are proposing to include two changes to the
categories: we will add contract labor costs and hours for top
management positions and replace the fringe benefit category with the
wage-related costs associated with hospital and home office salaries
category. These two changes reflect changes to the Medicare cost report
that were implemented in the FY 1995 hospital prospective payment
system September 1, 1994 final rule with comment period (59 FR 45355).
The changes were made to the cost report for cost reporting periods
beginning during FY 1995. Because we are using wage data from the FY
1995 cost report for the proposed FY 1999 wage index, these two changes
will be reflected in the wage index for the first time in FY 1999.
As discussed in detail in the September 1, 1994 final rule with
comment period (59 FR 45355), we expanded the definition of contract
services reported on the Worksheet S-3 to include the labor-related
costs associated with contract personnel in a hospital's top four
management positions: Chief Executive Officer (CEO)/Hospital
Administrator, Chief Operating Officer (COO), Chief Financial Officer
(CFO), and Nursing Administrator. We also revised the cost report to
reflect a change in terminology from ``fringe benefits'' to ``wage-
related costs,'' to promote the consistent reporting of these costs.
(See September 1, 1994 final rule with comment period 59 FR 45356-
45359.) We made this change in terminology because we believe that it
will eliminate confusion regarding those wage-related costs that are
incorporated in the wage index versus the broader definition of fringe
benefits recognized under the Medicare cost reimbursement principles.
Wage-related costs, which include core and other wage-related costs,
are reported on the Form HCFA-339, the Provider Cost Report
Reimbursement Questionnaire.
Finally, we have analyzed the wage data for the following costs,
which were separately reported for the first time on the FY 1995 cost
reports:
Physician Part A costs.
Resident and Certified Registered Nurse Anesthetist (CRNA)
Part A costs.
Overhead cost and hours by cost center.
Our analysis and proposals concerning these data are set forth
below in section III.C.
[[Page 25586]]
C. Proposals Concerning the FY 1999 Wage Index
1. Physician Part A Costs.
Currently, if a hospital directly employs a physician, the Part A
portion of the physician's salary and wage-related costs (that is,
administrative and teaching service) is included in the calculation of
the wage index. However, the costs for contract physician Part A
services are not included. Our policy has been that, to be included in
the wage index calculation, a contracted service must be related to
direct patient care, or, beginning with the FY 1999 wage index, top
level management (see discussion above). Because some States have laws
that prohibit hospitals from directly hiring physicians, the hospitals
in those States have claimed that they are disadvantaged by the wage
index's exclusion of contract physician Part A costs. We began
collecting separate wage data for both direct and contract physician
Part A services on the FY 1995 cost report in order to analyze this
issue. As we discussed in the September 1, 1994 final rule with comment
period (59 FR 45354), our original purpose in collecting these data was
to exclude all Part A physician costs from the wage index.
When we made the change to the cost report, there were five States
in which hospitals were prohibited from directly employing physicians.
We understand that only two States currently maintain this prohibition:
Texas and California. Thus, the number of hospitals affected by our
current policy has decreased. Nevertheless, the fact that hospitals in
these two States are still prohibited from directly employing
physicians for Part A services and, therefore, must enter into
contractual agreements with physicians for these services, perpetuates
the perceived inequity.
The main reasons we planned to exclude all Part A physician costs
rather than include the contract costs was our concern that it would be
difficult to accurately attribute the Part A costs and hours of these
contract physicians and including these costs could inappropriately
inflate the hospitals' average hourly wages. That is, we anticipated
that average costs for contract physicians would be significantly
higher than the costs for those physicians directly employed by the
hospital. However, our analysis of the data shows that the average
hourly wages for contract physician Part A costs are very similar to,
and, in fact slightly lower than, the costs for salaried Part A
physician services.
Based on this result, we believe that continuing to include the
direct physician Part A costs and adding the costs for contract
physicians would be the better policy. Thus, we are proposing to
calculate the FY 1999 wage index including both direct and contract
physician Part A costs.
Of the 5,115 hospitals included in the FY 1995 wage data file,
approximately 23 percent reported contract physician Part A costs.
Including these costs would raise the wage index values for one MSA (2
hospitals) by more than 5 percent and 5 MSAs (60 hospitals) by between
2 and 5 percent. One Statewide rural area (68 hospitals) would
experience a decrease between 2 and 5 percent. The wage index values
for the remaining 365 areas (5,055 hospitals) would be relatively
unaffected, experiencing changes of between -2 and 2 percent. We
understand that an unusually large number of hospitals have requested
changes to these wage data; therefore, there may be relatively
significant differences between the wage data file used to calculate
the proposed wage index and the final corrected wage data in the file
used to calculate the final wage index. Because of this, we will
reevaluate our decision based on that final wage data, which will be
submitted by April 6, 1998. If we find significant differences in the
contract labor costs, we may reconsider our proposal.
2. Resident and CRNA Part A Costs
The wage index presently includes salaries and wage-related costs
for residents in approved medical education programs and for CRNAs
employed by hospitals under the rural pass-through provision. However,
Medicare pays for these costs outside the prospective payment system.
Removing these costs from the wage index calculation would be
consistent with our general policy to exclude costs that are not paid
through the prospective payment system, but, because they were not
separately identifiable, we could not remove them.
In the September 1, 1994 final rule with comment period (59 FR
45355), we stated that we would begin collecting the resident and CRNA
wage data separately and would evaluate the data before proposing a
change in computing the wage index. However, there were data reporting
problems associated with these costs on the FY 1995 cost report. The
original instructions for reporting resident costs on Line 6 of
Worksheet S-3, Part III, erroneously included teaching physician
salaries and other teaching program costs from Worksheet A of the cost
report. Although we issued revised instructions to correct this error,
we now understand these revisions may not have been uniformly
instituted. Another issue relating to residents' salaries stems from
apparent underreporting of these costs by hospitals and inconsistent
treatment of the associated wage-related costs.
In addition, the original Worksheet S-3 and reporting instructions
did not provide for the separate reporting of CRNA wage-related costs.
Another issue with the FY 1995 wage data is the inclusion of contract
CRNA Part A costs in the contract labor costs reported on Worksheet S-
3. We believe that much of the CRNA Part A costs are reported under
contract labor, rather than under salaried employee costs, due to the
heavy use of contract labor by rural hospitals. We do not believe that
it would be feasible at this time to try to remove these CRNA Part A
costs from the contract labor costs. We improved the reporting
instructions for CRNA costs on the FY 1996 cost report.
Our analysis of the CRNA and resident wage data submitted on the FY
1995 cost report convinces us that these data are inaccurately and
incompletely reported by hospitals. For example, although there are
over 900 teaching hospitals receiving graduate medical education
payments, only about 800 hospitals reported resident cost data. Because
we do not want to make a relatively significant change in the wage
index data calculation without complete and accurate data upon which to
base our decision, we are proposing to delay any decision regarding
excluding resident and CRNA costs from the wage index until at least
next year. We will review the FY 1996 data when it becomes available
later this year and present our analysis and any proposals in next
year's proposed rule.
3. Overhead Allocation
Prior years' wage index calculations have excluded the direct wages
and hours associated with certain subprovider components that are
excluded from the prospective payment system; however, the overhead
costs associated with excluded components have not been removed. We
have previously attempted to remove the overhead costs associated with
these excluded areas of the hospital on two separate occasions. Based
on the quality of the data, as well as comments we received from the
public, these proposals were never implemented.
In the September 1, 1995 final rule with comment period (60 FR
45797), we discussed the results of the second of these efforts. Our
analysis was prompted by several suggestions from hospital
representatives that the current methodology, which removes the higher
[[Page 25587]]
nursing costs in excluded areas from the hospital's direct salaries but
leaves in the lower general services salaries, negatively distorts
wages. However, the results of our analysis at that time dissuaded us
from proposing to exclude these areas' overhead costs because the data
were unreliable. We revised the FY 1995 cost report to allow for the
reporting of the overhead salaries and hours. We stated that we would
reexamine this issue when the FY 1995 cost report data became
available.
To allocate overhead costs based on the data reported on Worksheet
S-3, we first determined the ratio of the hours reported directly to
excluded areas compared to the total hours. Total overhead hours and
salaries were then multiplied by this ratio to allocate the proportion
of overhead costs attributable to excluded areas. Next, the overhead
hours and salaries attributable to excluded areas were subtracted from
the hospital's total hours and salaries, and an average hourly wage
reflecting this overhead allocation was computed.
Of the 5,115 hospitals in the FY 1995 wage data file, 3,661
reported overhead hours (hospitals were only required to separately
report overhead hours if their number of directly assigned excluded
hours exceeded 5 percent of their total hours). The overhead allocation
would result in an increase in the wage index value of more than 5
percent for only one MSA (2 hospitals). A total of 12 labor areas (5
Statewide rural (206 hospitals) and 7 MSAs (25 hospitals)) would
experience an increase of between 2 percent and 5 percent. Only one MSA
(29 hospitals) would experience a decline of between 2 and 5 percent.
The wage index value for the remaining 358 areas (4,921 hospitals)
would be affected by less than 2 percent.
We are proposing to include this exclusion of overhead allocation
in the calculation of the FY 1999 wage index. Although the overall
impact on hospitals of this change is relatively small, we believe it
is an appropriate step toward improving the overall consistency of the
wage index. Additionally, we believe this change will significantly
increase the accuracy of the wage data for individual hospitals,
especially hospitals that have a relatively small portion of their
facility devoted to acute inpatient care.
D. Verification of Wage Data From the Medicare Cost Report
The data for the proposed FY 1999 wage index were obtained from
Worksheet S-3, Parts III and IV of the FY 1995 Medicare cost reports.
The data file used to construct the proposed wage index includes FY
1995 data submitted to the Health Care Provider Cost Report Information
System (HCRIS) as of early January 1998. 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 5,123 hospitals originally in the data file, 851 hospitals
had data elements that failed an edit. From mid-January to mid-February
1998, intermediaries contacted hospitals to revise or verify data
elements that resulted in the edit failures.
As of February 17, 1998, 31 hospitals still had unresolved data
elements. These unresolved data elements are included in the
calculation of the proposed FY 1999 wage index pending their resolution
before calculation of the final FY 1999 wage index. We have instructed
the intermediaries to complete their verification of questionable data
elements and to transmit any changes to the wage data (through HCRIS)
no later than April 6, 1998. We expect that all unresolved data
elements will be resolved by that date. The revised data will be
reflected in the final rule.
Also, as part of our editing process, we deleted data for eight
hospitals that failed edits. For two of these hospitals, we were unable
to obtain sufficient documentation to verify or revise the data because
the hospitals are no longer participating in the Medicare program or
are in bankruptcy status. The data from the remaining six participating
hospitals were removed because inclusion of their data would have
significantly distorted the wage index values. The data for these six
hospitals will be included in the final wage index if we receive
corrected data that passes our edits. As a result, the proposed FY 1999
wage index is calculated based on FY 1995 wage data for 5,115
hospitals.
E. 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 1999 wage
index on wage data reported on the FY 1995 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, Parts III
and IV of the Medicare cost report for the hospital's cost reporting
period beginning on or after October 1, 1994 and before October 1,
1995. In addition, we included data from a few hospitals that had cost
reporting periods beginning in September 1994 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 1995 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
wage-related costs, we added the costs of contract labor for direct
patient care, certain top management, and physician Part A services;
hospital wage-related costs, and any home office salaries and wage-
related costs reported by the hospital, to the net hospital salaries.
The actual calculation is the sum of lines 2, 4, 6, and 33 of Worksheet
S-3, Part III. This calculation differs from the one computed on line
32 of Worksheet S-3, Part III. Therefore, a hospital's average hourly
wage calculated under Step 2 will be different from the average hourly
wage shown on line 32, column 5.
Step 3--For each hospital, we subtracted the reported excluded
hours from the gross hospital hours to determine net hospital hours. To
determine total hours, we increased the net hours by the addition of
home office hours and hours for contract labor attributable to direct
patient care, certain top management, and physician Part A salaries.
Step 4--For each hospital reporting both total overhead salaries
and total overhead hours greater than zero, we then allocated overhead
costs. First, we determined the ratio of excluded area hours (Line 24
of Worksheet S-3, Part III) to revised total hours (Line 9 of Worksheet
S-3, Part III, adding back CRNA Part A, physician Part A, and resident
hours). Second, we computed the amounts of overhead salaries and hours
to be allocated to excluded areas by multiplying the above ratio by the
total overhead salaries and hours reported on Line 16 of Worksheet S-3,
Part IV. Finally, we subtracted the computed overhead salaries and
hours associated with excluded areas from the total salaries and hours
derived in Steps 2 and 3.
Step 5--For each hospital, we adjusted the total salaries plus
wage-related costs to a common period to determine total adjusted
salaries plus wage-related costs. To make the wage inflation
adjustment, we estimated the percentage change in the employment
[[Page 25588]]
cost index (ECI) for compensation for each 30-day increment from
October 14, 1994 through April 15, 1996, for private industry hospital
workers from the Bureau of Labor Statistics Compensation and Working
Conditions. For previous wage indexes, we used the percentage change in
average hourly earnings for hospital industry workers to make the wage
inflation adjustment. For FY 1999 we are proposing to use the ECI for
compensation for private industry hospital workers because it reflects
the price increase associated with total compensation (salaries plus
fringes) rather than just the increase in salaries, which is what the
average hourly earnings category reflected. In addition, the ECI
includes managers as well as other hospital workers. We are also
proposing to change the methodology used to compute the monthly update
factors. This new methodology uses actual quarterly ECI data to
determine the monthly update factors. The methodology assures that the
update factors match the actual quarterly and annual percent changes.
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
------------------------------------------------------------------------
Adjustment
After Before factor
------------------------------------------------------------------------
10/14/94...................................... 11/15/94 1.032882
11/14/94...................................... 12/15/94 1.030771
12/14/94...................................... 01/15/95 1.028721
01/14/95...................................... 02/15/95 1.026731
02/14/95...................................... 03/15/95 1.024776
03/14/95...................................... 04/15/95 1.022827
04/14/95...................................... 05/15/95 1.020886
05/14/95...................................... 06/15/95 1.018901
06/14/95...................................... 07/15/95 1.016822
07/14/95...................................... 08/15/95 1.014649
08/14/95...................................... 09/15/95 1.012446
09/14/95...................................... 10/15/95 1.010279
10/14/95...................................... 11/15/95 1.008146
11/14/95...................................... 12/15/95 1.006047
12/14/95...................................... 01/15/96 1.003981
01/14/96...................................... 02/15/96 1.001950
02/14/96...................................... 03/15/96 1.000000
03/14/96...................................... 04/15/96 0.998181
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1995 and ending December 31, 1995 is June 30, 1995. An
inflation adjustment factor of 1.016822 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 1995 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 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 wage-
related costs obtained in Step 5 for all hospitals in that area to
determine the total adjusted salaries plus wage-related costs for the
labor market area.
Step 7--We divided the total adjusted salaries plus wage-related
costs 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 wage-related
costs obtained in Step 5 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 $20.6036.
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 wage-related costs (as calculated in Step 5) 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
$9.3339 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.
Step 11--Section 4410 of Public Law 105-33 provides that, for
discharges on or after October 1, 1997, the area wage index applicable
to any hospital that is not located in a rural area may not be less
than the area wage index applicable to hospitals located in rural areas
in that State. Furthermore, this wage index floor is to be implemented
in such a manner as to assure that aggregate prospective payment system
payments are not greater or less than those which would have been made
in the year if this section did not apply. For FY 1999, this change
affects 229 hospitals in 34 MSAs. The MSAs affected by this provision
are identified in Table 4A by a footnote.
F. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to which they have been redesignated. Therefore, as
provided in section 1886(d)(8)(C) of the Act, the wage index values
were determined by considering the following:
If including the wage data for the redesignated hospitals
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 urban or 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
[[Page 25589]]
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.
We note that, except for those rural areas where redesignation
would reduce the rural wage index value, 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 1999 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 urban or 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 hospital is redesignated is lower than the wage
index value for the rural areas of the State in which the hospital is
located, the redesignated 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 1995
wage data. In addition, Table 3C in the Addendum to this proposed rule
includes the adjusted average hourly wage for each hospital based on
the FY 1995 data (as calculated from Steps 4 and 5, above). 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(w)(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 may use the proposed wage data in applying to the
MGCRB for wage index reclassifications that would be effective for FY
2000. We note that in adjudicating these wage index reclassification
requests during FY 1999, the MGCRB will use the average hourly wages
for each hospital and labor market area that are reflected in the final
FY 1999 wage index.
At the time this proposed wage index was constructed, the MGCRB had
completed its review. The proposed FY 1999 wage index values
incorporate all 435 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 1999. 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 1999 must be received by the MGCRB by June 22, 1998. A
hospital that requests to withdraw its application may not later
request that the MGCRB decision be reinstated.
G. Requests for Wage Data Corrections
As a part of the August 29, 1997 final rule with comment period, we
implemented a new timetable for requesting wage data corrections (62 FR
45990). In February 1998, we notified hospitals again of these changes
through a memorandum to the fiscal intermediaries. To allow hospitals
time to evaluate the wage data used to construct the proposed FY 1999
hospital wage index, we made available to the public a data file
containing the FY 1995 hospital wage data. In a memorandum dated
February 2, 1998, we instructed all Medicare intermediaries to inform
the prospective payment hospitals that they serve of the availability
of the wage data file and the process and timeframe for requesting
revisions. The wage data file was made available February 6, 1998,
through the Internet at HCFA's home page (http://www.hcfa.gov). The
intermediaries were also instructed to advise hospitals of the
alternative availability of these data through their representative
hospital organizations or directly from HCFA. Additional details on
ordering this data file are discussed in section IX.A of this preamble,
``Requests for Data from the Public.''
In addition, 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 adjusted
average hourly wage, as calculated from Steps 4 and 5 of the
computation of the wage index (see section III.E of this preamble,
above) based on the wage data on the hospital's 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 adjustment factors as set forth above in Step 5 of the computation
of the wage index. As noted above, however, a hospital's average hourly
wages using this calculation will vary from the average hourly wages
shown on Line 32 of Worksheet S-3, Part III. An updated Table 3C (along
with applicable wage adjustment factors) will be included in the final
rule.
We believe hospitals have had ample time to ensure the accuracy of
their FY 1995 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 released February
6, a hospital believed that its FY 1995 wage data were incorrectly
reported, the hospital was to submit corrections along with complete,
detailed supporting documentation to its intermediary by March 9, 1998.
To be reflected in the final wage index, any wage data corrections must
be reviewed and verified by the intermediary and transmitted to HCFA on
or before April 6, 1998. These deadlines are necessary
[[Page 25590]]
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 1, 1998. We
cannot guarantee that corrections transmitted to HCFA after April 6
will be reflected in the final wage index.
After reviewing requested changes submitted by hospitals,
intermediaries transmitted any revised cost reports to HCRIS and
forwarded a copy of the revised Worksheet S-3, Parts III and IV to the
hospitals. If requested changes were not accepted, fiscal
intermediaries notified hospitals of the reasons why the changes were
not accepted. This procedure ensures 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 policy disputes. We note that the April 6 deadline
also applies to these requested changes. We will not consider factual
determinations at this time as these should have been resolved earlier
in the process.
We have created the process described above to resolve all
substantive wage data correction disputes before we finalize the wage
data for the FY 1999 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 note that, beginning this year with the FY 1999 wage index, the
final wage index that is published August 1 will incorporate all
corrections, including those to correct data entry or tabulation errors
of the final wage data by the intermediary or HCFA. The final wage data
public use file will be released by May 7, 1998. Hospitals will have
until June 5, 1998, to submit requests to correct errors in the final
wage data due to data entry or tabulation errors by the intermediary or
HCFA. The correction requests that will be considered after the March 9
deadline will be limited to errors in the entry or tabulation of the
final wage data which the hospital could not have known about prior to
March 9, 1998.
The final wage data file released in early May 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 February, HCFA will make
the final wage data file released in May available to hospital
associations and the public (on the Internet). This 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 correction process described above
(with the March 9 deadline), 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 final file.
If, after reviewing the final 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 June 5, 1998. Requests mailed to
HCFA should be sent to: Health Care Financing Administration; Center
for Health Plans and Providers; Attention: Stephen Phillips, Technical
Advisor; Division of Acute Care; 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.
At this time, changes to the hospital wage data will be made 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 final wage data file. Specifically, neither the intermediary nor
HCFA will accept the following types of requests at this stage of the
process:
Requests for wage data corrections that were submitted too
late to be included in the data transmitted to HCRIS on or before April
6, 1998.
Requests for correction of errors that were not, but could
have been, identified during the hospital's review of the February 1998
wage data file.
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
June 5, 1998) will be incorporated into the final wage index to be
published by August 1, 1998, and effective October 1, 1998.
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 final wage data by early May, they will have
the opportunity to detect any data entry or tabulation errors made by
the intermediary or HCFA before the development and publication of the
FY 1999 wage index by August 1, 1998, and the implementation of the FY
1999 wage index on October 1, 1998. 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 errors
should occur after that date, we retain the right to make midyear
changes to the wage index under very limited circumstances.
Specifically, in accordance with Sec. 412.63(w)(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 1999 (that is, by the
June 5, 1998 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.
IV.-V. Other Decisions and Changes to the Prospective Payment
System for Inpatient Operating Costs
A. Definition of Transfers (Sec. 412.4)
Pursuant to section 1886(d)(5)(I) of the Act, the prospective
payment system distinguishes between ``discharges,'' situations in
which a patient leaves an acute care (prospective payment) hospital
after receiving complete acute care treatment, and ``transfers,''
situations in which the patient is transferred to another acute care
hospital for related care. If a full DRG payment were made to each
hospital involved in a transfer situation, irrespective of the length
of time the patient spent in the ``sending'' hospital prior to
transfer, a strong incentive to increase transfers would be created,
thereby unnecessarily endangering
[[Page 25591]]
patients' health. Therefore, our policy, which is set forth in the
regulations at Sec. 412.4, provides that, in a transfer situation, full
payment is made to the final discharging hospital and each transferring
hospital is paid a per diem rate for each day of the stay, not to
exceed the full DRG payment that would have been made if the patient
had been discharged without being transferred.
Currently, the per diem rate paid to a transferring hospital is
determined by dividing the full DRG payment that would have been paid
in a nontransfer situation by the geometric mean length of stay for the
DRG into which the case falls. Hospitals receive twice the per diem for
the first day of the stay and the per diem for every following day up
to the full DRG amount. Transferring hospitals are also eligible for
outlier payments for cases that meet the cost outlier criteria
established for all other cases (nontransfer and transfer cases alike)
classified to the DRG. Two exceptions to the transfer payment policy
are transfer cases classified into DRG 385 (Neonates, Died or
Transferred to Another Acute Care Facility) and DRG 456 (Burns,
Transferred to Another Acute Care Facility), which receive the full DRG
payment instead of being paid on a per diem basis.
Under section 1886(d)(5)(J) of the Act, which was added by section
4407 of the Balanced Budget Act of 1997, a ``qualified discharge'' from
one of 10 DRGs selected by the Secretary to a postacute care provider
will be treated as a transfer case beginning with discharges on or
after October 1, 1998. Section 1886(d)(5)(J)(iii) confers broad
authority on the Secretary to select 10 DRGs ``based upon a high volume
of discharges classified within such group and a disproportionate use
of'' certain post discharge services. Section 1886(d)(5)(J)(ii) defines
a ``qualified discharge'' as a discharge from a prospective payment
hospital of an individual whose hospital stay is classified in one of
the 10 selected DRGs if, upon such discharge, the individual--
Is admitted to a hospital or hospital unit that is not a
prospective payment system hospital;
Is admitted to a skilled nursing facility; or
Is provided home health services by a home health agency
if the services relate to the condition or diagnosis for which the
individual received inpatient hospital services and if these services
are provided within an appropriate period as determined by the
Secretary.
The Conference Agreement that accompanied the law noted that
``(t)he Conferees are concerned that Medicare may in some cases be
overpaying hospitals for patients who are transferred to a post acute
care setting after a very short acute care hospital stay. The Conferees
believe that Medicare's payment system should continue to provide
hospitals with strong incentives to treat patients in the most
effective and efficient manner, while at the same time, adjust PPS
[prospective payment system] payments in a manner that accounts for
reduced hospital lengths of stay because of a discharge to another
setting.'' (H.R. Rep. No. 105-217, 740.) In its March 1, 1997 report,
ProPAC expressed similar concerns: ``* * * length of stay declines have
been greater in DRGs associated with substantial postacute care use,
suggesting a shift in care from hospital inpatient to postacute
settings'' (pp. 21-22).
In fact, based on the latest available data, overall Medicare
hospital costs per case have decreased during FYs 1994 and 1995. This
unprecedented real decline in costs per case has led to historically
high Medicare operating margins (over 10 percent on average). Along
with these declining lengths of stay and costs per case, there has been
an increase in the utilization of postacute care. In 1990, the rate of
skilled nursing facility services per 1,000 Medicare enrollees was 19.
By 1995, it had grown to 33. Corresponding numbers for home health
agency services are 58 per 1,000 Medicare enrollees during 1990 and 93
per 1,000 enrollees during 1995. Although home health services are not
always directly related to a hospitalization episode, there does appear
to be a trend toward increased use of home health for the provision of
postacute care rehabilitation services. Previous analysis of the
percentage of hospital discharges that receive postacute home health
care showed a 10.3 percent increase in 1994 compared to 1992.
Our proposals to implement section 1886(d)(5)(J) of the Act are set
forth below.
1. Selection of 10 DRGs
Section 1886(d)(5)(J)(iii)(I) of the Act provides that the
Secretary select 10 DRGs based on a high volume of discharges to
postacute care and a disproportionate use of postacute care services.
Therefore, in order to select the DRGs to be paid as transfers, we
first identified those DRGs with the highest percentage of postacute
care.
We used the FY 1996 MedPAR file because the complete FY 1997 MedPAR
file was not available at the time we conducted our analysis. To
identify postacute care utilization, we merged hospital inpatient bill
files with postacute care bill files matching beneficiary
identification numbers and discharge and admission dates. We created
this file rather than depend on information concerning discharge
destination on the inpatient bill because we have found that the
discharge destination codes included on the hospital bills are often
inaccurate in identifying discharges to a facility other than another
prospective payment hospital.
Section 1886(d)(5)(J)(ii)(III) of the Act requires the Secretary to
choose an appropriate window of days in which the home health services
start in order for the discharge to meet the definition of a transfer.
In order to include postdischarge home health utilization in our
analysis, we identified all hospital discharges for patients who
received any home health care within 7 days after the date of
discharge. (As described below in section IV.A.2., we ultimately
decided to propose 3 days as the window for home health services.)
Starting with the DRG with the highest percentage of postacute care
discharges and continuing in descending order, we selected the first 20
DRGs that had a relatively large number of discharges to postacute care
(our lower limit was 14,000 cases). In order to select 10 DRGs from the
20 DRGs on our list, for each of the DRGs we considered the volume and
percent age of discharges to postacute care that occurred before the
mean length of stay and whether the discharges occurring early in the
stay were more likely to receive postacute care. The following table
lists the 10 DRGs we are proposing to include under our expanded
transfer definition, their percentage of postacute utilization compared
to total cases, and the total number of cases identified as going to
postacute care.
[[Page 25592]]
------------------------------------------------------------------------
Percent of Number of
DRG Title and type of DRG postacute postacute
(surgical or medical) utilization cases
------------------------------------------------------------------------
14................. Specific Cerebrovascular 49.5 186,845
Disorders Except
Transient Ischemic
Attack (Medical).
113................ Amputation for 59.0 28,402
Circulatory System
Disorders Excluding
Upper Limb and Toe
(Surgical).
209................ Major Joint Limb 71.9 257,875
Reattachment Procedures
of Lower Extremity
(Surgical).
210................ Hip and Femur Procedures 77.8 111,799
Except Major Joint Age
>17 With CC (Surgical).
211................ Hip and Femur Procedures 74.2 19,548
Except Major Joint Age
>17 Without CC
(Surgical).
236................ Fractures of Hip and 61.2 24,498
Pelvis (Medical).
263................ Skin Graft and/or 49.4 14,499
Debridement for Skin
Ulcer or Cellulitis With
CC (Surgical).
264................ Skin Graft and/or 39.3 1,328
Debridement for Skin
Ulcer or Cellulitis W/O
CC (Surgical).
429................ Organic Disturbances and 45.4 19,314
Mental Retardation
(Medical).
483................ Tracheostomy Except for 45.3 18,254
Face, Mouth and Neck
Diagnoses (Surgical).
------------------------------------------------------------------------
We included DRG 263 on the list because of its ranking in the top
20 DRGs in terms of postacute utilization and volume of discharges to
postacute care. DRGs 263 and 264 are paired DRGS; that is, the only
difference in the cases assigned to DRG 263 as opposed to DRG 264 is
that the patient has a complicating or comorbid condition. If we
included only DRG 263 in the list, it would be possible for a transfer
case with a relatively short length of stay that should be assigned to
DRG 263 and receive a relatively small transfer payment to be assigned
instead to DRG 264, and receive the full DRG payment, simply by failing
to include the CC diagnosis code on the bill. Therefore, our choice was
to either delete DRG 263 from the list or add DRG 264. We decided to
include DRG 264 in the proposed list because DRG 263 fully meets all
the conditions for inclusion on the list of 10 DRGS.
2. Postacute Care Settings
Section 1886(d)(5)(J)(ii) of the Act requires the Secretary to
define and pay as transfers cases from one of 10 DRGs selected by the
Secretary if the individual is discharged to one of the following
settings:
A hospital or hospital unit that is not a subsection
[1886](d) hospital, that is a hospital or unit excluded from the
inpatient prospective payment system.
A skilled nursing facility that is, a facility that meets
the definition of a skilled nursing facility set forth at section 1819
of the Act.
Home health services provided by a home health agency, if
the services are related to the condition or diagnosis for which the
individual received inpatient hospital services, and if the home health
services are provided within an appropriate period (as determined by
the Secretary).
Section 1886(d)(1)(B) of the Act defines the hospitals and hospital
units that are excluded from the prospective payment system as the
following: psychiatric, rehabilitation, childrens', long-term care, and
cancer hospitals and psychiatric and rehabilitation distinct part units
of a hospital. Therefore, any discharge from a prospective payment
hospital from one of the 10 proposed DRGS that is admitted to one of
these types of facilities on the date of discharge from the acute
hospital, on or after October 1, 1998, would be considered a transfer
and paid accordingly under the prospective payment systems (operating
and capital) for inpatient hospital services.
A discharge from a prospective payment hospital to a skilled
nursing facility would include cases discharged from one of the 10 DRGS
from an inpatient bed in the hospital to a bed in the same hospital
that has been designated for the provision of skilled nursing care (a
``swing'' bed). The swing bed provision allows certain small rural
hospitals to furnish services in inpatient beds which, if furnished by
a skilled nursing facility, would constitute extended care services. In
addition, any patient who receives swing-bed services is deemed to have
received extended care services as if furnished by a skilled nursing
facility. Thus, if swing beds are not included in the transfer policy,
those hospitals with swing bed agreements could move patients assigned
to one of the 10 selected DRGs as if it were a discharge from an
inpatient bed to a swing bed and receive payment. We do not believe
that this would be a fair policy in that it would create a payment
advantage for swing bed hospitals. Therefore, we are providing in the
regulations that a discharge to a swing bed will be paid as a transfer
when the patient is classified to one of the 10 selected DRGs.
Section 1886(d)(5)(J)(ii)(III) of the Act states that the discharge
of an individual who receives home health services upon discharge will
be treated as a transfer if ``such services are provided within an
appropriate period (as determined by the Secretary) * * *.'' As
discussed above in section IV.A.1, we began our analysis using 7 days
(one week) as the time period we would consider. We now believe that 3
days after the date of discharge is a more appropriate timeframe. Based
on our analysis of the FY 1996 bills, approximately 90 percent of
patients began receiving home health care within 3 days. We are
particularly interested in receiving comments on the appropriate period
of time in which home health services should begin in the context of
the transfer policy.
With regard to an appropriate definition of ``home health services
* * * relate[d] to the condition or diagnosis for which the individual
received inpatient hospital services * * *'', we considered several
possible approaches. Under one approach we could compare the principal
diagnosis of the inpatient stay to the diagnosis code indicated on the
home health bill, similar to our policy on the 3-day payment window for
preadmission services. However, we believe that is far too restrictive
in terms of qualifying discharges for transfer payment. In addition, a
hospital will not know when it discharges a patient to home health what
diagnosis code the home health agency will put on the bill. Therefore,
the hospital would not be able to correctly code the inpatient bill as
a transfer or discharge.
We also considered proposing that any home health care that begins
within the designated timeframe be included ``as related'' in our
definition. However, this definition might be too broad and the
hospital would not be able to predict which cases should be coded as
transfers because the hospital often may not know about home health
services that are provided upon discharge but were not ordered or
planned for as part of the hospital discharge plan.
We are proposing that home health services would be considered
related to the hospital discharge if the patient is discharged from the
hospital with a written plan of care for the provision of home health
care services from a home health agency. In this way, the hospital
would be fully aware of the status of the patient when discharged and
could be held responsible for correctly coding the
[[Page 25593]]
discharge as a transfer on the inpatient bill. In general, this would
mean that the home health service would qualify as a Part A home health
benefit under section 1861(tt) of the Act as added by section 4611(b)
of the BBA.
We note, however, that we plan to compare inpatient bills with home
health service bills for care provided within 3 days after discharge,
similar to our current claims edit for hospital to hospital transfers.
If we find that home health services were provided within the
postdischarge window, the hospital will be notified and the hospital
payment adjusted unless the hospital can submit documentation verifying
the discharge status of the patient. This will alert hospitals if there
are problems with their discharge/transfer billing and allow them to
adjust their discharge planning process and billing practices. If we
find a continued pattern of a hospital billing for cases from the 10
DRGs as discharges and our records indicate that the patients are
receiving postacute care services from an excluded hospital, a skilled
nursing facility, or within the 3-day home health service window, the
hospitals may be investigated for fraudulent or abusive billing
practices.
3. Payment Methodology
The statute does not dictate the payment methodology we must use
for these transfer cases. However, section 1886(d)(5)(J)(i) of the Act
provides that the payment amount for a case may not exceed the sum of
half the full DRG payment amount and half of the payment amount under
the current per diem payment methodology.
Based on our analysis comparing the costs per case for the
transfers in the 10 DRGs with payments under our current transfer
payment methodology, we found that most of the 10 DRGs are
appropriately paid using our current methodology (that is, twice the
per diem for the first day and the per diem for each subsequent day).
In fact, this payment would, on average, slightly exceed costs.
However, this is not true of DRGs 209, 210, and 211. For those three
DRGs, a disproportionate percentage (about 50 percent) of the costs of
the case are incurred on the first day of the stay. Therefore, we are
proposing to pay DRGs 209, 210, and 211 based on 50 percent of the DRG
payment for the first day of the stay and 50 percent of the per diem
for the remaining days of the stay. The other seven DRGs would be paid
under the current transfer payment methodology.
In Appendix E to this proposed rule, we have included tables that
illustrate, for 9 of the 10 DRGs, the number of total and postacute
discharges by length of stay, the geometric mean lengths of stay from
FY 1983 through FY 1997, and the estimated average costs and transfer
payments by length of stay. (The summary information for DRG 264 was
not available at the time of publication because it was not included in
the original data file of 20 DRGs used for our analysis.) For DRGs 209,
210, and 211, the payment line is determined on the basis of the
alternative payment formula described above.
These tables demonstrate that a very large number of discharges
from these 10 DRGs receive postacute care. In addition, the length of
stay for these DRGs has decreased sharply over the last several years.
We believe that this proposed policy will both decrease the hospitals'
financial incentive to discharge patients very early in the stay, often
before the full course of acute care treatment has ended, as well as
pay the hospital at an appropriate level when it does move patients
into postacute care.
We would revise Sec. 412.4 to reflect these proposed policies. In
addition, we would delete the reference in current Sec. 412.4(d)(2) to
DRG 456 (Burns, Transferred to Another Acute Care Facility) because we
are proposing to replace that DRG, as discussed in section II.B.3 of
this preamble. There would no longer be any burn DRG with a transfer
designation.
B. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act,
Sec. 412.96 sets forth the criteria a hospital must meet in order to
receive special treatment under the prospective payment system as a
rural referral center. For discharges occurring before October 1, 1994,
rural referral centers received the benefit of payment based on the
other urban rather than the rural standardized amount. As of that date,
the other urban and rural standardized amounts were the same. However,
rural referral centers continue to receive special treatment under both
the disproportionate share hospital payment adjustment and the criteria
for geographic reclassification.
One of the criteria under which a rural hospital may qualify as a
rural referral center is to have 275 or more beds available for use. A
rural hospital that does not meet the bed size criterion can qualify as
a rural referral center if the hospital meets two mandatory criteria
(specifying a minimum case-mix index and a minimum number of
discharges) and at least one of the three optional criteria (relating
to specialty composition of medical staff, source of inpatients, or
volume of referrals). With respect to the two mandatory criteria, a
hospital may be classified as a rural referral center if its--
Case-mix index is at least equal to the lower of the
median case-mix index for urban hospitals in its census region,
excluding hospitals with approved teaching programs, or the median
case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 discharges per year
or, if fewer, the median number of discharges for urban hospitals in
the census region in which the hospital is located. (The number of
discharges criterion for an osteopathic hospital is at least 3,000
discharges per year.)
1. Case-Mix Index
Section 412.96(c)(1) provides that HCFA will establish updated
national and regional case-mix index values in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. The methodology we use to determine the
proposed national and regional case-mix index values, is set forth in
regulations at Sec. 412.96(c)(1)(ii). 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 1997
(October 1, 1996 through September 30, 1997) and include bills posted
to HCFA's records through December 1997. Therefore, in addition to
meeting other criteria, for hospitals with fewer than 275 beds, we are
proposing that to qualify for initial rural referral center status for
cost reporting periods beginning on or after October 1, 1998, a
hospital's case-mix index value for FY 1997 would have to be at least--
1.3578; 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)..................... 1.2533
2. Middle Atlantic (PA, NJ, NY)............................. 1.2499
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 1.3468
[[Page 25594]]
4. East North Central (IL, IN, MI, OH, WI).................. 1.2717
5. East South Central (AL, KY, MS, TN)...................... 1.2965
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 1.2264
7. West South Central (AR, LA, OK, TX)...................... 1.3351
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 1.3752
9. Pacific (AK, CA, HI, OR, WA)............................. 1.3405
------------------------------------------------------------------------
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 March 31, 1997.
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 1997 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.
2. Discharges
Section 412.96(c)(2)(i) provides that HCFA will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, we
are proposing to update the regional standards. The proposed regional
standards are based on discharges for urban hospitals' cost reporting
periods that began during FY 1996 (that is, October 1, 1995 through
September 30, 1996). 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 for cost
reporting periods beginning on or after October 1, 1998, the number of
discharges a hospital must have for its cost reporting period that
began during FY 1997 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)..................... 6658
2. Middle Atlantic (PA, NJ, NY)............................. 8477
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 7505
4. East North Central (IL, IN, MI, OH, WI).................. 7273
5. East South Central (AL, KY, MS, TN)...................... 6852
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 5346
7. West South Central (AR, LA, OK, TX)...................... 5179
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 7926
9. Pacific (AK, CA, HI, OR, WA)............................. 5945
------------------------------------------------------------------------
We note that the number of discharges for hospitals in each census
region is greater than the national standard of 5,000 discharges.
Therefore, 5,000 discharges is the minimum criteria for all hospitals.
These numbers will be revised in the final rule based on the latest FY
1996 cost report data.
We reiterate that, to qualify for rural referral center status for
cost reporting periods beginning on or after October 1, 1998, 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.
C. Payments to Disproportionate Share Hospitals: Conforming Change
Regarding Interpretation of Medicaid Patient Days Included in
Disproportionate Patient Percentage (Sec. 412.106)
Effective for discharges beginning on or after May 1, 1986,
hospitals that treat a disproportionately large number of low-income
patients receive additional payments through the disproportionate share
(DSH) adjustment. One means of determining a hospital's DSH payment
adjustment for a cost reporting period requires calculation of its
disproportionate patient percentage for the period. The
disproportionate patient percentage is the sum of a prescribed Medicare
fraction and a Medicaid fraction for the hospital's fiscal period.
Under clause (I) of section 1886(d)(5)(F)(vi) of the Act and
Sec. 412.106(b)(2), the Medicare fraction is determined by dividing the
number of the hospital's patient days for patients who were entitled
(for such days) to benefits under both Medicare Part A and Supplemental
Security Income (SSI) under Title XVI of the Act, by the total number
of the hospital's patient days for the patients who were entitled to
Medicare Part A. The Medicaid fraction is determined, in accordance
with clause (II) of section 1886(d)(5)(F)(vi) of the Act and
Sec. 412.106(b)(4), by dividing the number of the hospital's patient
days for patients who (for such days) were eligible for medical
assistance under a State Medicaid plan approved under Title XIX of the
Act but who were not entitled to Medicare Part A, by the total number
of the hospital's patient days for that period.
Initially, HCFA calculated the Medicaid fraction by interpreting
section 1886(d)(5)(F)(vi)(II) of the Act to recognize as Medicaid
patient days only those days for which the hospital received Medicaid
payment for inpatient hospital services. See 51 FR 31454, 31460 (1986).
The agency's interpretation was declared invalid by four Federal
circuit courts of appeals. See Cabell Huntington Hosp., Inc. v.
Shalala, 101 F.3d 984, 990-91 (4th Cir. 1996) (following three other
circuits). These courts held that the statute requires, for purposes of
calculating the Medicaid fraction, inclusion of each patient day of
service for which a patient was eligible on that day for medical
assistance under an approved State Medicaid plan. Specifically, the
statute requires inclusion of each hospital patient day for a patient
eligible for Medicaid on such day, regardless of whether particular
items or services were covered or paid under the State Medicaid plan.
On February 27, 1997, the HCFA Administrator issued HCFA Ruling 97-
2, which acquiesced in the four adverse appellate court decisions. The
Ruling changed the agency's statutory construction to comport with
those decisions, in order to facilitate nationwide uniformity in the
calculation of the Medicaid fraction. Like the court decisions, the
Ruling provides that a hospital's Medicaid patient days include each
patient day of service for which a patient was eligible on such day for
medical assistance under an approved State Medicaid plan, regardless of
whether particular items or services were covered or paid under the
State plan. The Ruling also reflects the hospital's burden of
furnishing data adequate to prove each claimed Medicaid patient day,
and of verifying with the State that a patient was eligible for
Medicaid during each day of the inpatient hospital stay.
The Ruling further provides that the agency's new interpretation is
effective February 27, 1997 for each cost reporting period that: (1)
Begins on or after that effective date; (2) was not settled, as of that
date, on the Medicaid patient days issue, by means of an applicable
notice of program reimbursement (NPR) (see Sec. 405.1803); or (3) was
settled through such an NPR
[[Page 25595]]
as of the Ruling's effective date and is the subject of a pending
administrative appeal or civil action that satisfies all applicable
jurisdictional requirements of the Medicare statute and regulations.
The Ruling also provides, however, that the change in statutory
interpretation effected by the Ruling is not a basis for reopening a
hospital cost reporting period (see Secs. 405.1885-405.1889) that was
finalized previously on the same matter at issue.
We propose to revise Sec. 412.106(b)(4) in order to conform the
Medicare regulations to the new statutory construction issued in HCFA
Ruling 97-2. The revisions are necessary to ensure that the regulations
comport with the four appellate court decisions that declared invalid
the agency's prior interpretation and led to the issuance of the HCFA
Ruling. The proposed revisions will further facilitate nationwide
uniformity in the calculation of the Medicaid fraction.
Since the proposed revisions are intended simply to conform the
regulations to HCFA Ruling 97-2 (and hence to the four adverse court
decisions), revised Sec. 412.106(b)(4) would reiterate the Ruling's
change of interpretation that the Medicaid fraction under section
1886(d)(5)(F)(vi)(II) of the Act includes each hospital patient day for
a patient eligible for Medicaid on such day, regardless of whether
particular items or services were covered or paid under the State
Medicaid Plan. Our proposed revisions to Sec. 412.106(b)(4), like the
Ruling, would continue to place on the hospital the burdens of
production, proof, and verification as to each claimed Medicaid patient
day.
Under our proposal, revised Sec. 412.106(b)(4) would apply to cost
reporting periods beginning on or after October 1, 1998. HCFA Ruling
97-2, which includes the same provisions as proposed
Sec. 412.106(b)(4), would continue to apply to any cost reporting
period beginning before October 1, 1998 provided that, as of February
27, 1997, there is for such period: no submitted cost report; no cost
report settled on the Medicaid patient days issue through an applicable
NPR; or a cost report settled on that issue, which is also the subject
of a jurisdictionally proper administrative appeal or civil action on
the issue.
D. Payment for Bad Debts (Sec. 413.80)
Section 4451 of the Balanced Budget Act of 1997 reduces the payment
for enrollee bad debt for hospitals. Specifically, this provision
reduces the amount of bad debts otherwise treated as allowable costs,
attributable to the deductibles and coinsurance amounts under this
title, by 25 percent for cost reporting periods beginning during fiscal
year 1998, by 40 percent for cost reporting periods beginning during
fiscal year 1999, and by 45 percent for cost reporting periods
beginning during a subsequent fiscal year. This proposed rule would
conform the regulations to the statute.
Section 4451 of the Balanced Budget Act of 1997 also provides that
in determining such reasonable costs for hospitals, any copayments
reduced under the election available for hospital outpatient services
under section 1833(t)(5)(B) of the Act will not be treated as a bad
debt. This provision will be implemented in the outpatient prospective
payment system regulation that implements section 4521, 4522, and 4523
of the Balanced Budget Act of 1997, to be published later this year.
E. Payment for Direct Costs of Graduate Medical Education to Hospitals
and Nonhospital Providers (Secs. 405.2468, 413.85, and 413.86)
1. Introduction
Currently, under section 1886(h) of the Act, Medicare pays only
hospitals for the costs of graduate medical education (GME) training.
We do not pay nonhospital sites for the costs they incur in training
medical residents. There has been a general trend to shift patient care
from the inpatient setting to the less expensive nonhospital setting
where appropriate. Consistent with this trend in patient care, the BBA
allows for direct GME payment to qualified nonhospital providers to
encourage more training of future physicians in nonhospital settings.
Under section 1886(k) of the Act, as added by section 4625 of the
BBA, the Secretary is now authorized, but not required, to pay
qualified nonhospital providers for the direct costs of GME training.
The Conference Report also notes that the Conferees believe paying
nonhospital providers for GME costs may help alleviate physician
shortages in underserved rural areas. We believe that providing
Medicare payment directly to nonhospital providers may facilitate more
training and better quality training in nonhospital sites.
2. Statutory Background
Section 1886(k) of the Act states: ``For cost reporting periods
beginning on or after October 1, 1997, the Secretary may establish
rules for payment to qualified nonhospital providers for their direct
costs of medical education, if those costs are incurred in the
operation of an approved medical residency training programs described
in subsection (h).'' The statute further provides that, to the extent
the Secretary exercises this broad discretionary authority, the rules
``shall specify the amounts, form, and manner in which such payments
will be made and the portion of such payments that will be made from
each of the trust funds under this title.''
a. Payments Only to ``Qualified Nonhospital Providers''. The
statute confers broad discretion on the Secretary regarding whether and
how to pay nonhospital providers for direct GME costs. However, the
statute does specify the entities whom the Secretary can pay--
``qualified nonhospital providers.'' Section 1886(k)(2) of the Act
defines ``qualified nonhospital providers'' to include: Federally
Qualified Health Centers (FQHCs), as defined in section 1861(aa)(4);
Rural Health Centers (RHCs), as defined in section 1861(aa)(2);
Medicare+Choice organizations; and such other providers (other than
hospitals) as the Secretary determines to be appropriate.
b. Payments Only for the ``Direct Costs'' of Training. The statute
also specifies the costs the Secretary can pay for under section
1886(k) of the Act. Medicare pays hospitals for both the direct and
indirect costs of medical education under sections 1886(h) and
1886(d)(5)(B) of the Act respectively, but section 1886(k) of the Act
provides for payment to nonhospital providers only for the direct costs
of medical education.
In addition, section 1886(k) of the Act provides for payment for
the direct costs of training medical residents only if those costs are
incurred in the operation of an ``approved medical residency training
program.'' Section 1886(h)(5)(A) of the Act defines an ``approved
medical residency training program'' as a ``residency or other
postgraduate medical training program participation in which may be
counted toward certification in a specialty or subspecialty and
includes formal postgraduate training programs in geriatric medicine
approved by the Secretary.'' Implementing regulations at Sec. 413.86(b)
state that an approved medical residency training program includes
allopathic and osteopathic training programs as well as training
programs for dentistry and podiatry. Therefore, the statute authorizes
Medicare payments to nonhospital providers only for the costs of
training medical residents, not for the costs of training other health
professionals.
In addition to adding section 1886(k) of the Act, section 4625 of
the BBA amends section 1886(h)(3)(B) of the Act to prohibit double
payments for direct
[[Page 25596]]
GME to a hospital and a qualified nonhospital provider. This
prohibition on double payments requires that the Secretary reduce a
hospital's GME payments (the ``aggregate approved amount'' as defined
in section 1886(h)(3)(b) of the Act) to the extent we pay a nonhospital
provider for GME under section 1886(k) of the Act.
3. Proposed Policies
Pursuant to section 4625 of the BBA, we are proposing policies to
provide Medicare payment to nonhospital providers for the direct costs
of GME training, effective for portions of cost reporting periods
occurring on or after January 1, 1999. We believe that these payments
will serve the Congressional intent to encourage and support training
in nonhospital settings.
a. Definition of ``Qualified Non-Hospital Providers''. Under our
proposed policy, Medicare would make GME payments to the following
``qualified nonhospital providers''--FQHCs, RHCs, and Medicare+Choice
organizations. Under the authority of section 1886(k)(2)(D) of the Act,
the Secretary may expand the definition of a ``qualified nonhospital
provider'' to include such other providers (other than hospitals) as
the Secretary determines to be appropriate. Once we have gained
experience providing direct GME payments to FQHCs, RHCs, and
Medicare+Choice organizations, we may consider including other types of
nonhospital providers in the definition of a ``qualified nonhospital
provider.''
Additionally, we propose that, under certain circumstances, a
hospital may continue to receive GME payments for residents who train
in the nonhospital setting. In those instances where a hospital is
eligible to continue receiving GME payments for residents who train in
the nonhospital setting, the nonhospital provider could receive payment
from the hospital for costs they incur in training medical residents.
Thus, our policy promotes the intent of section 4625 of the BBA to
provide financial support, either directly from Medicare or through the
hospital, to nonhospital providers for the direct costs of training
residents in the nonhospital site.
b. Definition of ``Direct Costs'' of Medical Education for Non-
Hospital Providers. Section 4625 of the BBA provides for payment to
nonhospital providers only for the direct costs of training residents.
Our proposed definition of ``direct costs'' for nonhospital providers
is comparable to the direct costs for hospitals under section 1886(h)
of the Act. Under our proposed policy, direct GME costs are those costs
that are incurred by the nonhospital site for the education activities
of the approved program and that are the proximate result of training
medical residents in the nonhospital site. Direct costs for nonhospital
providers would include:
Residents' salaries and fringe benefits (including related
travel and lodging expenses where applicable);
That portion of costs of the teaching physicians' salaries
and fringe benefits that are related to the time spent in teaching and
supervision of residents; and
Other related GME overhead costs.
Consistent with our policies on direct GME costs for hospitals,
direct GME costs for nonhospital providers would not include normal
operating costs or the marginal increase in costs that the nonhospital
site experiences as a result of having an approved medical residency
training program. For example, a decrease in productivity and increased
intensity in treatment patterns as the result of a training program do
not constitute ``direct costs'' of training residents in the
nonhospital setting; rather, these are the ``indirect costs'' of such
training.
Also consistent with our policies for direct GME payments to
hospitals, we propose to pay qualified nonhospital providers only for
training that is related to the delivery of patient care services.
Sections 1886(h) (``Payments for Direct GME Costs'') and 1886(h)(4)(E)
of the Act (``Counting Time Spent in Outpatient Settings'') provide
support continuing our longstanding policy of paying only for training
that is associated with patient care services. In particular, section
1886(h)(4)(E) of the Act states:
Such rules shall provide that only time spent in activities
relating to patient care shall be counted and that all the time so
spent by a resident under an approved medical residency training
program shall be counted towards the determination of full-time
equivalency, without regard to the setting in which the activities
are performed, if the hospital incurs all, or substantially all, of
the costs for the training program in that setting.
In addition, section 1861(b) of the Act describes the types of patient
care services that are reimbursable. Specifically, section 1861(b)(6)
of the Act indicates that the training of interns or residents under an
approved teaching program are included as reimbursable patient care
costs.
Moreover, direct GME costs for nonhospital providers, like direct
GME costs for hospitals, would include only that portion of costs of
the teaching physicians' salaries and fringe benefits associated with
time spent in teaching and supervising residents. Specifically, a
teaching physician's time spent on teaching of a general nature would
constitute a direct GME cost, while teaching of a patient-specific
nature would not constitute a direct cost. In addition, direct costs in
the nonhospital setting would include that portion of teaching
physicians' salaries and fringe benefits associated with time spent
developing resident schedules and evaluating or rating the residents.
Direct costs would also include a teaching physician's office costs
allocated to GME.
By contrast, direct GME costs for nonhospital providers would not
include the following: A teaching physician's time spent in the care of
individual patients which results in billable services; teaching
physicians' activities that are related to the education of other
health professionals (i.e., classroom instruction in connection with
approved activities other than GME such as provider-operated nursing
programs); teaching physicians' time spent on administrative and
supervisory services to the provider that are unrelated to approved
educational activities (i.e. operating costs); and teaching physician
activities that involve nonallowable costs such as research and medical
school activities that are not related to patient care in the
nonhospital setting.
GME overhead costs include only those costs that are allocable to
direct GME and that are not used in patient care. For example, a
portion of administrative and general costs could be appropriately
allocated to an RHC or FQHC's GME cost center. Similarly, a conference
room that is dedicated specifically for the training of residents could
be appropriately allocated to an RHC or FQHC's GME cost center. By
contrast, patient care rooms added to an RHC or an FQHC cannot be
appropriately allocated to an RHC or FQHC's GME cost center.
One of the advantages of our proposed definition of ``direct
costs'' is that it is administratively feasible. Our definition of
``direct costs'' for nonhospital providers is comparable to the direct
costs that are included in the per resident amount paid to hospitals
under section 1886(h) of the Act. At present, there is limited
information regarding the actual costs of training residents in
nonhospital sites. After we gain experience providing direct GME
payments to qualified nonhospital providers and have reviewed the GME
costs separately reported by these nonhospital providers, we may revise
the definition of ``direct costs.'' We are
[[Page 25597]]
soliciting comments on other elements that may constitute direct costs
of GME in the nonhospital site that can be identified, reported, and
verified as directly attributable to GME activities through the cost
reporting process. We are interested in comments on whether we should
include other costs in the definition of ``direct costs'' for
nonhospital providers and on the administrative feasibility of
identifying the GME portion of those costs.
c. Determining Direct Costs. One of our major concerns in
developing policies for paying nonhospital providers for the direct
costs of GME is the administrative feasibility of determining the
amount of direct costs incurred by the nonhospital provider. It is our
understanding that, currently, hospitals and nonhospital sites often
share, to varying degrees, the costs of training residents in the
nonhospital site. Because of the difficulty in apportioning costs
between the hospital and the nonhospital for the training in the
nonhospital site, we believe that it is not administratively feasible
to pay both the hospital and the nonhospital site for the cost of
training in the nonhospital site. We have been unable to devise a
method for accurately apportioning costs between the two entities.
Furthermore, the potential for both the hospital and the
nonhospital site to be paid for the same direct GME expenses poses a
significant problem for complying with section 1886(h)(3)(B) of the
Act, as amended by the BBA, which specifically prohibits double
payments. Under this provision, the Secretary shall reduce the
hospital's GME payment (the ``aggregate approved amount'') to the
extent we pay nonhospital providers for GME costs under section 1886(k)
of the Act. Consequently, our policy must ensure that Medicare does not
pay two entities for the same training time in the nonhospital site.
Given that the hospital's per resident amount can include, but is
not necessarily based on the costs of training in the nonhospital site,
we were not able to devise an equitable way of reducing the hospital's
per resident payment to reflect payments made under section 1886(k) of
the Act. It would not be equitable to subtract the exact amount of
payment made to the qualified nonhospital provider from the hospital's
per resident payment because the payment made to the nonhospital site
is unrelated to the hospital's per resident amount. The hospital per
resident amount is based on specific GME costs incurred by the hospital
in the 1984 base year. Those costs included in the per resident amount
have no relevance to the costs incurred in the nonhospital setting
almost 15 years after the 1984 base year. We believe that the
residents' salaries, teaching physicians' salaries, and overhead costs
for the nonhospital setting will constitute a different proportion of
the total GME costs in the nonhospital setting as compared with the
hospital setting. Rather, it would be more equitable to determine the
proportion of costs incurred by each entity and reduce the hospital's
per resident payment by the proportion of GME costs incurred by the
nonhospital site; however, since specific components of the per
resident amount were not identified in the hospital's GME base year
(1984), we cannot accurately determine the appropriate amount to reduce
the current year hospital per resident payment amount. Moreover, to
reduce the hospital's GME payments based solely on the amount paid to
the nonhospital site could result in inequitable payments to the
hospital, which has ongoing costs even when the resident is training in
the nonhospital site. In fact, it could leave the hospital at risk of
receiving no payment for the GME costs it has incurred.
In order to encourage training in nonhospital sites, it is
important to develop a policy that, while providing payment to
nonhospital providers, would also be equitable to hospitals. We believe
that paying only the nonhospital site for the training costs could
result in hospitals choosing not to rotate their residents to the
nonhospital site. We have been unable to devise an equitable and
accurate method for dividing up the GME payment for training in the
nonhospital site if neither the hospital, nor the nonhospital site
incurs ``all or substantially all'' of the costs. As such, we are
soliciting comment on possible methods for allocating the GME payments
for training in the nonhospital site where neither the hospital nor the
nonhospital provider is incurring ``all or substantially all'' of the
costs for the training program. We believe that the proposed policies
discussed below are equitable to both hospital and nonhospital
providers and will achieve Congress' objective of encouraging and
supporting training in the nonhospital setting.
Given our concerns about administrative feasibility, the statutory
prohibition on double payments, and developing policies that are
equitable to hospitals as well as nonhospital providers, we believe the
only feasible way to pay for training in nonhospital settings is to pay
either the hospital or the nonhospital provider. Currently, hospitals
may receive payment for the time residents spend in the nonhospital
setting if the hospital incurs ``all or substantially all'' of the
training costs. We propose to adopt a similar policy for nonhospital
providers; that is, a qualified nonhospital provider may receive
payment for the direct costs of GME if the nonhospital provider incurs
``all or substantially all'' of the training costs.
d. Modifications of Policy To Pay Hospitals For GME. In the course
of developing our policies for nonhospital providers, we have reviewed
our method for paying hospitals for the costs of training residents in
the nonhospital site. Accordingly, as part of our policy to pay
nonhospital providers for the costs of training residents, we are
proposing necessary and appropriate modifications to our current policy
for paying hospitals for such nonhospital training. Specifically, as
part of our proposal to implement section 1886(k) of the Act, we
propose to modify the regulations at Sec. 413.86(f).
Presently, under sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of
the Act, if a hospital incurs ``all or substantially all'' of the costs
of training residents in the nonhospital site, then the hospital may
include the resident in its indirect medical education (IME) and direct
GME full-time equivalent count. Under Sec. 413.86(f)(1)(iii), currently
a hospital incurs ``all or substantially all'' of the costs of training
the resident in the nonhospital site if the hospital pays the
residents' salaries and fringe benefits. Based on our review of data in
Medicare cost reports on the Hospital Cost Reporting Information System
(HCRIS), we decided to reexamine the issue of what constitutes ``all or
substantially all'' of the costs of training the resident. In our
analysis, we determined that, on average, residents' salaries and
fringe benefits are less than half of the total amount of the direct
costs of a hospital's GME program. Therefore, we are proposing to
revise the standard for incurring ``all or substantially all'' of the
costs for the training program in the nonhospital setting.
We propose to redefine ``all or substantially all'' of the costs
for the training program in the nonhospital setting to include at a
minimum:
the portion of costs of the teaching physicians' salaries
and fringe benefits that are related to the time spent in teaching and
supervision of residents; and
residents' salaries and fringe benefits (including travel
and lodging expenses where applicable).
e. Payment Proposal. In light of the numerous considerations
discussed
[[Page 25598]]
above, we are proposing a system whereby we will pay either the
hospital or the nonhospital site for the cost of training in the
nonhospital site, depending on which entity incurs ``all or
substantially all'' of the costs of training in the nonhospital site.
An entity incurs ``all or substantially all'' of the costs for the
training program in the nonhospital setting if it pays for, at a
minimum: that portion of the costs of the teaching physicians' salaries
and fringe benefits that are related to the time spent in teaching and
supervision of residents; and residents' salaries and fringe benefits
(including travel and lodging expenses where applicable). Our proposal
accommodates three alternative payment scenarios that are discussed
below.
i. Payment to FQHCs and RHCs. In the first payment scenario, if the
FQHC or RHC incurs ``all or substantially all'' of the costs for the
training program in the nonhospital setting, we are proposing to pay
the nonhospital site cost-based reimbursement for the direct costs of
training. By reporting these direct GME costs in a reimbursable cost
center on the cost report, an FQHC or RHC would be attesting that it is
incurring ``all or substantially all'' of the costs for the training
program in the nonhospital site. Conversely, where an FQHC or RHC is
not incurring ``all or substantially all'' of the costs of training
residents in the nonhospital site, the FQHC or RHC would report these
training costs in a nonreimbursable cost center on the cost report.
As previously stated, we propose to define the direct costs of
training to include:
Residents' salaries and fringe benefits (including related
travel and lodging expenses where applicable);
That portion of the costs of teaching physicians' salaries
and fringe benefits that are related to the time spent in teaching and
supervision of residents; and
Other related overhead costs that are allocated to GME.
We are proposing that the FQHC's and RHC's allowable direct GME
costs be subject to reasonable cost principles in 42 CFR part 413 and
other relevant provisions referenced in part 413. As such we are
proposing to add language to Sec. 415.60 to make the reasonable cost
principles applicable to FQHC's and RHC's. In addition, the FQHC's and
RHC's direct GME costs would be subject to the Reasonable Compensation
Equivalency limits under Secs. 415.60 and 415.70. Accordingly, we are
proposing to add language to Sec. 415.70 to make the reasonable
compensation equivalency limits applicable to FQHC's and RHC's.
Also, Medicare would pay only for Medicare's share of the direct
costs of training in the nonhospital site. We are proposing that the
FQHC's and RHC's Medicare share equal the nonhospital provider's ratio
of Medicare visits to total visits. Thus, the amount of Medicare
payment would equal the product of the clinic's Medicare allowed direct
GME costs and the clinic's ratio of Medicare visits to total visits.
For FQHCs and RHCs that incur ``all or substantially all'' of the
costs for the training program in the nonhospital setting, the direct
GME costs are not subject to the existing per visit payment caps for
reimbursement under sections 505.1 and 505.2 of the Medicare Rural
Health Clinic and Federally Qualified Health Centers Manual. Moreover,
we believe participation in GME training should not affect any FQHCs or
RHCs ability to meet the productivity standards outlined in section 503
of the Medicare Rural Health Clinic and Federally Qualified Health
Centers Manual. Therefore, we are proposing that, where payment is
available under section 1886(k) of the Act for residents working in
either an FQHC or an RHC, the FQHCs and RHCs do not need to include
residents as health care staff in the calculation of productivity
standards under section 503 of the Manual.
ii. Payment to Medicare+Choice organizations. In the second payment
scenario, if a Medicare+Choice organization incurs ``all or
substantially all'' of the costs for the training program in the
nonhospital setting, we propose making the direct GME payment to the
Medicare+Choice organization. The Medicare+Choice organization would be
eligible to receive cost-based reimbursement for the residents'
salaries and fringe benefits only for the time that the resident spends
in the nonhospital setting. In addition, we are proposing that the
Medicare+Choice organization's allowed costs include only that portion
of the teaching physician salaries and fringe benefits that is related
to training in the nonhospital setting.
Unlike our proposed policy in paying FQHCs and RHCs for GME, at
this time we are not proposing to pay Medicare+Choice organizations for
the costs of overhead that are directly associated with a GME program.
We have no historical data on the GME costs of managed care
organizations and the extent to which these costs are incurred directly
or indirectly under contracts between the managed care organization and
physician groups or other providers engaged in ambulatory care.
Moreover, we have an established methodology for allocating and
reporting overhead costs for FQHCs and RHCs on Medicare cost reports
that does not currently exist for Medicare+Choice organizations. Since
Medicare+Choice organizations do not use the Medicare cost report,
there is currently no mechanism to review and audit these costs in the
managed care context. Because Medicare+Choice organizations are paid on
a capitated basis, we have no method for paying Medicare+Choice
organizations for variable costs such as GME overhead that require a
sophisticated cost allocation methodology. By contrast, it is currently
feasible to pay Medicare+Choice organizations for the costs of the
residents' salaries and teaching physicians' salaries because those
costs are more readily documented and auditable.
However, we are open to suggestions about how we can create a
methodology for allocating and reporting overhead costs for
Medicare+Choice organizations. Any comments should include not only a
proposed methodology for paying Medicare+Choice organizations for GME
overhead costs, but also proposed mechanisms for the audit and review
of the costs of these organizations.
Similar to our proposed policy for paying FQHCs and RHCs for direct
costs of GME, the Medicare+Choice organization's reimbursement for
residents' salaries and fringe benefits (including related travel and
lodging expenses where applicable) would be subject to the reasonable
cost principles in 42 CFR part 413 and any other relevant provisions
referenced in part 413. As such we are proposing to add language to
Sec. 415.60 to make the reasonable cost principles applicable to
Medicare+Choice organizations. In addition, the Medicare+Choice
organization's GME reimbursement would also be subject to the
Reasonable Compensation Equivalency limits under Secs. 415.60 and
415.70. Accordingly, we are proposing to add language to Sec. 415.70 to
make reasonable compensation equivalency limits applicable to
Medicare+Choice organizations. While we would pay the Medicare+Choice
organization for certain GME costs in nonhospital settings under this
proposal, the cost of residents' and teaching physicians' salaries and
fringe benefits in the hospital setting would be paid to the hospital,
not the Medicare+Choice organization.
The Medicare+Choice organization would receive direct GME payment
only for the direct costs of training in the nonhospital site that are
associated with the delivery of patient care services. In
[[Page 25599]]
determining the amount of direct GME payments to Medicare+Choice
organizations, we must adjust for Medicare's share of those education
costs. Medicare's share would equal the ratio of the total number of
Medicare enrollees in the Medicare+Choice organization to total
enrollees in the Medicare+Choice organization.
We are proposing that, in order to receive the direct GME payment,
the Medicare+Choice organization must produce a contractual agreement
between itself and the nonhospital providers. Medicare+Choice
organizations may contract with any nonhospital patient care site,
including freestanding clinics, nursing homes, and physicians' offices
in connection with approved programs. The contract between the
Medicare+Choice organization and the nonhospital site must indicate
that, for the time that residents spend in the nonhospital site, the
Medicare+Choice organization agrees to pay for the cost of residents'
salaries and fringe benefits. In addition, the contract must indicate
that the Medicare+Choice organization agrees to pay the portion of the
costs of teaching physicians' salaries and fringe benefits that is
related to the time spent in teaching and supervision of residents and
that is unrelated to the volume of services. The contract must
stipulate the portion of each teaching physician's time that will be
spent training residents in the nonhospital setting. Moreover, the
contract must indicate that the Medicare+Choice organization agrees to
identify an amount for the cost of the teaching physician's salary
based on the time that the resident spends in the nonhospital setting,
not based upon a capitated rate for the delivery of physician services.
Under our proposed rule, we could pay a Medicare+Choice
organization for the direct costs of training medical residents in a
physician's office if such office had a contractual agreement with the
organization whereby the organization agrees to pay for ``all or
substantially all'' of the costs for the training program in the
nonhospital setting. However, an independent physician office would not
be eligible to receive payment directly from Medicare for the cost of
training residents because it would not be a ``qualified nonhospital
provider'' under our proposed policy. Similarly, if a hospital rotates
a resident through a physician's office, the hospital must pay for
``all or substantially all'' of the costs of training the resident in
the physician's office in order to include that resident in its FTE
count for IME and direct GME purposes. (In this instance, the
hospital's responsibility in assuming ``all or substantially all'' of
the costs of training the resident in the nonhospital site would not be
based on section 4625 of BBA which permits payment to nonhospital
providers.) The hospital would have to assume ``all or substantially
all'' of the training costs for that nonhospital training time in order
to avail itself of the benefit of including the resident in the
hospital's FTE count for IME and direct GME purposes based on the
proposed modifications to Sec. 413.86.
iii. Payment to Hospitals. In the third payment scenario, if the
hospital itself incurs ``all or substantially all'' of the costs for
the training program in the nonhospital setting, then the hospital may
include the residents' training time in the nonhospital setting in the
hospital's FTE counts for direct GME and for IME. In order to include
the residents' training in the nonhospital site, the hospital must
produce a contractual agreement between the hospital and the
nonhospital provider. Under Sec. 413.86(f)(1)(iii), hospitals may
contract with any nonhospital patient care provider such as
freestanding clinics, nursing homes, and physicians' offices in
connection with approved programs.
Currently, a hospital must produce a written agreement between the
hospital and the nonhospital provider that states that the resident's
compensation for training time spent outside of the hospital setting is
to be paid by the hospital. Since this proposal changes the definition
of what constitutes ``all or substantially all'' of the costs of
training in the nonhospital site, hospitals must produce a written
agreement that demonstrates that they are assuming responsibility for
more of the costs of training in the nonhospital site than had
previously been required.
In accordance with our proposed definition of what constitutes
``all or substantially all'' of the costs of training while the
resident is in the nonhospital site, we are proposing that the contract
must indicate that the hospital is assuming financial responsibility
for, at a minimum, the cost of residents' salaries and fringe benefits
(including travel and lodging expenses where applicable) and the costs
for that portion of teaching physicians' salaries and fringe benefits
related to the time spent in teaching and supervision of residents.
The contract must indicate that the hospital is assuming financial
responsibility for these costs directly or that the hospital agrees to
reimburse the nonhospital provider for such costs. The contract must
also contain an acknowledgment on the part of the nonhospital provider
that, since the residents' time is being counted by the hospital, the
nonhospital site cannot claim GME costs on their Medicare cost report.
The nonhospital provider must agree to report its direct GME costs as
well as any money received from the hospital for GME purposes in a
nonallowable cost center on its cost report. In addition, in order to
determine teaching physician compensation that may be allocated to
direct GME, the nonhospital provider must specify the portion of the
teaching physicians' time that will be spent training residents in the
nonhospital setting. Finally, any payment to the hospital for the
direct costs of GME training in the nonhospital setting will continue
to reflect Medicare's share, which equals the hospital's ratio of
Medicare inpatient days to total inpatient days.
Hospitals that have residents who rotate to nonhospital sites are,
like all teaching hospitals, subject to an institutional cap on the
number of FTE residents that may be counted for both indirect and
direct GME under sections 1886(d)(5)(B)(v) and 1886(h)(6)(F) of the
Act. For hospitals that have residents who rotate to a nonhospital
site, those residents will be subject to the hospital's FTE caps.
f. Trust Funds. Under section 1886(k)(1) of the Act, the rules
established by the Secretary for paying nonhospital providers for GME
must specify the portion of Medicare payments that will be made from
each of the Medicare trust funds. We propose that GME payments made
directly to an FQHC, RHC, or Medicare+Choice organization would be made
from the Federal Supplementary Medical Insurance Trust Fund.
g. Conclusion. Under this proposed rule, clinics that are presently
ineligible to receive payments for direct GME may now receive such
payments. Moreover, this proposal provides Medicare+Choice
organizations the opportunity to receive direct GME payments for
training residents in the nonhospital setting. As Medicare+Choice
organizations, managed care entities will, for the first time, be
eligible to receive direct GME payments for training residents in
various types of nonhospital sites. This proposed rule would help
bridge the disparity between hospital and nonhospital providers in
obtaining payment for direct GME costs.
We believe this proposed rule may encourage the development of new
programs in nonhospital settings. Similarly, it may also encourage
approved residency training programs to
[[Page 25600]]
rotate additional residents to nonhospital sites.
In developing this proposed rule, we considered establishing a
fixed payment rate for the direct costs of training residents in the
nonhospital setting. We are not proposing a policy of a fixed payment
at this time because we presently have no reliable data on the direct
costs of training residents in nonhospital settings. Moreover, we are
concerned that a fixed payment for these costs may not be appropriate
if there is significant variation in cost among participating
nonhospital sites.
Given these considerations, our policy to pay FQHCs, RHCs, and
Medicare+Choice organizations on a cost reimbursement basis may be
revised in the future. Once we have acquired data such that we can
estimate the direct costs of training residents in the nonhospital
site, we will revisit our payment methodology for paying FQHCs, RHCs,
and Medicare+Choice organizations for direct GME. We believe that
ultimately it might be appropriate to pay FQHCs, RHCs, and
Medicare+Choice organizations using a national average per resident
amount. This national per resident amount would be based on the
national average for the direct costs of training medical residents in
the nonhospital site. As such, we are interested in receiving comments
on a fixed payment methodology and on how to derive such a payment.
These comments should include empirical data on training costs in
nonhospital sites.
The effective date of these provisions for FQHCs, RHCs,
Medicare+Choice organizations, and hospitals will be January 1, 1999.
In particular, the effective date for IME payments to hospitals under
this provision applies to discharges occurring on or after January 1,
1999. In addition, the effective date for direct medical education
payments to FQHCs, RHCs, Medicare+Choice organizations, and hospitals
applies to that portion of cost reporting periods occurring on or after
January 1, 1999.
VI. Changes to the Prospective Payment System for Capital-Related
Costs
A. Proposed Cap on the Capital Indirect Medical Education Adjustment
Ratio (Sec. 417.322)
Under section 1886(g) of the Act, the Secretary has broad
discretion in implementing the capital prospective payment system.
Section 412.322 of the regulations specifies the formula for the
capital indirect medical education (IME) adjustment factor. The capital
IME adjustment is intended to pay the capital prospective payment
system share of the indirect costs of medical education to teaching
hospitals. The formula was adopted in the August 30, 1991 final rule
for the capital prospective payment system (56 FR 43380) and uses the
ratio of interns and residents to average daily census (defined as
total inpatient days divided by the number of days in the cost
reporting period). Section 1886(d)(5)(B) of the Act requires the use of
the ratio of residents-to-beds to calculate the IME adjustment for the
operating Prospective payment system. However, pursuant to our
authority under section 1886(g) of the Act, we adopted the resident to
average daily census ratio for the capital prospective payment system
because we believed it was a more appropriate method for measuring
teaching intensity and because we believed it was less subject to
manipulation.
The IME adjustment factor increases by approximately 2.8 percentage
points for each .10 increase in the hospital's ratio of residents to
average daily census. The IME adjustment for inpatient capital-related
costs for hospitals paid under the prospective payment system takes the
form of e raised to the power (.2822 x ratio of interns and residents
to average daily census)-1] where e is the natural antilogy of 1, based
on the total cost regression results. In order to determine the Federal
rate portion of the hospital's payment, the IME adjustment factor is
multiplied by the standard federal rate, the DRG weight, the geographic
adjustment factor, and any other relevant payment adjustments such as
the DSH adjustment or the large urban add-on. The formula is 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).
It has come to our attention that because of the application of the
capital IME adjustment, one hospital would receive a capital IME
payment greater than its total hospital costs. We have also recently
learned that of the approximately 1,200 teaching hospitals in the
United States, based on December 1997 data, 8 hospitals have a resident
to average daily census ratio of more than 1.5. A resident to average
daily census ratio of 1.5 results in a capital IME adjustment factor of
.53, which increases the Federal rate portion of the hospital's capital
payment by 53 percent.
To address this unintended effect of the capital IME methodology,
we are proposing to cap the capital IME ratio at 1.5. A ratio greater
than 1.5 means a hospital has, on average, considerably more residents
than inpatients. Capping the ratio at 1.5 would allow for one resident
per patient on the inpatient side plus some outpatient training, and
would keep capital IME payments more consistent with the costs
incurred. Because of the large number of unoccupied beds in most
hospitals, the operating IME ratio has only slightly exceeded 1.0 in
two cases. This change would ensure that the capital IME adjustment is
more in line with hospital costs.
B. Payment Methodology for Mergers Involving New Hospitals
(Sec. 412.331)
The August 30, 1991 final rule (56 FR 43418), which implemented the
capital prospective payment system, established special payment
provisions for new hospitals. Under Sec. 412.324(b), a new hospital is
paid 85 percent of its allowable Medicare capital-related costs through
its first cost reporting period ending at least 2 years after the
hospital accepts its first patient. The first cost reporting period
beginning at least 1 year after the hospital accepts its first patient
is the hospital's base year for purposes of determining its hospital-
specific rate. Section 412.302(b) defines a new hospital's old capital
costs as allowable capital-related costs for land and depreciable
assets that were put in use for patient care on or before the last day
of the hospital's base year cost reporting period. Beginning with the
third year, the hospital is paid under the fully prospective or hold-
harmless payment methodology, as appropriate. If the hospital is paid
under the hold-harmless payment methodology, the hospital's hold-
harmless payments for its old capital costs can continue for up to 8
years.
In the August 30, 1991 final rule, we defined a new hospital as one
that had operated (under previous or present ownership) for less than 2
years and did not have a 12-month cost reporting period that ended on
or before December 31, 1990. In the September 1, 1992 final rule (57 FR
39789), as a result of situations brought to our attention after
publication of the prospective payment system final rule, we clarified
the new hospital exemption under the capital prospective payment
system. We explained that the new hospital exemption would not apply to
a facility that opened as an acute care hospital if that hospital had
previously operated under current or prior ownership and had a historic
asset base. We also clarified that a hospital that replaced its entire
facility (with or without a change of ownership) would not qualify for
a
[[Page 25601]]
new hospital exemption and that a previously existing excluded hospital
(paid under section 1886(b) of the Act) that became an acute care
hospital (paid under section 1886(d)) of the Act would not qualify.
We explained our belief that the reasonable cost payment protection
under the new hospital exemption should only be available to those
hospitals that had not received reasonable cost payments in the past
and needed special protection during their initial period of operation.
We also stated in the June 4, 1992 proposed rule (57 FR 23649) that we
were clarifying the new hospital exemption to ensure that hospitals
that had an existing asset base before December 31, 1990 were not
provided with an extended transition period and inappropriately higher
payments relative to other hospitals. We also explained our belief that
it was essential to maintain the integrity of the capital prospective
payment system by allowing only truly new providers of hospital care to
qualify for the new hospital exemption.
Since publication of our last clarification of the payment rules
for new hospitals, questions have arisen regarding application of our
rules for payment of new hospitals in merger situations. Consistent
with our previously stated policy that only truly new hospitals without
an existing asset base should be eligible for the new hospital
exemption, we are further clarifying the new hospital payment
provisions.
If during the period it is eligible for payment as a new hospital
(as defined at Sec. 412.300(b) and Sec. 412.328(b)), a new hospital
merges with one or more existing hospitals and the merger meets the
existing capital-related reasonable cost rules regarding the criteria
for recognizing a merger at Sec. 413.134 and the new hospital is the
surviving corporation (as defined in Sec. 413.134(l)(2)) we would treat
as old capital only those assets of the existing hospital that met the
definition of old capital (as defined in Sec. 412.302(b)) prior to the
merger, for purposes of determining payments after the merger.
Any assets of the existing hospital that were considered new
capital prior to the merger will still be considered new capital after
the merger. The merger cannot be used to convert the existing
hospital's new capital into old capital. After the merger, the
discharges of each campus of the merged entity would maintain their
pre-merger payment methodology until the end of the 2 year period that
the ``new hospital'' campus was eligible for reasonable cost
reimbursement as defined at Sec. 412.324(b). At the end of this period,
the intermediary would devise a hospital specific rate for the ``new''
campus of the merged hospital. Finally, the calculation methodology for
hospital mergers at new Sec. 412.331(a)(1) and (2) would be performed
and a combined hospital-specific rate would be determined and a payment
methodology selected for the merged hospital as a whole.
The calculation at Sec. 412.331(a)(1) and (2) uses each hospital's
base year old capital costs. Any new capital of the previously existing
hospital would not be used in the determination. If the new merged
entity qualifies for the hold-harmless payment methodology, only the
capital which meets the definition of old capital at Sec. 412.302(b)
would be eligible for hold-harmless payments.
We note that this proposed change is consistent with the principles
underlying existing Sec. 412.331(a)(3), which provides that in the case
of a merger only the existing capital-related costs related to the
assets of each merged or consolidated hospital as of December 31, 1990
are recognized as old capital costs during the transition period. If
the hospital is paid under the hold-harmless methodology after merger
or consolidation, only that original base year old capital is eligible
for hold-harmless payments.
Example: Hospital A is a new hospital in its first 2 years of
operation and is being paid 85 percent of its allowable Medicare
inpatient hospital capital-related costs. Hospital A's base year for
establishing its hospital-specific rate will end September 30, 1998.
Hospital B is an existing hospital whose base year for capital
prospective payment system purposes was June 30, 1990. Hospital B is
a hold-harmless hospital paid 100 percent of the Federal rate.
Hospital A merged with Hospital B (in accordance with to
Sec. 413.134(l)) on March 1, 1998, and Hospital A is a new merged
entity, with two campuses: one which used to be the original
Hospital A--the ``new'' hospital, and one which used to be hospital
B--the ``existing'' hospital). The merged Hospital A retains the
corporate structure, provider number, and cost reporting period of
the original Hospital A, which is the surviving hospital. The merged
Hospital A's discharges will be paid under two different payment
methodologies until the ``new'' campus completes its base period
under the payment rules for new hospitals and a hospital-specific
rate and a payment methodology can be determined for the merged
Hospital A. Until that time, the discharges of the ``new'' hospital
campus (previously the original Hospital A) will be paid in
accordance with Sec. 412.324(b) as a new hospital. Any capital that
meets the definition of old capital acquired by the ``new'' campus
before the end of its base year will be accorded old capital status
in accordance with Sec. 412.302(b). The ``existing'' hospital campus
(previously hospital B) will continue to be paid on a hold-harmless
basis. Any capital acquired by the ``existing'' campus will be
accorded new capital status in accordance with section 2807.3A of
the Provider Reimbursement Manual (PRM). At the end of the ``new''
campus' base year, a hospital-specific rate will be determined for
that campus. After a hospital specific rate is determined, the
calculation methodology for hospital mergers at Sec. 412.331(a)(1)
and (2) will be performed. As part of the calculation and before
combining the data, the base years of the two hospitals used to
establish the hospital-specific rate are brought to the same point
by discharge-weighting and updating. The calculation uses only the
old capital costs of each hospital in order to determine a combined
hospital-specific rate and payment methodology. After a payment
methodology determination is made, the two campuses will be paid
using the same payment methodology for all of their discharges.
VII. Changes for Hospitals and Units Excluded From the Prospective
Payment System
Limits on and Adjustments to the Target Amounts for Excluded Hospitals
and Units (Sec. 413.40(g))
1. Updated Caps
Section 1886(b)(3) of the Act as amended by section 4414 of the BBA
established caps on the target amounts for excluded hospitals and units
for cost reporting periods beginning on or after October 1, 1997,
through September 30, 2002. The caps on the target amounts apply to the
following three categories of excluded hospitals: psychiatric hospitals
and units, rehabilitation hospitals and units, and long-term care
hospitals.
A discussion of how the caps on the target amounts were calculated
can be found in the August 29, 1997 final rule with comment period (62
FR 46018). For purposes of calculating the caps for cost reporting
periods beginning during FY 1999 through FY 2002, the statute requires
us to calculate the 75th percentile of the target amounts for each
class of hospital (psychiatric, rehabilitation, or long-term care) for
cost reporting periods ending during FY 1996. The resulting amounts are
updated by the market basket percentage to the applicable fiscal year.
The projected market basket for excluded hospitals and units for FY
1999 is 2.5 percent. Accordingly, the caps on the target amount for FY
1999 as follows:
(1) Psychiatric hospitals and units: $10,443
(2) Rehabilitation hospitals and units: $18,938
(3) Long-term care hospitals: $37,360
[[Page 25602]]
2. Classification of Hospitals and Units
Since publication of the August 29, 1997 final rule with comment
period, some excluded facilities have suggested that if they are
currently excluded as one class of hospital or unit but also qualify
for exclusion as another class of hospital, they should be permitted to
choose which classification applies for purposes of applying the cap on
target amounts. For example, some hospitals that participate in
Medicare as psychiatric hospitals (defined under section 1861(f) of the
Act, and the special conditions of participation in 42 CFR part 482
subpart E) have noted that they have average lengths of stay greater
than 25 days. Those hospitals have asked to be ``reclassified'' as
long-term care hospitals and given the benefit of the higher cap on
target amounts applicable to that hospital class.
We have considered these hospitals' suggestions, but we believe it
would not be appropriate to adopt them. Section 1886(b)(3)(H)(iv) of
Act makes it clear that each category of hospital and corresponding
units--psychiatric (section 1886(d)(1)(B)(I)), rehabilitation (section
1886(d)(1)(B)(ii)), and long-term care hospitals (section
1886(d)(1)(B)(iv)) is treated separately. We believe it is consistent
with effective implementation of this provision to prevent hospitals or
units that could potentially be assigned to more than one category of
excluded facility from choosing the category to which they wish to be
assigned. Even though some hospitals or units in one group might
potentially have been assigned to a different group, each group has its
own limit based on the target amounts for similarly classified
facilities. It would not be appropriate to apply a limit to a hospital
or unit based on the target amount derived from the cost experience of
differently classified hospitals and units.
In addition, there are a number of hospitals that could potentially
move from the psychiatric hospital cap to the long-term care hospital
cap. This movement would have a significant impact on the
appropriateness of both caps. In the case of the psychiatric hospitals,
had those hospitals with the longest lengths of stay and therefore
higher per discharge target amount been excluded in the original
calculation of the caps, the cap for all remaining psychiatric
hospitals would invariably have been lower. Furthermore, had those
psychiatric hospitals been included in the calculation of the long-term
care hospital cap, that cap could also have been lower. To allow such a
significant change in the application of the caps is to raise a serious
question as to the appropriateness of the current caps for all
psychiatric and long-term care hospitals.
Thus, to clarify the application of the caps, we propose to revise
Sec. 413.40(c)(4)(iii) to specify that, for purposes of that paragraph,
the classification of a hospital that was excluded from the prospective
payment system for its cost reporting period ending in FY 1996 will be
determined by its classification (that is, the basis on which it was
excluded) in FY 1996. If a hospital or unit was not excluded for a cost
reporting period ending in FY 1996 but could be excluded on more than
one basis (for example, as either a rehabilitation or long-term care
hospital) it will be assigned to the classification group with the
lowest limit.
3. Exceptions
The August 29, 1997 final rule with comment period (62 FR 46018)
specified that a hospital that has a target amount that is capped at
the 75th percentile would not be granted an adjustment payment to the
target amount (also referred to as an exception payment) as governed by
Sec. 413.40(g) based solely on a comparison of its costs or patient mix
in its base year to its costs or patient mix in the payment year. Since
the hospital's target amount would not be determined based on its own
experience in a base year, any comparison of costs or patient mix in
its base year to costs or patient mix in the payment year would be
irrelevant.
We propose to clarify that, to the extent we grant an exception to
a hospital not affected by the cap, the amount of the exception would
be limited to the cap on the hospital's target amount. This policy is
consistent with the caps. By establishing caps on TEFRA target amounts,
Congress has limited payments to individual hospitals based on amounts
that reflect the cost experience of other hospitals. Therefore, in
determining the extent of any adjustment paid to a hospital as an
exception under our regulations at Sec. 413.40(g)(3), we believe it is
consistent with Congressional intent to limit the extent of the
adjustment to the hospital's cap on its target amount.
We propose to revise Sec. 413.40(g)(1) to set forth the limitation
on the adjustment payments.
VIII. MedPAC Recommendations
We have reviewed the March 1998 report submitted by MedPAC to
Congress and have given its recommendations careful consideration in
conjunction with the proposals set forth in this document.
Recommendations concerning the update factors for inpatient operating
costs and for hospitals and hospital distinct-part units excluded from
the prospective payment system are discussed in Appendix D, to this
proposed rule. The remaining recommendations are discussed below.
A. Disproportionate Share Hospitals (DSH)
Recommendation: The Medicare Payment Advisory Commission (MedPAC)
made several recommendations concerning the Medicare disproportionate
share adjustment calculation. In general, the Commission's proposal
would base the amount of DSH payment each hospital receives on its
volume and mix of cases paid under the prospective payment system and
its share of low-income patients. The low-income share measure would
reflect the costs of care provided to low-income individuals (Medicare
patients eligible for Supplemental Security Income (SSI), Medicaid
patients, patients sponsored by local indigent care programs, and
patients receiving uncompensated care) as a proportion of total patient
care expenses. Both inpatient and outpatient costs were included in the
data used to calculate the low-income shares, although payment would be
made only on inpatient discharges.
The same formula would be applied to all prospective payment
hospitals. Under the recommendation, there would be a threshold or
minimum low-income share, that must be reached for a hospital to
receive any Medicare disproportionate share adjustment. The payment the
hospital would receive is proportionate to the segment of its low-
income share that lies above the threshold. MedPAC simulated the
potential effects of applying their approach on the distribution of
Medicare disproportionate share payments made in 1995. For purposes of
MedPAC's simulations, the threshold was set at a level that would limit
payments to about 40 percent of prospective payment hospitals--roughly
the same as under the current DSH adjustment. MedPAC stated that this
proportion could be adjusted, or the threshold could be set using a
different method, as deemed appropriate by policy makers. (For more
information see Volume 1, chapter 6, page 63 of the March 1998 report.)
Response: Section 1886(d)(5)(F) of the Act, as amended by section
4403(b) of the BBA, requires us to prepare a report to Congress, due by
August 5, 1998, which will include our recommendations for an
appropriate
[[Page 25603]]
formula for determining DSH payments. We appreciate MedPAC's efforts to
assist HCFA in restructuring the Medicare disproportionate share
adjustment and we will further examine and consider their
recommendations as we develop our report to Congress.
B. Potential Effects of Target Amount Caps
Recommendation: The wage-related portion of the excluded hospital
target amount caps should be adjusted by the appropriate hospital wage
index to account for geographic differences in wages. (For more
information see Volume 1, chapter 7, page 71 of the March 1998 report.)
Response: As MedPAC indicated in its recommendation, legislation
would be required to adjust the target amount caps in such a
substantial manner as to adjust for differences in area labor costs.
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 or cartridge format;
however, some files are available on diskette as well as 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, that is, discharges occurring October 1 through September 30
of the requested year.)
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, an agreement for use
of HCFA Beneficiary Encrypted Files must be signed by the purchaser
before release of these data. For all files requiring a signed
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 (April beginning
in 1998). 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 (August beginning with the FY
1999 final rule). For final rules published before 1998, this file is
derived from the MedPAR file with a cutoff of 9 months after the end of
the fiscal year (June file). The FY 1997 MedPar file used for the FY
1999 final rule will have a cutoff of 6 months after the end of the
fiscal year (March file).
Media: Tape/Cartridge
File Cost: $3,415.00 per fiscal year
Periods Available: FY 1988 through FY 1997
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, an agreement
for use of HCFA Beneficiary Encrypted Files 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 (April beginning in 1998). 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 (August beginning with the FY
1999 final rule). For final rules published before 1998, this file is
derived from the MedPAR file with a cutoff of 9 months after the end of
the fiscal year (June file). The FY 1997 MedPar file used for the FY
1999 final rule will be cut off 6 months after the end of the fiscal
year (March file).
Media: Tape/Cartridge
File Cost: $1,050.00 per State per year
Periods Available: FY 1988 through FY 1997
3. HCFA Wage Data
This file contains the hospital hours and salaries for 1995 used to
create the proposed FY 1999 prospective payment system wage index. The
file will be available by the beginning of February for the NPRM and
the beginning of May for the final rule.
------------------------------------------------------------------------
Processing year Wage data year PPS fiscal year
------------------------------------------------------------------------
1998................... 1995 1999
1997................... 1994 1998
1996................... 1993 1997
1995................... 1992 1996
1994................... 1991 1995
1993................... 1990 1994
1992................... 1989 1993
1991................... 1988 1992
------------------------------------------------------------------------
These files support the following:
NPRM published in the Federal Register, usually by the end
of April.
Final Rule published in the Federal Register, usually by
the first week of August.
Media: Diskette/Internet
File Cost: $145.00 per year
Periods Available: FY 1999 PPS Update
4. HCFA Hospital Wages Indices (Formally: Urban and Rural Wage Index
Values Only)
This file contains a history of all wage indices since October 1,
1983.
Media: Diskette/Internet
File Cost: $145.00 per year
Periods Available: FY 1999 PPS Update
5. PPS SSA/FIPS MSA State and County Crosswalk
This file contains a crosswalk of State and county codes used by
the Social Security Administration (SSA) and the Federal Information
Processing Standards (FIPS), county name, and a historical list of
Metropolitan Statistical Area (MSA).
Media: Diskette/Internet
[[Page 25604]]
File Cost: $145.00 per year
Periods Available: FY 1999 PPS Update
6. Reclassified Hospitals by Provider Only
This file contains a list of hospitals that were reclassified for
the purpose of the proposed FY 1999 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 April.
Final Rule published in the Federal Register, usually by
the first week of August.
Media: Diskette/Internet
File Cost: $145.00 per year
Periods Available: FY 1999 PPS Update
7. PPS-IV to PPS-XII 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
------------------------------------------------------------------------
(Note: The PPS XIII Minimum Data Set covering FY 1997 will not be
available until July 31, 1998.)
File Cost: $715.00 per year
8. PPS-IX to PPS-XII Capital Data Set
The Capital Data Set contains selected data for capital-related
costs, interest expense and related information and complete balance
sheet data from the Medicare hospital cost report. The data set
includes only the most current cost report (as submitted, final settled
or reopened) submitted for a Medicare certified hospital by the
Medicare fiscal intermediary to HCFA. This data set is updated at the
end of each calendar quarter and is available on the last day of the
following month.
Media: Tape/Cartridge
------------------------------------------------------------------------
Periods
beginning 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
------------------------------------------------------------------------
(Note: The PPS XIII Capital Data Set covering FY 1997 will not be
available until July 31, 1998.)
File Cost: $715.00 per year
9. 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: Diskette/Internet
File Cost: $265.00
Periods Available: FY 1998 PPS Update
10. 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 (April beginning in 1998).
Final rule published in the Federal Register, usually by
the first week of September (August beginning in 1998).
Media: Diskette/Internet
Price: $145.00 per year
Periods Available: FY 1985 through FY 1997 (Internet--FY 1997)
11. DRG Relative Weights (Formerly Table 5 DRG)
This file contains a listing of DRGs, DRG narrative description,
relative weights, 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 (April beginning in
1998).
b. Final rule, usually published by the first week of September
(August beginning in 1999).
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1999 PPS Update
12. 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 1999 PPS Update
13. 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 April.
Final rule published in the Federal Register, usually by
the first week of August.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1999 PPS Update
For further information concerning these data tapes, contact Mary
R. White at (410) 786-3691.
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
[[Page 25605]]
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 1999 be
published by August 1, 1998, we will consider only those comments that
deal specifically with the matters discussed in this proposed rule.
List of Subjects
42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
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 Chapter IV would be amended as set forth below:
A. Part 405 is amended as follows:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
1. The authority citation for part 405 is revised to read as
follows:
Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and
1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a),
1395hh, 1395kk, 1395rr and 1395ww(k)), and sec. 353 of the Public
Health Service Act (42 U.S.C. 263a), unless otherwise noted.
Subpart X--Rural Health Clinic and Federally Qualified Health
Center Services
Sec. 405.2468 [Amended]
2. In Sec. 405.2468, a new paragraph (f) is added to read as
follows:
* * * * *
(f) Graduate medical education. (1) Effective for that portion of
cost reporting periods occurring on or after January 1, 1999, if an RHC
or an FQHC incurs ``all or substantially all'' of the costs for the
training program in the nonhospital setting as defined in
Sec. 413.86(b) of this chapter, the RHC or FQHC may receive direct
graduate medical education payment for those residents.
(2) Direct graduate medical education costs are not included as
allowable cost under Sec. 405.2466(b)(1)(i); and therefore, are not
subject to the limit on the all-inclusive rate for allowable costs.
(3) Allowable graduate medical education costs must be reported on
the RHC's or the FQHC's cost report under a separate cost center.
(4) Allowable direct graduate medical education costs under
paragraphs (f)(5) and (6)(i) of this section, are subject to reasonable
cost principles under part 413 and the reasonable compensation
equivalency limits in Secs. 415.60 and 415.70 of this chapter.
(5) The allowable direct graduate medical education costs are those
costs incurred by the nonhospital site for the educational activities
associated with patient care services of an approved program, subject
to the redistribution and community support principles in
Sec. 413.85(c).
(i) The following costs are included in allowable direct graduate
medical education costs to the extent that they are reasonable--
(A) The costs of the residents' salaries and fringe benefits
(including travel and lodging expenses where applicable).
(B) The portion of teaching physicians' salaries and fringe
benefits that are related to the time spent teaching and supervising
residents.
(C) Facility overhead costs that are allocated to direct graduate
medical education.
(ii) The following costs are not included as allowable graduate
medical education costs--
(A) Costs associated with training, but not related to patient care
services.
(B) Normal operating and capital-related costs.
(C) The marginal increase in patient care costs that the RHC or
FQHC experiences as a result of having an approved program.
(D) The costs associated with activities described in
Sec. 413.85(d) of this chapter.
(6) Payment is equal to the product of--
(i) The RHC's or the FQHC's allowable direct graduate medical
education costs; and
(ii) Medicare's share of the direct graduate medical education
payment which is equal to the ratio of Medicare visits to the total
number of visits (as defined in Sec. 405.2463).
(7) Direct graduate medical education payments to RHCs and FQHCs
made under this section are made from the Federal Supplementary Medical
Insurance Trust Fund.
* * * * *
B. Part 412 is amended as set forth below:
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 1895hh).
Subpart A--General Provisions
2. Section 412.4 is revised to read as follows:
Sec. 412.4 Discharges and transfers.
(a) Discharges. Subject to the provisions of paragraphs (b) and (c)
of this section, a hospital inpatient is considered discharged from a
hospital paid under the prospective payment system when --
(1) The patient is formally released from the hospital; or
(2) The patient dies in the hospital.
(b) Transfer--Basic rule. A discharge of a hospital inpatient is
considered to be a transfer for purposes of payment under this part if
the discharge is made under any of the following circumstances:
(1) From a hospital to the care of another hospital that is--
(i) Paid under the prospective payment system; or
(ii) Excluded from being paid under the prospective payment system
because of participation in an approved Statewide cost control program
as described in subpart C of part 403 of this chapter.
(2) From one inpatient area or unit of a hospital to another
inpatient area or unit of the hospital that is paid under the
prospective payment system.
(c) Transfers--Special 10 DRG rule. For discharges occurring on or
after October 1, 1998, a discharge of a hospital inpatient is
considered to be a transfer for purposes of this part when the
patient's discharge is assigned, as described in Sec. 412.60(c), to one
of the qualifying diagnosis-related groups (DRGs) listed in paragraph
(d) of this section and the discharge is made under any of the
following circumstances--
(1) To a hospital or distinct part hospital unit excluded from the
prospective payment system under subpart B of this part.
(2) To a skilled nursing facility or to a swing bed in the hospital
that meets the provisions of Sec. 482.66 of this chapter.
(3) To home under a written plan of care for the provision of home
health services from a home health agency and those services begin
within 3 days after the date of discharge.
[[Page 25606]]
(d) Qualifying DRGs. The qualifying DRGs for purposes of paragraph
(c) of this section are DRGs 14, 113, 209, 210, 211, 236, 263, 264,
429, and 483.
(e) Payment for discharges. The hospital discharging an inpatient
(under paragraph (a) of this section) is paid in full, in accordance
with Sec. 412.2(b).
(f) Payment for transfers--(1) General rule. Except as provided in
paragraph (f)(2) or (f)(3) of this section, a hospital that transfers
an inpatient under the circumstances described in paragraph (b) or (c)
of this section, is paid a graduated per diem rate for each day of the
patient's stay in that hospital, not to exceed the amount that would
have been paid under subparts D and M of this part if the patient had
been discharged to another setting. The per diem rate is determined by
dividing the appropriate prospective payment rates (as determined under
subparts D, and M of this part) by the geometric mean length of stay
for the specific which the case is assigned. Payment is graduated by
paying twice the per diem amount for the first day of the stay, and the
per diem amount for each subsequent day, up to the full DRG payment.
(2) Special rule for DRGs 209, 210, and 211. A hospital that
transfers an inpatient under the circumstances described in paragraph
(c) of this section and the transfer is assigned to DRGs 209, 210 or
211 is paid as follows:
(i) 50 percent of the appropriate prospective payment rate (as
determined under subparts D and M of this part) for the first day of
the stay; and
(ii) 50 percent of the per diem amount as calculated under
paragraph (f)(1) of this section for the remaining days of the stay, up
to the full DRG payment.
(3) Transfer assigned to DRG 385. If a transfer is classified into
DRG No. 385 (Neonates, died or transferred) the transferring hospital
is paid in accordance with Sec. 412.2(e).
(4) Outliers. Effective with discharges occurring on or after
October 1, 1994, a transferring hospital may qualify for an additional
payment for extraordinarily high-cost cases that meet the criteria for
cost outliers as described in subpart F of this part.
Subpart G--Special Treatment of Certain Facilities Under the
Prospective Payment System for Inpatient Operating Costs
3. In Sec. 412.106, paragraph (b)(4) is revised to read as follows:
Sec. 412.106 Special treatment: Hospitals that serve a
disproportionate share of low-income patients.
* * * * *
(b) * * *
(4) Second computation. The fiscal intermediary determines, for the
same cost reporting period used for the first computation, the number
of the hospital's patient days of service for which patients were
eligible for Medicaid but not entitled to Medicare Part A, and divides
that number by the total number of patient days in the same period.
(i) For purpose of paragraph (b)(4), a patient is deemed eligible
for Medicaid on a given day if the patient is eligible for medical
assistance under an approved State Medicaid plan on such day,
regardless of whether particular items or services were covered or paid
under the State plan.
(ii) The hospital has the burden of furnishing data adequate to
prove eligibility for each Medicaid patient day claimed under this
paragraph, and of verifying with the State that a patient was eligible
for Medicaid during each claimed patient hospital day.
* * * * *
Subpart M--Prospective Payment System for inpatient Hospital
Capital Costs
4. In Sec. 412.322, a new sentence is added at the end of paragraph
(a)(3) to read as follows:
Sec. 412.322 Indirect medical education adjustment factor.
(a) * * *
(3) * * * This ratio cannot exceed 1.5.
* * * * *
5. In Sec. 412.331, paragraphs (a) and (b) are redesignated as
paragraphs (b) and (c) respectively, a new paragraph (a) is added, and
the first sentences of new paragraphs (b) introductory text and (b)(2)
are revised to read as follows:
Sec. 412.331 Determining hospital-specific rates in cases of hospital
merger, consolidation, or dissolution.
(a) New hospital merger or consolidation. If, after a new hospital
accepts its first patient but before the end of its base year, it
merges with one or more existing hospitals, and two or more separately
located hospital campuses are maintained, hospital specific rate and
payment determination for the merged entity are determined as follows--
(1) The ``new'' campus continues to be paid based on reasonable
costs until the end of its base year. The existing campus remains on
its previous payment methodology until the end of the new campus' base
year. Effective with the first cost reporting period beginning after
the ``new'' campus, the intermediary determines a hospital-specific
rate applicable to the new campus, and then determines a revised
hospital-specific rate for the merged entity in accordance with
paragraph(a) of this section.
(2) Payment determination. To determine the applicable payment
methodology under Sec. 412.336 and for payment purposes under
Sec. 412.340 or Sec. 412.344, the discharge-weighted hospital-specific
rate is compared to the Federal rate. The revised payment methodology
is effective on the first day of the cost reporting period beginning
after the end of the ``new'' campus'' base year.
(b) Hospital merger or consolidation. If, after the base year, two
or more hospitals merge or consolidate into one hospital as provided
for under Sec. 413.134(k) of this chapter and are not subject to the
provisions of paragraph (a) of this section, the intermediary
determines a revised hospital-specific rate applicable to the combined
facility under Sec. 412.328, which is effective beginning with the date
of merger or consolidation. * * *
(2) Payment determination. To determine the applicable payment
methodology under Sec. 412.336 and for payment purposes under
Sec. 412.340 or Sec. 412.344, the discharge-weighted hospital-specific
rate is compared to the Federal rate. * * *
* * * * *
C. 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 FOR SKILLED NURSING FACILITIES
1. The authority citation for part 413 is revised to read as
follows:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (I) and
(n), 1861(v), 1871, 1881, 1883, and 1866 of the Social Security Act
(42 U.S.C. 1302, 1395f(b), 1395g, 1395l, 1395l(a), (I) and (n),
1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww).
Subpart C--Limits on Cost Reimbursement
2. In Sec. 413.40, paragraph (c)(4)(iv) is redesignated as
paragraph (v), a new paragraph (iv) is added, and paragraph (g)(1) is
revised to read as follows:
Sec. 413.40 Ceiling on the rate of increase in hospital inpatient
costs.
* * * * *
(c) * * *
[[Page 25607]]
(4) * * *
(iv) For purposes of the limits on target amounts established under
paragraph (c)(4)(iii) of this section, each hospital or unit that was
excluded from the prospective payment system for its cost reporting
period ending during FY 1996 will be classified in the same way (that
is, as a psychiatric hospital or unit, or a long-term care hospital) as
it was classified under subpart B of part 412 of this chapter for
purposes of exclusion from prospective payment systems for its cost
reporting period ending during FY 1996. If a hospital or unit was not
excluded from the prospective payment system for a cost reporting
period ending during FY 1996 but could qualify to be classified in more
than one way under the exclusion criteria in subpart B of part 412 of
this chapter, the hospital is assigned to the classification group that
has the lowest limit on its target amounts.
* * * * *
(g) Adjustments--(1) General rule. HCFA may adjust the amount of
the operating costs considered in establishing the rate-of-increase
ceiling for one or more cost reporting periods, including both periods
subject to the ceiling and the hospital's base period, under the
circumstances specified below. When an adjustment is requested by the
hospital, HCFA makes an adjustment only to the extent that the
hospital's operating costs are reasonable, attributable to the
circumstances specified separately identified by the hospital, and
verified by the intermediary. HCFA may grant an adjustment requested by
the hospital only if the hospital's operating costs exceed the rate-of-
increase ceiling imposed under this section. In the case of a
psychiatric hospital or unit, rehabilitation hospital or unit, or long
term care hospital, the amount of payment made to a hospital after an
adjustment under paragraph (g)(3) of this section may not exceed the
75th percentile of the target amounts for hospitals of the same class
as described in Sec. 413.40(c)(4)(iii).
Subpart F--Specific Categories of Costs
3. In Sec. 413.80, paragraph (h) is redesignated as paragraph (i),
and a new paragraph (h) is added to read as follows:
Sec. 413.80 Bad debts, charity, and courtesy allowances.
* * * * *
(h) Limitations on bad debts. In determining reasonable costs for
hospitals, the amount of bad debts otherwise treated as allowable costs
(as defined in paragraph (e) of this section) is reduced--
(1) For cost reporting periods beginning during fiscal year 1998,
by 25 percent;
(2) For cost reporting periods beginning during fiscal year 1999,
by 40 percent; and
(3) For cost reporting periods beginning during a subsequent fiscal
year, by 45 percent.
* * * * *
4. In Sec. 413.85, a new paragraph (h) is added to read as follows:
Sec. 413.85 Cost of educational activities.
* * * * *
(h) Medicare+Choice organizations. (1) Effective for that portion
of cost reporting periods occurring on or after January 1, 1999,
Medicare+Choice organizations may receive direct graduate medical
education payments for the time that residents spend in nonhospital
provider settings such as freestanding clinics, nursing homes, and
physicians' offices in connection with approved programs.
(2) Medicare+Choice organizations may receive direct graduate
medical education payments if all of the following conditions are met--
(i) The resident spends his or her time in patient care activities.
(ii) The Medicare+Choice organization incurs ``all or substantially
all'' of the costs for the training program in the nonhospital setting
as defined in Sec. 413.86(b).
(iii) There is a written agreement between the Medicare+Choice
organization and the nonhospital provider that contains--
(A) A statement by the nonhospital provider that, all or
substantially all of the direct graduate medical education costs as
defined in paragraph (f)(1)(ii) of this section are being assumed by
the Medicare+Choice organization;
(B) A statement that the nonhospital site agrees to offset the
revenue received from the Medicare+Choice organization.
(C) A statement that the nonhospital site agrees to report its
direct graduate medical education costs in a nonreimbursable cost
center on its cost report; and
(D) A statement indicating how much time the teaching physicians
will spend training residents in the nonhospital setting, subject to
the provisions of Secs. 415.60 and 415.70 of this chapter.
(3) A Medicare+Choice organization's allowable direct graduate
medical education costs, subject to the redistribution and community
support principles in Sec. 413.85(c), consist of--
(i) Residents' salaries and fringe benefits (including travel and
lodging where applicable); and
(ii) The portion of teaching physicians' salaries and fringe
benefits that are related to the time spent in teaching and supervising
residents.
(4) Allowable direct graduate medical education costs under
paragraph (h)(3) of this section are subject to the reasonable cost
principles of part 413 and the reasonable compensation equivalency
limits in Secs. 415.60 and 415.70 of this chapter.
(5) The direct graduate medical education payment is equal to the
product of--
(i) The Medicare+Choice organization's allowable direct graduate
medical education costs as defined in paragraph (h)(3) of this section;
and
(ii) Medicare's share of the Medicare+Choice organization's direct
graduate medical education payment in the nonhospital site which is
equal to the ratio of the number of Medicare beneficiaries enrolled to
the total number of individuals enrolled in the Medicare+Choice
organization.
(6) Direct graduate medical education payments made to
Medicare+Choice organizations under this section are made from the
Federal Supplementary Medical Insurance Trust Fund.
* * * * *
5. In Sec. 413.86, the introductory text of paragraph (b) is
republished, a new definition in alphabetical order is added to
paragraph (b), paragraphs (i) and (j) are redesignated as paragraphs
(j) and (k) respectively, paragraph (f)(2) is redesignated as new
paragraph (i), paragraphs (f)(2)(i) through (vii) are redesignated as
paragraphs (i)(1) through (7) respectively, the introductory text of
paragraph (f)(1) is redesignated as the introductory text of paragraph
(f), paragraphs (f)(1)(i) through (iii) are redesignated as paragraphs
(f)(1) through (3) respectively, paragraphs (f)(1)(iii)(A) and (B) are
redesignated as (f)(3)(i) and (ii) respectively, new paragraph (f)(2)
and the introductory text of new paragraph (f)(3) are revised, and a
new paragraph (f)(4) is added to read as follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(b) Definitions. For purposes of this section, the following
definitions apply:
* * * * *
All or substantially all of the costs for the training program in
the nonhospital setting means the residents' salaries and fringe
benefits (including travel and lodging where applicable) and the
[[Page 25608]]
portion of the cost of teaching physicians' salaries and fringe
benefits.
* * * * *
(f) * * *
(2) No individual may be counted as more than one FTE. If a
resident spends time in more than one hospital or, except as provided
in paragraphs (f)(3) and (4) of this section, in a nonprovider setting,
the resident counts as partial FTE based on the proportion of time
worked at the hospital to the total time worked. A part-time resident
counts as a partial FTE based on the proportion of allowable time
worked compared to the total time necessary to fill a full-time
internship or residency slot.
(3) On or after July 1, 1987 and for the portion of the cost
reporting period ocurring before January 1, 1999, the time residents
spend in nonprovider settings such as freestanding clinics, nursing
homes, and physicians' offices in connection with approved programs is
not excluded in determining the number of FTE residents in the
calculation of a hospital's resident count if the following conditions
are met--
* * * * *
(4) On or after July 1, 1987 and for the portion cost reporting
period occurring on or after January 1, 1999, the time residents spend
in nonprovider settings such as freestanding clinics, nursing homes,
and physicians' offices in connection with approved programs is not
excluded in determining the number of FTE residents in the calculation
of a hospital's resident count if the following conditions are met--
(i) The resident spends his or her time in patient care activities.
(ii) The written agreement between the hospital and the nonhospital
provider must contain--
(A) A statement by the nonhospital provider that, all or
substantially all of the direct graduate medical education costs as
defined in paragraph (b) of this section are being assumed by the
hospital;
(B) A statement that the nonhospital site agrees to offset the
revenue received from the hospital;
(C) A statement that the nonhospital site agrees to report its
direct graduate medical education costs on its cost report in a
graduate medical education cost center; and
(D) A statement indicating how much time the teaching physicians
will spend training residents in the nonhospital setting, subject to
the provisions of Secs. 415.60 and 415.70 of this chapter.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance)
Dated: April 28, 1998.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
Dated: May 1, 1998.
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, 1998 and Update Factors and
Rate-of-Increase Percentages Effective With Cost Reporting Periods
Beginning On or After October 1, 1998
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, 1998, except for
sole community hospitals, Medicare-dependent, small rural 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 yield 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. Medicare-dependent, small rural hospitals are paid
based on the Federal national rate or, if higher, the Federal national
rate plus 50 percent of the difference between the Federal national
rate and the updated hospital-specific rate based on FY 1982 or FY 1987
cost per discharge, whichever is higher. For hospitals in Puerto Rico,
the payment per discharge is based on the sum of 50 percent of a Puerto
Rico rate and 50 percent of a national rate.
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 of
this addendum, we discuss our proposed changes for determining the
prospective payment rates for Medicare inpatient capital-related costs.
Section IV of this addendum 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 1999
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 proposed 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, 1998. 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 1999.
In summary, the proposed standardized amounts set forth in Tables
1A and 1C of section V of this addendum reflect--
Updates of 0.7 percent for all areas (that is, the market
basket percentage increase of 2.6 percent minus 1.9 percentage points);
An adjustment to ensure budget neutrality as provided for
in sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act by applying new
budget neutrality adjustment factors to the large urban and other
standardized amounts;
An adjustment to ensure budget neutrality as provided for
in section 1886(d)(8)(D) of the Act by removing the FY 1998 budget
neutrality factor and applying a revised factor;
An adjustment to apply the revised outlier offset by
removing the FY 1998 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.
The standardized amounts set forth in Tables 1E and 1F of section V
of this addendum, which apply to ``temporary relief'' hospitals (see 62
FR 46001 for a discussion of these hospitals), reflect updates of 1.0
percent for all areas but otherwise reflect the same adjustments
[[Page 25609]]
as the national standardized amounts. As described in Sec. 412.107,
these hospitals receive an update that is 0.3 percentage points more
than the update factor applicable to all other prospective payment
hospitals for FY 1999.
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, 1997, when the market basket was last
revised, we have considered 71.1 percent of costs to be labor-related
for purposes of the prospective payment system. We are revising the
Puerto Rico standardized amounts by the average labor share in Puerto
Rico of 71.3 percent. We are revising the discharge-weighted national
standardized amount for Puerto Rico to reflect the proportion of
discharges in large urban and other areas from the FY 1997 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 50 percent of the applicable Puerto Rico standardized amount
and 50 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 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 1996 population estimates published by the Bureau of the
Census, 60 areas meet the criteria to be defined as large urban areas
for FY 1999. These areas are identified by a footnote 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 1999
using the applicable percentage increases specified in section
1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XIV) of the Act
specifies that, for hospitals in all areas, the update factor for the
standardized amounts for FY 1999 is equal to the market basket
percentage increase minus 1.9 percentage points. The ``temporary
relief'' provision under section 4401 of Public Law 105-33 provides for
an update equal to the market basket percentage increase minus 1.6
percentage points for hospitals that are not Medicare-dependent, small
rural hospitals, that receive no IME or DSH payments, that are located
in a state in which aggregate Medicare operating payments for such
hospitals were less than their aggregate allowable Medicare operating
costs for their cost reporting periods beginning during FY 1995, and
whose Medicare operating payments are less than their allowable
Medicare operating costs for their cost reporting period beginning
during FY 1999.
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
hospital market basket increase for FY 1999 is 2.6 percent. Thus, for
FY 1999, the proposed update to the average standardized amounts equals
0.7 percent (1.0 percent for those hospitals qualifying under the
``temporary relief'' provision of Public Law 105-33).
As in the past, we are adjusting the FY 1998 standardized amounts
to remove the effects of the FY 1998 geographic reclassifications and
outlier payments before applying the FY 1999 updates. That is, we are
increasing the standardized amounts to restore the reductions that were
made for the effects of geographic reclassification and outliers. We
then apply the new offsets to the standardized amounts for outliers and
geographic reclassifications for FY 1999.
Although the update factor for FY 1999 is set by law, we are
required by section 1886(e)(3) of the Act to report to Congress on our
initial recommendation of update factors for FY 1999 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 C 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 MedPAC's recommendation concerning the update factor, are
set forth as Appendix D to this proposed rule.
[[Page 25610]]
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 1998 relative weights and wage index to aggregate payments
using the proposed FY 1999 relative weights and wage index. The same
methodology was used for the FY 1998 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 0.999227. 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 0.998946. These
budget neutrality adjustment factors are applied to the standardized
amounts without removing the effects of the FY 1998 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 1999
adjustment factor to the hospital-specific rates that are effective for
cost reporting periods beginning on or after October 1, 1998, 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 1999 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 0.994019 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 1998 budget neutrality adjustment
factor. We note that the proposed FY 1999 adjustment reflects wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of February 27, 1998. The effects of any
additional reclassification changes resulting from appeals and reviews
of the MGCRB decisions for FY 1999 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 1999.
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). 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.
For FY 1998, the fixed loss cost outlier threshold is equal to the
prospective payment for the DRG plus $11,050 ($10,080 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 1998 standardized
amounts of 0.948840 for the large urban and other areas rates and
0.9382 for the capital Federal rate.
We are proposing a fixed loss cost outlier threshold in FY 1999
equal to the prospective payment rate for the DRG plus $11,350 ($10,355
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 1999 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 1999 will result in outlier
payments equal to 5.1
[[Page 25611]]
percent of operating DRG payments and 6.2 percent of capital payments
based on the Federal rate.
The proposed outlier adjustment factors applied to the standardized
amounts for FY 1999 are as follows:
------------------------------------------------------------------------
Operating
standardized Capital
amounts federal rate
------------------------------------------------------------------------
National................................ 0.948819 0.9378
Puerto Rico............................. 0.972962 0.9626
------------------------------------------------------------------------
We apply the proposed outlier adjustment factors after removing the
effects of the FY 1998 outlier adjustment factors on the standardized
amounts.
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 29,
1997 final rule with comment period (62 FR 46113), effective October 1,
1998. 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 0.217279 or greater
than 1.28985 and capital cost-to-charge ratios lower than 0.01281 or
greater than 0.18084. 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 during FY 1999 when hospital-specific
cost-to-charge ratios based on the latest settled cost report are
either not available or outside the three standard deviations range.
In the August 29, 1997 final rule with comment period (62 FR
46041), we stated that, based on available data, we estimated that
actual FY 1997 outlier payments would be approximately 4.8 percent of
actual total DRG payments. This was computed by simulating payments
using actual FY 1996 bill data available at the time. That is, the
estimate of actual outlier payments did not reflect actual FY 1997
bills but instead reflected the application of FY 1997 rates and
policies to available FY 1996 bills. Our current estimate, using
available FY 1997 bills, is that actual outlier payments for FY 1997
were approximately 5.5 percent of actual total DRG payments. We note
that the MedPAR file for FY 1997 discharges continues to be updated.
We currently estimate that actual outlier payments for FY 1998 will
be approximately 5.4 percent of actual total DRG payments, slightly
higher than the 5.1 percent we projected in setting outlier policies
for FY 1998. This estimate is based on simulations using the December
1997 update of the provider-specific file and the December 1997 update
of the FY 1997 MedPAR file (discharge data for FY 1997 bills). We used
these data to calculate an estimate of the actual outlier percentage
for FY 1998 by applying FY 1998 rates and policies to available FY 1997
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. For FY 1998, we used a cost inflation factor of
minus 2.005 percent (a cost per case decrease of 2.005 percent). For FY
1999, based on more recent data, we are proposing a cost inflation
factor of minus 1.831 percent to set outlier thresholds. We will
reevaluate this factor when we develop the final rule for FY 1999. At
that time, more recent data should be available for analysis,
specifically, cost report data for cost reporting periods beginning in
FY 1997.
5. FY 1999 Standardized Amounts
The adjusted standardized amounts are divided into labor and
nonlabor portions. Table 1A (Table 1E for ``temporary relief''
hospitals) contains the two national standardized amounts that we are
proposing to 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 and
1E). The labor and nonlabor portions of the national average
standardized amounts for Puerto Rico hospitals are set forth in Table
1C (Table 1F for ``temporary relief'' hospitals). These tables also
include the Puerto Rico standardized amounts.
B. Adjustments for Area Wage Levels and Cost of Living
Tables 1A, 1C, 1E and 1F, 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. 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 1999,
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 July 1, 1998, we will publish them in the
final rule and use them in determining FY 1999 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
[[Page 25612]]
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 1999. These factors have been recalibrated as explained
in section II of the preamble.
D. Calculation of Prospective Payment Rates for FY 1999
General Formula for Calculation of Prospective Payment Rates for FY
1999
Prospective payment rate for all hospitals located outside of
Puerto Rico except sole community hospitals and Medicare-dependent,
small rural 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 Medicare-dependent, small rural
hospitals = 100 percent of the Federal rate plus, if the greater of the
updated FY 1982 hospital-specific rate or the updated FY 1987 hospital-
specific rate is higher than the Federal rate, 50 percent of the
difference between the applicable hospital-specific rate and the
Federal rate.
Prospective payment rate for Puerto Rico = 50 percent of the Puerto
Rico rate + 50 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, 1998 and before
October 1, 1999, except for sole community hospitals, Medicare-
dependent, small rural hospitals, and hospitals in Puerto Rico, the
hospital's payment is based exclusively on 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 or 1E, in 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
and Medicare-Dependent, Small Rural 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.
Sections 1886(d)(5)(G) and (b)(3)(D) of the Act provide that
Medicare-dependent, small rural hospitals are paid based on whichever
of the following rates yields the greatest aggregate payment: the
Federal rate or the Federal rate plus 50 percent of the difference
between the Federal rate and the greater of the updated hospital-
specific rate based on FY 1982 and 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
1999. We are proposing to increase the hospital-specific rates by 0.7
percent (the hospital market basket percentage increase of 2.6 percent
minus 1.9 percentage points) for sole community hospitals and Medicare-
dependent, small rural hospitals located in all areas for FY 1999.
Section 1886(b)(3)(C)(iv) 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)(iv) of
the Act, which, for FY 1999, is the market basket rate of increase
minus 1.9 percentage points. Section 1886(b)(3)(D) of the Act provides
that the update factor applicable to the hospital-specific rates for
Medicare-dependent, small rural hospitals equals the update factor
provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY
1999, is the market basket rate of increase minus 1.9 percentage
points.
b. Calculation of Hospital-Specific Rate. For sole community
hospitals and Medicare-dependent, small rural hospitals, the applicable
FY 1999 hospital-specific rate would be calculated by increasing the
hospital's hospital-specific rate for the preceding fiscal year by the
applicable update factor (0.7 percent), which is the same as the update
for all prospective payment hospitals except ``temporary relief''
hospitals. In addition, the hospital-specific rate would be adjusted by
the budget neutrality adjustment factor (that is, 0.999227) 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
or Medicare-dependent, small rural hospital is paid for its discharges
beginning on or after October 1, 1998, 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, 1998
and Before October 1, 1999.
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 or 1F 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 50 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 or 1F 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.
[[Page 25613]]
Step 3--Multiply the result in Step 2 by 50 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 1999
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 1999. The rates will be effective for
discharges occurring on or after October 1, 1998.
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. Section 412.308(b)(2) describes the 7.4 percent reduction to
the rate which was made in FY 1994, and Sec. 412.308(b)(3) describes
the 0.28 percent reduction to the rate made in FY 1996 as a result of
the revised policy of paying for transfers. In the FY 1998 final rule
with comment period (62 FR 45966) we implemented section 4402 of the
BBA, which required that for discharges occurring on or after October
1, 1997, and before October 1, 2002, the unadjusted standard Federal
rate was reduced by 17.78 percent. A small part of that reduction will
be restored effective October 1, 2002.
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. In the
FY 1998 final rule with comment period (62 FR 46012) we implemented
section 4402 of the BBA, which required that for discharges occurring
on or after October 1, 1997, and before October 1, 2002, the unadjusted
hospital-specific rate should be reduced by 17.78 percent. A small part
of that reduction will also be restored effective October 1, 2002.
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 of this proposed rule.
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. Prior to FY 1998, hospitals in Puerto Rico were paid a
blended rate that consisted of 75 percent of the applicable
standardized amount specific to Puerto Rico hospitals and 25 percent of
the applicable national average standardized amount. However, effective
October 1, 1998, as a result of section 4406 of the BBA, operating
payments to hospitals in Puerto Rico are based on a blend of 50 percent
of the applicable standardized amount specific to Puerto Rico hospitals
and 50 percent of the applicable national average standardized amount.
In conjunction with this change to the operating blend percentage,
effective with discharges on or after October 1, 1997, we compute
capital payments to hospitals in Puerto Rico based on a blend of 50
percent of the Puerto Rico rate and 50 percent of the Federal rate.
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.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
For FY 1998, the Federal rate is $371.51. With the changes we are
proposing to the factors used to establish the Federal rate, the
proposed FY 1999 Federal rate is $377.25.
In the discussion that follows, we explain the factors that were
used to determine the proposed FY 1999 Federal rate. In particular, we
explain why the proposed FY 1999 Federal rate has increased 1.55
percent compared to the FY 1998 Federal rate. Even though we estimate
that Medicare hospital inpatient discharges will decline by
approximately 2.25 between FY 1998 and FY 1999, we also estimate that
aggregate capital payments will increase by 2.60 percent during this
same period. This aggregate increase is primarily due to the change in
the federal rate blend percentage from 70 percent to 80 percent, the
1.55 percent increase in the rate, and a projected increase in case
mix.
The major factor contributing to the increase in the proposed
capital Federal rate for FY 1999 relative to FY 1998 is
[[Page 25614]]
that the proposed FY 1999 exceptions reduction factor is 1.06 percent
higher than the factor for FY 1998. The exceptions reduction factor
equals 1 minus the projected percentage of exceptions payments. We
estimate that the projected percentage of exceptions payments for FY
1999 will be lower than the projected percentage for FY 1998;
accordingly, the proposed FY 1999 rate reflects less of a reduction to
account for exceptions than the FY 1998 rate.
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 1999 compared to FY 1998.
1. Standard Federal Rate Update
a. Description of the Update Framework. Under section
412.308(c)(1), 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 1999 under that framework is 0.2 percent. This
proposal is based on a projected 0.8 percent increase in the CIPI,
policy adjustment factors of -0.2, and a forecast error correction of
-0.4 percent. We explain the basis for the FY 1999 CIPI projection in
section II.D of this addendum. Here we describe the policy adjustments.
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 1999, 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 1999. Therefore, the proposed net adjustment for case-mix
change in FY 1999 is -0.2 percentage points.
We estimate that DRG reclassification and recalibration result 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 capital 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 1997 through an adjustment to the FY 1999 update. Because we
only introduced this analytical framework in FY 1996, FY 1998 was the
first year in which a forecast error adjustment could be required. We
estimate that the FY 1997 CIPI was 0.4 percentage points higher than
our current data show, which means that we estimate a forecast error of
-0.4 percentage points for FY 1997. Therefore we are making an -0.4
percent adjustment for forecast error in FY 1999.
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 1999, we have developed a Medicare-specific intensity
measure based on a 5-year average using FY 1993-1997 data. In
determining case-mix constant intensity, we found that observed case-
mix increase was 0.9 percent in FY 1993, 0.8 percent in FY
[[Page 25615]]
1994, 1.7 percent in FY 1995, 1.6 percent in FY 1996, and 0.3 percent
in FY 1997. For 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 usually 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 1992 through FY 1997. Based on this analysis, we believe
that all of the observed case-mix increase for FY 1993, FY 1994 and FY
1997 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 case-mix. Given estimates of
real case mix of 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, and 0.3 percent for
FY 1997, we estimate that case-mix constant intensity declined by an
average 1.5 percent during FYs 1993 through 1997, for a cumulative
decrease of 7.3 percent. If we assume that real case-mix increase was
0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.4 percent for FY
1995, 1.4 percent for FY 1996 and 0.3 percent for FY 1997, we estimate
that case-mix constant intensity declined by an average 1.6 percent
during FYs 1993 through 1997, for a cumulative decrease of 7.7 percent.
Since we estimate that intensity has declined during that period, we
are recommending a 0.0 percent intensity adjustment for FY 1999.
b. Comparison of HCFA and MedPAC Update Recommendations. MedPAC
recommends a 0.0 to 0.7 percent update to the standard Federal rate and
we are recommending a 0.2 percent update. There are some significant
differences between the HCFA and MedPAC 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 capital 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 MedPAC capital market basket does not include interest
expense; instead the MedPAC 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. MedPAC'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 MedPAC's input price
index, the percentage change in HCFA's CIPI is 0.8 percent, and the
percentage change in MedPAC's market basket is 2.4 percent.
MedPAC and HCFA also differ in the adjustments they make to their
price indices. (See Table 1 for a comparison of HCFA and MedPAC's
update recommendations.) MedPAC makes an adjustment for productivity,
while HCFA has not adopted an adjustment for capital productivity or
efficiency. MedPAC 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.
The Commission also includes a product change adjustment to account for
changes in the service content of hospital stays, which adjusts the
base payment rates to eliminate overpayments in the future. MedPAC
recommends a -3.0 to a -1.0 adjustment for product change for FY 1999.
For FY 1999 MedPAC recommends a -0.7 to a -0.3 adjustment for
productivity. 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 1999. MedPAC
makes a two part adjustment for case mix changes, which takes into
account changes in case mix in the past year. They recommend a -0.2 to
-0.0 adjustment for coding change and an 0.0 to 0.2 adjustment for
within-DRG complexity change. We recommend a -0.4 adjustment for
forecast error correction, and MedPAC recommends a -0.4 adjustment for
forecast error correction.
The net result of these adjustments is that MedPAC's capital update
framework suggests a -1.9 to 1.4 percent update. MedPAC has recommended
a 0.0 to 0.7 percent update to the rate for FY 1999. This range is
consistent with the PPS operating update recommended by the Commission.
We describe the basis for our proposed 0.2 percent total update in the
preceding section. HCFA and MedPAC's update recommendations are quite
close, with HCFA's recommendation within the range recommended by
MedPAC.
Table 1.--HCFA's FY 1999 Update Factor and MedPAC's Recommendation
------------------------------------------------------------------------
HCFA's update MedPAC's recommenda
factor tion
------------------------------------------------------------------------
Capital Input Price Index..... 0.8 2.4
Policy Adjustment Factors:
Productivity.............. ................. -0.7 to -0.3
Intensity................. 0.0 .....................
Science and Technology ................. 0.0 to 0.5
Intensity............. ................. (\1\)
Real within DRG Change ................. (\2\)
Product Change............ ................. -3.0 to -1.0
-----------------------------------------
Subtotal............ 0.0 -3.7 to -0.8
=========================================
Case-Mix Adjustment Factors:
Projected Case-Mix Change. -1.0 .....................
Real Across DRG Change.... 0.8 .....................
[[Page 25616]]
Coding Change............. ................. -0.2 to -0.0
Real within DRG Change.... (\3\) 0.0 to 0.2
-----------------------------------------
Subtotal............ -0.2 -0.2 to 0.2
=========================================
Effect of FY 1996 0.0 .....................
Reclassification and
Recalibration.
Forecast Error Correction..... -0.4 -0.4
-----------------------------------------
Total Update............ 0.2 -1.9 to 1.4
------------------------------------------------------------------------
\1\ Included in MedPAC's productivity measure.
\2\ Included in MedPAC'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, 80
percent for cost reporting periods beginning in FY 1999 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 100
percent of the Federal rate. For purposes of calculating the outlier
thresholds and the outlier reduction factor, we model payments as if
all hospitals 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 29, 1997 final rule with comment period, we estimated
that outlier payments for capital in FY 1998 would equal 6.18 percent
of inpatient capital-related payments based on the Federal rate.
Accordingly, we applied an outlier adjustment factor of 0.9382 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 6.22 percent of inpatient capital-related payments based on the
Federal rate in FY 1999. We are, therefore, proposing an outlier
adjustment factor of 0.9378 to the Federal rate. Thus, estimated
capital outlier payments for FY 1999 represent a higher percentage of
total capital standard payments than in FY 1998.
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 1999 is 0.9996 (0.9378/0.9382).
Thus, the outlier adjustment decreases the FY 1999 Federal rate by 0.04
percent (0.9996--1) compared with the FY 1998 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 of this proposed rule, 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 1998, we calculated a GAF/DRG budget neutrality factor of
0.9989. For FY 1999, we are proposing a GAF/DRG budget neutrality
factor of 1.0032. 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 1998 to FY 1999 is 1.0032. The proposed
cumulative change in the rate due to this adjustment is 1.0034 (the
product of the incremental factors for FY 1993, FY 1994, FY 1995, FY
1996, FY 1997, FY 1998, and the proposed incremental factor for FY
1999: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9987 x 0.9989 x
1.0032 = 1.0034).
This proposed factor accounts for DRG reclassifications and
recalibration and for changes in the GAF. It also incorporates the
effects on the GAF of FY 1999 geographic reclassification decisions
made by the MGCRB compared to FY 1998 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
[[Page 25617]]
exceptions payment adjustment factor. We describe that model in
Appendix B to this proposed rule.
For FY 1998, we estimated that exceptions payments would equal 3.41
percent of aggregate payments based on the Federal rate and the
hospital-specific rate. Therefore, we applied an exceptions reduction
factor of 0.9659 (1-0.0341) in determining the Federal rate. For this
proposed rule, we estimate that exceptions payments for FY 1999 will
equal 2.39 percent of aggregate payments based on the Federal rate and
the hospital-specific rate. Therefore, we are proposing an exceptions
payment reduction factor of 0.9761 to the Federal rate for FY 1999. The
proposed exceptions reduction factor for FY 1999 is 1.06 percent higher
than the factor for FY 1998.
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 1999
Federal rate is 0.9761/0.9659, or 1.0106.
5. Standard Capital Federal Rate for FY 1999
For FY 1998, the capital Federal rate was $371.51. With the changes
we are proposing to the factors used to establish the Federal rate, the
FY 1999 Federal rate would be $377.25. The proposed Federal rate for FY
1999 was calculated as follows:
The proposed FY 1999 update factor is 1.0020, that is, the
proposed update is 0.20 percent.
The proposed FY 1999 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 1.0032.
The proposed FY 1999 outlier adjustment factor is 0.9378.
The proposed FY 1999 exceptions payments adjustment factor
is 0.9761.
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 1999 affected the computation of the proposed FY
1999 Federal rate in comparison to the FY 1998 Federal rate. The
proposed FY 1999 update factor has the effect of increasing the Federal
rate by 0.20 percent compared to the rate in FY 1998, while the
proposed geographic and DRG budget neutrality factor has the effect of
increasing the Federal rate by 0.32 percent. The proposed FY 1999
outlier adjustment factor has the effect of decreasing the Federal rate
by 0.04 percent compared to FY 1998. The proposed FY 1999 exceptions
reduction factor has the effect of increasing the Federal rate by 1.06
percent compared to the exceptions reduction for FY 1998. The combined
effect of all the proposed changes is to increase the proposed Federal
rate by 1.55 percent compared to the Federal rate for FY 1998.
Comparison of Factors and Adjustments--FY 1998 Federal Rate and Proposed FY 1999 Federal Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Percent
FY 98 99 Change change
----------------------------------------------------------------------------------------------------------------
Update factor\1\............................................ 1.0090 1.0020 1.0020 0.20
GAF/DRG Adjustment Factor\1\................................ 0.9989 1.0032 1.0032 0.32
Outlier Adjustment Factor\2\................................ 0.9382 0.9378 0.9996 -0.04
Exceptions Adjustment Factor\2\............................. 0.9659 0.9761 1.0106 1.06
Federal Rate................................................ $371.51 $377.25 1.0155 1.55
----------------------------------------------------------------------------------------------------------------
\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 1998 to FY 1999 resulting from the application of the 1.0032 GAF/DRG
budget neutrality factor for FY 1999 is 1.0032.
\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 1999 outlier reduction factor is 0.9378/0.9382, or 0.9996.
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of this section, hospitals in Puerto
Rico are paid based on 50 percent of the Puerto Rico rate and 50
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. We use the Puerto Rico wage index to determine the GAF for the
Puerto Rico part of the capital blended rate and the national wage
index to determine the GAF for the national part of the blended rate.
Since we implemented a separate GAF for Puerto Rico, we also
propose to apply separate budget neutrality adjustments for the
national GAF and for the Puerto Rico GAF. We propose to apply the same
budget neutrality factor for DRG reclassifications and recalibration
nationally and for Puerto Rico. Separate adjustments were unnecessary
for FY 1998 since the Puerto Rico specific GAF was implemented that
year. The Puerto Rico GAF budget neutrality factor is 0.9989, while the
DRG adjustment is 1.0033, for a combined cumulative adjustment of
1.0022. (For a more detailed explanation of this proposed change see
Appendix B.)
In computing the payment for a particular Puerto Rico hospital, the
Puerto Rico portion of the rate (50%) is multiplied by the Puerto Rico-
specific GAF for the MSA in which the hospital is located, and the
national portion of the rate (50%) is 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).
In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico
rate as a result of the BBA.
For FY 1998, before application of the GAF, the special rate for
Puerto Rico hospitals was $177.57. With the changes we are proposing to
the factors used to determine the rate, the proposed FY 1999 special
rate for Puerto Rico is $180.73.
B. Determination of Hospital-Specific Rate Update
Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 1999 be determined by adjusting
[[Page 25618]]
the FY 1998 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 1999, we are proposing that the hospital-
specific rate be updated by a factor of 1.0020.
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 1999, we estimate that exceptions
payments will be 2.39 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. Therefore, we propose that
the updated hospital-specific rate be reduced by a factor of 0.9761.
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. The proposed net adjustment to the FY 1999
hospital-specific rate is 0.9761/0.9659, or 1.0106.
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 1998 and FY 1999 and
the net adjustment for each factor. It also shows that the proposed
cumulative net adjustment from FY 1998 to FY 1999 is 1.0126, which
represents a proposed increase of 1.26 percent to the hospital-specific
rate. For each hospital, the proposed FY 1999 hospital-specific rate is
determined by multiplying the FY 1998 hospital-specific rate by the
cumulative net adjustment of 1.0126.
Proposed FY 1999 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
Proposed FY Net Percent
FY 98 99 Adjustment Change
----------------------------------------------------------------------------------------------------------------
Update Factor............................................... 1.0090 1.0020 1.0020 0.20
Exceptions Payment Adjustment Factor........................ 0.9659 0.9761 1.0106 1.06
Cumulative Adjustments...................................... 0.9746 0.9869 1.0026 1.26
----------------------------------------------------------------------------------------------------------------
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 1998 to FY 1999 is 1.0020. In contrast, the exceptions
payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the
exceptions reduction factor from FY 1998 to FY 1999 is 0.9761/0.9659, or 1.0106.
C. Calculation of Inpatient Capital-Related Prospective Payments for FY
1999
During the capital prospective payment system transition period, a
hospital is paid for the inpatient capital-related costs under one of
two 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 redution 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 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 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 the
following:
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 following:
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 1999 are 80 percent of the adjusted Federal rate and 20 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 80 percent
of the Federal rate for
[[Page 25619]]
discharges occurring in cost reporting periods beginning during FY
1999. Thus, a fully prospective hospital will receive 80 percent of the
capital-related outlier payment calculated for the case for discharges
occurring in cost reporting periods beginning in FY 1999. 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 1999 are in section II.A.4.c
of this Addendum. For FY 1999, a case qualifies as a cost outlier if
the cost for the case (after standardization for the indirect teaching
adjustment and disproportionate share adjustment) is greater than the
prospective payment rate for the DRG plus $11,350.
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 1999 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
Like the prospective payment hospital operating input price index,
the Capital Input Price Index (CIPI) is a fixed-weight price index that
measures the price changes associated with costs during a given year.
The CIPI differs from the operating input price index in one important
aspect--the CIPI reflects 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, the CIPI is based to FY 1992 and was last
rebased in 1997. The most recent explanation of the CIPI was discussed
in the final rule with comment period for FY 1998 published in the
August 29, 1997 Federal Register (62 FR 46050). The following Federal
Register documents also describe development and revisions of the
methodology involved with the construction of the CIPI: September 1,
1992 (57 FR 40016), May 26, 1993 (58 FR 30448), September 1, 1993 (58
FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517),
June 2, 1995 (60 FR 29229), and September 1, 1995 (60 FR 45815), May
31, 1996 (61 FR 27466), August 30, 1996 (61 FR 46196), and June 2, 1997
(62 FR 29953).
2. Forecast of the CIPI for Federal Fiscal Year 1999
DRI forecasts a 0.8 percent increase in the CIPI for FY 1999. This
is the outcome of a projected 2.0 percent increase in vintage-weighted
depreciation prices (building and fixed equipment, and movable
equipment) and a 2.6 percent increase in other capital expense prices
in FY 1999, partially offset by a 2.7 percent decline in vintage-
weighted interest rates in FY 1999. The weighted average of these three
factors produces the 0.8 percent increase for the CIPI as a whole.
IV. Proposed Changes to Payment Rates for Excluded Hospitals and
Hospital Units: Rate-of-Increase Percentages
A. Rate-of-Increase Percentages for Excluded Hospitals and Hospital
Units
The inpatient operating costs of hospitals and hospital units
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of
the Act, which is implemented in Sec. 413.40 of the regulations. Under
these limits, an annual target amount (expressed in terms of the
inpatient operating cost per discharge) is set for each hospital, based
on the hospital's own historical cost experience trended forward by the
applicable rate-of-increase percentages (update factors). In the case
of a psychiatric hospital or unit, rehabilitation hospital or unit, or
long-term care hospital, the target amount may not exceed the 75th
percentile of target amounts for hospitals and units in the same class
(psychiatric, rehabilitation, and long-term care). 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.
Each hospital's target amount is adjusted annually, at the
beginning of its cost reporting period, by an applicable update factor.
Section 1886(b)(3)(B) of the Act provides that for cost reporting
periods beginning on or after October 1, 1998 and before October 1,
1999, the update factor is the market basket less a percentage point
between 0 and 2.5 depending on the hospital's or
[[Page 25620]]
unit's costs in relation to the ceiling. For hospitals with costs
exceeding the ceiling by 10 percent or more, the update factor is the
market basket increase. For hospitals with costs exceeding the ceiling
by less than 10 percent, the update factor is the market basket minus
.25 percent for each percentage point by which costs are less than 10
percent over the ceiling. For hospitals with costs equal to or less
than the ceiling but greater than 66.7 percent of the ceiling, the
update factor is the greater of 0 percent or the market basket minus
2.5 percent. For hospitals with costs that do not exceed 66.7 percent
of the ceiling, the update factor is 0.
The most recent forecast of the market basket increase for FY 1999
for hospitals and hospital units excluded from the prospective payment
system is 2.5 percent; therefore, the update to a hospital's target
amount for its cost reporting period beginning in FY 1999 would be
between 0 and 2.5 percent.
In addition, section 1886(b)(3)(H) of the Act provides that for
cost reporting periods beginning on or after October 1, 1998 and before
October 1, 1999, the target amount for psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals will
be the lower of the hospital's specific target amount or the 75th
percentile target amount for hospitals in the same class. The FY 1998
75th percentile target amounts were $10,534 for psychiatric hospitals
and units, $19,104 for rehabilitation hospital and units, and $37,688
for long-term care hospitals. For 1999, these 75th percentile figures
must be updated by the market basket increase. Section 1886(b) of the
Act was revised to change the formulas for determining bonus and relief
payments for excluded hospitals and also establishes an additional
bonus payment for continuous improvement, for cost reporting periods on
or after October 1, 1997. Finally, a new statutory payment methodology
for new hospitals and units (psychiatric, rehabilitation, and long-term
care) was effective October 1, 1997 as governed by section 1886(b)(7)
of the Act.
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, 1E, 1F, 3C, 4A, 4B, 4C, 4D, 4E, 4F, 5, 6A, 6B, 6C,
6D, 6E, 6F, 6G, 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 1E--National Adjusted Operating Standardized Amounts for
``Temporary Relief'' Hospitals, Labor/Nonlabor
Table 1F--Adjusted Operating Standardized Amounts for ``Temporary
Relief'' Hospitals in Puerto Rico, Labor/Nonlabor
Table 3C--Hospital Case Mix Indexes for Discharges Occurring in Federal
Fiscal Year 1997 and Hospital Average Hourly Wage for Federal Fiscal
Year 1999 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 Capital Geographic Adjustment
Factor (GAF)
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric Mean Length of Stay, and Arithmetic Mean Length of
Stay Points Used in the Prospective Payment System
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
Table 6E--Revised Diagnosis Code Titles
Table 6F--Additions to the CC Exclusions List
Table 6G--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 97 MEDPAR Update 12/97 GROUPER V15.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 97 MEDPAR Update 12/97 GROUPER V16.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) March 1998
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) March 1998
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
----------------------------------------------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
----------------------------------------------------------------------------------------------------------------
2,776.21................... 1,128.44 2,732.26 1,110.58
----------------------------------------------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts For Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National.................................................... 2,752.36 1,118.74 2,752.36 1,118.74
Puerto Rico................................................. 1,323.01 532.55 1,302.07 524.11
----------------------------------------------------------------------------------------------------------------
[[Page 25621]]
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................... 371.51
Puerto Rico................................................ 177.57
------------------------------------------------------------------------
Table 1E.--National Adjusted Operating Standardized Amounts For ``Temporary Relief'' Hospitals, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
----------------------------------------------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
----------------------------------------------------------------------------------------------------------------
2,790.09................... 1,134.08 2,745.92 1,116.13
----------------------------------------------------------------------------------------------------------------
Table 1F.--Adjusted Operating Standardized Amounts For ``Temporary Relief'' Hospitals in Puerto Rico, Labor/
Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National.................................................... 2,766.12 1,124.33 2,766.12 1,124.33
Puerto Rico................................................. 1,329.63 535.21 1,308.58 526.73
----------------------------------------------------------------------------------------------------------------
[[Page 25622]]
Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1997; Hospital Average Hourly Wage For Federal Fiscal Year 1999 Wage Index
Page 1 of 15
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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....................... 01.4634 15.97 010097.......... 00.9183 14.87 030006......... 01.5689 18.22 040005......... 01.0400 13.38 040118......... 01.3520 15.27
010004....................... 01.0055 13.79 010098.......... 01.1894 13.02 030007......... 01.3034 17.95 040007......... 01.8696 18.99 040119......... 01.1640 15.33
010005....................... 01.1699 15.89 010099.......... 01.1010 09.13 030008......... 02.2412 14.19 040008......... 01.0301 13.20 040124......... 01.0549 16.23
010006....................... 01.4636 16.19 010100.......... 01.3314 15.67 030009......... 01.2640 17.83 040010......... 01.3262 16.83 040126......... 00.9551 13.26
010007....................... 01.1300 14.09 010101.......... 01.0382 14.69 030010......... 01.4386 20.05 040011......... 00.9590 11.65 040134......... 02.6975 ......
010008....................... 01.0838 13.76 010102.......... 00.9504 12.71 030011......... 01.4734 19.48 040014......... 01.2138 18.12 050002......... 01.5241 27.86
010009....................... 01.1456 17.50 010103.......... 01.8119 17.65 030012......... 01.2358 18.04 040015......... 01.1668 14.80 050006......... 01.5662 20.69
010010....................... 01.0888 15.40 010104.......... 01.6869 18.66 030013......... 01.2951 20.90 040016......... 01.6762 16.66 050007......... 01.5312 27.11
010011....................... 01.6411 20.28 010108.......... 01.2192 16.69 030014......... 01.5263 19.07 040017......... 01.2700 14.62 050008......... 01.4438 25.60
010012....................... 01.2728 17.45 010109.......... 01.1224 13.41 030016......... 01.1871 19.00 040018......... 01.2583 18.08 050009......... 01.6484 24.26
010015....................... 01.1428 14.04 010110.......... 01.0248 14.97 030017......... 01.4718 19.72 040019......... 01.1438 12.08 050013......... 01.8476 23.25
010016....................... 01.2538 17.40 010112.......... 01.1997 14.59 030018......... 01.8083 27.57 040020......... 01.5404 15.42 050014......... 01.1816 23.57
010018....................... 00.9607 17.72 010113.......... 01.6522 15.97 030019......... 01.2636 23.65 040021......... 01.2056 16.15 050015......... 01.3820 24.35
010019....................... 01.2435 15.00 010114.......... 01.3201 16.49 030022......... 01.4160 18.79 040022......... 01.5321 23.41 050016......... 01.1889 18.74
010021....................... 01.2461 15.83 010115.......... 00.8706 08.92 030023......... 01.4822 20.04 040024......... 01.0031 13.38 050017......... 02.0973 24.47
010022....................... 01.0069 18.25 010117.......... 00.8624 ....... 030024......... 01.6963 20.87 040025......... 00.9000 12.48 050018......... 01.2579 17.02
010023....................... 01.6877 16.06 010118.......... 01.3033 28.66 030025......... 01.0483 14.97 040026......... 01.5700 17.88 050021......... 01.4154 24.41
010024....................... 01.4236 15.62 010119.......... 00.8398 16.57 030027......... 01.0392 17.17 040027......... 01.2930 13.77 050022......... 01.5819 23.22
010025....................... 01.3834 14.53 010120.......... 01.0107 16.62 030030......... 01.7154 18.21 040028......... 01.0462 14.24 050024......... 01.3639 20.68
010027....................... 00.8180 36.37 010121.......... 01.3471 13.03 030033......... 01.2640 15.67 040029......... 01.2975 17.64 050025......... 01.8279 21.99
010029....................... 01.6109 17.24 010123.......... 01.2883 16.28 030034......... 01.0795 17.44 040030......... 00.8325 12.20 050026......... 01.5433 28.62
010031....................... 01.2801 17.36 010124.......... 01.2886 16.44 030035......... 01.2315 17.93 040032......... 00.9669 11.81 050028......... 01.3707 15.51
010032....................... 00.9803 13.81 010125.......... 01.0743 15.15 030036......... 01.2603 20.35 040035......... 00.9837 10.12 050029......... 01.4900 21.71
010033....................... 01.9671 18.82 010126.......... 01.2171 18.91 030037......... 02.0594 20.18 040036......... 01.5104 17.85 050030......... 01.3267 20.82
010034....................... 01.1086 14.54 010127.......... 01.3575 18.07 030038......... 01.6264 20.57 040037......... 01.1061 12.40 050032......... 01.2557 19.03
010035....................... 01.1827 17.08 010128.......... 00.9738 ....... 030040......... 01.1572 14.74 040039......... 01.2394 13.39 050033......... 01.4502 24.74
010036....................... 01.1899 17.99 010129.......... 01.0590 12.94 030041......... 00.9538 14.31 040040......... 00.9817 15.09 050036......... 01.6546 15.95
010038....................... 01.3028 19.03 010130.......... 00.9980 15.85 030043......... 01.2213 17.92 040041......... 01.2978 17.08 050038......... 01.4456 29.35
010039....................... 01.7055 17.67 010131.......... 01.3864 17.25 030044......... 00.9736 16.04 040042......... 01.2567 15.12 050039......... 01.6097 21.59
010040....................... 01.6110 18.52 010134.......... 00.8391 10.86 030047......... 00.9401 18.63 040044......... 01.0524 13.02 050040......... 01.2411 32.71
010043....................... 01.0489 11.63 010137.......... 01.2373 18.84 030049......... 00.9939 20.75 040045......... 01.0079 17.86 050042......... 01.2889 22.76
010044....................... 01.1028 15.92 010138.......... 00.9399 12.43 030054......... 00.8332 14.41 040047......... 01.1013 15.48 050043......... 01.5649 31.83
010045....................... 01.2056 14.77 010139.......... 01.6766 20.38 030055......... 01.2012 17.65 040050......... 01.1795 12.44 050045......... 01.2364 18.69
010046....................... 01.5054 17.67 010143.......... 01.2743 15.07 030059......... 01.3005 22.74 040051......... 01.1670 13.51 050046......... 01.1880 22.24
010047....................... 00.9884 12.14 010144.......... 01.3459 16.59 030060......... 01.1528 17.75 040053......... 01.1178 15.65 050047......... 01.5646 34.07
010049....................... 01.1575 13.82 010145.......... 01.3390 16.15 030061......... 01.6564 20.08 040054......... 01.0532 13.50 050051......... 01.1348 20.91
010050....................... 01.1489 14.17 010146.......... 01.2470 16.83 030062......... 01.2455 16.61 040055......... 01.4655 15.78 050054......... 01.1263 18.44
010051....................... 00.9234 11.17 010148.......... 00.9483 ....... 030064......... 01.7664 18.45 040058......... 01.0463 15.12 050055......... 01.3276 22.45
010052....................... 01.0479 13.68 010149.......... 01.3349 17.75 030065......... 01.7843 19.91 040060......... 00.9290 11.03 050056......... 01.3074 24.36
010053....................... 01.0750 08.17 010150.......... 01.1552 15.82 030067......... 01.0939 16.99 040062......... 01.6786 15.55 050057......... 01.5828 20.60
010054....................... 01.1995 17.28 010152.......... 01.2892 16.12 030068......... 01.1092 15.82 040064......... 01.0657 13.92 050058......... 01.4871 25.22
010055....................... 01.4737 16.47 010155.......... 01.0788 10.90 030069......... 01.4037 21.66 040066......... 01.1801 16.36 050060......... 01.5008 18.49
010056....................... 01.3306 19.46 020001.......... 01.5208 27.19 030071......... 01.0057 ....... 040067......... 01.2165 12.63 050061......... 01.3507 22.13
010058....................... 00.9765 13.47 020002.......... 01.0595 24.09 030072......... 00.8620 ....... 040069......... 01.1095 15.47 050063......... 01.4701 23.89
010059....................... 01.0774 15.44 020004.......... 01.1712 25.49 030073......... 01.0041 ....... 040070......... 00.9098 14.25 050065......... 01.7005 21.95
010061....................... 01.1893 15.80 020005.......... 00.9285 28.73 030074......... 00.9408 ....... 040071......... 01.6234 16.49 050066......... 01.2265 19.77
010062....................... 01.0206 13.27 020006.......... 01.1834 25.07 030075......... 00.8242 ....... 040072......... 01.0982 15.41 050067......... 01.3204 21.48
010064....................... 01.7552 20.86 020007.......... 00.9834 25.64 030076......... 00.9614 ....... 040074......... 01.2503 16.30 050068......... 01.1315 19.98
010065....................... 01.3692 15.35 020008.......... 01.1238 30.06 030077......... 00.8060 ....... 040075......... 01.0369 12.15 050069......... 01.6246 24.57
010066....................... 00.9184 10.89 020009.......... 00.8881 25.77 030078......... 01.0727 ....... 040076......... 01.0407 16.99 050070......... 01.3716 31.44
010068....................... 01.2837 17.18 020010.......... 01.0169 25.93 030079......... 00.8528 ....... 040077......... 01.0621 12.57 050071......... 01.3791 33.07
010069....................... 01.1851 12.84 020011.......... 00.9299 25.75 030080......... 01.5008 19.77 040078......... 01.5099 22.64 050072......... 01.4414 32.14
010072....................... 01.1579 15.22 020012.......... 01.2746 26.15 030083......... 01.3763 22.10 040080......... 01.0790 16.38 050073......... 01.3063 33.68
010073....................... 01.0650 11.04 020013.......... 01.0266 26.76 030084......... 01.1228 ....... 040081......... 00.9679 10.85 050075......... 01.3412 32.86
010078....................... 01.2573 17.97 020014.......... 01.1152 22.90 030085......... 01.4617 18.59 040082......... 01.2191 14.71 050076......... 01.9181 32.26
010079....................... 01.2411 14.42 020017.......... 01.4752 25.14 030086......... 01.4318 20.19 040084......... 01.1006 16.62 050077......... 01.6304 24.52
010081....................... 01.8296 17.69 020018.......... 00.9680 ....... 030087......... 01.6536 19.77 040085......... 01.1954 15.29 050078......... 01.3632 25.59
010083....................... 01.0337 15.64 020019.......... 00.9067 ....... 030088......... 01.4231 19.42 040088......... 01.4395 13.39 050079......... 01.5434 31.90
010084....................... 01.5048 18.27 020020.......... 00.7369 ....... 030089......... 01.6391 19.70 040090......... 00.9349 14.77 050080......... 01.4214 19.44
010085....................... 01.2796 17.32 020021.......... 00.8551 ....... 030092......... 01.6833 21.25 040091......... 01.1266 18.55 050082......... 01.6661 21.99
010086....................... 01.0395 15.44 020024.......... 01.1349 22.66 030093......... 01.3770 18.77 040093......... 00.9413 13.01 050084......... 01.6759 22.53
010087....................... 01.6587 16.36 020025.......... 01.0164 26.32 030094......... 01.2784 19.19 040100......... 01.2392 12.91 050088......... 00.9877 19.55
010089....................... 01.2392 18.50 020026.......... 01.2873 ....... 030095......... 01.0461 18.85 040105......... 01.0353 13.05 050089......... 01.3688 18.85
010090....................... 01.6235 17.44 020027.......... 01.0891 ....... 030099......... 00.9439 ....... 040106......... 01.0675 13.53 050090......... 01.2668 23.85
010091....................... 01.0247 13.51 030001.......... 01.3399 19.87 040001......... 01.1079 13.42 040107......... 01.1428 16.75 050091......... 01.1370 21.99
010092....................... 01.4011 15.82 030002.......... 01.7944 20.96 040002......... 01.1468 13.33 040109......... 01.1342 13.95 050092......... 00.9386 16.26
010094....................... 01.2128 16.01 030003.......... 02.0396 22.65 040003......... 01.0880 13.97 040114......... 01.8758 17.98 050093......... 01.5500 23.90
010095....................... 00.9779 12.73 030004.......... 01.1011 12.52 040004......... 01.6709 17.69 040116......... 01.2656 16.72 050096......... 01.2374 21.29
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[[Page 25623]]
Page 2 of 15
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050097....................... 01.3873 18.48 050204.......... 01.5825 24.52 050313......... 01.2044 22.00 050443......... 00.9057 18.82 050571......... 01.5096 20.05
050099....................... 01.4747 23.55 050205.......... 01.2709 21.52 050315......... 01.3579 20.47 050444......... 01.2967 22.54 050573......... 01.6294 28.41
050100....................... 01.6983 33.49 050207.......... 01.2640 20.02 050317......... 01.2655 21.86 050446......... 00.9770 10.06 050575......... 01.1367 ......
050101....................... 01.4168 31.68 050211.......... 01.3186 30.67 050320......... 01.2324 27.70 050447......... 01.0672 18.58 050577......... 01.4644 20.19
050102....................... 01.3532 17.01 050213.......... 01.5794 22.96 050324......... 01.9664 26.19 050448......... 01.0974 20.95 050578......... 01.4689 30.62
050103....................... 01.5661 23.46 050214.......... 01.4659 21.31 050325......... 01.2308 21.08 050449......... 01.3366 21.14 050579......... 01.4970 28.52
050104....................... 01.4815 23.94 050215.......... 01.5572 29.63 050327......... 01.5599 18.67 050454......... 01.8425 25.82 050580......... 01.4380 27.74
050107....................... 01.4511 23.02 050217.......... 01.3457 19.08 050329......... 01.2928 19.88 050455......... 01.7746 16.56 050581......... 01.3930 24.39
050108....................... 01.8295 23.87 050219.......... 01.1139 18.83 050331......... 01.4843 24.20 050456......... 01.1694 16.92 050583......... 01.6266 21.88
050110....................... 01.1656 20.59 050222.......... 01.6256 31.91 050333......... 01.1427 24.96 050457......... 02.0310 31.03 050584......... 01.1966 20.18
050111....................... 01.3578 20.16 050224.......... 01.5705 23.23 050334......... 01.7269 34.59 050459......... 01.2985 29.51 050585......... 01.2772 27.19
050112....................... 01.4824 19.36 050225.......... 01.6075 22.02 050335......... 01.4534 21.39 050464......... 01.8738 22.01 050586......... 01.3490 20.52
050113....................... 01.3756 31.25 050226.......... 01.4119 24.79 050336......... 01.3695 20.14 050468......... 01.3879 19.71 050588......... 01.3220 24.70
050114....................... 01.3693 23.13 050228.......... 01.2880 30.89 050342......... 01.3706 17.71 050469......... 01.0972 16.63 050589......... 01.2474 24.07
050115....................... 01.5640 20.46 050230.......... 01.3342 25.40 050343......... 01.0225 14.95 050470......... 01.1474 18.51 050590......... 01.3578 24.92
050116....................... 01.4487 23.36 050231.......... 01.6681 25.54 050348......... 01.6579 25.44 050471......... 01.8883 23.41 050591......... 01.3784 22.87
050117....................... 01.4515 20.79 050232.......... 01.7123 21.50 050349......... 00.8825 14.57 050476......... 01.3512 21.10 050592......... 01.3661 18.46
050118....................... 01.1901 23.81 050234.......... 01.2536 30.23 050350......... 01.3957 24.28 050477......... 01.4936 26.90 050593......... 01.1846 ......
050121....................... 01.3531 24.60 050235.......... 01.6014 24.55 050351......... 01.4653 32.84 050478......... 00.9635 21.11 050594......... 01.6739 19.05
050122....................... 01.5966 26.85 050236.......... 01.4693 25.40 050352......... 01.3034 19.07 050481......... 01.4648 27.13 050597......... 01.2665 21.36
050124....................... 01.3182 17.12 050238.......... 01.5517 24.76 050353......... 01.6669 24.77 050482......... 01.0978 16.07 050598......... 01.3875 32.07
050125....................... 01.3970 27.55 050239.......... 01.5877 21.67 050355......... 00.9808 16.04 050483......... 01.1821 22.22 050599......... 01.6318 23.23
050126....................... 01.5414 24.94 050240.......... 01.4863 21.17 050357......... 01.4011 23.77 050485......... 01.6561 23.81 050601......... 01.6150 32.05
050127....................... 01.3406 24.15 050241.......... 01.2337 26.32 050359......... 01.2854 19.11 050486......... 01.3493 23.00 050603......... 01.4035 22.60
050128....................... 01.6211 21.63 050242.......... 01.4284 29.91 050360......... 01.4136 31.05 050488......... 01.3349 32.94 050604......... 01.5622 37.27
050129....................... 01.6194 14.25 050243.......... 01.5930 22.58 050366......... 01.3455 22.32 050491......... 01.1935 21.97 050607......... 01.1545 20.69
050131....................... 01.3023 29.90 050245.......... 01.4385 23.33 050367......... 01.2485 27.64 050492......... 01.4113 22.37 050608......... 01.3080 15.26
050132....................... 01.4257 23.74 050248.......... 01.2618 27.54 050369......... 01.2376 21.58 050494......... 01.2167 26.20 050609......... 01.4505 32.31
050133....................... 01.2911 25.55 050251.......... 01.0989 14.91 050373......... 01.4446 24.31 050496......... 01.7259 31.88 050613......... 01.0696 31.83
050135....................... 01.3964 25.36 050253.......... 01.2992 25.63 050376......... 01.3991 26.32 050497......... 00.8270 10.59 050615......... 01.6042 23.31
050136....................... 01.4011 24.04 050254.......... 01.2141 14.11 050377......... 00.9333 19.49 050498......... 01.2434 24.96 050616......... 01.3591 22.85
050137....................... 01.4012 30.81 050256.......... 01.7518 23.91 050378......... 01.1364 20.86 050502......... 01.7222 22.74 050618......... 01.1163 22.63
050138....................... 01.9630 33.22 050257.......... 01.1275 19.38 050379......... 00.9589 15.15 050503......... 01.3400 23.15 050623......... 02.0034 27.05
050139....................... 01.2532 31.55 050260.......... 01.0044 24.07 050380......... 01.6867 29.30 050506......... 01.4395 27.49 050624......... 01.3554 22.18
050140....................... 01.2757 31.54 050261.......... 01.2723 18.81 050382......... 01.3984 23.86 050510......... 01.3791 31.86 050625......... 01.6074 25.23
050144....................... 01.6355 29.12 050262.......... 01.8576 27.43 050385......... 01.4021 26.64 050512......... 01.5743 33.03 050630......... 01.3401 23.93
050145....................... 01.3861 31.48 050264.......... 01.3335 27.45 050388......... 00.9019 20.64 050515......... 01.3473 32.36 050633......... 01.3131 21.95
050146....................... 01.4762 ....... 050267.......... 01.6544 27.78 050390......... 01.1857 16.75 050516......... 01.5400 26.16 050636......... 01.5051 26.10
050148....................... 01.1151 21.00 050270.......... 01.3573 24.13 050391......... 01.3292 21.68 050517......... 01.1822 19.69 050638......... 01.1025 24.90
050149....................... 01.4748 22.78 050272.......... 01.3703 21.55 050392......... 00.9917 18.42 050522......... 01.2252 30.95 050641......... 01.2588 14.88
050150....................... 01.2678 23.95 050274.......... 00.9903 21.63 050393......... 01.4860 17.95 050523......... 01.2384 28.96 050643......... 00.8426 ......
050152....................... 01.3850 23.39 050276.......... 01.2072 33.01 050394......... 01.5488 20.22 050526......... 01.3236 13.42 050644......... 01.0506 22.44
050153....................... 01.6231 28.40 050277.......... 01.4723 19.05 050396......... 01.6148 24.12 050528......... 01.2785 19.70 050660......... 01.4613 ......
050155....................... 01.0917 22.33 050278.......... 01.5669 22.63 050397......... 00.9890 20.00 050531......... 01.1762 20.18 050661......... 00.8186 20.05
050158....................... 01.3649 27.94 050279.......... 01.3441 19.04 050401......... 01.1257 19.64 050534......... 01.4679 23.66 050662......... 00.8651 33.41
050159....................... 01.2998 19.09 050280.......... 01.7639 25.90 050404......... 01.0765 15.96 050535......... 01.3453 23.23 050663......... 01.1547 24.12
050167....................... 01.2885 21.83 050281.......... 01.5490 33.56 050406......... 01.0708 19.56 050537......... 01.3680 18.57 050666......... 00.9460 34.46
050168....................... 01.5276 22.07 050282.......... 01.3068 23.58 050407......... 01.3597 29.45 050539......... 01.2567 19.52 050667......... 01.0189 28.01
050169....................... 01.4399 24.49 050283.......... 01.5231 27.35 050410......... 01.0632 13.08 050541......... 01.5665 33.44 050668......... 01.1332 39.35
050170....................... 01.4906 21.04 050286.......... 00.8525 18.46 050411......... 01.3589 33.17 050542......... 01.1186 14.45 050670......... 00.7487 20.84
050172....................... 01.2523 19.87 050289.......... 01.6964 30.78 050414......... 01.3074 23.74 050543......... 00.9409 23.72 050674......... 01.3219 32.55
050173....................... 01.3729 21.72 050290.......... 01.6895 33.81 050417......... 01.3155 20.45 050545......... 00.8583 27.87 050675......... 01.9709 14.65
050174....................... 01.6799 29.40 050291.......... 01.1544 30.54 050419......... 01.4360 16.25 050546......... 00.6946 31.14 050676......... 00.9474 16.75
050175....................... 01.3660 23.84 050292.......... 01.0469 22.19 050420......... 01.3375 23.41 050547......... 00.8417 36.25 050677......... 01.3998 32.89
050177....................... 01.2731 16.69 050293.......... 01.1254 20.70 050423......... 01.0173 19.31 050549......... 01.7120 26.33 050678......... 01.2229 ......
050179....................... 01.3003 21.22 050295.......... 01.4947 21.01 050424......... 01.8153 23.48 050550......... 01.4607 22.49 050680......... 01.1971 28.94
050180....................... 01.6017 32.17 050296.......... 01.1902 23.74 050425......... 01.3094 34.22 050551......... 01.3289 24.83 050682......... 00.8928 22.32
050183....................... 01.1126 19.44 050298.......... 01.3275 22.54 050426......... 01.3708 25.47 050552......... 01.2293 20.52 050684......... 01.2450 17.19
050186....................... 01.2933 27.51 050299.......... 01.3607 20.49 050427......... 00.9189 19.93 050557......... 01.5109 21.78 050685......... 01.2468 28.37
050188....................... 01.4286 26.90 050300.......... 01.4936 19.23 050430......... 01.0555 19.53 050559......... 01.3996 23.82 050686......... 01.3134 32.42
050189....................... 01.0831 22.39 050301.......... 01.2481 24.81 050432......... 01.6129 22.37 050561......... 01.1996 32.15 050688......... 01.2792 25.15
050191....................... 01.4729 20.67 050302.......... 01.3482 27.55 050433......... 01.1058 20.42 050564......... 01.3309 06.57 050689......... 01.4155 30.16
050192....................... 01.1901 20.19 050305.......... 01.5457 29.10 050434......... 01.1365 19.87 050565......... 01.3544 13.81 050690......... 01.5124 32.17
050193....................... 01.3308 22.67 050307.......... 01.3027 19.99 050435......... 01.2208 29.08 050566......... 00.9061 13.99 050693......... 01.3049 29.48
050194....................... 01.2435 27.41 050308.......... 01.4832 27.92 050436......... 00.9412 15.20 050567......... 01.6269 24.54 050694......... 01.3586 18.36
050195....................... 01.5834 33.92 050309.......... 01.3376 24.61 050438......... 01.8098 19.83 050568......... 01.3990 19.06 050695......... 01.0960 28.46
050196....................... 01.3052 15.36 050310.......... 01.0912 20.24 050440......... 01.3403 18.63 050569......... 01.3783 23.26 050696......... 02.3021 26.75
050197....................... 01.8716 30.49 050312.......... 01.9222 24.66 050441......... 02.0343 26.41 050570......... 01.7110 23.79 050697......... 01.4515 20.60
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 25624]]
Page 3 of 15
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050698....................... 00.9075 ....... 060073.......... 01.0655 16.43 100009......... 01.4921 21.67 100102......... 01.0245 18.11 100210......... 01.6031 18.18
050699....................... 00.6236 20.97 060075.......... 01.3102 24.34 100010......... 01.5263 24.50 100103......... 00.9830 16.14 100211......... 01.3282 20.20
050700....................... 01.5678 31.31 060076.......... 01.3829 19.28 100012......... 01.6950 16.74 100105......... 01.4360 21.03 100212......... 01.6623 20.46
050701....................... 01.3360 30.27 060085.......... 00.9348 12.76 100014......... 01.4918 21.94 100106......... 01.0823 16.69 100213......... 01.5199 18.60
050704....................... 01.1294 15.23 060087.......... 01.6777 21.08 100015......... 01.4344 17.47 100107......... 01.3253 18.60 100217......... 01.3379 18.88
050707....................... 01.0702 27.09 060088.......... 00.9931 23.16 100017......... 01.4976 17.71 100108......... 01.0633 14.31 100220......... 01.7265 26.34
050708....................... 01.2629 22.59 060090.......... 00.9777 13.54 100018......... 01.5086 21.03 100109......... 01.3838 18.97 100221......... 01.7374 25.21
050709....................... 01.3280 18.88 060096.......... 01.0685 21.94 100019......... 01.5290 19.50 100110......... 01.4040 20.80 100222......... 01.4127 20.13
050710....................... 01.3480 26.13 060100.......... 01.5060 ....... 100020......... 01.3336 23.86 100112......... 00.9244 12.57 100223......... 01.4858 18.81
050713....................... 00.8060 ....... 060103.......... 01.2902 23.16 100022......... 01.9055 24.49 100113......... 02.1161 19.93 100224......... 01.4049 20.57
050714....................... 01.3480 ....... 060104.......... 01.2502 21.91 100023......... 01.4358 17.35 100114......... 01.4078 18.20 100225......... 01.4014 20.59
050715....................... 01.7138 ....... 060107.......... 01.1286 ....... 100024......... 01.3638 19.67 100117......... 01.3161 19.37 100226......... 01.4003 18.53
050716....................... 03.8652 ....... 070001.......... 01.7599 25.86 100025......... 01.8449 18.06 100118......... 01.2409 19.51 100228......... 01.3287 20.31
050717....................... 00.8003 ....... 070002.......... 01.8086 24.34 100026......... 01.5872 18.06 100121......... 01.2121 16.03 100229......... 01.3032 18.10
050718....................... 00.9336 ....... 070003.......... 01.1454 25.30 100027......... 00.9920 15.86 100122......... 01.3058 16.67 100230......... 01.3648 22.35
050899....................... 00.5288 ....... 070004.......... 01.2352 24.34 100028......... 01.2339 18.03 100124......... 01.3284 14.64 100231......... 01.7051 16.97
060001....................... 01.6504 20.31 070005.......... 01.4131 24.84 100029......... 01.4199 19.56 100125......... 01.3273 18.00 100232......... 01.3660 19.83
060003....................... 01.3293 18.91 070006.......... 01.4122 27.20 100030......... 01.3066 19.01 100126......... 01.4408 18.89 100234......... 01.5349 18.94
060004....................... 01.2793 20.57 070007.......... 01.3912 24.35 100032......... 01.8893 17.78 100127......... 01.6387 19.58 100235......... 01.5525 17.92
060006....................... 01.1829 18.36 070008.......... 01.2534 22.94 100034......... 01.7634 19.44 100128......... 02.1517 21.53 100236......... 01.4246 19.87
060007....................... 01.1389 15.33 070009.......... 01.2944 24.56 100035......... 01.6050 17.98 100129......... 01.2696 17.72 100237......... 02.2024 23.28
060008....................... 01.1684 15.83 070010.......... 01.6774 20.35 100038......... 01.5798 18.23 100130......... 01.2454 18.62 100238......... 01.5894 13.88
060009....................... 01.4660 21.35 070011.......... 01.4579 23.69 100039......... 01.5397 21.36 100131......... 01.3794 20.96 100239......... 01.4442 19.35
060010....................... 01.5585 22.31 070012.......... 01.2488 23.36 100040......... 01.7626 17.97 100132......... 01.3098 19.53 100240......... 00.7775 15.37
060011....................... 01.3645 22.12 070015.......... 01.4162 24.05 100043......... 01.3643 15.33 100134......... 00.9935 13.03 100241......... 00.9329 13.90
060012....................... 01.4391 18.62 070016.......... 01.3810 23.00 100044......... 01.4082 21.18 100135......... 01.6123 17.62 100242......... 01.4132 16.91
060013....................... 01.3221 16.29 070017.......... 01.3702 24.60 100045......... 01.4052 19.25 100137......... 01.3170 18.60 100243......... 01.4048 24.16
060014....................... 01.7402 ....... 070018.......... 01.4229 28.54 100046......... 01.4822 20.36 100138......... 01.0153 10.76 100244......... 01.4078 19.39
060015....................... 01.5816 21.13 070019.......... 01.2953 24.83 100047......... 01.7725 18.92 100139......... 01.1145 15.04 100246......... 01.4106 17.86
060016....................... 01.2616 17.07 070020.......... 01.3139 24.55 100048......... 00.9695 13.58 100140......... 01.2249 17.48 100248......... 01.6271 18.75
060018....................... 01.2400 17.15 070021.......... 01.2930 24.85 100049......... 01.3276 17.97 100142......... 01.2594 18.68 100249......... 01.3503 18.84
060020....................... 01.6773 17.56 070022.......... 01.8192 23.48 100050......... 01.1456 15.90 100144......... 01.2818 19.61 100252......... 01.2846 21.94
060022....................... 01.6160 19.49 070024.......... 01.3153 23.84 100051......... 01.2118 19.11 100146......... 01.0877 16.15 100253......... 01.5082 20.97
060023....................... 01.6591 17.02 070025.......... 01.8600 19.43 100052......... 01.4303 16.90 100147......... 01.0605 14.54 100254......... 01.5827 18.66
060024....................... 01.7966 22.84 070026.......... 01.1616 18.55 100053......... 01.2198 18.09 100150......... 01.3984 19.96 100255......... 01.2900 24.34
060027....................... 01.6866 21.24 070027.......... 01.2854 23.11 100054......... 01.3283 17.76 100151......... 01.7240 18.08 100256......... 02.0081 18.90
060028....................... 01.4966 21.55 070028.......... 01.5443 24.77 100055......... 01.3757 17.93 100154......... 01.5955 19.74 100258......... 01.6280 21.07
060029....................... 00.9005 15.35 070029.......... 01.3587 21.95 100056......... 01.4068 19.38 100156......... 01.2007 19.92 100259......... 01.4194 18.73
060030....................... 01.3241 19.00 070030.......... 01.2292 25.18 100057......... 01.4184 18.63 100157......... 01.5860 21.06 100260......... 01.4513 21.73
060031....................... 01.6355 19.53 070031.......... 01.2535 23.12 100060......... 01.7365 21.02 100159......... 00.9550 11.69 100262......... 01.3943 21.16
060032....................... 01.4770 20.78 070033.......... 01.4122 26.38 100061......... 01.4813 21.68 100160......... 01.2495 18.43 100263......... 01.2482 18.64
060033....................... 01.0722 13.41 070034.......... 01.3825 29.05 100062......... 01.7465 18.11 100161......... 01.7073 21.30 100264......... 01.4012 17.62
060034....................... 01.5666 ....... 070035.......... 01.4072 22.69 100063......... 01.2890 18.31 100162......... 01.4540 19.83 100265......... 01.3352 15.01
060036....................... 01.1694 15.76 070036.......... 01.5709 27.95 100067......... 01.4095 16.81 100165......... 01.1337 13.18 100266......... 01.3566 18.10
060037....................... 01.0286 13.56 070038.......... 01.0707 ....... 100068......... 01.3733 17.72 100166......... 01.4808 19.75 100267......... 01.3379 19.83
060038....................... 01.0310 13.78 070039.......... 00.9302 23.64 100069......... 01.3153 15.88 100167......... 01.4454 20.58 100268......... 01.2241 22.61
060041....................... 00.9383 14.14 080001.......... 01.7025 27.32 100070......... 01.4966 18.19 100168......... 01.3650 19.91 100269......... 01.4247 20.37
060042....................... 01.0363 14.73 080002.......... 01.2023 15.33 100071......... 01.2953 16.97 100169......... 01.8710 20.54 100270......... 00.8682 20.06
060043....................... 00.9025 12.99 080003.......... 01.3849 20.16 100072......... 01.2360 23.32 100170......... 01.4100 15.49 100271......... 01.7428 20.02
060044....................... 01.1085 16.07 080004.......... 01.3094 19.45 100073......... 01.7511 20.04 100172......... 01.3995 14.68 100275......... 01.4146 20.36
060046....................... 01.0901 18.50 080006.......... 01.4184 21.83 100075......... 01.6523 18.22 100173......... 01.6957 17.25 100276......... 01.2702 22.13
060047....................... 00.9872 13.98 080007.......... 01.4486 16.75 100076......... 01.3180 17.07 100174......... 01.3787 17.95 100277......... 01.0519 15.24
060049....................... 01.3479 20.25 090001.......... 01.5888 27.79 100077......... 01.3753 16.82 100175......... 01.2198 15.49 100279......... 01.3775 12.47
060050....................... 01.2593 16.03 090002.......... 01.3122 19.74 100078......... 01.1969 16.33 100176......... 02.0937 23.45 100280......... 01.3550 16.99
060052....................... 01.0840 13.49 090003.......... 01.3697 25.82 100079......... 01.6561 19.15 100177......... 01.3473 18.58 100281......... 01.3003 22.78
060053....................... 01.1047 14.93 090004.......... 01.7397 24.43 100080......... 01.6318 22.70 100179......... 01.7319 19.47 100282......... 01.1124 17.70
060054....................... 01.3319 18.61 090005.......... 01.3450 23.71 100081......... 01.0539 14.21 100180......... 01.4631 19.43 110001......... 01.3047 15.63
060056....................... 00.9946 15.37 090006.......... 01.3214 20.39 100082......... 01.4614 18.91 100181......... 01.2111 21.61 110002......... 01.3058 16.54
060057....................... 01.0133 23.55 090007.......... 01.3635 19.38 100084......... 01.4186 20.77 100183......... 01.2830 18.48 110003......... 01.3845 15.24
060058....................... 00.9506 15.60 090008.......... 01.4969 20.72 100085......... 01.3915 21.33 100187......... 01.4150 19.92 110004......... 01.3881 18.05
060060....................... 00.9769 14.53 090010.......... 01.0223 17.93 100086......... 01.2392 21.23 100189......... 01.3952 24.14 110005......... 01.1802 17.38
060062....................... 00.9096 16.53 090011.......... 02.0090 25.70 100087......... 01.8553 21.28 100191......... 01.2949 20.19 110006......... 01.4001 19.78
060064....................... 01.4880 21.56 100001.......... 01.4825 16.62 100088......... 01.6726 21.08 100199......... 01.3616 19.76 110007......... 01.6056 16.12
060065....................... 01.3260 22.85 100002.......... 01.4763 19.92 100090......... 01.3888 17.89 100200......... 01.3456 21.55 110008......... 01.2651 18.30
060066....................... 01.0226 15.09 100004.......... 01.0119 13.82 100092......... 01.5281 19.47 100204......... 01.6026 19.37 110009......... 01.1532 15.80
060068....................... 01.0475 18.74 100006.......... 01.6406 20.10 100093......... 01.5080 15.93 100206......... 01.3988 19.96 110010......... 02.1459 24.74
060070....................... 01.1221 17.17 100007.......... 01.8866 20.87 100098......... 01.1552 19.33 100208......... 01.5848 22.72 110011......... 01.2262 16.24
060071....................... 01.2194 16.52 100008.......... 01.7096 20.20 100099......... 01.2922 13.50 100209......... 01.5855 17.58 110013......... 01.1130 16.61
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
110014....................... 01.0448 16.21 110101.......... 01.1323 12.27 110198......... 01.3303 25.48 130048......... 01.0690 14.17 140081......... 01.0654 14.36
110015....................... 01.1788 19.15 110103.......... 00.9185 11.59 110200......... 01.8824 19.23 130049......... 01.2597 19.05 140082......... 01.4505 22.85
110016....................... 01.2943 16.27 110104.......... 01.0983 15.18 110201......... 01.5092 18.30 130054......... 00.8904 17.88 140083......... 01.3069 18.82
110017....................... 00.8766 13.46 110105.......... 01.2904 15.96 110203......... 00.9956 20.45 130056......... 00.8204 17.37 140084......... 01.2298 19.27
110018....................... 01.1447 18.80 110107.......... 01.8386 18.54 110204......... 00.8148 18.89 130060......... 01.3078 20.72 140086......... 01.1655 15.72
110020....................... 01.3285 18.61 110108.......... 00.9689 17.58 110205......... 01.0763 22.85 130061......... 00.9403 09.29 140087......... 01.3956 17.07
110023....................... 01.2840 18.65 110109.......... 01.0955 15.30 110207......... 01.1607 12.46 130063......... 01.1768 ....... 140088......... 01.7029 21.97
110024....................... 01.4669 19.21 110111.......... 01.1955 15.74 110208......... 00.9903 15.74 140001......... 01.3044 15.14 140089......... 01.2384 17.29
110025....................... 01.4282 17.90 110112.......... 01.1297 18.83 110209......... 00.7381 16.57 140002......... 01.3201 18.33 140090......... 01.4953 23.24
110026....................... 01.2060 14.58 110113.......... 01.1014 14.21 110211......... 00.9586 ....... 140003......... 01.0457 15.69 140091......... 01.8169 18.10
110027....................... 01.1287 15.90 110114.......... 01.0561 15.10 110212......... 01.1651 ....... 140004......... 01.0989 16.55 140093......... 01.1840 18.79
110028....................... 01.6783 20.65 110115.......... 01.6734 22.60 110213......... 00.7480 ....... 140005......... 00.9503 10.22 140094......... 01.3097 20.06
110029....................... 01.3697 20.27 110118.......... 01.0544 11.38 120001......... 01.8279 27.25 140007......... 01.4925 21.24 140095......... 01.3835 20.89
110030....................... 01.2736 17.81 110120.......... 01.0683 12.89 120002......... 01.2601 23.99 140008......... 01.5269 20.27 140097......... 00.9245 15.85
110031....................... 01.2780 19.47 110121.......... 01.2134 14.59 120003......... 01.1064 24.14 140010......... 01.3777 23.35 140100......... 01.3042 20.50
110032....................... 01.3079 15.70 110122.......... 01.3699 18.25 120004......... 01.2164 24.55 140011......... 01.1962 16.35 140101......... 01.2281 18.42
110033....................... 01.4405 21.48 110124.......... 01.3180 14.58 120005......... 01.2966 21.62 140012......... 01.2712 18.24 140102......... 01.1167 15.46
110034....................... 01.6284 18.31 110125.......... 01.2718 16.36 120006......... 01.3249 24.64 140013......... 01.5981 16.59 140103......... 01.4637 15.98
110035....................... 01.4374 23.29 110127.......... 00.9214 14.72 120007......... 01.6729 21.82 140014......... 01.2346 18.98 140105......... 01.3523 20.16
110036....................... 01.7729 ....... 110128.......... 01.1853 18.34 120009......... 00.9647 19.58 140015......... 01.2859 14.77 140107......... 01.0723 14.19
110038....................... 01.4872 17.19 110129.......... 01.6924 17.61 120010......... 01.8131 23.76 140016......... 00.9826 12.09 140108......... 01.3529 22.83
110039....................... 01.3748 19.83 110130.......... 01.0679 11.85 120011......... 01.3231 32.97 140018......... 01.3572 19.73 140109......... 01.2235 14.65
110040....................... 01.1392 17.40 110132.......... 01.1281 13.98 120012......... 00.8889 21.42 140019......... 01.0877 14.26 140110......... 01.2260 18.89
110041....................... 01.1919 16.68 110134.......... 00.9052 12.22 120014......... 01.3437 23.53 140024......... 00.9826 13.82 140112......... 01.1475 14.27
110042....................... 01.2326 16.85 110135.......... 01.3155 17.76 120015......... 00.8945 23.63 140025......... 01.0844 16.04 140113......... 01.5963 18.16
110043....................... 01.8013 16.83 110136.......... 01.1358 15.43 120016......... 01.0773 26.99 140026......... 01.2533 16.60 140114......... 01.3451 19.18
110044....................... 01.1835 15.11 110140.......... 01.0384 15.81 120018......... 01.0119 22.29 140027......... 01.3199 17.12 140115......... 01.3318 19.21
110045....................... 01.2010 19.00 110141.......... 01.0430 13.17 120019......... 01.2134 20.93 140029......... 01.4133 20.69 140116......... 01.2572 20.69
110046....................... 01.2702 19.27 110142.......... 00.9278 10.94 120021......... 00.8363 19.89 140030......... 01.7236 21.88 140117......... 01.5466 20.39
110048....................... 01.2958 14.77 110143.......... 01.4312 20.93 120022......... 01.6938 17.36 140031......... 01.1981 14.47 140118......... 01.6712 23.20
110049....................... 01.0595 12.66 110144.......... 01.1053 18.09 120026......... 01.2420 24.30 140032......... 01.3088 17.51 140119......... 01.7295 21.17
110050....................... 01.2663 17.24 110146.......... 01.1084 16.74 120027......... 01.4788 22.77 140033......... 01.2949 22.13 140120......... 01.4493 16.54
110051....................... 01.0328 13.87 110149.......... 01.1383 18.93 120028......... 01.2495 ....... 140034......... 01.1849 18.25 140121......... 01.4033 14.91
110052....................... 01.1633 08.57 110150.......... 01.3908 18.34 130001......... 00.9237 20.88 140035......... 01.0753 13.77 140122......... 01.5946 22.76
110054....................... 01.3234 18.80 110152.......... 01.0769 15.05 130002......... 01.3874 15.94 140036......... 01.2318 17.01 140124......... 01.2207 25.20
110056....................... 01.1047 16.02 110153.......... 01.0943 18.60 130003......... 01.3296 19.77 140037......... 01.0362 13.33 140125......... 01.3391 16.31
110059....................... 01.3075 12.05 110154.......... 01.0296 13.75 130005......... 01.4326 19.70 140038......... 01.2131 14.65 140127......... 01.4371 18.66
110061....................... 01.0818 13.87 110155.......... 01.1450 14.18 130006......... 01.8387 19.10 140040......... 01.3081 15.90 140128......... 01.0565 16.08
110062....................... 00.8961 14.52 110156.......... 01.0223 15.53 130007......... 01.6496 19.28 140041......... 01.1977 16.33 140129......... 01.1941 16.61
110063....................... 01.1382 15.19 110161.......... 01.3086 20.74 130008......... 00.9899 12.07 140042......... 01.0291 13.94 140130......... 01.2719 24.16
110064....................... 01.3862 18.18 110162.......... 00.8099 ....... 130009......... 00.9347 15.62 140043......... 01.1678 17.93 140132......... 01.5121 23.60
110065....................... 01.0241 12.93 110163.......... 01.5208 18.71 130010......... 00.9101 19.08 140045......... 01.0478 15.21 140133......... 01.3440 20.51
110066....................... 01.4714 20.37 110164.......... 01.4277 21.27 130011......... 01.3476 19.35 140046......... 01.3159 15.70 140135......... 01.2990 16.16
110069....................... 01.2824 18.52 110165.......... 01.4010 18.70 130012......... 01.0020 22.02 140047......... 01.1731 16.57 140137......... 01.0428 17.24
110070....................... 01.1006 17.18 110166.......... 01.5150 18.65 130013......... 01.3101 19.25 140048......... 01.3315 21.58 140138......... 01.0982 14.18
110071....................... 01.1356 11.04 110168.......... 01.7223 20.47 130014......... 01.3693 17.03 140049......... 01.5511 20.89 140139......... 01.1145 15.86
110072....................... 01.0173 12.51 110169.......... 01.1931 18.66 130015......... 00.9264 17.50 140051......... 01.5114 19.42 140140......... 01.1906 18.58
110073....................... 01.2272 14.32 110171.......... 01.4942 20.46 130016......... 00.9173 17.25 140052......... 01.3990 17.19 140141......... 01.3059 14.79
110074....................... 01.4541 17.24 110172.......... 01.4235 21.34 130017......... 01.1709 16.55 140053......... 02.0119 18.24 140143......... 01.1514 17.94
110075....................... 01.3591 16.51 110174.......... 00.9675 15.24 130018......... 01.7382 17.35 140054......... 01.3761 22.90 140144......... 01.0424 17.37
110076....................... 01.5073 20.04 110176.......... 02.5217 20.96 130019......... 01.1641 17.99 140055......... 00.9267 13.99 140145......... 01.1604 16.19
110078....................... 01.7630 21.73 110177.......... 01.5788 19.87 130021......... 00.9692 15.30 140058......... 01.2943 16.54 140146......... 01.0612 16.77
110079....................... 01.3856 19.30 110178.......... 02.9393 16.83 130022......... 01.2437 18.53 140059......... 01.2264 15.77 140147......... 01.3933 15.62
110080....................... 01.2083 18.22 110179.......... 01.1105 20.42 130024......... 01.0773 18.00 140061......... 01.1070 14.15 140148......... 01.8210 17.46
110082....................... 02.1044 21.81 110181.......... 00.9493 14.70 130025......... 01.1043 14.20 140062......... 01.2892 26.44 140150......... 01.5671 25.02
110083....................... 01.7148 20.98 110183.......... 01.3855 21.18 130026......... 01.1592 19.63 140063......... 01.4336 22.90 140151......... 01.0723 19.64
110086....................... 01.2336 13.04 110184.......... 01.2704 19.37 130027......... 00.8923 19.57 140064......... 01.3056 17.80 140152......... 01.1727 21.63
110087....................... 01.3469 20.67 110185.......... 01.1237 15.51 130028......... 01.2366 16.83 140065......... 01.5316 24.12 140155......... 01.3024 17.47
110089....................... 01.2215 17.12 110186.......... 01.3551 15.59 130029......... 01.1095 17.62 140066......... 01.2213 15.60 140158......... 01.3851 22.91
110091....................... 01.3195 19.73 110187.......... 01.3406 19.18 130030......... 00.8668 18.40 140067......... 01.7964 17.99 140160......... 01.2137 16.52
110092....................... 01.1612 15.18 110188.......... 01.3408 18.49 130031......... 00.9616 16.44 140068......... 01.2411 18.98 140161......... 01.2198 18.07
110093....................... 00.9463 11.69 110189.......... 01.1257 17.51 130034......... 01.0096 19.35 140069......... 01.0622 16.04 140162......... 01.7869 17.93
110094....................... 01.0827 14.08 110190.......... 01.0981 15.41 130035......... 01.0090 19.47 140070......... 01.2423 17.31 140164......... 01.4470 20.29
110095....................... 01.3819 14.69 110191.......... 01.3627 17.96 130036......... 01.3025 13.66 140074......... 01.0465 17.25 140165......... 01.1078 13.70
110096....................... 01.1427 14.85 110192.......... 01.4687 21.41 130037......... 01.2910 16.97 140075......... 01.4117 14.13 140166......... 01.3247 17.54
110097....................... 01.0561 14.44 110193.......... 01.2426 17.89 130043......... 00.9508 15.79 140077......... 01.2351 16.89 140167......... 01.1271 15.06
110098....................... 00.9804 15.28 110194.......... 00.9257 14.21 130044......... 01.1952 10.50 140079......... 01.2417 17.22 140168......... 01.1771 16.36
110100....................... 01.0482 16.39 110195.......... 01.1159 13.34 130045......... 00.9956 15.28 140080......... 01.6294 20.58 140170......... 01.0929 13.81
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
140171....................... 00.9828 12.95 140300.......... 01.5868 23.72 150074......... 01.6442 19.08 160030......... 01.3920 18.00 160109......... 01.0993 14.76
140172....................... 01.6579 18.91 150001.......... 01.1146 19.10 150075......... 01.1491 15.63 160031......... 01.1010 14.50 160110......... 01.5914 15.04
140173....................... 00.9180 16.52 150002.......... 01.5657 18.51 150076......... 01.1723 21.36 160032......... 01.1307 16.27 160111......... 01.0133 12.29
140174....................... 01.5914 20.01 150003.......... 01.6957 19.07 150077......... 01.1446 17.40 160033......... 01.8232 17.57 160112......... 01.4106 16.06
140176....................... 01.2364 19.89 150004.......... 01.5034 19.60 150078......... 01.0704 17.34 160034......... 01.1382 15.15 160113......... 01.0099 13.35
140177....................... 01.3461 17.27 150005.......... 01.1843 18.97 150079......... 01.2096 15.90 160035......... 01.0002 16.77 160114......... 01.0199 15.40
140179....................... 01.3420 20.09 150006.......... 01.2849 18.75 150082......... 01.5715 18.22 160036......... 00.9948 19.22 160115......... 01.0123 15.21
140180....................... 01.4432 20.79 150007.......... 01.2112 23.06 150084......... 01.9333 21.85 160037......... 01.0667 17.12 160116......... 01.1438 16.05
140181....................... 01.4074 19.27 150008.......... 01.4533 20.34 150086......... 01.3607 16.73 160039......... 01.0325 17.49 160117......... 01.4481 16.57
140182....................... 01.4406 15.18 150009.......... 01.3592 17.29 150088......... 01.3868 18.67 160040......... 01.3654 17.43 160118......... 01.0367 15.14
140184....................... 01.2681 15.18 150010.......... 01.3797 16.85 150089......... 01.4239 19.56 160041......... 01.1128 14.40 160120......... 01.0155 11.33
140185....................... 01.5341 17.64 150011.......... 01.2435 18.61 150090......... 01.2347 18.94 160043......... 01.0103 14.43 160122......... 01.0901 18.27
140186....................... 01.3891 20.30 150012.......... 01.6411 21.50 150091......... 01.0113 16.53 160044......... 01.2318 15.75 160124......... 01.2824 16.47
140187....................... 01.4964 16.84 150013.......... 01.1763 15.74 150092......... 01.0684 14.87 160045......... 01.7278 18.63 160126......... 01.0538 15.68
140188....................... 00.9537 13.20 150014.......... 01.5052 18.35 150094......... 00.9903 17.59 160046......... 00.9983 11.21 160129......... 01.0655 15.03
140189....................... 01.1992 17.72 150015.......... 01.2408 20.85 150095......... 01.0953 18.41 160047......... 01.3985 16.53 160130......... 01.2040 14.80
140190....................... 01.1009 16.47 150017.......... 01.8553 19.45 150096......... 01.0629 17.95 160048......... 01.0493 13.27 160131......... 01.0625 14.49
140191....................... 01.4397 22.26 150018.......... 01.3501 18.66 150097......... 01.1098 17.18 160049......... 00.9436 12.67 160134......... 00.9376 12.70
140193....................... 01.1059 14.46 150019.......... 01.1845 14.94 150098......... 01.1241 16.63 160050......... 01.0811 15.90 160135......... 01.0142 15.11
140197....................... 01.2541 16.79 150020.......... 01.1512 13.22 150099......... 01.2843 17.66 160051......... 00.9312 13.79 160138......... 01.0655 14.59
140199....................... 01.1100 17.14 150021.......... 01.6165 18.36 150100......... 01.6568 17.51 160052......... 01.0078 14.41 160140......... 01.1400 16.69
140200....................... 01.4621 21.75 150022.......... 01.1136 17.58 150101......... 01.1211 19.95 160054......... 01.0121 13.35 160142......... 01.1009 15.31
140202....................... 01.3111 21.58 150023.......... 01.6061 19.97 150102......... 01.1598 12.14 160055......... 00.9931 13.61 160143......... 00.9819 15.10
140203....................... 01.1647 22.19 150024.......... 01.3888 18.92 150103......... 00.9512 19.44 160056......... 01.1741 14.54 160145......... 01.1407 14.85
140205....................... 00.9675 15.10 150025.......... 01.4888 17.26 150104......... 01.0823 16.22 160057......... 01.3770 17.28 160146......... 01.4416 16.29
140206....................... 01.2352 20.80 150026.......... 01.2078 18.81 150105......... 01.3386 17.27 160058......... 01.7722 19.62 160147......... 01.3353 17.49
140207....................... 01.3748 20.67 150027.......... 01.0411 17.50 150106......... 01.0981 15.15 160060......... 01.1076 15.15 160151......... 01.1079 16.09
140208....................... 01.6884 24.61 150029.......... 01.3890 20.73 150109......... 01.4355 18.03 160061......... 01.1171 16.03 160152......... 01.0039 14.39
140209....................... 01.6540 14.76 150030.......... 01.2567 17.00 150110......... 01.0392 15.28 160062......... 00.9454 15.66 160153......... 01.8054 18.68
140210....................... 01.0799 14.99 150031.......... 01.0946 15.03 150111......... 01.1656 15.08 160063......... 01.1546 16.85 170001......... 01.1951 16.74
140211....................... 01.2061 19.50 150032.......... 01.8612 19.41 150112......... 01.3267 18.92 160064......... 01.6269 18.72 170004......... 01.0677 13.57
140213....................... 01.3176 21.25 150033.......... 01.5986 21.73 150113......... 01.2282 18.52 160065......... 01.0220 16.04 170006......... 01.1576 15.84
140215....................... 01.0859 14.05 150034.......... 01.4872 21.18 150114......... 01.0692 17.02 160066......... 01.1481 15.76 170008......... 00.9797 13.42
140217....................... 01.3129 22.52 150035.......... 01.5616 19.66 150115......... 01.3601 17.18 160067......... 01.4072 17.52 170009......... 01.2006 17.07
140218....................... 01.0528 15.20 150036.......... 01.0369 18.92 150122......... 01.1376 18.53 160068......... 01.0212 15.43 170010......... 01.3037 16.52
140220....................... 01.1009 17.26 150037.......... 01.2481 18.31 150123......... 01.0540 14.07 160069......... 01.4919 17.39 170012......... 01.4254 15.95
140223....................... 01.6061 23.21 150038.......... 01.4463 18.74 150124......... 01.1303 15.08 160070......... 00.9590 14.55 170013......... 01.3060 16.49
140224....................... 01.3499 22.21 150039.......... 00.9739 16.62 150125......... 01.4487 19.02 160072......... 01.0768 14.19 170014......... 01.0310 17.45
140228....................... 01.6505 17.83 150042.......... 01.2851 16.54 150126......... 01.4679 20.96 160073......... 00.9704 13.66 170015......... 00.9909 15.23
140230....................... 00.9336 15.97 150043.......... 01.0389 16.96 150127......... 01.0314 15.89 160074......... 01.0474 15.71 170016......... 01.6836 22.29
140231....................... 01.5659 21.90 150044.......... 01.2351 18.03 150128......... 01.2813 18.07 160075......... 01.1806 15.77 170017......... 01.2077 18.08
140233....................... 01.8328 18.16 150045.......... 01.1303 16.21 150129......... 01.1222 24.48 160076......... 01.0409 17.07 170018......... 01.1380 14.10
140234....................... 01.2359 17.76 150046.......... 01.4926 16.66 150130......... 01.3484 16.53 160077......... 01.0730 11.38 170019......... 01.2203 16.42
140236....................... 01.0046 14.29 150047.......... 01.6176 19.11 150132......... 01.4914 18.89 160079......... 01.4250 17.85 170020......... 01.2910 15.58
140239....................... 01.7410 18.31 150048.......... 01.2267 18.58 150133......... 01.1644 17.44 160080......... 01.2026 17.07 170022......... 01.1333 16.84
140240....................... 01.4331 22.78 150049.......... 01.1415 15.37 150134......... 01.1629 17.56 160081......... 01.0971 15.21 170023......... 01.3998 17.38
140242....................... 01.6616 22.15 150050.......... 01.2343 16.20 150136......... 00.8607 20.95 160082......... 01.9400 17.26 170024......... 01.1587 13.03
140245....................... 01.2200 15.19 150051.......... 01.4673 18.63 150145......... 03.7024 ....... 160083......... 01.6760 17.94 170025......... 01.1942 16.10
140246....................... 01.1107 12.78 150052.......... 01.1526 14.50 160001......... 01.2869 18.91 160085......... 00.9877 15.41 170026......... 01.1060 13.45
140250....................... 01.3085 23.24 150053.......... 01.0122 18.92 160002......... 01.1579 14.48 160086......... 00.9510 15.78 170027......... 01.3149 15.96
140251....................... 01.3487 20.32 150054.......... 01.0954 15.80 160003......... 01.0272 14.39 160088......... 01.1853 16.87 170030......... 01.0487 12.94
140252....................... 01.4849 23.55 150056.......... 01.8319 23.14 160005......... 01.0962 15.72 160089......... 01.2264 16.16 170031......... 00.8797 12.80
140253....................... 01.3970 14.08 150057.......... 02.3139 18.25 160007......... 01.0149 13.81 160090......... 01.0121 15.53 170032......... 01.0645 15.46
140258....................... 01.5859 22.07 150058.......... 01.7734 20.30 160008......... 01.1611 14.74 160091......... 01.0690 12.74 170033......... 01.3680 15.54
140271....................... 01.0367 14.78 150059.......... 01.3588 21.47 160009......... 01.2225 15.87 160092......... 01.0710 15.37 170034......... 01.0172 13.85
140275....................... 01.2393 16.99 150060.......... 01.1408 14.72 160012......... 01.0015 15.93 160093......... 01.0603 15.71 170035......... 00.8913 14.00
140276....................... 02.0402 21.39 150061.......... 01.2235 15.33 160013......... 01.2088 16.74 160094......... 01.1200 15.60 170036......... 00.9101 14.08
140280....................... 01.3633 17.80 150062.......... 01.1228 17.69 160014......... 00.9551 14.41 160095......... 01.0625 14.27 170037......... 01.0368 16.58
140281....................... 01.6894 22.14 150063.......... 01.0545 16.90 160016......... 01.2452 17.25 160097......... 01.0952 14.59 170038......... 00.9220 12.68
140285....................... 01.2529 26.86 150064.......... 01.2804 16.17 160018......... 00.9374 13.77 160098......... 01.0002 15.05 170039......... 01.0941 14.19
140286....................... 01.1496 18.53 150065.......... 01.2062 18.66 160020......... 01.0918 13.84 160099......... 00.9166 12.91 170040......... 01.6491 19.98
140288....................... 01.7475 22.93 150066.......... 01.0055 17.04 160021......... 01.0569 15.16 160101......... 01.0582 17.55 170041......... 01.0778 11.22
140289....................... 01.3491 16.32 150067.......... 01.1690 16.20 160023......... 01.0267 14.75 160102......... 01.4133 16.83 170044......... 00.9909 13.97
140290....................... 01.3868 20.06 150069.......... 01.2637 17.75 160024......... 01.5208 18.26 160103......... 01.0464 16.71 170045......... 01.0394 15.99
140291....................... 01.3999 23.45 150070.......... 01.0571 17.16 160026......... 01.0784 17.30 160104......... 01.2767 17.17 170049......... 01.2914 18.45
140292....................... 01.1440 20.62 150071.......... 01.1147 14.38 160027......... 01.1359 15.04 160106......... 01.0226 15.39 170051......... 00.9111 13.41
140294....................... 01.1807 18.17 150072.......... 01.2157 16.13 160028......... 01.2457 29.74 160107......... 01.1907 16.26 170052......... 01.1183 14.31
140297....................... 03.6153 42.09 150073.......... 01.0490 20.53 160029......... 01.5683 20.19 160108......... 01.1241 15.98 170053......... 00.9906 13.83
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[[Page 25627]]
Page 6 of 15
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
170054....................... 01.0978 13.64 170150.......... 01.1546 14.00 180067......... 01.9594 17.80 190034......... 01.1818 15.36 190155......... 00.7261 16.10
170055....................... 01.0862 14.51 170151.......... 00.9807 12.49 180069......... 01.1523 17.35 190035......... 01.4071 ....... 190156......... 01.0217 12.27
170056....................... 00.8958 14.93 170152.......... 01.0368 14.21 180070......... 01.1536 13.55 190036......... 01.6970 20.46 190158......... 01.1942 20.62
170057....................... 00.9835 12.90 170160.......... 01.0025 11.81 180072......... 01.1750 15.81 190037......... 00.9050 11.28 190160......... 01.2638 17.06
170058....................... 01.1567 17.07 170164.......... 01.0153 15.00 180075......... 01.6587 12.66 190039......... 01.4112 16.98 190161......... 01.0650 14.05
170060....................... 01.1064 14.95 170166.......... 01.1487 17.40 180078......... 01.0858 18.97 190040......... 01.3258 20.34 190162......... 01.0985 19.57
170061....................... 01.1697 14.15 170171.......... 01.0693 12.88 180079......... 01.2462 12.71 190041......... 01.5988 19.98 190164......... 01.2766 14.89
170063....................... 00.8588 11.84 170175.......... 01.3959 17.67 180080......... 01.0624 15.09 190043......... 01.0674 12.52 190167......... 01.1707 18.78
170066....................... 01.0038 13.66 170176.......... 01.6751 23.94 180087......... 01.3024 14.29 190044......... 01.1587 21.11 190170......... 00.9093 13.69
170067....................... 01.0353 14.44 170182.......... 01.4638 21.54 180088......... 01.5749 21.13 190045......... 01.4309 21.34 190173......... 01.4304 19.33
170068....................... 01.2562 17.01 170183.......... 02.0468 15.05 180092......... 01.2237 15.98 190046......... 01.4383 18.69 190175......... 01.6161 20.46
170070....................... 01.0330 12.73 170184.......... 01.7569 ....... 180093......... 01.3704 16.69 190048......... 01.2557 15.02 190176......... 01.6907 20.76
170073....................... 01.1796 15.56 180001.......... 01.3958 17.78 180094......... 01.0627 12.86 190049......... 00.9841 15.98 190177......... 01.7756 18.85
170074....................... 01.1210 13.48 180002.......... 01.1271 17.71 180095......... 01.1988 13.96 190050......... 01.0974 14.68 190178......... 00.9828 10.60
170075....................... 00.9167 10.71 180004.......... 01.1260 15.79 180099......... 01.2011 12.83 190053......... 01.1305 12.51 190182......... 01.2638 19.89
170076....................... 01.0539 12.59 180005.......... 01.2488 18.80 180101......... 01.2773 16.26 190054......... 01.3434 16.77 190183......... 01.1934 15.22
170077....................... 00.9613 12.55 180006.......... 00.9249 12.49 180102......... 01.4712 18.17 190059......... 00.8927 14.11 190184......... 01.0340 15.61
170079....................... 00.9525 12.75 180007.......... 01.4823 16.55 180103......... 02.2948 18.25 190060......... 01.4334 14.94 190185......... 01.3460 19.22
170080....................... 00.9784 12.95 180009.......... 01.4022 20.11 180104......... 01.5599 16.85 190064......... 01.5728 22.67 190186......... 00.9219 14.11
170081....................... 00.9351 11.91 180010.......... 01.9106 18.13 180105......... 00.9458 15.32 190065......... 01.4938 18.08 190190......... 00.8904 12.48
170082....................... 00.9822 12.06 180011.......... 01.3471 18.96 180106......... 00.8758 13.13 190071......... 00.9048 12.68 190191......... 01.2236 19.55
170084....................... 00.9112 29.87 180012.......... 01.4127 18.41 180108......... 00.8320 13.64 190077......... 00.9403 13.95 190196......... 00.9611 16.22
170085....................... 00.9055 12.47 180013.......... 01.4174 17.18 180115......... 01.0027 16.43 190078......... 01.1522 12.81 190197......... 01.1855 17.51
170086....................... 01.7294 18.97 180014.......... 01.7276 18.00 180116......... 01.3502 16.15 190079......... 01.3216 17.02 190199......... 01.2599 10.95
170088....................... 00.9532 10.70 180016.......... 01.3059 14.83 180117......... 01.1374 17.24 190081......... 00.9314 13.70 190200......... 01.5884 20.17
170089....................... 00.9736 12.13 180017.......... 01.3626 14.79 180118......... 01.0477 11.54 190083......... 01.1019 16.51 190201......... 01.0893 18.83
170090....................... 00.9993 11.36 180018.......... 01.3348 15.32 180120......... 01.0374 16.25 190086......... 01.3466 15.04 190202......... 01.2511 18.81
170092....................... 00.8320 12.01 180019.......... 01.2531 16.76 180121......... 01.3111 14.05 190088......... 01.3395 19.01 190203......... 01.5559 22.35
170093....................... 00.9126 12.94 180020.......... 01.1266 16.86 180122......... 01.1060 15.93 190089......... 01.0953 12.63 190204......... 01.4971 20.42
170094....................... 00.9330 16.97 180021.......... 01.0695 14.26 180123......... 01.4019 18.92 190090......... 01.1136 16.03 190205......... 01.9390 18.91
170095....................... 01.1284 13.41 180023.......... 00.9119 14.80 180124......... 01.4305 16.87 190092......... 01.4163 21.19 190206......... 01.6020 21.26
170097....................... 00.9893 14.02 180024.......... 01.4455 15.89 180125......... 01.1083 17.87 190095......... 01.0410 15.00 190207......... 01.2223 17.10
170098....................... 01.1633 14.54 180025.......... 01.1748 16.40 180126......... 01.2108 11.42 190098......... 01.4884 19.10 190208......... 00.8302 10.93
170099....................... 01.2147 12.86 180026.......... 01.2509 13.57 180127......... 01.3576 16.72 190099......... 01.2333 17.67 190218......... 01.1701 17.36
170100....................... 01.0623 13.73 180027.......... 01.3139 15.23 180128......... 01.1777 16.18 190102......... 01.5818 18.10 190227......... 00.8692 30.27
170101....................... 00.9176 13.46 180028.......... 01.0814 17.78 180129......... 01.0392 15.30 190103......... 00.8978 11.00 190231......... 01.4412 13.27
170102....................... 01.0142 12.99 180029.......... 01.3033 16.86 180130......... 01.4202 17.56 190106......... 01.1713 17.85 190235......... 01.6524 ......
170103....................... 01.2839 15.92 180030.......... 01.1614 16.38 180132......... 01.2846 16.14 190109......... 01.2506 14.31 190236......... 01.4037 ......
170104....................... 01.4518 20.25 180031.......... 01.1179 14.02 180133......... 01.3195 22.68 190110......... 00.9671 13.76 200001......... 01.4021 16.84
170105....................... 01.0732 15.22 180032.......... 01.0939 16.97 180134......... 01.0985 14.44 190111......... 01.5353 19.83 200002......... 01.1101 23.41
170106....................... 00.9680 10.48 180033.......... 01.1805 16.08 180136......... 01.6663 19.72 190112......... 01.6582 20.08 200003......... 01.1421 16.08
170109....................... 00.9935 16.20 180034.......... 01.1401 15.45 180138......... 01.2692 17.70 190113......... 01.3372 19.82 200006......... 01.0161 18.67
170110....................... 01.0011 15.05 180035.......... 01.6042 19.58 180139......... 01.1175 17.89 190114......... 01.0360 13.12 200007......... 01.0238 16.64
170112....................... 01.0327 13.55 180036.......... 01.2081 18.69 180140......... 01.0543 22.60 190115......... 01.2011 19.30 200008......... 01.2487 20.05
170113....................... 01.0910 15.23 180037.......... 01.3315 19.96 180141......... 01.7850 ....... 190116......... 01.1612 15.43 200009......... 01.8248 20.28
170114....................... 01.0309 14.05 180038.......... 01.4356 15.84 190001......... 00.9574 22.06 190118......... 01.0653 13.08 200012......... 01.1253 16.83
170115....................... 00.9963 12.43 180040.......... 01.9798 18.75 190002......... 01.7233 18.29 190120......... 01.0389 13.99 200013......... 01.1175 15.39
170116....................... 01.0782 15.42 180041.......... 01.1067 14.94 190003......... 01.4208 18.68 190122......... 01.3127 13.83 200015......... 01.2672 17.80
170117....................... 00.9897 13.41 180042.......... 01.1356 15.00 190004......... 01.4619 16.87 190124......... 01.6393 19.92 200016......... 01.0377 16.48
170119....................... 00.9907 13.57 180043.......... 01.1907 19.10 190005......... 01.5814 16.64 190125......... 01.5379 18.47 200018......... 01.2179 16.45
170120....................... 01.3100 12.93 180044.......... 01.2212 17.26 190006......... 01.3309 15.31 190128......... 01.1054 18.95 200019......... 01.2635 18.12
170122....................... 01.7443 18.82 180045.......... 01.3799 17.34 190007......... 01.0296 14.17 190130......... 00.9720 12.14 200020......... 01.1295 19.42
170123....................... 01.7876 18.98 180046.......... 01.1868 16.65 190008......... 01.6750 19.37 190131......... 01.2328 17.54 200021......... 01.1599 18.52
170124....................... 00.9925 13.55 180047.......... 01.0316 14.66 190009......... 01.3215 14.70 190133......... 00.9626 12.86 200023......... 00.9037 14.08
170126....................... 00.9618 12.53 180048.......... 01.2731 16.28 190010......... 01.1133 16.24 190134......... 01.0045 16.50 200024......... 01.4120 19.55
170128....................... 00.9122 14.70 180049.......... 01.3932 16.09 190011......... 01.1696 15.32 190135......... 01.4522 20.69 200025......... 01.1595 19.60
170131....................... 01.1686 12.10 180050.......... 01.2650 17.25 190013......... 01.3473 16.26 190136......... 01.2074 11.11 200026......... 01.0448 15.97
170133....................... 01.1015 16.69 180051.......... 01.3715 15.43 190014......... 01.1457 16.03 190138......... 00.8637 20.29 200027......... 01.2326 16.90
170134....................... 00.9044 13.04 180053.......... 01.1052 14.96 190015......... 01.2583 18.74 190140......... 00.9874 11.98 200028......... 00.9883 16.14
170137....................... 01.1656 17.98 180054.......... 01.1345 15.82 190017......... 01.3983 14.84 190142......... 00.9321 14.53 200031......... 01.2524 15.04
170139....................... 01.0729 12.91 180055.......... 01.2319 14.70 190018......... 01.1580 17.48 190144......... 01.2665 16.26 200032......... 01.2974 17.40
170142....................... 01.2852 17.02 180056.......... 01.1288 16.33 190019......... 01.7296 19.64 190145......... 01.0068 14.74 200033......... 01.7963 ......
170143....................... 01.1875 15.24 180058.......... 01.0463 13.04 190020......... 01.1693 17.77 190146......... 01.6123 21.10 200034......... 01.2207 18.06
170144....................... 01.6583 13.79 180059.......... 00.8671 15.28 190025......... 01.3335 13.33 190147......... 00.9695 14.36 200037......... 01.2183 16.94
170145....................... 01.1081 14.18 180063.......... 01.1789 11.94 190026......... 01.5020 18.00 190148......... 00.9710 13.91 200038......... 01.1302 19.07
170146....................... 01.5294 18.68 180064.......... 01.3252 14.68 190027......... 01.5422 17.46 190149......... 01.0118 14.40 200039......... 01.2896 19.74
170147....................... 01.2024 18.98 180065.......... 01.0035 12.89 190029......... 01.1748 17.67 190151......... 01.2151 12.80 200040......... 01.1290 19.05
170148....................... 01.4951 17.89 180066.......... 01.1563 18.08 190033......... 00.9756 10.02 190152......... 01.4896 20.71 200041......... 01.1543 18.64
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[[Page 25628]]
Page 7 of 15
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
200043....................... 00.7365 18.37 220017.......... 01.3977 14.12 220153......... 01.0232 22.56 230100......... 01.1670 15.57 230213......... 00.9993 15.25
200050....................... 01.1575 17.35 220019.......... 01.1645 19.12 220154......... 00.9445 22.42 230101......... 01.1095 18.36 230216......... 01.5651 17.80
200051....................... 01.0114 19.57 220020.......... 01.2268 19.47 220162......... 01.2697 ....... 230103......... 01.0400 20.72 230217......... 01.2521 22.94
200052....................... 01.0406 15.56 220023.......... 00.6107 19.30 220163......... 02.1199 24.87 230104......... 01.5911 22.43 230219......... 00.8768 19.28
200055....................... 01.1614 17.37 220024.......... 01.2158 21.22 220171......... 01.6207 22.92 230105......... 01.7568 20.27 230221......... 00.8720 24.54
200062....................... 00.9472 15.91 220025.......... 01.1292 18.70 230001......... 01.1902 18.07 230106......... 01.3003 20.51 230222......... 01.4495 19.43
200063....................... 01.3059 18.34 220028.......... 01.4722 21.01 230002......... 01.2759 20.69 230107......... 00.9076 14.72 230223......... 01.3326 21.85
200066....................... 01.1622 16.74 220029.......... 01.1851 24.16 230003......... 01.1581 18.62 230108......... 01.2121 18.37 230227......... 01.4724 21.56
210001....................... 01.4925 21.16 220030.......... 01.1533 15.00 230004......... 01.7098 22.86 230110......... 01.3576 17.83 230230......... 01.6794 22.01
210002....................... 01.9930 18.07 220031.......... 01.9215 ....... 230005......... 01.2844 18.86 230113......... 00.9199 20.15 230232......... 00.9510 17.15
210003....................... 01.6014 21.93 220033.......... 01.2840 20.97 230006......... 01.1008 18.53 230115......... 01.0388 17.19 230235......... 01.0957 16.27
210004....................... 01.3657 23.18 220035.......... 01.2837 24.51 230007......... 00.9571 18.95 230116......... 00.9248 16.31 230236......... 01.3249 21.58
210005....................... 01.2762 19.38 220036.......... 01.5965 21.66 230012......... 00.8563 12.18 230117......... 01.8993 26.08 230239......... 01.1389 13.72
210006....................... 01.1400 17.16 220038.......... 01.2959 26.32 230013......... 01.4022 21.05 230118......... 01.2189 17.43 230241......... 01.1643 17.52
210007....................... 01.7371 25.17 220041.......... 01.2273 23.41 230015......... 01.2010 20.91 230119......... 01.2966 21.44 230244......... 01.3959 21.17
210008....................... 01.3938 19.26 220042.......... 01.2464 24.13 230017......... 01.5028 28.89 230120......... 01.1514 18.40 230253......... 00.9911 18.85
210009....................... 01.8131 21.72 220046.......... 01.3702 23.14 230019......... 01.4696 22.20 230121......... 01.2299 20.61 230254......... 01.2624 21.20
210010....................... 01.1495 15.64 220049.......... 01.3541 18.47 230020......... 01.7404 21.30 230122......... 01.3428 19.37 230257......... 00.7824 18.51
210011....................... 01.3419 19.67 220050.......... 01.1242 19.98 230021......... 01.5653 18.27 230124......... 01.1625 18.52 230259......... 01.1882 21.59
210012....................... 01.6374 22.07 220051.......... 01.2183 21.10 230022......... 01.2543 18.76 230128......... 01.3957 22.70 230264......... 01.6939 14.86
210013....................... 01.3219 19.82 220052.......... 01.3247 24.59 230024......... 01.4460 22.98 230130......... 01.6687 22.34 230269......... 01.3782 22.69
210015....................... 01.2992 19.60 220053.......... 01.2325 20.02 230027......... 01.1127 17.48 230132......... 01.3690 24.82 230270......... 01.1731 20.20
210016....................... 01.8243 22.33 220055.......... 01.2994 13.69 230029......... 01.5562 19.51 230133......... 01.2687 17.99 230273......... 01.4465 22.29
210017....................... 01.2218 15.90 220057.......... 01.4056 22.67 230030......... 01.3295 16.78 230135......... 01.3180 23.03 230275......... 00.5262 19.58
210018....................... 01.3056 21.29 220058.......... 01.1529 18.51 230031......... 01.4311 19.42 230137......... 01.1560 18.31 230276......... 00.6644 21.40
210019....................... 01.5805 18.39 220060.......... 01.2952 25.42 230032......... 01.7502 19.80 230141......... 01.6323 22.96 230277......... 01.2430 23.05
210022....................... 01.5039 21.14 220062.......... 00.5762 19.65 230034......... 01.2739 18.80 230142......... 01.3057 19.01 230278......... 01.4214 17.82
210023....................... 01.3373 21.51 220063.......... 01.2663 19.84 230035......... 01.0906 20.47 230143......... 01.3112 18.35 230279......... 00.6584 15.95
210024....................... 01.5453 20.11 220064.......... 01.2830 21.51 230036......... 01.2229 20.75 230144......... 01.1462 20.61 230280......... 00.9997 12.33
210025....................... 01.3740 18.95 220065.......... 01.2956 19.95 230037......... 01.1368 17.66 230145......... 01.1934 18.05 240001......... 01.5448 22.78
210026....................... 01.3830 17.97 220066.......... 01.3789 21.73 230038......... 01.6671 21.58 230146......... 01.2748 19.36 240002......... 01.7516 20.94
210027....................... 01.2945 17.66 220067.......... 01.3230 22.81 230040......... 01.1819 20.58 230147......... 01.3954 17.47 240004......... 01.5826 21.10
210028....................... 01.2229 18.31 220070.......... 01.2219 19.89 230041......... 01.2518 19.27 230149......... 01.1505 16.14 240005......... 00.9321 17.38
210029....................... 01.2710 14.51 220071.......... 01.9036 24.06 230042......... 01.2328 20.08 230151......... 01.4024 21.20 240006......... 01.1358 20.97
210030....................... 01.1576 19.24 220073.......... 01.3068 25.94 230046......... 01.9346 23.28 230153......... 01.1458 16.66 240007......... 01.0656 15.50
210031....................... 01.2844 16.76 220074.......... 01.4397 28.44 230047......... 01.3796 19.17 230154......... 00.9500 14.32 240008......... 01.1157 19.71
210032....................... 01.1792 18.71 220075.......... 01.4818 20.18 230053......... 01.6002 24.58 230155......... 01.0478 17.35 240009......... 00.9226 14.31
210033....................... 01.2737 18.96 220076.......... 01.1822 ....... 230054......... 01.8075 19.80 230156......... 01.7144 23.80 240010......... 01.9880 24.41
210034....................... 01.3510 20.17 220077.......... 01.7973 24.84 230055......... 01.1704 19.01 230157......... 01.2003 22.20 240011......... 01.1532 17.81
210035....................... 01.2976 19.08 220079.......... 01.1889 21.38 230056......... 00.9664 15.57 230159......... 01.3458 17.84 240013......... 01.3350 18.17
210037....................... 01.2736 18.27 220080.......... 01.3076 19.50 230058......... 01.0994 18.45 230162......... 01.0605 19.93 240014......... 01.0774 20.29
210038....................... 01.4108 21.78 220081.......... 01.0949 26.78 230059......... 01.5035 19.06 230165......... 01.8769 22.77 240016......... 01.3927 18.22
210039....................... 01.1817 19.69 220082.......... 01.2893 19.76 230060......... 01.2247 18.53 230167......... 01.7979 19.39 240017......... 01.0659 17.25
210040....................... 01.2977 23.05 220083.......... 01.1675 21.76 230062......... 00.9643 15.71 230169......... 01.3453 23.25 240018......... 01.2884 17.23
210043....................... 01.3140 21.29 220084.......... 01.3389 26.31 230063......... 01.3202 19.89 230171......... 01.0161 14.41 240019......... 01.2645 21.39
210044....................... 01.3429 21.63 220086.......... 01.7743 ....... 230065......... 01.3020 20.37 230172......... 01.1855 19.10 240020......... 01.1651 20.04
210045....................... 01.0234 11.01 220088.......... 01.6385 23.68 230066......... 01.3702 21.26 230174......... 01.3641 20.84 240021......... 01.0408 16.96
210048....................... 01.2485 22.46 220089.......... 01.2541 21.52 230069......... 01.1366 22.24 230175......... 03.7062 ....... 240022......... 01.1137 19.13
210049....................... 01.1655 17.20 220090.......... 01.2774 21.06 230070......... 01.6318 20.99 230176......... 01.2172 22.12 240023......... 00.9935 19.88
210051....................... 01.4205 22.78 220092.......... 01.2563 29.72 230071......... 01.1883 22.62 230178......... 01.0025 17.48 240025......... 01.1418 16.29
210054....................... 01.3626 21.94 220094.......... 01.4476 18.10 230072......... 01.2717 19.89 230180......... 01.1699 14.55 240027......... 01.0297 16.33
210055....................... 01.2721 22.10 220095.......... 01.2243 18.87 230075......... 01.4810 20.07 230184......... 01.1598 18.23 240028......... 01.1529 18.52
210056....................... 01.3993 17.67 220098.......... 01.3462 17.39 230076......... 01.3291 22.97 230186......... 01.2450 15.20 240029......... 01.1603 18.10
210057....................... 01.4721 24.67 220100.......... 01.2697 25.09 230077......... 01.9370 19.36 230188......... 01.1176 15.81 240030......... 01.2834 17.99
210058....................... 01.4828 18.67 220101.......... 01.4781 24.24 230078......... 01.2553 16.56 230189......... 00.9585 15.39 240031......... 00.9756 16.71
210059....................... 01.2611 21.98 220104.......... 01.4373 23.69 230080......... 01.2411 19.94 230190......... 01.0724 24.98 240036......... 01.5650 20.26
210060....................... 01.2540 ....... 220105.......... 01.3499 20.60 230081......... 01.2578 16.66 230191......... 00.9623 17.58 240037......... 01.0233 18.19
210061....................... 01.1774 18.56 220106.......... 01.2300 23.09 230082......... 01.1162 17.08 230193......... 01.2584 17.77 240038......... 01.4973 24.56
220001....................... 01.2775 27.10 220108.......... 01.1989 22.28 230085......... 01.0922 18.91 230195......... 01.3347 21.46 240040......... 01.2454 20.15
220002....................... 01.5400 18.62 220110.......... 02.0189 29.18 230086......... 00.9486 17.36 230197......... 01.4218 21.17 240041......... 01.1644 17.48
220003....................... 01.1363 17.49 220111.......... 01.2643 21.79 230087......... 01.0889 16.19 230199......... 01.1115 19.29 240043......... 01.1966 17.00
220006....................... 01.4328 20.39 220116.......... 01.9394 ....... 230089......... 01.2754 23.86 230201......... 01.1456 15.09 240044......... 01.1842 18.04
220008....................... 01.2873 21.58 220119.......... 01.3311 23.69 230092......... 01.3562 19.28 230204......... 01.4307 21.66 240045......... 01.0477 21.34
220010....................... 01.3417 21.70 220123.......... 01.0577 23.94 230093......... 01.2768 19.05 230205......... 01.0377 16.37 240047......... 01.5436 21.26
220011....................... 01.1581 28.81 220126.......... 01.3572 19.87 230095......... 01.1791 17.06 230207......... 01.2683 19.90 240048......... 01.2443 22.64
220012....................... 01.3404 35.18 220128.......... 00.8929 21.18 230096......... 01.0974 24.02 230208......... 01.3205 17.76 240049......... 01.7730 22.43
220015....................... 01.1918 22.77 220133.......... 00.9081 27.36 230097......... 01.6121 19.12 230211......... 00.9047 21.59 240050......... 01.1639 24.71
220016....................... 01.3686 21.58 220135.......... 01.3076 26.10 230099......... 01.1463 19.68 230212......... 01.0827 23.46 240051......... 01.0123 18.49
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
240052....................... 01.3097 18.64 240139.......... 00.9667 16.59 250042......... 01.2795 15.45 260003......... 01.1304 13.48 260105......... 01.8950 20.26
240053....................... 01.5210 20.25 240141.......... 01.1702 21.09 250043......... 00.9854 12.25 260004......... 01.0516 13.31 260107......... 01.4575 19.81
240056....................... 01.2479 21.74 240142.......... 01.1458 19.27 250044......... 01.0267 15.41 260005......... 01.6188 20.26 260108......... 01.8607 21.29
240057....................... 01.8120 22.68 240143.......... 00.9530 13.94 250045......... 01.2004 18.75 260006......... 01.5009 20.55 260109......... 00.9884 12.92
240058....................... 00.9732 14.79 240144.......... 01.0302 16.74 250047......... 00.9728 15.45 260008......... 01.3629 16.53 260110......... 01.6869 15.15
240059....................... 01.0983 21.81 240145.......... 01.0332 15.57 250048......... 01.5487 15.26 260009......... 01.2581 16.29 260113......... 01.1477 14.76
240061....................... 01.8085 24.36 240146.......... 00.9306 19.10 250049......... 00.8905 11.34 260011......... 01.6980 18.75 260115......... 01.2593 17.02
240063....................... 01.4355 22.81 240148.......... 01.0485 14.55 250050......... 01.2741 13.43 260012......... 01.1050 12.84 260116......... 01.0817 15.06
240064....................... 01.2914 21.93 240150.......... 00.9199 12.84 250051......... 00.8862 10.57 260013......... 01.1935 15.32 260119......... 01.2307 15.30
240065....................... 01.0337 12.44 240152.......... 01.0164 19.91 250057......... 01.2316 15.59 260015......... 01.2710 16.27 260120......... 01.1985 16.64
240066....................... 01.3815 21.19 240153.......... 01.0056 15.23 250058......... 01.1873 14.40 260017......... 01.2333 15.54 260122......... 01.1738 12.73
240069....................... 01.1890 19.07 240154.......... 01.0449 17.00 250059......... 01.0410 14.21 260018......... 00.9010 10.09 260123......... 01.0789 14.05
240071....................... 01.1104 19.55 240155.......... 00.8945 19.40 250060......... 00.7799 08.90 260019......... 01.0877 14.52 260127......... 01.0109 15.92
240072....................... 01.0197 16.80 240157.......... 01.0929 14.13 250061......... 00.8857 17.69 260020......... 01.7249 20.07 260128......... 01.0125 10.96
240073....................... 00.9372 16.40 240160.......... 01.0026 16.30 250063......... 00.8515 12.44 260021......... 01.4657 17.59 260129......... 01.2317 15.69
240075....................... 01.1813 19.91 240161.......... 00.9970 14.99 250065......... 00.9231 12.61 260022......... 01.2879 19.05 260131......... 01.2494 18.04
240076....................... 01.0703 21.04 240162.......... 01.0628 16.59 250066......... 00.9111 13.53 260023......... 01.4980 34.66 260134......... 01.1693 15.67
240077....................... 00.9446 14.31 240163.......... 00.9935 17.79 250067......... 01.1344 14.67 260024......... 00.9639 12.96 260137......... 01.7177 15.26
240078....................... 01.4829 23.66 240166.......... 01.1120 15.60 250068......... 00.8476 11.36 260025......... 01.3101 14.68 260138......... 01.8700 21.26
240079....................... 01.0280 15.37 240169.......... 00.9128 15.98 250069......... 01.3525 17.35 260027......... 01.6202 21.58 260141......... 01.9087 19.54
240080....................... 01.5649 22.34 240170.......... 01.1056 17.38 250071......... 00.9308 11.63 260029......... 01.2388 19.02 260142......... 01.1144 15.65
240082....................... 01.1936 17.03 240171.......... 01.0726 15.79 250072......... 01.4199 18.43 260030......... 01.1850 10.36 260143......... 00.9985 12.75
240083....................... 01.3140 17.90 240172.......... 00.9529 15.82 250077......... 00.9293 11.97 260031......... 01.6090 18.38 260147......... 00.9753 13.55
240084....................... 01.2434 20.04 240173.......... 00.8928 16.66 250078......... 01.4771 14.93 260032......... 01.6629 18.43 260148......... 00.9263 10.32
240085....................... 00.9719 17.41 240179.......... 01.0132 16.66 250079......... 00.8824 17.44 260034......... 01.0573 15.99 260158......... 01.0224 12.65
240086....................... 01.0849 17.64 240184.......... 00.9886 13.04 250081......... 01.3211 16.03 260035......... 01.0046 11.74 260159......... 00.9863 19.26
240087....................... 01.2026 14.87 240187.......... 01.1930 18.48 250082......... 01.4033 13.51 260036......... 01.0154 15.34 260160......... 01.0544 15.82
240088....................... 01.3869 19.81 240193.......... 01.0223 17.61 250083......... 00.9515 12.27 260039......... 01.1258 13.86 260162......... 01.5557 20.64
240089....................... 00.9840 17.72 240196.......... 00.6319 22.78 250084......... 01.1844 17.73 260040......... 01.6625 15.28 260163......... 01.2241 14.59
240090....................... 01.0465 14.69 240200.......... 00.8680 14.48 250085......... 00.9749 12.58 260042......... 01.2599 17.82 260164......... 00.9519 13.24
240093....................... 01.3293 17.64 240205.......... 00.9138 ....... 250088......... 01.0022 16.53 260044......... 01.0487 15.91 260166......... 01.2346 19.78
240094....................... 00.9622 20.49 240206.......... 00.8411 ....... 250089......... 01.2121 13.89 260047......... 01.4767 17.20 260172......... 00.9986 12.55
240096....................... 00.9800 17.63 240207.......... 01.2109 21.80 250093......... 01.1337 14.36 260048......... 01.2953 20.70 260173......... 01.0314 12.21
240097....................... 01.0196 21.79 240210.......... 01.2788 22.90 250094......... 01.3184 15.45 260050......... 01.0431 16.40 260175......... 01.1175 16.34
240098....................... 00.9533 20.33 240211.......... 00.9038 14.75 250095......... 01.0053 15.92 260052......... 01.3352 19.75 260176......... 01.6500 17.62
240099....................... 01.0631 13.30 250001.......... 01.5514 17.39 250096......... 01.1988 17.01 260053......... 01.1737 11.73 260177......... 01.2846 20.19
240100....................... 01.2892 18.97 250002.......... 00.9820 17.13 250097......... 01.3216 15.83 260054......... 01.3147 16.07 260178......... 01.4976 20.94
240101....................... 01.1825 20.41 250003.......... 01.0084 18.40 250098......... 00.8380 16.66 260055......... 00.9908 10.97 260179......... 01.6431 20.52
240102....................... 00.9603 12.87 250004.......... 01.4873 17.91 250099......... 01.2609 14.01 260057......... 01.1503 16.96 260180......... 01.7064 18.96
240103....................... 01.0505 16.28 250005.......... 00.9412 09.95 250100......... 01.2905 15.26 260059......... 01.2691 14.66 260183......... 01.5177 16.58
240104....................... 01.2301 21.81 250006.......... 00.9862 14.60 250101......... 00.8850 16.65 260061......... 01.1020 14.06 260186......... 01.4347 17.27
240105....................... 00.9597 13.46 250007.......... 01.2808 19.42 250102......... 01.6048 17.06 260062......... 01.2033 18.91 260188......... 01.2198 18.37
240106....................... 01.4052 26.55 250008.......... 00.9814 13.33 250104......... 01.4486 17.62 260063......... 01.0697 15.44 260189......... 00.8526 10.87
240107....................... 00.9916 17.31 250009.......... 01.2300 17.50 250105......... 00.9434 13.40 260064......... 01.3240 16.92 260190......... 01.2045 18.00
240108....................... 01.0081 17.24 250010.......... 01.0398 12.77 250107......... 00.8815 14.53 260065......... 01.8217 18.25 260191......... 01.2516 18.58
240109....................... 00.9484 12.99 250012.......... 00.9311 19.88 250109......... 00.8949 15.37 260066......... 01.0266 15.01 260193......... 01.2915 26.66
240110....................... 00.9668 16.33 250015.......... 01.0847 10.44 250112......... 00.9717 13.07 260067......... 00.8671 13.74 260195......... 01.2198 16.53
240111....................... 01.0666 19.00 250017.......... 00.9989 16.64 250117......... 01.0769 14.70 260068......... 01.6718 20.21 260197......... 01.1405 25.99
240112....................... 00.9994 14.73 250018.......... 00.9513 13.02 250119......... 01.1164 12.45 260070......... 01.0429 14.48 260198......... 01.3077 16.46
240114....................... 00.9257 14.74 250019.......... 01.4335 17.00 250120......... 01.1106 13.09 260073......... 01.1387 12.89 260200......... 01.2666 19.43
240115....................... 01.6191 21.63 250020.......... 00.9455 13.52 250122......... 01.2481 16.91 260074......... 01.3021 13.93 260205......... 01.3757 ......
240116....................... 00.9343 13.96 250021.......... 00.8815 08.57 250123......... 01.2786 18.73 260077......... 01.7307 17.13 270002......... 01.3026 14.15
240117....................... 01.1588 18.18 250023.......... 00.9552 12.77 250124......... 00.9126 11.59 260078......... 01.1782 14.62 270003......... 01.2653 21.02
240119....................... 00.8258 20.58 250024.......... 00.9084 13.60 250125......... 01.3155 16.38 260079......... 01.0765 14.32 270004......... 01.6961 18.01
240121....................... 00.9397 21.27 250025.......... 01.2071 18.06 250126......... 00.9754 14.17 260080......... 01.0516 11.77 270006......... 00.9221 16.35
240122....................... 01.0517 18.93 250027.......... 00.9570 11.90 250127......... 00.8201 ....... 260081......... 01.6079 18.83 270007......... 00.8770 12.23
240123....................... 01.0109 15.03 250029.......... 00.8773 12.96 250128......... 01.0941 12.06 260082......... 01.1768 13.93 270009......... 01.1201 19.32
240124....................... 00.9676 18.39 250030.......... 00.9739 14.45 250131......... 01.0232 11.03 260085......... 01.5720 19.71 270011......... 01.0312 18.28
240125....................... 00.9278 11.73 250031.......... 01.3079 18.54 250134......... 00.9919 16.70 260086......... 01.0978 15.09 270012......... 01.5921 18.33
240127....................... 01.1171 14.25 250032.......... 01.2608 16.21 250136......... 00.8821 17.66 260091......... 01.7219 19.76 270014......... 01.8294 17.81
240128....................... 01.1221 15.77 250033.......... 01.0514 15.66 250138......... 01.2904 17.90 260094......... 01.1985 16.48 270016......... 00.8992 15.97
240129....................... 01.0143 17.56 250034.......... 01.6577 14.46 250141......... 01.2616 15.71 260095......... 01.4477 16.89 270017......... 01.2378 19.09
240130....................... 00.9625 15.66 250035.......... 00.8681 13.84 250145......... 00.8232 10.04 260096......... 01.5927 22.03 270019......... 01.0001 15.86
240132....................... 01.2209 22.40 250036.......... 00.9700 14.48 250146......... 00.9630 13.97 260097......... 01.2007 14.79 270021......... 01.1771 16.67
240133....................... 01.1986 17.72 250037.......... 00.9132 10.05 250148......... 01.0955 19.08 260100......... 01.0435 15.72 270023......... 01.3055 21.22
240135....................... 00.8725 14.11 250038.......... 00.9700 14.37 250149......... 00.8930 12.04 260102......... 01.0442 18.57 270026......... 00.8850 14.97
240137....................... 01.2258 18.97 250039.......... 00.9941 13.36 260001......... 01.7040 18.05 260103......... 01.2885 17.51 270027......... 01.1158 12.40
240138....................... 00.9522 12.97 250040.......... 01.3026 16.20 260002......... 01.4644 21.10 260104......... 01.7564 18.42 270028......... 01.1217 15.50
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[[Page 25630]]
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
270029....................... 00.9579 18.18 280051.......... 01.0812 15.15 290021......... 01.6244 21.94 310041......... 01.4067 23.71 320023......... 01.0840 16.73
270032....................... 01.1262 16.20 280052.......... 01.0846 13.32 290022......... 01.7010 17.94 310042......... 01.2416 23.53 320030......... 01.1495 16.84
270033....................... 00.8614 15.58 280054.......... 01.2607 17.98 290027......... 00.9528 17.23 310043......... 01.1431 20.86 320031......... 00.8258 17.05
270035....................... 01.0099 18.28 280055.......... 00.9182 14.40 290029......... 00.9833 ....... 310044......... 01.2847 20.70 320032......... 00.9003 17.10
270036....................... 00.8802 12.78 280056.......... 00.9752 14.45 290032......... 01.4115 22.30 310045......... 01.4639 27.19 320033......... 01.1552 22.76
270039....................... 01.0024 15.36 280057.......... 00.9835 15.40 290036......... 00.9391 51.78 310047......... 01.3682 24.34 320035......... 01.0299 22.89
270040....................... 01.1080 18.24 280058.......... 01.3029 18.34 290038......... 00.9923 19.95 310048......... 01.2820 22.81 320037......... 01.2216 23.31
270041....................... 01.1062 15.74 280060.......... 01.5871 18.65 290039......... 01.3219 ....... 310049......... 01.2927 25.66 320038......... 01.2326 16.83
270044....................... 01.1453 13.98 280061.......... 01.4293 17.06 300001......... 01.3935 21.15 310050......... 01.2323 23.05 320046......... 01.2948 20.88
270046....................... 00.9619 14.85 280062.......... 01.0987 13.35 300003......... 01.9474 23.98 310051......... 01.3560 24.27 320048......... 01.2823 14.43
270048....................... 01.1003 16.41 280064.......... 01.0290 15.52 300005......... 01.2963 20.28 310052......... 01.2951 22.60 320057......... 00.9566 ......
270049....................... 01.7959 20.21 280065.......... 01.2779 18.54 300006......... 01.1897 19.05 310054......... 01.3459 24.60 320058......... 00.7512 ......
270050....................... 01.0985 17.98 280066.......... 01.0654 12.50 300007......... 01.1006 18.33 310057......... 01.3357 21.17 320059......... 01.0062 ......
270051....................... 01.3389 21.08 280068.......... 00.9650 09.45 300008......... 01.2856 19.44 310058......... 01.1060 24.61 320060......... 00.8691 ......
270052....................... 01.0417 17.86 280070.......... 01.0106 11.19 300009......... 01.1291 19.41 310060......... 01.2001 18.63 320061......... 01.1829 ......
270057....................... 01.2418 18.93 280073.......... 01.0056 13.68 300010......... 01.1911 19.48 310061......... 01.2520 21.39 320062......... 00.8839 ......
270058....................... 00.9052 13.38 280074.......... 01.1152 14.02 300011......... 01.3744 22.78 310062......... 01.3076 20.98 320063......... 01.3049 16.68
270059....................... 00.7748 15.90 280075.......... 01.1776 13.70 300012......... 01.3351 21.77 310063......... 01.3696 21.02 320065......... 01.2881 16.05
270060....................... 00.9593 15.08 280076.......... 01.0520 13.95 300013......... 01.1894 17.57 310064......... 01.3195 24.32 320067......... 00.8533 15.74
270063....................... 00.9957 14.82 280077.......... 01.3183 17.95 300014......... 01.2855 19.49 310067......... 01.3185 22.76 320068......... 00.9287 16.40
270072....................... 00.8066 13.85 280079.......... 01.0646 10.61 300015......... 01.2367 18.54 310069......... 01.2924 22.42 320069......... 00.9720 10.83
270073....................... 01.1764 11.83 280080.......... 01.1041 13.61 300016......... 01.2347 18.83 310070......... 01.4173 23.33 320070......... 00.9663 ......
270074....................... 00.8989 ....... 280081.......... 01.7829 18.66 300017......... 01.3038 21.18 310072......... 01.3090 21.25 320074......... 01.0956 18.00
270075....................... 00.9172 ....... 280082.......... 01.0111 13.50 300018......... 01.3126 20.22 310073......... 01.6320 25.21 320079......... 01.1739 17.24
270076....................... 00.7682 ....... 280083.......... 01.0442 14.26 300019......... 01.2127 19.97 310074......... 01.4198 22.66 330001......... 01.1965 25.94
270079....................... 00.8978 13.71 280084.......... 01.0067 11.42 300020......... 01.3060 20.45 310075......... 01.4342 24.11 330002......... 01.4751 25.86
270080....................... 01.1930 16.88 280088.......... 01.7594 ....... 300021......... 01.0885 17.07 310076......... 01.4454 29.78 330003......... 01.3224 15.68
270081....................... 01.0272 12.52 280089.......... 01.0559 17.29 300022......... 01.0547 17.35 310077......... 01.6821 25.08 330004......... 01.2944 19.87
270082....................... 01.0743 16.17 280090.......... 00.9608 14.34 300023......... 01.3847 20.45 310078......... 01.3970 23.81 330005......... 01.8198 23.51
270083....................... 01.0915 15.30 280091.......... 01.1064 14.54 300024......... 01.2611 19.20 310081......... 01.3268 21.63 330006......... 01.2708 26.60
270084....................... 00.8820 14.83 280092.......... 00.9797 13.94 300028......... 01.2139 17.28 310083......... 01.3087 22.57 330007......... 01.3120 18.50
280001....................... 01.1071 14.99 280094.......... 01.1321 15.40 300029......... 01.3666 22.33 310084......... 01.3916 21.85 330008......... 01.1599 16.96
280003....................... 02.1164 18.85 280097.......... 00.9649 11.94 300033......... 01.1353 16.28 310086......... 01.2187 21.24 330009......... 01.2889 30.94
280005....................... 01.4013 17.73 280098.......... 00.9699 10.71 300034......... 02.0334 22.41 310087......... 01.3224 20.28 330010......... 01.3763 12.50
280009....................... 01.7524 18.19 280101.......... 01.1002 13.51 310001......... 01.8034 25.91 310088......... 01.2207 20.56 330011......... 01.3000 19.95
280011....................... 00.8691 12.42 280102.......... 00.9272 12.45 310002......... 01.8222 25.58 310090......... 01.3629 24.24 330012......... 01.6985 29.74
280013....................... 01.9321 21.09 280104.......... 00.9947 13.11 310003......... 01.2776 23.65 310091......... 01.2907 20.77 330013......... 02.0896 17.73
280014....................... 00.9234 13.35 280105.......... 01.2732 18.10 310005......... 01.2322 21.08 310092......... 01.3142 21.20 330014......... 01.3552 29.38
280015....................... 01.0353 15.29 280106.......... 00.9818 14.48 310006......... 01.2754 22.66 310093......... 01.1662 20.42 330016......... 01.0658 16.94
280017....................... 01.1197 14.01 280107.......... 01.0910 11.45 310008......... 01.3528 23.42 310096......... 01.8816 23.74 330019......... 01.3051 27.77
280018....................... 01.0384 13.73 280108.......... 01.1303 15.09 310009......... 01.3133 23.49 310105......... 01.3010 24.12 330020......... 01.0469 14.30
280020....................... 01.6464 19.60 280109.......... 00.9214 10.58 310010......... 01.2849 20.79 310108......... 01.4365 24.39 330023......... 01.2634 23.47
280021....................... 01.2618 16.90 280110.......... 01.0019 11.44 310011......... 01.2108 21.51 310110......... 01.2714 20.54 330024......... 01.8333 31.66
280022....................... 01.0382 14.17 280111.......... 01.2495 18.27 310012......... 01.6569 26.14 310111......... 01.3831 23.33 330025......... 01.1052 13.57
280023....................... 01.3988 16.83 280114.......... 00.9200 13.00 310013......... 01.4193 21.54 310112......... 01.3408 21.93 330027......... 01.3596 31.94
280024....................... 00.9571 11.90 280115.......... 00.9323 16.12 310014......... 01.6973 25.20 310113......... 01.2698 21.81 330028......... 01.4711 25.53
280025....................... 00.9430 12.87 280117.......... 01.0899 15.93 310015......... 01.9538 25.55 310115......... 01.3332 21.37 330029......... 01.0082 19.40
280026....................... 01.2113 14.79 280118.......... 00.9335 16.45 310016......... 01.2558 24.30 310116......... 01.2758 22.74 330030......... 01.2557 16.43
280028....................... 01.1079 15.15 280119.......... 00.8703 ....... 310017......... 01.3828 23.95 310118......... 01.2657 22.78 330033......... 01.2798 16.66
280029....................... 01.1344 15.52 280123.......... 00.8938 ....... 310018......... 01.1258 21.68 310119......... 01.7103 30.34 330034......... 00.6391 30.46
280030....................... 01.7044 27.82 280125.......... 01.2392 ....... 310019......... 01.6672 24.86 310120......... 01.0971 20.79 330036......... 01.3056 19.62
280031....................... 01.0150 13.61 290001.......... 01.6935 23.03 310020......... 01.3887 22.65 320001......... 01.3857 17.43 330037......... 01.1546 15.46
280032....................... 01.3002 16.45 290002.......... 00.9128 16.13 310021......... 01.3817 23.63 320002......... 01.3670 19.13 330038......... 01.2340 15.52
280033....................... 01.0406 15.69 290003.......... 01.6810 25.76 310022......... 01.3156 21.10 320003......... 01.1238 13.29 330041......... 01.3043 36.69
280035....................... 01.0337 13.65 290005.......... 01.4874 20.79 310024......... 01.3022 23.65 320004......... 01.2792 14.96 330043......... 01.3194 33.46
280037....................... 01.0415 15.48 290006.......... 01.2561 19.14 310025......... 01.2009 21.93 320005......... 01.3531 20.75 330044......... 01.3085 18.10
280038....................... 01.0023 15.49 290007.......... 01.8502 27.93 310026......... 01.2043 23.19 320006......... 01.4170 14.55 330045......... 01.4176 27.45
280039....................... 01.0469 15.70 290008.......... 01.2147 19.60 310027......... 01.3265 21.41 320009......... 01.6244 17.17 330046......... 01.4603 30.06
280040....................... 01.6269 19.18 290009.......... 01.6221 17.91 310028......... 01.2526 21.94 320011......... 01.0077 17.05 330047......... 01.1772 16.85
280041....................... 00.9134 12.05 290010.......... 01.2399 14.00 310029......... 01.9458 23.14 320012......... 00.9924 16.53 330048......... 01.2917 17.45
280042....................... 01.0344 15.14 290011.......... 00.9015 15.52 310031......... 02.8675 22.58 320013......... 01.1521 17.67 330049......... 01.2386 17.85
280043....................... 01.0147 15.47 290012.......... 01.3753 21.50 310032......... 01.3467 22.51 320014......... 01.1514 14.63 330053......... 01.1874 14.83
280045....................... 01.0969 16.10 290013.......... 01.0527 18.62 310034......... 01.2580 21.58 320016......... 01.1211 15.17 330055......... 01.6244 29.81
280046....................... 01.1072 12.37 290014.......... 00.9699 17.46 310036......... 01.1893 19.11 320017......... 01.2111 16.75 330056......... 01.4395 30.22
280047....................... 01.0907 18.01 290015.......... 00.9197 15.18 310037......... 01.3653 27.57 320018......... 01.5827 18.43 330057......... 01.6763 18.74
280048....................... 01.2131 13.82 290016.......... 01.1837 22.67 310038......... 01.9545 26.13 320019......... 01.4848 19.57 330058......... 01.3057 16.66
280049....................... 01.0412 15.08 290019.......... 01.3426 19.74 310039......... 01.2827 21.22 320021......... 01.7502 17.99 330059......... 01.5787 33.67
280050....................... 00.9263 13.71 290020.......... 01.0445 17.29 310040......... 01.2393 23.99 320022......... 01.2213 16.24 330061......... 01.3166 24.36
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
330062....................... 01.0733 17.10 330179.......... 00.9045 14.60 330275......... 01.2903 22.06 340031......... 01.0066 12.83 340129......... 01.2985 18.11
330064....................... 01.4892 32.11 330180.......... 01.1983 16.27 330276......... 01.1685 17.92 340032......... 01.3624 18.77 340130......... 01.3225 19.83
330065....................... 01.2030 18.54 330181.......... 01.3528 31.07 330277......... 01.1085 16.57 340035......... 01.1531 17.23 340131......... 01.5209 18.16
330066....................... 01.2766 17.98 330182.......... 02.5453 30.48 330279......... 01.3577 19.05 340036......... 01.2139 18.25 340132......... 01.3256 16.27
330067....................... 01.3948 20.64 330183.......... 01.4677 19.94 330285......... 01.8458 22.66 340037......... 01.0873 14.46 340133......... 01.1268 14.74
330072....................... 01.4097 29.92 330184.......... 01.3264 27.58 330286......... 01.3379 24.38 340038......... 01.1012 16.68 340137......... 01.1310 15.62
330073....................... 01.2255 15.82 330185.......... 01.2827 24.72 330290......... 01.6841 32.27 340039......... 01.2681 19.88 340138......... 01.0625 16.94
330074....................... 01.3127 17.25 330186.......... 00.5618 20.30 330293......... 01.1953 15.09 340040......... 01.8191 18.61 340141......... 01.7229 20.28
330075....................... 01.0589 17.73 330188.......... 01.1830 18.71 330304......... 01.2338 27.04 340041......... 01.2094 17.69 340142......... 01.2350 15.79
330078....................... 01.4268 17.96 330189.......... 01.3232 16.54 330306......... 01.4286 28.10 340042......... 01.2260 15.70 340143......... 01.4228 19.62
330079....................... 01.2427 17.22 330191.......... 01.3283 18.17 330307......... 01.2663 19.23 340044......... 01.1020 18.87 340144......... 01.3656 18.96
330080....................... 01.3325 27.06 330193.......... 01.3516 28.64 330314......... 01.3785 21.50 340045......... 00.9956 14.02 340145......... 01.4314 18.88
330084....................... 01.0696 17.68 330194.......... 01.7808 31.20 330315......... 16.0413 30.36 340047......... 01.8288 19.42 340146......... 01.1145 14.28
330085....................... 01.2974 18.59 330195.......... 01.6416 31.94 330316......... 01.3084 22.23 340048......... 01.0275 05.23 340147......... 01.2535 19.21
330086....................... 01.2666 26.87 330196.......... 01.2608 27.80 330327......... 00.9713 16.98 340049......... 01.0355 17.75 340148......... 01.4937 18.55
330088....................... 01.0531 22.43 330197.......... 01.1287 16.79 330331......... 01.3121 29.10 340050......... 01.2003 17.95 340151......... 01.2078 15.67
330090....................... 01.5991 17.92 330198.......... 01.3837 23.21 330332......... 01.2892 26.99 340051......... 01.3356 16.79 340153......... 01.8814 19.87
330091....................... 01.3584 18.01 330199.......... 01.3382 25.90 330333......... 01.2444 51.91 340052......... 01.0223 21.14 340155......... 01.3840 21.24
330092....................... 01.0542 14.25 330201.......... 01.6866 40.72 330336......... 01.3094 30.29 340053......... 01.6440 19.44 340156......... 00.7966 ......
330094....................... 01.2399 17.06 330202.......... 01.3886 27.41 330338......... 01.2333 20.97 340054......... 01.2239 14.35 340158......... 01.1278 16.49
330095....................... 01.2452 18.40 330203.......... 01.3959 19.61 330339......... 00.9320 18.87 340055......... 01.2769 17.40 340159......... 01.1375 16.21
330096....................... 01.1887 15.81 330204.......... 01.3552 28.88 330340......... 01.2344 22.43 340060......... 01.1293 17.75 340160......... 01.1672 14.11
330097....................... 01.2171 15.32 330205.......... 01.1763 19.85 330350......... 01.6747 28.46 340061......... 01.7280 20.31 340162......... 01.1787 16.56
330100....................... 00.7936 28.03 330208.......... 01.2263 26.41 330353......... 01.2772 31.43 340063......... 01.0171 22.75 340164......... 01.4579 20.69
330101....................... 01.8106 30.39 330209.......... 01.1811 24.53 330354......... 01.5676 ....... 340064......... 01.2364 17.05 340166......... 01.2776 19.58
330102....................... 01.3312 17.00 330211.......... 01.2029 18.46 330357......... 01.3809 34.81 340065......... 01.2854 15.89 340168......... 00.4875 15.15
330103....................... 01.2449 16.63 330212.......... 01.1468 24.26 330359......... 00.9373 29.31 340067......... 01.1587 18.20 340171......... 01.2031 ......
330104....................... 01.4313 27.69 330213.......... 01.1701 18.39 330372......... 01.1964 22.25 340068......... 01.2139 16.56 340173......... 01.2130 ......
330106....................... 01.6949 34.04 330214.......... 01.8173 31.94 330381......... 01.2852 29.21 340069......... 01.8495 20.34 350001......... 00.9857 14.51
330107....................... 01.3314 26.04 330215.......... 01.2026 17.11 330385......... 01.1940 29.15 340070......... 01.3026 18.49 350002......... 01.8548 16.86
330108....................... 01.2467 16.97 330218.......... 01.0527 20.44 330386......... 01.2158 23.26 340071......... 01.0889 15.86 350003......... 01.1701 16.63
330111....................... 01.0751 15.08 330219.......... 01.6629 20.87 330387......... 00.7923 30.68 340072......... 01.1279 15.86 350004......... 01.9174 18.34
330114....................... 00.9490 15.82 330221.......... 01.2904 29.07 330389......... 01.7245 31.92 340073......... 01.5386 19.84 350005......... 01.0598 14.07
330115....................... 01.2405 16.12 330222.......... 01.2606 18.36 330390......... 01.3751 31.67 340075......... 01.1939 16.88 350006......... 01.5142 16.25
330116....................... 00.9611 15.34 330223.......... 01.0770 16.39 330393......... 01.7444 25.45 340080......... 01.0339 15.49 350007......... 00.8879 13.24
330118....................... 01.6591 20.00 330224.......... 01.2569 21.50 330394......... 01.5407 18.21 340084......... 01.0889 16.12 350008......... 00.9420 16.74
330119....................... 01.7636 32.85 330225.......... 01.1739 24.76 330395......... 01.3488 33.16 340085......... 01.1663 16.33 350009......... 01.1468 17.04
330121....................... 01.0383 15.12 330226.......... 01.2590 17.82 330396......... 01.1754 31.55 340087......... 01.1169 16.53 350010......... 01.1050 13.74
330122....................... 01.0650 22.97 330229.......... 01.3257 16.25 330397......... 01.3150 30.46 340088......... 01.1258 18.13 350011......... 01.8836 20.64
330125....................... 01.9179 20.66 330230.......... 01.3791 29.27 330398......... 01.3550 29.49 340089......... 01.0120 13.83 350012......... 01.1086 13.55
330126....................... 01.1519 22.70 330231.......... 01.0674 29.53 330399......... 01.2625 29.60 340090......... 01.1444 17.83 350013......... 01.1051 16.53
330127....................... 01.3403 29.65 330232.......... 01.2445 17.76 340001......... 01.4796 17.91 340091......... 01.7002 19.89 350014......... 00.9841 13.14
330128....................... 01.2625 29.68 330233.......... 01.4948 30.49 340002......... 01.8416 18.45 340093......... 01.0697 13.96 350015......... 01.7381 16.56
330132....................... 01.2001 13.55 330234.......... 02.3119 31.88 340003......... 01.1252 17.14 340094......... 01.4789 18.27 350016......... 01.0963 11.47
330133....................... 01.3701 34.67 330235.......... 01.1204 19.21 340004......... 01.4483 18.79 340096......... 01.1483 17.40 350017......... 01.3990 16.68
330135....................... 01.1994 19.14 330236.......... 01.4074 28.47 340005......... 01.1650 14.89 340097......... 01.1445 17.69 350018......... 01.0846 17.93
330136....................... 01.2894 19.26 330238.......... 01.1749 15.02 340006......... 01.0428 14.76 340098......... 01.6889 19.32 350019......... 01.6863 18.72
330140....................... 01.7769 18.58 330239.......... 01.1666 16.21 340007......... 01.1704 16.96 340099......... 01.2134 13.03 350021......... 01.0260 12.00
330141....................... 01.3850 24.49 330240.......... 01.3279 27.67 340008......... 01.1373 17.84 340101......... 01.0627 11.87 350023......... 00.9286 15.16
330144....................... 00.9394 15.19 330241.......... 01.9705 21.51 340010......... 01.2998 17.56 340104......... 00.9970 11.37 350024......... 01.0368 16.47
330148....................... 01.0767 15.47 330242.......... 01.3423 25.14 340011......... 01.1622 15.71 340105......... 01.3725 18.85 350025......... 01.0095 14.00
330151....................... 01.1172 14.68 330245.......... 01.3076 17.00 340012......... 01.3162 17.04 340106......... 01.2505 20.04 350027......... 00.9540 14.46
330152....................... 01.4137 30.10 330246.......... 01.3839 25.91 340013......... 01.2800 17.33 340107......... 01.3591 17.08 350029......... 00.8728 12.98
330153....................... 01.7338 16.97 330247.......... 00.9015 27.38 340014......... 01.5587 22.23 340109......... 01.3186 17.38 350030......... 01.0496 16.65
330154....................... 01.7268 ....... 330249.......... 01.1933 16.18 340015......... 01.3007 20.37 340111......... 01.1989 14.63 350033......... 00.9198 14.40
330157....................... 01.3501 19.72 330250.......... 01.2870 17.98 340016......... 01.1912 16.24 340112......... 00.9917 15.24 350034......... 00.9924 17.45
330158....................... 01.4999 20.48 330252.......... 00.9461 16.84 340017......... 01.2474 14.31 340113......... 01.8577 20.59 350035......... 00.9005 10.21
330159....................... 01.2907 17.88 330254.......... 01.1696 17.12 340018......... 01.2456 16.25 340114......... 01.5500 20.34 350038......... 01.0922 15.28
330160....................... 01.4736 29.42 330258.......... 01.3355 30.01 340019......... 01.0224 20.26 340115......... 01.5723 19.35 350039......... 01.0288 14.75
330162....................... 01.2185 27.06 330259.......... 01.5025 23.47 340020......... 01.1977 19.04 340116......... 01.8178 19.81 350041......... 01.0442 17.60
330163....................... 01.1905 19.14 330261.......... 01.2944 26.17 340021......... 01.2336 17.51 340119......... 01.2970 16.41 350042......... 01.1142 15.19
330164....................... 01.4954 19.87 330263.......... 01.0305 17.91 340022......... 01.0586 16.91 340120......... 01.0817 13.56 350043......... 01.5670 14.65
330166....................... 01.0125 13.56 330264.......... 01.2135 21.71 340023......... 01.3771 17.77 340121......... 01.0648 15.43 350044......... 00.8768 11.49
330167....................... 01.6539 29.65 330265.......... 01.3931 16.33 340024......... 01.1393 16.33 340123......... 01.0906 15.57 350047......... 01.1941 16.54
330169....................... 01.4639 32.41 330267.......... 01.3643 23.95 340025......... 01.2234 15.47 340124......... 01.0127 13.98 350049......... 01.3354 13.86
330171....................... 01.4007 23.94 330268.......... 00.9663 15.02 340027......... 01.2058 16.89 340125......... 01.4796 16.50 350050......... 00.9591 11.89
330175....................... 01.1894 15.10 330270.......... 01.9872 31.03 340028......... 01.5976 16.85 340126......... 01.3940 16.50 350051......... 00.9832 15.74
330177....................... 00.9633 14.78 330273.......... 01.3059 25.72 340030......... 02.0173 21.06 340127......... 01.3339 17.51 350053......... 01.0118 11.88
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[[Page 25632]]
Page 11 of 15
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
350055....................... 00.9999 13.76 360074.......... 01.3337 18.00 360159......... 01.2116 19.84 370029......... 01.2602 13.51 370149......... 01.2900 15.69
350056....................... 00.9564 13.88 360075.......... 01.4441 21.40 360161......... 01.2549 13.69 370030......... 01.1832 16.49 370153......... 01.0658 14.06
350058....................... 00.9230 12.18 360076.......... 01.3645 18.64 360163......... 01.8032 20.26 370032......... 01.5887 16.17 370154......... 01.0434 14.12
350060....................... 00.8587 08.80 360077.......... 01.5831 19.38 360164......... 00.9634 15.60 370033......... 01.0599 12.34 370156......... 01.0577 17.29
350061....................... 01.0645 15.31 360078.......... 01.2491 19.90 360165......... 01.1732 17.81 370034......... 01.2337 14.36 370158......... 01.0253 12.09
350063....................... 00.8843 ....... 360079.......... 01.8666 21.04 360166......... 01.1873 16.01 370035......... 01.6429 16.77 370159......... 01.3951 15.05
350064....................... 00.8364 ....... 360080.......... 01.1462 15.68 360170......... 01.3808 16.53 370036......... 01.0721 10.54 370163......... 01.0022 14.57
360001....................... 01.3790 17.65 360081.......... 01.3761 19.70 360172......... 01.3455 17.89 370037......... 01.7160 18.63 370165......... 01.1291 11.97
360002....................... 01.1925 17.82 360082.......... 01.3254 23.27 360174......... 01.3284 18.44 370038......... 01.0052 11.68 370166......... 01.1323 15.55
360003....................... 01.7561 22.14 360084.......... 01.6045 20.53 360175......... 01.1937 20.19 370039......... 01.2616 13.93 370169......... 01.0593 11.91
360006....................... 01.8372 20.93 360085.......... 01.8333 21.47 360176......... 01.1290 15.34 370040......... 01.0977 15.04 370170......... 01.0046 ......
360007....................... 01.0627 15.95 360086.......... 01.4331 17.81 360177......... 01.2931 18.27 370041......... 00.9733 16.47 370171......... 01.0182 ......
360008....................... 01.2396 17.78 360087.......... 01.4291 18.51 360178......... 01.2433 17.16 370042......... 00.8835 13.98 370172......... 00.9229 ......
360009....................... 01.4867 17.38 360088.......... 01.3676 19.09 360179......... 01.3391 19.50 370043......... 00.9443 15.18 370173......... 01.1000 ......
360010....................... 01.2461 17.09 360089.......... 01.1769 17.84 360180......... 02.1577 23.00 370045......... 00.9900 09.83 370174......... 00.7547 ......
360011....................... 01.3403 18.91 360090.......... 01.2425 19.75 360184......... 00.4293 18.76 370046......... 00.9817 10.89 370176......... 01.2219 16.29
360012....................... 01.3150 19.72 360091.......... 01.2836 20.40 360185......... 01.2259 18.13 370047......... 01.3904 15.04 370177......... 00.9737 10.48
360013....................... 01.1386 18.36 360092.......... 01.1263 19.47 360186......... 01.1539 10.45 370048......... 01.2228 15.40 370178......... 01.0021 11.20
360014....................... 01.2083 18.87 360093.......... 01.1654 17.64 360187......... 01.4085 17.67 370049......... 01.3327 15.44 370179......... 00.7441 15.19
360016....................... 01.6147 18.36 360094.......... 01.3940 18.15 360188......... 00.9725 17.11 370051......... 00.9867 11.30 370180......... 00.9135 ......
360017....................... 01.8633 21.51 360095.......... 01.2581 19.83 360189......... 01.1592 16.98 370054......... 01.4696 16.32 370183......... 01.0309 10.35
360018....................... 01.6285 19.87 360096.......... 01.1266 17.46 360192......... 01.3663 21.31 370056......... 01.5245 18.44 370186......... 00.9921 13.32
360019....................... 01.2657 21.76 360098.......... 01.4265 18.26 360193......... 01.2971 16.98 370057......... 01.1165 15.27 370190......... 01.5486 26.42
360020....................... 01.4424 20.72 360099.......... 01.0479 19.53 360194......... 01.2855 17.89 370059......... 01.0974 17.49 370192......... 01.2229 16.30
360024....................... 01.3762 17.75 360100.......... 01.2888 18.00 360195......... 01.1587 19.33 370060......... 01.1260 13.90 370196......... 00.8240 ......
360025....................... 01.3562 19.40 360101.......... 01.3901 21.04 360197......... 01.1688 19.16 370063......... 01.1782 16.95 370197......... 00.9846 ......
360026....................... 01.3485 16.21 360102.......... 01.2869 19.19 360200......... 01.0276 15.62 370064......... 00.9593 10.71 370198......... 01.7997 ......
360027....................... 01.4597 20.14 360103.......... 01.3578 19.87 360203......... 01.2094 14.41 370065......... 00.9924 15.36 380001......... 01.2902 18.13
360028....................... 01.4846 17.21 360106.......... 01.1021 16.08 360204......... 01.2422 19.09 370071......... 01.0530 10.05 380002......... 01.2715 18.07
360029....................... 01.1846 17.74 360107.......... 01.2417 17.37 360210......... 01.2012 20.61 370072......... 00.8635 14.04 380003......... 01.2260 28.86
360030....................... 01.2891 16.67 360108.......... 01.0913 16.45 360211......... 01.2671 19.64 370076......... 01.2612 12.45 380004......... 01.7003 23.04
360031....................... 01.2807 19.33 360109.......... 01.1094 18.64 360212......... 01.3941 20.16 370078......... 01.7411 16.06 380005......... 01.2187 22.81
360032....................... 01.0729 17.87 360112.......... 01.8012 23.33 360213......... 01.2686 18.05 370079......... 00.9534 15.91 380006......... 01.2870 19.61
360034....................... 01.3225 14.77 360113.......... 01.3630 15.36 360218......... 01.3047 18.29 370080......... 00.9738 14.18 380007......... 01.6852 24.92
360035....................... 01.6186 20.73 360114.......... 01.1017 17.48 360230......... 01.5624 21.16 370082......... 00.9220 13.85 380008......... 01.0543 19.56
360036....................... 01.3579 19.04 360115.......... 01.2554 17.92 360231......... 01.1494 12.39 370083......... 00.9508 12.81 380009......... 01.8821 22.90
360037....................... 02.0580 21.38 360116.......... 01.0983 17.49 360234......... 01.3469 16.44 370084......... 01.0827 13.65 380010......... 01.0520 22.58
360038....................... 01.5828 20.60 360118.......... 01.3521 18.34 360236......... 01.2893 25.36 370085......... 00.8717 13.21 380011......... 01.0490 19.05
360039....................... 01.3135 17.40 360121.......... 01.2409 19.22 360239......... 01.3034 19.65 370086......... 01.1713 11.51 380013......... 01.3177 20.62
360040....................... 01.3495 17.81 360123.......... 01.2744 19.33 360241......... 00.4699 21.14 370089......... 01.2580 15.23 380014......... 01.6295 22.02
360041....................... 01.3392 18.83 360125.......... 01.0992 17.41 360242......... 01.8068 ....... 370091......... 01.7259 19.16 380017......... 01.9390 25.87
360042....................... 01.1862 18.02 360126.......... 01.2179 20.75 360243......... 00.7287 14.26 370092......... 01.0247 14.09 380018......... 01.8034 20.94
360044....................... 01.1205 15.83 360127.......... 01.1844 17.85 360245......... 00.7295 15.21 370093......... 01.8539 17.71 380019......... 01.2880 21.45
360045....................... 01.4762 20.73 360128.......... 01.1314 15.05 360247......... 00.4164 ....... 370094......... 01.5130 19.25 380020......... 01.5022 21.41
360046....................... 01.1449 17.71 360129.......... 00.9665 15.12 360248......... 01.7504 ....... 370095......... 00.9994 11.75 380021......... 01.2890 21.57
360047....................... 01.1368 14.51 360130.......... 01.1237 15.93 370001......... 01.7845 20.06 370097......... 01.3708 17.38 380022......... 01.1715 22.57
360048....................... 01.8279 21.60 360131.......... 01.3442 18.99 370002......... 01.1524 13.71 370099......... 01.1771 14.07 380023......... 01.2243 18.43
360049....................... 01.1856 19.60 360132.......... 01.4255 18.28 370004......... 01.2310 16.67 370100......... 01.0076 14.49 380025......... 01.3449 25.35
360050....................... 01.0987 12.40 360133.......... 01.5948 18.70 370005......... 01.0032 14.07 370103......... 00.9320 16.27 380026......... 01.1604 19.09
360051....................... 01.6396 23.55 360134.......... 01.7247 20.07 370006......... 01.2654 15.48 370105......... 01.9777 18.43 380027......... 01.2943 22.82
360052....................... 01.7665 18.65 360136.......... 01.0811 16.90 370007......... 01.2216 14.36 370106......... 01.5469 18.37 380029......... 01.1592 18.33
360054....................... 01.2934 16.53 360137.......... 01.6532 19.95 370008......... 01.3784 17.77 370108......... 01.1298 11.81 380031......... 00.9808 22.48
360055....................... 01.2577 19.64 360140.......... 00.9788 16.21 370011......... 01.0524 12.91 370112......... 01.0696 14.65 380033......... 01.7744 24.22
360056....................... 01.4280 20.89 360141.......... 01.5661 23.32 370012......... 00.8733 09.87 370113......... 01.1887 15.11 380035......... 01.2910 21.53
360057....................... 01.1603 15.46 360142.......... 01.0197 16.62 370013......... 01.8435 19.24 370114......... 01.6464 15.79 380036......... 01.0585 20.79
360058....................... 01.2702 17.56 360143.......... 01.4294 19.90 370014......... 01.2842 19.35 370121......... 01.1723 16.84 380037......... 01.2761 20.52
360059....................... 01.6935 21.65 360144.......... 01.3319 19.89 370015......... 01.2181 17.16 370122......... 01.1283 12.45 380038......... 01.3383 25.28
360062....................... 01.5157 20.52 360145.......... 01.6848 18.18 370016......... 01.3747 16.52 370123......... 01.3288 17.25 380039......... 01.3184 21.50
360063....................... 01.1355 18.29 360147.......... 01.2300 16.40 370017......... 01.1872 11.23 370125......... 00.9809 12.01 380040......... 01.2643 21.08
360064....................... 01.6110 21.73 360148.......... 01.1746 17.80 370018......... 01.3459 18.25 370126......... 00.9821 12.07 380042......... 01.0847 17.33
360065....................... 01.2978 18.23 360149.......... 01.2144 18.68 370019......... 01.3577 14.79 370131......... 00.9568 15.71 380047......... 01.7005 21.15
360066....................... 01.5064 18.92 360150.......... 01.2765 20.02 370020......... 01.3041 11.86 370133......... 01.1458 11.04 380048......... 01.0727 15.35
360067....................... 01.1473 13.46 360151.......... 01.3441 17.15 370021......... 00.9234 10.38 370138......... 01.0828 15.12 380050......... 01.4632 18.30
360068....................... 01.7403 21.49 360152.......... 01.5138 19.73 370022......... 01.3220 17.34 370139......... 01.1101 11.70 380051......... 01.6000 20.79
360069....................... 01.1413 17.25 360153.......... 01.1322 13.86 370023......... 01.3350 16.03 370140......... 01.0074 11.92 380052......... 01.2194 17.97
360070....................... 01.6991 16.22 360154.......... 01.0127 13.29 370025......... 01.3416 16.09 370141......... 01.3413 15.22 380055......... 01.0479 25.16
360071....................... 01.3655 14.35 360155.......... 01.3655 20.38 370026......... 01.4980 16.66 370146......... 01.1663 11.23 380056......... 01.1095 16.82
360072....................... 01.2294 17.52 360156.......... 01.2889 18.45 370028......... 01.9096 20.31 370148......... 01.4901 27.04 380060......... 01.4546 22.68
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[[Page 25633]]
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
380061....................... 01.5010 21.24 390054.......... 01.1925 16.20 390138......... 01.3274 17.99 390242......... 01.3211 18.77 400120......... 01.3210 09.45
380062....................... 01.2271 18.32 390055.......... 01.8803 26.53 390139......... 01.5292 23.00 390244......... 00.9008 12.10 400121......... 00.9061 06.57
380063....................... 01.2398 18.55 390056.......... 01.1583 16.53 390142......... 01.6012 28.56 390245......... 01.4283 21.37 400122......... 01.0071 07.20
380064....................... 01.3645 18.24 390057.......... 01.3181 19.58 390145......... 01.3627 20.30 390246......... 01.2381 17.91 400123......... 01.1923 08.39
380065....................... 01.2612 22.48 390058.......... 01.2736 18.64 390146......... 01.2696 16.85 390247......... 01.0888 20.42 400124......... 02.6899 11.00
380066....................... 01.3314 20.01 390060.......... 01.2044 16.88 390147......... 01.2520 20.55 390249......... 01.0117 12.79 410001......... 01.3885 21.15
380068....................... 00.9929 21.71 390061.......... 01.5126 20.08 390150......... 01.1850 20.98 390256......... 01.8065 24.05 410004......... 01.3542 21.95
380069....................... 01.1237 19.35 390062.......... 01.1873 16.43 390151......... 01.2236 19.88 390258......... 01.3894 20.71 410005......... 01.3893 22.97
380070....................... 01.3856 25.32 390063.......... 01.7711 20.19 390152......... 01.0833 17.35 390260......... 01.2324 23.05 410006......... 01.3047 21.58
380071....................... 01.2895 20.13 390065.......... 01.2445 19.95 390153......... 01.2347 22.04 390262......... 01.8663 18.17 410007......... 01.6895 21.22
380072....................... 00.9525 16.03 390066.......... 01.2979 19.58 390154......... 01.2149 17.37 390263......... 01.4746 19.75 410008......... 01.2641 20.03
380075....................... 01.3760 19.99 390067.......... 01.7841 19.97 390156......... 01.4353 20.56 390265......... 01.3029 19.06 410009......... 01.3206 23.53
380078....................... 00.9840 18.28 390068.......... 01.3034 19.04 390157......... 01.3790 18.98 390266......... 01.2200 16.95 410010......... 01.0628 26.80
380081....................... 01.1300 18.28 390069.......... 01.3386 20.08 390158......... 01.5582 19.47 390267......... 01.3089 19.01 410011......... 01.2360 23.92
380082....................... 01.3109 21.55 390070.......... 01.3343 19.37 390160......... 01.2930 19.68 390268......... 01.3484 21.17 410012......... 01.8346 21.15
380083....................... 01.2950 21.90 390071.......... 01.0930 15.04 390161......... 01.1318 13.75 390270......... 01.3595 17.08 410013......... 01.2926 24.44
380084....................... 01.2579 21.98 390072.......... 01.0866 15.49 390162......... 01.5617 21.02 390272......... 00.4562 ....... 420002......... 01.3852 21.83
380087....................... 01.0848 12.91 390073.......... 01.6243 19.82 390163......... 01.2249 16.11 390277......... 00.5292 23.14 420004......... 01.8530 18.30
380088....................... 01.0227 18.65 390074.......... 01.2608 16.62 390164......... 02.1585 22.59 390278......... 00.6728 16.94 420005......... 01.1718 15.14
380089....................... 01.3275 23.92 390075.......... 01.3632 17.48 390166......... 01.1125 18.97 390279......... 01.0386 14.40 420006......... 01.1714 17.68
380090....................... 01.2856 25.49 390076.......... 01.4253 21.97 390167......... 01.3655 21.84 400001......... 01.2646 09.39 420007......... 01.5056 17.78
380091....................... 01.3021 24.95 390078.......... 01.0805 18.92 390168......... 01.2845 18.12 400002......... 01.6156 10.99 420009......... 01.2431 17.01
390001....................... 01.4101 21.89 390079.......... 01.7802 17.91 390169......... 01.2814 18.85 400003......... 01.3181 08.34 420010......... 01.2029 15.22
390002....................... 01.2997 19.71 390080.......... 01.3128 18.40 390170......... 01.8882 21.93 400004......... 01.1998 08.16 420011......... 01.1862 15.88
390003....................... 01.2251 17.48 390081.......... 01.3443 21.33 390173......... 01.2026 17.81 400005......... 01.0804 06.50 420014......... 01.0521 15.49
390004....................... 01.3957 17.68 390083.......... 01.2260 17.49 390174......... 01.6821 28.75 400006......... 01.2047 07.62 420015......... 01.3602 17.27
390005....................... 01.0449 16.56 390084.......... 01.1848 15.92 390176......... 01.1634 18.54 400007......... 01.1616 07.13 420016......... 00.9967 14.27
390006....................... 01.7963 18.43 390086.......... 01.1623 17.91 390178......... 01.3125 19.14 400009......... 01.0382 07.64 420018......... 01.8076 19.64
390007....................... 01.2165 20.24 390088.......... 01.3418 21.04 390179......... 01.3565 21.31 400010......... 00.9135 10.07 420019......... 01.1909 14.81
390008....................... 01.1475 16.70 390090.......... 01.7964 20.56 390180......... 01.4771 23.13 400011......... 01.0608 07.81 420020......... 01.2623 17.58
390009....................... 01.6945 19.72 390091.......... 01.1404 18.52 390181......... 01.0478 19.10 400012......... 01.1906 07.69 420023......... 01.4452 19.27
390010....................... 01.2666 16.99 390093.......... 01.1546 15.95 390183......... 01.1759 18.03 400013......... 01.2834 08.06 420026......... 01.8876 18.73
390011....................... 01.2805 18.32 390095.......... 01.2041 15.21 390184......... 01.1047 18.24 400014......... 01.3803 08.68 420027......... 01.3581 17.34
390012....................... 01.2209 19.43 390096.......... 01.5027 17.87 390185......... 01.2232 17.20 400015......... 01.3729 ....... 420030......... 01.2949 17.49
390013....................... 01.2405 18.14 390097.......... 01.2959 22.07 390189......... 01.1429 19.19 400016......... 01.3717 11.37 420031......... 00.9613 12.23
390015....................... 01.1529 13.06 390100.......... 01.6655 20.58 390191......... 01.2270 16.80 400017......... 01.2069 06.56 420033......... 01.2721 19.24
390016....................... 01.2456 17.76 390101.......... 01.2042 17.62 390192......... 01.1586 15.64 400018......... 01.2977 09.29 420036......... 01.4355 18.46
390017....................... 01.2175 15.86 390102.......... 01.3763 19.60 390193......... 01.2088 17.26 400019......... 01.7668 09.58 420037......... 01.1963 21.60
390018....................... 01.3160 19.26 390103.......... 01.1383 18.62 390194......... 01.1410 18.95 400021......... 01.4606 09.43 420038......... 01.3331 15.74
390019....................... 01.1409 16.01 390104.......... 01.0956 14.75 390195......... 01.8448 22.62 400022......... 01.3456 11.18 420039......... 01.1544 16.21
390022....................... 01.3648 20.49 390106.......... 01.0527 15.96 390196......... 01.3776 ....... 400024......... 01.0267 07.45 420042......... 01.1022 14.56
390023....................... 01.2385 18.03 390107.......... 01.3456 19.43 390197......... 01.3002 17.67 400026......... 00.9852 06.04 420043......... 01.2299 18.79
390024....................... 01.0879 23.53 390108.......... 01.3676 19.21 390198......... 01.2119 15.83 400027......... 01.1410 08.07 420048......... 01.2492 13.44
390025....................... 00.6397 15.37 390109.......... 01.2783 14.91 390199......... 01.3245 15.86 400028......... 01.0099 07.98 420049......... 01.1743 16.46
390026....................... 01.3006 21.98 390110.......... 01.6319 19.36 390200......... 01.0981 17.18 400029......... 01.0884 10.05 420051......... 01.6278 17.99
390027....................... 01.8620 28.88 390111.......... 01.8454 29.97 390201......... 01.2808 20.12 400031......... 01.2349 09.50 420053......... 01.1996 16.08
390028....................... 01.8946 19.73 390112.......... 01.2860 13.72 390203......... 01.3856 22.12 400032......... 01.2495 08.99 420054......... 01.2953 17.01
390029....................... 01.9719 18.87 390113.......... 01.2274 17.00 390204......... 01.3041 20.57 400044......... 01.1780 09.84 420055......... 01.0131 15.72
390030....................... 01.2422 18.37 390114.......... 01.2178 21.25 390206......... 01.3925 19.09 400048......... 01.1548 08.23 420056......... 01.0853 13.21
390031....................... 01.1866 18.45 390115.......... 01.3792 23.95 390209......... 01.0699 16.37 400061......... 01.6558 14.42 420057......... 01.1687 14.71
390032....................... 01.2567 19.11 390116.......... 01.2709 23.74 390211......... 01.2499 18.17 400079......... 01.2819 10.43 420059......... 00.9796 15.11
390035....................... 01.2478 17.14 390117.......... 01.1848 16.64 390213......... 01.1615 19.15 400087......... 01.4420 10.90 420061......... 01.1681 17.58
390036....................... 01.4518 19.18 390118.......... 01.1802 16.48 390215......... 01.2938 24.51 400094......... 01.0401 06.88 420062......... 01.4640 15.61
390037....................... 01.3834 19.24 390119.......... 01.3516 18.05 390217......... 01.2323 20.29 400098......... 01.3576 08.48 420064......... 01.1124 14.50
390039....................... 01.1357 16.31 390121.......... 01.3576 19.61 390219......... 01.3267 19.86 400102......... 01.1698 04.27 420065......... 01.3464 18.10
390040....................... 00.9663 16.73 390122.......... 01.1007 18.49 390220......... 01.2025 18.22 400103......... 01.4518 09.30 420066......... 00.9577 16.65
390041....................... 01.2908 18.92 390123.......... 01.3805 20.31 390222......... 01.2859 20.89 400104......... 01.3442 09.05 420067......... 01.2622 18.10
390042....................... 01.5647 21.41 390125.......... 01.2001 15.48 390223......... 01.5318 22.49 400105......... 01.2514 08.85 420068......... 01.4309 17.58
390043....................... 01.1558 18.18 390126.......... 01.2793 19.94 390224......... 00.9047 15.35 400106......... 01.2522 08.61 420069......... 01.0556 18.03
390044....................... 01.6721 19.24 390127.......... 01.2446 21.39 390225......... 01.1782 17.76 400109......... 01.4903 09.61 420070......... 01.2279 16.89
390045....................... 01.8045 17.60 390128.......... 01.2398 19.93 390226......... 01.7896 23.48 400110......... 01.0649 08.99 420071......... 01.3120 18.25
390046....................... 01.5550 20.26 390130.......... 01.1635 16.56 390228......... 01.2819 19.19 400111......... 01.1917 08.80 420072......... 00.9800 11.63
390047....................... 01.9134 30.25 390131.......... 01.3311 16.73 390231......... 01.4331 24.08 400112......... 01.1131 08.91 420073......... 01.3017 20.68
390048....................... 01.1814 18.12 390132.......... 01.2825 22.21 390233......... 01.3151 18.31 400113......... 01.2139 08.29 420074......... 01.0054 13.73
390049....................... 01.6700 21.29 390133.......... 01.8226 22.97 390235......... 01.5371 23.51 400114......... 01.0730 08.19 420075......... 00.9408 13.75
390050....................... 02.1813 22.47 390135.......... 01.2353 21.67 390236......... 01.1865 16.40 400115......... 01.0700 08.58 420078......... 01.8491 21.18
390051....................... 02.1743 25.65 390136.......... 01.1261 15.10 390237......... 01.6160 19.08 400117......... 01.1921 09.36 420079......... 01.5774 19.07
390052....................... 01.1794 15.47 390137.......... 01.5138 16.40 390238......... 01.4870 18.78 400118......... 01.2634 10.06 420080......... 01.3760 24.17
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[[Page 25634]]
Page 13 of 15
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
420082....................... 01.5220 18.32 440011.......... 01.3887 17.79 440135......... 01.2276 19.84 450039......... 01.4508 17.93 450150......... 00.9615 10.86
420083....................... 01.2939 19.79 440012.......... 01.6038 18.49 440137......... 01.0953 13.42 450040......... 01.5337 17.64 450151......... 01.1421 15.82
420085....................... 01.4964 17.31 440014.......... 00.9585 14.66 440141......... 01.0489 16.14 450042......... 01.7796 17.20 450152......... 01.2733 16.88
420086....................... 01.4475 18.16 440015.......... 01.7375 15.39 440142......... 01.0746 12.75 450044......... 01.5602 20.09 450153......... 01.5917 18.67
420087....................... 01.6840 18.21 440016.......... 01.0127 12.66 440143......... 01.0957 17.21 450046......... 01.4559 12.99 450154......... 01.1522 14.43
420088....................... 01.1409 16.23 440017.......... 01.7209 19.76 440144......... 01.2961 17.79 450047......... 01.1070 11.09 450155......... 01.0382 24.42
420089....................... 01.2826 21.79 440018.......... 01.3665 16.68 440145......... 00.9607 13.88 450050......... 00.9968 11.53 450157......... 01.1365 15.32
420091....................... 01.2793 16.06 440019.......... 01.6964 20.11 440147......... 01.5847 16.28 450051......... 01.6355 19.77 450160......... 00.9535 15.51
420093....................... 01.0268 ....... 440020.......... 01.2407 15.60 440148......... 01.1655 16.26 450052......... 01.0576 13.42 450162......... 01.2604 21.24
430004....................... 01.1554 16.77 440023.......... 01.1507 14.25 440149......... 01.1555 14.35 450053......... 01.0823 14.15 450163......... 01.0682 16.72
430005....................... 01.3595 15.32 440024.......... 01.3297 17.96 440150......... 01.3246 18.41 450054......... 01.6306 21.89 450164......... 01.2194 14.62
430007....................... 01.0638 13.91 440025.......... 01.2064 13.85 440151......... 01.3017 17.69 450055......... 01.0921 12.18 450165......... 01.0931 13.25
430008....................... 01.1481 16.06 440029.......... 01.3155 17.57 440152......... 01.8871 18.01 450056......... 01.6523 16.13 450166......... 00.9365 10.68
430010....................... 01.1348 14.54 440030.......... 01.2445 13.96 440153......... 01.2219 16.01 450058......... 01.6081 16.97 450169......... 00.7896 12.56
430011....................... 01.2481 15.59 440031.......... 01.0365 13.97 440156......... 01.5838 22.45 450059......... 01.3520 13.67 450170......... 00.9586 11.25
430012....................... 01.3134 16.94 440032.......... 01.0487 14.25 440157......... 01.0574 15.33 450063......... 00.9136 12.64 450176......... 01.3488 14.31
430013....................... 01.2626 16.44 440033.......... 01.1447 11.81 440159......... 01.3462 13.80 450064......... 01.4496 15.32 450177......... 01.2792 13.51
430014....................... 01.3447 18.19 440034.......... 01.5652 19.30 440161......... 01.9004 19.94 450065......... 01.1111 19.22 450178......... 00.9692 13.80
430015....................... 01.1468 16.06 440035.......... 01.2851 17.56 440166......... 01.6175 18.67 450068......... 01.8913 24.40 450181......... 01.0425 19.19
430016....................... 01.8285 18.86 440039.......... 01.7990 18.40 440168......... 01.0818 16.29 450072......... 01.2252 19.03 450184......... 01.5030 23.29
430018....................... 00.9273 14.23 440040.......... 01.0268 14.47 440173......... 01.6639 17.92 450073......... 01.2014 18.74 450185......... 01.0475 10.84
430022....................... 00.9234 11.69 440041.......... 01.0192 12.50 440174......... 01.0421 15.12 450076......... 01.6720 ....... 450187......... 01.2512 19.67
430023....................... 00.9009 11.59 440046.......... 01.2308 14.28 440175......... 01.1542 17.31 450078......... 00.9841 09.74 450188......... 01.0367 14.02
430024....................... 01.0343 14.51 440047.......... 00.9274 16.03 440176......... 01.4262 19.42 450079......... 01.4681 20.51 450191......... 01.0301 19.15
430027....................... 01.7770 18.58 440048.......... 01.8485 16.82 440178......... 01.2426 22.63 450080......... 01.2200 17.44 450192......... 01.2312 17.99
430028....................... 01.0635 15.50 440049.......... 01.6623 17.56 440180......... 01.2421 16.19 450081......... 01.0655 15.61 450193......... 02.0166 22.67
430029....................... 01.0237 15.69 440050.......... 01.3806 16.99 440181......... 01.0545 10.98 450082......... 01.0038 13.31 450194......... 01.2934 20.99
430031....................... 00.9251 12.23 440051.......... 00.9613 14.08 440182......... 00.9998 16.20 450083......... 01.7323 19.48 450196......... 01.4438 17.07
430033....................... 00.9805 13.99 440052.......... 01.1465 15.14 440183......... 01.5912 20.71 450085......... 01.0847 12.24 450200......... 01.4043 14.95
430034....................... 01.0590 12.76 440053.......... 01.3823 17.37 440184......... 01.3803 19.32 450087......... 01.4908 17.64 450201......... 01.0004 17.33
430036....................... 01.0975 12.56 440054.......... 01.1902 13.52 440185......... 01.2481 18.83 450090......... 01.2450 13.44 450203......... 01.2382 18.28
430037....................... 00.8770 14.57 440056.......... 01.1204 14.40 440186......... 01.0953 17.87 450092......... 01.2228 12.47 450209......... 01.5951 18.25
430038....................... 00.9865 11.26 440057.......... 01.0459 12.35 440187......... 01.2081 15.76 450094......... 01.3052 ....... 450210......... 01.1066 13.17
430040....................... 01.0299 13.59 440058.......... 01.2301 15.98 440189......... 01.5755 18.56 450096......... 01.4605 16.91 450211......... 01.3831 16.37
430041....................... 00.9403 14.87 440059.......... 01.3550 13.94 440192......... 01.2296 16.54 450097......... 01.4472 18.03 450213......... 01.6843 16.75
430043....................... 01.1676 12.87 440060.......... 01.2762 16.56 440193......... 01.2803 17.93 450098......... 01.1799 16.58 450214......... 01.3531 19.24
430044....................... 00.8239 16.48 440061.......... 01.2361 17.43 440194......... 01.2787 22.50 450099......... 01.2415 17.53 450217......... 01.0704 11.12
430047....................... 01.0575 14.80 440063.......... 01.6979 18.02 440197......... 01.3863 19.25 450101......... 01.4681 16.40 450219......... 01.1743 12.93
430048....................... 01.2187 17.49 440064.......... 01.1639 17.44 440200......... 01.1095 16.93 450102......... 01.7052 17.78 450221......... 01.2410 19.52
430049....................... 00.8976 13.24 440065.......... 01.2574 19.20 440203......... 00.9488 14.18 450104......... 01.1807 14.62 450222......... 01.5738 17.18
430051....................... 00.9900 16.00 440067.......... 01.2538 17.02 440205......... 01.1295 14.78 450107......... 01.6561 19.78 450224......... 01.3931 21.57
430054....................... 01.0254 13.60 440068.......... 01.2810 17.51 440206......... 01.0269 17.93 450108......... 00.9943 13.51 450229......... 01.6431 15.88
430056....................... 00.8484 13.33 440070.......... 01.0737 15.47 440210......... 00.8638 ....... 450109......... 00.9201 14.10 450231......... 01.6402 17.02
430057....................... 00.8887 13.52 440071.......... 01.3827 15.29 440211......... 00.8634 ....... 450110......... 01.3519 18.61 450234......... 01.0158 11.70
430060....................... 00.9648 09.05 440072.......... 01.4283 17.03 450002......... 01.5007 16.67 450111......... 01.2674 19.21 450235......... 01.0278 13.81
430064....................... 01.1062 13.30 440073.......... 01.3083 18.15 450004......... 01.1706 13.46 450112......... 01.3283 14.83 450236......... 01.1414 12.89
430066....................... 00.9328 12.75 440078.......... 01.0126 12.13 450005......... 01.2847 14.90 450113......... 01.2951 16.69 450237......... 01.5569 16.22
430073....................... 01.0259 15.30 440081.......... 01.1637 14.99 450007......... 01.2371 18.19 450118......... 01.5992 18.24 450239......... 01.0932 16.23
430076....................... 00.9397 11.72 440082.......... 02.0438 21.84 450008......... 01.3035 15.35 450119......... 01.4448 19.05 450241......... 00.9370 17.05
430077....................... 01.6490 17.05 440083.......... 01.1524 12.07 450010......... 01.3484 15.69 450121......... 01.5409 18.89 450243......... 00.9835 11.45
430079....................... 00.9894 13.32 440084.......... 01.1534 13.82 450011......... 01.5105 16.02 450123......... 01.1160 18.35 450249......... 00.9517 10.86
430081....................... 00.8564 ....... 440091.......... 01.6220 18.42 450014......... 01.0623 15.48 450124......... 01.7023 18.45 450250......... 00.9991 15.66
430082....................... 00.9185 ....... 440100.......... 01.0732 14.88 450015......... 01.6551 16.86 450126......... 01.4337 17.01 450253......... 01.1681 12.65
430083....................... 00.7926 ....... 440102.......... 01.1389 13.79 450016......... 01.5914 18.01 450128......... 01.2114 13.18 450258......... 01.0492 12.74
430084....................... 00.8631 ....... 440103.......... 01.2114 17.04 450018......... 01.4744 20.02 450130......... 01.4736 18.04 450264......... 00.8597 15.18
430085....................... 00.8586 ....... 440104.......... 01.6329 18.95 450020......... 00.9726 16.92 450131......... 01.2712 20.21 450269......... 01.0555 15.78
430087....................... 00.7737 10.24 440105.......... 01.5362 15.40 450021......... 01.8369 20.79 450132......... 01.6805 17.53 450270......... 01.2103 11.06
430089....................... 00.8702 ....... 440109.......... 01.1650 13.89 450023......... 01.4090 17.41 450133......... 01.6198 14.09 450271......... 01.2446 15.37
430090....................... 01.6368 ....... 440110.......... 01.0533 16.25 450024......... 01.3806 17.30 450135......... 01.6577 19.58 450272......... 01.3032 15.86
430091....................... 01.2774 ....... 440111.......... 01.3627 20.00 450025......... 01.4884 16.75 450137......... 01.5282 21.67 450276......... 01.0699 12.98
440001....................... 01.1359 14.55 440114.......... 01.0912 14.77 450028......... 01.5646 18.21 450140......... 00.9498 11.63 450278......... 00.9644 12.52
440002....................... 01.6162 17.64 440115.......... 01.0532 15.54 450029......... 01.5963 15.23 450143......... 00.9918 12.21 450280......... 01.5125 18.38
440003....................... 01.2559 17.39 440120.......... 01.5957 18.89 450031......... 01.4996 18.63 450144......... 01.0331 12.01 450283......... 01.0389 12.79
440006....................... 01.4841 18.92 440125.......... 01.5453 18.50 450032......... 01.3522 13.79 450145......... 00.8532 14.34 450288......... 01.1750 15.16
440007....................... 01.0194 10.84 440130.......... 01.1768 14.86 450033......... 01.6513 17.18 450146......... 01.0084 23.62 450289......... 01.4006 17.39
440008....................... 00.9915 14.52 440131.......... 01.1562 14.49 450034......... 01.6287 18.76 450147......... 01.3928 16.89 450292......... 01.1576 19.69
440009....................... 01.2565 14.35 440132.......... 01.1233 13.67 450035......... 01.4187 19.20 450148......... 01.2800 19.65 450293......... 00.9323 12.72
440010....................... 00.9659 12.64 440133.......... 01.5603 19.98 450037......... 01.6096 18.97 450149......... 01.5185 19.99 450296......... 01.4152 19.20
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 25635]]
Page 14 of 15
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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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450299....................... 01.4072 17.64 450508.......... 01.3603 17.56 450666......... 01.3312 17.90 450795......... 01.1350 11.54 470023......... 01.2895 20.23
450303....................... 01.0154 09.91 450514.......... 01.1700 21.10 450668......... 01.5943 20.06 450796......... 01.1114 18.43 470024......... 01.1727 19.52
450306....................... 01.3057 13.64 450517.......... 00.9399 10.56 450669......... 01.4186 18.58 450797......... 00.6077 20.39 490001......... 01.1946 22.18
450307....................... 00.8801 14.50 450518.......... 01.5820 18.69 450670......... 01.3482 19.53 450798......... 00.8050 13.86 490002......... 01.1337 13.48
450309....................... 01.0743 11.89 450523.......... 01.5399 20.21 450672......... 01.6957 15.51 450801......... 01.4763 15.51 490003......... 00.6057 17.48
450315....................... 01.0586 19.19 450530.......... 01.2367 14.42 450673......... 01.0679 13.71 450802......... 01.3938 21.70 490004......... 01.2252 17.71
450320....................... 01.2414 18.72 450534.......... 00.9886 15.40 450674......... 01.2022 19.92 450803......... 00.9037 14.23 490005......... 01.5926 15.95
450321....................... 00.9614 13.82 450535.......... 01.2414 21.39 450675......... 01.4594 18.09 450804......... 01.7378 18.83 490006......... 01.1499 14.40
450322....................... 00.6639 17.10 450537.......... 01.3383 20.33 450677......... 01.3331 18.92 450807......... 00.8978 09.72 490007......... 02.0606 17.85
450324....................... 01.6384 16.95 450539.......... 01.4022 16.04 450678......... 01.4407 20.79 450808......... 01.2265 20.55 490009......... 01.9210 21.78
450327....................... 01.0202 15.94 450544.......... 01.2272 18.82 450683......... 01.3459 16.70 450809......... 01.6064 11.29 490010......... 01.1786 18.22
450330....................... 01.1889 17.95 450545.......... 01.2791 10.16 450684......... 01.2082 18.70 450810......... 00.9015 ....... 490011......... 01.4566 17.62
450334....................... 01.0427 12.16 450547.......... 01.1421 14.03 450686......... 01.5023 14.59 450811......... 02.1718 ....... 490012......... 01.2121 13.77
450337....................... 01.1368 15.71 450551.......... 01.0935 11.37 450688......... 01.3506 18.63 450812......... 01.4107 ....... 490013......... 01.2228 16.47
450340....................... 01.4648 13.10 450558.......... 01.8402 18.19 450690......... 01.4263 17.85 450813......... 00.9625 ....... 490014......... 01.5159 22.68
450341....................... 01.0639 17.56 450561.......... 01.6276 17.05 450694......... 01.1099 20.41 460001......... 01.7571 20.72 490015......... 01.4427 21.35
450346....................... 01.5308 16.52 450563.......... 01.2546 26.74 450696......... 01.8786 18.73 460003......... 01.6596 13.31 490017......... 01.3665 14.05
450347....................... 01.1688 17.43 450565.......... 01.2517 16.37 450697......... 01.5484 15.64 460004......... 01.7671 21.27 490018......... 01.3418 17.01
450348....................... 01.0269 11.60 450570.......... 01.0924 15.62 450698......... 00.9596 13.36 460005......... 01.6688 17.23 490019......... 01.2321 16.49
450351....................... 01.2346 20.05 450571.......... 01.4622 16.04 450700......... 01.0540 13.52 460006......... 01.3436 19.96 490020......... 01.2247 16.07
450352....................... 01.2368 17.88 450573.......... 01.0277 13.94 450702......... 01.5379 17.73 460007......... 01.4903 20.38 490021......... 01.3831 18.08
450353....................... 01.2532 18.38 450574.......... 00.9377 11.77 450703......... 01.5073 10.03 460008......... 01.4270 16.77 490022......... 01.4805 20.25
450355....................... 01.1328 14.56 450575.......... 01.0523 17.94 450704......... 01.3187 18.39 460009......... 01.8533 20.44 490023......... 01.2675 18.77
450358....................... 02.0759 22.13 450578.......... 00.9641 14.60 450705......... 00.8680 17.81 460010......... 02.0765 21.33 490024......... 01.8219 17.17
450362....................... 01.0834 14.11 450580.......... 01.1420 14.05 450706......... 01.3743 20.77 460011......... 01.4411 15.69 490027......... 01.1416 14.52
450369....................... 01.0290 11.76 450583.......... 01.0040 11.81 450709......... 01.2530 18.28 460013......... 01.4727 18.36 490030......... 01.1740 11.44
450370....................... 01.1810 09.42 450584.......... 01.1354 12.88 450711......... 01.6382 26.65 460014......... 01.3196 16.46 490031......... 01.1290 13.85
450371....................... 01.3147 12.05 450586.......... 01.0874 12.54 450712......... 00.7382 11.77 460015......... 01.2639 19.92 490032......... 01.7735 19.88
450372....................... 01.2321 21.35 450587.......... 01.2170 17.55 450713......... 01.5244 20.73 460016......... 00.9270 16.64 490033......... 01.1962 17.39
450373....................... 01.1823 18.71 450591.......... 01.2310 17.41 450715......... 01.4406 18.46 460017......... 01.4957 17.56 490035......... 01.0236 07.57
450374....................... 00.9860 12.21 450596.......... 01.3163 18.97 450716......... 01.3997 19.33 460018......... 00.9784 16.10 490037......... 01.1888 14.88
450378....................... 01.0667 21.41 450597.......... 01.0268 13.68 450717......... 01.3232 22.11 460019......... 01.1733 16.25 490038......... 01.2703 14.98
450379....................... 01.5480 20.94 450603.......... 00.7219 14.21 450718......... 01.2781 17.49 460020......... 00.9866 17.05 490040......... 01.4415 21.70
450381....................... 01.0325 13.87 450604.......... 01.3496 14.64 450723......... 01.4075 18.75 460021......... 01.3876 20.12 490041......... 01.2682 16.01
450388....................... 01.8150 15.21 450605.......... 01.2166 16.69 450724......... 01.3091 18.28 460022......... 00.9246 18.19 490042......... 01.3042 16.38
450389....................... 01.2994 14.80 450609.......... 00.8719 12.26 450725......... 01.0043 19.85 460023......... 01.2160 20.38 490043......... 01.3803 19.82
450393....................... 01.3200 11.86 450610.......... 01.4645 18.06 450727......... 01.0811 16.87 460025......... 00.8007 20.08 490044......... 01.3514 17.17
450395....................... 01.0597 16.54 450614.......... 01.0531 12.79 450728......... 00.8837 07.46 460026......... 01.0552 17.32 490045......... 01.2228 19.98
450399....................... 00.9655 11.15 450615.......... 01.1326 12.36 450730......... 01.2614 21.03 460027......... 00.8883 20.44 490046......... 01.5215 17.89
450400....................... 01.1933 13.63 450617.......... 01.3492 19.91 450733......... 01.6021 15.09 460029......... 01.0308 17.00 490047......... 01.1505 16.65
450403....................... 01.3197 19.63 450620.......... 01.1109 12.27 450735......... 00.9833 13.78 460030......... 01.1423 16.55 490048......... 01.5931 17.94
450411....................... 00.9264 13.09 450623.......... 01.2008 18.97 450742......... 01.2757 20.17 460032......... 01.0597 19.39 490050......... 01.4805 20.95
450417....................... 01.2299 15.17 450626.......... 01.0125 16.38 450743......... 01.4277 17.77 460033......... 00.9172 17.19 490052......... 01.6347 16.26
450418....................... 01.4876 21.54 450628.......... 00.9890 17.19 450746......... 01.0074 14.71 460035......... 00.9441 12.43 490053......... 01.3129 15.12
450419....................... 01.2224 20.33 450630.......... 01.6105 19.66 450747......... 01.3436 17.58 460036......... 01.0266 20.56 490054......... 01.0153 15.45
450422....................... 00.8593 25.07 450631.......... 01.6903 13.59 450749......... 00.9909 14.54 460037......... 00.9572 18.38 490057......... 01.5481 18.87
450423....................... 01.4768 22.62 450632.......... 01.0398 11.43 450750......... 01.0134 12.54 460039......... 01.0909 23.84 490059......... 01.6281 19.99
450424....................... 01.2921 16.39 450633.......... 01.5622 12.13 450751......... 01.3102 19.24 460041......... 01.3319 20.51 490060......... 01.1169 18.19
450429....................... 01.0852 12.33 450634.......... 01.7215 23.78 450754......... 00.9192 13.20 460042......... 01.4554 14.11 490063......... 01.7955 23.28
450431....................... 01.6026 18.46 450638.......... 01.5546 25.20 450755......... 01.1391 17.26 460043......... 00.9829 21.91 490066......... 01.2905 20.77
450438....................... 01.2764 13.12 450639.......... 01.4457 23.25 450757......... 00.9009 13.23 460044......... 01.1823 20.42 490067......... 01.2750 16.60
450446....................... 00.7248 15.16 450641.......... 01.0829 17.56 450758......... 01.9407 19.90 460046......... 01.9599 17.71 490069......... 01.4205 14.56
450447....................... 01.3800 17.19 450643.......... 01.2095 15.10 450760......... 01.2017 18.55 460047......... 01.7392 19.91 490071......... 01.4266 17.71
450451....................... 01.1660 15.20 450644.......... 01.5151 18.19 450761......... 01.0213 11.87 460049......... 02.0096 19.97 490073......... 01.4914 22.82
450457....................... 01.7808 18.77 450646.......... 01.5429 20.32 450763......... 00.9975 17.58 460050......... 01.3199 19.33 490074......... 01.4074 17.39
450460....................... 01.0157 12.81 450647.......... 01.9096 20.84 450766......... 02.0886 21.59 460051......... 01.2227 13.29 490075......... 01.4408 18.79
450462....................... 01.7455 16.26 450648.......... 00.9381 12.65 450769......... 00.8730 11.77 470001......... 01.2556 20.25 490077......... 01.2421 19.03
450464....................... 01.0024 12.89 450649.......... 00.9870 14.53 450770......... 01.0213 15.47 470003......... 01.8563 19.92 490079......... 01.3591 15.64
450465....................... 01.3399 15.41 450651.......... 01.7586 19.35 450771......... 01.7967 16.42 470004......... 01.1211 15.87 490084......... 01.2514 16.34
450467....................... 00.9850 17.15 450652.......... 00.8798 14.52 450774......... 01.6108 20.17 470005......... 01.2357 21.12 490085......... 01.2505 15.31
450469....................... 01.4058 19.15 450653.......... 01.1829 16.63 450775......... 01.3187 41.14 470006......... 01.2066 17.97 490088......... 01.1793 16.50
450473....................... 01.0205 14.61 450654.......... 00.9596 10.61 450776......... 00.9848 10.16 470008......... 01.2542 17.91 490089......... 01.1277 16.41
450475....................... 01.1210 13.56 450656.......... 01.4624 18.35 450777......... 00.9836 16.72 470010......... 01.1439 19.71 490090......... 01.1658 16.31
450484....................... 01.4951 19.64 450658.......... 00.9767 12.49 450779......... 01.2890 22.50 470011......... 01.1753 20.37 490091......... 01.2201 19.80
450488....................... 01.3238 17.72 450659.......... 01.5010 21.19 450780......... 01.6074 16.21 470012......... 01.2872 18.28 490092......... 01.2429 15.01
450489....................... 01.0359 13.90 450661.......... 01.1973 21.13 450785......... 00.9638 18.31 470015......... 01.1589 19.34 490093......... 01.3892 15.78
450497....................... 01.1631 14.82 450662.......... 01.6029 16.56 450788......... 01.5172 16.06 470018......... 01.2011 20.89 490094......... 01.1193 16.40
450498....................... 00.9818 12.66 450665.......... 00.9015 13.23 450794......... 01.4587 16.66 470020......... 00.9543 16.28 490095......... 01.4744 17.31
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 25636]]
Page 15 of 15
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
490097....................... 01.2401 15.08 500055.......... 01.1102 22.34 510030......... 01.0609 15.76 520045......... 01.6699 18.60 520144......... 01.0176 16.36
490098....................... 01.2771 13.23 500057.......... 01.2911 17.73 510031......... 01.4605 16.76 520047......... 00.9944 17.42 520145......... 00.9470 16.85
490099....................... 00.9704 16.66 500058.......... 01.5107 21.64 510033......... 01.3690 16.31 520048......... 01.4624 18.04 520146......... 01.0694 15.76
490100....................... 01.5522 18.36 500059.......... 01.0873 22.72 510035......... 01.3504 18.82 520049......... 01.9631 19.12 520148......... 01.1567 16.73
490101....................... 01.2218 23.44 500060.......... 01.4688 23.67 510036......... 01.0367 12.45 520051......... 01.8043 15.77 520149......... 00.9333 12.72
490104....................... 00.8484 21.14 500061.......... 01.0054 20.43 510038......... 01.1249 14.36 520053......... 01.1564 15.87 520151......... 01.0435 16.58
490105....................... 00.5902 30.04 500062.......... 01.1028 19.07 510039......... 01.3356 15.69 520054......... 01.0412 19.44 520152......... 01.1259 17.97
490106....................... 00.8464 21.07 500064.......... 01.6849 24.85 510043......... 00.9429 14.14 520057......... 01.1771 18.10 520153......... 00.9590 14.95
490107....................... 01.3556 22.35 500065.......... 01.2258 20.87 510046......... 01.3048 17.25 520058......... 01.1268 20.40 520154......... 01.1615 18.07
490108....................... 00.9494 19.84 500068.......... 01.0622 18.61 510047......... 01.2964 18.83 520059......... 01.3542 19.76 520156......... 01.1721 19.10
490109....................... 00.9167 20.38 500069.......... 01.1722 19.05 510048......... 01.1292 18.03 520060......... 01.4225 17.08 520157......... 01.0942 15.30
490110....................... 01.3455 15.76 500071.......... 01.3952 20.91 510050......... 01.6030 16.38 520062......... 01.3120 17.21 520159......... 00.9415 19.52
490111....................... 01.2018 15.96 500072.......... 01.2463 24.49 510053......... 01.0108 14.63 520063......... 01.2008 19.95 520160......... 01.7765 19.26
490112....................... 01.6587 19.70 500073.......... 01.0093 18.07 510055......... 01.2826 22.31 520064......... 01.5671 20.70 520161......... 01.0404 17.96
490113....................... 01.2995 22.73 500074.......... 01.0970 18.46 510058......... 01.2636 17.21 520066......... 01.5292 19.84 520170......... 01.2542 21.23
490114....................... 01.1138 15.90 500077.......... 01.3337 22.82 510059......... 02.4160 15.98 520068......... 00.9889 18.59 520171......... 00.9070 14.86
490115....................... 01.1964 16.62 500079.......... 01.3407 21.42 510060......... 01.0691 15.10 520069......... 01.1861 18.14 520173......... 01.1585 19.58
490116....................... 01.1887 16.24 500080.......... 00.8399 13.35 510061......... 01.0314 13.59 520070......... 01.5734 17.44 520177......... 01.6324 19.38
490117....................... 01.1938 10.57 500084.......... 01.2536 21.57 510062......... 01.2784 17.15 520071......... 01.2420 18.44 520178......... 01.1172 16.98
490118....................... 01.7261 20.56 500085.......... 01.0506 18.46 510066......... 01.1573 13.24 520074......... 01.0372 16.81 520187......... 00.2986 ......
490119....................... 01.4062 17.02 500086.......... 01.3459 21.47 510067......... 01.1882 16.39 520075......... 01.4602 18.96 530002......... 01.2253 21.84
490120....................... 01.3763 17.93 500088.......... 01.3211 23.74 510068......... 01.1347 15.46 520076......... 01.1673 16.36 530003......... 00.8835 14.70
490122....................... 01.4040 22.46 500089.......... 01.0985 16.55 510070......... 01.3876 15.31 520077......... 00.9774 14.51 530004......... 00.9574 14.14
490123....................... 01.1230 15.45 500090.......... 00.9182 14.04 510071......... 01.3472 15.76 520078......... 01.6274 18.24 530005......... 01.0465 14.61
490124....................... 01.1222 15.81 500092.......... 00.9896 19.29 510072......... 01.0515 13.30 520082......... 01.2908 17.60 530006......... 01.1196 20.18
490126....................... 01.4055 16.47 500094.......... 00.9176 17.96 510077......... 01.1535 15.63 520083......... 01.7091 21.38 530007......... 01.1095 14.87
490127....................... 01.0287 16.05 500096.......... 01.0080 18.80 510080......... 01.2046 16.32 520084......... 01.0866 17.62 530008......... 01.2996 13.79
490129....................... 01.0607 23.65 500097.......... 01.1573 19.47 510081......... 01.1996 13.50 520087......... 01.7203 18.61 530009......... 00.9922 18.12
490130....................... 01.2347 15.72 500098.......... 01.0903 14.96 510082......... 01.2149 13.50 520088......... 01.2637 18.97 530010......... 01.2158 18.65
490132....................... 01.0026 ....... 500101.......... 00.9755 19.08 510084......... 00.9664 12.91 520089......... 01.4904 20.44 530011......... 01.1586 17.22
500001....................... 01.4111 21.97 500102.......... 00.9657 20.71 510085......... 01.3282 17.98 520090......... 01.2889 17.51 530012......... 01.5605 18.08
500002....................... 01.4114 21.64 500104.......... 01.1802 22.63 510086......... 01.1820 13.59 520091......... 01.3199 19.68 530014......... 01.4027 19.27
500003....................... 01.4119 24.03 500106.......... 00.9602 19.85 520002......... 01.2720 18.86 520092......... 01.1556 16.83 530015......... 01.2690 19.02
500005....................... 01.8033 21.24 500107.......... 01.2297 16.68 520003......... 01.0633 15.78 520094......... 00.7870 19.19 530016......... 01.2999 17.19
500007....................... 01.3070 23.24 500108.......... 01.7227 20.48 520004......... 01.1862 18.46 520095......... 01.3843 19.38 530017......... 00.8709 15.80
500008....................... 01.9296 25.09 500110.......... 01.1878 20.80 520006......... 01.0492 20.59 520096......... 01.3993 18.60 530018......... 01.0972 16.71
500011....................... 01.3263 22.98 500118.......... 01.1808 22.66 520007......... 01.0781 14.87 520097......... 01.2965 19.05 530019......... 01.0350 11.26
500012....................... 01.5418 22.34 500119.......... 01.3050 21.86 520008......... 01.6437 22.59 520098......... 01.8306 20.96 530022......... 01.1106 17.60
500014....................... 01.5358 22.94 500122.......... 01.2794 22.76 520009......... 01.6467 18.07 520100......... 01.2826 18.08 530023......... 00.8946 19.55
500015....................... 01.4382 22.41 500123.......... 00.8946 16.33 520010......... 01.2081 20.01 520101......... 01.0947 17.84 530025......... 01.2196 21.13
500016....................... 01.5256 24.13 500124.......... 01.3290 23.72 520011......... 01.2493 19.33 520102......... 01.1586 09.85 530026......... 01.1680 21.55
500019....................... 01.3845 22.33 500125.......... 01.1430 15.98 520013......... 01.3654 19.29 520103......... 01.3295 18.39 530027......... 00.9464 32.50
500021....................... 01.4791 18.72 500129.......... 01.7655 23.34 520014......... 01.1483 16.47 520107......... 01.3313 18.69 530029......... 01.0347 14.86
500023....................... 01.2237 21.48 500132.......... 00.9488 17.26 520015......... 01.1656 17.59 520109......... 00.9890 18.27 530031......... 00.8621 18.36
500024....................... 01.6929 25.17 500134.......... 00.5730 17.47 520016......... 01.1202 12.53 520110......... 01.2401 18.59 530032......... 01.0887 20.69
500025....................... 01.8624 25.48 500138.......... 06.3328 ....... 520017......... 01.1603 18.49 520111......... 00.9933 17.44
500026....................... 01.4298 24.13 500139.......... 01.4946 20.62 520018......... 01.1396 17.51 520112......... 01.1309 17.67
500027....................... 01.6083 25.89 500141.......... 01.3409 22.31 520019......... 01.3102 19.27 520113......... 01.2560 19.14
500028....................... 01.1018 17.84 500143.......... 00.5980 15.77 520021......... 01.3145 19.71 520114......... 01.1466 15.59
500029....................... 00.9778 17.28 500146.......... 01.1943 17.52 520024......... 01.1085 13.94 520115......... 01.2493 17.57
500030....................... 01.4685 23.64 510001.......... 01.8062 18.22 520025......... 01.1185 16.59 520116......... 01.2386 19.24
500031....................... 01.3076 22.42 510002.......... 01.3476 17.07 520026......... 01.0738 18.95 520117......... 01.0212 17.30
500033....................... 01.3568 20.98 510005.......... 00.9799 14.53 520027......... 01.2317 20.05 520118......... 00.8786 12.73
500036....................... 01.3789 20.93 510006.......... 01.2876 17.40 520028......... 01.4023 20.17 520120......... 00.8917 16.22
500037....................... 01.1777 20.35 510007.......... 01.5321 19.91 520029......... 00.9252 17.80 520121......... 00.9810 16.30
500039....................... 01.3856 22.97 510008.......... 01.2363 16.30 520030......... 01.6637 20.22 520122......... 01.0140 16.52
500041....................... 01.2891 24.11 510012.......... 01.0194 15.51 520031......... 01.1181 15.70 520123......... 01.0617 17.45
500042....................... 01.4113 21.93 510013.......... 01.1629 16.85 520032......... 01.1645 16.87 520124......... 01.0920 16.50
500043....................... 01.0687 19.43 510015.......... 01.0179 13.81 520033......... 01.2055 17.42 520130......... 01.0256 14.89
500044....................... 01.9209 23.59 510018.......... 01.1368 14.07 520034......... 01.0827 17.18 520131......... 01.0431 17.56
500045....................... 01.0517 22.10 510020.......... 01.0662 12.22 520035......... 01.3492 17.15 520132......... 01.1994 17.01
500048....................... 00.9665 19.03 510022.......... 01.8733 19.32 520037......... 01.6601 19.33 520134......... 01.0791 16.37
500049....................... 01.5515 22.21 510023.......... 01.2461 15.36 520038......... 01.3396 17.69 520135......... 00.9793 24.20
500050....................... 01.3757 20.94 510024.......... 01.4907 18.04 520039......... 01.0178 18.09 520136......... 01.5411 19.31
500051....................... 01.6476 24.14 510026.......... 01.0369 13.05 520040......... 01.4388 19.39 520138......... 01.8963 19.63
500052....................... 01.2052 ....... 510027.......... 00.9899 16.49 520041......... 01.1377 15.58 520139......... 01.2903 20.36
500053....................... 01.3356 21.20 510028.......... 01.1102 14.91 520042......... 01.1067 17.13 520140......... 01.6170 19.69
500054....................... 01.8578 22.51 510029.......... 01.2666 16.61 520044......... 01.4365 17.04 520142......... 00.8928 16.53
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 25637]]
Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Wage
Urban area (Constituent counties) index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.8081 0.8642
Taylor, TX
0060 Aguadilla, PR................................. 0.4772 0.6025
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 1.0011 1.0008
Portage, OH
Summit, OH
0120 Albany, GA.................................... 0.8098 0.8655
Dougherty, GA
Lee, GA
0160 \2\ Albany-Schenectady-Troy, NY............... 0.8640 0.9047
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.8813 0.9171
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.8598 0.9017
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 1.0219 1.0149
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9398 0.9584
Blair, PA
0320 Amarillo, TX.................................. 0.8483 0.8935
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.3088 1.2024
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1127 1.0759
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8731 0.9113
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.8899 0.9232
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR................................... 0.4915 0.6148
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.9016 0.9315
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.8746 0.9123
Clarke, GA
Madison, GA
Oconee, GA
0520 \1\ Atlanta, GA............................... 1.0024 1.0016
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......................... 1.0442 1.0301
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.......................... 0.9309 0.9521
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 \1\ Austin-San Marcos, TX..................... 0.8158 0.8699
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 \2\ Bakersfield, CA........................... 0.9976 0.9984
Kern, CA
0720 \1\ Baltimore, MD............................. 0.9760 0.9835
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 \2\ Bangor, ME................................ 0.8538 0.8974
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.5644 1.3586
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8940 0.9261
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8660 0.9062
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1475 1.0988
Whatcom, WA
0870 \2\ Benton Harbor, MI......................... 0.8988 0.9295
Berrien, MI
0875 \1\ Bergen-Passaic, NJ........................ 1.1845 1.1229
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 0.9220 0.9459
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8291 0.8796
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.9103 0.9377
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.9150 0.9410
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.8015 0.8594
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.9041 0.9333
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.8926 0.9251
McLean, IL
1080 Boise City, ID................................ 0.9267 0.9492
Ada, ID
Canyon, ID
1123 \1\ \2\ Boston-Worcester-Lawrence-Lowell-
Brockton, MA-NH (Massachusetts Hospitals).......... 1.0917 1.0619
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1123 \1\ Boston-Worcester-Lawrence-Lowell-Brockton,
MA-NH (New Hampshire Hospitals).................... 1.0885 1.0598
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.......................... 1.0122 1.0083
Boulder, CO
1145 Brazoria, TX.................................. 0.8895 0.9229
Brazoria, TX
1150 Bremerton, WA................................. 1.1148 1.0773
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.8291 0.8796
Cameron, TX
1260 Bryan-College Station, TX..................... 0.7962 0.8555
[[Page 25638]]
Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY................. 0.9592 0.9719
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 0.9612 0.9733
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4445 0.5739
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.......................... 0.8895 0.9229
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.9227 0.9464
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.8888 0.9224
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.8844 0.9193
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8931 0.9255
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9042 0.9334
Kanawha, WV
Putnam, WV
1520 \1\ Charlotte-Gastonia-Rock Hill, NC-SC....... 0.9568 0.9702
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 1.0359 1.0244
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.9123 0.9391
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY.................................. 0.9354 0.9553
Laramie, WY
1600 \1\ Chicago, IL............................... 1.0507 1.0344
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0231 1.0158
Butte, CA
1640 \1\ Cincinnati, OH-KY-IN...................... 0.9465 0.9630
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............... 0.8204 0.8732
Christian, KY
Montgomery, TN
1680 \1\ Cleveland-Lorain-Elyria, OH............... 0.9970 0.9979
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9469 0.9633
El Paso, CO
1740 Columbia, MO.................................. 0.9678 0.9778
Boone, MO
1760 Columbia, SC.................................. 0.9368 0.9563
Lexington, SC
Richland, SC
1800 Columbus, GA-AL............................... 0.8573 0.8999
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 \1\ Columbus, OH.............................. 0.9929 0.9951
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8112 0.8665
Nueces, TX
San Patricio, TX
1900 \2\ Cumberland, MD-WV (Maryland Hospitals).... 0.8627 0.9038
Allegany, MD
Mineral, WV
1900 Cumberland, MD-WV (West Virginia Hospital).... 0.8407 0.8880
Allegany, MD
Mineral, WV
1920 \1\ Dallas, TX................................ 0.9149 0.9409
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.9121 0.9389
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8496 0.8944
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9670 0.9773
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL............................. 0.9211 0.9453
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8302 0.8804
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.8140 0.8686
Macon, IL
2080 \1\ Denver, CO................................ 1.0532 1.0361
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8576 0.9001
Dallas, IA
Polk, IA
Warren, IA
2160 \1\ Detroit, MI............................... 1.0601 1.0408
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7827 0.8455
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.9441 0.9614
Kent, DE
2200 Dubuque, IA................................... 0.8292 0.8796
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 1.0133 1.0091
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 0.9860 0.9904
Dutchess, NY
2290 Eau Claire, WI................................ 0.8755 0.9130
Chippewa, WI
[[Page 25639]]
Eau Claire, WI
2320 El Paso, TX................................... 0.8978 0.9288
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.9168 0.9422
Elkhart, IN
2335 \2\ Elmira, NY................................ 0.8640 0.9047
Chemung, NY
2340 Enid, OK...................................... 0.8050 0.8620
Garfield, OK
2360 Erie, PA...................................... 0.9343 0.9545
Erie, PA
2400 Eugene-Springfield, OR........................ 1.1288 1.0865
Lane, OR
2440 Evansville-Henderson, IN-KY................... 0.8505 0.8950
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN (North Dakota Hospitals) 0.7905 0.8513
Clay, MN
Cass, ND
2520 \2\ Fargo-Moorhead, ND-MN (Minnesota
Hospitals)......................................... 0.8665 0.9065
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.8460 0.8918
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.8686 0.9080
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 0.9602 0.9726
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1106 1.0745
Genesee, MI
2650 Florence, AL.................................. 0.7740 0.8391
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8368 0.8851
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0383 1.0261
Larimer, CO
2680 \1\ Ft. Lauderdale, FL........................ 1.0534 1.0363
Broward, FL
2700 Fort Myers-Cape Coral, FL..................... 0.9017 0.9316
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 0.9847 0.9895
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7687 0.8352
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 \2\ Fort Walton Beach, FL..................... 0.8947 0.9266
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.8896 0.9230
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 \1\ Forth Worth-Arlington, TX................. 0.9192 0.9439
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.0491 1.0334
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8854 0.9200
Etowah, AL
2900 Gainesville, FL............................... 0.9542 0.9684
Alachua, FL
2920 Galveston-Texas City, TX...................... 0.9549 0.9689
Galveston, TX
2960 Gary, IN...................................... 0.9542 0.9684
Lake, IN
Porter, IN
2975 \2\ Glens Falls, NY........................... 0.8640 0.9047
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8523 0.8963
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.8996 0.9301
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.9110 0.9382
Mesa, CO
3000 \1\ Grand Rapids-Muskegon-Holland, MI......... 1.0018 1.0012
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 0.9362 0.9559
Cascade, MT
3060 Greeley, CO................................... 0.9856 0.9901
Weld, CO
3080 Green Bay, WI................................. 0.9323 0.9531
Brown, WI
3120 \1\ Greensboro-Winston-Salem-High Point, NC... 0.9418 0.9598
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9034 0.9328
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.9318 0.9528
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................ 1.0268 1.0183
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.9292 0.9510
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 0.9572 0.9705
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 \1\ \2\ Hartford, CT.......................... 1.2175 1.1443
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 \2\ Hattiesburg, MS........................... 0.7359 0.8106
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.8687 0.9081
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1628 1.1088
Honolulu, HI
3350 Houma, LA..................................... 0.8266 0.8777
Lafourche, LA
Terrebonne, LA
3360 \1\ Houston, TX............................... 1.0017 1.0012
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9728 0.9813
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8428 0.8895
Limestone, AL
Madison, AL
3480 \1\ Indianapolis, IN.......................... 0.9901 0.9932
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9561 0.9697
Johnson, IA
3520 Jackson, MI................................... 0.9302 0.9517
Jackson, MI
[[Page 25640]]
3560 Jackson, MS................................... 0.8279 0.8787
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.8632 0.9042
Madison, TN
Chester, TN
3600 \1\ \2\ Jacksonville, FL...................... 0.8947 0.9266
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 \2\ Jacksonville, NC.......................... 0.8162 0.8702
Onslow, NC
3610 \2\ Jamestown, NY............................. 0.8640 0.9047
Chautauqua, NY
3620 Janesville-Beloit, WI......................... 0.9128 0.9394
Rock, WI
3640 Jersey City, NJ............................... 1.1372 1.0920
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8847 0.9195
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA................................. 0.8671 0.9070
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.7643 0.8319
Craighead, AR
3710 Joplin, MO.................................... 0.7933 0.8534
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.2009 1.1336
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.9175 0.9427
Kankakee, IL
3760 \1\ Kansas City, KS-MO........................ 0.9672 0.9774
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................................... 0.9206 0.9449
Kenosha, WI
3810 Killeen-Temple, TX............................ 1.0180 1.0123
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.8569 0.8996
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.9350 0.9550
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.8989 0.9296
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8363 0.8848
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.8984 0.9293
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.7738 0.8389
Calcasieu, LA
3980 Lakeland-Winter Haven, FL..................... 0.8947 0.9266
Polk, FL
4000 Lancaster, PA................................. 0.9646 0.9756
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 1.0130 1.0089
Clinton, MI
Eaton, MI
Ingham, MI
4080 \2\ Laredo, TX................................ 0.7404 0.8140
Webb, TX
4100 Las Cruces, NM................................ 0.9045 0.9336
Dona Ana, NM
4120 \1\ Las Vegas, NV-AZ.......................... 1.1349 1.0905
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8728 0.9110
Douglas, KS
4200 Lawton, OK.................................... 0.8770 0.9140
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.9226 0.9463
Androscoggin, ME
4280 Lexington, KY................................. 0.8579 0.9004
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.8885 0.9222
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9082 0.9362
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8598 0.9017
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8583 0.9007
Gregg, TX
Harrison, TX
Upshur, TX
4480 \1\ Los Angeles-Long Beach, CA................ 1.2124 1.1410
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9212 0.9453
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8460 0.8918
Lubbock, TX
4640 Lynchburg, VA................................. 0.8680 0.9076
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.9109 0.9381
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0103 1.0070
Dane, WI
4800 Mansfield, OH................................. 0.8606 0.9023
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4360 0.5664
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8541 0.8976
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0109 1.0075
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9289 0.9507
Brevard, Fl
4920 \1\ Memphis, TN-AR-MS......................... 0.8423 0.8891
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 1.0304 1.0207
Merced, CA
5000 \1\ Miami, FL................................. 0.9427 0.9604
Dade, FL
5015 \1\ Middlesex-Somerset-Hunterdon, NJ.......... 1.0871 1.0589
[[Page 25641]]
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 \1\ Milwaukee-Waukesha, WI.................... 0.9470 0.9634
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 \1\ Minneapolis-St. Paul, MN-WI............... 1.0956 1.0645
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.................................... 0.7942 0.8540
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0406 1.0276
Stanislaus, CA
5190 \1\ Monmouth-Ocean, NJ........................ 1.1285 1.0863
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8288 0.8793
Ouachita, LA
5240 Montgomery, AL................................ 0.7919 0.8523
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 0.9493 0.9650
Delaware, IN
5330 \2\ Myrtle Beach, SC.......................... 0.8110 0.8664
Horry, SC
5345 Naples, FL.................................... 1.0205 1.0140
Collier, FL
5360 \1\ Nashville, TN............................. 0.9336 0.9540
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 \1\ Nassau-Suffolk, NY........................ 1.3123 1.2046
Nassau, NY
Suffolk, NY
5483 \1\ \2\ New Haven-Bridgeport-Stamford-
Waterbury-Danbury, CT.............................. 1.2175 1.1443
Fairfield, CT
New Haven, CT
5523 \2\ New London-Norwich, CT.................... 1.2175 1.1443
New London, CT
5560 \1\ New Orleans, LA........................... 0.9397 0.9583
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 \1\ New York, NY.............................. 1.4537 1.2920
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 \1\ Newark, NJ................................ 1.0899 1.0607
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.1226 1.0824
Orange, NY
Pike, PA
5720 \1\ Norfolk-Virginia Beach-Newport News, VA-NC 0.8235 0.8755
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 \1\ Oakland, CA............................... 1.5309 1.3386
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9229 0.9465
Marion, FL
5800 Odessa-Midland, TX............................ 0.7773 0.8415
Ector, TX
Midland, TX
5880 \1\ Oklahoma City, OK......................... 0.8764 0.9136
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.1605 1.1073
Thurston, WA
5920 Omaha, NE-IA.................................. 0.9938 0.9958
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 \1\ Orange County, CA......................... 1.1153 1.0776
Orange, CA
5960 \1\ Orlando, FL............................... 0.9933 0.9954
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 \2\ Owensboro, KY............................. 0.7902 0.8511
Daviess, KY
6015 \2\ Panama City, FL........................... 0.8947 0.9266
Bay, FL
6020 Parkersburg-Marietta, WV-OH (West Virginia
Hospitals)......................................... 0.8118 0.8669
Washington, OH
Wood, WV
6020 \2\ Parkersburg-Marietta, WV-OH (Ohio
Hospitals)......................................... 0.8576 0.9001
Washington, OH
Wood, WV
6080 \2\ Pensacola, FL............................. 0.8947 0.9266
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8157 0.8698
Peoria, IL
Tazewell, IL
Woodford, IL
6160 \1\ Philadelphia, PA-NJ....................... 1.1427 1.0957
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 \1\ Phoenix-Mesa, AZ.......................... 0.9759 0.9834
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.8003 0.8585
Jefferson, AR
6280 \1\ Pittsburgh, PA............................ 0.9896 0.9929
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 \2\ Pittsfield, MA............................ 1.0917 1.0619
Berkshire, MA
6340 Pocatello, ID................................. 0.8760 0.9133
[[Page 25642]]
Bannock, ID
6360 Ponce, PR..................................... 0.4740 0.5998
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9537 0.9681
Cumberland, ME
Sagadahoc, ME
York, ME
6440 \1\ Portland-Vancouver, OR-WA................. 1.1274 1.0856
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 \1\ Providence-Warwick-Pawtucket, RI.......... 1.0888 1.0600
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 0.9910 0.9938
Utah, UT
6560 Pueblo, CO.................................... 0.8785 0.9151
Pueblo, CO
6580 Punta Gorda, FL............................... 0.8994 0.9300
Charlotte, FL
6600 Racine, WI.................................... 0.9207 0.9450
Racine, WI
6640 \1\ Raleigh-Durham-Chapel Hill, NC............ 0.9909 0.9938
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8277 0.8785
Pennington, SD
6680 Reading, PA................................... 0.9282 0.9503
Berks, PA
6690 Redding, CA................................... 1.2017 1.1341
Shasta, CA
6720 Reno, NV...................................... 1.0169 1.0115
Washoe, NV
6740 \2\ Richland-Kennewick-Pasco, WA.............. 1.0577 1.0392
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9257 0.9485
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 \1\ Riverside-San Bernardino, CA.............. 1.0151 1.0103
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8581 0.9005
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.1797 1.1198
Olmsted, MN
6840 \1\ Rochester, NY............................. 0.9678 0.9778
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.8703 0.9093
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.8214 0.8740
Edgecombe, NC
Nash, NC
6920 \1\ Sacramento, CA............................ 1.1952 1.1299
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9567 0.9701
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9667 0.9771
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.9972 0.9981
Andrew, MO
Buchanan, MO
7040 \1\ St. Louis, MO-IL.......................... 0.9063 0.9348
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..................................... 0.9987 0.9991
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.5270 1.3363
Monterey, CA
7160 \1\ Salt Lake City-Ogden, UT.................. 0.9458 0.9626
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7512 0.8221
Tom Green, TX
7240 \1\ San Antonio, TX........................... 0.7744 0.8394
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 \1\ San Diego, CA............................. 1.2388 1.1579
San Diego, CA
7360 \1\ San Francisco, CA......................... 1.3621 1.2357
Marin, CA
San Francisco, CA
San Mateo, CA
7400 \1\ San Jose, CA.............................. 1.3783 1.2457
Santa Clara, CA
7440 \1\ San Juan-Bayamon, PR...................... 0.4521 0.5806
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.... 1.0825 1.0558
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.1233 1.0829
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.4099 1.2652
Santa Cruz, CA
7490 Santa Fe, NM.................................. 0.9525 0.9672
[[Page 25643]]
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................ 1.3167 1.2073
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9567 0.9701
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.8776 0.9145
Bryan, GA
Chatham, GA
Effingham, GA
7560 \2\ Scranton-Wilkes-Barre-Hazleton, PA........ 0.8615 0.9029
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 \1\ Seattle-Bellevue-Everett, WA.............. 1.1634 1.1092
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.................................... 0.8948 0.9267
Mercer, PA
7620 \2\ Sheboygan, WI............................. 0.8557 0.8988
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.8229 0.8750
Grayson, TX
7680 Shreveport-Bossier City, LA................... 0.9436 0.9610
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8530 0.8968
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.8988 0.9295
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9939 0.9958
St. Joseph, IN
7840 Spokane, WA................................... 1.1020 1.0688
Spokane, WA
7880 Springfield, IL............................... 0.8793 0.9157
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.8151 0.8694
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA............................... 1.0917 1.0619
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9528 0.9674
Centre, PA
8080 \2\ Steubenville-Weirton, OH-WV (Ohio
Hospitals)......................................... 0.8576 0.9001
Jefferson, OH
Brooke, WV
Hancock, WV
8080 Steubenville-Weirton, OH-WV (West Virginia
Hospitals)......................................... 0.8476 0.8929
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.1157 1.0779
San Joaquin, CA
8140 Sumter, SC.................................... 0.8195 0.8726
Sumter, SC
8160 Syracuse, NY.................................. 0.9410 0.9592
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 \2\ Tacoma, WA................................ 1.0577 1.0392
Pierce, WA
8240 \2\ Tallahassee, FL........................... 0.8947 0.9266
Gadsden, FL
Leon, FL
8280 \1\ Tampa-St. Petersburg-Clearwater, FL....... 0.9179 0.9430
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.9063 0.9348
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.7538 0.8240
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 1.0132 1.0090
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 0.9894 0.9927
Shawnee, KS
8480 Trenton, NJ................................... 1.0399 1.0272
Mercer, NJ
8520 Tucson, AZ.................................... 0.9104 0.9377
Pima, AZ
8560 Tulsa, OK..................................... 0.8520 0.8961
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.7706 0.8366
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.8792 0.9156
Smith, TX
8680 \2\ Utica-Rome, NY............................ 0.8640 0.9047
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.3458 1.2255
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.0764 1.0517
Ventura, CA
8750 Victoria, TX.................................. 0.8451 0.8911
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0460 1.0313
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 1.0168 1.0115
Tulare, CA
8800 Waco, TX...................................... 0.8027 0.8603
McLennan, TX
8840 \1\ Washington, DC-MD-VA-WV................... 1.0863 1.0583
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...................... 0.8402 0.8876
Black Hawk, IA
8940 Wausau, WI.................................... 0.9814 0.9872
Marathon, WI
8960 West Palm Beach-Boca Raton, FL................ 1.0288 1.0196
Palm Beach, FL
9000 \2\ Wheeling, WV-OH (West Virginia Hospitals). 0.7938 0.8537
Belmont, OH
Marshall, WV
Ohio, WV
9000 \2\ Wheeling, WV-OH (Ohio Hospitals).......... 0.8576 0.9001
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.8990 0.9297
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.7864 0.8483
Archer, TX
Wichita, TX
[[Page 25644]]
9140 \2\ Williamsport, PA.......................... 0.8615 0.9029
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1968 1.1309
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9427 0.9604
New Hanover, NC
Brunswick, NC
9260 \2\ Yakima, WA................................ 1.0577 1.0392
Yakima, WA
9270 Yolo, CA...................................... 1.0702 1.0476
Yolo, CA
9280 York, PA...................................... 0.9509 0.9661
York, PA
9320 Youngstown-Warren, OH......................... 0.9897 0.9929
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0957 1.0646
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 1.0143 1.0098
Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area
\2\ Hospitals geographically located in the area are assigned the
statewide rural wage index for FY 1999.
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7385 0.8125
Alaska.............................................. 1.2534 1.1673
Arizona............................................. 0.8082 0.8643
Arkansas............................................ 0.7274 0.8042
California.......................................... 0.9976 0.9984
Colorado............................................ 0.8454 0.8914
Connecticut......................................... 1.2175 1.1443
Delaware............................................ 0.8590 0.9012
Florida............................................. 0.8947 0.9266
Georgia............................................. 0.7933 0.8534
Hawaii.............................................. 1.1011 1.0682
Idaho............................................... 0.8548 0.8981
Illinois............................................ 0.7985 0.8572
Indiana............................................. 0.8429 0.8896
Iowa................................................ 0.7846 0.8469
Kansas.............................................. 0.7334 0.8087
Kentucky............................................ 0.7902 0.8511
Louisiana........................................... 0.7517 0.8225
Maine............................................... 0.8538 0.8974
Maryland............................................ 0.8627 0.9038
Massachusetts....................................... 1.0917 1.0619
Michigan............................................ 0.8988 0.9295
Minnesota........................................... 0.8665 0.9065
Mississippi......................................... 0.7359 0.8106
Missouri............................................ 0.7510 0.8219
Montana............................................. 0.8645 0.9051
Nebraska............................................ 0.7683 0.8349
Nevada.............................................. 0.9267 0.9492
New Hampshire....................................... 1.0324 1.0221
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.7927 0.8529
New York............................................ 0.8640 0.9047
North Carolina...................................... 0.8162 0.8702
North Dakota........................................ 0.7471 0.8190
Ohio................................................ 0.8576 0.9001
Oklahoma............................................ 0.7207 0.7991
Oregon.............................................. 0.9957 0.9971
Pennsylvania........................................ 0.8615 0.9029
Puerto Rico......................................... 0.4083 0.5415
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.8110 0.8664
South Dakota........................................ 0.7564 0.8260
Tennessee........................................... 0.7483 0.8199
Texas............................................... 0.7404 0.8140
Utah................................................ 0.8851 0.9198
Vermont............................................. 0.9489 0.9647
Virginia............................................ 0.7890 0.8502
Washington.......................................... 1.0577 1.0392
West Virginia....................................... 0.7938 0.8537
Wisconsin........................................... 0.8557 0.8988
Wyoming............................................. 0.8763 0.9135
------------------------------------------------------------------------
All counties within the State are classified as urban.
Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That Are Reclassified
------------------------------------------------------------------------
Wage
Area index GAF
------------------------------------------------------------------------
Abilene, TX......................................... 0.8081 0.8642
Albany, GA.......................................... 0.7933 0.8534
Albuquerque, NM..................................... 0.8813 0.9171
Alexandria, LA...................................... 0.8598 0.9017
Allentown-Bethlehem-Easton, PA...................... 1.0219 1.0149
Amarillo, TX........................................ 0.8483 0.8935
Anchorage, AK....................................... 1.3088 1.2024
Asheville, NC....................................... 0.9016 0.9315
Atlanta, GA......................................... 1.0024 1.0016
Augusta-Aiken, GA-SC................................ 0.9309 0.9521
Baltimore, MD....................................... 0.9760 0.9835
Barnstable-Yarmouth, MA............................. 1.4646 1.2986
Baton Rouge, LA..................................... 0.8940 0.9261
Benton Harbor, MI................................... 0.8988 0.9295
Bergen-Passaic, NJ.................................. 1.1845 1.1229
Billings, MT........................................ 0.9220 0.9459
Binghamton, NY...................................... 0.8989 0.9296
Birmingham, AL...................................... 0.9150 0.9410
Bismarck, ND........................................ 0.7838 0.8464
Boise City, ID...................................... 0.9267 0.9492
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.0885 1.0598
Brazoria, TX........................................ 0.8895 0.9229
Bryan-College Station, TX........................... 0.7962 0.8555
Buffalo-Niagara Falls, NY........................... 0.9592 0.9719
Burlington, VT...................................... 0.9612 0.9733
Caguas, PR.......................................... 0.4445 0.5739
Canton-Massillon, OH................................ 0.8895 0.9229
Casper, WY.......................................... 0.9227 0.9464
Champaign-Urbana, IL................................ 0.8844 0.9193
Charleston-North Charleston, SC..................... 0.8931 0.9255
Charleston, WV...................................... 0.8819 0.9175
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9568 0.9702
Charlottesville, VA................................. 0.9803 0.9865
Chattanooga, TN-GA.................................. 0.8885 0.9222
Chicago, IL......................................... 1.0507 1.0344
Cincinnati, OH-KY-IN................................ 0.9465 0.9630
Clarksville-Hopkinsville, TN-KY..................... 0.8204 0.8732
Cleveland-Lorain-Elyria, OH......................... 0.9970 0.9979
Columbia, MO........................................ 0.9331 0.9537
Columbus, GA-AL..................................... 0.8573 0.8999
Columbus, OH........................................ 0.9929 0.9951
Corpus Christi, TX.................................. 0.8112 0.8665
Dallas, TX.......................................... 0.9149 0.9409
Danville, VA........................................ 0.8779 0.9147
Davenport-Moline-Rock Island, IA-IL................. 0.8496 0.8944
Dayton-Springfield, OH.............................. 0.9670 0.9773
Denver, CO.......................................... 1.0532 1.0361
Des Moines, IA...................................... 0.8576 0.9001
Duluth-Superior, MN-WI.............................. 1.0133 1.0091
Dutchess County, NY................................. 0.9860 0.9904
Elkhart-Goshen, IN.................................. 0.9168 0.9422
Eugene-Springfield, OR.............................. 1.1141 1.0768
Evansville-Henderson, IN-KY......................... 0.8505 0.8950
Fargo-Moorhead, ND-MN (Minnesota Hospital).......... 0.8665 0.9065
Fargo-Moorhead, ND-MN (South Dakota Hospital)....... 0.7905 0.8513
Fayetteville, NC.................................... 0.8460 0.8918
Flagstaff, AZ-UT.................................... 0.9602 0.9726
Flint, MI........................................... 1.1106 1.0745
Fort Collins-Loveland, CO........................... 1.0383 1.0261
Ft. Lauderdale, FL.................................. 1.0534 1.0363
Fort Pierce-Port St. Lucie, FL...................... 0.9847 0.9895
Fort Smith, AR-OK................................... 0.7582 0.8273
Fort Walton Beach, FL............................... 0.8694 0.9086
Forth Worth-Arlington, TX........................... 0.9192 0.9439
Gadsden, AL......................................... 0.8854 0.9200
Gainesville, FL..................................... 0.9542 0.9684
Goldsboro, NC....................................... 0.8366 0.8850
Grand Forks, ND-MN.................................. 0.8996 0.9301
Grand Junction, CO.................................. 0.9110 0.9382
Grand Rapids-Muskegon-Holland, MI................... 0.9908 0.9937
Great Falls, MT..................................... 0.9362 0.9559
Greeley, CO......................................... 0.9663 0.9768
Green Bay, WI....................................... 0.9323 0.9531
Greenville, NC...................................... 0.8844 0.9193
Greenville-Spartanburg-Anderson, SC................. 0.9318 0.9528
Harrisburg-Lebanon-Carlisle, PA..................... 0.9572 0.9705
[[Page 25645]]
Hartford, CT........................................ 1.1152 1.0775
Hattiesburg, MS..................................... 0.7359 0.8106
Hickory-Morganton-Lenoir, NC........................ 0.8687 0.9081
Honolulu, HI........................................ 1.1628 1.1088
Houston, TX......................................... 1.0017 1.0012
Huntington-Ashland, WV-KY-OH........................ 0.9353 0.9552
Huntsville, AL...................................... 0.8269 0.8780
Indianapolis, IN.................................... 0.9901 0.9932
Iowa City, IA....................................... 0.9441 0.9614
Jackson, MS......................................... 0.8279 0.8787
Jackson, TN......................................... 0.8632 0.9042
Jacksonville, FL.................................... 0.8915 0.9244
Johnson City-Kingsport-Bristol, TN-VA............... 0.8847 0.9195
Jonesboro, AR....................................... 0.7643 0.8319
Joplin, MO.......................................... 0.7710 0.8369
Kalamazoo-Battlecreek, MI........................... 1.1713 1.1144
Kansas City, KS-MO.................................. 0.9672 0.9774
Knoxville, TN....................................... 0.8569 0.8996
Lafayette, LA....................................... 0.8363 0.8848
Lansing-East Lansing, MI............................ 1.0025 1.0017
Las Cruces, NM...................................... 0.9045 0.9336
Las Vegas, NV-AZ.................................... 1.1349 1.0905
Lexington, KY....................................... 0.8579 0.9004
Lima, OH............................................ 0.8715 0.9101
Lincoln, NE......................................... 0.8900 0.9233
Little Rock-North Little Rock, AR................... 0.8598 0.9017
Los Angeles-Long Beach, CA.......................... 1.2124 1.1410
Louisville, KY-IN................................... 0.9212 0.9453
Macon, GA........................................... 0.8886 0.9223
Madison, WI......................................... 1.0103 1.0070
Mansfield, OH....................................... 0.8606 0.9023
Memphis, TN-AR-MS................................... 0.8423 0.8891
Merced, CA.......................................... 1.0304 1.0207
Milwaukee-Waukesha, WI.............................. 0.9289 0.9507
Minneapolis-St. Paul, MN-WI......................... 1.0956 1.0645
Modesto, CA......................................... 1.0406 1.0276
Monroe, LA.......................................... 0.8148 0.8691
Montgomery, AL...................................... 0.7919 0.8523
Myrtle Beach, SC.................................... 0.8162 0.8702
Nashville, TN....................................... 0.9336 0.9540
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2175 1.1443
New London-Norwich, CT.............................. 1.1738 1.1160
New Orleans, LA..................................... 0.9397 0.9583
New York, NY........................................ 1.4537 1.2920
Newark, NJ.......................................... 1.0899 1.0607
Newburgh, NY-PA..................................... 1.1356 1.0910
Oakland, CA......................................... 1.5309 1.3386
Odessa-Midland, TX.................................. 0.7773 0.8415
Oklahoma City, OK................................... 0.8764 0.9136
Omaha, NE-IA........................................ 0.9938 0.9958
Orange County, CA................................... 1.1153 1.0776
Orlando, FL......................................... 0.9933 0.9954
Peoria-Pekin, IL.................................... 0.8157 0.8698
Philadelphia, PA-NJ................................. 1.1427 1.0957
Pittsburgh, PA...................................... 0.9740 0.9821
Pocatello, ID (Idaho Hospital)...................... 0.8760 0.9133
Pocatello, ID (Wyoming Hospitals)................... 0.8763 0.9135
Portland, ME........................................ 0.9537 0.9681
Portland-Vancouver, OR-WA........................... 1.1274 1.0856
Provo-Orem, UT...................................... 0.9910 0.9938
Raleigh-Durham-Chapel Hill, NC...................... 0.9909 0.9938
Rapid City, SD...................................... 0.8277 0.8785
Reno, NV............................................ 1.0169 1.0115
Rochester, MN....................................... 1.1797 1.1198
Rockford, IL........................................ 0.8703 0.9093
Sacramento, CA...................................... 1.1952 1.1299
Saginaw-Bay City-Midland, MI........................ 0.9567 0.9701
St. Cloud, MN....................................... 0.9667 0.9771
St. Louis, MO-IL.................................... 0.9063 0.9348
Salt Lake City-Ogden, UT............................ 0.9458 0.9626
San Diego, CA....................................... 1.2388 1.1579
Santa Fe, NM........................................ 0.9414 0.9595
Santa Rosa, CA...................................... 1.3003 1.1970
Seattle-Bellevue-Everett, WA........................ 1.1634 1.1092
Sharon, PA.......................................... 0.8835 0.9187
Sherman-Denison, TX................................. 0.8061 0.8628
Sioux City, IA-NE................................... 0.8530 0.8968
Sioux Falls, SD..................................... 0.8885 0.9222
South Bend, IN...................................... 0.9939 0.9958
Spokane, WA......................................... 1.0819 1.0554
Springfield, IL..................................... 0.8793 0.9157
Springfield, MO..................................... 0.8151 0.8694
State College, PA................................... 0.8845 0.9194
Syracuse, NY........................................ 0.9410 0.9592
Tallahassee, FL..................................... 0.8566 0.8994
Tampa-St. Petersburg-Clearwater, FL................. 0.9179 0.9430
Texarkana, AR-Texarkana, TX......................... 0.7538 0.8240
Topeka, KS.......................................... 0.9667 0.9771
Tucson, AZ.......................................... 0.9104 0.9377
Tulsa, OK........................................... 0.8418 0.8888
Tuscaloosa, AL...................................... 0.7706 0.8366
Tyler, TX........................................... 0.8792 0.9156
Vallejo-Fairfield-Napa, CA.......................... 1.3458 1.2255
Victoria, TX........................................ 0.8451 0.8911
Washington, DC-MD-VA-WV............................. 1.0863 1.0583
Waterloo-Cedar Falls, IA............................ 0.8402 0.8876
Wausau, WI.......................................... 0.9501 0.9656
Wichita, KS......................................... 0.8853 0.9200
Wichita Falls, TX................................... 0.7695 0.8357
Rural Alabama....................................... 0.7385 0.8125
Rural Illinois...................................... 0.7985 0.8572
Rural Louisiana..................................... 0.7517 0.8225
Rural Massachusetts................................. 1.0481 1.0327
Rural Michigan...................................... 0.8988 0.9295
Rural Minnesota..................................... 0.8665 0.9065
Rural Missouri...................................... 0.7510 0.8219
Rural Nevada........................................ 0.8855 0.9201
Rural New Mexico.................................... 0.7927 0.8529
Rural Oregon........................................ 0.9957 0.9971
Rural Washington.................................... 1.0577 1.0392
Rural Wyoming....................................... 0.8763 0.9135
------------------------------------------------------------------------
Table 4D.--Average Hourly Wage For Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 16.4503
Aguadilla, PR................................................ 9.8326
Akron, OH.................................................... 20.5582
Albany, GA................................................... 16.6839
Albany-Schenectady-Troy, NY.................................. 17.3615
Albuquerque, NM.............................................. 18.1579
Alexandria, LA............................................... 17.7146
Allentown-Bethlehem-Easton, PA............................... 21.0540
Altoona, PA.................................................. 19.3623
Amarillo, TX................................................. 17.4756
Anchorage, AK................................................ 26.6324
Ann Arbor, MI................................................ 22.9259
Anniston, AL................................................. 17.9884
Appleton-Oshkosh-Neenah, WI.................................. 18.3354
Arecibo, PR.................................................. 10.1277
Asheville, NC................................................ 18.5755
Athens, GA................................................... 18.0203
Atlanta, GA.................................................. 20.6523
Atlantic-Cape May, NJ........................................ 23.3952
Augusta-Aiken, GA-SC......................................... 19.1799
Austin-San Marcos, TX........................................ 16.8088
Bakersfield, CA.............................................. 18.4123
Baltimore, MD................................................ 20.1089
Bangor, ME................................................... 16.5207
Barnstable-Yarmouth, MA...................................... 32.2329
Baton Rouge, LA.............................................. 18.4192
Beaumont-Port Arthur, TX..................................... 17.8430
Bellingham, WA............................................... 23.6418
Benton Harbor, MI............................................ 17.7241
Bergen-Passaic, NJ........................................... 25.1292
Billings, MT................................................. 18.9960
Biloxi-Gulfport-Pascagoula, MS............................... 17.0828
Binghamton, NY............................................... 18.7554
Birmingham, AL............................................... 18.8514
Bismarck, ND................................................. 16.5132
Bloomington,IN............................................... 18.6271
Bloomington-Normal, IL....................................... 18.3900
Boise City, ID............................................... 19.0323
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.3344
Boulder-Longmont, CO......................................... 20.8550
Brazoria, TX................................................. 18.3273
Bremerton, WA................................................ 22.9686
Brownsville-Harlingen-San Benito, TX......................... 17.0823
Bryan-College Station, TX.................................... 16.3918
Buffalo-Niagara Falls, NY.................................... 19.7621
Burlington, VT............................................... 19.7504
Caguas, PR................................................... 9.1371
Canton-Massillon, OH......................................... 18.3270
Casper, WY................................................... 18.0774
Cedar Rapids, IA............................................. 18.3134
Champaign-Urbana, IL......................................... 18.1242
Charleston-North Charleston, SC.............................. 18.4009
Charleston, WV............................................... 18.6306
[[Page 25646]]
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 19.7132
Charlottesville, VA.......................................... 21.3425
Chattanooga, TN-GA........................................... 18.7967
Cheyenne, WY................................................. 19.2719
Chicago, IL.................................................. 21.6476
Chico-Paradise, CA........................................... 21.0787
Cincinnati, OH-KY-IN......................................... 19.5020
Clarksville-Hopkinsville, TN-KY.............................. 16.6908
Cleveland-Lorain-Elyria, OH.................................. 20.5422
Colorado Springs, CO......................................... 19.5098
Columbia, MO................................................. 19.9392
Columbia, SC................................................. 19.3016
Columbus, GA-AL.............................................. 17.6626
Columbus, OH................................................. 20.4569
Corpus Christi, TX........................................... 16.6221
Cumberland, MD-WV............................................ 17.3219
Dallas, TX................................................... 18.9048
Danville, VA................................................. 18.7936
Davenport-Moline-Rock Island, IA-IL.......................... 17.5045
Dayton-Springfield, OH....................................... 19.9239
Daytona Beach, FL............................................ 18.9775
Decatur, AL.................................................. 17.1051
Decatur, IL.................................................. 16.7703
Denver, CO................................................... 21.6957
Des Moines, IA............................................... 17.5941
Detroit, MI.................................................. 21.8417
Dothan, AL................................................... 16.1254
Dover, DE.................................................... 19.4527
Dubuque, IA.................................................. 17.0843
Duluth-Superior, MN-WI....................................... 20.7877
Dutchess County, NY.......................................... 21.5269
Eau Claire, WI............................................... 18.0385
El Paso, TX.................................................. 18.4982
Elkhart-Goshen, IN........................................... 18.7060
Elmira, NY................................................... 17.5584
Enid, OK..................................................... 16.5863
Erie, PA..................................................... 19.2498
Eugene-Springfield, OR....................................... 23.2566
Evansville, Henderson, IN-KY................................. 17.5235
Fargo-Moorhead, ND-MN........................................ 15.4103
Fayetteville, NC............................................. 17.4302
Fayetteville-Springdale-Rogers, AR........................... 17.8965
Flagstaff, AZ-UT............................................. 19.7008
Flint, MI.................................................... 22.8823
Florence, AL................................................. 15.9479
Florence, SC................................................. 17.2402
Fort Collins-Loveland, CO.................................... 21.3936
Fort Lauderdale, FL.......................................... 20.3768
Fort Myers-Cape Coral, FL.................................... 18.5790
Fort Pierce-Port St. Lucie, FL............................... 19.9753
Fort Smith, AR-OK............................................ 15.8375
Fort Walton Beach, FL........................................ 17.8995
Fort Wayne, IN............................................... 18.3283
Fort Worth-Arlington, TX..................................... 18.8266
Fresno, CA................................................... 21.6143
Gadsden, AL.................................................. 18.2411
Gainesville, FL.............................................. 19.6396
Galveston-Texas City, TX..................................... 19.6738
Gary, IN..................................................... 19.5496
Glens Falls, NY.............................................. 17.6404
Goldsboro, NC................................................ 17.5612
Grand Forks, ND-MN........................................... 18.4172
Grand Junction, CO........................................... 17.0997
Grand Rapids-Muskegon-Holland, MI............................ 20.6411
Great Falls, MT.............................................. 18.4336
Greeley, CO.................................................. 20.3075
Green Bay, WI................................................ 19.0230
Greensboro-Winston-Salem-High Point, NC...................... 19.4045
Greenville, NC............................................... 18.6140
Greenville-Spartanburg-Anderson, SC.......................... 19.1991
Hagerstown, MD............................................... 21.1564
Hamilton-Middletown, OH...................................... 19.1458
Harrisburg-Lebanon-Carlisle, PA.............................. 19.7220
Hartford, CT................................................. 22.8114
Hattiesburg, MS.............................................. 15.0868
Hickory-Morganton-Lenoir, NC................................. 18.4430
Honolulu, HI................................................. 23.9579
Houma, LA.................................................... 17.0314
Houston, TX.................................................. 20.6380
Huntington-Ashland, WV-KY-OH................................. 20.0441
Huntsville, AL............................................... 17.3657
Indianapolis, IN............................................. 20.3998
Iowa City, IA................................................ 19.6992
Jackson, MI.................................................. 19.1645
Jackson, MS.................................................. 17.0541
Jackson, TN.................................................. 17.7852
Jacksonville, FL............................................. 18.3674
Jacksonville, NC............................................. 15.6996
Jamestown, NY................................................ 15.9060
Janesville-Beloit, WI........................................ 18.8060
Jersey City, NJ.............................................. 23.4307
Johnson City-Kingsport-Bristol, TN-VA........................ 18.2276
Johnstown, PA................................................ 17.8659
Jonesboro, AR................................................ 15.3904
Joplin, MO................................................... 16.3448
Kalamazoo-Battlecreek, MI.................................... 24.7428
Kankakee, IL................................................. 18.9037
Kansas City, KS-MO........................................... 19.9286
Kenosha, WI.................................................. 18.9676
Killeen-Temple, TX........................................... 20.9746
Knoxville, TN................................................ 17.6557
Kokomo, IN................................................... 19.2639
La Crosse, WI-MN............................................. 18.5196
Lafayette, LA................................................ 17.1506
Lafayette, IN................................................ 18.3693
Lake Charles, LA............................................. 15.9437
Lakeland-Winter Haven, FL.................................... 18.5691
Lancaster, PA................................................ 19.8739
Lansing-East Lansing, MI..................................... 20.8707
Laredo, TX................................................... 15.2064
Las Cruces, NM............................................... 18.4298
Las Vegas, NV-AZ............................................. 23.3827
Lawrence, KS................................................. 17.9827
Lawton, OK................................................... 18.0698
Lewiston-Auburn, ME.......................................... 19.0090
Lexington, KY................................................ 17.6767
Lima, OH..................................................... 18.3062
Lincoln, NE.................................................. 18.7127
Little Rock-North Little Rock, AR............................ 17.6667
Longview-Marshall, TX........................................ 17.6848
Los Angeles-Long Beach, CA................................... 24.9118
Louisville, KY-IN............................................ 18.9791
Lubbock, TX.................................................. 17.4301
Lynchburg, VA................................................ 17.8831
Macon, GA.................................................... 18.7672
Madison, WI.................................................. 20.8155
Mansfield, OH................................................ 17.7321
Mayaguez, PR................................................. 8.9825
McAllen-Edinburg-Mission, TX................................. 17.5983
Medford-Ashland, OR.......................................... 20.8288
Melbourne-Titusville-Palm Bay, FL............................ 19.1394
Memphis, TN-AR-MS............................................ 17.3550
Merced, CA................................................... 20.8449
Miami, FL.................................................... 20.7248
Middlesex-Somerset-Hunterdon, NJ............................. 23.1938
Milwaukee-Waukesha, WI....................................... 19.5106
Minneapolis-St. Paul, MN-WI.................................. 22.5733
Mobile, AL................................................... 16.3627
Modesto, CA.................................................. 21.4409
Monmouth-Ocean, NJ........................................... 23.2510
Monroe, LA................................................... 17.0762
Montgomery, AL............................................... 16.2493
Muncie, IN................................................... 19.5589
Myrtle Beach, SC............................................. 16.4379
Naples, FL................................................... 21.0253
Nashville, TN................................................ 19.2358
Nassau-Suffolk, NY........................................... 28.5558
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 24.7905
New London-Norwich, CT....................................... 24.1351
New Orleans, LA.............................................. 19.3612
New York, NY................................................. 29.9516
Newark, NJ................................................... 24.1961
Newburgh, NY-PA.............................................. 23.1287
Norfolk-Virginia Beach-Newport News, VA-NC................... 16.9674
Oakland, CA.................................................. 31.0918
Ocala, FL.................................................... 19.0159
Odessa-Midland, TX........................................... 16.0153
Oklahoma City, OK............................................ 18.0573
Olympia, WA.................................................. 23.9108
Omaha, NE-IA................................................. 20.4749
Orange County, CA............................................ 23.1127
Orlando, FL.................................................. 20.4664
Owensboro, KY................................................ 16.1460
Panama City, FL.............................................. 17.6753
Parkersburg-Marietta, WV-OH.................................. 16.7267
Pensacola, FL................................................ 16.9466
Peoria-Pekin, IL............................................. 16.7415
Philadelphia, PA-NJ.......................................... 23.5434
Phoenix-Mesa, AZ............................................. 20.1062
Pine Bluff, AR............................................... 16.4882
Pittsburgh, PA............................................... 20.3893
Pittsfield, MA............................................... 22.4781
Pocatello, ID................................................ 18.0491
Ponce, PR.................................................... 9.7656
Portland, ME................................................. 19.6358
Portland-Vancouver, OR-WA.................................... 23.2280
Providence-Warwick, RI....................................... 22.4328
Provo-Orem, UT............................................... 20.4158
Pueblo, CO................................................... 18.1010
Punta Gorda, FL.............................................. 18.5303
Racine, WI................................................... 18.9689
Raleigh-Durham-Chapel Hill, NC............................... 20.4162
Rapid City, SD............................................... 17.0546
Reading, PA.................................................. 19.1241
Redding, CA.................................................. 24.7586
Reno, NV..................................................... 20.9521
Richland-Kennewick-Pasco, WA................................. 21.3732
Richmond-Petersburg, VA...................................... 19.0728
Riverside-San Bernardino, CA................................. 21.3055
Roanoke, VA.................................................. 17.6802
Rochester, MN................................................ 24.3054
Rochester, NY................................................ 19.9396
Rockford, IL................................................. 17.9308
Rocky Mount, NC.............................................. 18.5969
Sacramento, CA............................................... 24.6188
Saginaw-Bay City-Midland, MI................................. 19.7109
St. Cloud, MN................................................ 19.9167
[[Page 25647]]
St. Joseph, MO............................................... 20.5465
St. Louis, MO-IL............................................. 18.6721
Salem, OR.................................................... 20.5776
Salinas, CA.................................................. 31.4614
Salt Lake City-Ogden, UT..................................... 19.4515
San Angelo, TX............................................... 15.4776
San Antonio, TX.............................................. 15.9548
San Diego, CA................................................ 25.4297
San Francisco, CA............................................ 28.9991
San Jose, CA................................................. 28.6758
San Juan-Bayamon, PR......................................... 9.3148
San Luis Obispo-Atascadero-Paso Robles, CA................... 22.3026
Santa Barbara-Santa Maria-Lompoc, CA......................... 23.1439
Santa Cruz-Watsonville, CA................................... 29.0487
Santa Fe, NM................................................. 19.6247
Santa Rosa, CA............................................... 28.2324
Sarasota-Bradenton, FL....................................... 19.7119
Savannah, GA................................................. 18.0808
Scranton-Wilkes Barre-Hazleton, PA........................... 17.5663
Seattle-Bellevue-Everett, WA................................. 23.9527
Sharon, PA................................................... 18.4366
Sheboygan, WI................................................ 17.0899
Sherman-Denison, TX.......................................... 16.9538
Shreveport-Bossier City, LA.................................. 19.4408
Sioux City, IA-NE............................................ 17.5754
Sioux Falls, SD.............................................. 18.5187
South Bend, IN............................................... 20.4772
Spokane, WA.................................................. 22.7055
Springfield, IL.............................................. 18.1176
Springfield, MO.............................................. 16.7941
Springfield, MA.............................................. 22.7477
State College, PA............................................ 19.6319
Steubenville-Weirton, OH-WV.................................. 17.4636
Stockton-Lodi, CA............................................ 22.9869
Sumter, SC................................................... 16.8850
Syracuse, NY................................................. 19.3881
Tacoma, WA................................................... 21.5661
Tallahassee, FL.............................................. 17.5545
Tampa-St. Petersburg-Clearwater, FL.......................... 18.7444
Terre Haute, IN.............................................. 18.6722
Texarkana, AR-Texarkana, TX.................................. 14.8193
Toledo, OH................................................... 20.8755
Topeka, KS................................................... 20.3862
Trenton, NJ.................................................. 21.4255
Tucson, AZ................................................... 18.7576
Tulsa, OK.................................................... 17.5538
Tuscaloosa, AL............................................... 15.8762
Tyler, TX.................................................... 18.1141
Utica-Rome, NY............................................... 17.2785
Vallejo-Fairfield-Napa, CA................................... 27.9551
Ventura, CA.................................................. 22.7487
Victoria, TX................................................. 17.4131
Vineland-Millville-Bridgeton, NJ............................. 21.5511
Visalia-Tulare-Porterville, CA............................... 20.9493
Waco, TX..................................................... 16.5375
Washington, DC-MD-VA-WV...................................... 22.3812
Waterloo-Cedar Falls, IA..................................... 16.5347
Wausau, WI................................................... 20.2214
West Palm Beach-Boca Raton, FL............................... 21.2686
Wheeling, OH-WV.............................................. 15.8460
Wichita, KS.................................................. 18.5231
Wichita Falls, TX............................................ 16.2020
Williamsport, PA............................................. 17.5305
Wilmington-Newark, DE-MD..................................... 24.6591
Wilmington, NC............................................... 19.4232
Yakima, WA................................................... 21.4371
Yolo, CA..................................................... 22.0507
York, PA..................................................... 19.5923
Youngstown-Warren, OH........................................ 20.3921
Yuba City, CA................................................ 22.5751
Yuma, AZ..................................................... 20.8977
------------------------------------------------------------------------
Table 4E.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
Average
Nonurban area hourly
wage
------------------------------------------------------------------------
Alabama...................................................... 15.1489
Alaska....................................................... 25.8250
Arizona...................................................... 16.6528
Arkansas..................................................... 14.9880
California................................................... 20.5534
Colorado..................................................... 17.4187
Connecticut.................................................. 25.0854
Delaware..................................................... 17.6976
Florida...................................................... 18.4340
Georgia...................................................... 16.3451
Hawaii....................................................... 22.6872
Idaho........................................................ 17.6124
Illinois..................................................... 16.4317
Indiana...................................................... 17.3659
Iowa......................................................... 16.1658
Kansas....................................................... 15.1110
Kentucky..................................................... 16.2801
Louisiana.................................................... 15.4622
Maine........................................................ 17.5914
Maryland..................................................... 17.7750
Massachusetts................................................ 22.4920
Michigan..................................................... 18.5026
Minnesota.................................................... 17.8522
Mississippi.................................................. 15.1615
Missouri..................................................... 15.4743
Montana...................................................... 17.8114
Nebraska..................................................... 15.8291
Nevada....................................................... 19.0933
New Hampshire................................................ 21.2716
New Jersey \1\............................................... .........
New Mexico................................................... 16.3322
New York..................................................... 17.8012
North Carolina............................................... 16.8177
North Dakota................................................. 15.3932
Ohio......................................................... 17.6689
Oklahoma..................................................... 14.8488
Oregon....................................................... 20.5099
Pennsylvania................................................. 17.7499
Puerto Rico.................................................. 8.4134
Rhode Island \1\............................................. .........
South Carolina............................................... 16.7085
South Dakota................................................. 15.5851
Tennessee.................................................... 15.4168
Texas........................................................ 15.2542
Utah......................................................... 18.2372
Vermont...................................................... 19.5500
Virginia..................................................... 16.2563
Washington................................................... 21.7931
West Virginia................................................ 16.3543
Wisconsin.................................................... 17.6308
Wyoming...................................................... 18.0559
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4F.--Puerto Rico Wage Index and Capital Geogaphic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Wage index--
Area Wage index GAF Reclass. GAF--Reclass.
hospitals hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR......................................... 1.0534 1.0363 ............... .............
Arecibo, PR........................................... 1.0850 1.0575 ............... .............
Caguas, PR............................................ 0.9812 0.9871 0.9812 0.9871
Mayaguez, PR.......................................... 0.9624 0.9741 ............... .............
Ponce, PR............................................. 1.0462 1.0314 ............... .............
San Juan-Bayamon, PR.................................. 0.9980 0.9986 ............... .............
Rural Puerto Rico..................................... 0.9014 0.9314 ............... .............
----------------------------------------------------------------------------------------------------------------
[[Page 25648]]
Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
Length of Stay
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1............... 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.0645 6.8 9.6
FOR TRAUMA.
2............... 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.1009 7.5 10.1
>17.
3............... 01 SURG *CRANIOTOMY AGE 0-17....... 1.9573 12.7 12.7
4............... 01 SURG SPINAL PROCEDURES.......... 2.3259 5.1 7.7
5............... 01 SURG EXTRACRANIAL VASCULAR 1.4845 2.7 3.6
PROCEDURES.
6............... 01 SURG CARPAL TUNNEL RELEASE...... .7763 2.1 3.0
7............... 01 SURG PERIPH & CRANIAL NERVE & 2.3911 6.8 10.1
OTHER NERV SYST PROC W CC.
8............... 01 SURG PERIPH & CRANIAL NERVE & 1.2891 2.2 3.2
OTHER NERV SYST PROC W/O
CC.
9............... 01 MED SPINAL DISORDERS & INJURIES 1.2867 4.8 6.6
10.............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2113 5.1 7.0
CC.
11.............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .8233 3.1 4.2
O CC.
12.............. 01 MED DEGENERATIVE NERVOUS SYSTEM .9034 4.8 6.7
DISORDERS.
13.............. 01 MED MULTIPLE SCLEROSIS & .7792 4.4 5.5
CEREBELLAR ATAXIA.
14.............. 01 MED SPECIFIC CEREBROVASCULAR 1.1973 4.9 6.4
DISORDERS EXCEPT TIA.
15.............. 01 MED TRANSIENT ISCHEMIC ATTACK & .7327 3.1 3.9
PRECEREBRAL OCCLUSIONS.
16.............. 01 MED NONSPECIFIC CEREBROVASCULAR 1.0715 4.5 5.9
DISORDERS W CC.
17.............. 01 MED NONSPECIFIC CEREBROVASCULAR .6186 2.7 3.4
DISORDERS W/O CC.
18.............. 01 MED CRANIAL & PERIPHERAL NERVE .9285 4.3 5.6
DISORDERS W CC.
19.............. 01 MED CRANIAL & PERIPHERAL NERVE .6463 3.0 3.8
DISORDERS W/O CC.
20.............. 01 MED NERVOUS SYSTEM INFECTION 2.6134 7.9 10.5
EXCEPT VIRAL MENINGITIS.
21.............. 01 MED VIRAL MENINGITIS........... 1.4785 5.1 6.8
22.............. 01 MED HYPERTENSIVE ENCEPHALOPATHY .8984 3.6 4.7
23.............. 01 MED NONTRAUMATIC STUPOR & COMA. .7776 3.2 4.3
24.............. 01 MED SEIZURE & HEADACHE AGE >17 .9579 3.8 5.1
W CC.
25.............. 01 MED SEIZURE & HEADACHE AGE >17 .5905 2.7 3.4
W/O CC.
26.............. 01 MED SEIZURE & HEADACHE AGE 0-17 .6950 2.4 3.1
27.............. 01 MED TRAUMATIC STUPOR & COMA, 1.3017 3.4 5.3
COMA >1 HR.
28.............. 01 MED TRAUMATIC STUPOR & COMA, 1.1699 4.3 6.0
COMA <1 HR AGE >17 W CC.
29.............. 01 MED TRAUMATIC STUPOR & COMA, .6370 2.7 3.6
COMA <1 HR AGE >17 W/O CC.
30.............. 01 MED *TRAUMATIC STUPOR & COMA, .3310 2.0 2.0
COMA <1 HR AGE 0-17.
31.............. 01 MED CONCUSSION AGE >17 W CC.... .8039 3.2 4.4
32.............. 01 MED CONCUSSION AGE >17 W/O CC.. .5138 2.2 3.0
33.............. 01 MED *CONCUSSION AGE 0-17....... .2080 1.6 1.6
34.............. 01 MED OTHER DISORDERS OF NERVOUS 1.0067 4.1 5.5
SYSTEM W CC.
35.............. 01 MED OTHER DISORDERS OF NERVOUS .5915 2.7 3.6
SYSTEM W/O CC.
36.............. 02 SURG RETINAL PROCEDURES......... .6873 1.3 1.5
37.............. 02 SURG ORBITAL PROCEDURES......... .9614 2.5 3.7
38.............. 02 SURG PRIMARY IRIS PROCEDURES.... .4876 1.9 2.6
39.............. 02 SURG LENS PROCEDURES WITH OR .5686 1.5 2.0
WITHOUT VITRECTOMY.
40.............. 02 SURG EXTRAOCULAR PROCEDURES .7937 2.1 3.2
EXCEPT ORBIT AGE >17.
41.............. 02 SURG *EXTRAOCULAR PROCEDURES .3369 1.6 1.6
EXCEPT ORBIT AGE 0-17.
42.............. 02 SURG INTRAOCULAR PROCEDURES .6034 1.6 2.1
EXCEPT RETINA, IRIS & LENS.
43.............. 02 MED HYPHEMA.................... .4370 2.7 3.4
44.............. 02 MED ACUTE MAJOR EYE INFECTIONS. .6100 4.2 5.1
45.............. 02 MED NEUROLOGICAL EYE DISORDERS. .6822 2.8 3.5
46.............. 02 MED OTHER DISORDERS OF THE EYE .7546 3.6 4.7
AGE >17 W CC.
47.............. 02 MED OTHER DISORDERS OF THE EYE .4618 2.5 3.3
AGE >17 W/O CC.
48.............. 02 MED *OTHER DISORDERS OF THE EYE .2969 2.9 2.9
AGE 0-17.
49.............. 03 SURG MAJOR HEAD & NECK 1.7597 3.7 5.0
PROCEDURES.
50.............. 03 SURG SIALOADENECTOMY............ .8288 1.6 2.0
51.............. 03 SURG SALIVARY GLAND PROCEDURES .8590 1.8 2.8
EXCEPT SIALOADENECTOMY.
52.............. 03 SURG CLEFT LIP & PALATE REPAIR.. .9567 2.0 2.8
53.............. 03 SURG SINUS & MASTOID PROCEDURES 1.1402 2.3 3.7
AGE >17.
54.............. 03 SURG *SINUS & MASTOID PROCEDURES .4812 3.2 3.2
AGE 0-17.
55.............. 03 SURG MISCELLANEOUS EAR, NOSE, .8886 2.0 3.0
MOUTH & THROAT PROCEDURES.
56.............. 03 SURG RHINOPLASTY................ .9008 2.1 2.8
57.............. 03 SURG T&A PROC, EXCEPT .9381 2.6 3.7
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE
>17.
58.............. 03 SURG *T&A PROC, EXCEPT .2732 1.5 1.5
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE 0-
17.
59.............. 03 SURG TONSILLECTOMY &/OR .6750 1.8 2.4
ADENOIDECTOMY ONLY, AGE
>17.
60.............. 03 SURG *TONSILLECTOMY &/OR .2081 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-
17.
61.............. 03 SURG MYRINGOTOMY W TUBE 1.1456 2.6 4.5
INSERTION AGE >17.
62.............. 03 SURG *MYRINGOTOMY W TUBE .2946 1.3 1.3
INSERTION AGE 0-17.
63.............. 03 SURG OTHER EAR, NOSE, MOUTH & 1.3248 3.0 4.4
THROAT O.R. PROCEDURES.
64.............. 03 MED EAR, NOSE, MOUTH & THROAT 1.2201 4.4 6.8
MALIGNANCY.
65.............. 03 MED DYSEQUILIBRIUM............. .5173 2.4 3.0
66.............. 03 MED EPISTAXIS.................. .5418 2.6 3.3
67.............. 03 MED EPIGLOTTITIS............... .8230 3.0 3.8
68.............. 03 MED OTITIS MEDIA & URI AGE >17 .6733 3.4 4.2
W CC.
[[Page 25649]]
69.............. 03 MED OTITIS MEDIA & URI AGE >17 .5076 2.7 3.3
W/O CC.
70.............. 03 MED OTITIS MEDIA & URI AGE 0-17 .3860 2.1 2.5
71.............. 03 MED LARYNGOTRACHEITIS.......... .7663 3.2 4.0
72.............. 03 MED NASAL TRAUMA & DEFORMITY... .6534 2.8 3.8
73.............. 03 MED OTHER EAR, NOSE, MOUTH & .7507 3.3 4.4
THROAT DIAGNOSES AGE >17.
74.............. 03 MED *OTHER EAR, NOSE, MOUTH & .3347 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75.............. 04 SURG MAJOR CHEST PROCEDURES..... 3.1785 8.1 10.2
76.............. 04 SURG OTHER RESP SYSTEM O.R. 2.6860 8.4 11.3
PROCEDURES W CC.
77.............. 04 SURG OTHER RESP SYSTEM O.R. 1.1569 3.4 4.9
PROCEDURES W/O CC.
78.............. 04 MED PULMONARY EMBOLISM......... 1.4068 6.3 7.4
79.............. 04 MED RESPIRATORY INFECTIONS & 1.6331 6.7 8.4
INFLAMMATIONS AGE >17 W CC.
80.............. 04 MED RESPIRATORY INFECTIONS & .9177 4.7 5.9
INFLAMMATIONS AGE >17 W/O
CC.
81.............. 04 MED *RESPIRATORY INFECTIONS & 1.5160 6.1 6.1
INFLAMMATIONS AGE 0-17.
82.............. 04 MED RESPIRATORY NEOPLASMS...... 1.3628 5.3 7.2
83.............. 04 MED MAJOR CHEST TRAUMA W CC.... .9508 4.4 5.6
84.............. 04 MED MAJOR CHEST TRAUMA W/O CC.. .5041 2.7 3.3
85.............. 04 MED PLEURAL EFFUSION W CC...... 1.2361 5.1 6.7
86.............. 04 MED PLEURAL EFFUSION W/O CC.... .6843 3.0 3.9
87.............. 04 MED PULMONARY EDEMA & 1.3672 4.8 6.4
RESPIRATORY FAILURE.
88.............. 04 MED CHRONIC OBSTRUCTIVE .9558 4.4 5.4
PULMONARY DISEASE.
89.............. 04 MED SIMPLE PNEUMONIA & PLEURISY 1.0865 5.2 6.3
AGE >17 W CC.
90.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .6669 3.8 4.5
AGE >17 W/O CC.
91.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .7210 3.3 4.0
AGE 0-17.
92.............. 04 MED INTERSTITIAL LUNG DISEASE W 1.2047 5.1 6.4
CC.
93.............. 04 MED INTERSTITIAL LUNG DISEASE W/ .7722 3.5 4.4
O CC.
94.............. 04 MED PNEUMOTHORAX W CC.......... 1.1904 4.9 6.5
95.............. 04 MED PNEUMOTHORAX W/O CC........ .6060 3.1 3.9
96.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .7917 4.0 4.9
W CC.
97.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .5942 3.2 3.8
W/O CC.
98.............. 04 MED BRONCHITIS & ASTHMA AGE 0- .6921 3.6 4.9
17.
99.............. 04 MED RESPIRATORY SIGNS & .6739 2.3 3.0
SYMPTOMS W CC.
100............. 04 MED RESPIRATORY SIGNS & .5155 1.7 2.1
SYMPTOMS W/O CC.
101............. 04 MED OTHER RESPIRATORY SYSTEM .8304 3.3 4.4
DIAGNOSES W CC.
102............. 04 MED OTHER RESPIRATORY SYSTEM .5402 2.2 2.8
DIAGNOSES W/O CC.
103............. 05 SURG HEART TRANSPLANT........... 16.8723 30.4 48.1
104............. 05 SURG CARDIAC VALVE & OTH MAJ 7.2756 9.9 12.5
CARDIOTHORACIC PROC W CARD
CATH.
105............. 05 SURG CARDIAC VALVE & OTH MAJ 5.7011 7.9 9.7
CARDIOTHORACIC PROC W/O
CARD CATH.
106............. 05 SURG CORONARY BYPASS WITH PTCA.. 7.3400 9.2 10.9
107............. 05 SURG CORONARY BYPASS W CARDIAC 5.4891 9.5 10.7
CATH.
108............. 05 SURG OTHER CARDIOTHORACIC 5.9512 8.6 11.3
PROCEDURES.
109............. 05 SURG CORONARY BYPASS W/O CARDIAC 4.0670 7.0 8.0
CATH.
110............. 05 SURG MAJOR CARDIOVASCULAR 4.1419 7.4 9.7
PROCEDURES W CC.
111............. 05 SURG MAJOR CARDIOVASCULAR 2.2188 5.1 5.9
PROCEDURES W/O CC.
112............. 05 SURG PERCUTANEOUS CARDIOVASCULAR 1.9862 2.8 3.9
PROCEDURES.
113............. 05 SURG AMPUTATION FOR CIRC SYSTEM 2.7407 9.8 13.0
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............. 05 SURG UPPER LIMB & TOE AMPUTATION 1.5023 6.0 8.4
FOR CIRC SYSTEM DISORDERS.
115............. 05 SURG PERM PACE IMPLNT W AMI, HRT 3.5531 6.4 8.8
FAIL OR SHOCK OR AICD LEAD
OR GEN PROC.
116............. 05 SURG OTH PERM CARDIAC PACEMAKER 2.4811 3.0 4.2
IMPLANT OR PTCA W CORONARY
ART STENT.
117............. 05 SURG CARDIAC PACEMAKER REVISION 1.2368 2.7 4.0
EXCEPT DEVICE REPLACEMENT.
118............. 05 SURG CARDIAC PACEMAKER DEVICE 1.5711 2.0 2.9
REPLACEMENT.
119............. 05 SURG VEIN LIGATION & STRIPPING.. 1.2960 3.2 5.4
120............. 05 SURG OTHER CIRCULATORY SYSTEM 1.9568 4.9 8.2
O.R. PROCEDURES.
121............. 05 MED CIRCULATORY DISORDERS W AMI 1.6354 5.7 7.0
& MAJOR COMP DISCH ALIVE.
122............. 05 MED CIRCULATORY DISORDERS W AMI 1.1299 3.6 4.4
W/O MAJOR COMP DISCH ALIVE.
123............. 05 MED CIRCULATORY DISORDERS W 1.4874 2.7 4.4
AMI, EXPIRED.
124............. 05 MED CIRCULATORY DISORDERS 1.3790 3.5 4.5
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............. 05 MED CIRCULATORY DISORDERS 1.0130 2.2 2.9
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............. 05 MED ACUTE & SUBACUTE 2.5820 9.7 12.7
ENDOCARDITIS.
127............. 05 MED HEART FAILURE & SHOCK...... 1.0143 4.3 5.5
128............. 05 MED DEEP VEIN THROMBOPHLEBITIS. .7671 5.3 6.0
129............. 05 MED CARDIAC ARREST, UNEXPLAINED 1.0878 1.8 3.0
130............. 05 MED PERIPHERAL VASCULAR .9435 4.9 6.0
DISORDERS W CC.
131............. 05 MED PERIPHERAL VASCULAR .6077 3.9 4.7
DISORDERS W/O CC.
[[Page 25650]]
132............. 05 MED ATHEROSCLEROSIS W CC....... .6711 2.5 3.2
133............. 05 MED ATHEROSCLEROSIS W/O CC..... .5562 2.0 2.5
134............. 05 MED HYPERTENSION............... .5838 2.7 3.5
135............. 05 MED CARDIAC CONGENITAL & .8519 3.3 4.4
VALVULAR DISORDERS AGE >17
W CC.
136............. 05 MED CARDIAC CONGENITAL & .5766 2.4 3.0
VALVULAR DISORDERS AGE >17
W/O CC.
137............. 05 MED *CARDIAC CONGENITAL & .8168 3.3 3.3
VALVULAR DISORDERS AGE 0-
17.
138............. 05 MED CARDIAC ARRHYTHMIA & .8012 3.1 4.1
CONDUCTION DISORDERS W CC.
139............. 05 MED CARDIAC ARRHYTHMIA & .4981 2.1 2.6
CONDUCTION DISORDERS W/O
CC.
140............. 05 MED ANGINA PECTORIS............ .5973 2.4 3.0
141............. 05 MED SYNCOPE & COLLAPSE W CC.... .7029 3.0 3.9
142............. 05 MED SYNCOPE & COLLAPSE W/O CC.. .5316 2.2 2.8
143............. 05 MED CHEST PAIN................. .5265 1.8 2.3
144............. 05 MED OTHER CIRCULATORY SYSTEM 1.1123 3.8 5.3
DIAGNOSES W CC.
145............. 05 MED OTHER CIRCULATORY SYSTEM .6305 2.2 2.9
DIAGNOSES W/O CC.
146............. 06 SURG RECTAL RESECTION W CC...... 2.7210 9.0 10.3
147............. 06 SURG RECTAL RESECTION W/O CC.... 1.5887 6.1 6.7
148............. 06 SURG MAJOR SMALL & LARGE BOWEL 3.4239 10.3 12.3
PROCEDURES W CC.
149............. 06 SURG MAJOR SMALL & LARGE BOWEL 1.5698 6.3 6.9
PROCEDURES W/O CC.
150............. 06 SURG PERITONEAL ADHESIOLYSIS W 2.7465 8.9 10.9
CC.
151............. 06 SURG PERITONEAL ADHESIOLYSIS W/O 1.2832 4.8 5.9
CC.
152............. 06 SURG MINOR SMALL & LARGE BOWEL 1.9427 7.0 8.3
PROCEDURES W CC.
153............. 06 SURG MINOR SMALL & LARGE BOWEL 1.1905 5.1 5.6
PROCEDURES W/O CC.
154............. 06 SURG STOMACH, ESOPHAGEAL & 4.1849 10.3 13.4
DUODENAL PROCEDURES AGE
>17 W CC.
155............. 06 SURG STOMACH, ESOPHAGEAL & 1.3570 3.6 4.7
DUODENAL PROCEDURES AGE
>17 W/O CC.
156............. 06 SURG *STOMACH, ESOPHAGEAL & .8412 6.0 6.0
DUODENAL PROCEDURES AGE 0-
17.
157............. 06 SURG ANAL & STOMAL PROCEDURES W 1.2071 3.9 5.4
CC.
158............. 06 SURG ANAL & STOMAL PROCEDURES W/ .6434 2.1 2.6
O CC.
159............. 06 SURG HERNIA PROCEDURES EXCEPT 1.2873 3.7 5.0
INGUINAL & FEMORAL AGE >17
W CC.
160............. 06 SURG HERNIA PROCEDURES EXCEPT .7413 2.2 2.7
INGUINAL & FEMORAL AGE >17
W/O CC.
161............. 06 SURG INGUINAL & FEMORAL HERNIA 1.0742 2.9 4.1
PROCEDURES AGE >17 W CC.
162............. 06 SURG INGUINAL & FEMORAL HERNIA .6129 1.7 2.0
PROCEDURES AGE >17 W/O CC.
163............. 06 SURG *HERNIA PROCEDURES AGE 0-17 .8700 2.1 2.1
164............. 06 SURG APPENDECTOMY W COMPLICATED 2.3206 7.3 8.5
PRINCIPAL DIAG W CC.
165............. 06 SURG APPENDECTOMY W COMPLICATED 1.2301 4.3 5.0
PRINCIPAL DIAG W/O CC.
166............. 06 SURG APPENDECTOMY W/O 1.4518 4.0 5.1
COMPLICATED PRINCIPAL DIAG
W CC.
167............. 06 SURG APPENDECTOMY W/O .8548 2.4 2.8
COMPLICATED PRINCIPAL DIAG
W/O CC.
168............. 03 SURG MOUTH PROCEDURES W CC...... 1.1593 3.1 4.6
169............. 03 SURG MOUTH PROCEDURES W/O CC.... .7155 1.9 2.5
170............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 2.8008 7.9 11.3
PROCEDURES W CC.
171............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 1.1668 3.6 4.8
PROCEDURES W/O CC.
172............. 06 MED DIGESTIVE MALIGNANCY W CC.. 1.3152 5.2 7.1
173............. 06 MED DIGESTIVE MALIGNANCY W/O CC .7316 2.8 4.0
174............. 06 MED G.I. HEMORRHAGE W CC....... .9945 4.0 4.9
175............. 06 MED G.I. HEMORRHAGE W/O CC..... .5305 2.5 3.0
176............. 06 MED COMPLICATED PEPTIC ULCER... 1.1068 4.3 5.5
177............. 06 MED UNCOMPLICATED PEPTIC ULCER .8646 3.7 4.6
W CC.
178............. 06 MED UNCOMPLICATED PEPTIC ULCER .6344 2.7 3.2
W/O CC.
179............. 06 MED INFLAMMATORY BOWEL DISEASE. 1.1084 5.0 6.4
180............. 06 MED G.I. OBSTRUCTION W CC...... .9184 4.2 5.4
181............. 06 MED G.I. OBSTRUCTION W/O CC.... .5254 2.9 3.5
182............. 06 MED ESOPHAGITIS, GASTROENT & .7709 3.4 4.4
MISC DIGEST DISORDERS AGE
>17 W CC.
183............. 06 MED ESOPHAGITIS, GASTROENT & .5594 2.4 3.0
MISC DIGEST DISORDERS AGE
>17 W/O CC.
184............. 06 MED ESOPHAGITIS, GASTROENT & .5224 2.5 3.2
MISC DIGEST DISORDERS AGE
0-17.
185............. 03 MED DENTAL & ORAL DIS EXCEPT .8303 3.3 4.5
EXTRACTIONS &
RESTORATIONS, AGE >17.
186............. 03 MED *DENTAL & ORAL DIS EXCEPT .3207 2.9 2.9
EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187............. 03 MED DENTAL EXTRACTIONS & .7415 3.0 4.0
RESTORATIONS.
188............. 06 MED OTHER DIGESTIVE SYSTEM 1.0758 4.1 5.6
DIAGNOSES AGE >17 W CC.
189............. 06 MED OTHER DIGESTIVE SYSTEM .5600 2.4 3.2
DIAGNOSES AGE >17 W/O CC.
190............. 06 MED OTHER DIGESTIVE SYSTEM .7636 3.8 5.3
DIAGNOSES AGE 0-17.
191............. 07 SURG PANCREAS, LIVER & SHUNT 4.4088 10.8 14.6
PROCEDURES W CC.
192............. 07 SURG PANCREAS, LIVER & SHUNT 1.7111 5.4 6.7
PROCEDURES W/O CC.
[[Page 25651]]
193............. 07 SURG BILIARY TRACT PROC EXCEPT 3.3324 10.4 12.5
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
194............. 07 SURG BILIARY TRACT PROC EXCEPT 1.6689 5.8 6.9
ONLY CHOLECYST W OR W/O
C.D.E. W/O CC.
195............. 07 SURG CHOLECYSTECTOMY W C.D.E. W 2.7947 8.3 9.8
CC.
196............. 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6378 4.9 5.7
O CC.
197............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.3864 7.1 8.6
LAPAROSCOPE W/O C.D.E. W
CC.
198............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.2024 4.0 4.6
LAPAROSCOPE W/O C.D.E. W/O
CC.
199............. 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3873 7.7 10.2
PROCEDURE FOR MALIGNANCY.
200............. 07 SURG HEPATOBILIARY DIAGNOSTIC 3.2791 7.4 11.5
PROCEDURE FOR NON-
MALIGNANCY.
201............. 07 SURG OTHER HEPATOBILIARY OR 3.5903 10.4 14.4
PANCREAS O.R. PROCEDURES.
202............. 07 MED CIRRHOSIS & ALCOHOLIC 1.3123 5.1 6.8
HEPATITIS.
203............. 07 MED MALIGNANCY OF HEPATOBILIARY 1.2979 5.1 6.9
SYSTEM OR PANCREAS.
204............. 07 MED DISORDERS OF PANCREAS 1.2114 4.7 6.1
EXCEPT MALIGNANCY.
205............. 07 MED DISORDERS OF LIVER EXCEPT 1.2109 4.9 6.6
MALIG, CIRR, ALC HEPA W CC.
206............. 07 MED DISORDERS OF LIVER EXCEPT .6932 3.1 4.1
MALIG, CIRR, ALC HEPA W/O
CC.
207............. 07 MED DISORDERS OF THE BILIARY 1.0711 4.0 5.2
TRACT W CC.
208............. 07 MED DISORDERS OF THE BILIARY .6178 2.3 2.9
TRACT W/O CC.
209............. 08 SURG MAJOR JOINT & LIMB 2.1818 4.9 5.5
REATTACHMENT PROCEDURES OF
LOWER EXTREMITY.
210............. 08 SURG HIP & FEMUR PROCEDURES 1.8153 6.1 7.1
EXCEPT MAJOR JOINT AGE >17
W CC.
211............. 08 SURG HIP & FEMUR PROCEDURES 1.2530 4.7 5.2
EXCEPT MAJOR JOINT AGE >17
W/O CC.
212............. 08 SURG HIP & FEMUR PROCEDURES .8679 3.2 3.8
EXCEPT MAJOR JOINT AGE 0-
17.
213............. 08 SURG AMPUTATION FOR 1.6323 6.2 8.4
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 2.1241 7.0 9.8
SYSTEM & CONNECTIVE TISSUE.
217............. 08 SURG WND DEBRID & SKN GRFT 2.7825 8.7 13.0
EXCEPT HAND,FOR MUSCSKELET
& CONN TISS DIS.
218............. 08 SURG LOWER EXTREM & HUMER PROC 1.4630 4.2 5.3
EXCEPT HIP, FOOT, FEMUR
AGE >17 W CC.
219............. 08 SURG LOWER EXTREM & HUMER PROC .9926 2.8 3.3
EXCEPT HIP, FOOT, FEMUR
AGE >17 W/O CC.
220............. 08 SURG *LOWER EXTREM & HUMER PROC .5827 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, .9257 2.0 2.6
OR OTHER UPPER EXTREMITY
PROC W CC.
224............. 08 SURG SHOULDER, ELBOW OR FOREARM .7876 1.7 2.1
PROC, EXC MAJOR JOINT
PROC, W/O CC.
225............. 08 SURG FOOT PROCEDURES............ 1.0120 3.0 4.4
226............. 08 SURG SOFT TISSUE PROCEDURES W CC 1.4076 4.0 5.9
227............. 08 SURG SOFT TISSUE PROCEDURES W/O .7916 2.1 2.7
CC.
228............. 08 SURG MAJOR THUMB OR JOINT PROC, 1.0048 2.3 3.4
OR OTH HAND OR WRIST PROC
W CC.
229............. 08 SURG HAND OR WRIST PROC, EXCEPT .7055 1.8 2.4
MAJOR JOINT PROC, W/O CC.
230............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.1097 3.1 4.5
INT FIX DEVICES OF HIP &
FEMUR.
231............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.2922 3.0 4.6
INT FIX DEVICES EXCEPT HIP
& FEMUR.
232............. 08 SURG ARTHROSCOPY................ 1.0895 2.3 3.8
233............. 08 SURG OTHER MUSCULOSKELET SYS & 2.0599 5.4 7.7
CONN TISS O.R. PROC W CC.
234............. 08 SURG OTHER MUSCULOSKELET SYS & 1.1712 2.8 3.6
CONN TISS O.R. PROC W/O CC.
235............. 08 MED FRACTURES OF FEMUR......... .7526 3.9 5.4
236............. 08 MED FRACTURES OF HIP & PELVIS.. .7260 4.1 5.3
237............. 08 MED SPRAINS, STRAINS, & .5367 2.9 3.6
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238............. 08 MED OSTEOMYELITIS.............. 1.3382 6.7 8.9
239............. 08 MED PATHOLOGICAL FRACTURES & .9661 5.0 6.4
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............. 08 MED CONNECTIVE TISSUE DISORDERS 1.2253 5.0 6.7
W CC.
241............. 08 MED CONNECTIVE TISSUE DISORDERS .5875 3.1 4.0
W/O CC.
242............. 08 MED SEPTIC ARTHRITIS........... 1.0391 5.2 6.8
243............. 08 MED MEDICAL BACK PROBLEMS...... .7159 3.8 4.9
244............. 08 MED BONE DISEASES & SPECIFIC .7056 3.9 5.0
ARTHROPATHIES W CC.
[[Page 25652]]
245............. 08 MED BONE DISEASES & SPECIFIC .4961 2.9 3.8
ARTHROPATHIES W/O CC.
246............. 08 MED NON-SPECIFIC ARTHROPATHIES. .5662 3.1 3.9
247............. 08 MED SIGNS & SYMPTOMS OF .5542 2.6 3.5
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............. 08 MED TENDONITIS, MYOSITIS & .7487 3.6 4.7
BURSITIS.
249............. 08 MED AFTERCARE, MUSCULOSKELETAL .6514 2.6 3.6
SYSTEM & CONNECTIVE TISSUE.
250............. 08 MED FX, SPRN, STRN & DISL OF .6776 3.2 4.2
FOREARM, HAND, FOOT AGE
>17 W CC.
251............. 08 MED FX, SPRN, STRN & DISL OF .4622 2.3 3.0
FOREARM, HAND, FOOT AGE
>17 W/O CC.
252............. 08 MED *FX, SPRN, STRN & DISL OF .2532 1.8 1.8
FOREARM, HAND, FOOT AGE 0-
17.
253............. 08 MED FX, SPRN, STRN & DISL OF .7188 3.7 4.9
UPARM, LOWLEG EX FOOT AGE
>17 W CC.
254............. 08 MED FX, SPRN, STRN & DISL OF .4315 2.7 3.4
UPARM, LOWLEG EX FOOT AGE
>17 W/O CC.
255............. 08 MED *FX, SPRN, STRN & DISL OF .2947 2.9 2.9
UPARM, LOWLEG EX FOOT AGE
0-17.
256............. 08 MED OTHER MUSCULOSKELETAL .7564 3.8 5.1
SYSTEM & CONNECTIVE TISSUE
DIAGNOSES.
257............. 09 SURG TOTAL MASTECTOMY FOR .9219 2.4 3.0
MALIGNANCY W CC.
258............. 09 SURG TOTAL MASTECTOMY FOR .7237 1.9 2.1
MALIGNANCY W/O CC.
259............. 09 SURG SUBTOTAL MASTECTOMY FOR .8840 2.0 3.1
MALIGNANCY W CC.
260............. 09 SURG SUBTOTAL MASTECTOMY FOR .6238 1.4 1.5
MALIGNANCY W/O CC.
261............. 09 SURG BREAST PROC FOR NON- .9138 1.7 2.2
MALIGNANCY EXCEPT BIOPSY &
LOCAL EXCISION.
262............. 09 SURG BREAST BIOPSY & LOCAL .8738 2.9 4.2
EXCISION FOR NON-
MALIGNANCY.
263............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0055 8.8 11.9
SKN ULCER OR CELLULITIS W
CC.
264............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.1061 5.4 7.2
SKN ULCER OR CELLULITIS W/
O CC.
265............. 09 SURG SKIN GRAFT &/OR DEBRID 1.4806 4.2 6.5
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............. 09 SURG SKIN GRAFT &/OR DEBRID .8252 2.5 3.4
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............. 09 SURG PERIANAL & PILONIDAL .9378 3.0 4.6
PROCEDURES.
268............. 09 SURG SKIN, SUBCUTANEOUS TISSUE & 1.0673 2.3 3.6
BREAST PLASTIC PROCEDURES.
269............. 09 SURG OTHER SKIN, SUBCUT TISS & 1.5778 5.6 7.9
BREAST PROC W CC.
270............. 09 SURG OTHER SKIN, SUBCUT TISS & .7218 2.2 3.2
BREAST PROC W/O CC.
271............. 09 MED SKIN ULCERS................ 1.0023 5.7 7.2
272............. 09 MED MAJOR SKIN DISORDERS W CC.. 1.0465 4.9 6.4
273............. 09 MED MAJOR SKIN DISORDERS W/O CC .6251 3.6 4.8
274............. 09 MED MALIGNANT BREAST DISORDERS 1.1170 4.8 6.8
W CC.
275............. 09 MED MALIGNANT BREAST DISORDERS .5288 2.6 3.6
W/O CC.
276............. 09 MED NON-MALIGANT BREAST .6416 3.6 4.5
DISORDERS.
277............. 09 MED CELLULITIS AGE >17 W CC.... .8345 4.8 5.9
278............. 09 MED CELLULITIS AGE >17 W/O CC.. .5561 3.8 4.5
279............. 09 MED CELLULITIS AGE 0-17........ .6697 4.3 5.0
280............. 09 MED TRAUMA TO THE SKIN, SUBCUT .6624 3.3 4.3
TISS & BREAST AGE >17 W CC.
281............. 09 MED TRAUMA TO THE SKIN, SUBCUT .4540 2.5 3.2
TISS & BREAST AGE >17 W/O
CC.
282............. 09 MED *TRAUMA TO THE SKIN, SUBCUT .2563 2.2 2.2
TISS & BREAST AGE 0-17.
283............. 09 MED MINOR SKIN DISORDERS W CC.. .6961 3.6 4.8
284............. 09 MED MINOR SKIN DISORDERS W/O CC .4419 2.6 3.3
285............. 10 SURG AMPUTAT OF LOWER LIMB FOR 2.0445 8.1 11.0
ENDOCRINE, NUTRIT, &
METABOL DISORDERS.
286............. 10 SURG ADRENAL & PITUITARY 2.2173 5.5 7.0
PROCEDURES.
287............. 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8652 8.0 11.3
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............. 10 SURG O.R. PROCEDURES FOR OBESITY 2.0156 4.7 5.9
289............. 10 SURG PARATHYROID PROCEDURES..... 1.0132 2.2 3.2
290............. 10 SURG THYROID PROCEDURES......... .9181 1.9 2.5
291............. 10 SURG THYROGLOSSAL PROCEDURES.... .5752 1.5 1.8
292............. 10 SURG OTHER ENDOCRINE, NUTRIT & 2.5779 7.5 10.7
METAB O.R. PROC W CC.
293............. 10 SURG OTHER ENDOCRINE, NUTRIT & 1.2954 3.9 5.5
METAB O.R. PROC W/O CC.
294............. 10 MED DIABETES AGE >35........... .7500 3.8 4.9
295............. 10 MED DIABETES AGE 0-35.......... .7234 3.0 4.0
296............. 10 MED NUTRITIONAL & MISC .8511 4.1 5.4
METABOLIC DISORDERS AGE
>17 W CC.
297............. 10 MED NUTRITIONAL & MISC .5206 2.9 3.7
METABOLIC DISORDERS AGE
>17 W/O CC.
298............. 10 MED NUTRITIONAL & MISC .5479 2.4 3.7
METABOLIC DISORDERS AGE 0-
17.
299............. 10 MED INBORN ERRORS OF METABOLISM .8774 3.9 5.4
300............. 10 MED ENDOCRINE DISORDERS W CC... 1.0807 4.8 6.3
301............. 10 MED ENDOCRINE DISORDERS W/O CC. .6023 2.9 3.8
302............. 11 SURG KIDNEY TRANSPLANT.......... 3.6251 8.6 10.1
[[Page 25653]]
303............. 11 SURG KIDNEY, URETER & MAJOR 2.6598 7.5 9.2
BLADDER PROCEDURES FOR
NEOPLASM.
304............. 11 SURG KIDNEY, URETER & MAJOR 2.3331 6.5 9.0
BLADDER PROC FOR NON-NEOPL
W CC.
305............. 11 SURG KIDNEY, URETER & MAJOR 1.1358 3.2 3.9
BLADDER PROC FOR NON-NEOPL
W/O CC.
306............. 11 SURG PROSTATECTOMY W CC......... 1.2407 3.8 5.5
307............. 11 SURG PROSTATECTOMY W/O CC....... .6423 2.0 2.4
308............. 11 SURG MINOR BLADDER PROCEDURES W 1.5218 4.1 6.0
CC.
309............. 11 SURG MINOR BLADDER PROCEDURES W/ .9101 2.1 2.6
O CC.
310............. 11 SURG TRANSURETHRAL PROCEDURES W 1.0630 3.0 4.3
CC.
311............. 11 SURG TRANSURETHRAL PROCEDURES W/ .6087 1.6 2.0
O CC.
312............. 11 SURG URETHRAL PROCEDURES, AGE .9880 2.9 4.3
>17 W CC.
313............. 11 SURG URETHRAL PROCEDURES, AGE .6269 1.8 2.4
>17 W/O CC.
314............. 11 SURG *URETHRAL PROCEDURES, AGE 0- .4939 2.3 2.3
17.
315............. 11 SURG OTHER KIDNEY & URINARY 2.0691 4.6 8.0
TRACT O.R. PROCEDURES.
316............. 11 MED RENAL FAILURE.............. 1.3318 5.0 6.9
317............. 11 MED ADMIT FOR RENAL DIALYSIS... .6194 2.0 2.9
318............. 11 MED KIDNEY & URINARY TRACT 1.0973 4.4 6.1
NEOPLASMS W CC.
319............. 11 MED KIDNEY & URINARY TRACT .6170 2.2 3.0
NEOPLASMS W/O CC.
320............. 11 MED KIDNEY & URINARY TRACT .8675 4.5 5.6
INFECTIONS AGE >17 W CC.
321............. 11 MED KIDNEY & URINARY TRACT .5826 3.4 4.0
INFECTIONS AGE >17 W/O CC.
322............. 11 MED KIDNEY & URINARY TRACT .5394 3.3 4.1
INFECTIONS AGE 0-17.
323............. 11 MED URINARY STONES W CC, &/OR .7679 2.4 3.2
ESW LITHOTRIPSY.
324............. 11 MED URINARY STONES W/O CC...... .4360 1.6 1.9
325............. 11 MED KIDNEY & URINARY TRACT .6246 3.0 4.0
SIGNS & SYMPTOMS AGE >17 W
CC.
326............. 11 MED KIDNEY & URINARY TRACT .4152 2.1 2.7
SIGNS & SYMPTOMS AGE >17 W/
O CC.
327............. 11 MED *KIDNEY & URINARY TRACT .3532 3.1 3.1
SIGNS & SYMPTOMS AGE 0-17.
328............. 11 MED URETHRAL STRICTURE AGE >17 .7189 2.8 3.7
W CC.
329............. 11 MED URETHRAL STRICTURE AGE >17 .4911 1.7 2.3
W/O CC.
330............. 11 MED *URETHRAL STRICTURE AGE 0- .3182 1.6 1.6
17.
331............. 11 MED OTHER KIDNEY & URINARY .9946 4.2 5.6
TRACT DIAGNOSES AGE >17 W
CC.
332............. 11 MED OTHER KIDNEY & URINARY .6236 2.7 3.6
TRACT DIAGNOSES AGE >17 W/
O CC.
333............. 11 MED OTHER KIDNEY & URINARY .7891 3.5 5.0
TRACT DIAGNOSES AGE 0-17.
334............. 12 SURG MAJOR MALE PELVIC 1.5998 4.4 5.0
PROCEDURES W CC.
335............. 12 SURG MAJOR MALE PELVIC 1.2055 3.4 3.7
PROCEDURES W/O CC.
336............. 12 SURG TRANSURETHRAL PROSTATECTOMY .8873 2.8 3.6
W CC.
337............. 12 SURG TRANSURETHRAL PROSTATECTOMY .6186 2.0 2.3
W/O CC.
338............. 12 SURG TESTES PROCEDURES, FOR 1.0888 3.2 4.8
MALIGNANCY.
339............. 12 SURG TESTES PROCEDURES, NON- .9811 2.9 4.2
MALIGNANCY AGE >17.
340............. 12 SURG *TESTES PROCEDURES, NON- .2828 2.4 2.4
MALIGNANCY AGE 0-17.
341............. 12 SURG PENIS PROCEDURES........... 1.1213 2.1 3.0
342............. 12 SURG CIRCUMCISION AGE >17....... .8601 2.6 3.5
343............. 12 SURG *CIRCUMCISION AGE 0-17..... .1536 1.7 1.7
344............. 12 SURG OTHER MALE REPRODUCTIVE 1.0395 1.8 2.6
SYSTEM O.R. PROCEDURES FOR
MALIGNANCY.
345............. 12 SURG OTHER MALE REPRODUCTIVE .8659 2.5 3.6
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............. 12 MED MALIGNANCY, MALE .9541 4.3 5.8
REPRODUCTIVE SYSTEM, W CC.
347............. 12 MED MALIGNANCY, MALE .5764 2.3 3.1
REPRODUCTIVE SYSTEM, W/O
CC.
348............. 12 MED BENIGN PROSTATIC .6894 3.2 4.3
HYPERTROPHY W CC.
349............. 12 MED BENIGN PROSTATIC .4142 2.1 2.8
HYPERTROPHY W/O CC.
350............. 12 MED INFLAMMATION OF THE MALE .6931 3.6 4.4
REPRODUCTIVE SYSTEM.
351............. 12 MED *STERILIZATION, MALE....... .2358 1.3 1.3
352............. 12 MED OTHER MALE REPRODUCTIVE .6279 2.7 3.6
SYSTEM DIAGNOSES.
353............. 13 SURG PELVIC EVISCERATION, 1.9243 5.6 6.9
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354............. 13 SURG UTERINE, ADNEXA PROC FOR 1.4969 4.8 5.8
NON-OVARIAN/ADNEXAL MALIG
W CC.
355............. 13 SURG UTERINE, ADNEXA PROC FOR .9332 3.2 3.5
NON-OVARIAN/ADNEXAL MALIG
W/O CC.
356............. 13 SURG FEMALE REPRODUCTIVE SYSTEM .7878 2.3 2.6
RECONSTRUCTIVE PROCEDURES.
357............. 13 SURG UTERINE & ADNEXA PROC FOR 2.4468 7.3 9.0
OVARIAN OR ADNEXAL
MALIGNANCY.
358............. 13 SURG UTERINE & ADNEXA PROC FOR 1.2133 3.7 4.4
NON-MALIGNANCY W CC.
359............. 13 SURG UTERINE & ADNEXA PROC FOR .8676 2.8 3.0
NON-MALIGNANCY W/O CC.
360............. 13 SURG VAGINA, CERVIX & VULVA .8910 2.6 3.2
PROCEDURES.
361............. 13 SURG LAPAROSCOPY & INCISIONAL 1.2140 2.3 3.3
TUBAL INTERRUPTION.
362............. 13 SURG *ENDOSCOPIC TUBAL .3014 1.4 1.4
INTERRUPTION.
[[Page 25654]]
363............. 13 SURG D&C, CONIZATION & RADIO- .7481 2.5 3.3
IMPLANT, FOR MALIGNANCY.
364............. 13 SURG D&C, CONIZATION EXCEPT FOR .7290 2.6 3.6
MALIGNANCY.
365............. 13 SURG OTHER FEMALE REPRODUCTIVE 1.7398 4.6 6.9
SYSTEM O.R. PROCEDURES.
366............. 13 MED MALIGNANCY, FEMALE 1.1946 4.8 6.9
REPRODUCTIVE SYSTEM W CC.
367............. 13 MED MALIGNANCY, FEMALE .5666 2.2 2.9
REPRODUCTIVE SYSTEM W/O CC.
368............. 13 MED INFECTIONS, FEMALE 1.0553 5.0 6.4
REPRODUCTIVE SYSTEM.
369............. 13 MED MENSTRUAL & OTHER FEMALE .5264 2.3 3.1
REPRODUCTIVE SYSTEM
DISORDERS.
370............. 14 SURG CESAREAN SECTION W CC...... 1.0533 4.3 5.5
371............. 14 SURG CESAREAN SECTION W/O CC.... .7197 3.2 3.5
372............. 14 MED VAGINAL DELIVERY W .5679 2.4 3.2
COMPLICATING DIAGNOSES.
373............. 14 MED VAGINAL DELIVERY W/O .3987 1.8 2.1
COMPLICATING DIAGNOSES.
374............. 14 SURG VAGINAL DELIVERY W .7188 2.1 3.0
STERILIZATION &/OR D&C.
375............. 14 SURG *VAGINAL DELIVERY W O.R. .6840 4.4 4.4
PROC EXCEPT STERIL &/OR
D&C.
376............. 14 MED POSTPARTUM & POST ABORTION .4925 2.4 2.9
DIAGNOSES W/O O.R.
PROCEDURE.
377............. 14 SURG POSTPARTUM & POST ABORTION 1.4598 3.4 4.5
DIAGNOSES W O.R. PROCEDURE.
378............. 14 MED ECTOPIC PREGNANCY.......... .8441 2.2 2.6
379............. 14 MED THREATENED ABORTION........ .4401 2.2 3.6
380............. 14 MED ABORTION W/O D&C........... .4235 1.7 2.0
381............. 14 SURG ABORTION W D&C, ASPIRATION .5583 1.6 2.1
CURETTAGE OR HYSTEROTOMY.
382............. 14 MED FALSE LABOR................ .1917 1.1 1.3
383............. 14 MED OTHER ANTEPARTUM DIAGNOSES .4732 2.7 3.7
W MEDICAL COMPLICATIONS.
384............. 14 MED OTHER ANTEPARTUM DIAGNOSES .3576 1.9 2.7
W/O MEDICAL COMPLICATIONS.
385............. 15 .................... *NEONATES, DIED OR 1.3728 1.8 1.8
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386............. 15 .................... *EXTREME IMMATURITY OR 4.5269 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387............. 15 .................... *PREMATURITY W MAJOR 3.0918 13.3 13.3
PROBLEMS.
388............. 15 .................... *PREMATURITY W/O MAJOR 1.8655 8.6 8.6
PROBLEMS.
389............. 15 .................... *FULL TERM NEONATE W MAJOR 1.4930 4.7 4.7
PROBLEMS.
390............. 15 .................... NEONATE W OTHER SIGNIFICANT 1.6281 4.2 6.0
PROBLEMS.
391............. 15 .................... *NORMAL NEWBORN............ .1522 3.1 3.1
392............. 16 SURG SPLENECTOMY AGE >17........ 3.2630 7.8 10.4
393............. 16 SURG *SPLENECTOMY AGE 0-17...... 1.3447 9.1 9.1
394............. 16 SURG OTHER O.R. PROCEDURES OF 1.6349 4.1 7.1
THE BLOOD AND BLOOD
FORMING ORGANS.
395............. 16 MED RED BLOOD CELL DISORDERS .8209 3.4 4.7
AGE >17.
396............. 16 MED RED BLOOD CELL DISORDERS 2.2655 5.5 18.5
AGE 0-17.
397............. 16 MED COAGULATION DISORDERS...... 1.2544 4.0 5.5
398............. 16 MED RETICULOENDOTHELIAL & 1.2457 4.7 6.0
IMMUNITY DISORDERS W CC.
399............. 16 MED RETICULOENDOTHELIAL & .6933 3.0 3.7
IMMUNITY DISORDERS W/O CC.
400............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 2.6552 6.1 9.4
O.R. PROCEDURE.
401............. 17 SURG LYMPHOMA & NON-ACUTE 2.5729 7.7 11.0
LEUKEMIA W OTHER O.R. PROC
W CC.
402............. 17 SURG LYMPHOMA & NON-ACUTE 1.0126 2.7 3.9
LEUKEMIA W OTHER O.R. PROC
W/O CC.
403............. 17 MED LYMPHOMA & NON-ACUTE 1.6817 5.8 8.2
LEUKEMIA W CC.
404............. 17 MED LYMPHOMA & NON-ACUTE .8288 3.2 4.5
LEUKEMIA W/O CC.
405............. 17 .................... *ACUTE LEUKEMIA W/O MAJOR 1.9065 4.9 4.9
O.R. PROCEDURE AGE 0-17.
406............. 17 SURG MYELOPROLIF DISORD OR 2.5701 6.9 9.5
POORLY DIFF NEOPL W MAJ
O.R.PROC W CC.
407............. 17 SURG MYELOPROLIF DISORD OR 1.1786 3.4 4.3
POORLY DIFF NEOPL W MAJ
O.R.PROC W/O CC.
408............. 17 SURG MYELOPROLIF DISORD OR 1.8039 4.6 7.5
POORLY DIFF NEOPL W OTHER
O.R.PROC.
409............. 17 MED RADIOTHERAPY............... 1.0112 4.3 5.8
410............. 17 MED CHEMOTHERAPY W/O ACUTE .8403 2.7 3.4
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............. 17 MED HISTORY OF MALIGNANCY W/O .3229 2.0 2.9
ENDOSCOPY.
412............. 17 MED HISTORY OF MALIGNANCY W .5222 1.9 2.3
ENDOSCOPY.
413............. 17 MED OTHER MYELOPROLIF DIS OR 1.3511 5.4 7.5
POORLY DIFF NEOPL DIAG W
CC.
414............. 17 MED OTHER MYELOPROLIF DIS OR .7210 3.1 4.2
POORLY DIFF NEOPL DIAG W/O
CC.
415............. 18 SURG O.R. PROCEDURE FOR 3.5656 10.5 14.4
INFECTIOUS & PARASITIC
DISEASES.
416............. 18 MED SEPTICEMIA AGE >17......... 1.4885 5.7 7.4
417............. 18 MED SEPTICEMIA AGE 0-17........ 1.3566 4.5 6.0
418............. 18 MED POSTOPERATIVE & POST- .9882 4.9 6.2
TRAUMATIC INFECTIONS.
419............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .8779 4.0 5.0
>17 W CC.
420............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .6351 3.2 4.0
>17 W/O CC.
421............. 18 MED VIRAL ILLNESS AGE >17...... .6757 3.1 4.0
[[Page 25655]]
422............. 18 MED VIRAL ILLNESS & FEVER OF .5729 2.6 3.3
UNKNOWN ORIGIN AGE 0-17.
423............. 18 MED OTHER INFECTIOUS & 1.6011 5.8 7.8
PARASITIC DISEASES
DIAGNOSES.
424............. 19 SURG O.R. PROCEDURE W PRINCIPAL 2.3280 9.0 14.3
DIAGNOSES OF MENTAL
ILLNESS.
425............. 19 MED ACUTE ADJUST REACT & .6791 3.0 4.1
DISTURBANCES OF
PSYCHOSOCIAL DYSFUNCTION.
426............. 19 MED DEPRESSIVE NEUROSES........ .5537 3.5 4.9
427............. 19 MED NEUROSES EXCEPT DEPRESSIVE. .5609 3.4 4.8
428............. 19 MED DISORDERS OF PERSONALITY & .7031 4.5 7.2
IMPULSE CONTROL.
429............. 19 MED ORGANIC DISTURBANCES & .8721 5.2 7.4
MENTAL RETARDATION.
430............. 19 MED PSYCHOSES.................. .8073 6.2 8.8
431............. 19 MED CHILDHOOD MENTAL DISORDERS. .7541 4.6 7.3
432............. 19 MED OTHER MENTAL DISORDER .7008 3.4 5.2
DIAGNOSES.
433............. 20 .................... ALCOHOL/DRUG ABUSE OR .3024 2.3 3.2
DEPENDENCE, LEFT AMA.
434............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .6998 3.9 5.2
DETOX OR OTH SYMPT TREAT W
CC.
435............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .4143 3.5 4.4
DETOX OR OTH SYMPT TREAT W/
O CC.
436............. 20 .................... ALC/DRUG DEPENDENCE W .8189 11.4 14.1
REHABILITATION THERAPY.
437............. 20 .................... ALC/DRUG DEPENDENCE, .7027 7.7 9.2
COMBINED REHAB & DETOX
THERAPY.
438............. ....... .................... NO LONGER VALID............ .0000 .0 .0
439............. 21 SURG SKIN GRAFTS FOR INJURIES... 1.5601 5.0 7.7
440............. 21 SURG WOUND DEBRIDEMENTS FOR 1.7978 5.7 8.9
INJURIES.
441............. 21 SURG HAND PROCEDURES FOR 1.0114 2.3 3.4
INJURIES.
442............. 21 SURG OTHER O.R. PROCEDURES FOR 2.2637 5.2 8.1
INJURIES W CC.
443............. 21 SURG OTHER O.R. PROCEDURES FOR .9271 2.5 3.3
INJURIES W/O CC.
444............. 21 MED TRAUMATIC INJURY AGE >17 W .7110 3.5 4.5
CC.
445............. 21 MED TRAUMATIC INJURY AGE >17 W/ .4790 2.6 3.4
O CC.
446............. 21 MED *TRAUMATIC INJURY AGE 0-17. .2955 2.4 2.4
447............. 21 MED ALLERGIC REACTIONS AGE >17. .4935 1.9 2.5
448............. 21 MED *ALLERGIC REACTIONS AGE 0- .0972 2.9 2.9
17.
449............. 21 MED POISONING & TOXIC EFFECTS .7848 2.7 3.8
OF DRUGS AGE >17 W CC.
450............. 21 MED POISONING & TOXIC EFFECTS .4333 1.6 2.1
OF DRUGS AGE >17 W/O CC.
451............. 21 MED *POISONING & TOXIC EFFECTS .2625 2.1 2.1
OF DRUGS AGE 0-17.
452............. 21 MED COMPLICATIONS OF TREATMENT .9785 3.6 5.0
W CC.
453............. 21 MED COMPLICATIONS OF TREATMENT .4855 2.2 2.9
W/O CC.
454............. 21 MED OTHER INJURY, POISONING & .8478 3.2 4.7
TOXIC EFFECT DIAG W CC.
455............. 21 MED OTHER INJURY, POISONING & .4694 2.0 2.7
TOXIC EFFECT DIAG W/O CC.
456............. ....... .................... NO LONGER VALID............ .0000 .0 .0
457............. ....... .................... NO LONGER VALID............ .0000 .0 .0
458............. ....... .................... NO LONGER VALID............ .0000 .0 .0
459............. ....... .................... NO LONGER VALID............ .0000 .0 .0
460............. ....... .................... NO LONGER VALID............ .0000 .0 .0
461............. 23 SURG O.R. PROC W DIAGNOSES OF 1.0644 2.4 4.4
OTHER CONTACT W HEALTH
SERVICES.
462............. 23 MED REHABILITATION............. 1.3849 10.1 12.6
463............. 23 MED SIGNS & SYMPTOMS W CC...... .6757 3.3 4.4
464............. 23 MED SIGNS & SYMPTOMS W/O CC.... .5006 2.6 3.4
465............. 23 MED AFTERCARE W HISTORY OF .5238 1.9 2.9
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466............. 23 MED AFTERCARE W/O HISTORY OF .6193 2.3 4.1
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............. 23 MED OTHER FACTORS INFLUENCING .4944 2.3 4.4
HEALTH STATUS.
468............. ....... .................... EXTENSIVE O.R. PROCEDURE 3.6566 9.5 13.5
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 3.3201 5.3 6.1
JOINT PROCS OF LOWER
EXTREMITY.
472............. ....... .................... NO LONGER VALID............ .0000 .0 .0
473............. 17 .................... ACUTE LEUKEMIA W/O MAJOR 3.4688 7.6 13.0
O.R. PROCEDURE AGE >17.
474............. ....... .................... NO LONGER VALID............ .0000 .0 .0
475............. 04 MED RESPIRATORY SYSTEM 3.7373 8.1 11.3
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............. ....... SURG PROSTATIC O.R. PROCEDURE 2.2226 8.9 11.9
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............. ....... SURG NON-EXTENSIVE O.R. 1.7581 5.3 8.2
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............. 05 SURG OTHER VASCULAR PROCEDURES W 2.3334 5.1 7.5
CC.
479............. 05 SURG OTHER VASCULAR PROCEDURES W/ 1.4224 3.0 3.8
O CC.
480............. ....... SURG LIVER TRANSPLANT........... 10.6455 19.4 26.8
481............. ....... SURG BONE MARROW TRANSPLANT..... 9.7725 24.5 27.2
[[Page 25656]]
482............. ....... SURG TRACHEOSTOMY FOR FACE, 3.5950 10.0 12.8
MOUTH & NECK DIAGNOSES.
483............. ....... SURG TRACHEOSTOMY EXCEPT FOR 16.2677 33.9 42.1
FACE, MOUTH & NECK
DIAGNOSES.
484............. 24 SURG CRANIOTOMY FOR MULTIPLE 5.3170 9.5 14.8
SIGNIFICANT TRAUMA.
485............. 24 SURG LIMB REATTACHMENT, HIP AND 3.0440 7.7 9.6
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TR.
486............. 24 SURG OTHER O.R. PROCEDURES FOR 4.9559 8.4 12.4
MULTIPLE SIGNIFICANT
TRAUMA.
487............. 24 MED OTHER MULTIPLE SIGNIFICANT 1.9036 5.4 7.5
TRAUMA.
488............. 25 SURG HIV W EXTENSIVE O.R. 4.5576 11.9 17.2
PROCEDURE.
489............. 25 MED HIV W MAJOR RELATED 1.7700 6.2 8.9
CONDITION.
490............. 25 MED HIV W OR W/O OTHER RELATED .9720 3.9 5.4
CONDITION.
491............. 08 SURG MAJOR JOINT & LIMB 1.6670 3.1 3.7
REATTACHMENT PROCEDURES OF
UPPER EXTREMITY.
492............. 17 MED CHEMOTHERAPY W ACUTE 4.5197 11.4 17.2
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493............. 07 SURG LAPAROSCOPIC 1.7952 4.2 5.6
CHOLECYSTECTOMY W/O C.D.E.
W CC.
494............. 07 SURG LAPAROSCOPIC .9989 1.9 2.4
CHOLECYSTECTOMY W/O C.D.E.
W/O CC.
495............. ....... SURG LUNG TRANSPLANT............ 9.0247 13.7 17.0
496............. 08 SURG COMBINED ANTERIOR/POSTERIOR 5.4507 8.6 10.6
SPINAL FUSION.
497............. 08 SURG SPINAL FUSION W CC......... 2.7585 5.0 6.3
498............. 08 SURG SPINAL FUSION W/O CC....... 1.6870 2.9 3.5
499............. 08 SURG BACK & NECK PROCS EXCEPT 1.4669 3.8 5.0
SPINAL FUSION W CC.
500............. 08 SURG BACK & NECK PROCS EXCEPT .9709 2.4 2.9
SPINAL FUSION W/O CC.
501............. 08 SURG KNEE PROC W PDX OF 2.5459 8.4 10.4
INFECTION W CC.
502............. 08 SURG KNEE PROC W PDX OF 1.5548 5.5 6.6
INFECTION W/O CC.
503............. 08 SURG KNEE PROCEDURES W/O PDX OF 1.2316 3.2 4.2
INFECTION.
504............. 22 SURG EXTENSIVE 3RD DEGREE BURN W 13.9440 23.1 31.6
SKIN GRAFT.
505............. 22 .................... EXTENSIVE 3RD DEGREE BURN W/ 1.7871 2.3 5.9
O SKIN GRAFT.
506............. 22 .................... FULL THICK BURN W SK GRAFT 4.2300 12.2 16.8
OR INHAL INJ W CC OR SIG
TR.
507............. 22 .................... FULL THICK BURN W SK GRAFT 1.7017 6.5 9.0
OR INHAL INJ W/O CC OR SIG
TR.
508............. 22 .................... FULL THICK BURN W/O SK 1.3792 5.2 7.8
GRAFT OR INHAL INJ W CC OR
SIG TR.
509............. 22 .................... FULL THICK BURN W/O SK .7376 3.3 4.9
GRAFT OR INHAL INJ W/O CC
OR SIG TR.
510............. 22 .................... NON-EXTENSIVE BURNS W CC OR 1.1408 4.8 6.9
SIGNIFICANT TRAUMA.
511............. 22 .................... NON-EXTENSIVE BURNS W/O CC .6001 3.5 4.8
OR SIGNIFICANT TRAUMA.
----------------------------------------------------------------------------------------------------------------
* Medicare data have been supplemented by data from 19 states for low volume DRGs.
** DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is used only to determine payment for outlier cases.
Note: Relative weights are based on medicare patient data and may not be appropriate for other patients.
Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
codes Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
337.3....... Autonomic dysreflexia..... N 1 18,19
438.53...... Other paralytic syndrome, N 1 12
bilateral.
482.40...... Pneumonia due to Y 4 79, 80, 81 \1\
Staphyloccus, unspecified. 5 121
15 387, 389,\2\ 489 \3\
25
482.41...... Pneumonia due to Y 4 79, 80, 81
Staphylococcus aureus. 5 121 \1\
15 387, 389 \2\
25 489 \3\
482.49...... Other Staphylococcus Y 4 79, 80, 81
pneumonia. 5 121 \1\
15 387, 389 \2\
25 489 \3\
518.83...... Chronic respiratory Y 4 87
failure.
518.84...... Acute and chronic Y 4 87
respiratory. 22 506, 507
519.00...... Unspecified tracheostomy Y Pre 482
complication. 4 101, 102
519.01...... Infection of tracheostomy. Y Pre 482
4 101, 102
519.02...... Mechanical complication of Y Pre 482
tracheostomy. 4 101, 102
519.09...... Other tracheostomy Y Pre 482
complication. 4 101, 102
[[Page 25657]]
536.40...... Unspecified gastrostomy Y 6 188, 189, 190
complication.
536.41...... Infection of gastrostomy.. Y 6 188, 189, 190
536.42...... Mechanical complication of Y 6 188, 189, 190
gastrostomy.
536.49...... Other gastrostomy Y 6 188, 189, 190
complication.
564.81...... Neurogenic bowel.......... N 6 182, 183, 184
564.89...... Other functional disorders N 6 182, 183, 184
of intestine.
569.62...... Mechanical complication of Y 6 188, 189, 190
colostomy and enterostomy.
659.70...... Abnormality in fetal heart N 14 370, 371, 372, 373, 374, 375
rate/rhythm, unspecified
as to episode of care or
not applicable.
659.71...... Abnormality in fetal heart N 14 370, 371, 372, 373, 374, 375
rate/rhythm, delivered,
with or without mention
of antepartum condition.
659.73...... Abnormality in fetal heart N 14 383, 384
rate/rhythm, antepartum
condition or complication.
763.81...... Abnormality in fetal heart N 15 390
rate or rhythm before the
onset of labor.
763.82...... Abnormality in fetal heart N 15 390
rate or rhythm during
labor.
763.83...... Abnormality in N 15 390
fetal heart rate or
rhythm, unspecified as to
time of onset.
763.89...... Other specified N 15 390
complications of labor
and delivery affecting
fetus and newborn.
780.71...... Chronic fatigue syndrome.. N 23 463, 464
25 490
780.79...... Other malaise and N 23 463, 464
fatigue. 25 490
786.03...... Apnea..................... Y 4 99, 100
25 490
786.04...... Cheyne-Stokes respiration. Y 4 99, 100
25 490
786.05...... Shortness of breath....... N 4 99, 100
25 490
786.06...... Tachypnea................. N 4 99, 100
25 490
786.07...... Wheezing.................. N 4 99, 100
25 490
965.61...... Poisoning by propionic N 21 449, 450, 451
acid derivatives.
965.69...... Poisoning by other N 21 449, 450, 451
antirheumatics.
995.86...... Malignant hyperthermia.... Y 21 454, 455
996.55...... Mechanical complications Y 21 452, 453
due to artificial skin
graft and decellularized
allodermis.
996.56...... Mechanical complications Y 21 452, 453
due to peritoneal
dialysis catheter.
996.68...... Infection and inflammatory Y 21 452, 453
reaction due to
peritoneal dialysis
catheter.
V02.51...... Carrier or suspected N 23 467
carrier of Group B
streptococcus.
V02.52...... Carrier or suspected N 23 467
carrier of other
streptococcus.
V02.59...... Carrier or suspected N 23 467
carrier of other
specified bacterial
diseases.
V10.48...... Personal history of N 17 411, 412
malignant neoplasm of
epididymis.
V13.61...... Personal history of N 23 467
hypospadias.
V13.69...... Personal history other N 23 467
congenital malformation.
V16.51...... Family history of N 23 467
malignant neoplasm of
kidney.
V16.59...... Family history of N 23 467
malignant neoplasm of
other urinary organs.
V18.61...... Family history of N 23 467
polycystic kidney.
V18.69...... Family history of other N 23 467
kidney diseases.
V23.81...... Supervision of high-risk Y 14 469
pregnancy of elderly
primigravida.
V23.82...... Supervision of high-risk Y 14 469
pregnancy of elderly
multigravida.
V23.83...... Supervision of high-risk Y 14 469
pregnancy of young
primigravida.
V23.84...... Supervision of high-risk Y 14 469
pregnancy of young
multigravida.
V23.89...... Supervision of other high- Y 14 469
risk pregnancy.
V26.51...... Tubal ligation status..... N 23 467
V26.52...... Vasectomy status.......... N 23 467
V29.3....... Observation for suspected N 23 467
genetic or metabolic
condition.
V43.83...... Organ or tissue replaced N 23 467
by artificial skin.
V44.50...... Unspecified cystostomy N 23 467
status.
V44.51...... Cutaneous-vesicostomy N 23 467
status.
V44.52...... Appendico-vesicostomy N 23 467
status.
V44.59...... Other cystostomy status... N 23 467
V56.2....... Fitting and adjustment of N 11 317
peritoneal dialysis
catheter.
V58.62...... Encounter for aftercare N 23 465, 466
for long-term (current)
use of antibiotics.
V76.44...... Special screening for N 23 467
malignant neoplasm of
prostate.
V76.45...... Special screening for N 23 467
malignant neoplasm of
testis.
----------------------------------------------------------------------------------------------------------------
\1\ Classified as a ``major complication'' in this DRG.
\2\ Classified as a ``major problem'' in these DRGs.
\3\ HIV major related condition in this DRG.
[[Page 25658]]
Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
36.31....... Open chest transmyocardial Y 5 108
revascularization.
36.32....... Other transmyocardial Y 5 108
revascularization.
36.39....... Other heart Y 5 108
revascularization.
37.67....... Implantation of Y 5 110, 111
cardiomyostimulation 21 442, 443
system. 24 486
75.37....... Amnioinfusion............. N
86.67....... Dermal regenerative graft. Y 1 7, 8
3 63
5 120
6 170, 171
8 217
9 263, 264, 265,
10 266
21 287
22 439
24 458, 472
504, 506, 507
486
92.30....... Stereotactic radiosurgery, N \1\ 1 7, 8
not otherwise specified. 10 292, 293
17 401, 402, 408
92.31....... Single source photon N 1 7, 8
radiosurgery. 10 292, 293
17 401, 402, 408
92.32....... Multi-source photon N 1 7, 8
radiosurgery. 10 292, 293
17 401, 402, 408
92.33....... Particulate radiosurgery.. N 1 7, 8
10 292, 293
17 401, 402, 408
92.39....... Stereotactic radiosurgery, N 1 7, 8
not elsewhere classified. 10 292, 293
17 401, 402, 408
96.29....... Reduction of N
intussusception of
alimentary tract.
99.10....... Injection or infusion of N
thrombolytic agent.
99.20....... Injection or infusion of N
platelet inhibitor.
----------------------------------------------------------------------------------------------------------------
\1\ Nonoperating room, but affecting DRG
Table 6C.--Invalid Diagnosis Code
----------------------------------------------------------------------------------------------------------------
Diagnosis
codes Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
482.4....... Pneumonia due to Y 4 79, 80, 81
Staphylococcus. 5 121 \1\
15 387, 389 \2\
25 489 \3\
519.0....... Tracheostomy complication. Y PRE 482
4 101, 102
564.8....... Other specified functional N 6 182, 183, 184
disorders of intestine.
763.8....... Other specified N 15 390
complications of labor
and delivery affecting
fetus and newborn.
780.7....... Malaise and fatigue....... N 23 463, 464
25 490
965.6....... Poisoning by N 21 449, 450, 451
antirheumatics
[antiphlogistics].
V02.5....... Carrier or suspected N 23 467
carrier of other
specified bacterial
diseases.
V13.6....... Personal history of N 23 467
congenital malformations.
V16.5....... Family history of N 23 467
malignant neoplasm of
urinary organs.
V18.6....... Family history of kidney N 23 467
diseases.
V23.8....... Supervision of other high- Y 14 469
risk pregnancy.
V44.5....... Cystostomy status......... N 23 467
----------------------------------------------------------------------------------------------------------------
\1\ Classified as a ``major complication'' in this DRG.
\2\ Classified as a ``major problem'' in these DRGs.
\3\ HIV major related condition in this DRG.
[[Page 25659]]
Table 6D.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
36.3........ Other heart Y 5 108
revascularization.
92.3........ Stereotactic radiosurgery. N \1\ 1 7, 8
10 292, 293
17 401, 402, 408
----------------------------------------------------------------------------------------------------------------
\1\ Nonoperation room but effecting DRG.
Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
518.81...... Acute respiratory failure. Y 4 87
22 506, 507
659.60...... Elderly multigravida N 14 370, 371, 372, 373, 374, 375
unspecified as to episode
of care or not applicable.
659.61...... Elderly multigravida N 14 370, 371, 372, 373, 374, 375
delivered, with mention
of antepartum condition.
659.63...... Elderly multigravida with N 14 383, 384
antepartum condition or
complication.
V56.1....... Fitting and adjustment of N 11 317
extracorporeal dialysis
catheter.
V82.4....... Maternal postnatal N 23 467
screening of chromosomal
anomalies.
----------------------------------------------------------------------------------------------------------------
[[Page 25660]]
Table 6F.--Additions to the CC Exclusions List
Page 1 of 3 Pages
CCs that are added to the list are in Table 6F--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.
------------------------------------------------------------------------
------------------------------------------------------------------------
*01100 *01123 *01146 *01172 *01195 *01281 *11515 48249
48240 48240 48240 48240 48240 48240 48240 *48230
48241 48241 48241 48241 48241 48241 48241 48240
48249 48249 48249 48249 48249 48249 48249 48241
*01101 *01124 *01150 *01173 *01196 *01282 *11595 48249
48240 48240 48240 48240 48240 48240 48240 *48231
48241 48241 48241 48241 48241 48241 48241 48240
48249 48249 48249 48249 48249 48249 48249 48241
*01102 *01125 *01151 *01174 *01200 *01283 *1221 48249
48240 48240 48240 48240 48240 48240 48240 *48232
48241 48241 48241 48241 48241 48241 48241 48240
48249 48249 48249 48249 48249 48249 48249 48241
*01103 *01126 *01152 *01175 *01201 *01284 *1304 48249
48240 48240 48240 48240 48240 48240 48240 *48239
48241 48241 48241 48241 48241 48241 48241 48240
48249 48249 48249 48249 48249 48249 48249 48241
*01104 *01130 *01153 *01176 *01202 *01285 *1363 48249
48240 48240 48240 48240 48240 48240 48240 *48240
48241 48241 48241 48241 48241 48241 48241 01100
48249 48249 48249 48249 48249 48249 48249 01101
*01105 *01131 *01154 *01180 *01203 *01286 *3373 01102
48240 48240 48240 48240 48240 48240 3350 01103
48241 48241 48241 48241 48241 48241 33510 01104
48249 48249 48249 48249 48249 48249 33511 01105
*01106 *01132 *01155 *01181 *01204 *01790 33519 01106
48240 48240 48240 48240 48240 48240 33520 01110
48241 48241 48241 48241 48241 48241 33521 01111
48249 48249 48249 48249 48249 48249 33522 01112
*01110 *01133 *01156 *01182 *01205 *01791 33523 01113
48240 48240 48240 48240 48240 48240 33524 01114
48241 48241 48241 48241 48241 48241 33529 01115
48249 48249 48249 48249 48249 48249 3358 01116
*01111 *01134 *01160 *01183 *01206 *01792 3359 01120
48240 48240 48240 48240 48240 48240 *4800 01121
48241 48241 48241 48241 48241 48241 48240 01122
48249 48249 48249 48249 48249 48249 48241 01123
*01112 *01135 *01161 *01184 *01210 *01793 48249 01124
48240 48240 48240 48240 48240 48240 *4801 01125
48241 48241 48241 48241 48241 48241 48240 01126
48249 48249 48249 48249 48249 48249 48241 01130
*01113 *01136 *01162 *01185 *01211 *01794 48249 01131
48240 48240 48240 48240 48240 48240 *4802 01132
48241 48241 48241 48241 48241 48241 48240 01133
48249 48249 48249 48249 48249 48249 48241 01134
*01114 *01140 *01163 *01186 *01212 *01795 48249 01135
48240 48240 48240 48240 48240 48240 *4808 01136
48241 48241 48241 48241 48241 48241 48240 01140
48249 48249 48249 48249 48249 48249 48241 01141
*01115 *01141 *01164 *01190 *01213 *01796 48249 01142
48240 48240 48240 48240 48240 48240 *4809 01143
48241 48241 48241 48241 48241 48241 48240 01144
48249 48249 48249 48249 48249 48249 48241 01145
*01116 *01142 *01165 *01191 *01214 *0212 48249 01146
48240 48240 48240 48240 48240 48240 *481 01150
48241 48241 48241 48241 48241 48241 48240 01151
48249 48249 48249 48249 48249 48249 48241 01152
*01120 *01143 *01166 *01192 *01215 *0310 48249 01153
48240 48240 48240 48240 48240 48240 *4820 01154
48241 48241 48241 48241 48241 48241 48240 01155
48249 48249 48249 48249 48249 48249 48241 01156
*01121 *01144 *01170 *01193 *01216 *0391 48249 01160
48240 48240 48240 48240 48240 48240 *4821 01161
48241 48241 48241 48241 48241 48241 48240 01162
48249 48249 48249 48249 48249 48249 48241 01163
*01122 *01145 *01171 *01194 *01280 *11505 48249 01164
48240 48240 48240 48240 48240 48240 *4822 01165
48241 48241 48241 48241 48241 48241 48240 01166
48249 48249 48249 48249 48249 48249 48241 01170
------------------------------------------------------------------------
[[Page 25661]]
Page 2 of 3 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
01171 4955 01183 5078 01195 48240 48241 48249
01172 4956 01184 5080 01196 48241 48249 *5061
01173 4957 01185 5081 01200 48249 *4950 48240
01174 4958 01186 5171 01201 *48283 48240 48241
01175 4959 01190 *48249 01202 48240 48241 48249
01176 5060 01191 01100 01203 48241 48249 *5062
01180 5061 01192 01101 01204 48249 *4951 48240
01181 5070 01193 01102 01205 *48284 48240 48241
01182 5071 01194 01103 01206 48240 48241 48249
01183 5078 01195 01104 01210 48241 48249 *5063
01184 5080 01196 01105 01211 48249 *4952 48240
01185 5081 01200 01106 01212 *48289 48240 48241
01186 5171 01201 01110 01213 48240 48241 48249
01190 *48241 01202 01111 01214 48241 48249 *5064
01191 01100 01203 01112 01215 48249 *4953 48240
01192 01101 01204 01113 01216 *4829 48240 48241
01193 01102 01205 01114 0310 48240 48241 48249
01194 01103 01206 01115 11505 48241 48249 *5069
01195 01104 01210 01116 11515 48249 *4954 48240
01196 01105 01211 01120 1304 *4830 48240 48241
01200 01106 01212 01121 1363 48240 48241 48249
01201 01110 01213 01122 481 48241 48249 *5070
01202 01111 01214 01123 4820 48249 *4955 48240
01203 01112 01215 01124 4821 *4831 48240 48241
01204 01113 01216 01125 4822 48240 48241 48249
01205 01114 0310 01126 48230 48241 48249 *5071
01206 01115 11505 01130 48231 48249 *4956 48240
01210 01116 11515 01131 48232 *4838 48240 48241
01211 01120 1304 01132 48239 48240 48241 48249
01212 01121 1363 01133 48240 48241 48249 *5078
01213 01122 481 01134 48241 48249 *4957 48240
01214 01123 4820 01135 48249 *4841 48240 48241
01215 01124 4821 01136 48281 48240 48241 48249
01216 01125 4822 01140 48282 48241 48249 *5080
0310 01126 48230 01141 48283 48249 *4958 48240
11505 01130 48231 01142 48284 *4843 48240 48241
11515 01131 48232 01143 48289 48240 48241 48249
1304 01132 48239 01144 4829 48241 48249 *5081
1363 01133 48240 01145 4830 48249 *4959 48240
481 01134 48241 01146 4831 *4845 48240 48241
4820 01135 48249 01150 4838 48240 48241 48249
4821 01136 48281 01151 4841 48241 48249 *5088
4822 01140 48282 01152 4843 48249 *496 48240
48230 01141 48283 01153 4845 *4846 48240 48241
48231 01142 48284 01154 4846 48240 48241 48249
48232 01143 48289 01155 4847 48241 48249 *5089
48239 01144 4829 01156 4848 48249 *500 48240
48240 01145 4830 01160 485 *4847 48240 48241
48241 01146 4831 01161 486 48240 48241 48249
48249 01150 4838 01162 4870 48241 48249 *5171
48281 01151 4841 01163 4950 48249 *501 48240
48282 01152 4843 01164 4951 *4848 48240 48241
48283 01153 4845 01165 4952 48240 48241 48249
48284 01154 4846 01166 4953 48241 48249 *5178
48289 01155 4847 01170 4954 48249 *502 48240
4829 01156 4848 01171 4955 *485 48240 48241
4830 01160 485 01172 4956 48240 48241 48249
4831 01161 486 01173 4957 48241 48249 *51881
4838 01162 4870 01174 4958 48249 *503 51883
4841 01163 4950 01175 4959 *486 48240 51884
4843 01164 4951 01176 5060 48240 48241 78603
4845 01165 4952 01180 5061 48241 48249 78604
4846 01166 4953 01181 5070 48249 *504 *51882
4847 01170 4954 01182 5071 *4870 48240 51883
4848 01171 4955 01183 5078 48240 48241 51884
485 01172 4956 01184 5080 48241 48249 78603
486 01173 4957 01185 5081 48249 *505 78604
4870 01174 4958 01186 5171 *4871 48240 *51883
4950 01175 4959 01190 *48281 48240 48241 51881
4951 01176 5060 01191 48240 48241 48249 51882
4952 01180 5061 01192 48241 48249 *5060 51883
4953 01181 5070 01193 48249 *494 48240 51884
4954 01182 5071 01194 *48282 48240 48241 78603
------------------------------------------------------------------------
[[Page 25662]]
Page 3 of 3 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
78604 53642 *99656 56962 V2384 V2384
7991 53649 99655 *99791 V2389 V2389
*51884 56962 99656 53640 *V230 V239
51881 9974 99659 53641 V2381 *V2389
51882 *53642 99660 53642 V2382 V237
51883 53640 99661 53649 V2383 V2381
51884 53641 99662 56962 V2384 V2382
78603 53642 99663 99586 V2389 V2383
78604 53649 99664 99655 *V231 V2384
7991 56962 99665 99656 V2381 V2389
*51889 9974 99666 99668 V2382 V239
48240 *53649 99667 *99799 V2383 *V239
48241 53640 99668 53640 V2384 V2381
48249 53641 99669 53641 V2389 V2382
*51900 53642 99670 53642 *V232 V2383
51900 53649 99671 53649 V2381 V2384
51901 56962 99672 56962 V2382 V2389
51902 9974 99673 99586 V2383
51909 *56960 99674 99655 V2384
*51901 56962 99675 99656 V2389
51900 *56961 99676 99668 *V233
51901 56962 99677 *9980 V2381
51902 *56962 99678 99586 V2382
51909 56960 99679 *99811 V2383
*51902 56961 *99659 99586 V2384
51900 56962 99655 *99812 V2389
51901 56969 99656 99586 *V234
51902 *56969 99668 *99813 V2381
51909 56962 *99660 99586 V2382
*51909 *74861 99655 *99881 V2383
51900 48240 99656 53640 V2384
51901 48241 99668 53641 V2389
51902 48249 *99668 53642 *V235
51909 *78603 99655 53649 V2381
*5191 78603 99656 56962 V2382
51900 78604 99659 99586 V2383
51901 *78604 99660 *99883 V2384
51902 78603 99661 53640 V2389
51909 78604 99662 53641 *V237
*5198 *7991 99663 53642 V2381
48240 51883 99664 53649 V2382
48241 51884 99665 56962 V2383
48249 78603 99666 99586 V2384
51883 78604 99667 *99889 V2389
51884 *9584 99668 53640 *V2381
51900 99586 99669 53641 V237
51901 *9954 99670 53642 V2381
51902 99586 99671 53649 V2382
51909 *99586 99672 56962 V2383
78603 99586 99673 99586 V2384
78604 *99652 99674 *9989 V2389
*5199 99655 99675 53640 V239
48240 *99655 99676 53641 *V2382
48241 99652 99677 53642 V237
48249 99655 99678 53649 V2381
51883 99660 99679 56962 V2382
51884 99661 *99669 99586 V2383
51900 99662 99655 *V220 V2384
51901 99663 99656 V2381 V2389
51902 99665 99668 V2382 V239
51909 99666 *99670 V2383 *V2383
78603 99667 99655 V2384 V237
78604 99669 99656 V2389 V2381
*53640 99670 99668 *V221 V2382
53640 99671 *99679 V2381 V2383
53641 99672 99655 V2382 V2384
53642 99673 99656 V2383 V2389
53649 99674 99668 V2384 V239
56962 99675 *9974 V2389 *V2384
9974 99676 53640 *V222 V237
*53641 99677 53641 V2381 V2381
53640 99678 53642 V2382 V2382
53641 99679 53649 V2383 V2383
------------------------------------------------------------------------
[[Page 25663]]
Table 6G.--Deletions to the CC Exclusions List
[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.]
------------------------------------------------------------------------
------------------------------------------------------------------------
*01100 *01146 *01195 *11515 01143 48282 4824 4824
4824 4824 4824 4824 01144 48283 *4870 *5178
*01101 *01150 *01196 *11595 01145 48284 4824 4824
4824 4824 4824 4824 01146 48289 *4871 *51889
*01102 *01151 *01200 *1221 01150 4829 4824 4824
4824 4824 4824 4824 01151 4830 *494 *5190
*01103 *01152 *01201 *1304 01152 4831 4824 5190
4824 4824 4824 4824 01153 4838 *4950 *5191
*01104 *01153 *01202 *1363 01154 4841 4824 5190
4824 4824 4824 4824 01155 4843 *4951 *5198
*01105 *01154 *01203 *4800 01156 4845 4824 4824
4824 4824 4824 4824 01160 4846 *4952 5190
*01106 *01155 *01204 *4801 01161 4847 4824 *5199
4824 4824 4824 4824 01162 4848 *4953 4824
*01110 *01156 *01205 *4802 01163 485 4824 5190
4824 4824 4824 4824 01164 486 *4954 *74861
*01111 *01160 *01206 *4808 01165 4870 4824 4824
4824 4824 4824 4824 01166 4950 *4955 *V220
*01112 *01161 *01210 *4809 01170 4951 4824 V238
4824 4824 4824 4824 01171 4952 *4956 *V221
*01113 *01162 *01211 *481 01172 4953 4824 V238
4824 4824 4824 4824 01173 4954 *4957 *V222
*01114 *01163 *01212 *4820 01174 4955 4824 V238
4824 4824 4824 4824 01175 4956 *4958 *V230
*01115 *01164 *01213 *4821 01176 4957 4824 V238
4824 4824 4824 4824 01180 4958 *4959 *V231
*01116 *01165 *01214 *4822 01181 4959 4824 V238
4824 4824 4824 4824 01182 5060 *496 *V232
*01120 *01166 *01215 *48230 01183 5061 4824 V238
4824 4824 4824 4824 01184 5070 *500 *V233
*01121 *01170 *01216 *48231 01185 5071 4824 V238
4824 4824 4824 4824 01186 5078 *501 *V234
*01122 *01171 *01280 *48232 01190 5080 4824 V238
4824 4824 4824 4824 01191 5081 *502 *V235
*01123 *01172 *01281 *48239 01192 5171 4824 V238
4824 4824 4824 4824 01193 *48281 *503 *V237
*01124 *01173 *01282 *4824 01194 4824 4824 V238
4824 4824 4824 01100 01195 *48282 *504 *V238
*01125 *01174 *01283 01101 01196 4824 4824 V237
4824 4824 4824 01102 01200 *48283 *505 V238
*01126 *01175 *01284 01103 01201 4824 4824 V239
4824 4824 4824 01104 01202 *48284 *5060 *V239
*01130 *01176 *01285 01105 01203 4824 4824 V238
4824 4824 4824 01106 01204 *48289 *5061
*01131 *01180 *01286 01110 01205 4824 4824
4824 4824 4824 01111 01206 *4829 *5062
*01132 *01181 *01790 01112 01210 4824 4824
4824 4824 4824 01113 01211 *4830 *5063
*01133 *01182 *01791 01114 01212 4824 4824
4824 4824 4824 01115 01213 *4831 *5064
*01134 *01183 *01792 01116 01214 4824 4824
4824 4824 4824 01120 01215 *4838 *5069
*01135 *01184 *01793 01121 01216 4824 4824
4824 4824 4824 01122 0310 *4841 *5070
*01136 *01185 *01794 01123 11505 4824 4824
4824 4824 4824 01124 11515 *4843 *5071
*01140 *01186 *01795 01125 1304 4824 4824
4824 4824 4824 01126 1363 *4845 *5078
*01141 *01190 *01796 01130 481 4824 4824
4824 4824 4824 01131 4820 *4846 *5080
*01142 *01191 *0212 01132 4821 4824 4824
4824 4824 4824 01133 4822 *4847 *5081
*01143 *01192 *0310 01134 48230 4824 4824
4824 4824 4824 01135 48231 *4848 *5088
*01144 *01193 *0391 01136 48232 4824 4824
4824 4824 4824 01140 48239 *485 *5089
*01145 *01194 *11505 01141 4824 4824 4824
4824 4824 4824 01142 48281 *486 *5171
------------------------------------------------------------------------
[[Page 25664]]
Table 7A.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay
[FY97 MEDPAR Update 12/97 Grouper V15.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36587 9.6084 2 4 7 12 20
2....................................... 6967 10.0350 3 5 8 13 20
3....................................... 3 9.3333 7 7 9 12 12
4....................................... 6322 7.7259 1 3 5 9 17
5....................................... 101105 3.6387 1 2 2 4 8
6....................................... 355 3.0225 1 1 2 4 7
7....................................... 12601 10.0945 2 4 7 12 20
8....................................... 3030 3.1845 1 1 2 4 7
9....................................... 1692 6.4923 1 3 5 8 13
10...................................... 19727 6.8631 2 3 5 8 14
11...................................... 2960 4.1365 1 2 3 5 8
12...................................... 38339 6.6619 2 3 5 8 12
13...................................... 6315 5.4716 2 3 4 6 9
14...................................... 372136 6.2938 2 3 5 8 12
15...................................... 145631 3.8599 1 2 3 5 7
16...................................... 13905 5.9283 2 3 4 7 11
17...................................... 3212 3.4315 1 2 3 4 7
18...................................... 27489 5.5809 2 3 4 7 10
19...................................... 7294 3.8174 1 2 3 5 7
20...................................... 6590 10.1862 2 5 8 13 19
21...................................... 1369 6.8152 2 3 5 8 14
22...................................... 2789 4.6587 2 2 4 6 9
23...................................... 6884 4.2594 1 2 3 5 8
24...................................... 57890 5.0641 1 2 4 6 10
25...................................... 22696 3.4294 1 2 3 4 7
26...................................... 34 3.1176 1 1 2 4 6
27...................................... 4153 5.4211 1 1 3 7 12
28...................................... 13896 5.9431 1 2 4 7 12
29...................................... 4266 3.5375 1 1 3 4 7
31...................................... 3075 4.4062 1 2 3 5 8
32...................................... 1343 2.9717 1 1 2 3 6
34...................................... 20072 5.4331 1 3 4 7 11
35...................................... 4264 3.5561 1 2 3 4 7
36...................................... 5393 1.5366 1 1 1 1 2
37...................................... 1685 3.7187 1 1 2 4 8
38...................................... 116 2.5948 1 1 2 3 5
39...................................... 1898 2.0327 1 1 1 2 4
40...................................... 2281 3.1806 1 1 2 4 7
42...................................... 4026 2.0904 1 1 1 2 4
43...................................... 120 3.4250 1 2 3 5 7
44...................................... 1343 5.0551 2 3 4 6 9
45...................................... 2414 3.4731 1 2 3 4 6
46...................................... 3148 4.6436 1 2 4 6 9
47...................................... 1220 3.2975 1 1 3 4 7
48...................................... 2 4.5000 4 4 5 5 5
49...................................... 2277 5.0097 1 2 4 6 9
50...................................... 3004 1.9767 1 1 2 2 3
51...................................... 299 2.8194 1 1 1 3 6
52...................................... 89 2.7528 1 1 2 3 7
53...................................... 2989 3.6554 1 1 2 4 8
54...................................... 2 6.0000 5 5 7 7 7
55...................................... 1686 2.9543 1 1 2 3 6
56...................................... 684 2.8436 1 1 2 3 6
57...................................... 608 3.7237 1 1 3 4 7
59...................................... 120 2.4333 1 1 2 3 5
60...................................... 1 4.0000 4 4 4 4 4
61...................................... 278 4.5144 1 1 2 5 10
62...................................... 4 1.2500 1 1 1 1 2
63...................................... 3676 4.4502 1 2 3 5 9
64...................................... 3408 6.7183 1 2 5 8 14
65...................................... 29086 2.9715 1 2 2 4 5
66...................................... 6812 3.2606 1 2 3 4 6
67...................................... 489 3.7996 1 2 3 4 7
68...................................... 11522 4.1519 1 2 3 5 7
69...................................... 3450 3.3183 1 2 3 4 6
70...................................... 37 2.5405 1 1 2 3 4
71...................................... 99 3.9394 1 2 3 6 7
72...................................... 817 3.7931 1 2 3 5 7
73...................................... 6282 4.4062 1 2 3 6 8
74...................................... 2 2.5000 2 2 3 3 3
[[Page 25665]]
75...................................... 40757 10.2370 4 5 8 13 20
76...................................... 41668 11.3195 3 5 9 14 21
77...................................... 2040 4.8819 1 2 4 7 10
78...................................... 30845 7.3107 3 5 7 9 12
79...................................... 247000 8.4030 3 4 7 10 15
80...................................... 8299 5.8754 2 3 5 7 10
81...................................... 6 12.6667 2 3 6 8 8
82...................................... 71035 7.1298 2 3 6 9 14
83...................................... 7249 5.5655 2 3 4 7 10
84...................................... 1290 3.3256 1 2 3 4 6
85...................................... 22415 6.6640 2 3 5 8 13
86...................................... 1501 3.8741 1 2 3 5 7
87...................................... 73076 6.3172 1 3 5 8 12
88...................................... 388565 5.4142 2 3 4 7 10
89...................................... 469073 6.2791 2 4 5 8 11
90...................................... 38989 4.4632 2 3 4 6 8
91...................................... 48 3.9375 1 2 3 5 7
92...................................... 14464 6.3794 2 3 5 8 12
93...................................... 1314 4.3653 1 2 4 6 8
94...................................... 13391 6.4833 2 3 5 8 12
95...................................... 1388 3.8739 1 2 3 5 7
96...................................... 61778 4.8513 2 3 4 6 9
97...................................... 25587 3.8266 1 2 3 5 7
98...................................... 28 4.9286 1 2 3 5 13
99...................................... 26442 3.0393 1 1 2 4 6
100..................................... 10283 2.1219 1 1 2 3 4
101..................................... 20140 4.4383 1 2 3 5 9
102..................................... 4520 2.7914 1 1 2 3 5
103..................................... 490 48.0898 9 14 29 67 115
104..................................... 29151 12.4470 4 7 10 16 23
105..................................... 25542 9.6459 4 6 8 11 17
106..................................... 106585 10.6917 6 7 9 12 17
107..................................... 68972 7.9520 4 5 7 9 13
108..................................... 8075 11.7282 4 6 9 14 22
110..................................... 62245 9.6084 2 5 8 12 18
111..................................... 5581 5.8094 2 4 6 7 9
112..................................... 118470 3.9277 1 1 3 5 8
113..................................... 46689 12.2570 4 6 9 15 24
114..................................... 8489 8.3873 2 4 7 11 16
115..................................... 15007 8.7475 2 4 7 11 17
116..................................... 208927 4.1747 1 2 3 5 8
117..................................... 3726 3.9847 1 1 2 5 9
118..................................... 6481 2.9303 1 1 2 3 6
119..................................... 1629 5.3640 1 1 3 7 13
120..................................... 37814 8.1649 1 2 5 10 18
121..................................... 170012 6.6480 2 4 6 8 12
122..................................... 83182 4.2023 1 2 4 6 7
123..................................... 43363 4.4029 1 1 2 5 10
124..................................... 154194 4.4587 1 2 4 6 9
125..................................... 62627 2.8721 1 1 2 4 6
126..................................... 5399 12.4253 4 6 9 15 25
127..................................... 719871 5.5133 2 3 4 7 10
128..................................... 16049 6.0323 3 4 5 7 9
129..................................... 4455 2.9495 1 1 1 3 7
130..................................... 98047 5.9926 2 3 5 7 10
131..................................... 24574 4.6703 1 3 4 6 8
132..................................... 174092 3.1532 1 2 3 4 6
133..................................... 6631 2.4803 1 1 2 3 5
134..................................... 30358 3.4496 1 2 3 4 6
135..................................... 8217 4.3269 1 2 3 5 8
136..................................... 1113 2.9695 1 1 2 4 5
138..................................... 209079 4.0464 1 2 3 5 8
139..................................... 67303 2.5774 1 1 2 3 5
140..................................... 107658 2.9719 1 1 2 4 5
141..................................... 81733 3.8534 1 2 3 5 7
142..................................... 36613 2.7911 1 1 2 3 5
143..................................... 143826 2.2585 1 1 2 3 4
144..................................... 78710 5.2279 1 2 4 7 10
145..................................... 6350 2.8698 1 1 2 4 6
146..................................... 10372 10.2717 5 7 9 12 17
[[Page 25666]]
147..................................... 1779 6.7482 4 5 7 8 10
148..................................... 146892 12.2593 5 7 10 15 22
149..................................... 14387 6.8504 4 5 6 8 10
150..................................... 23756 10.8870 4 6 9 13 19
151..................................... 4149 5.8894 2 3 5 8 10
152..................................... 4713 8.3393 4 5 7 10 14
153..................................... 1604 5.6359 3 4 5 7 8
154..................................... 34348 13.3603 4 7 10 16 25
155..................................... 4743 4.6884 1 2 4 6 9
156..................................... 2 18.0000 6 6 30 30 30
157..................................... 9287 5.3854 1 2 4 7 11
158..................................... 4110 2.6190 1 1 2 3 5
159..................................... 18320 4.9678 1 2 4 6 9
160..................................... 9765 2.6768 1 1 2 3 5
161..................................... 14601 4.0877 1 2 3 5 9
162..................................... 7065 2.0350 1 1 1 2 4
163..................................... 5 11.8000 4 4 11 13 22
164..................................... 5272 8.5277 4 5 7 10 15
165..................................... 1639 4.9555 2 3 5 6 8
166..................................... 3542 5.1256 2 3 4 6 9
167..................................... 2325 2.8456 1 2 2 4 5
168..................................... 1700 4.5476 1 2 3 6 9
169..................................... 843 2.5326 1 1 2 3 5
170..................................... 12774 11.2370 2 5 8 14 23
171..................................... 1004 4.8337 1 2 4 6 9
172..................................... 32993 7.1114 2 3 5 9 14
173..................................... 2135 3.9611 1 1 3 5 8
174..................................... 248770 4.9263 2 3 4 6 9
175..................................... 21672 3.0085 1 2 3 4 5
176..................................... 18343 5.4925 2 3 4 7 10
177..................................... 11138 4.5572 2 2 4 6 8
178..................................... 3486 3.2114 1 2 3 4 6
179..................................... 12485 6.4200 2 3 5 8 12
180..................................... 93327 5.4284 2 3 4 7 10
181..................................... 21330 3.5057 1 2 3 4 6
182..................................... 234973 4.3571 1 2 3 5 8
183..................................... 69893 3.0179 1 1 2 4 6
184..................................... 91 3.1648 1 2 2 4 7
185..................................... 4046 4.4881 1 2 3 6 9
187..................................... 870 3.9908 1 2 3 5 8
188..................................... 75257 5.5524 1 2 4 7 11
189..................................... 8618 3.2060 1 1 2 4 6
190..................................... 59 5.2712 1 2 4 7 11
191..................................... 10625 14.5648 4 7 11 18 29
192..................................... 831 6.7088 2 4 6 8 12
193..................................... 7334 12.5020 5 7 10 15 22
194..................................... 773 6.9288 3 4 6 9 12
195..................................... 7094 9.8105 4 6 8 12 17
196..................................... 1260 5.7254 2 4 5 7 10
197..................................... 25012 8.6285 3 5 7 10 15
198..................................... 6357 4.5945 2 3 4 6 8
199..................................... 2037 10.1733 3 5 8 14 20
200..................................... 1339 11.4593 2 4 8 14 23
201..................................... 1651 14.2938 4 6 11 18 29
202..................................... 28649 6.7440 2 3 5 8 13
203..................................... 29508 6.8400 2 3 5 9 14
204..................................... 53140 6.0853 2 3 5 7 11
205..................................... 22927 6.5500 2 3 5 8 13
206..................................... 1614 4.0694 1 2 3 5 8
207..................................... 35502 5.1397 1 2 4 6 10
208..................................... 9472 2.8992 1 1 2 4 6
209..................................... 362634 5.4336 3 4 5 6 8
210..................................... 141586 7.0191 3 4 6 8 12
211..................................... 26005 5.1476 3 4 5 6 8
212..................................... 13 3.7692 1 2 4 5 6
213..................................... 7496 8.4066 2 4 6 11 16
216..................................... 6117 9.8190 2 4 7 12 19
217..................................... 20587 12.9505 3 5 9 16 27
218..................................... 23700 5.3217 2 3 4 6 10
219..................................... 18252 3.2882 1 2 3 4 5
[[Page 25667]]
220..................................... 5 3.2000 1 1 3 4 7
223..................................... 18540 2.6177 1 1 2 3 5
224..................................... 7682 2.0607 1 1 2 3 4
225..................................... 5644 4.3556 1 2 3 5 9
226..................................... 5540 5.9224 1 2 4 7 12
227..................................... 4597 2.7261 1 1 2 3 5
228..................................... 2757 3.4345 1 1 2 4 8
229..................................... 1100 2.3827 1 1 2 3 5
230..................................... 2386 4.5306 1 2 3 5 9
231..................................... 10685 4.5647 1 2 3 5 9
232..................................... 496 3.8327 1 1 2 4 9
233..................................... 4903 7.6490 2 3 5 9 16
234..................................... 2258 3.6151 1 2 3 5 7
235..................................... 5348 5.3113 1 2 4 6 10
236..................................... 39380 5.1518 1 3 4 6 9
237..................................... 1593 3.6353 1 2 3 5 7
238..................................... 7851 8.8615 3 4 7 11 17
239..................................... 59615 6.4289 2 3 5 8 12
240..................................... 13635 6.6882 2 3 5 8 13
241..................................... 2905 3.9983 1 2 3 5 7
242..................................... 2634 6.7358 2 3 5 8 13
243..................................... 81633 4.8627 2 3 4 6 9
244..................................... 12420 4.9928 2 3 4 6 9
245..................................... 4361 3.7420 1 2 3 5 7
246..................................... 1273 3.9309 1 2 3 5 7
247..................................... 12240 3.4938 1 2 3 4 7
248..................................... 8122 4.6959 1 2 4 6 9
249..................................... 10840 3.6358 1 1 3 4 7
250..................................... 3561 4.2263 1 2 3 5 8
251..................................... 2210 2.9570 1 1 2 4 5
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 19384 4.8629 1 3 4 6 9
254..................................... 9275 3.3439 1 2 3 4 6
255..................................... 2 3.5000 1 1 6 6 6
256..................................... 5517 5.1064 1 2 4 6 10
257..................................... 21137 2.9877 1 2 2 3 5
258..................................... 16396 2.1344 1 1 2 3 3
259..................................... 3772 3.0803 1 1 2 3 7
260..................................... 4464 1.5383 1 1 1 2 2
261..................................... 1967 2.2466 1 1 2 3 4
262..................................... 659 4.2231 1 1 3 6 9
263..................................... 27474 11.3931 3 5 8 14 22
264..................................... 3318 7.0530 2 3 5 8 14
265..................................... 4309 6.5331 1 2 4 8 13
266..................................... 2464 3.4054 1 1 2 4 7
267..................................... 250 4.6400 1 2 3 5 9
268..................................... 875 3.5783 1 1 2 4 7
269..................................... 9415 7.8786 2 3 6 10 16
270..................................... 2662 3.1480 1 1 2 4 7
271..................................... 22961 7.1545 3 4 6 9 13
272..................................... 5940 6.4330 2 3 5 8 12
273..................................... 1307 4.7980 1 2 4 6 8
274..................................... 2409 6.7430 1 3 5 8 14
275..................................... 210 3.5143 1 1 2 4 7
276..................................... 932 4.4678 1 2 4 6 8
277..................................... 81663 5.9066 2 3 5 7 10
278..................................... 24598 4.4950 2 3 4 6 8
279..................................... 12 5.0000 2 2 4 7 9
280..................................... 14156 4.3177 1 2 3 5 8
281..................................... 5945 3.1527 1 1 3 4 6
282..................................... 2 2.0000 2 2 2 2 2
283..................................... 5201 4.8029 1 2 4 6 9
284..................................... 1656 3.3255 1 2 3 4 6
285..................................... 5534 11.0193 3 5 8 13 21
286..................................... 2141 6.9650 3 4 5 8 13
287..................................... 6161 11.2446 3 5 8 13 22
288..................................... 1478 5.9303 2 3 5 6 9
289..................................... 5457 3.2448 1 1 2 3 7
290..................................... 8922 2.5158 1 1 2 3 4
291..................................... 66 1.7576 1 1 1 2 3
[[Page 25668]]
292..................................... 5029 10.7174 2 4 8 14 21
293..................................... 347 5.5476 1 2 4 7 12
294..................................... 82039 4.9200 1 2 4 6 9
295..................................... 3593 3.9585 1 2 3 5 7
296..................................... 235524 5.3934 2 3 4 7 10
297..................................... 32715 3.6521 1 2 3 4 7
298..................................... 91 3.7253 1 1 2 4 8
299..................................... 968 5.3657 1 2 4 7 10
300..................................... 16820 6.2855 2 3 5 8 12
301..................................... 2395 3.8113 1 2 3 5 7
302..................................... 7784 10.1382 5 6 8 12 18
303..................................... 19638 9.2247 4 5 7 10 16
304..................................... 12813 8.9904 2 4 7 11 18
305..................................... 2552 3.8985 1 2 3 5 7
306..................................... 10658 5.5019 1 2 3 7 12
307..................................... 2355 2.3996 1 1 2 3 4
308..................................... 9167 6.0165 1 2 4 8 13
309..................................... 3541 2.5945 1 1 2 3 5
310..................................... 26694 4.2835 1 2 3 5 9
311..................................... 7805 1.9543 1 1 1 2 4
312..................................... 1731 4.3437 1 1 3 6 9
313..................................... 587 2.3799 1 1 2 3 5
314..................................... 1 10.0000 10 10 10 10 10
315..................................... 28283 8.0413 1 2 5 10 18
316..................................... 93071 6.8024 2 3 5 9 14
317..................................... 787 2.8666 1 1 2 3 6
318..................................... 6194 6.1022 1 3 5 8 12
319..................................... 407 2.9902 1 1 2 4 6
320..................................... 177474 5.5698 2 3 4 7 10
321..................................... 23679 4.0416 2 2 3 5 7
322..................................... 82 4.1098 2 2 3 4 7
323..................................... 16931 3.2166 1 1 2 4 6
324..................................... 7513 1.9385 1 1 1 2 4
325..................................... 7409 3.9591 1 2 3 5 8
326..................................... 2192 2.7199 1 1 2 3 5
327..................................... 9 2.8889 1 1 2 3 4
328..................................... 759 3.7167 1 2 3 5 7
329..................................... 87 2.2644 1 1 1 3 4
331..................................... 43598 5.5769 1 3 4 7 11
332..................................... 4517 3.5603 1 1 3 5 7
333..................................... 306 4.9477 1 2 4 6 11
334..................................... 18572 4.9690 3 3 4 6 8
335..................................... 10338 3.7163 2 3 3 4 5
336..................................... 54082 3.6046 1 2 3 4 7
337..................................... 31770 2.2858 1 1 2 3 4
338..................................... 2767 4.7879 1 2 3 6 10
339..................................... 1987 4.1726 1 1 3 5 9
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4909 2.9589 1 1 2 3 6
342..................................... 1007 3.4518 1 2 2 4 7
344..................................... 3882 2.6285 1 1 1 3 5
345..................................... 1343 3.6389 1 1 2 4 8
346..................................... 4844 5.8179 1 3 4 7 11
347..................................... 365 3.1370 1 1 2 4 6
348..................................... 3181 4.2521 1 2 3 5 8
349..................................... 632 2.7658 1 1 2 4 5
350..................................... 6114 4.3999 2 2 4 5 8
352..................................... 638 3.6160 1 2 3 4 7
353..................................... 2816 6.9457 3 4 5 8 12
354..................................... 9926 5.7743 3 3 4 6 10
355..................................... 5640 3.4624 2 3 3 4 5
356..................................... 28862 2.6478 1 2 2 3 4
357..................................... 6330 9.0289 3 5 7 11 17
358..................................... 27373 4.3708 2 3 3 5 7
359..................................... 27990 2.9775 2 2 3 3 4
360..................................... 17843 3.1581 1 2 3 4 5
361..................................... 540 3.3259 1 1 2 3 7
363..................................... 3943 3.3109 1 2 2 3 6
364..................................... 1828 3.5656 1 1 2 5 8
365..................................... 2298 6.8903 1 2 5 9 14
[[Page 25669]]
366..................................... 4368 6.8116 1 3 5 8 14
367..................................... 506 2.8893 1 1 2 3 6
368..................................... 2895 6.3530 2 3 5 8 12
369..................................... 2588 3.0622 1 1 2 4 6
370..................................... 1154 5.4610 2 3 4 5 9
371..................................... 1157 3.4754 2 3 3 4 5
372..................................... 975 3.1549 1 2 2 3 5
373..................................... 3868 2.1171 1 1 2 2 3
374..................................... 147 3.0340 1 2 2 3 3
375..................................... 9 5.1111 2 2 3 9 10
376..................................... 214 2.9252 1 2 2 3 6
377..................................... 52 4.4808 1 2 3 6 9
378..................................... 168 2.5952 1 1 2 3 4
379..................................... 334 3.5868 1 1 2 3 7
380..................................... 87 2.0345 1 1 2 2 3
381..................................... 187 2.1283 1 1 1 2 4
382..................................... 40 1.2750 1 1 1 1 2
383..................................... 1460 3.7301 1 2 3 4 8
384..................................... 123 2.6585 1 1 2 3 6
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 9 8.6667 1 3 7 10 15
390..................................... 13 6.0000 2 2 4 5 17
392..................................... 2513 10.3828 4 5 7 12 21
394..................................... 1805 7.0853 1 2 4 8 16
395..................................... 70948 4.7241 1 2 3 6 9
396..................................... 15 18.4667 1 2 5 11 15
397..................................... 18814 5.5200 1 2 4 7 11
398..................................... 18127 6.0414 2 3 5 7 11
399..................................... 1322 3.7239 1 2 3 5 7
400..................................... 7225 9.3664 2 3 6 12 20
401..................................... 6653 11.0137 2 4 8 14 23
402..................................... 1464 3.8907 1 1 3 5 9
403..................................... 38919 8.1409 2 3 6 10 17
404..................................... 3797 4.4464 1 2 3 6 9
406..................................... 3308 9.5299 2 4 7 12 20
407..................................... 634 4.3202 1 2 4 5 8
408..................................... 2667 7.5047 1 2 5 9 16
409..................................... 4644 5.8404 2 3 4 6 11
410..................................... 59252 3.4182 1 2 3 4 6
411..................................... 18 2.8889 1 1 2 2 6
412..................................... 24 2.3333 1 1 2 3 4
413..................................... 7781 7.4429 2 3 6 9 15
414..................................... 676 4.2219 1 2 3 5 8
415..................................... 45158 14.3432 4 7 11 18 28
416..................................... 230365 7.3967 2 4 6 9 14
417..................................... 41 5.9024 2 2 5 7 11
418..................................... 21184 6.1906 2 3 5 8 11
419..................................... 15269 5.0200 2 3 4 6 9
420..................................... 2680 3.9474 1 2 3 5 7
421..................................... 12113 3.9569 1 2 3 5 7
422..................................... 86 3.3372 1 2 2 5 7
423..................................... 10723 7.7520 2 3 6 9 15
424..................................... 1621 14.2961 2 5 10 18 29
425..................................... 15405 4.1352 1 2 3 5 8
426..................................... 4449 4.9020 1 2 3 6 10
427..................................... 1633 4.8010 1 2 3 6 10
428..................................... 940 7.1755 1 2 4 8 14
429..................................... 32769 7.1661 2 3 5 8 14
430..................................... 56829 8.7198 2 4 7 11 17
431..................................... 217 7.3088 1 3 5 9 13
432..................................... 409 5.2152 1 2 3 6 12
433..................................... 6811 3.2053 1 1 2 4 7
434..................................... 21537 5.1804 2 3 4 6 9
435..................................... 14552 4.4078 1 2 4 5 8
436..................................... 3322 13.9618 4 7 13 21 28
437..................................... 12779 9.2061 3 5 8 12 16
439..................................... 1138 7.7065 1 3 5 9 16
440..................................... 5155 8.9081 2 3 6 10 19
441..................................... 570 3.4333 1 1 2 4 7
442..................................... 16247 8.1177 1 3 6 10 17
[[Page 25670]]
443..................................... 3153 3.3321 1 1 2 4 7
444..................................... 3425 4.5007 1 2 3 5 8
445..................................... 1243 3.3628 1 2 3 4 6
446..................................... 1 2.0000 2 2 2 2 2
447..................................... 4257 2.5130 1 1 2 3 5
449..................................... 27905 3.7822 1 1 3 5 8
450..................................... 6171 2.0826 1 1 1 2 4
451..................................... 9 2.7778 1 1 1 4 5
452..................................... 22863 5.0341 1 2 4 6 10
453..................................... 3796 2.9236 1 1 2 4 6
454..................................... 3855 4.6905 1 2 3 6 9
455..................................... 758 2.7401 1 1 2 3 5
456..................................... 194 8.5670 1 1 3 9 21
457..................................... 128 3.5859 1 1 1 3 9
458..................................... 1526 15.0308 3 7 12 19 31
459..................................... 480 8.9771 2 3 6 11 19
460..................................... 2327 6.0812 1 3 4 7 12
461..................................... 3047 4.4322 1 1 2 4 11
462..................................... 10348 12.4504 4 6 10 16 23
463..................................... 13983 4.4209 1 2 3 5 8
464..................................... 3556 3.3751 1 2 3 4 6
465..................................... 210 2.9095 1 1 1 3 5
466..................................... 1748 4.0955 1 1 2 4 9
467..................................... 1332 4.3949 1 1 2 4 7
468..................................... 61704 13.4718 3 6 10 17 27
471..................................... 12918 6.0694 3 4 5 7 10
472..................................... 179 27.2179 1 8 19 37 55
473..................................... 8429 12.7713 2 3 7 18 33
475..................................... 109339 11.1900 2 5 9 15 22
476..................................... 5924 11.9158 3 6 10 15 22
477..................................... 28747 8.1623 1 3 6 11 17
478..................................... 123286 7.4571 1 3 5 9 15
479..................................... 18337 3.8430 1 2 3 5 7
480..................................... 400 26.7550 8 11 20 32 53
481..................................... 256 27.1133 16 20 24 32 43
482..................................... 6596 12.7329 4 7 10 15 23
483..................................... 41763 40.0560 14 21 33 50 73
484..................................... 391 14.6931 2 6 11 18 27
485..................................... 3471 9.5906 4 5 7 11 18
486..................................... 2244 12.3382 1 5 10 16 25
487..................................... 4210 7.3983 2 3 6 9 14
488..................................... 865 17.0532 4 7 12 22 35
489..................................... 14894 8.9049 2 4 6 11 19
490..................................... 4863 5.4148 1 2 4 7 11
491..................................... 11011 3.6593 2 2 3 4 6
492..................................... 2334 17.1418 4 5 12 27 36
493..................................... 56210 5.6284 1 2 5 7 11
494..................................... 25155 2.4285 1 1 2 3 5
495..................................... 125 16.9920 7 10 13 19 31
496..................................... 895 10.5821 4 6 8 13 20
497..................................... 21969 6.2886 2 3 5 7 11
498..................................... 12500 3.5058 1 2 3 5 6
499..................................... 36205 4.9604 2 2 4 6 9
500..................................... 36448 2.8726 1 2 2 4 5
501..................................... 1895 10.4391 4 6 8 12 19
502..................................... 468 6.5876 3 4 6 8 10
503..................................... 6317 4.2169 1 2 3 5 8
----------------
11244775
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7B.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay
[FY97 MEDPAR Update 12/97 Grouper V16.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36587 9.6084 2 4 7 12 20
2....................................... 6967 10.0350 3 5 8 13 20
3....................................... 3 9.3333 7 7 9 12 12
[[Page 25671]]
4....................................... 6322 7.7259 1 3 5 9 17
5....................................... 101105 3.6387 1 2 2 4 8
6....................................... 355 3.0225 1 1 2 4 7
7....................................... 12601 10.0945 2 4 7 12 20
8....................................... 3030 3.1845 1 1 2 4 7
9....................................... 1692 6.4923 1 3 5 8 13
10...................................... 19727 6.8631 2 3 5 8 14
11...................................... 2960 4.1365 1 2 3 5 8
12...................................... 38339 6.6619 2 3 5 8 12
13...................................... 6315 5.4716 2 3 4 6 9
14...................................... 372136 6.2938 2 3 5 8 12
15...................................... 145631 3.8599 1 2 3 5 7
16...................................... 13905 5.9283 2 3 4 7 11
17...................................... 3212 3.4315 1 2 3 4 7
18...................................... 27489 5.5809 2 3 4 7 10
19...................................... 7294 3.8174 1 2 3 5 7
20...................................... 6590 10.1862 2 5 8 13 19
21...................................... 1369 6.8152 2 3 5 8 14
22...................................... 2789 4.6587 2 2 4 6 9
23...................................... 6884 4.2594 1 2 3 5 8
24...................................... 57890 5.0641 1 2 4 6 10
25...................................... 22696 3.4294 1 2 3 4 7
26...................................... 34 3.1176 1 1 2 4 6
27...................................... 4153 5.4211 1 1 3 7 12
28...................................... 13896 5.9431 1 2 4 7 12
29...................................... 4266 3.5375 1 1 3 4 7
31...................................... 3075 4.4062 1 2 3 5 8
32...................................... 1343 2.9717 1 1 2 3 6
34...................................... 20072 5.4331 1 3 4 7 11
35...................................... 4264 3.5561 1 2 3 4 7
36...................................... 5393 1.5366 1 1 1 1 2
37...................................... 1685 3.7187 1 1 2 4 8
38...................................... 116 2.5948 1 1 2 3 5
39...................................... 1898 2.0327 1 1 1 2 4
40...................................... 2281 3.1806 1 1 2 4 7
42...................................... 4026 2.0904 1 1 1 2 4
43...................................... 120 3.4250 1 2 3 5 7
44...................................... 1343 5.0551 2 3 4 6 9
45...................................... 2414 3.4731 1 2 3 4 6
46...................................... 3148 4.6436 1 2 4 6 9
47...................................... 1220 3.2975 1 1 3 4 7
48...................................... 2 4.5000 4 4 5 5 5
49...................................... 2277 5.0097 1 2 4 6 9
50...................................... 3004 1.9767 1 1 2 2 3
51...................................... 299 2.8194 1 1 1 3 6
52...................................... 89 2.7528 1 1 2 3 7
53...................................... 2989 3.6554 1 1 2 4 8
54...................................... 2 6.0000 5 5 7 7 7
55...................................... 1686 2.9543 1 1 2 3 6
56...................................... 684 2.8436 1 1 2 3 6
57...................................... 608 3.7237 1 1 3 4 7
59...................................... 120 2.4333 1 1 2 3 5
60...................................... 1 4.0000 4 4 4 4 4
61...................................... 278 4.5144 1 1 2 5 10
62...................................... 4 1.2500 1 1 1 1 2
63...................................... 3676 4.4502 1 2 3 5 9
64...................................... 3408 6.7183 1 2 5 8 14
65...................................... 29086 2.9715 1 2 2 4 5
66...................................... 6812 3.2606 1 2 3 4 6
67...................................... 489 3.7996 1 2 3 4 7
68...................................... 11522 4.1519 1 2 3 5 7
69...................................... 3450 3.3183 1 2 3 4 6
70...................................... 37 2.5405 1 1 2 3 4
71...................................... 99 3.9394 1 2 3 6 7
72...................................... 817 3.7931 1 2 3 5 7
73...................................... 6282 4.4062 1 2 3 6 8
74...................................... 2 2.5000 2 2 3 3 3
75...................................... 40757 10.2370 4 5 8 13 20
76...................................... 41668 11.3195 3 5 9 14 21
77...................................... 2040 4.8819 1 2 4 7 10
[[Page 25672]]
78...................................... 30845 7.3107 3 5 7 9 12
79...................................... 247000 8.4030 3 4 7 10 15
80...................................... 8299 5.8754 2 3 5 7 10
81...................................... 6 12.6667 2 3 6 8 8
82...................................... 71035 7.1298 2 3 6 9 14
83...................................... 7249 5.5655 2 3 4 7 10
84...................................... 1290 3.3256 1 2 3 4 6
85...................................... 22415 6.6640 2 3 5 8 13
86...................................... 1501 3.8741 1 2 3 5 7
87...................................... 73076 6.3172 1 3 5 8 12
88...................................... 388565 5.4142 2 3 4 7 10
89...................................... 469073 6.2791 2 4 5 8 11
90...................................... 38989 4.4632 2 3 4 6 8
91...................................... 48 3.9375 1 2 3 5 7
92...................................... 14464 6.3794 2 3 5 8 12
93...................................... 1314 4.3653 1 2 4 6 8
94...................................... 13391 6.4833 2 3 5 8 12
95...................................... 1388 3.8739 1 2 3 5 7
96...................................... 61778 4.8513 2 3 4 6 9
97...................................... 25587 3.8266 1 2 3 5 7
98...................................... 28 4.9286 1 2 3 5 13
99...................................... 26442 3.0393 1 1 2 4 6
100..................................... 10283 2.1219 1 1 2 3 4
101..................................... 20140 4.4383 1 2 3 5 9
102..................................... 4520 2.7914 1 1 2 3 5
103..................................... 490 48.0898 9 14 29 67 115
104..................................... 29920 12.5288 4 7 10 16 23
105..................................... 26799 9.7413 4 6 8 11 17
106..................................... 4737 10.9261 5 7 9 13 19
107..................................... 101848 10.6808 6 7 9 12 17
108..................................... 6049 11.2420 4 6 9 14 21
109..................................... 68972 7.9520 4 5 7 9 13
110..................................... 62245 9.6084 2 5 8 12 18
111..................................... 5581 5.8094 2 4 6 7 9
112..................................... 118470 3.9277 1 1 3 5 8
113..................................... 46689 12.2570 4 6 9 15 24
114..................................... 8489 8.3873 2 4 7 11 16
115..................................... 15007 8.7475 2 4 7 11 17
116..................................... 208927 4.1747 1 2 3 5 8
117..................................... 3726 3.9847 1 1 2 5 9
118..................................... 6481 2.9303 1 1 2 3 6
119..................................... 1629 5.3640 1 1 3 7 13
120..................................... 37814 8.1649 1 2 5 10 18
121..................................... 170012 6.6480 2 4 6 8 12
122..................................... 83182 4.2023 1 2 4 6 7
123..................................... 43363 4.4029 1 1 2 5 10
124..................................... 154194 4.4587 1 2 4 6 9
125..................................... 62627 2.8721 1 1 2 4 6
126..................................... 5399 12.4253 4 6 9 15 25
127..................................... 719871 5.5133 2 3 4 7 10
128..................................... 16049 6.0323 3 4 5 7 9
129..................................... 4455 2.9495 1 1 1 3 7
130..................................... 98047 5.9926 2 3 5 7 10
131..................................... 24574 4.6703 1 3 4 6 8
132..................................... 174092 3.1532 1 2 3 4 6
133..................................... 6631 2.4803 1 1 2 3 5
134..................................... 30358 3.4496 1 2 3 4 6
135..................................... 8217 4.3269 1 2 3 5 8
136..................................... 1113 2.9695 1 1 2 4 5
138..................................... 209079 4.0464 1 2 3 5 8
139..................................... 67303 2.5774 1 1 2 3 5
140..................................... 107658 2.9719 1 1 2 4 5
141..................................... 81733 3.8534 1 2 3 5 7
142..................................... 36613 2.7911 1 1 2 3 5
143..................................... 143826 2.2585 1 1 2 3 4
144..................................... 78710 5.2279 1 2 4 7 10
145..................................... 6350 2.8698 1 1 2 4 6
146..................................... 10372 10.2717 5 7 9 12 17
147..................................... 1779 6.7482 4 5 7 8 10
148..................................... 146892 12.2593 5 7 10 15 22
[[Page 25673]]
149..................................... 14387 6.8504 4 5 6 8 10
150..................................... 23756 10.8870 4 6 9 13 19
151..................................... 4149 5.8894 2 3 5 8 10
152..................................... 4713 8.3393 4 5 7 10 14
153..................................... 1604 5.6359 3 4 5 7 8
154..................................... 34348 13.3603 4 7 10 16 25
155..................................... 4743 4.6884 1 2 4 6 9
156..................................... 2 18.0000 6 6 30 30 30
157..................................... 9287 5.3854 1 2 4 7 11
158..................................... 4110 2.6190 1 1 2 3 5
159..................................... 18320 4.9678 1 2 4 6 9
160..................................... 9765 2.6768 1 1 2 3 5
161..................................... 14601 4.0877 1 2 3 5 9
162..................................... 7065 2.0350 1 1 1 2 4
163..................................... 5 11.8000 4 4 11 13 22
164..................................... 5272 8.5277 4 5 7 10 15
165..................................... 1639 4.9555 2 3 5 6 8
166..................................... 3542 5.1256 2 3 4 6 9
167..................................... 2325 2.8456 1 2 2 4 5
168..................................... 1700 4.5476 1 2 3 6 9
169..................................... 843 2.5326 1 1 2 3 5
170..................................... 12774 11.2370 2 5 8 14 23
171..................................... 1004 4.8337 1 2 4 6 9
172..................................... 32993 7.1114 2 3 5 9 14
173..................................... 2135 3.9611 1 1 3 5 8
174..................................... 248770 4.9263 2 3 4 6 9
175..................................... 21672 3.0085 1 2 3 4 5
176..................................... 18343 5.4925 2 3 4 7 10
177..................................... 11138 4.5572 2 2 4 6 8
178..................................... 3486 3.2114 1 2 3 4 6
179..................................... 12485 6.4200 2 3 5 8 12
180..................................... 93327 5.4284 2 3 4 7 10
181..................................... 21330 3.5057 1 2 3 4 6
182..................................... 234973 4.3571 1 2 3 5 8
183..................................... 69893 3.0179 1 1 2 4 6
184..................................... 91 3.1648 1 2 2 4 7
185..................................... 4046 4.4881 1 2 3 6 9
187..................................... 870 3.9908 1 2 3 5 8
188..................................... 75257 5.5524 1 2 4 7 11
189..................................... 8618 3.2060 1 1 2 4 6
190..................................... 59 5.2712 1 2 4 7 11
191..................................... 10625 14.5648 4 7 11 18 29
192..................................... 831 6.7088 2 4 6 8 12
193..................................... 7334 12.5020 5 7 10 15 22
194..................................... 773 6.9288 3 4 6 9 12
195..................................... 7094 9.8105 4 6 8 12 17
196..................................... 1260 5.7254 2 4 5 7 10
197..................................... 25012 8.6285 3 5 7 10 15
198..................................... 6357 4.5945 2 3 4 6 8
199..................................... 2037 10.1733 3 5 8 14 20
200..................................... 1339 11.4593 2 4 8 14 23
201..................................... 1651 14.2938 4 6 11 18 29
202..................................... 28649 6.7440 2 3 5 8 13
203..................................... 29508 6.8400 2 3 5 9 14
204..................................... 53140 6.0853 2 3 5 7 11
205..................................... 22927 6.5500 2 3 5 8 13
206..................................... 1614 4.0694 1 2 3 5 8
207..................................... 35502 5.1397 1 2 4 6 10
208..................................... 9472 2.8992 1 1 2 4 6
209..................................... 362634 5.4336 3 4 5 6 8
210..................................... 141586 7.0191 3 4 6 8 12
211..................................... 26005 5.1476 3 4 5 6 8
212..................................... 13 3.7692 1 2 4 5 6
213..................................... 7496 8.4066 2 4 6 11 16
216..................................... 6117 9.8190 2 4 7 12 19
217..................................... 20587 12.9505 3 5 9 16 27
218..................................... 23700 5.3217 2 3 4 6 10
219..................................... 18252 3.2882 1 2 3 4 5
220..................................... 5 3.2000 1 1 3 4 7
223..................................... 18540 2.6177 1 1 2 3 5
[[Page 25674]]
224..................................... 7682 2.0607 1 1 2 3 4
225..................................... 5644 4.3556 1 2 3 5 9
226..................................... 5540 5.9224 1 2 4 7 12
227..................................... 4597 2.7261 1 1 2 3 5
228..................................... 2757 3.4345 1 1 2 4 8
229..................................... 1100 2.3827 1 1 2 3 5
230..................................... 2386 4.5306 1 2 3 5 9
231..................................... 10685 4.5647 1 2 3 5 9
232..................................... 496 3.8327 1 1 2 4 9
233..................................... 4903 7.6490 2 3 5 9 16
234..................................... 2258 3.6151 1 2 3 5 7
235..................................... 5348 5.3113 1 2 4 6 10
236..................................... 39380 5.1518 1 3 4 6 9
237..................................... 1593 3.6353 1 2 3 5 7
238..................................... 7851 8.8615 3 4 7 11 17
239..................................... 59615 6.4289 2 3 5 8 12
240..................................... 13635 6.6882 2 3 5 8 13
241..................................... 2905 3.9983 1 2 3 5 7
242..................................... 2634 6.7358 2 3 5 8 13
243..................................... 81633 4.8627 2 3 4 6 9
244..................................... 12420 4.9928 2 3 4 6 9
245..................................... 4361 3.7420 1 2 3 5 7
246..................................... 1273 3.9309 1 2 3 5 7
247..................................... 12240 3.4938 1 2 3 4 7
248..................................... 8122 4.6959 1 2 4 6 9
249..................................... 10840 3.6358 1 1 3 4 7
250..................................... 3561 4.2263 1 2 3 5 8
251..................................... 2210 2.9570 1 1 2 4 5
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 19384 4.8629 1 3 4 6 9
254..................................... 9275 3.3439 1 2 3 4 6
255..................................... 2 3.5000 1 1 6 6 6
256..................................... 5517 5.1064 1 2 4 6 10
257..................................... 21137 2.9877 1 2 2 3 5
258..................................... 16396 2.1344 1 1 2 3 3
259..................................... 3772 3.0803 1 1 2 3 7
260..................................... 4464 1.5383 1 1 1 2 2
261..................................... 1967 2.2466 1 1 2 3 4
262..................................... 659 4.2231 1 1 3 6 9
263..................................... 27474 11.3931 3 5 8 14 22
264..................................... 3318 7.0530 2 3 5 8 14
265..................................... 4309 6.5331 1 2 4 8 13
266..................................... 2464 3.4054 1 1 2 4 7
267..................................... 250 4.6400 1 2 3 5 9
268..................................... 875 3.5783 1 1 2 4 7
269..................................... 9415 7.8786 2 3 6 10 16
270..................................... 2662 3.1480 1 1 2 4 7
271..................................... 22961 7.1545 3 4 6 9 13
272..................................... 5940 6.4330 2 3 5 8 12
273..................................... 1307 4.7980 1 2 4 6 8
274..................................... 2409 6.7430 1 3 5 8 14
275..................................... 210 3.5143 1 1 2 4 7
276..................................... 932 4.4678 1 2 4 6 8
277..................................... 81663 5.9066 2 3 5 7 10
278..................................... 24598 4.4950 2 3 4 6 8
279..................................... 12 5.0000 2 2 4 7 9
280..................................... 14156 4.3177 1 2 3 5 8
281..................................... 5945 3.1527 1 1 3 4 6
282..................................... 2 2.0000 2 2 2 2 2
283..................................... 5201 4.8029 1 2 4 6 9
284..................................... 1656 3.3255 1 2 3 4 6
285..................................... 5534 11.0193 3 5 8 13 21
286..................................... 2141 6.9650 3 4 5 8 13
287..................................... 6161 11.2446 3 5 8 13 22
288..................................... 1478 5.9303 2 3 5 6 9
289..................................... 5457 3.2448 1 1 2 3 7
290..................................... 8922 2.5158 1 1 2 3 4
291..................................... 66 1.7576 1 1 1 2 3
292..................................... 5029 10.7174 2 4 8 14 21
293..................................... 347 5.5476 1 2 4 7 12
[[Page 25675]]
294..................................... 82039 4.9200 1 2 4 6 9
295..................................... 3593 3.9585 1 2 3 5 7
296..................................... 235524 5.3934 2 3 4 7 10
297..................................... 32715 3.6521 1 2 3 4 7
298..................................... 91 3.7253 1 1 2 4 8
299..................................... 968 5.3657 1 2 4 7 10
300..................................... 16820 6.2855 2 3 5 8 12
301..................................... 2395 3.8113 1 2 3 5 7
302..................................... 7784 10.1382 5 6 8 12 18
303..................................... 19638 9.2247 4 5 7 10 16
304..................................... 12813 8.9904 2 4 7 11 18
305..................................... 2552 3.8985 1 2 3 5 7
306..................................... 10658 5.5019 1 2 3 7 12
307..................................... 2355 2.3996 1 1 2 3 4
308..................................... 9167 6.0165 1 2 4 8 13
309..................................... 3541 2.5945 1 1 2 3 5
310..................................... 26694 4.2835 1 2 3 5 9
311..................................... 7805 1.9543 1 1 1 2 4
312..................................... 1731 4.3437 1 1 3 6 9
313..................................... 587 2.3799 1 1 2 3 5
314..................................... 1 10.0000 10 10 10 10 10
315..................................... 28283 8.0413 1 2 5 10 18
316..................................... 93071 6.8024 2 3 5 9 14
317..................................... 787 2.8666 1 1 2 3 6
318..................................... 6194 6.1022 1 3 5 8 12
319..................................... 407 2.9902 1 1 2 4 6
320..................................... 177474 5.5698 2 3 4 7 10
321..................................... 23679 4.0416 2 2 3 5 7
322..................................... 82 4.1098 2 2 3 4 7
323..................................... 16931 3.2166 1 1 2 4 6
324..................................... 7513 1.9385 1 1 1 2 4
325..................................... 7409 3.9591 1 2 3 5 8
326..................................... 2192 2.7199 1 1 2 3 5
327..................................... 9 2.8889 1 1 2 3 4
328..................................... 759 3.7167 1 2 3 5 7
329..................................... 87 2.2644 1 1 1 3 4
331..................................... 43598 5.5769 1 3 4 7 11
332..................................... 4517 3.5603 1 1 3 5 7
333..................................... 306 4.9477 1 2 4 6 11
334..................................... 18572 4.9690 3 3 4 6 8
335..................................... 10338 3.7163 2 3 3 4 5
336..................................... 54082 3.6046 1 2 3 4 7
337..................................... 31770 2.2858 1 1 2 3 4
338..................................... 2767 4.7879 1 2 3 6 10
339..................................... 1987 4.1726 1 1 3 5 9
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4909 2.9589 1 1 2 3 6
342..................................... 1007 3.4518 1 2 2 4 7
344..................................... 3882 2.6285 1 1 1 3 5
345..................................... 1343 3.6389 1 1 2 4 8
346..................................... 4844 5.8179 1 3 4 7 11
347..................................... 365 3.1370 1 1 2 4 6
348..................................... 3181 4.2521 1 2 3 5 8
349..................................... 632 2.7658 1 1 2 4 5
350..................................... 6114 4.3999 2 2 4 5 8
352..................................... 638 3.6160 1 2 3 4 7
353..................................... 2816 6.9457 3 4 5 8 12
354..................................... 9926 5.7743 3 3 4 6 10
355..................................... 5640 3.4624 2 3 3 4 5
356..................................... 28862 2.6478 1 2 2 3 4
357..................................... 6330 9.0289 3 5 7 11 17
358..................................... 27373 4.3708 2 3 3 5 7
359..................................... 27990 2.9775 2 2 3 3 4
360..................................... 17843 3.1581 1 2 3 4 5
361..................................... 540 3.3259 1 1 2 3 7
363..................................... 3943 3.3109 1 2 2 3 6
364..................................... 1828 3.5656 1 1 2 5 8
365..................................... 2298 6.8903 1 2 5 9 14
366..................................... 4368 6.8116 1 3 5 8 14
367..................................... 506 2.8893 1 1 2 3 6
[[Page 25676]]
368..................................... 2895 6.3530 2 3 5 8 12
369..................................... 2588 3.0622 1 1 2 4 6
370..................................... 1154 5.4610 2 3 4 5 9
371..................................... 1157 3.4754 2 3 3 4 5
372..................................... 975 3.1549 1 2 2 3 5
373..................................... 3868 2.1171 1 1 2 2 3
374..................................... 147 3.0340 1 2 2 3 3
375..................................... 9 5.1111 2 2 3 9 10
376..................................... 214 2.9252 1 2 2 3 6
377..................................... 52 4.4808 1 2 3 6 9
378..................................... 168 2.5952 1 1 2 3 4
379..................................... 334 3.5868 1 1 2 3 7
380..................................... 87 2.0345 1 1 2 2 3
381..................................... 187 2.1283 1 1 1 2 4
382..................................... 40 1.2750 1 1 1 1 2
383..................................... 1460 3.7301 1 2 3 4 8
384..................................... 123 2.6585 1 1 2 3 6
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 9 8.6667 1 3 7 10 15
390..................................... 13 6.0000 2 2 4 5 17
392..................................... 2513 10.3828 4 5 7 12 21
394..................................... 1805 7.0853 1 2 4 8 16
395..................................... 70948 4.7241 1 2 3 6 9
396..................................... 15 18.4667 1 2 5 11 15
397..................................... 18814 5.5200 1 2 4 7 11
398..................................... 18127 6.0414 2 3 5 7 11
399..................................... 1322 3.7239 1 2 3 5 7
400..................................... 7225 9.3664 2 3 6 12 20
401..................................... 6653 11.0137 2 4 8 14 23
402..................................... 1464 3.8907 1 1 3 5 9
403..................................... 38919 8.1409 2 3 6 10 17
404..................................... 3797 4.4464 1 2 3 6 9
406..................................... 3308 9.5299 2 4 7 12 20
407..................................... 634 4.3202 1 2 4 5 8
408..................................... 2667 7.5047 1 2 5 9 16
409..................................... 4644 5.8404 2 3 4 6 11
410..................................... 59252 3.4182 1 2 3 4 6
411..................................... 18 2.8889 1 1 2 2 6
412..................................... 24 2.3333 1 1 2 3 4
413..................................... 7781 7.4429 2 3 6 9 15
414..................................... 676 4.2219 1 2 3 5 8
415..................................... 45158 14.3432 4 7 11 18 28
416..................................... 230365 7.3967 2 4 6 9 14
417..................................... 41 5.9024 2 2 5 7 11
418..................................... 21184 6.1906 2 3 5 8 11
419..................................... 15269 5.0200 2 3 4 6 9
420..................................... 2680 3.9474 1 2 3 5 7
421..................................... 12113 3.9569 1 2 3 5 7
422..................................... 86 3.3372 1 2 2 5 7
423..................................... 10723 7.7520 2 3 6 9 15
424..................................... 1621 14.2961 2 5 10 18 29
425..................................... 15405 4.1352 1 2 3 5 8
426..................................... 4449 4.9020 1 2 3 6 10
427..................................... 1633 4.8010 1 2 3 6 10
428..................................... 940 7.1755 1 2 4 8 14
429..................................... 32769 7.1661 2 3 5 8 14
430..................................... 56829 8.7198 2 4 7 11 17
431..................................... 217 7.3088 1 3 5 9 13
432..................................... 409 5.2152 1 2 3 6 12
433..................................... 6811 3.2053 1 1 2 4 7
434..................................... 21537 5.1804 2 3 4 6 9
435..................................... 14552 4.4078 1 2 4 5 8
436..................................... 3322 13.9618 4 7 13 21 28
437..................................... 12779 9.2061 3 5 8 12 16
439..................................... 1138 7.7065 1 3 5 9 16
440..................................... 5155 8.9081 2 3 6 10 19
441..................................... 570 3.4333 1 1 2 4 7
442..................................... 16247 8.1177 1 3 6 10 17
443..................................... 3153 3.3321 1 1 2 4 7
444..................................... 3425 4.5007 1 2 3 5 8
[[Page 25677]]
445..................................... 1243 3.3628 1 2 3 4 6
446..................................... 1 2.0000 2 2 2 2 2
447..................................... 4257 2.5130 1 1 2 3 5
449..................................... 27905 3.7822 1 1 3 5 8
450..................................... 6171 2.0826 1 1 1 2 4
451..................................... 9 2.7778 1 1 1 4 5
452..................................... 22863 5.0341 1 2 4 6 10
453..................................... 3796 2.9236 1 1 2 4 6
454..................................... 3855 4.6905 1 2 3 6 9
455..................................... 758 2.7401 1 1 2 3 5
461..................................... 3047 4.4322 1 1 2 4 11
462..................................... 10348 12.4504 4 6 10 16 23
463..................................... 13983 4.4209 1 2 3 5 8
464..................................... 3556 3.3751 1 2 3 4 6
465..................................... 210 2.9095 1 1 1 3 5
466..................................... 1748 4.0955 1 1 2 4 9
467..................................... 1332 4.3949 1 1 2 4 7
468..................................... 61704 13.4718 3 6 10 17 27
471..................................... 12918 6.0694 3 4 5 7 10
473..................................... 8429 12.7713 2 3 7 18 33
475..................................... 109339 11.1900 2 5 9 15 22
476..................................... 5924 11.9158 3 6 10 15 22
477..................................... 28747 8.1623 1 3 6 11 17
478..................................... 123286 7.4571 1 3 5 9 15
479..................................... 18337 3.8430 1 2 3 5 7
480..................................... 400 26.7550 8 11 20 32 53
481..................................... 256 27.1133 16 20 24 32 43
482..................................... 6596 12.7329 4 7 10 15 23
483..................................... 41763 40.0560 14 21 33 50 73
484..................................... 391 14.6931 2 6 11 18 27
485..................................... 3471 9.5906 4 5 7 11 18
486..................................... 2244 12.3382 1 5 10 16 25
487..................................... 4210 7.3983 2 3 6 9 14
488..................................... 865 17.0532 4 7 12 22 35
489..................................... 14894 8.9049 2 4 6 11 19
490..................................... 4863 5.4148 1 2 4 7 11
491..................................... 11011 3.6593 2 2 3 4 6
492..................................... 2334 17.1418 4 5 12 27 36
493..................................... 56210 5.6284 1 2 5 7 11
494..................................... 25155 2.4285 1 1 2 3 5
495..................................... 125 16.9920 7 10 13 19 31
496..................................... 895 10.5821 4 6 8 13 20
497..................................... 21969 6.2886 2 3 5 7 11
498..................................... 12500 3.5058 1 2 3 5 6
499..................................... 36205 4.9604 2 2 4 6 9
500..................................... 36448 2.8726 1 2 2 4 5
501..................................... 1895 10.4391 4 6 8 12 19
502..................................... 468 6.5876 3 4 6 8 10
503..................................... 6317 4.2169 1 2 3 5 8
504..................................... 157 31.5669 8 14 25 39 57
505..................................... 171 5.8421 1 1 1 4 11
506..................................... 1130 16.7522 4 8 13 21 34
507..................................... 391 8.9668 2 4 7 12 17
508..................................... 1206 7.7355 2 3 5 9 16
509..................................... 462 4.8528 1 2 3 6 10
510..................................... 1006 6.8897 2 3 5 8 13
511..................................... 311 4.8135 1 2 3 6 9
----------------
11244775
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 25678]]
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios For Urban
and Rural Hospitals (Case Weighted) March 1998
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.373 0.446
ALASKA................................................ 0.503 0.731
ARIZONA............................................... 0.375 0.540
ARKANSAS.............................................. 0.515 0.457
CALIFORNIA............................................ 0.363 0.481
COLORADO.............................................. 0.467 0.565
CONNECTICUT........................................... 0.546 0.532
DELAWARE.............................................. 0.506 0.488
DISTRICT OF COLUMBIA.................................. 0.521 .......
FLORIDA............................................... 0.384 0.389
GEORGIA............................................... 0.497 0.497
HAWAII................................................ 0.430 0.559
IDAHO................................................. 0.564 0.582
ILLINOIS.............................................. 0.445 0.546
INDIANA............................................... 0.559 0.597
IOWA.................................................. 0.513 0.640
KANSAS................................................ 0.429 0.644
KENTUCKY.............................................. 0.496 0.519
LOUISIANA............................................. 0.442 0.496
MAINE................................................. 0.620 0.576
MARYLAND.............................................. 0.765 0.818
MASSACHUSETTS......................................... 0.540 0.571
MICHIGAN.............................................. 0.467 0.580
MINNESOTA............................................. 0.532 0.611
MISSISSIPPI........................................... 0.478 0.499
MISSOURI.............................................. 0.441 0.516
MONTANA............................................... 0.524 0.569
NEBRASKA.............................................. 0.482 0.639
NEVADA................................................ 0.320 0.584
NEW HAMPSHIRE......................................... 0.573 0.586
NEW JERSEY............................................ 0.436 .......
NEW MEXICO............................................ 0.466 0.510
NEW YORK.............................................. 0.553 0.633
NORTH CAROLINA........................................ 0.523 0.461
NORTH DAKOTA.......................................... 0.620 0.666
OHIO.................................................. 0.533 0.576
OKLAHOMA.............................................. 0.460 0.529
OREGON................................................ 0.546 0.624
PENNSYLVANIA.......................................... 0.407 0.527
PUERTO RICO........................................... 0.481 0.569
RHODE ISLAND.......................................... 0.571 .......
SOUTH CAROLINA........................................ 0.472 0.494
SOUTH DAKOTA.......................................... 0.537 0.620
TENNESSEE............................................. 0.481 0.508
TEXAS................................................. 0.427 0.536
UTAH.................................................. 0.538 0.635
VERMONT............................................... 0.615 0.577
VIRGINIA.............................................. 0.476 0.499
WASHINGTON............................................ 0.599 0.662
WEST VIRGINIA......................................... 0.592 0.573
WISCONSIN............................................. 0.568 0.641
WYOMING............................................... 0.495 0.694
------------------------------------------------------------------------
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) March 1998
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.047
ALASKA......................................................... 0.066
ARIZONA........................................................ 0.043
ARKANSAS....................................................... 0.054
CALIFORNIA..................................................... 0.038
COLORADO....................................................... 0.052
CONNECTICUT.................................................... 0.042
DELAWARE....................................................... 0.058
DISTRICT OF COLUMBIA........................................... 0.040
FLORIDA........................................................ 0.046
GEORGIA........................................................ 0.049
HAWAII......................................................... 0.045
IDAHO.......................................................... 0.054
ILLINOIS....................................................... 0.042
INDIANA........................................................ 0.059
IOWA........................................................... 0.054
KANSAS......................................................... 0.052
KENTUCKY....................................................... 0.051
LOUISIANA...................................................... 0.067
MAINE.......................................................... 0.040
MARYLAND....................................................... 0.013
MASSACHUSETTS.................................................. 0.056
MICHIGAN....................................................... 0.046
MINNESOTA...................................................... 0.056
MISSISSIPPI.................................................... 0.054
MISSOURI....................................................... 0.049
MONTANA........................................................ 0.052
NEBRASKA....................................................... 0.057
NEVADA......................................................... 0.068
NEW HAMPSHIRE.................................................. 0.066
NEW JERSEY..................................................... 0.039
NEW MEXICO..................................................... 0.047
NEW YORK....................................................... 0.053
NORTH CAROLINA................................................. 0.047
NORTH DAKOTA................................................... 0.075
OHIO........................................................... 0.053
OKLAHOMA....................................................... 0.054
OREGON......................................................... 0.055
PENNSYLVANIA................................................... 0.043
PUERTO RICO.................................................... 0.054
RHODE ISLAND................................................... 0.033
SOUTH CAROLINA................................................. 0.053
SOUTH DAKOTA................................................... 0.061
TENNESSEE...................................................... 0.056
TEXAS.......................................................... 0.052
UTAH........................................................... 0.056
VERMONT........................................................ 0.047
VIRGINIA....................................................... 0.058
WASHINGTON..................................................... 0.066
WEST VIRGINIA.................................................. 0.056
WISCONSIN...................................................... 0.052
WYOMING........................................................ 0.056
------------------------------------------------------------------------
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 1999, 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. GME Payment to Nonhospital Providers
In the past, Medicare only paid hospitals for GME costs.
Therefore, FQHCs, RHCs and Medicare+Choice organizations may have
been reluctant to train many residents since they would incur costs
in training the residents but would not be reimbursed for those
costs by Medicare. Under this proposed regulation, where the non-
hospital site incurs all or substantially all of the costs of the
training at that site, Medicare will reimburse
[[Page 25679]]
the provider for Medicare's share of the reasonable costs of the
training. The proposal to allow for payments directly to these non-
hospital sites for the costs of training residents in approved
programs will facilitate more training of residents in settings that
will be similar to the settings that many of those residents will
ultimately practice after their training is completed. Additionally,
this could result in an increase in the number of physicians
practicing in underserved areas.
In addition, hospitals are currently allowed to count residents,
working in nonhospital sites in their count of residents and the
hospital would be paid GME payments, if it paid for all or
substantially all of the costs of the program at the non-hospital
site. Previously the regulation defined the statutory requirement of
``all or substantially all'' to mean at least the residents''
salaries and fringe benefits. Under the proposal we would redefine
``all or substantially all'' of the costs of the program at the
nonhospital site to also include the GME portion of the teaching
physicians' salaries and fringe benefits. This will require
hospitals to incur more of the costs of the training at the
nonhospital site in order to receive both direct and indirect GME
payments for those residents.
Section 4625 of the Balanced Budget Act, which provides for
direct graduate medical education payments to nonhospital providers,
would have minimal impact in the context of total graduate medical
education costs. We believe that the most significant impact
resulting from section 4625 will be the movement of resident
training from the inpatient setting to the nonhospital setting. We
expect that such a shift in the site where resident training occurs
will result in little if any additional cost to Medicare. In
addition to the expected shift in training from the inpatient
setting to the nonhospital setting, in relatively few cases, section
4625 could result in additional resident training being paid by
Medicare. However, Medicare's share of costs incurred in those
nonhospital sites based on Medicare utilization is often generally
low, so we expect the impact of the cost of training of any
additional residents to be negliglible.
V. 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 March 1998, we have
included 4,956 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.
VI. Impact on Excluded Hospitals and Units
As of March 1998, there were 1,082 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 2,393 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.
As required by 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 1999 would be between 0 and 2.5 percent,
depending on the hospital's costs in relation to its limit.
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.
We note that, under Sec. 413.40(d)(3), an excluded hospital or
unit whose costs exceed 110 percent of its rate-of-increase limit
receives its rate-of-increase limit plus 50 percent of the
difference between its reasonable costs and 110 percent of the
limit, not to exceed 110 percent of its limit. In addition, under
the various provisions set forth in Sec. 413.40, certain 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.
VII. 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 estimate the total payment
impact of these changes on FY 1999 payments compared to FY 1998
payments, to be approximately a $400 million reduction. We have
prepared separate impact 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 1997 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 categorize hospitals. 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 1997 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 1999 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 implementing the expanded transfer
definition enacted by section 4407 of the BBA, which counts as a
transfer any discharge from one of 10 DRGs if upon discharge the
patient is admitted to an excluded hospital or distinct part unit or
a skilled nursing facility, or is provided home health care that is
related to the hospitalization within 3 days of the date of
discharge.
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 1995 data).
The effects of two proposed changes to the wage index:
(1) including the costs associated with Part A physician costs under
contract; and (2) removing the overhead costs related to departments
excluded from the wage data used to calculate the wage index (for
example, skilled nursing facilities and distinct part units).
The effects of geographic reclassifications by the
Medicare Geographic Classification Review Board (MGCRB) that will be
effective in FY 1999.
[[Page 25680]]
The total change in payments based on FY 1999 policies
relative to payments based on FY 1998 policies.
To illustrate the impacts of the FY 1999 proposed changes, our
analysis begins with a FY 1999 baseline simulation model using: The
FY 1998 GROUPER (version 15.0); the FY 1998 wage index; the transfer
definition prior to implementation of section 4407 of the BBA; 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 1999
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 1998 to FY 1999. Four 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 1999 using the most recently forecasted
hospital market basket increase for FY 1999 of 2.6 percent minus 1.9
percentage points. 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), essential access
community hospitals (EACHs) (which are treated as SCHs for payment
purposes), and Medicare-dependent, small rural hospitals (MDHs) is
equal to the market basket increase of 2.6 percent minus 1.9
percentage points (for an update of 0.7 percent).
A second significant factor impacting changes in hospitals'
payments per case from FY 1998 to FY 1999 is a change in MGCRB
reclassification status from one year to the next. That is,
hospitals reclassified in FY 1998 that are no longer reclassified in
FY 1999 may have a negative payment impact going from FY 1998 to FY
1999; conversely, hospitals not reclassified in FY 1998 that are
reclassified in FY 1999 may have a positive impact. In some cases,
these impacts can be quite substantial, so if a relatively small
number of hospitals in a particular category lose their
reclassification status, the percentage increase in payments for the
category may be below the national mean.
A third significant factor is that we currently estimate that
actual outlier payments during FY 1998 will be 5.4 percent of actual
total DRG payments. When the FY 1998 final rule was published, we
projected FY 1998 outlier payments would be 5.1 percent of total DRG
payments, and the standardized amounts were reduced correspondingly.
The effects of the slightly higher than expected outlier payments
during FY 1998 (as discussed in the Addendum to this proposed rule)
are reflected in the analyses below comparing our current estimates
of FY 1998 payments per case to estimated FY 1999 payments per case.
Fourth, payments per case in FY 1999 are reduced from FY 1998
for hospitals that receive the indirect medical education (IME) or
the disproportionate share (DSH) adjustments. Section
1886(d)(5)(B)(ii) of the Act provides that the IME adjustment is
reduced from approximately a 7.0 percent increase for every 10
percent increase in a hospital's resident-to-bed ratio in FY 1998,
to a 6.5 percent increase in FY 1999. Similarly, in accordance with
section 1886(d)(5)(F)(ix) of the Act, the DSH adjustment for FY 1999
is reduced by 2 percent from what would otherwise have been paid,
compared to a 1 percent reduction for FY 1998.
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 4,956 hospitals included in the analysis. This is 132
fewer hospitals than were included in the impact analysis in the FY
1998 final rule with comment period (62 FR 46119).
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 2,792
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,588 hospitals located in large
urban areas (populations over 1 million), and 1,204 hospitals in
other urban areas (populations of 1 million or fewer). In addition,
there are 2,164 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 1999 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 paid based on these categorizations (after
consideration of geographic reclassifications) are 2,877, 1,681,
1,196, and 2,079, 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 3,875 nonteaching hospitals in our analysis, 841 teaching
hospitals with fewer than 100 residents, and 240 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 or for purposes
of the DSH adjustment. (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 row separately examines hospitals that available data
show may qualify under section 4401(b) of the BBA for the special
temporary relief provision, which grants an additional 0.3 percent
update to the standardized amounts (in addition to the 0.7 percent
update other hospitals would receive during FY 1999), resulting in a
1.0 percent update for this category of hospitals. To be eligible, a
hospital must not be an MDH, nor may it receive either IME or DSH
payments. It must also experience a negative margin on its operating
prospective payments during FY 1999. We estimated eligible hospitals
based on whether they had a negative operating margin on their FY
1995 cost report (latest available data). Finally, to qualify, a
hospital must be located in a State where the aggregate FY 1995
operating prospective payments were less than the aggregate
associated costs for all of the non-IME, non-DSH, non-MDH hospitals
in the State. There are 356 hospitals in this row.
The next four rows examine the impacts of the proposed changes
on rural hospitals by special payment groups (SCHs, rural referral
centers (RRCs), MDHs, and EACHs), as well as rural hospitals not
receiving a special payment designation. The RRCs (137), SCH/EACHs
(633), MDHs (351), and SCH/EACH and RRCs (54) shown here were not
reclassified for purposes of the standardized amount. There is one
SCH that will be reclassified for the standardized amount in FY 1999
that, therefore, is not included in these rows. There are six EACHs
included in our analysis and three 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 95 hospitals. For the
most part, these are new hospitals.
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
1998 and FY 1999, or for either of those 2 years, by urban/rural
status. The next rows illustrate the overall number of FY 1999
reclassifications, as well as the numbers of reclassified hospitals
grouped by urban and rural location. The final row in Table I
contains hospitals located in rural counties but deemed to be urban
under section 1886(d)(8)(B) of the Act.
[[Page 25681]]
Table I.--Impact Analysis of Changes for FY 1999 Operating Prospective Payment System
[Percent changes in payments per case]
PAC tran. Contract Allocated MGCRB recl-
Number of prov- DRG re- New wage phys. pt a overhead DRG & WI assifi- All FY 99
hosps.\1\ ision \2\ calib. \3\ data \4\ costs \5\ costs \6\ changes cation \8\ changes
(0) (1) (2) (3) (4) (5) (6) (7) (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
ALL HOSPITALS........................... 4,956 -0.6 0.1 0.1 0.0 -0.1 0.0 0.0 -0.7
URBAN HOSPITALS......................... 2,792 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.4 -1.1
LARGE URBAN......................... 1,588 -0.7 0.1 -0.3 0.0 -0.2 -0.5 -0.4 -1.4
OTHER URBAN......................... 1,204 -0.6 0.1 0.4 0.0 -0.2 0.2 -0.3 -0.5
RURAL HOSPITALS......................... 2,164 -0.4 0.1 0.9 -0.1 0.3 1.3 2.4 1.5
BED SIZE (URBAN):
0-99 BEDS........................... 690 -0.8 0.2 -0.3 0.0 -0.1 -0.3 -0.5 -0.7
100-199 BEDS........................ 936 -0.8 0.2 -0.2 0.0 -0.1 -0.3 -0.4 -1.0
200-299 BEDS........................ 566 -0.7 0.1 -0.1 0.0 -0.1 -0.3 -0.3 -0.9
300-499 BEDS........................ 448 -0.6 0.1 0.0 0.0 -0.2 -0.3 -0.5 -1.2
500 OR MORE BEDS.................... 152 -0.5 0.1 0.3 0.0 -0.3 0.1 -0.2 -1.2
BED SIZE (RURAL):
0-49 BEDS........................... 1,135 -0.3 0.1 0.9 -0.1 0.5 1.3 -0.1 1.3
50-99 BEDS.......................... 635 -0.4 0.1 0.8 -0.1 0.3 1.1 0.9 1.1
100-149 BEDS........................ 229 -0.5 0.1 0.8 -0.1 0.4 1.3 3.3 1.3
150-199 BEDS........................ 91 -0.5 0.1 1.0 -0.1 0.3 1.5 3.9 2.7
200 OR MORE BEDS.................... 74 -0.4 0.1 1.0 0.0 0.2 1.4 4.6 1.6
URBAN BY CENSUS DIVISION:
NEW ENGLAND......................... 152 -0.7 0.1 -2.4 -0.1 0.1 -2.7 0.1 -3.5
MIDDLE ATLANTIC..................... 425 -0.4 0.2 0.4 0.3 -0.2 0.6 -0.5 -0.5
SOUTH ATLANTIC...................... 413 -0.6 0.1 0.8 -0.1 -0.2 0.6 -0.6 -0.3
EAST NORTH CENTRAL.................. 475 -0.8 0.1 0.0 -0.1 -0.4 -0.6 -0.3 -1.5
EAST SOUTH CENTRAL.................. 159 -0.6 0.1 0.5 -0.1 -0.4 0.0 -0.5 -0.7
WEST NORTH CENTRAL.................. 186 -0.7 0.0 0.9 0.0 0.1 1.0 -0.6 0.1
WEST SOUTH CENTRAL.................. 350 -0.9 0.1 -1.1 0.1 -0.2 -1.4 -0.1 -2.0
MOUNTAIN............................ 126 -0.8 0.1 0.4 0.2 -0.2 0.5 -0.6 -0.3
PACIFIC............................. 458 -0.8 0.1 -0.5 -0.1 0.0 -0.7 -0.3 -1.4
PUERTO RICO......................... 48 -0.2 0.3 0.8 -0.3 -0.3 0.3 -0.5 0.3
RURAL BY CENSUS DIVISION:
NEW ENGLAND......................... 53 -0.4 0.0 1.3 0.1 0.0 1.4 0.6 -0.4
MIDDLE ATLANTIC..................... 80 -0.3 0.1 0.9 0.1 0.0 1.2 1.2 1.1
SOUTH ATLANTIC...................... 286 -0.4 0.2 0.8 -0.1 0.3 1.1 3.3 2.0
EAST NORTH CENTRAL.................. 284 -0.5 0.1 1.0 -0.3 0.3 1.2 1.9 1.5
EAST SOUTH CENTRAL.................. 269 -0.4 0.1 1.5 -0.1 0.3 1.9 2.5 2.0
[[Page 25682]]
WEST NORTH CENTRAL.................. 499 -0.4 0.0 1.1 0.0 0.7 1.9 2.1 1.8
WEST SOUTH CENTRAL.................. 341 -0.5 0.1 0.3 -0.1 0.5 0.8 3.1 0.7
MOUNTAIN............................ 206 -0.3 0.0 0.3 -0.1 0.5 0.8 1.6 1.2
PACIFIC............................. 141 -0.6 0.1 0.4 -0.1 0.4 1.0 2.3 1.1
PUERTO RICO......................... 5 -0.4 0.1 2.3 0.1 -0.3 2.2 1.9 0.8
(BY PAYMENT CATEGORIES):
URBAN HOSPITALS......................... 2,877 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.3 -1.0
LARGE URBAN......................... 1,681 -0.7 0.1 -0.3 0.0 -0.2 -0.4 -0.3 -1.3
OTHER URBAN......................... 1,196 -0.6 0.1 0.4 0.0 -0.2 0.2 -0.4 -0.5
RURAL HOSPITALS......................... 2,079 -0.4 0.1 0.9 -0.1 0.4 1.3 2.0 1.4
TEACHING STATUS:
NON-TEACHING........................ 3,875 -0.7 0.1 0.2 -0.1 0.0 0.2 0.3 -0.1
LESS THAN 100 RES................... 841 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.3 -0.9
100+ RESIDENTS...................... 240 -0.6 0.1 0.0 0.1 -0.2 -0.1 -0.3 -1.7
DISPROPORTIONATE SHARE HOSPITALS (DSH):
NON-DSH............................. 3,074 -0.6 0.1 0.1 0.0 -0.1 0.1 0.3 -0.4
URBAN DSH:
100 BEDS OR MORE................ 1,402 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.3 -1.1
FEWER THAN 100 BEDS............. 93 -0.7 0.2 -0.2 -0.1 -0.1 -0.3 -0.5 -0.7
RURAL DSH:
SOLE COMMUNITY (SCH)............ 156 -0.2 0.1 0.8 -0.1 0.2 1.1 -0.1 1.3
REFERRAL CENTERS (RRC).......... 47 -0.5 0.2 1.3 -0.1 0.3 1.9 4.8 2.9
OTHER RURAL DSH HOSP.:
100 BEDS OR MORE................ 64 -0.6 0.2 1.2 -0.1 0.4 1.8 1.3 0.8
FEWER THAN 100 BEDS............. 120 -0.3 0.1 1.4 -0.1 0.4 1.8 0.0 1.7
URBAN TEACHING AND DSH:
[[Page 25683]]
BOTH TEACHING AND DSH............... 700 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.4 -1.4
TEACHING AND NO DSH................. 328 -0.6 0.0 0.0 0.0 -0.3 -0.2 -0.1 -1.0
NO TEACHING AND DSH................. 795 -0.8 0.2 0.0 -0.1 -0.1 -0.1 -0.2 -0.6
NO TEACHING AND NO DSH.............. 1,054 -0.7 0.1 -0.2 0.0 -0.1 -0.3 -0.3 -0.6
SPECIAL UPDATE HOSPITALS (UNDER SEC.
4401(b) OF PUBLIC LAW 105-33).......... 356 -0.6 0.2 0.1 -0.1 -0.1 0.1 0.3 -0.3
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS......... 904 -0.5 0.2 1.1 -0.1 0.5 1.6 1.1 1.0
RRC................................. 137 -0.6 0.1 1.2 0.0 0.4 1.8 5.6 2.5
SCH/EACH............................ 633 -0.2 0.0 0.4 0.0 0.2 0.6 0.1 0.8
MDH................................. 351 -0.3 0.1 1.1 -0.1 0.5 1.5 0.4 1.3
SCH/EACH AND RRC.................... 54 -0.2 0.0 0.3 0.0 0.1 0.4 1.5 1.3
TYPE OF OWNERSHIP:
VOLUNTARY........................... 2,859 -0.6 0.1 0.1 0.0 -0.1 -0.1 -0.1 -0.8
PROPRIETARY......................... 671 -0.9 0.2 0.1 -0.1 -0.1 -0.1 0.1 -0.9
GOVERNMENT.......................... 1,331 -0.5 0.1 0.3 -0.1 0.0 0.3 0.3 -0.3
UNKNOWN............................. 95 -0.7 0.2 0.3 -0.1 -0.1 0.2 -0.2 -0.7
MEDICARE UTILIZATION AS A PERCENT OF
INPATIENT DAYS:
0-25................................ 249 -0.7 0.2 -0.7 -0.1 -0.1 -1.0 0.1 -1.6
25-50............................... 1,267 -0.7 0.1 0.0 0.0 -0.1 -0.2 -0.2 -1.2
50-65............................... 1,975 -0.6 0.1 0.2 0.0 -0.1 0.1 0.1 -0.4
OVER 65............................. 1,370 -0.6 0.1 0.3 0.0 0.0 0.4 0.0 0.0
UNKNOWN............................. 95 -0.7 0.2 0.3 -0.1 -0.1 0.2 -0.2 -0.7
HOSPITALS RECLASSIFIED BY THE MEDICARE
GEOGRAPHIC REVIEW BOARD:
RECLASSIFICATION STATUS DURING FY 98 AND
FY 99:
RECLASSIFIED DURING BOTH FY98 AND
FY99............................... 311 -0.5 0.1 0.6 -0.1 0.1 0.8 6.6 -0.1
URBAN........................... 70 -0.5 0.1 0.2 -0.1 -0.3 -0.1 5.4 -0.5
RURAL........................... 241 -0.5 0.1 1.0 -0.1 0.4 1.5 7.5 0.2
RECLASSIFIED DURING FY99 ONLY....... 178 -0.5 0.1 0.8 -0.1 0.2 1.0 4.0 4.7
[[Page 25684]]
URBAN........................... 25 -0.5 0.1 0.4 -0.1 0.0 0.4 3.1 1.9
RURAL........................... 153 -0.5 0.1 1.0 -0.1 0.3 1.3 4.4 6.1
RECLASSIFIED DURING FY98 ONLY....... 111 -0.7 0.1 0.6 0.0 -0.2 0.5 -0.5 -3.1
URBAN........................... 38 -0.7 0.1 0.5 0.1 -0.3 0.2 -0.6 -2.2
RURAL........................... 73 -0.4 0.1 0.9 -0.1 0.4 1.3 -0.5 -6.1
FY 99 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSP............... 489 -0.5 0.1 0.7 -0.1 0.1 0.9 5.7 1.6
STAND. AMOUNT ONLY.............. 94 -0.6 0.1 0.6 0.1 -0.3 0.5 1.0 -0.3
WAGE INDEX ONLY................. 281 -0.5 0.1 0.5 -0.1 0.3 0.8 6.6 -0.9
BOTH............................ 47 -0.6 0.2 0.9 -0.1 -0.4 0.6 3.8 -1.6
NONRECLASSIFIED................. 4,507 -0.7 0.1 0.1 0.0 -0.1 -0.1 -0.4 -0.7
ALL URBAN RECLASS................... 95 -0.5 0.1 0.3 -0.1 -0.2 0.0 4.7 0.2
STAND. AMOUNT ONLY.............. 25 -0.4 0.2 0.9 0.1 -0.4 0.7 0.7 0.0
WAGE INDEX ONLY................. 45 -0.5 0.1 0.0 -0.1 0.1 -0.1 6.5 0.6
BOTH............................ 25 -0.5 0.1 0.6 -0.2 -0.6 -0.1 2.9 -0.5
NONRECLASSIFIED................. 2,670 -0.7 0.1 0.0 0.0 -0.2 -0.2 -0.6 -1.1
ALL RURAL RECLASS................... 394 -0.5 0.1 1.0 -0.1 0.4 1.4 6.3 2.5
STAND. AMOUNT ONLY.............. 57 -0.5 0.1 1.1 -0.2 0.3 1.5 5.1 2.4
WAGE INDEX ONLY................. 309 -0.5 0.1 0.9 -0.1 0.4 1.4 6.1 2.3
BOTH............................ 28 -0.6 0.1 1.1 -0.1 0.3 1.6 9.2 3.8
NONRECLASSIFIED................. 1,770 -0.3 0.1 0.9 -0.1 0.3 1.2 -0.5 0.8
OTHER RECLASSIFIED HOSPITALS (SECTION
1886(d)(8)(B))......................... 27 -0.5 0.1 -0.9 0.2 -0.3 -0.9 0.7 -0.6
.......... .......... .......... .......... .......... .......... .......... .......... ..........
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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 1997, and hospital cost report data are from reporting periods beginning in FY 1994 and FY 1995.
\2\ This column displays the impact of the change enacted by section 4407 of the BBA, which defines discharges from 1 of 10 DRGs to postacute care as
transfers. Under our proposed policy, 3 of the 10 DRGs would be paid under an alternative methodology where they would receive 50 percent of the full
DRG amount on the first day and 50 percent of the current per diem transfer payment amount for each remaining day of the stay. The remaining seven
DRGs would be paid using our current transfer payment methodology.
\3\ This column displays the payment impact of the recalibration of the DRG weights based on FY 1997 MedPAR data and the DRG classification changes, in
accordance with section 1886(d)(4)(C) of the Act.
[[Page 25685]]
\4\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1995 cost reports.
\5\ This column displays the impact of adding contract Part A physician costs to the wage data.
\6\ This column illustrates the payment impact of removing the overhead costs allocated to departments where the directly assigned costs are already
excluded from the wage index calculation (for example, SNFs and distinct part units).
\7\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised 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 2, 3, 4, and 5, and the FY 1999 budget neutrality factor of 0.999227.
\8\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects shown here
demonstrate the FY 1999 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 1999.
Reclassification for prior years has no bearing on the payment impacts shown here.
\9\ This column shows changes in payments from FY 1998 to FY 1999. It incorporates all of the changes displayed in columns 1, 6, and 7 (the changes
displayed in columns 2, 3, 4 and 5 are included in column 6). It also displays the impact of the FY 1999 update, changes in hospitals'
reclassification status in FY 1999 compared to FY 1998, the difference in outlier payments from FY 1998 to FY 1999, and the reductions to payments
through the IME and DSH adjustments taking effect during FY 1999. The sum of these columns may be different from the percentage changes shown here due
to rounding and interactive effects.
B. Impact of the Proposed Implementation of the Expanded Transfer
Definition (Column 1)
Section 1886(d)(5)(J) of the Act (added by section 4407 of the
BBA) requires the Secretary to select 10 DRGs for which discharges
(from any one of these DRGs) to a postacute care provider will be
treated as a transfer beginning with discharges on or after October
1, 1998. Column 1 shows the impact of this provision.
Although the expanded definition encompasses only 10 DRGs, they
were selected, in accordance with the statute, based upon their
large and disproportionate volume of cases receiving postacute care.
We estimate that approximately 25 percent of all cases receiving
follow-up postacute care come from these 10 DRGs. Therefore, the
overall payment impact of this change is significant (a 0.6 percent
decrease in payments per case).
The 10 DRGs that we are proposing to include under this
provision are identified in section V.A. of the preamble to this
proposed rule. In addition to selecting 10 DRGs, the statute
authorizes the Secretary to develop an alternative transfer payment
methodology for DRGs where a substantial portion of the costs of the
cases occur very early in the stay. This is particularly likely to
happen in some surgical DRGs because of the high cost of the
surgical procedure. Based on our analysis comparing the costs per
case for these cases with payments under our current transfer
payment methodology, we are proposing to pay the current transfer
per diem for all DRGs except DRGs 209, 210, and 211. For those three
DRGs, the alternative payment methodology we are proposing is 50
percent of the full DRG payment amount for the first day of the
stay, plus 50 percent of the current per diem transfer payment for
each remaining day, up to the full DRG payment.
To simulate the impact of these proposed policies, we adjusted
hospitals' transfer-adjusted discharges and case-mix index values
(using version 15 of the GROUPER) to reflect the impact of this
expansion in the transfer definition. The transfer-adjusted
discharge amount is calculated one of two ways, depending on the
transfer payment methodology. Under our current transfer payment
methodology, and for all but the three DRGs receiving special
payment consideration, this adjustment is made simply by adding one
to the length of stay and dividing that amount by the geometric mean
length of stay for the DRG (not to exceed 1.0). For example, a
transfer after 3 days from a DRG with a geometric mean length of
stay of 6 days would have a transfer-adjusted discharge weight of
0.667 ((3+1)/6).
For transfers from any one of the three DRGs receiving the
alternative payment methodology, the transfer-adjusted discharge
amount is 0.5 (to reflect that these cases receive half the full DRG
amount the first day), plus one-half of the result of dividing one
plus the length of stay prior to transfer by the geometric mean
length of stay for the DRG. As with the above adjustment, the result
is equal to the lesser of the transfer-adjusted DRG or 1.
The transfer-adjusted case-mix index values are calculated by
summing the transfer-adjusted DRG weights and dividing by the
transfer-adjusted discharges. The transfer-adjusted DRG weights are
calculated by multiplying the DRG weight by the lesser of 1 or the
transfer-adjusted discharge for the case, divided by the geometric
mean length of stay for the DRG. In this way, simulated payments per
case can be compared before and after the change to the transfer
policy.
This change has the greatest impact among urban hospitals (0.7
percent decrease). Among urban hospitals, smaller hospitals (under
200 beds) are most affected, with a 0.8 percent reduction in
payments. For urban hospitals grouped by census division, Puerto
Rico and the Middle Atlantic division have the smallest negative
impacts, 0.2 and 0.4 percent decreases, respectively. The Middle
Atlantic division has traditionally had the longest average lengths
of stay, therefore, it is not surprising that the impact is smallest
here. Transfer cases with a length of stay more than the (geometric)
mean length of stay minus one day do not experience any payment
impact under this provision. (Full payment is reached one day prior
to the mean length of stay due to the double per diem paid for the
first day under our current transfer payment methodology.) The small
impact in Puerto Rico would indicate that these hospitals also are
not discharging patients to postacute care early in the stay.
Rural hospitals experience a smaller payment impact overall,
especially the smallest rural hospitals: Those with fewer than 50
beds (a 0.3 percent decrease). The smallest impacts among rural
census divisions are in the Middle Atlantic and the Mountain. The
largest rural impact is in the Pacific division, with a 0.6 percent
decrease. This change is consistent with the shorter lengths of stay
in this geographic region.
The largest negative impact is a 0.9 percent decrease in
payments, observed among urban West South Central hospitals, and
proprietary hospitals. The smallest negative impact besides urban
Puerto Rico hospitals occurs in SCHs (0.2 percent decrease). Those
SCHs paid based on their hospital-specific amount would see no
impact related to this change, since there is no transfer adjustment
made to the hospital-specific amount.
C. Impact of the Proposed Changes to the DRG Classifications and
Relative Weights (Column 2)
In column 2 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 to annually 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 1998 DRG relative
weights (GROUPER version 15) to aggregate payments using the
proposed FY 1999 DRG relative weights (GROUPER version 16). 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 6). Consistent with the minor changes
we are proposing for the FY 1999 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, as well as for rural hospitals). Within hospital
categories, the net effects for urban hospitals are small positive
changes for all hospitals (a 0.2 percent increase for hospitals with
fewer than 200 beds and a 0.1 percent increase for larger
hospitals). Among rural hospitals, all hospital categories
experience an increase of 0.1 percent.
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 Puerto Rico. For
rural hospitals, there is no impact (that is, a 0.0 percent change)
for hospitals in the New England, West North Central, and Mountain
census divisions. All other divisions experience a 0.1 percent
increase.
This pattern of small increases or no change applies to all
other hospital categories. Overall, we attribute this change to the
increasing severity of illness of
[[Page 25686]]
hospital inpatients. That is, as greater numbers of less acutely ill
patients are treated outside the inpatient setting, the acuity of
the remaining hospital inpatients increases. Although, in the past,
this effect was seen more clearly in large urban and very large
rural hospitals, which often had more outpatient settings available
for patient treatment, hospitals in all areas now appear to be able
to take advantage of this practice. Of course, in general, these
positive impacts are very minor, with virtually no hospital group
experiencing more than a 0.2 percent increase.
D. Impact of Updating the Wage Data (Column 3)
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 1999 is based on data submitted for hospital cost
reporting periods beginning on or after October 1, 1994 and before
October 1, 1995. 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 3 shows
the percentage changes in payments when going from a model using the
FY 1998 wage index based on FY 1994 wage data before geographic
reclassifications to a model using the FY 1999 prereclassification
wage index based on FY 1995 wage data.
The wage data collected on the FY 1995 cost reports includes,
for the first time, contract labor costs and hours for top
management positions as allowable in the wage index calculation. In
addition, the changes to wage-related costs associated with hospital
and home office salaries that were discussed in the September 1,
1994 final rule (59 FR 45355) are reflected in the FY 1995 data.
These changes are reflected in column 3, as well as other year-to-
year changes in hospitals' labor costs.
The results indicate that the new wage data have an overall
impact of a 0.1 percent increase in hospital payments (prior to
applying the budget neutrality factor, see column 6). Rural
hospitals especially appear to benefit from the update. Their
payments increase by 0.9 percent. These increases are attributable
to relatively large increases in the wage index values for the rural
areas of particular States; South Dakota, Hawaii, Mississippi,
Wyoming, New Hampshire, and Iowa all had increases greater than 6
percent in their prereclassification wage index values.
Urban hospitals as a group are not significantly affected by the
updated wage data. The gains of hospitals in other urban areas (0.4
percent increase) are offset by decreases among hospitals in large
urban areas (0.3 percent decrease). The negative impact among large
urban areas appears to be largely due to a 5.8 percent decrease in
the wage index values for the Boston MSA. This impact is especially
evident in the 2.4 percent decrease for urban New England hospitals.
Urban West South Central hospitals experience a 1.1 percent
decrease, largely due to 11 Texas MSAs with FY 1999 wage indexes
that fall by more than 7 percent. These appear to be primarily
related to large changes in the average hourly wages of individual
hospitals in MSAs with only a few hospitals. We would point out that
the wage data used for the proposed wage index is not final, and we
understand that many hospitals have submitted revision requests. To
the extent these requests are granted by hospitals' fiscal
intermediaries, these revisions are likely to affect the impacts
shown in the final rule. In addition, we continue to verify the
accuracy of the data for hospitals with extraordinary changes in
their data from the prior year. We anticipate that all these
verifications will be completed when we calculate the final FY 1999
wage index.
The largest increases are seen in the rural census divisions.
Rural Puerto Rico experiences the greatest positive impact, 2.3
percent. Hospitals in three other census divisions receive positive
impacts over 1.0 percent; East South Central at 1.5 percent, New
England at 1.3 percent, and West North Central at 1.1 percent. We
believe these positive impacts of the new wage data for rural
hospitals stem from the expansion of the contract labor definition,
specifically to include certain management categories. On average,
the hourly cost of contract labor increased for rural hospitals by
5.9 percent. Among urban hospitals, the increase was 4.2 percent.
E. Impact of Including Contract Physician Part A Costs (Column 4)
As discussed in section III.C.1 of the preamble, we began
collecting separate wage data for both direct and contract physician
Part A services on the FY 1995 cost report. This change was made in
order to address any potential inequity of including only salaried
Part A physician costs in the wage index while some States had laws
prohibiting their hospitals from employing physicians directly
(forcing hospitals to contract with physicians for administrative
services). Based on our analysis, we are proposing to include
contract physician Part A costs in the wage index calculation.
Column 4 shows the payment impacts of including these data.
Although only two States currently maintain the prohibition against
hospitals directly employing physicians (Texas and California), many
hospitals in other States reported these costs as well. Thus, the
impacts of this proposed change extend well beyond Texas and
California. In fact, the urban Middle Atlantic census division shows
the largest positive impact from this change (0.3 percent).
In general, hospitals in other areas experience either no
changes due to this proposed policy, or small (0.1 percent)
increases or decreases. However, urban hospitals in Puerto Rico and
rural hospitals in the East North Central census division experience
0.3 percent decreases. The negative rural East North Central impact
is largely due to a negative impact of this change on the rural
Wisconsin wage index.
As noted above, the data used to prepare the proposed FY 1999
wage index are subject to revision, and we understand that many
hospitals requested changes to their contract physician Part A costs
prior to the March 9 deadline for all requests for wage data changes
to be submitted to the fiscal intermediaries. The extent of these
requests and the number which are approved by the fiscal
intermediaries may change the impacts in the final rule.
F. Impact of Removing Overhead Costs of Excluded Areas (Column 5)
Prior years' wage index calculations have removed the direct
wages and hours associated with certain subprovider components
excluded from the prospective payment system; however, the overhead
costs associated with these excluded components have not been
removed. We revised the FY 1995 cost report to allow hospitals to
report separately overhead salaries and hours, and we are proposing
to remove the overhead costs and hours allocated to areas of the
hospital excluded from the wage index calculation.
Column 5 displays the impacts on FY 1999 payments per case of
implementing this change. The overall impact is a 0.1 percent
decline in payments; however, once again (as with the impacts of the
FY 1995 data), the impact diverges along urban and rural lines.
Urban hospitals lose 0.2 percent as a result of removing these
overhead costs, while rural hospitals gain 0.3 percent. Among rural
hospitals by bed size, the smallest rural hospitals benefit the
most, with a 0.5 percent increase for rural hospitals with fewer
than 50 beds.
Hospitals in the rural West North Central census division
experience the largest percentage increase (0.7 percent). The
largest negative impacts are in Puerto Rico (urban and rural), and
urban East North Central and urban East South Central.
The combined wage index changes in Table I are determined by
summing the individual impacts in columns 3, 4, and 5. For example,
the rural West North Central census division gains 1.1 percent from
the new wage data, and 0.7 percent from removing the overhead costs
allocated to excluded areas. Therefore, the combined impact of the
FY 1999 wage index for these hospitals is a 1.8 percent increase.
The following chart compares the shifts in wage index values for
labor market areas for FY 1999 relative to FY 1998. This chart
demonstrates the impact of the proposed changes for the FY 1999 wage
index relative to the FY 1998 wage index. The majority of labor
market areas (282) experience less than a 5 percent change. A total
of 54 labor market areas experience an increase of more than 5
percent with 13 having an increase greater than 10 percent. A total
of 34 areas experience decreases of more than 5 percent (all urban).
Of those, 6 decline by 10 percent or more.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values ---------------------
FY 1998 FY 1999
------------------------------------------------------------------------
Increase more than 10 percent..................... 2 13
Increase more than 5 percent and less than 10
percent.......................................... 24 41
Increase or decrease less than 5 percent.......... 334 282
[[Page 25687]]
Decrease more than 5 percent and less than 10
percent.......................................... 9 28
Decrease more than 10 percent..................... 1 6
------------------------------------------------------------------------
Among urban hospitals, 164 would experience an increase of more
than 5 percent and 29 more than 10 percent. More rural hospitals
have increases greater than 5 percent (360), but none greater than
10 percent. On the negative side, 268 urban hospitals but no rural
hospitals have decreases in their wage index values of at least 5
percent (30 of the urban hospitals have decreases greater 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..................... 29 0
Increase more than 5 percent and less than 10
percent.......................................... 164 360
Increase or decrease less than 5 percent.......... 2440 1924
Decrease more than 5 percent and less than 10
percent.......................................... 238 0
Decrease more than 10 percent..................... 30 0
------------------------------------------------------------------------
G. Combined Impact of DRG and Wage Index Changes--Including Budget
Neutrality Adjustment (Column 6)
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 noted in the Addendum to this proposed
rule, we compared aggregate payments using the FY 1998 DRG relative
weights and wage index to aggregate payments using the FY 1999 DRG
relative weights and wage index. Based on this comparison, we
computed a wage and recalibration budget neutrality factor of
0.999227. 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 6. 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 2, 3, 4, and 5, minus approximately 0.1 percent
attributable to the budget neutrality factor. There may, of course,
be some variation of plus or minus 0.1 percent due to rounding.
H. Impact of MGCRB Reclassifications (Column 7)
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 7 reflect
the per case payment impact of moving from this baseline to a
simulation incorporating the MGCRB decisions for FY 1999. 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.
Beginning in 1998, by February 28 of each year, the MGCRB makes
reclassification determinations that will be effective for the next
fiscal year, which begins on October 1. (In previous years, these
determinations were made by March 30.) 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 or for
FYS 1999-2001 for purposes of qualifying for a DSH adjustment or to
receive a higher DSH payment.
The proposed FY 1999 wage index values incorporate all of the
MGCRB's reclassification decisions for FY 1999. The wage index
values also reflect any decisions made by the HCFA Administrator
through the appeals and review process for MGCRB decisions as of
February 27, 1998. 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 1999.
The overall effect of geographic reclassification is required by
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we
applied an adjustment of 0.994019 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 2.4 percent, while payments to
urban hospitals decline 0.4 percent. Hospitals in other urban areas
see a decrease in payments of 0.3 percent, while large urban
hospitals lose 0.4 percent. Among urban hospital groups (that is,
bed size, census division, and special payment status), payments
generally decline.
A positive impact is evident among all rural hospital groups
except the smallest hospitals (under 50 beds), which experience a
slight decrease of 0.1 percent. The smallest increase among the
rural census divisions is 0.6 percent for New England. The largest
increase is in rural South Atlantic, with an increase of 3.3
percent.
Among rural hospitals designated as RRCs, 108 hospitals are
reclassified for purposes of the wage index only, leading to the 5.6
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 4.6 percent increase in payments.
Rural hospitals reclassified for FY 1998 and FY 1999 experience
a 6.6 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 1999 only experience a 4.4 percent increase in
payments, while rural hospitals reclassified for FY 1998 only
experience a 0.5 percent decrease in payments. Urban hospitals
reclassified for FY 1998 but not FY 1999 experience a 0.6 percent
decline in payments overall. Urban hospitals reclassified for FY
1999 but not for FY 1998 experience a 3.1 percent increase in
payments.
The FY 1999 Reclassification rows of Table I show the changes in
payments per case for all FY 1999 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 9.2 percent increase in payments. In addition, rural
hospitals reclassified just for the wage index receive a 6.1 percent
payment increase. The overall impact on reclassified hospitals is to
increase their payments per case by an average of 5.7 percent for FY
1999.
Among the 27 rural hospitals deemed to be urban under section
1886(d)(8)(B) of the Act, payments increase 0.7 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 1999, 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 0.4 percent. Rural
nonreclassified hospitals decrease slightly more, experiencing a 0.5
percent decrease, and urban nonreclassified hospitals lose 0.6
percent (the amount of the budget neutrality offset).
The number of reclassifications for purposes of the standardized
amount, or for both the standardized amount and the wage index, has
increased from 149 in FY 1998 to 162 in FY 1999. The number of wage
index only reclassifications increased from 284 in FY 1998 to 358 in
FY 1999. These increases are mainly attributable to two changes made
by the BBA. Section 4202 of the BBA amended section 1886(d)(10)(D)
of the Act to allow RRCs to reclassify for wage index purposes based
only on comparison of the RRC's average hourly wage to the average
hourly wage of the area to which it applies to be reclassified. In
addition, section 4203 provides that for FYs 1999-2001, a rural
[[Page 25688]]
hospital may be reclassified to an other urban area for the sole
purpose of receiving a higher DSH payment.
The foregoing analysis was based on MGCRB and HCFA Administrator
decisions made by February 27 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.
I. All Changes (Column 8)
Column 8 compares our estimate of payments per case,
incorporating all changes reflected in this proposed rule for FY
1999 (including statutory changes), to our estimate of payments per
case in FY 1998. It includes the effects of the 0.7 percent update
to the standardized amounts and the hospital-specific rates for
SCHs, EACHs, and MDHs. It also reflects the 0.3 percentage point
difference between the projected outlier payments in FY 1999 (5.1
percent of total DRG payments) and the current estimate of the
percentage of actual outlier payments in FY 1998 (5.4 percent), as
described in the introduction to this Appendix and the Addendum to
this proposed rule.
Additional changes affecting the difference between FY 1998 and
FY 1999 payments are the reductions to the IME and DSH adjustments
enacted by the BBA. These changes initially went into effect during
FY 1998 and include additional decreases in payment for each of
several succeeding years. As noted in the introduction to this
impact analysis, for FY 1999, IME is reduced to approximately a 6.5
percent rate of increase, and DSH is reduced by 2 percent from what
hospitals otherwise would receive. We estimate the overall effect of
these statutory changes to be a 0.4 percent reduction in FY 1999
payments. For hospitals receiving both IME and DSH, the impact is
estimated to be a 0.9 percent reduction in payments per case.
We also note that column 8 includes the impacts of FY 1999 MGCRB
reclassifications compared to the payment impacts of FY 1998
reclassifications. Therefore, when comparing FY 1999 payments to FY
1998, the percent changes due to FY 1999 reclassifications shown in
column 7 need to be offset by the effects of reclassification on
hospitals' FY 1998 payments (column 7 of Table 1, August 29, 1997
final rule with comment period; 62 FR 46119). For example, the
impact of MGCRB reclassifications on rural hospitals' FY 1998
payments was approximately a 2.2 percent increase, offsetting much
of the 2.4 percent increase in column 7 for FY 1999. Therefore, the
net change in FY 1999 payments due to reclassification for rural
hospitals is actually closer to an increase of 0.2 percent relative
to FY 1998. 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 8 may not equal the
sum of the changes in columns 1, 6, and 7, plus the other impacts
that we are able to identify.
The overall payment change from FY 1998 to FY 1999 for all
hospitals is a 0.7 percent decrease. This reflects the 0.6 percent
net change in total payments due to the postacute transfer change
for FY 1999 shown in column 1; the 0.7 percent update for FY 1999,
the 0.3 percent lower outlier payments in FY 1999 compared to FY
1998 (5.1 percent compared to 5.4 percent); and the 0.4 percent
reduction due to lower IME and DSH payments.
Hospitals in urban areas experience a 1.1 percent drop in
payments per case compared to FY 1998. Urban hospitals lose 0.9
percent due to the expanded transfer definition and the DRG and wage
index changes combined. The 0.4 percent negative impact due to
reclassification is offset by an identical negative impact for FY
1998. The impact of reducing IME and DSH is a 0.6 percent reduction
in FY 1999 payments per case. Most of this negative impact is
incurred by hospitals in large urban areas, where payments are
expected to fall 1.4 percent per case compared to 0.5 percent per
case for hospitals in other urban areas.
Hospitals in rural areas, meanwhile, experience a 1.5 percent
payment increase. As discussed previously, this is primarily due to
a smaller negative impact due to the expanded transfer definition
(0.4 percent decrease compared to 0.6 percent nationally) and the
positive effect due to the wage index and DRG changes (1.3 percent
increase).
Among census divisions, urban New England displays the largest
negative impact, 3.5 percent. This outcome is primarily related to the
2.4 percent decrease due to the new wage data. Similarly, urban West
South Central experiences a 2.0 percent drop in payments per case, due
to a 1.1 percent drop due to the new wage data. The urban East North
Central and the urban Pacific also experience overall payment declines
of more than 1.0 percent, with 1.5 and 1.4 percent decreases,
respectively. The West North Central is the only urban census category
to experience a rise in payments, stemming primarily from a 0.9 percent
increase due to the new wage data. Hospitals in this census division
also are less reliant on IME and DSH funding, and are therefore,
impacted less by these reductions.
The only rural census division to experience a negative payment
impact is New England (0.4 percent fall). This appears to result from a
much smaller reclassification effect for rural New England hospitals in
FY 1999. For FY 1998, the impact of MGCRB reclassification for these
hospitals was a 2.1 percent increase (see 62 FR 46119). For FY 1999,
the increase is only 0.6 percent. The largest increases by rural census
division are in the South Atlantic and the East South Central, both
with 2.0 percent increases in their FY 1999 payments per case. In the
South Atlantic, this is primarily due to a larger FY 1999 benefit from
MGCRB reclassifications. For the East South Central, it is largely due
to a 1.5 percent increase from the FY 1995 wage data.
Among special categories of rural hospitals, RRCs have the largest
increase, 2.5 percent. This carries over to other categories as well:
rural hospitals with between 150 and 200 beds have a 2.7 percent rise
in payments (there are 37 RRCs in this category); and RRCs receiving
DSH see a 2.9 percent increase.
The largest negative payment impacts from FY 1998 to FY 1999 are
among hospitals that were reclassified for FY 1998 and are not
reclassified for FY 1999. Overall, these hospitals lose 3.1 percent.
The urban hospitals in this category lose 2.2 percent, while the rural
hospitals lose 6.1 percent. On the other hand, hospitals reclassified
for FY 1999 that were not reclassified for FY 1998 would experience the
greatest payment increases: 4.7 percent overall; 6.1 percent for 153
rural hospitals in this category and 1.9 percent for 25 urban
hospitals.
Table II.--Impact Analysis of Changes for FY 1999 Operating Prospective Payment System
[Payments per case]
Average FY Average FY
Number of 1998 1999
hospitals payment per payment per All changes
case case
(1) (2) \1\ (3) \1\ (4)
----------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
ALL HOSPITALS........................................... 4,956 6,764 6,715 -0.7
URBAN HOSPITALS......................................... 2,792 7,332 7,255 -1.1
LARGE URBAN AREAS....................................... 1,588 7,891 7,782 -1.4
[[Page 25689]]
OTHER URBAN AREAS....................................... 1,204 6,584 6,549 -0.5
RURAL AREAS............................................. 2,164 4,461 4,528 1.5
BED SIZE (URBAN):
0-99 BEDS............................................... 690 4,922 4,890 -0.7
100-199 BEDS............................................ 936 6,127 6,069 -1.0
200-299 BEDS............................................ 566 6,921 6,860 -0.9
300-499 BEDS............................................ 448 7,839 7,744 -1.2
500 OR MORE BEDS........................................ 152 9,724 9,607 -1.2
BED SIZE (RURAL):
0-49 BEDS............................................... 1,135 3,663 3,712 1.3
50-99 BEDS.............................................. 635 4,173 4,218 1.1
100-149 BEDS............................................ 229 4,609 4,669 1.3
150-199 BEDS............................................ 91 4,799 4,927 2.7
200 OR MORE BEDS........................................ 74 5,603 5,692 1.6
URBAN BY CENSUS DIV.:
NEW ENGLAND............................................. 152 7,873 7,597 -3.5
MIDDLE ATLANTIC......................................... 425 8,168 8,123 -0.5
SOUTH ATLANTIC.......................................... 413 6,973 6,955 -0.3
EAST NORTH CENTRAL...................................... 475 7,016 6,909 -1.5
EAST SOUTH CENTRAL...................................... 159 6,558 6,511 -0.7
WEST NORTH CENTRAL...................................... 186 7,001 7,011 0.1
WEST SOUTH CENTRAL...................................... 350 6,807 6,672 -2.0
MOUNTAIN................................................ 126 7,065 7,045 -0.3
PACIFIC................................................. 458 8,403 8,289 -1.4
PUERTO RICO............................................. 48 3,049 3,057 0.3
RURAL BY CENSUS DIV.:
NEW ENGLAND............................................. 53 5,308 5,285 -0.4
MIDDLE ATLANTIC......................................... 80 4,802 4,857 1.1
SOUTH ATLANTIC.......................................... 286 4,606 4,697 2.0
EAST NORTH CENTRAL...................................... 284 4,492 4,559 1.5
EAST SOUTH CENTRAL...................................... 269 4,160 4,242 2.0
WEST NORTH CENTRAL...................................... 499 4,174 4,250 1.8
WEST SOUTH CENTRAL...................................... 341 3,989 4,019 0.7
MOUNTAIN................................................ 206 4,815 4,871 1.2
PACIFIC................................................. 141 5,603 5,664 1.1
PUERTO RICO............................................. 5 2,369 2,389 0.8
(BY PAYMENT CATEGORIES):
URBAN HOSPITALS......................................... 2,877 7,289 7,215 -1.0
LARGE URBAN AREAS....................................... 1,681 7,795 7,691 -1.3
OTHER URBAN AREAS....................................... 1,196 6,564 6,533 -0.5
RURAL AREAS............................................. 2,079 4,440 4,501 1.4
TEACHING STATUS:
NON-TEACHING............................................ 3,875 5,478 5,472 -0.1
FEWER THAN 100 RESIDENTS................................ 841 7,219 7,155 -0.9
100 OR MORE RESIDENTS................................... 240 10,987 10,796 -1.7
DISPROPORTIONATE SHARE HOSPITALS (DSH):
NON-DSH................................................. 3,074 5,830 5,809 -0.4
URBAN DSH:
100 BEDS OR MORE.................................... 1,402 7,941 7,850 -1.1
FEWER THAN 100 BEDS................................. 93 5,024 4,990 -0.7
RURAL DSH:
SOLE COMMUNITY (SCH)................................ 156 4,255 4,310 1.3
REFERRAL CENTERS (RRC).............................. 47 5,293 5,446 2.9
OTHER RURAL DSH HOSP.:
100 BEDS OR MORE.................................... 64 4,196 4,229 0.8
FEWER THAN 100 BEDS................................. 120 3,572 3,633 1.7
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH............................... 700 8,961 8,837 -1.4
TEACHING AND NO DSH................................. 328 7,390 7,318 -1.0
NO TEACHING AND DSH................................. 795 6,342 6,303 -0.6
NO TEACHING AND NO DSH.............................. 1,054 5,661 5,626 -0.6
SPECIAL UPDATE HOSPITALS (UNDER SEC. 4401(b) OF PUBLIC
LAW 105-33............................................. 356 5,322 5,305 -0.3
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS
HOSPITALS........................................... 904 3,948 3,986 1.0
[[Page 25690]]
RRC................................................. 137 5,182 5,309 2.5
SCH/EACH............................................ 633 4,490 4,525 0.8
MDH................................................. 351 3,701 3,747 1.3
SCH/EACH AND RRC.................................... 54 5,363 5,433 1.3
TYPE OF OWNERSHIP:
VOLUNTARY........................................... 2,859 6,949 6,894 -0.8
PROPRIETARY......................................... 671 6,148 6,092 -0.9
GOVERNMENT.......................................... 1,331 6,233 6,215 -0.3
UNKNOWN............................................. 95 7,984 7,928 -0.7
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS:
0-25................................................ 249 8,884 8,740 -1.6
25-50............................................... 1,267 8,243 8,142 -1.2
50-65............................................... 1,975 6,168 6,143 -0.4
OVER 65............................................. 1,370 5,250 5,247 0.0
UNKNOWN............................................. 95 7,984 7,928 -0.7
HOSPITALS RECLASSIFIED BY THE MEDICARE GEOGRAPHIC REVIEW
BOARD:
RECLASSIFICATION STATUS DURING FY98 AND FY99:
RECLASSIFIED DURING BOTH FY98 AND FY99.............. 311 5,995 5,989 -0.1
URBAN........................................... 70 7,505 7,468 -0.5
RURAL........................................... 241 5,250 5,258 0.2
RECLASSIFIED DURING FY99 ONLY....................... 178 5,512 5,773 4.7
URBAN........................................... 25 8,442 8,605 1.9
RURAL........................................... 153 4,705 4,993 6.1
RECLASSIFIED DURING FY98 ONLY....................... 111 6,192 6,000 -3.1
URBAN........................................... 38 7,018 6,865 -2.2
RURAL........................................... 73 4,458 4,185 -6.1
FY 99 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSP............................... 489 5,815 5,908 1.6
STAND. AMT. ONLY................................ 94 5,938 5,920 -0.3
WAGE INDEX ONLY................................. 281 5,994 5,940 -0.9
BOTH............................................ 47 6,390 6,290 -1.6
NONRECLASS...................................... 4,507 6,844 6,795 -0.7
ALL URBAN RECLASS................................... 95 7,767 7,786 0.2
STAND. AMT. ONLY................................ 25 5,922 5,924 0.0
WAGE INDEX ONLY................................. 45 9,138 9,194 0.6
BOTH............................................ 25 6,679 6,647 -0.5
NONRECLASS...................................... 2,670 7,327 7,245 -1.1
ALL RURAL RECLASS................................... 394 5,026 5,149 2.5
STAND. AMT. ONLY................................ 57 4,516 4,626 2.4
WAGE INDEX ONLY................................. 309 5,086 5,204 2.3
BOTH............................................ 28 5,038 5,230 3.8
NONRECLASS...................................... 1,770 4,106 4,137 0.8
OTHER RECLASSIFIED HOSPITALS (SECTION 1886(d)(8)(B)).... 27 4,725 4,695 -0.6
----------------------------------------------------------------------------------------------------------------
\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 1999 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 1999 with the average estimated per case
payments for FY 1998, 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 8 of Table I.
VIII. 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 available for the fourth year of the
capital prospective payment system (cost reports beginning in FY
1995) available through the December 1997 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.
[[Page 25691]]
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 1999 capital cost
projections. In Appendix B of this proposed rule, we discuss the
assumptions and computations that we employ to generate the amount
of obligated capital commitments for use in the FY 1999 capital cost
projections.
In Table III of this section, we present the redistributive
effects that are expected to occur between ``hold-harmless''
hospitals and ``fully prospective'' hospitals in FY 1999. In
addition, we have integrated sufficient hospital-specific
information into our actuarial model to project the impact of the
proposed FY 1999 capital payment policies by the standard
prospective payment system hospital groupings. 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 still
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
1999 capital costs for individual hospitals, but with the most
recent data hospitals' experience under the capital prospective
payment system, there is adequate information to estimate the
aggregate impact on most hospital groupings.
B. Projected Impact Based on the Proposed FY 1999 Actuarial Model
1. Assumptions. In this impact analysis, we model dynamically
the impact of the capital prospective payment system from FY 1998 to
FY 1999 using a capital cost model. The FY 1999 model, as 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 as reported on the December 1997 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, 1998 in the
provider-specific file. We used these data to determine the proposed
FY 1999 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 1995, and we age that capital by a formula described in Appendix
B. Therefore, we need to randomly generate only new capital
acquisitions for any year after FY 1995. All Federal rate payment
parameters are assigned to the applicable hospital.
For purposes of this impact analysis, the FY 1999 actuarial
model includes the following assumptions:
Medicare inpatient capital costs per discharge will
change at the following rates during these periods:
Average percentage change in capital costs per discharge
------------------------------------------------------------------------
Percentage
Fiscal Year Change
------------------------------------------------------------------------
1997....................................................... -2.20
1998....................................................... -0.44
1999....................................................... 0.61
------------------------------------------------------------------------
We have reduced our estimate of the growth in Medicare costs per
discharge from the August 29, 1997 final rule with comment period to
this proposed rule based on later cost data. We are now estimating a
much smaller increase in costs per discharge.
The Medicare case-mix index will increase by 1.0
percent in FY 1998 and FY 1999.
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 1999 update for inflation is 0.20 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 1998 to FY 1999.
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 and the applicable Federal
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 for FY 1999
----------------------------------------------------------------------------------------------------------------
Percent of Percent of
Type of hospital Percent of Percent of capital capital
hospitals discharges costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital........................................... 67 62 53 58
High Cost Hospital.......................................... 33 38 47 42
----------------------------------------------------------------------------------------------------------------
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 to
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 continue 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 1998 to FY 1999
using the above described actuarial model. With the proposed Federal
rate, we estimate aggregate Medicare capital payments will increase by
2.60 percent in FY 1999.
[[Page 25692]]
Table III.--Impact of Proposed Changes for FY 1999 on Payments per Discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent
Number of Adjusted Average Hospital Hold Exceptions Total change
hospitals Discharges federal federal specific harmless payment payment over FY
payment percent payment payment 1998
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 1998 Payments per Discharge:
Low Cost Hospitals............................... 3,260 6,746,172 $458.89 72.51 $86.07 $4.04 $8.87 $557.88 .........
Fully Prospective............................ 3,021 6,102,199 440.78 70.00 95.16 ......... 8.21 544.15 .........
100% Federal Rate............................ 208 567,402 661.26 100.00 ......... ......... 11.10 672.36 .........
Hold Harmless................................ 31 76,570 402.65 59.69 ......... 355.79 45.50 803.94 .........
High Cost Hospitals.............................. 1,637 4,163,057 636.32 95.82 ......... 36.64 16.72 689.68 .........
100% Federal Rate............................ 1,398 3,701,256 667.50 100.00 ......... ......... 11.65 679.14 .........
Hold Harmless................................ 239 461,801 386.44 60.70 ......... 330.33 57.34 774.12 .........
------------------------------------------------------------------------------------------------------
Total Hospitals............................ 4,897 10,909,229 526.60 81.67 53.23 16.48 11.87 608.18 .........
FY 1999 Payments per Discharge:
Low Cost Hospitals............................... 3,260 6,596,003 $529.51 81.61 $58.10 $3.38 $9.53 $597.52 7.11
Fully Prospective............................ 3,021 5,966,449 513.52 80.00 64.23 ......... 8.47 586.21 7.73
100% Federal Rate............................ 211 561,909 674.19 100.00 ......... ......... 10.98 685.17 1.91
Hold Harmless................................ 28 67,646 445.71 64.76 ......... 329.56 91.77 867.04 7.85
High Cost Hospitals.............................. 1,637 4,068,306 655.17 97.22 ......... 25.50 23.85 704.52 2.15
100% Federal Rate............................ 1,417 3,678,286 681.02 100.00 ......... ......... 16.94 697.97 2.77
Hold Harmless................................ 220 390,020 411.40 67.81 ......... 265.94 88.99 766.33 -1.01
------------------------------------------------------------------------------------------------------
Total Hospitals............................ 4,897 10,664,309 575.59 87.73 35.93 11.82 15.00 638.34 4.96
--------------------------------------------------------------------------------------------------------------------------------------------------------
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase
in payments per case of 7.73 percent, and high capital cost
hospitals will experience an average increase of 2.15 percent.
For hospitals paid under the fully prospective payment
methodology, the Federal rate payment percentage will increase from
70 percent to 80 percent and the hospital-specific rate payment
percentage will decrease from 30 to 20 percent in FY 1999. 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 60.70 percent to 67.81
percent. We estimate the percentage of hold-harmless hospitals paid
based on 100 percent of the Federal rate will increase from 85.6
percent to 86.8 percent. We estimate that high cost hold-harmless
hospitals will experience a decrease in payments of 1.01 percent
from FY 1998 to FY 1999. The apparent decrease occurs because we
estimate that there will be 19 fewer high-cost hold-harmless
hospitals in FY 1999. These 19 hospitals may have higher payments
than the remaining hospitals, hence the apparent decrease when they
are removed from the group. This decrease is partially offset by an
increase in the Federal portion of the hospital's payments and a
projected increase in exceptions payments.
We expect that the average hospital-specific rate payment per
discharge will decrease from $95.16 in FY 1998 to $64.23 in FY 1999.
This is partly due to the decrease in the hospital-specific rate
payment percentage from 30 percent in FY 1998 to 20 percent in FY
1999.
We are proposing no changes in our exceptions policies for FY
1999. 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 1.95
percent of total capital payments in FY 1998 to 2.35 percent of
payments in FY 1999. Since the August 29, 1997 final rule with
comment period, we have reduced our estimates of capital cost per
case based on more recent data. Although we still estimate that more
hospitals will receive exceptions payment in FY 1999 than in FY 1998
fewer hospitals will have costs over the exceptions threshold then
we previously estimated. The projected distribution of the exception
payments is shown in the table below:
Estimated FY 1999 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital Number of exceptions
hospitals payments
------------------------------------------------------------------------
Low Capital Cost.............................. 178 39
High Capital Cost............................. 200 61
-------------------------
Total..................................... 378 100
------------------------------------------------------------------------
C. Cross-Sectional Comparison of Capital Prospective Payment
Methodologies
Table IV presents a cross-sectional summary of hospital
groupings by capital prospective payment methodology. This
distribution is generated by our actuarial model.
Table IV.--Distribution by Method of Payment (Hold-Harmless/Fully Prospective) of Hospitals Receiving Capital
Payments
----------------------------------------------------------------------------------------------------------------
(2) Hold-harmless
-------------------------- (3)
(1) Total Percentage Percentage
No. of paid hold- Percentage paid fully
Hospitals harmless paid fully prospective
(A) federal (B) rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals........................................... 4,897 5.1 33.2 61.7
Large urban areas (populations over 1 million).......... 1,558 5.7 40.7 53.6
[[Page 25693]]
Other urban areas (populations of 1 million or fewer)... 1,188 6.2 40.8 52.9
Rural areas............................................. 2,151 4.0 23.7 72.4
Urban hospitals......................................... 2,746 5.9 40.8 53.3
0-99 beds........................................... 653 5.8 33.8 60.3
100-199 beds........................................ 928 8.5 45.9 45.6
200-299 beds........................................ 565 5.8 40.9 53.3
300-499 beds........................................ 448 2.2 40.8 56.9
500 or more beds.................................... 152 2.0 38.2 59.9
Rural hospitals......................................... 2,151 4.0 23.7 72.4
0-49 beds........................................... 1,124 3.5 16.1 80.4
50-99 beds.......................................... 633 4.3 28.8 67.0
100-149 beds........................................ 229 4.8 38.0 57.2
150-199 beds........................................ 91 7.7 25.3 67.0
200 or more beds.................................... 74 1.4 48.6 50.0
By Region
Urban by Region......................................... 2,746 5.9 40.8 53.3
New England......................................... 151 0.0 27.8 72.2
Middle Atlantic..................................... 421 4.5 34.0 61.5
South Atlantic...................................... 409 5.4 53.5 41.1
East North Central.................................. 472 5.5 30.5 64.0
East South Central.................................. 157 10.8 48.4 40.8
West North Central.................................. 183 6.0 36.6 57.4
West South Central.................................. 332 13.3 55.7 31.0
Mountain............................................ 122 4.9 50.8 44.3
Pacific............................................. 451 3.3 37.7 59.0
Puerto Rico......................................... 48 6.3 22.9 70.8
Rural by Region......................................... 2,151 4.0 23.7 72.4
New England......................................... 53 0.0 22.6 77.4
Middle Atlantic..................................... 79 5.1 25.3 69.6
South Atlantic...................................... 282 2.5 33.0 64.5
East North Central.................................. 283 3.2 19.1 77.7
East South Central.................................. 267 1.9 34.1 64.0
West North Central.................................. 498 3.6 16.1 80.3
West South Central.................................. 339 3.8 27.4 68.7
Mountain............................................ 205 10.7 15.6 73.7
Pacific............................................. 140 5.0 23.6 71.4
Large urban areas (populations over 1 million).......... 1,651 5.9 40.5 53.7
Other urban areas (populations of 1 million or fewer)... 1,180 5.8 41.1 53.1
Rural areas............................................. 2,066 4.0 23.0 73.0
Teaching Status:
Non-teaching............................................ 3,818 5.1 32.8 62.0
Fewer than 100 Residents................................ 840 5.7 35.1 59.2
100 or more Residents................................... 239 1.7 33.5 64.9
Disproportionate share hospitals (DSH):
Non-DSH................................................. 3,029 5.3 28.9 65.8
Urban DSH:
100 or more beds.................................... 1,397 5.2 43.7 51.0
Less than 100 beds.................................. 87 1.1 29.9 69.0
Rural DSH:
Sole Community (SCH/EACH)........................... 156 5.1 22.4 72.4
Referral Center (RRC/EACH).......................... 47 2.1 53.2 44.7
Other Rural:
100 or more beds................................ 64 4.7 37.5 57.8
Less than 100 beds.............................. 117 0.9 28.2 70.9
Urban teaching and DSH:
Both teaching and DSH................................... 699 4.0 36.6 59.4
Teaching and no DSH..................................... 327 6.7 31.5 61.8
No teaching and DSH..................................... 785 5.9 48.5 45.6
No teaching and no DSH.................................. 1,020 6.8 40.5 52.7
Rural Hospital Types:
Non special status hospitals............................ 894 2.0 24.0 73.9
RRC/EACH................................................ 137 2.2 40.1 57.7
SCH/EACH................................................ 632 8.2 19.9 71.8
Medicare-dependent hospitals (MDH)...................... 349 1.1 17.5 81.4
SCH, RRC and EACH....................................... 54 11.1 33.3 55.6
[[Page 25694]]
Type of Ownership:
Voluntary............................................... 2,847 4.9 33.0 62.1
Proprietary............................................. 656 10.1 58.2 31.7
Government.............................................. 1,329 3.2 21.1 75.7
Medicare Utilization as a Percent of Inpatient Days:
0-25.................................................... 238 4.2 30.7 65.1
25-50................................................... 1,260 5.9 41.0 53.2
50-65................................................... 1,970 5.6 33.0 61.4
Over 65................................................. 1,364 3.8 26.6 69.6
----------------------------------------------------------------------------------------------------------------
As we explain in Appendix B, we were not able to determine a
hospital-specific rate for 59 of the 4,956 hospitals in our
database. Consequently, the payment methodology distribution is
based on 4,897 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 the
hold-harmless payment methodology.
The percentage of hospitals paid fully Federal (100 percent of
the Federal rate) as hold-harmless hospitals is expected to increase
to 33.2 percent in FY 1999. We note that the number of hospitals
paid fully Federal as hold-harmless hospitals has not increased as
quickly as we predicted in the August 29, 1997 final rule with
comment period because of revised estimates.
Table IV indicates that 61.7 percent of hospitals will be paid
under the fully prospective payment methodology. (This figure,
unlike the figure of 67 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 (73.0 percent and 75.7 percent, respectively
by payment classification) are being paid under the fully
prospective methodology. This is a reflection of their lower than
average capital costs per case. In contrast, only 31.7 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 1999 actuarial model to estimate the potential
impact of our proposed changes for FY 1999 on total capital payments
per case, using a universe of 4,897 hospitals. The individual
hospital payment parameters are taken from the best available data,
including: The January 1, 1998 update to the provider-specific file,
cost report data, and audit information supplied by intermediaries.
In Table V we present the results of the cross-sectional analysis
using the results of our actuarial model and the aggregate impact of
the FY 1999 payment policies. Columns 3 and 4 show estimates of
payments per case under our model for FY 1998 and FY 1999. Column 5
shows the total percentage change in payments from FY 1998 to FY
1999. Column 6 presents the percentage change in payments that can
be attributed to Federal rate changes alone.
Federal rate changes represented in Column 6 include the 1.5
percent increase 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 5
includes the effects of the Federal rate changes represented in
Column 6. Column 5 also reflects the effects of all other changes,
including: the change from 70 percent to 80 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 5.0 percent in FY 1999. The
results show that the effect of the Federal rate changes alone is to
increase payments by 1.5 percent. In addition to the increase
attributable to the Federal rate changes, a 3.5 percent increase is
attributable to the effects of all other changes.
Our comparison by geographic location shows that urban and rural
hospitals will experience slightly different rates of increase in
capital payments per case (4.8 percent and 6.3 percent,
respectively). This difference is due to the lower rate of increase
for urban hospitals relative to rural hospitals (1.3 percent and 3.2
percent, respectively) from the Federal rate changes alone. Urban
hospitals will gain approximately the same as rural hospitals (3.5
percent versus 3.1 percent) from the effects of all other changes.
All regions are estimated to receive increases in total capital
payments per case, partly due to the increased share of payments
that are based on the Federal rate (from 70 to 80 percent). Changes
by region vary from a low of 3.6 percent increase (West South
Central urban region) to a high of 7.8 percent increase (Pacific
rural region).
By type of ownership, government hospitals are projected to have
the largest rate of increase (6.2 percent, 1.9 percent due to
Federal rate changes and 4.3 percent from the effects of all other
changes). Payments to voluntary hospitals will increase 5.1 percent
(a 1.5 percent increase due to Federal rate changes and a 3.6
percent increase from the effects of all other changes) and payments
to proprietary hospitals will increase 2.8 percent (a 1.1 percent
increase due to Federal rate changes and a 1.7 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 and for purposes of DSH, for FY 1999-
2001. 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 1999 compared to the effects of reclassification for FY 1998, we
show the average payment percentage increase for hospitals
reclassified in each
[[Page 25695]]
fiscal year and in total. For FY 1999 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 1999 as a whole are projected to
experience a 6.8 percent increase in payments (a 3.5 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 (5.1
percent) than reclassified hospitals (6.8 percent) overall. Payments
to nonreclassified hospitals will increase less than reclassified
hospitals from the Federal rate changes (1.5 percent compared to 3.5
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 1998 Compared to FY 1999)
----------------------------------------------------------------------------------------------------------------
Portion
Number of Average FY Average FY attributable
hospitals 1998 pay- 1999 pay- All changes to federal
ments/case ments/case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................. 4,897 608 638 5.0 1.5
Large urban areas (populations over 1
million)................................. 1,558 700 732 4.5 1.1
Other urban areas (populations of 1
million of fewer)........................ 1,188 601 633 5.2 1.5
Rural areas............................... 2,151 405 431 6.3 3.2
Urban hospitals........................... 2,746 658 689 4.8 1.3
0-99 beds............................. 653 482 502 4.1 1.2
100-199 beds.......................... 928 584 605 3.6 1.1
200-299 beds.......................... 565 628 661 5.4 1.3
300-499 beds.......................... 448 686 720 4.9 1.2
500 or more beds...................... 152 824 866 5.1 1.4
Rural hospitals........................... 2,151 405 431 6.3 3.2
0-49 beds............................. 1,124 325 348 6.9 2.9
50-99 beds............................ 633 382 407 6.6 2.8
100-149 beds.......................... 229 421 446 5.9 3.0
150-199 beds.......................... 91 442 469 6.0 3.8
200 or more beds...................... 74 500 531 6.2 3.7
By Region:
Urban by Region........................... 2,746 658 689 4.8 1.3
New England........................... 151 659 685 4.0 -0.4
Middle Atlantic....................... 421 708 743 5.0 1.8
South Atlantic........................ 409 649 678 4.4 1.8
East North Central.................... 472 616 650 5.5 1.0
East South Central.................... 157 611 633 3.6 0.8
West North Central.................... 183 638 673 5.6 2.3
West South Central.................... 332 664 688 3.6 0.5
Mountain.............................. 122 691 728 5.4 1.6
Pacific............................... 451 719 755 5.1 1.0
Puerto Rico........................... 48 277 288 4.1 1.9
Rural by Region........................... 2,151 405 431 6.3 3.2
New England........................... 53 475 497 4.5 1.9
Middle Atlantic....................... 79 413 443 7.4 3.4
South Atlantic........................ 282 430 455 5.9 3.5
East North Central.................... 283 401 431 7.4 3.4
East South Central.................... 267 376 400 6.6 3.4
West North Central.................... 498 390 411 5.6 3.4
West South Central.................... 339 370 390 5.5 2.5
Mountain.............................. 205 434 461 6.4 2.4
Pacific............................... 140 478 515 7.8 2.8
By Payment Classification:
All hospitals............................. 4,897 608 638 5.0 1.5
Large urban areas (populations over 1
million)................................. 1,651 692 724 4.5 1.1
Other urban areas (populations of 1
million of fewer)........................ 1,180 599 631 5.2 1.5
Rural areas............................... 2,066 402 427 6.2 3.0
Teaching Status:
Non-teaching.......................... 3,818 517 540 4.5 1.7
Fewer than 100 Residents.............. 840 647 682 5.4 1.3
100 or more Residents................. 239 889 936 5.3 1.3
Urban DSH:
100 or more beds.................. 1,397 693 727 4.9 1.3
Less than 100 beds................ 87 444 467 5.1 1.1
Rural DSH:
Sole Community (SCH/EACH)......... 156 364 383 5.2 2.5
Referral Center (RRC/EACH)........ 47 462 494 7.0 4.5
Other Rural:
100 or more beds.................. 64 384 400 4.3 2.8
Less than 100 beds................ 117 320 340 6.3 3.3
Urban teaching and DSH:
Both teaching and DSH................. 699 761 801 5.3 1.2
Teaching and no DSH................... 327 659 696 5.5 1.3
[[Page 25696]]
No teaching and DSH................... 785 585 610 4.3 1.3
No teaching and no DSH................ 1,020 558 579 3.7 1.3
Rural Hospital Types:
Non special status hospitals.......... 894 367 389 6.0 2.6
RRC/EACH.............................. 137 475 506 6.5 3.9
SCH/EACH.............................. 632 391 416 6.2 2.4
Medicare-dependent hospitals (MDH).... 349 324 355 9.5 3.6
SCH, RRC and EACH..................... 54 483 500 3.5 3.1
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY98
and FY99:
Reclassified During Both FY98 and
FY99............................. 311 540 566 4.8 1.7
Reclassified During FY99 Only......... 178 487 537 10.4 6.8
Reclassified During FY98 Only......... 110 580 587 1.2 -1.4
FY99 Reclassifications:
All Reclassified Hospitals........ 489 520 555 6.8 3.5
All Nonreclassified Hospitals..... 4,449 614 646 5.1 1.5
All Urban Reclassified Hospitals.. 95 663 708 6.8 2.3
Urban Nonreclassified Hospitals... 2,624 659 689 4.7 1.2
All Reclassified Rural Hospitals.. 394 462 494 6.8 4.2
Rural Nonreclassified Hospitals... 1,757 369 391 6.0 2.4
Other Reclassified Hospitals (Section
1886 (D)(8)(B))...................... 27 461 476 3.3 1.1
Type of Ownership:
Voluntary............................. 2,847 622 653 5.1 1.5
Proprietary........................... 656 617 634 2.8 1.1
Government............................ 1,329 530 563 6.2 1.9
Medicare Utilization as a Percent of
Inpatient Days:
0-25.................................. 238 685 725 5.8 1.1
25-50................................. 1,260 724 759 4.7 1.3
50-65................................. 1,970 565 594 5.2 1.6
----------------------------------------------------------------------------------------------------------------
Appendix B: Technical Appendix on the 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. For FY 1998,
we developed a new capital cost model to replace the capital
acquisition model. This revised 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, 1997 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, 1998 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 through FY 1998 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................................ 99
Provider-Specific and Audit File........................... 4857
------------
Total.................................................. 4956
------------------------------------------------------------------------
Eighty-six of the 4,956 hospitals had unusable or missing data
or had no cost reports available. We determined from the cost
reports that 27 of the 86 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 27 hospitals in the analysis. We used the cost report data of
4,897 hospitals for the analysis. Fifty-nine hospitals could not be
used in the analysis because of insufficient information. These
hospitals account for approximately 0.3 percent of admissions,
therefore, any effects from the elimination of their cost report
data should be minimal.
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 changes in
bed-size (greater than 20 percent). 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 to decreases in old capital. We did this since the
opportunity for most hospitals to treat ``obligated'' capital put
into service as
[[Page 25697]]
old capital has expired. Old capital costs should, therefore,
decrease as assets become fully depreciated, and as 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 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 as
follows:
(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 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.)
We used discharge counts from the cost reports to calculate
capital cost per discharge. To estimate total capital costs for FY
1997 (the MedPAR data year) and later, we use the number of
discharges from the MEDPAR data. Some hospitals have considerably
more discharges in FY 1997 than in the years for which we calculated
cost per discharge from the cost report data. Consequently, a
hospital with few cost report discharges would have a high capital
cost per discharge since fixed costs would be allocated over only a
few discharges. If discharges increase substantially, the cost per
discharge would decrease because fixed costs would be allocated over
more discharges. If the projection of capital cost per discharge is
not adjusted for increases in discharges, the projection of
exceptions would be overstated. We address this situation by
recalculating the cost per discharge with the MedPAR discharges if
the MedPAR discharges exceed the cost report discharges by more than
20 percent. We do not adjust for increases of less than 20 percent
because we have not received all of the FY 1997 discharges, and we
have removed some discharges from the analysis because they are
statistical outliers. This adjustment reduces our estimate of
exceptions payments, and consequently, the reduction to the Federal
rate for exceptions is smaller. We will continue to monitor our
modeling of exceptions payments and make adjustments as needed.
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 is 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 1997 MedPAR file using the FY 1998 DRG relative weights
published in section V. of the Addendum to this proposed rule. The
case-mix index is increased each year after FY 1997 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 1.0 percent in FY 1998 and 1.0 percent in FY 1999.
(Since we are using FY 1997 cases for our analysis, the FY 1997
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 1998, the budget neutrality adjustment factor
was 1.00015.
Since we implemented a separate geographic adjustment factor for
Puerto Rico, we propose to apply separate budget neutrality
adjustments for the national geographic adjustment factor and the
Puerto Rico geographic adjustment factor. We propose to apply the
same budget neutrality factor for DRG reclassifications and
recalibration nationally and for Puerto Rico. Separate adjustments
were unnecessary for FY 1998 since the geographic adjustment factor
for Puerto Rico was implemented in 1998.
To determine the factors for FY 1999, we first determined the
portions of the Federal national and Puerto Rico rates that would be
paid for each hospital in FY 1999 based on its applicable payment
methodology. Using our model, we then compared, separately for the
national rate and the Puerto Rico rate, estimated aggregate Federal
rate payments based on the FY 1998 DRG relative weights and the FY
1998 geographic adjustment factor to estimated aggregate Federal
rate payments based on the FY 1998 relative weights and the FY 1999
geographic adjustment factor. In making the comparison, we held the
FY 1999 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 national geographic adjustment factor, an incremental
budget neutrality adjustment of 0.99995 for FY 1999 should be
applied to the previous cumulative FY 1998 adjustment of 1.00015,
yielding a cumulative adjustment of 1.00010 through FY 1999. Since
this is the first adjustment for Puerto Rico, the incremental and
cumulative adjustment for Puerto Rico would be 0.99887 through 1999.
We apply these new adjustments then compare estimated aggregate
Federal rate payments based on the FY 1998 DRG relative weights and
the FY 1999 geographic adjustment factors to estimated aggregate
[[Page 25698]]
Federal rate payments based on the FY 1999 DRG relative weights and
the FY 1999 geographic adjustment factors. The incremental
adjustment for DRG classifications and changes in relative weights
would be 1.00328 nationally and for Puerto Rico. The cumulative
adjustments for DRG classifications and changes in relative weights
and for changes in the geographic adjustment factors through 1999
would be 1.00338 nationally, and 1.00215 for Puerto Rico. The
following table summarizes the adjustment factors for each fiscal
year:
Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
--------------------------------------------------------------------------------------------------------------------------------------------------------
National Puerto Rico
-------------------------------------------------------------------------------------------------------------------
Incremental Adjustment Incremental Adjustment
Fiscal year --------------------------------------------- ---------------------------------------------
Geographic DRG Cumulative Geographic DRG Cumulative
Adjustment Reclassifications Combined Adjustment Reclassifications Combined
Factor and Recalibration Factor and Recalibration
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992................................ ........... ................. ........... 1,000.00 ........... ................. ........... ...........
1993................................ ........... ................. 0.998.00 0.998.00 ........... ................. ........... ...........
1994................................ ........... ................. 1.00531 1.00330 ........... ................. ........... ...........
1995................................ ........... ................. 0.99980 1.00310 ........... ................. ........... ...........
1996................................ ........... ................. 0.99940 1.00250 ........... ................. ........... ...........
1997................................ ........... ................. 0.99873 1.00123 ........... ................. ........... ...........
1998................................ ........... ................. 0.99892 1.00015 ........... ................. ........... 1.00000
1999................................ 0.99995 1.00328 1.00323 1.00338 0.99887 1.00328 1.00215 1.00215
--------------------------------------------------------------------------------------------------------------------------------------------------------
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 (the national
rate and the Puerto Rico rate are determined separately) 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 fiscal years 1992
through 1998, the proposed factors for fiscal year 1999, and the
estimated factors that would be applicable through FY 2003. We
caution that these are estimates for fiscal years 2000 and later,
and are subject to revisions resulting from continued methodological
refinements, receipt of additional data, and changes in payment
policy changes. We note that in making these projections, we have
assumed that the cumulative national DRG/GAF budget neutrality
adjustment factor will remain at 1.00338 (1.00215 for Puerto Rico)
for FY 1999 and later because we do not have sufficient information
to estimate the change that will occur in the factor for years after
FY 1999.
The projections are as follows:
[[Page 25699]]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Federal
Update Exceptions Budget DRG/GAF Outlier Federal rate (after
Fiscal year factor reduction neutrality adjustment adjustment rate 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.................................................... 0.90 .9659 N/A .9989 .9382 \4\.8222 371.51
1999.................................................... 0.20 .9761 N/A 1.0032 .9378 ........... 377.25
2000.................................................... 0.80 .9749 N/A \5\ 1.0000 \5\.9378 ........... 379.80
2001.................................................... 0.80 .9720 N/A 1.0000 .9378 ........... 381.70
2002.................................................... 0.90 \6\ 1.0000 N/A 1.0000 .9378 ........... 396.23
2003.................................................... 0.90 \6\ 1.0000 N/A 1.0000 .9378 \4\ 1.0255 410.01
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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: Balanced Budget Act of 1997 adjustment.
\5\ Note: Future adjustments are, for purposes of this projection, assumed to remain at the same level.
\6\ Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (Sec. 412.348(g) of the regulations)
because the regular exceptions provision (Sec. 412.348(e)) expires.
BILLING CODE 4120-03-U
[[Page 25700]]
[GRAPHIC] [TIFF OMITTED] TP08MY98.026
[[Page 25701]]
[GRAPHIC] [TIFF OMITTED] TP08MY98.027
[[Page 25702]]
[GRAPHIC] [TIFF OMITTED] TP08MY98.028
[[Page 25703]]
[GRAPHIC] [TIFF OMITTED] TP08MY98.029
BILLING CODE 4120-03-C
[[Page 25704]]
Appendix D: 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 1999 by hospitals
subject to the prospective payment system and those excluded from
the prospective payment system. Section 1886(b)(3)(B)(i)(XIV) of the
Act sets the FY 1999 percentage increase in the operating cost
standardized amounts equal to the rate of increase in the hospital
market basket minus 1.9 percent for prospective payment hospitals in
all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 1999
percentage increase in the hospital-specific rates applicable to
sole community and Medicare-dependent, small rural hospitals equal
to the rate set forth in section 1886(b)(3)(B)(i) of the Act, that
is, the same update factor as all other hospitals subject to the
prospective payment system, or the rate of increase in the market
basket minus 1.9 percentage points. (We note that, as provided in
section 4401(b) of the Balanced Budget Act of 1997, certain
hospitals that do not receive indirect medical education or
disproportionate share payments and are not designated as Medicare-
dependent, small rural hospitals will receive an update that is 0.3
percent higher than the update for other prospective payment
hospitals. Section 1886(b)(3)(B)(ii) of the Act sets the FY 1999
percentage increase in the rate of increase limits for hospitals
excluded from the prospective payment system equal to the rate of
increase in the excluded hospital market basket minus a percentage
between 0 and 2.5 percent percentage points, depending on the
hospital's costs in relation to its limit.
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 fourth quarter 1997 forecast of the FY 1999
market basket increase of 2.6 percent for hospitals subject to the
prospective payment system, the proposed updates to the standardized
amounts are 0.7 percent (that is, the market basket rate of increase
minus 1.9 percent) for hospitals in both large urban and other
areas. The proposed update to the hospital-specific rate applicable
to sole community and Medicare-dependent, small rural hospitals is
also 0.7 percent. The proposed update for hospitals excluded from
the prospective payment system is the percentage increase in the
excluded hospital market basket (currently estimated at 2.5 percent)
less a percentage between 0 and 2.5 percentage points, or an update
equal to between 0 and 2.5 percent.
Section 1886(e)(4) of the Act requires that the Secretary,
taking into consideration the recommendations of the Medicare
Payment Advisory Commission (MedPAC), 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 MedPAC
recommendations concerning the update factors.
In its March 1, 1998 report, MedPAC stated that the legislated
update of market basket increase minus 1.9 percentage points will
provide a reasonable level of payment to hospitals. Although MedPAC
suggests that a somewhat lower update could be justified in light of
changes in the utilization and provision of hospital inpatient care,
the Commission does not believe it is necessary to recommend a lower
update for FY 1999. MedPAC did not make a separate recommendation
for the hospital-specific rates applicable to sole community and
Medicare-dependent, small rural hospitals. We discuss MedPAC's
recommendations concerning the update factors and our responses to
these recommendations below.
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 0.7
percent for hospitals located in large urban and other areas. We are
also recommending an update of 0.7 percent to the hospital-specific
rate for sole community hospitals and Medicare-dependent, small
rural hospitals. These figures are consistent with the President's
FY 1999 budget recommendations, which reflect the update provided by
section 4401(a) of the Balanced Budget Act of 1997. 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. When the President's budget was submitted, the
market basket rate of increase was projected at 2.7 percent. As
noted above, this proposed recommendation is based on the most
recent forecast of the market basket, 2.6 percent.
We recommend that hospitals excluded from the prospective
payment system receive an update of between 0 and 2.5 percent. The
update for excluded hospitals and units is equal to the increase in
the excluded hospital operating market basket, less a percentage
between 0 and 2.5 percentage points depending on the hospital's or
unit's costs in relation to its rate-of-increase limit. The market
basket rate of increase is currently forecast at 2.5 percentage
points. This recommendation is consistent with the President's FY
1999 budget, although we note that the market basket rate of
increase was forecast at 2.7 percent when the budget was submitted.
As required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of MedPAC in setting these
recommended update factors. Our responses to the MedPAC
recommendations concerning the update factors are discussed below.
III. MedPAC Recommendation for Updating the Prospective Payment
System Standardized Amounts
For FY 1999, MedPAC's update framework would support an update
of the increase in the hospital market basket minus a figure between
4.4 percentage points and 1.1 percentage points. MedPAC notes that
costs per case have grown more slowly than payments per case since
1992 and, as a result, overall Medicare operating margins for
hospitals have been rising. MedPAC predicts that Medicare operating
margins will continue to be quite favorable even with the payment
reductions enacted by the Balanced Budget Act of 1997. MedPAC
further notes that Medicare payments are just one of many factors
that affect hospital margins. Thus, while MedPAC agrees with the
proposed update of market basket increase minus 1.9 percentage
points for 1999, that update is closer to the higher end than the
lower end of MedPAC's update framework. The Commission 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. MedPAC's estimate of the market basket
increase is 2.5 percent, which is 0.1 percentage points below HCFA's
current estimate. MedPAC's market basket estimate focuses on
employee compensation changes in the hospital industry and the
economy in general, while HCFA's market basket forecast gives less
weight to the projected changes in the hospital industry's wages.
Thus, MedPAC's update framework reflects a 0.1 percent adjustment
for this difference.
Response: We agree with MedPAC's recommendation of an update for
FY 1999 for prospective payment system hospitals of market basket
minus 1.9 percentage points. 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:
a. 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. MedPAC's predecessor, the
Prospective Payment Assessment Commission (ProPAC), estimated
cumulative service productivity growth to be 4.9 percent from 1985-
1989, or 1.2 percent annually. At the same time, MedPAC estimated
total output growth at 3.4 percent
[[Page 25705]]
annually, implying a ratio of service productivity growth to output
growth of 0.35.
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 larger in years that output growth is higher than
the historical averages. 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 (-2.0 percent for FY 1999), and projected real case-mix
growth (0.8 percent), or -1.2 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
(-1.2 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 61.4, provides our productivity standard of
-0.2 to -0.3 percent.
MedPAC believes that the update should also take into account
the effects of product change. MedPAC analysis indicates that
between 1992 and 1996, the decline in length of stay and
corresponding increase in the intensity of services per day resulted
in a net reduction of about 11 percent for services provided per
hospital admission. In the past, ProPAC 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, MedPAC believes a product adjustment in the range
of -3.0 to -1.0 percentage points is appropriate. In addition,
MedPAC's update framework contains a productivity adjustment of
between -0.7 to -0.3 percent, which is slightly more optimistic than
our estimate.
b. 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 1999, 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. A study published in the
Winter 1992 issue of the Health Care Financing Review,
``Contributions of case mix and intensity change to hospital cost
increases'' (p. 151-163), suggests that one-third of the intensity
change is attributable to high-cost technology. The balance was
unexplained but the authors speculated that it is attributable to
fixed costs in service delivery.
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.
All things being equal, per-discharge fixed costs tend to
fluctuate in inverse proportion to changes in volume. Fixed costs
exist whether patients are treated or not. If volume is declining,
per-discharge fixed costs will rise, but the reverse is true if
volume is increasing.
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 1993-FY 1997 MedPAR billing data. Case-mix
constant intensity is calculated as the change in total Medicare
charges per discharge adjusted for changes in the average charge per
unit of service as measured by the Medical CPI hospital component
and changes in real case mix. Thus, in order to measure changes in
intensity, one must measure changes in real case mix.
For FY 1993-FY 1997, observed case mix index change ranged from
a low of 0.8 percent to a high of 1.7 percent, with a 5-year average
change of 1.3 percent. Based on evidence from past studies of case-
mix change, we estimate that real case mix change fluctuates between
1.0 and 1.4 percent and the observed values generally fall in this
range. The average percentage change in charge per discharge was 3.4
percent and the average annual change in the medical CPI was 5.7
percent. Dividing the change in charge per discharge by the quantity
of the real case-mix index change and the medical CPI, yields an
average annual change in intensity of -3.4 percent. Assuming the
technology/fixed cost ratio still holds, technology would account
for a -1.1 percent annual decline while fixed costs would account
for a -2.3 percent annual decline. The decline in fixed costs per
discharge makes intuitive sense as volume, measured by total
discharges, as increased during the period. Since we estimate that
intensity has declined during that period, we are recommending a 0.0
percent intensity adjustment for FY 1999.
c. Quality Enhancing New Science and Technology
For FY 1999, MedPAC 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. As in past
recommendations, MedPAC has included an adjustment ranging from 0.3
to 1.0 percentage points. MedPAC 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, MedPAC recommends an adjustment of 0.5
percentage points for the increase in operating costs due to
scientific and technological advances.
d. 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 1999 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 1999, 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. Thus, we are projecting an increase of 0.8 percentage points
for the real case-mix index.
Unlike ProPAC's case-mix recommendation in previous years,
MedPAC did not make a specific percentage change recommendation but
rather estimated a range from -0.2 to 0.2 percentage point change
based on changes in the 1998 case mix index.
e. Effect of FY 1997 DRG Reclassification and Recalibration
We estimate that DRG reclassification and recalibration for FY
1997 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. MedPAC does not make an adjustment for DRG reclassification
and recalibration in its update recommendation.
f. Correction for Market Basket Forecast Error
The estimated market basket percentage increase used to update
the FY 1997 payment
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rates was 2.5 percent. Our most recent data indicate the actual FY
1997 increase was 2.1 percent. The resulting forecast error in the
FY 1997 market basket rate of increase is 0.4 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 -0.4 percentage points to reflect
this overestimation of the FY 1997 market basket rate of increase.
The following is a summary of the update ranges supported by our
analyses compared to MedPAC's framework.
Table 1.--Comparison of FY 1999 Update Recommendations
----------------------------------------------------------------------------------------------------------------
HHS MedPAC
----------------------------------------------------------------------------------------------------------------
Market Basket.................... MB................................... MB
Difference between HCFA & MedPAC ..................................... -0.1
Market Baskets.
Subtotal............. MB................................... MB
Policy Adjustments Factors:
Productivity................. -0.3 to -0.2......................... -0.7 to -0.3
Product...................... (3).................................. -3.0 to -1.0
Intensity.................... 0.0..................................
Science & Technology..... ..................................... 0.0 to 0.5
Practice Patterns........ ..................................... (1)
Real Within DRG Change... ..................................... (2)
Subtotal............. -0.3 to -0.2......................... -3.7 to -0.8
Case-Mix Adjustment Factors:
Projected Case-Mix Change.... -1.0................................. ......................................
Real Across DRG Change....... 0.8.................................. -0.2 to 0.0
Real Within DRG Change....... (3).................................. 0.0 to 0.2
Subtotal............. -0.2................................. -0.2 to 0.2
Effect of 1996 Reclassification & 0.0.................................. ......................................
Recalibration.
Forecast Error Correction........ -0.4................................. -0.4
Total Recommended MB -0.9 to MB -0.8................... MB -4.4 to MB -1.1
Update.
----------------------------------------------------------------------------------------------------------------
\1\ Included in MedPAC's Productivity Measure.
\2\ Included in MedPAC's Case-Mix Adjustment.
\3\ Included in HHS' Intensity Factor.
Because we are not recommending a negative adjustment for
intensity (as our methodology would suggest is appropriate), the
update suggested by our framework appears to be more generous than
the recommendation of MedPAC. While the above framework would
support an update of the market basket increase minus 0.9 percentage
points, we are recommending an update of the market basket increase
minus 1.9 percentage points (0.7 percent). 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 MedPAC that a
0.7 percent update for FY 1999 would not disadvantage the hospital
industry nor harm Medicare beneficiaries. We also recommend that the
hospital-specific rates applicable to sole community and Medicare-
dependent, small rural hospitals be increased by the same update,
0.7 percentage points.
IV. MedPAC Recommendation for Updating the Rate-of-Increase Limits
for Excluded Hospitals
MedPAC recommends an update factor equal to a 2.1 percent
average increase for TEFRA target amounts for excluded hospitals and
units. The update formula enacted by section 4411(a) of the Balanced
Budget Act is equal to the increase in the excluded hospital market
basket less a percentage point between 0 and 2.5 percent, depending
on the hospital's or unit's costs in relation to the target amount.
MedPAC's recommendation reflects a reduction of 0.4 percentage
points from HCFA's market basket increase forecast of 2.5 percent.
The reduction consists of an adjustment of -0.4 percentage points to
account for the forecast error in the FY 1997 market basket rate of
increase, and no allowance for new technology.
Response: We recommend that hospitals excluded from the
prospective payment system also receive a 2.5 percent increase in
the market basket used in the update formula for TEFRA target amount
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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[FR Doc. 98-12207 Filed 5-7-98; 8:45 am]
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